DIP Episode 268 - USMLE Nov 2020 Changes Series 4: Palliative Care 2

Okay, welcome. My name is Divine. This is episode 268 of the Divine intervention podcast. And in this podcast, I'll be continuing the Clean SP curriculum for the US Emily Step 2 CK exam. And also Step 3. I mean, basically, I'm sure many of you are well aware that there are changes coming down to the US Emily exams starting November 11th. And I essentially plan to cover all those new topics according to the US Emily content outline. So for me, three of those, I call it the Clean SP curriculum. Right? So Clean SP, there's Clean SP 1, there's Clean SP 2, and there's Clean SP 3. So I would highly encourage you to consider looking through those podcasts, especially if you're going to be taking the exam right around, you know, after November 11th. Although I won't be surprised if the US Emily has already studied testing a lot of this information. Right? And the thing about the Clean SP right? So if you want to know exactly which episode is what? Right? So episode 228, right? It's Clean SP 1, episode 230, it's Clean SP 2, episode 234, it's Clean SP 3. So episode 268 is Clean SP 4. Again, it's almost there are some things I've mentioned before that I'm going to be mentioning here. But I just wanted to kind of put it all together in one podcast and just read or read and, you know, probably better explain certain things. So basically this podcast is going to be focused on palliative care.

And as a reminder, if you're taking step to CK anytime soon, I'm offering an MBME test, taking strategies class is also very useful for step three. I'm offering that this Friday from 2 to 4 3 PM Pacific Standard Time via Zoom. And then I have a 10 hour step to CK class taking place this Saturday the seventh of October from we're going to go from 6 to 10 PM Pacific Standard Time. And then we'll take a tour break and then from noon to 4 PM Pacific Standard Time, we'll take a tour break and then from 6 to 8 PM Pacific Standard Time. Right? And then we'll be done and we'll pretty much go over about 800 concepts across like internal medicine, peds, surgery, all beguine, neurons, like. So if you're interested in that, just hit the contact button on the website, shoot me an email and I'll point you out in the right direction. Okay, so let's get right into it. Right? So we're going to be talking again, like I said, about palliative care. Again, I've kind of studied that topic in episode 2, 2, 28. That's the first clean SP podcast. Remember the second one is episode 230, third one is episode 234. But here in episode 268, again, I'm going to be seeing some more things about a palliative care because again, I want to be as complete as possible with these. And again, any bit of repetition also helps. Right? So palliative care. Right? So again, what is palliative care? So palliative care is basically something you do to people that are very ill. Right? So these people are seriously ill.

And the thing is when you're trying to administer palliative care, you're not just doing it for the well-being of the patient. You're actually doing it for the well-being of their families as well. Right? And the thing is one misconception about palliative care that again your friends at the end of the day, you'll care that you know is that palliative care is not something you do. I'm doing it just because the person is sick or I think this person is going to die kind of deal. No, you cannot really do palliative care at any stage in a person's illness. Right? And even if the person is currently being treated with the goal that all this person is going to be cured, it doesn't matter. Right? So palliative care is still an ideal thing in those people. Right? In fact, that's why there is palliative care fellowships in this day and age. Right? And really there is no age you have to hit to be eligible for palliative care, even in the pediatric population. They can be palliative care in the pediatric population. Right? Now, let's talk about some palliative care documents that again are commonly tested on exams. Right? So the thing is before I get to move forward, you won't get into those documents because this is kind of like a nice segue. Right? Before you start giving the person documents and telling them to fill out one form or the other, right? What are you typically supposed to do?

Typically, what you're supposed to do first is to try to figure out what are these patient's values? What are these patients preferences? Right? So like what does this patient want essentially? Right? And then once you figure those things out, once the patient communicates those things to you, you can then begin to try out these different documents. So have them fill out these different documents. The first big document you want to keep at the back of your mind for these US Emily exams is a living well. Right? So remember a living well, basically it's a patient that pretty more directs that. Right? So the living well, the patient says, okay, they will talk about like the extent to which you know they're looking for like life-sostaining treatment. Right? And especially if they become like, you know, like very ill or they're going to like a vegetative state. Right? Essentially, it's basically like the patient spelling out these are the life-saving measures that should be done or these are the life-saving measures I do not want been done when I'm in a state where I am incapacitated and unable to make decisions. Right? So that's a living well. And I'll try to make some clear distinction between living wells and other stuff that I'm going to be talking about. Right? And then a durable healthcare power of attorney, right? It's basically a legal document where you essentially designate someone, right? And that person that you designate, right?

