DIP Ep 572: Quick and Dirty Emergency Medicine For The USMLEs (Part 2)

So just something you want to keep in mind. All right. So

Let's continue from where we left off. So, um, what if they give you a question about a person that has any form of hemorrhage or some kind of GI bleed or whatever? What kind of volume resuscitation are you supposed to give first on your exam? Well I would really hope you're saying that, oh wait, I'm gonna give you fluids first, right? And typically on the USMLEs, they tend to want you to give normal sales.

Again, I know some people get all riled up about the fine details of normal saline versus lactated ringers. But the thing is in general, for purposes of the USMLE exams, they are not super concerned about that. I would pretty much regard both of those things as being pretty much interchangeable.

But I would say the right answer like 95 plus percent of the time on your exams is going to be normal ceiling, right? So just in general give normal ceiling, right? You want to give fluids first as your form of volume resuscitation before you give blood. And just as a general principle of fluid management, you're generally gonna be giving the person more fluid than you think that they have lost in terms of volume. You know why?

Because it's only about a third of that fluid that you're given that is going to stay within the vascular tree. Time will fail me to start going into the details of the body compartments and how water and fluids are distributed across the body. But remember most of the body water is inside your cell and interstitial, not really in the blood vessel. So

If you're giving a person about three liters of fluid, you're actually maybe resuscitating like a liter of volume. You're only putting like a liter of volume within the avascular tree. If you kind of work out the math, uh you're gonna see that that's what it kind of comes. Now, one common question that people ask me is: Divine, okay, when do we give blood? Well, again, remember, you always give fluids first, give like normal saline first.

But if for example you've given the person fluids and the person is still unstable, the person is still hypotensive, the person is still very tachycardic. Then you can go ahead and give blood. But typically we're gonna reserve blood for people that are still unstable, despite them getting fluids, or people that have hemoglobins that are less than seven.

Right, remember that's seven transmission threshold. But there's a third criteria that's actually kind of high yield to know for your exams, and that's if a person is still having ongoing bleeding, right? So it's almost like their hemoglobin is like a moving target, right? So right now their hemoglobin may be eight or nine, but they're still having like ongoing bleeding. Or the person has like an unstable heart.

Right, that number of seven. Oh, don't transfuse below uh till you're below seven. It doesn't really apply a ton in people that are cardiac patients, people that have like really bad cardiac disease.

So those things you want to keep those at the back of your mind as you prepare for your exams. All right. Now what if they give you a question about a patient and the person is like a trauma patient, comes in, you know, emergent situation, the person's palpable systolic blood pressure is like in the 60s.

And you're told that the person is giving fluids and the patient is still unstable and the patient is having an ongoing bleed and they won't tell you that, oh, the person's hemoglobin is less than seven. Right, they give you like a series of labs. They may not give you the hemoglobin, they may give you the hematocrite. Let's say the hematocrate is like 18%. Remember, your hematocrate divided by three is your hemoglobin.

And then they say what's the most appropriate next best step in management? And you're like, Oh, divine just said give blood, but the MBA means are like not so fast. And basically they give you a series of answers with many different blood groups and you're like, Oh Oh my goodness. Come on guys, really? You you could make this easy and just put an answer that says packed red blood cell transfusion. But of course you have to make it harder than you need it to be, right? So the thing I will say is

They give you different blood groups, right? Um the thing is, what is the kind of blood we give empirically? I mean, obviously we want to try to cross match. If possible. But you know what? You don't always have time to cross match, right? You don't want your patients dying while you're trying to figure out the person's blood group and all those things. So if you have to give blood empirically in a trauma situation, what kind of blood should you give?

I would really hope you're saying divine. I'm gonna give O-negative blood. Again, this all goes back to basic sciences. So, why is O-negative blood the ideal blood to give? Well first things first, let's break that up, right? O negative means there's an O and there's a negative. So what does the O stand for? Well blood group O. The thing is people that have blood group O They are red blots uh uh i i if you're getting blood group O, right, because you you're getting this blood.

Right, if you're getting blood group O, remember blood group O does not have the A antigen or the B antigen on its surface. So it's since it does not have the A antigen or the B antigen on its surface. Hmm. Could that be beneficial? Yeah, that could be beneficial because if you're the one receiving that blood,

has anti-A or anti-B antibodies in your serum. It's not gonna matter. Why is it not gonna matter? Because even if you have those antibodies, the blood group O you're receiving does not have the antigen. on its surface that are attacked by those antibodies. So it's not a big deal. Alright, so we've dealt with the O part. How about the negative part? Well remember whenever a person has uh blood group and you see the words positive the term positive or negative.

