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We are surgeons and we operate beyond our knives and operating rooms.
Underneath our incisions is a world that we must be part of
#racism #gunviolence are public health issues
#ThisIsOurLane
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Bellal Joseph
15.1K posts
Bellal Joseph
@TopKniFe_B
Trauma Surgeon part 🦄 and sometimes a researcher free spirit with a wild heart 🦁 🦅
citizen of the world Katılım Mayıs 2011
1.3K Takip Edilen16.5K Takipçiler
Bellal Joseph retweetledi
This review article provides a comprehensive description of the diagnostic and therapeutic strategies for treating Morel-Lavallee lesions.
@susan_kartiko; @Trauma_Q; #GW
journals.lww.com/jtrauma/fullte…
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Bellal Joseph retweetledi
Are you an experienced Trauma surgeon who wants to be TMD at a L1 center with:
- Pacific NW location
- a good crew already
- a pristine site survey
- Direct-to-OR 💪
- and you get to be my boss?
Legacy Emanuel is looking😁. Our TMD is retiring.
Link to posting in 1st reply…
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This is gold 👇
Dr. Chacón-Lozsán F .'.@franciscojlk
🫀The failing right ventricle: the most misunderstood chamber in critical care For years, we focused on the left ventricle. But in the ICU, the real killer is often the right ventricle. ->What is acute RV failure? 👉 Not just “weak contraction” It’s a hemodynamic collapse syndrome: RV dilation ↓ LV preload ↓ cardiac output ↑ venous congestion ➡️ → multi-organ failure ->The key pathophysiology (the vicious cycle) 1. ↑ Afterload (PE, ARDS, PH) 2. → RV dilation 3. → Septal shift → LV underfilling 4. → ↓ CO → hypotension 5. → ↓ RCA perfusion 6. → RV ischemia 👉 And the cycle accelerates ->The most important concept 👉 The RV does NOT tolerate pressure Handles preload very well Fails rapidly with afterload ➡️ Even small ↑ PVR → collapse ->Main causes you MUST think first 🔴 Pulmonary embolism 🔴 RV myocardial infarction 🔴 ARDS / mechanical ventilation 🔴 Decompensated pulmonary hypertension 🔴 Post-cardiac surgery ->Diagnosis is NOT obvious There is no single sign. 👉 It requires suspicion + integration: Clinical: congestion + hypoperfusion ECG + biomarkers POCUS (your best friend 🤓) Hemodynamics ->Echo mindset (fast ICU approach) 👉 Don’t overcomplicate Look for: ✔ RV dilation ✔ Septal shift (D-sign) ✔ TAPSE ↓ ✔ Venous congestion The real ICU mistake ❌ Treating RV failure like LV failure ->Management principles 👉 Think in 4 pillars: 1. Preload — “not too much, not too little” Hypovolemic → small fluid Congested → REMOVE fluid 👉 CVP is not a target, it’s a warning 2. Afterload, THE key target ✔ Treat PE ✔ Optimize ventilation ✔ Reduce PVR 👉 If afterload stays high → RV will fail 3. Contractility Dobutamine Milrinone Levosimendan 👉 Choose based on context 4. Perfusion pressure 👉 Norepinephrine is your anchor ✔ Maintains coronary perfusion ✔ Supports RV function ->Ventilation: the silent killer ⚠️ Positive pressure = ↑ PVR 👉 Over-ventilate → worsen RV failure ->When nothing works 👉 Think early: VA-ECMO RV assist devices 🤓Key insight This is NOT just a cardiac problem. 👉 It is a ventriculo–arterial coupling failure When: Ees / Ea ↓ → RV collapses 🤓Bottom line ✔ RV failure is preload dependent BUT afterload sensitive ✔ Small mistakes → rapid collapse ✔ Early recognition + physiology-based treatment saves lives ->Clinical mindset 👉 Don’t ask: “Is the RV failing?” 👉 Ask: “Why is the RV failing and, what is driving the afterload?” 📃Reference Giannakoulas G. et al. European Heart Journal (2025) 00, 1–16 doi.org/10.1093/eurhea…
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Ketamine was the "cool" 😎 answer
So many wanted it to be the answer.