Is going to be the one making healthcare decisions for you. Right? And one critical difference I will say from the get go between a living well and a durable healthcare power of attorney is basically a living well essentially focuses on all interventions that either in the past or in the past. But in like deal with like withholding care or we're drawing like, you know, like life-sostating interventions. Right? But the thing is people that have that durable healthcare power of attorney, they actually have a lot more power. Right? They have a lot more power. Like they have like much broader scopes in the kinds of decisions that that you can make. Right? And then one other thing you may see and this is something that you can make an ICU question on your exam. They can bring, they can talk about a person that has COVID or something like that. Right? And then they will tell you about like, or like a physician, like trying to like create other sets, you know, the physician basically like talk things over the patient, like, or like others where like, oh, okay, what should we do for in this situation? What should we do in that situation? But blah blah blah blah blah. Like, oh, you know, you came in with COVID, you're having worse things in symptoms. What do you like us to do if XYZ were to happen? Right? When a physician is basically going over those other sets with a patient or the healthcare power of attorney, that's actually something that is known as a post. Right?

So they are called it basically like post POLST means like physician orders, right? For life-sostating care. Sorry for life-sostating treatment. Right? So, uh, a post is basically it like it deals with how the patient is currently doing right now, not like some hypothetical situation in the future. And then you're like, oh, based on your health, based on your COVID-19 status, your declining oxygen requirements, let's go over some other sets as to what should be done and what should not be done. Right? But a living will on the other hand tends to focus more like future situations that are hypothetical that may not even happen, right? But again, a post form is based on, oh, this is exactly how this person is feeling right here right now, right? So again, the big thing you just want to keep in mind is you're doing all these advanced care planning just again in case the patient becomes incapacitated so that you can make decisions that are consistent with their values and their preferences. And if a patient has living, this is a classic USMD question, right? So if a patient has written a living will or has a durable health care power attorney, right? Or has fit or has gone over like a post form with a physician, but the patient is still lucid, right? And the patient is still able to make their own decisions. The patient's own decisions supersede all this other stuff. So, supersedes the post, supersedes the durable health care power attorney, supersedes the living will. Okay?

It's just one of those key critical things you want to keep at the back of your mind on exams, right? And then when a person is going through a palliative care, right? There are some key classic symptoms you want to be able to manage, right? So, if for example, a person is going through, you know, like these are like classic end of life things essentially, right? Like for a person is going through a lot of pain, right? One thing you want to keep in mind is, especially again, for a person who's like terminal illness or whatever, there is actually something that has been released by the WHO, again, that because I'm sure you've seen some of these NVME questions with, you talk about like the dash diet, like just like some interventions that are like going with like some organization or something like that. Like some of those alcohol screening tools or some depression screening tools that he tests on exams, you want to know that in palliative care, right? One thing that's commonly used, especially on the USML, is to screen to basically manage a person's pain in palliative care, right? So, the WHO is the three step analgesic ladder, right? So, it's from the WHO, it's called the three step analgesic ladder. Basically, it's like a pain scale, right? Like you're basically reading pain from mild, being like a pain score of like one to three moderate, which is like a pain score of like four to six, right? And then severe pain, which is scores from like seven to ten, right?

So, just start from one to three, four to six, seven to ten, right? And basically, if a person has mild pain, from this WHO analgesic ladder, for the most part of those people, you just give them like a pain reliever, that is not opioid-based, right? So, something like a set of menophan or you can give an answer, you can give us spring stuff like that, right? But then if a person has moderate pain, right, then you need to begin to use opioids, right? Basically, you start opioids from moderate pain, and you do that on a, you know, like a small dose, right? But if a person is having like very severe pain, right? In general, you then need to go with really big doses of opioids, you need to combine multiple opioids to try to control those people's pain. And one thing I want you to just keep at the back of your mind is that when a person has metastatic disease, right? It's a classic in being a scenario, metastatic disease, really severe pain, really severe symptoms. If their opioids are not coordinated for pain, either increase the dose, right? At least I traded till they don't have like side effects from the opioid, right? Or increase the frequency, right? That's a very important key point to know. You can increase the frequency of the opioids that they're getting, right? And then there are some weird specific scenarios that the endgones want you to keep in mind with regards to like some specific diseases and how you trade the pain associated with them, right?