It's just referring to the RH status, right? Are you Rh positive or U R H negative? So if you're R H positive, right, it means you have the Resource Antigen, R-H-E-S-U-S, right? Rh sus, right? So the either have the Resource Antigen or you don't.

Right. So why do we use O negative blood? Well we use Rh negative blood because again for two reasons. Number one, again, if you're negative for the resource antigen, if you have anti-Rh antibodies, you're the recipient. If you have anti-Rh antibodies in your serum. It's not gonna matter, you know? It's not gonna matter. It's not gonna matter because you don't have any Rh antigens in the blood that's coming in for you to attack. So that's not a big deal.

But also, we would love to not sensitize your immune system to making anti-RH antibodies, especially if you're a woman. Because what if you get pregnant in the future and your baby happens to be R-H-positive? Well, if you've been sensitized because of a blood transfusion in the past. And you now have anti arich anti budget. Remember, those antibodies can be IgG antibodies and they can cross the placenta and cause hemorrhytic disease in a newborn, right? That's not ideal.

Right. So just be careful on your exams. Why do you think I'm going off in this direction? I'm going off in this direction. Because many people all day in their minds at the classic situation that oh this woman is a negative and uh You know, you know the first pregnancy, you may not have hemolytic disease of the newborn. But from that first pregnancy, you're gonna make anti-Arich antibodies.

And then the second pregnancy is gonna be a problem. Yeah, fine. I'm sure you've learned that. Many resources preach and proselytize on that. But let me tell you something. On the USMLEs, you can have hemorrhytic disease of the newborn with the first pregnancy because mom could have mid anti-RH anti-bod. From a different from a different kind of exposure to RH positive blood. For example, in a trauma situation or in an ectopic pregnancy or in a molar pregnancy.

Right? She may have been exposed to R-H positive blood in a different setting. So just be careful that. First pregnancy, no problem. Second problems pregnancy, problem. No, that's that is an overtly simplistic way to think about it. Right. Um trust me the US MLEs have kinda moved well, well, well beyond that. So just be kinda kinda

Now, what if they give you a question about a patient that, you know, came into the emergency room, extremely hypotensive, extremely tachycardic, extremely unstable, and the person has gotten volume resuscitated, right? Volume resuscitated. And then you're told that uh which of the following uh which of the following will be w is one of the best measures of appropriate response to volume resuscitation.

And then of course they will give you a bunch of answers. They will tell you uh uh elevation in blood pressure. So like the person's blood pressure is catching up, or they can say reduction in heart rate, or they can say reduction in respiratory rate or whatever. And then they can give you an answer that says urine output. You want to pick the answer choice that says urine output.

One of the best ways for us to tell that you're responding to the fluids that we're giving you is that your kidneys are now willing to pee out some of that fluid, right? Because think about it, the body is a very wise machine. The body literally likes to hold on to fluids, right? But think just uh again, the body is wise. The body was created to be very smart. So think about it, if you're short on volume, do you think your kidneys will want to be letting go of extra fluid? No.

Right, because you're not perfection your JG cells. Well, you're gonna make a ton of renin, you know, a lot of aldosterone and jotensin and whatnot. And aldosterone and adh they make you keep fluid, right? So if Wow, you're in a trauma situation, you're getting fluids and you're barely peeing. It means that your body is still like, mmm, I'm in a volume deficient state. I ain't giving up any of this fluid.

But if you start peeing more, your body's like, hmm. It means that it's almost like your body's like, mm, it's fine. We can let some of the fluid go in the urine. It's not a big deal. So that tells you that yep. I'm pretty volume resuscitated, right? That's why in trauma patients it's not a bad idea to go ahead and get a fully you know, place a fully catheter so that you can just see how much urine that they're producing, how much urine they're producing. And I guess since we're on this topic of

Fully catheters. Let's maybe say a few high yield things about fully catheters, right? So the thing is There are certain trauma situations where you don't place fully cathode. Right. I'm sure many of you are yelling in your rooms or in your cars or as you work out right now. Ooh divine, blood at the urethral meatus. And that's true, right? If you have blood at the urethral meatus, you absolutely positively

should not do a fully catheter, right? Because if a person has blood at the urethrometus, it tells you that they have urethral injury. It'll be very, very, very unwise to try to plus place a fully catheter in that structure. Right. What should you do to people that have blood at the erythromid? Uh typically for those people you want to do a retrograde urethrogram, a retrograde urethrogram, retrograde urethrogram, urethrography spelled u-re-t-h-r-o-g-r-a-m urethrogram.