The hemodynamically safe induction agent.
The one that wouldn't tank your BP.
Turns out… maybe not so much in the ICU.
Like most things in trauma the bandwagon was fun until the data came out
armyemdoc@armyemdoc
The PROMINE trial, an open-label RCT comparing ketamine versus propofol for patients undergoing emergency intubation in the ICU, they found: -Minimal difference in the lowest MAP value of 66 versus 60, mean difference, 6.0 [95% CI − 0.0 to 11.9]; p = 0.050 -Less vasopressor use, 22% versus 33%, 0.56 (0.28 to 1.10) -A potential signal of worse mortality with ketamine, 60% versus 50%, p=0.17, OR 1.21; 95% CI 0.92–1.58) This potential mortality signal is quite interesting. PMID: 41870554 pubmed.ncbi.nlm.nih.gov/41870554/ #emergencymedicine #criticalcare #science #data #research
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Bellal Joseph retweetledi
⚠️Parenteral Nutrition (TPN) does NOT increase risk of INFECTION!
4 Large Randomized Trials in @NEJM , @TheLancet, @JAMA show NO association of TPN with infection of any kind.
See references 👇
#MedEd #FOAMed #MedX #ICUNutrition
🔗nejm.org/doi/full/10.10…
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Very interesting Sarcopenic Obesity
Obesity impact runs deep
Christoph Burch@ChristophBurch
Sarcopenic obesity in older adults: a clinical overview nature.com/articles/s4157…
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I love the PAC was sad to see it leave would welcome it back with open arms
🫣🙋♂️
Dr. Chacón-Lozsán F .'.@franciscojlk
🫀Pulmonary artery catheter: dead… or misunderstood?🤔 For years, we were told: ❌ “No mortality benefit” ❌ “Too invasive” ❌ “Old technology” But in cardiogenic shock… the story is changing. ->New meta-analysis. ~790,000 patients. 👉 The signal is clear: ↓ Mortality (OR 0.70) ↓ Hazard of death by 32% ↑ Use of MCS (OR 2.76) ⚠️ ↑ Sepsis risk (OR 1.83) ->So what’s really happening? This is NOT about the catheter. 👉 It’s about what you do with the data. ->PAC as a “therapeutic enabler” PAC doesn’t treat patients. 👉 It enables: Phenotype-driven shock classification Precise preload / afterload optimization Early identification of RV failure Timely escalation to MCS 👉 In other words: It transforms guesswork into strategy ->Why previous trials failed PACMAN. ESCAPE. They showed no benefit. But the problem wasn’t the catheter… 👉 It was the absence of: Structured protocols Shock teams Clear hemodynamic targets ->Modern cardiogenic shock is different Today we have: Shock teams SCAI staging Protocol-driven escalation Advanced MCS (Impella, ECMO) 👉 In this context, PAC becomes powerful. ->The trade-off Let’s be honest: ⚠️ Increased infection risk OR ~1.8 for sepsis So: 👉 Use it selectively 👉 Use it early 👉 Remove it as soon as possible ->Key takeaway PAC is not obsolete. 👉 It was misused. And now, in the right hands: It may be one of the most important tools in cardiogenic shock. 📃Reference Ortega-Hernández JA et al. Pulmonary artery catheter monitoring in cardiogenic shock: systematic review and meta-analysis. Shock 65(4):p 648-659, April 2026. | DOI: 10.1097/SHK.0000000000002784 esc365.escardio.org/presentation/3…
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Bellal Joseph retweetledi
New in Foregut
⚖️ Simple closure vs omental patch
📊 Outcomes: no difference
🕒 Time: simple closure faster
🎯 Efficient, safe, and practical in emergencies
journals.sagepub.com/doi/epub/10.11…
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Bellal Joseph retweetledi
Today is an incredibly meaningful day for me.
The Daily Surgeon is officially out in the world.
This book has been years in the making, built in the quiet moments most people never see. Early mornings. Late nights. Between cases. Between innings. Between responsibilities.
It’s a collection of 365 lessons shaped by the operating room, by sport, and by the pursuit of doing something at a high level, consistently, over time.