So say for example, a person has like metastatic disease, right? To like the bone, and they're getting like a lot of fractures from those bone meds, right? To help those people with pain, sometimes the endgones will give you a question and you won't put opioids or anything. For those people, actually giving this phosphonids, giving calcium tonin is actually the ideal in those circumstances, right? So you can give this phosphonids, you can give calcium tonin, works pretty well in those circumstances, right? Or let's see the tell you about a person that you know has like malignancy that has metastaticized to the bowel, right? Or primary bowel malignancy like colon cancer that's obstructing the bowel or stomach cancer that's obstructing the stomach, right? Or sometimes you know melanomas love to metastaticized to the small bowel as well, right? Like if a person has like malignancy that's like basically obstructing the GI tract, right? For those people, actually giving an anti-colonidic agent, right? Can actually help, right? Like a classic one you miss your exams is glycopyralid. Like opyralid is a most grainy receptor antagonist, right? So you can use that to your benefits to help with the pain associated with a person having like a bowel malignancy, although one thing you'd have to be careful with that is that can also mess up the person's GI mortality and cause a lot of problems, right? Almost in a sense those things are making your bowel not work.

If your bowel is not contracting, then you will not be contracting against that resistance, which is the obstruction from the malignancy, right? And then remember if a person has like neuropathic pain again from met, again can give them like an agent, right? That can help with neuropathic pain like gubapentin, you can give a pregabaline stuff like that, right? If a person has pain, right, from a tumor that is in feel treating like nerves, right? Or compressing the spinal cord steroids can help with pain in those circumstances, right? Like so say for example a person has malignancy that's like, let's say like it's a lung cancer and it's causing severe pain, right? Or let's say it's like a pancus tumor that is beginning to infiltrate the brachial plexus and then they're trying to treat those people for like their pain. The drug of choice in that circumstance will be a steroid, right? Stereoid really help in those circumstances, right? So without repain as one of these end-of-life symptoms that people can have, right? And then with regards to just being short of breath, right? Remember when people have cancer, I mean like these one of those things about the ICU, the ICU can be, I mean I've worked in the ICU and I absolutely enjoy working in the ICU. It's a fun place to work in. But I'll say you know the ICU is also mentally and emotionally draining. I'll tell you that right now.

When you see people at the point of death, you know, when you're like holding them in your arms, you know, for the last breath, they have very short of breath. They're like, they're literally just gasping for life, right? When a person has sharpness of breath, right? Or again, the 5 word for that will be this me, right? The asserting things you can do, right? First things first, the drug of choice is going to be an opioid, right? Opioids are the drugs of choice for treating this me in a person that has a, that has a malignancy, right? And I mean you may say, okay, define like why do opioids help? Well, the thing is opioids, especially more thin. If they give you multiple opioids on your exam to pick for this me, pick more thin as the first one you'd want to go with, right? And one of the reasons that opioids help, actually there's a few mechanistic reasons. The thing is opioids, right? They kind of depress the person's respiration in a sense, right? So your oxygen consumption is not as great when a person is on opioids, right? So, you know, if you're short of breath, it means you're gasping for oxygen. Well, if you decrease the person's need for oxygen, then they may not be gasping for it as much anymore, right? And then another thing is opioids, they actually also dilate your pulmonary vessels, right? So because they're very good at dilating your pulmonary vessels, right? Again, they can basically increase the person's oxygen delivery around the body in a sense, right?

And then remember, when a person is hypoxic, again, the body responds by hyperventilating, right? Like a represents seal to begin to build up, right? Or they become superhypoxic, the auto-goose down, they begin to hyperventilate. Opioids basically numb that response, right? So they may be not as hyper responsive to like hypoxia or hypercapnia, right? So those are the reasons, those are the mechanistic reasons behind why opioids help in a person that has a dismal internal disease, right? And again, they can give you some very, very weird specific scenarios on your exam, right? Like for example, if a person has like a lung cancer that is obstructing the earway, right? Like obstructing like a bronchus or something, right? If they are asking you for ways to treat your dysmiac, you want to go ahead and pick the answer choice that says to stench those people's earways, right? To stench those people's earways. They basically insert a stench, right? Essentially like widening out the earways so that those people can breathe better, right? So let's say for example, a person has like a somk like a malignancy, especially lung cancer, misothelium, right? That's building up like a big-time plural of fusion. For those people who want to go ahead and perform a thoracent thesis, right? You want to perform a thoracent thesis so that you can again consistently drain that malignan fluid that's building up. You usually like insert some kind of catheter so that again, they can consistently drain.