But again, our friends at the MBMEs, they're not stupid. They know that everybody that has the blood uh the job description, not blood description. We're talking about blood groups here, but job description medical students have memorized, oh, blood and the urethra meatus.

Do not place a fully catheter. Yeah, of course, they know that you all know that. But let's talk about some other unusual situations you may see on your exams. We should not place a fully catheter, right? Number one is if a person has a scroll hematoma. Right. You see a person scrotum, it's a trauma situation, it looks bloody, looks pulsatile.

Uh you see like a blood collection, uh, you really do not want to place a fully catheter in those people, right? Another classic one you may see is if a person, if they literally use this term in a Q stem, that the person has a high writing process.

If a person has a high riding prostate from you doing a digital rectal exam in a trauma situation, you absolutely positively do not want to place a fully catheter. So you may wonder, because that's one thing many people do. Many people just memorize buzzwords. But the thing is, memorizing buzz phrases and buzzwords is not as useful on the USMLEs anymore. These days the US MLEs are very descriptive. This is one of those things I talk about quite extensive.

In my test taking strategies class. And in many of my classes, uh like people that have attended my 20 hour class, um, or actually many of my other classes. You notice that many times I will say something in one way and say, hey, these are the other ways they could say the exact same thing, right? These are the other ways they could literally say the exact same thing.

Right, these are the other ways they could say the exact same thing. Right? So, what does the term high-riding prostate actually mean? It just pretty much means that your prostate. is farther from the anus than is normal, right? Your prostate should be pretty close to your anus. You should be able to feel a person's prostate on a G rectal exam pretty close to the anus. But if you notice that it's almost like the prostate has like started rising up in the person's body.

That's a huge problem. That's a high riding prostate. It's a lot farther from the illness than is normal. So instead of using the term high riding prostate, they may say, Oh, on digital rectal exam, the pr uh patient's prostate is observed to be like you know, more than X centimeters from the inner verge or whatever. When you see something like that That's the USMLE talk US M L E's talking about uh a high riding process.

Right. The thing is people that have a high riding prostate or scroll hematomas or whatever or blood at urethrometer. Probably tells you that. Something is out of place, right? So you don't have a straight shot to put a fully catheter You don't know where things are exactly, right? You probably want to get some kind of imaging. You don't know exactly where things are, so it's not wise to just blindly insert.

a fully catheter because you don't know where that fully catheter is going. You don't want to cause more damage. That's why for those people you do not place a fully catheter. Right? And then the next thing I want to talk about here is

Um, what if they give you a question about a patient and they tell you that oh they give you a set of vital signs. Many times when they write questions like these, they try to make them as nondescript as possible. So they give your patient, the person's blood pressure is like 190 over 110. And then you notice that the person's heart rate is like 45 beats per minute.

And then they tell you that the person's respirations are like eight breaths per minute, or you know, the person is having very shallow respirations. And then they ask which of the following is the most appropriate, next best step in managing. Well, the thing is I would really hope that you're saying you're gonna pick some answer that involves trying to lower the intracranial pressures. It involves doing what? Trying to lower their intracranial pressure.

This person has uh elevated ICP, right? So what did I just show forth with the labs that I just discussed? Well the thing I just did basically elaborated on here is uh the cushions reflex, right? So hypertension, breticardia, and irregular respirations, right? Those are signs of increased intracranial pressures. Okay. Those are signs of increased intracranial pressure. And the thing is, as we go along, uh I'm gonna talk about how to actually let's go ahead and just talk about.

Right. So how do we lower intracranial pressures? Right. So what is the fastest way actually to lower a person's IC? Well, the fastest way to lower a person's ICP is to hyperventilate, right? Hyperventilate those people, right? Now. Why am I going off in this direction? There is something useful here to know about your exams. In fact, you may notice something I'm trying to do these days with many of my partners.

I'm not just focusing on content. I'm focusing on hey, how can they test this information? How can they try to trip you up? What test taking strategy should you apply in this circumstance? The thing is, content alone is no longer enough on the USML. Being a good test taker, being a good critical thinker is something that's very, very valuable. Again, if you like the way I teach and you like the way I go over concepts, I really think you'll benefit from many of my clients.

I have a series of classes starting next week that I think you'd really benefit from. Starting from the test taking class to the biostats class to the social science class. to the last minute review, to the twenty hour class, to the Step one class taking place next month, you know, and to the fifty hour class for step two and step three taking place in June.

you're gonna benefit from it because in these classes I go over content, I go over critical reasoning and I have podcasts where I've mentioned what you're gonna get from those classes, why those classes maybe uh what you ex you should expect to get from those classes over my podcast. So just check those podcasts I'll attend. Shoot me an email through the website I can give you some more information. But let me explain something here. Let me explain something here.