Along the way, I’ve been fortunate to learn from incredible mentors, colleagues, athletes, and patients. Their influence is woven into every page.
I didn’t write this just for surgeons.
I wrote it for anyone committed to improving their craft…
for those who show up every day…
for those who understand that mastery isn’t a single achievement, it’s a daily process.
If even one lesson in this book helps someone take a step forward, then it was all worth it.
I’m incredibly proud to share this with you.
🖤 The Daily Surgeon -- available now:
dailysurgeon.com
#TheDailySurgeon #SurgicalMastery #Discipline #Excellence #Gratitude
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We’ve been measuring the wrong thing.
Higher procedural volume → lower mortality & complications.
Higher trauma volume alone → doesn’t cut it.
Time to rethink how we define “high-performing” trauma centers.
@acsTrauma @acsJACS
Practice Makes Perfect: Impact of Volume on Outcomes : Journal of the American College of Surgeons journals.lww.com/journalacs/abs…
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Bellal Joseph retweetledi
Smart @TopKniFe_B et al ➡️ journals.lww.com/journalacs/abs…
Norsk
Not a Fan — test looking for an indication
Mortality based on a test 🙋♂️🫣👀 not so much
Nick Mark MD@nickmmark
The results of the PRONTO RCT of procalcitonin in people with suspected sepsis are absolutely fascinating. Mortality was significantly lower in the procalcitonin-guided care group: 13.6% (372/2738) vs 16.6% (450/2715) (p=0.0009) but there was no difference in antibiotic initiation, narrowing, or days of therapy! So apparently procalcitonin saves lives even if it doesn’t change antibiotic prescribing? 🤔 1/
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Bellal Joseph retweetledi
Retraction—Today, we retract an unsigned 1977 commentary suggesting talc powder containing asbestos was not harmful. The Lancet was informed that the author had undisclosed competing interests and breached publication ethics. /4
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Fixed it.
IO is not your resuscitation strategy. It’s a temporary workaround when you’ve failed to get access.
Use it for meds if you must but stop pretending it replaces real vascular access.
In trauma, get definitive access early. That’s the job.
Osgenic@osgenic
IO access is an excellent way of establishing vascular access in urgent cases (trauma, burn, shock, resuscitation) when intravenous access fails or would take too long. See the technique for proximal tibia and humerus. #orthopaedics #trauma #IOneedle #orthotwitter #orthoX #meded
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Bellal Joseph retweetledi
The framing for this has always seemed strange to me.
Surgery has a 0% failure rate at preventing recurrent appendicitis (yes if done well) and antibiotics a 44% failure rate.
Unless surgery is strongly contraindicated, appendectomy seems like the right choice.
JAMA@JAMA_current
In adults with uncomplicated #appendicitis, 44% treated with antibiotics required appendectomy within 10 years, but complication rates were lower and quality of life similar to surgery. ja.ma/3NU446Z
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Bellal Joseph retweetledi
JUST RELEASED!
The 2026 Update of the Surviving #Sepsis Campaign Guidlines is now online!
Permanent Free Access
Adult: zurl.co/I7hBu
Children: zurl.co/JKedS
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Bellal Joseph retweetledi
In 2007 interview, Thomas Starzl, who performed the first liver transplant, described being ‘clipped from the Hopkins pyramid’.
In other words, he was told that he would not become one of the chief residents. He finished his residency at Miami, and the rest is history. 🧐
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Bellal Joseph retweetledi
Joining this fellowship fills me with nothing but pride, and maintaining a perfect match rate makes it even more meaningful.
Thank you, @TopKniFe_B, for opening the door to a step that changed my path forever. Eternally grateful 🙏
#fellowshipofthesun #thesecretsauce
Bellal Joseph@TopKniFe_B
Sunset on the #FellowshipofTheSun 🌞🌵 2 more matches closing with 100% and congrats to these two. @malmaaniMD @fcastillodiaz99 this is your dream we’re just witnessing! We matched 30 into USA residency. 28 in surgery. Every ending sets the next beginning. Every sunset… a new sunrise. Fellowship of the 🍑 😉 #Match2026
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