Another classic scenario we're seeing you examine with that regard is what is a stencode? If a person has like pancreatic cancer and that pancreatic cancer is, you know, it's like increasing the pancreatic ducts. And those people are having like very severe pain. Again, you can stench those people's pancreatic ducts. It actually helps with the pain. It actually helps with the itching. It just helps it. It doesn't improve life. I mean, it doesn't like improve survival, but it actually helps those people's quality of life, right? So that's how you deal with a dysmiac, right? You deal with shortness of breath. Now, in terms of nausea, right? So if a person is nauseous, right? Usually these are people that are on the wing chemotherapy. A nausea for the most part is a bunch of things you can use. I mean, the big one is on dancer truck, right? You can use on dancer truck. It's a serotonin receptor antagonist, right? Because remember, there's a lot of serotonin receptors in the chemoreceptor trigger zone, right? That can cause a lot of problems, right? So if you block those serotonin receptors, right? Then you can essentially help with nausea. It's like the drug of choice. Also, if you don't see that, right, don't forget the other drugs like the other drugs like metoclopromide, right? Metoclopromide actually, you know, it's a double-merit receptor antagonist, right? But it's also, it's a very good prokinetic agent.

But one other thing you want to keep at the back of your mind is that again, it's very good for nausea, right? In the setting of a, like terminal disease, in the setting of a malignancy. And don't forget though, because metoclopromide blocks dopamine receptors, your friends at the endemic can be very good and prudent, and essentially making it a psych question, right? So you can talk about a person that is in palliative care, right? And the person is getting a drug for nausea and vomiting, right? And then they tell you that this person, you know, develops like a leukocyteosis, develops a very high fever, develops muscle rigidity. If you see that, I would really hope that you're thinking about like neuroleptic malignant syndrome, right? And remember for that, those people you want to go ahead and give them denture, right? Denture is the drug of choice for neuroleptic malignant syndrome. Remember, denture is a ryanodine receptor antagonist, right? So by blocking those ryanodine receptors, it's essentially a calcium channel blocker, because the ryanodine receptor is a calcium channel, right? So it's a calcium channel blocker, and by blocking those calcium channels, I'll prevent you from releasing that calcium, right, from the sacroplasmic reticulum of the muscle, so that that can kind of dumb down that muscle contraction, right? And remember, you know, friends at the end of the evening, just like the classic brilliant way, the test of these complications of disease, right?

They can ask you which of the following is the most likely ryanocomplication, right? Or the most adverse ryanocomplication of neuroleptic malignant syndrome. In that case, they are going after a neuromyelosis, right? Because all that muscle breakdown, that myoglobin will go and touch the presence kidneys, cause an intra-inocular acute kidney injury, cause an acute tuberculosis, right? And that will cause a lot of problems, right? And remember, when a person has an eat, a rapdo, right? Remember, you'll have, you'll see a lot of blood by your analysis, right? But you won't see, you'll have almost no red blood cells by urine microscopy. And again, as I've said, in many podcasts, they're not going to test this by saying, or your analysis shows a lot of blood, but urine microscopy shows no red blood cells, right? That's ridiculous. Again, this is one of the reasons why flashcards, I know it, I know it, I'm not always the most helpful things, for example, right? You can memorize all the buzzwords you want. It's not really going to help you on these, you're an immune example. You actually need to understand, like, what in the world do these buzzwords mean, right? So, like the classic thing the immune you're doing is, they'll give you your analysis results, and then they'll put like blood, four plus, right? And then they'll put red blood cells, 0 to 2 per high power field, or 0 to 1 per high power field. That makes no sense, right?

That's like, that's almost like the albuminous cytologic dissociation of the urine, right? I'll explain what I mean, I know, so maybe like, what is the brain talking about, just hang on, right? So, because if you're seeing four plus blood, you should be seeing like tens and hundreds of red blood cells by hyperarfield, right? But if you're seeing like four plus blood, and you're seeing only like 0 to 2, 0 to 3 red blood cells per high power field, that makes absolutely no sense, right? So, there's almost a dissociation between the amount of blood you're seeing, and the actual amount of red blood cells you're seeing, right? That's what you find in rapdo my analysis, right? So, remember, albuminous cytologic dissociation is a famous CSF finding in a person that has a geometry syndrome, right? The thing is, that albuminous, remember albuminous protein in the body, right? And then cytologic means cells. Whenever you see very high protein in a person's CSF, you should see a ton of white blood cells, right? So, unless you're seeing a ton of protein, you should be able to see like, oh, like, 30, 50 or 100 white blood cells per hyperarfield, but if you're seeing a ton of protein, right? And then you're seeing like, wow, like 0 to 2 white blood cells per hyperarfield. Again, that makes no sense, right? That makes no sense. Whenever you see stuff like that, right? You absolutely want to think about the embryo syndrome, right?