The thing is, this thing I just said about ooh, if a person uh has high ICP, the quickest way to reduce their ICP is to hyperventilate. I'm sure many of you have memorized that, right? Well if you've not memorized that well, hopefully you know it now from what I just said. But the thing is the US MLEs again, like literally, again, I'm I've I've done this now, got thankfully, you know, thankful to God for many years.

Right? I can almost promise you that this is a mini onky decks. Hyperventilate, hyperventilate, hyperventilate. Right? The USMLEs, let me tell you this. They've been doing this for probably longer than you have been alive. So you know what? They also probably know that in every Anki deck known to mankind, there is the fastest way to reduce elevated ICP is by hyperventilating. Great. Okay. So what do they do these days on the exam? They will give you an answer that says endotracheal intubation.

And then in your mind, you know, if you're a person that has just memorized stuff from an Anki deck, you're just looking What am I supposed- And then you start doing all these things. You start scratching your head on the exam. I don't see hyperventilation as an answer. I don't see an answer that says to increase respiratory rate. I don't see any of those things. But you're only seeing an answer that says endotracheal intubation. Well, why do you think that that's gonna be the correct?

Because let me ask you this. How do you hyperventilate the trauma patient? How? Do you tell the person, hey, you slap the person, breathe faster, breathe harder, my friend. You slap the person, you hit their head. I I said breathe faster. No, that's not how you achieve hyperventilation. Right? The person is obtunded. The person is altered. They're not going to hyperventilate like that. No, you're gonna ram a tube down their throat.

Right, an endotracheal tube, and then you're gonna set the respiratory rate on the ventilator to the setting that you want, and then you're gonna tell them to hey, you need to hyperventilate. Right. So just something to keep in mind for exams. They may put a surrogate answer instead of putting the hyperventilation that you're looking for.

And remember when a person has high ICP besides hyperventilation there are many other things you can give, right? You can give uh monitol, right? Remember manitol is a non reabsorbable sugar. So it's gonna stay in the lumen of your GI tra I mean in the lumen of your blood vessel. Including cerebral vessels, it's going to attract water and it's going to reduce that amount of fluid, right? So just something you want to keep at the back of your mind for, for exams. All right. Now.

What if they give you an ethics situation on your test? I I don't know. For for whatever reason with emergency medicine, they love to give a bunch of ethics actually. So uh for example, they give you a question about a person that is like in a in a bad emergency. Right. You know, they're altered, they can barely respond. You know, you can't get anything out of them. Um, and then, you know, you want to do like a procedure.

And then they're asking, like, you know, consent has not been obtained. There's no advanced directive or whatever. And then they'll say, what's the next best step in management? Again, I would really hope on your exam. That you're not worried about consent. It's an emergency situation. Just jump in and save the patient, right? Don't try to delay care just because you're trying to obtain consent. Right? But obviously if the person is in a situation where they can give you consent.

You want to try to get consent. But again, if it's a situation where the patient really cannot give consent. Then honestly, just go ahead and do what you need to do as a as a physician, right? Now, be careful though, if a person has an advanced directive where they've clearly spelled out what they want to be done in an emergency situation, I will strongly, strongly, strongly encourage you.

to follow that advanced directive. Even if they can't give consent right now, if they have an advanced directive.

that has clearly spelled out that hey this is what I want to be done then you need to follow that you absolutely need to follow that all right now let me give you another kind of a weird ethic situation you may see on your ex on your exams right so what what if they give you a question about a patient that I was pretty much found trying to commit suicide, you know, and the patient, you know, stabbed themselves, you know.

You know, and the patient was found, brought to the emergency room. And the patient is conscious. The person can repeat world backwards. He can name the last seven presidents, whatever. And then the person is refusing treatment. And this is an adult. And they ask, which of the following is the most appropriate next best step in management?

Right. And then of course the USML is in their great wisdom, they will give you an answer that says to respect the patient's wishes and not treat and all those things. Let me tell you this. What are you supposed to do? Absolutely ignore that patient and treat them. Literally ignore that patient and treat them. See, this person is a suicidal patient.

The wishes of a suicidal patient, like refusing care, let's say they were stabbed and you're like, oh wait, we need to save this person's life. This person stabbed themselves or this person was trying to hang themselves and the person is lucid. The person is conscious and the person is saying, I do not want treatment. Doctor, do not treat me. Literally, let me tell you what you should do on your exam. Absolutely ignore those people and treat them.