So, a similar dissociation happens in a person that has rapdo my analysis, but it's more of a urinary finding. And the dissociation is between the amount of blood you're seeing by your analysis, and the amount of red blood cells you're seeing by urine, my crustopoe. And then you'll be like, why is the brain spinning two or three minutes talking about this stuff? I've seen this on the example. Personally, and this was an example a lot, that you want to make sure you know these things, right? So, we've talked about a dancer tron, a serotonin receptor antagonist. We've talked about a dopamine receptor antagonist, right? And also, don't forget this drug, aprypetent. So, it's spelled as APR, E, P-I-T-E-N-T, right? Aprypetent is basically like an antagonist at receptors called neurocainin receptors, right? It's actually a pretty powerful anti-nosemetication. Again, it's one of these things that we see in a positive-care question on the example. So, again, don't forget your dancer tron, don't forget your metopropamide, and don't forget aprypetent, right? Just remember the term Oma, Oma, like a maltoma, right? Just remember this as an Oma, right? So, O4 on dancer tron, and notice all these things are antagonists, right? So, on dancer tron antagonists, that's their 20 receptors, metopropamide antagonists, that dopamine receptors aprypetent antagonists at neurocainin 1, N-K-1 receptors. It's an N-K-1 receptor antagonist, okay?

And then, again, if a person has nausea because, again, they have like a bowel malignancy that's causing an obstruction or whatever, you can actually give those people steroids, right? Because, again, the big thing with steroids, maybe like divine, why are we giving steroids for these people? Stereots are amazing, they're cutting down on adema, right? And when they cut down on adema, they'll relieve obstruction, right? They'll relieve obstruction, right? We basically almost like cools down the tumor in a bit, right? So, that all that adema does not keep causing bowel obstruction, right? And then, remember, a person that also has malignancy because they're taking so many, like if the person has malignancy paying, those people tend to be taking autonocopyloids, right? Those opioids can cause a lot of constipation, right? So, constipation is another classic thing they find in a person that in a palliative care question on an N-B, they say, right? So, basically, those people have like a decrease in frequency of their stool, right? So, how can we help these people? The thing is, if you're trying to, let me tell you this, there is such a thing as prophylaxis against constipation, and there is such a thing as treatment for constipation, right? I know you may be like, divine wise, divine making a big deal about these salient differences. I promise you, I will not be making these salient difference discussions if it was not high yield to know, right?

So, this is actually one of those places where you actually want to kind of pay attention, right? That you want to pay attention here. So, the thing is, if you're trying to prophylax against constipation, the classic agent you want to use on an N-B exam is to give like a laxative that's like a stimuli, right? Like sena, right? Sena is SEWNA, right? You can use that as prophylaxis, you can use that as prevention, right? So, even clinically, when you're studying a person on an opioid, it probably makes sense to just put them on a smidge of sena, right? Now, after a person actually has constipation, well, what can we use to treat those people, right? Well, one thing we can do is, we can give people like agents that can make their stool like bulky, right? Like, for example, you can give like methyl cellulose, you can give salient, salient means PSY, WLIUM, right? But again, remember, you need to be taking a ton of fluid for these bulky agents to work, right? If you're not taking a lot of fluid, if your stool is bulky but hard, that's not very helpful, right? So, your stool needs to be bulky and be able to pass, right? And then another thing is you can also use polyethylene glycol, right? So, remember, polyethylene glycol is not reabsorbable in the GI tract, right? So, it's very good at, you know, taking fluid in, right? And then you'll poop out, right? And then don't forget lactulose, right? So, lactulose is not just used on NV Me exams for hepatic and cephalopathy, right?

With those hyperamonymia, lactulose also helps in many, many other ways, right? You can actually use it for treatment of constipation, right? Those people will go to the bathroom like a lot, right? This is one of the joys of treating people that have an end-stage liver disease, right? So, you give those people lactulose right? Again, lactulose is a sugar, it's not digestible, right? But first thing is first is very osmotic, right? So, it attracts a lot of water, right? And then the second thing is it also promotes the growth of microbes in your GI tract, right? Whenever people have a stomach bug, right? Stomach bugs cause problems, right? Many times when a person has gastroenteritis, they're going to have diarrhea with it, right? So, basically that lactulose is almost like you're organising things given, right? For bugs in the person's GI tract. As you organise that things given, they're going to have a wonderful time, right? They're going to eat it, eat it, but you're going to be fed or essentially to the bathroom at that point, right? And then, one of the drugs you may see on exams is this drug known as methyl maltrexyl. It's actually a drug that is now being used actually to treat like, if a person is on opioids, right? And they have like really bad constipation, you can use methyl maltrexyl. Methyl maltrexyl, as you should be able to tell from the name, is a, is a, is a, it's an op, is a mu receptor antagonist, right?

So, it's basically reversing the effects of those opioids, right? So, it's, you know, pretty helpful in those circumstances. Now, one thing I'll just go ahead and say is, if a person is, these drugs, right? That cause, that help your GI tract to go. I want to remember that if a person has like a high grade bowel obstruction, you don't want to put a person on these drugs, right? Because, again, you can induce like a peritonitis, you can use like a rupture of the presence of the presence of a peritoneal cavity or something, right? So, just be careful, right? They can give, they can throw that in as a small wrinkle to try to see if, if you, you fall for that bit, right? So, want to be careful with that. Usually when people have like a high grade obstruction, right? But you need the a bowel to go. Then one thing you can do is you can begin to use mechanical means, right? Like if it's a small bowel obstruction, you can consider doing stuff like, like an angitube, right? Connected to all suction. If it's a large bowel obstruction, right? Like something you may find in a person that has like a, like a sigmoid volvulus or something like that, right? You can basically do like a sigmoidoscopy, place a recto tube, right? And attach it to the wall, right? You're literally like suction, suctioning those people's a large bowel, right? Just something to keep out the back of your mind on exams, right?

Now, another classic symptom you may see in palliative care is a person just being anorexic, right? And cakecake, right? So, this person is essentially not eating, right? So, basically for these people, you know, they're losing a lot of skeletal muscle mass, right? And give them all the nutritional support you want. Those people are not really dealing with those nutrients. For the most part, the two big things that cause those problems. One is TNF alpha, right? TNF alpha is a pro-inflammatory cytokine, right? They can cause all those problems, right? But also, those people, as people get towards the end of life, they begin to have like abnormal metabolism of like energy products, right? So, those are the things that ultimately give rise to a person being like cakecake and anorexic. So, the thing is if a person is anorexic, again, if you want to treat those people, right? Typically on in-beaming exams, you want to go ahead and, again, people that, again, end of life care, right? You want to consider giving those people, especially for those people who are in the same state, especially from cancer, right? You want to give them a progestian analog, right? Again, you can give them something like majestral. You can even give them like mejoxy progesterone, right? You can give them mejoxy progesterone.

I mean, some of you may wonder why those birth control caused people to, in some cases, caused people to gain weight, is because those things are very powerful stimulants of a person's appetite, right? And again, if you don't see those things on exams, you can also give just straight-up steroids. So, there's a pretty good for those indications, right? And then don't forget a dronabino. Dronabino is a synthetic marijuana, basically, right? It's a synthetic cannabinoid. It can help in those circumstances, right? And then the final thing I think I would mention here is, the final thing I think I want to mention here is, I guess, hospice, right? Hospice, the big thing I want to know about hospice is, if a person's life expectancy is less than six months, right? And those people should be placed in hospice. And you can do hospice at home, you can do hospice in the hospice, I mean, in a nursing facility or whatever. Basically, you can do hospice where the patient lives, in general, right? It's not a big deal, right? And remember, on like palliative care, where you can be getting palliative care, and the goal is that, like, you know, a person can be getting palliative care if they're about to die, but a person can also be getting palliative care, if they are being treated with the goal of care, right? Palliative care doesn't mean, oh, we're giving you this because you're going to die. You get palliative care because you have a serious illness. That's actually high old to know.