Ignore those people and treat them. Again, you may think that wow, divine, this person is we're violating the patient's wishes. Well, this is a very good exception to that rule, right? So ignore what they're saying and just go ahead and treat them. All right. What if they give you a question about a patient, they tell you that the patient was shocked?

You know, in like gang violence gone wrong or whatever, and the person is brought to the emergency room, and the person is hypotensive, the person is tachycardic, the person is unresponsive, and they ask, What is the most appropriate next best step in managing?

Well I know many of you are probably screaming from the rooftops. Divine, penetrating injury to the abdomen. We're going to do exploratory laparotomy. That is true. You're gonna do an X Lap, right? But again, the MBMEs know that everybody knows the indications for X Lap these days. Right. And then you're looking through your answers and you see you're looking for X Lap and you don't see X LAP as an answer, you're like, Oh my goodness, you've got to be kidding me right now.

Right. So what may they put as an answer that you should kind of keep in mind? Well, the thing is I would really hope that um you're picking the answer that says to inform law enforcement, right? So obviously you're gonna fix the person's emergent situation, but whenever you suspect

Kind of a crazy situation, right? Like the person was shot, gunshot wound, right? Gunshot wound, yeah, it could be suicide, right? Gunshot, but gunshot wound could also be homicide. So maybe I've been trying to kill that person. You absolutely need to let law enforcement know, right? So if us if a suicide was attempted, law enforcement also has to know. Right? Whenever something happens under unusual circumstances and you suspect that criminal or suicidal activity

Law enforcement has to know. Law enforcement has to know. Right? But especially in the case of like homicide, like gunshot wound, you suspect a crime, you gotta let law enforcement know. Again, you may see those kinds of answers on your exam.

Right? You know, all these things about like oh ek uh again, that's the thing about the USMLEs. And again, you don't have to believe me. You can check out my free one twenty series, you can check out my free one thirty-seven series, right? You notice that many of the answers you see these days are just kind of like novel, unusual answers. It's not like they are suddenly testing things they've never tested before. What they are doing is they're just testing these same things in unusual ways.

Now, as we begin to slowly wrap up, uh, what if they give you w when you suspect head head injury of any sort? Uh, what are you supposed to do on your exams? Well, I would hope that you're getting a non-contrast head injury. of some sort, right? As your initial test, right? So remember non-conhead CTs are not just for strokes. You should also do non-conhead CTs when you suspect head injury and you're dealing with an emergency situation.

And then I guess since we're kind of talking about the head, let's just kind of wrap up with the head, right? So what are some signs of a basal score? Right? What are some signs of a fracture at the base of the skull? Well, you should think of things like raccoon eyes, right? So like they have bruising around their around their eyes, right? Like parabetal bruising, or you see blood.

In the middle ear on the eardrum, right? Hemo tympanum. Or you see like you know, you may see the term odorea, right? So you see or you know, uh where you see like CSF coming out of the ears or CSF coming out of the nose, or they have like a bruised mastoid problem. You know, sometimes this is called battle sign. Right? If you see any of these things, you're kind of worried about a basal skull fracture. For these people again, get that non-conscious.

And the thing is you may wonder, divine, why are you making such a big deal? Why are you making such a big fuss? About basal skull fractures. The thing is, if a person has a basal skull fracture, it's indicative of very severe head injury. Very, very severe head injury. This person is going to need uh brain imaging and they may need some very serious uh neurological intervention.

So I think this is a good stopping point. Let's go ahead and stop here. Uh again, I hope you found this podcast to be helpful. Again, if you're interested in any of my classes for step one to three or level one to three, shoot me an email through the website. I'll give you some more information.

And then I have these podcasts on Apple, Google and Spotify. I have a YouTube channel you can check out where I post all the podcasts that I make. Uh I mean where I post the videos that I make. And then I offer one on one tutoring for all the US MLEs, for all the Complex exams. And I help with ERS applications, mock interviews, personal statements and things things of that nature. And then I have another website called Divine Intervention Life Lessons.com. Divine Intervention Life Lessons.com.

Um I have actually more than 300 episodes on there. There is actually an Apple podcast associated with the website. It's called the Divine Intervention Life Lessons Podcast. Many of you know I'm a Christian. Many of you know I believe in God. I believe in Jesus. So every week I make like one, two, sometimes three podcasts where, from a biblical perspective, I address a life lesson. A lot of people, believe it or not.

actually listen to those podcasts and they find it to be very, very helpful. So I'll strongly encourage you to kinda check that out. So thank you for listening to me today. I will see an episode I guess five hundred and seventy three. A wonderful rest of your day. God bless you. Sleep well. Be kind to your fellow brethren and work hard. Bye for now. Thank you.