The thing that makes you eligible for palliative care is seriously illness, right? If you have a cough and a cold, you probably should not be getting palliative care as a result of that, right? So, but hospice, the goal is not care, right? You just want to make the person comfortable, right? So essentially, before a person checks into hospice, they need to essentially say, they need to essentially agree to only getting treatments that focuses on those people on managing their symptoms, right? You're not trying to cure, you're not trying to improve survival or anything. No, you're just trying to manage their symptoms and again, make them as comfortable as possible, right? Now, so that's pretty much the end of what I want to discuss today. The big thing I would just say is, please subscribe to the You Tube channel, Divine Intervention, USMD, Podcasts, and Videos, and again, they need a little bit of support helps. And then, if you can, these podcasts, at least the most recent 150, are an Apple podcast on Spotify or on Google Play. Please subscribe to those, although I think Google Play is not Google Podcasts, right? So please subscribe. If you're looking for all the earlier podcasts from like episode one, then you'd have to go on the website, divininterventionpodcast.com, together with those.

And actually, if you subscribe to the podcast website, again, divininterventionpodcast.com, when you get a, when I make a new podcast, you will get an email notification, which is kind of nice, right? I would love to put all the podcasts on these podcast apps, but it's a Word Press role. You can look it up. You basically cannot put more than the most recent 150 podcasts, right? So basically, when I upload this podcast, then one, the oldest 150, one fifth year podcast will then get off of these podcast apps, right? So again, sadly, right? That's kind of like the case with Word Press these days. It's just a Word Press role, so not much I can do there. And then I want to talk about a life lesson today, right? And my life lesson for today is on the importance of being a spreader of good news, okay? The importance of being a spreader of good news, right? The importance of being a spreader of good news. And actually, before I see that, again, if you need help with your ERAS application or an interview prep or your personal statements, reach out to me again, again, as well. I can give you some more information on pricing. So be a spreader of good news. So what do I mean by be a spreader of good news? Let me give you a, again, I know most of the people that listen to this podcast, right? Medical students or physicians and stuff like that, right? So what I mean by be a spreader of good news, give you an example, right? You see people post on Reddit. I just walked out of the exam.

I feel like I failed. I feel like I was guessing on every question. Blah, blah, blah, blah. Is the way you're feeling wrong? No, it's not. It's really not, right? It's really not. But are you doing people good by posting those things? I will argue that you're not, right? I will really argue that you're not. And the thing is when you post those kinds of things, people that are preparing for the exam are about to take it, they essentially kill their spirits when you post those kinds of things, right? That is why after you've taken these exams, keep a calm spirit. Sometimes it may even mean not talking to... I mean, you should, you can talk to like a close friend, a close confidante, right? But kind of posting these things online just really, really touches some people's minds, right? And the thing I always like saying is that mental health and wellness is a collective effort, right? It's a collective effort. I mean, personally, I believe that many people in Med School administration don't do enough. They actually do a pretty crappy job, right? Like these wellness lectures, like a lecture is going to make someone mentally well all of a sudden. Those things really don't help, right? But if, whoever at the top, as those people are still trying to figure out things, right? When I'm home, we can collectively try to ensure the wellness of our colleagues, of our friends, right? So again, I will encourage you, like, stop spreading that information.

I know you feel terrible, but maybe speak to someone about it instead of just posting it online. Again, this is one of the reasons why I tell people, when you're studying for these exams, just still have read it, and still for what is it called? SDN, right? Because again, I'm not seeing this to be trashed those websites. I look, I'm a big time-rated person. I'm a big time SDN person. I use both things extensively. So I'm encouraging you to use those things, right? But maybe use the parts of those websites that don't deal with exams, or like people's test experiences, when you are just finished a test or you're studying for a test. One other thing you can do, which is, again, my preferred approach, is months before you know you're going to be taking you exam, you can copy experiences and put in a word document, positive experiences of people like, oh, the test wasn't that bad, you know, I did XYZ, I got a 270 blah blah blah, right? And then whenever you're filling down, whenever you're feeling scared, go and read those positive experiences. Because again, like all this just spreading bad news, just really freaks yourself out one. And it also freaks other people out too, right? And you can disturb their mental wellness, right? I mean, again, I'm not going to mention any specific news channels, right? But these days, I almost never watch the news. You know why? Because you see some TV stations and they'll be putting like COVID-19 data, like it's like 24-7 on your screen, right?

Whenever you're seeing that COVID-19 data, your heart cannot feel right after being exposed to that kind of information, right? So again, I'm just saying this on your own, this is almost like a tick responsibility kind of a life lesson. But if you're feeling bad, speak to somebody, but don't spread it online or in a public forum, where you can really crush a person, right? Again, here's one way you want to be careful here. I'm not saying you cannot see things in public forums, right? Again, please hear me out because again, I know this may be a sticking point for some people, right? Like, oh, should I not share my bad experiences online?

No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no But just by not posting those kinds of like, oh, scary, scary, scary, scary, right? You're helping out your fellow money, right?

That's one of those reforms that will think that met students. These are things that we can easily execute ourselves, right? So just something to keep in mind, right? Like, there's like a classic biblical example of this, like, there's like the widow of Zarafaf. The widow of Zarafafaf, if I'm not mistaken, again, sorry, I'm giving this off the cuff, right? But this woman has some literally had just died. Literally had just died, right? And she walked outside of her home and she was telling, she, someone asked her like, oh, what is going on? And she said, it is well, right? Imagine, a person just suffering the loss of your own child, and you're literally using the term, it is well, when people are asking you how things are doing, right? That woman, what she was trying to do in that circumstance was she was trying to not be a spreader of bad news, because again, spreading bad news is just generally not a good thing, right? Because again, it crushes the soul and the spirit of the other people that hear it, right? So like, again, I also like to give that example of, again, the Israelite, right? As the sent spice to go spy on Kinen before they went into the land of Kinen. What is the thing that happened? Right? Some of those fights came and just polluted the minds of the Israelite, right? By just seeing things that freaked them out that, oh, we felt like grasshoppers blah, blah, blah, blah, blah, blah. So again, I'm not saying you cannot spread news, right?

But just maybe think about the news you're spreading before you spread it, right? Make sure that the words you're spreading are like the words you spread are helpful, right? So again, I'm not saying you cannot post exam experiences, but again, that's why again, I was very, I'm being very specific, right? Because again, I don't want people to quote me out of context, right? But posting experiences that, oh, I feel like I guess on every single question, again, I'm not saying that's not something you should share, but maybe sharing it in a smaller space than sharing in a bigger space that wouldn't freak out people and disturb your mental health, right? Again, look out for your fellow men. Again, in this world, we're not quoting this word to, oh, like, oh, look out for ourselves only, right? You should also look out for your neighbors, right? Look out for your neighbors because if everyone looked out for their neighbor, right? I feel like the suicide rates in this country and in the world who go down, especially amongst healthcare professionals, right? So let's not eat our own young. Let's look out for our own, right? Because again, if we don't look out for our own, as you've seen, many of the powers that being healthcare don't necessarily look out for the best of each and every one of us, right? So let's look out for our own, right? So again, hopefully this makes sense. Again, I know you may not agree with some of what I'm saying. And again, I'm sorry, right?

But I think it's the point that needs to be made because I feel like that's actually one big contributor to like stress and on wellness among medical students and a lot of healthcare professionals. So thank you for listening to this podcast. I'll see you in the next one. God bless you. Thank you.

To improve the quality of life for seriously ill patients and their families, regardless of the stage of illness.

POLST (Physician Orders for Life-Sustaining Treatment).

The patient's own current, expressed decision.

Non-opioid analgesics (e.g., acetaminophen). Opioids are reserved for moderate to severe pain.

Bisphosphonates or Calcium Tonin.

5-HT3 antagonists (e.g., Ondansetron).

Dantrolene (a ryanodine receptor antagonist).

Any stage of illness; it is not limited to end-of-life or terminal prognosis.

Durable Healthcare Power of Attorney (DHCPA).

They decrease oxygen consumption and dilate pulmonary vessels, reducing the body's hyperventilatory response to hypoxia.

Stimulant laxatives (e.g., Senna).

High protein on dipstick but low red blood cell count microscopically.

Lactulose; it is a non-digestible sugar that is highly osmotic, attracting water and promoting gut flora growth.

5-HT3 receptor antagonist (or NK-1 receptor antagonist); it blocks the Neurokinin-1 receptor.

Any stage of illness; it is not limited to end-of-life or terminal prognosis.

Durable Healthcare Power of Attorney (DHCPA).

They decrease oxygen consumption and dilate pulmonary vessels, reducing the body's hyperventilatory response to hypoxia.

Stimulant laxatives (e.g., Senna).

High protein on dipstick but low red blood cell count microscopically.

Lactulose; it is a non-digestible sugar that is highly osmotic, attracting water and promoting gut flora growth.

5-HT3 receptor antagonist (or NK-1 receptor antagonist); it blocks the Neurokinin-1 receptor.