DIP Episode 572 - Quick and Dirty Emergency Medicine For The USMLEs (Part 2)

Welcome everybody, welcome to episode 572 of the Divine Intervention Podcasts. Today's podcast, we're going to be seeing some more things about emergency medicine. Again, this podcast is going to be titled Quicken Dirty, Emergency Medicine Part 2. And again, this podcast I will see for sure is for people taking step 2, step 3, level 3, a surgery shelf, an emergency medicine shelf, an internal medicine shelf actually. So just something I want to keep in mind. Alright, so let's continue from where we left off. So 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 or resuscitation are you supposed to give first on your exams? Well, I really hope you're saying that, wait, I'm going to give you fluids first, right? And typically on the USMLE's, they tend to want you to give normal saline. Again, I know some people get all around about the fine details of normal saline versus lactated ringers. Well, 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 will see the right answer like 95% of the time on your exams is going to be normal saline, right? So just in general, give normal saline, 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 are generally going to 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 giving that is going to stay within the vascular tree. Some will fail me to start going into the details of the body compartments and how water and fluids are distributed across the body. Remember, most of the body water is inside your cell and interstitial, not really in the blood vessel. So if you're giving the person about three liters of fluid, you actually may be a resuscitation like a liter of volume. You're only putting like a liter of volume within the vascular tree. If you kind of work out the math, you're going to see that that's what it kind of comes to. 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 tacky, cardiac, then you can go ahead and give blood. But typically, we're going to reserve blood for people that are still unstable, despite them getting fluids, or people that have hemoglobin that are less than seven. Remember, that's seven transition threshold. But there's a third criteria that's actually kind of high you to know for your exams.

And that's if a person is still having ongoing bleeding. So it's almost like their hemoglobin is like a moving target. So right now, the hemoglobin may be eight or nine, but they're still having like ongoing bleeding. Well, the person has like an unstable heart, right? That number of seven, don't transphose below, until 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. Right. Now, what if they give you a question about a patient and the person is like a trauma patient, comes in, you know, emergency tuition, the person's pop-able, 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 hematocrit. Let's say the hematocrit is like 18%. Remember, your hematocrit divided by three is your hemoglobin. And then they say, what's the most appropriate next best step in management? And you're like, ooh, the fine just said, give blood, but the end of the end is like not so fast. And basically, they give you a series of answers with many different blood groups. And you're like, oh, my goodness. Come on, guys, really?

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? 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 going to give all negative blood. Again, this all goes back to basic sciences. So why is all negative blood the ideal blood to give? Well, first things first, let's break that up, right? All 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 have blood group O. They are red bloods, if you're getting blood group O, right? Because you're getting this blood, right? If you're getting blood group, or 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. Could that be beneficial? Yeah, that could be beneficial because if you don't want to receive in that blood, has anti-A or anti-BNT bodies in your serum.

It's not going to matter. Why is it not going to matter? Because even if you have those antibodies, the blood group O you're receiving does not have the antigens on its surface that are attacked by those antibodies. So it's not a big deal. All right, so dealt with the O part, how about the negative part? Remember, whenever a person has blood group, and you see the words positive, the term positive or negative, it's just referring to the RH status, right? Now you are RH positive while you are RH negative, right? So if you are RH positive, right? You have the RISO Sanctigen, RHE, S U S, right? RH sus, right? So the, you don't have the RISO Sanctigen or you don't, right? So why do we use O negative blood? We use RH negative blood because again, for two reasons. Number one, again, if you are negative for the RISO Sanctigen, if you have anti-RH antibodies, you the recipient, if you have anti-RH antibodies in your serum, it's not going to matter, you know? It's not going to matter. It's not going to 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 make it anti-RH antibodies, especially if you're a woman, because what if you get pregnant in the future and your baby happens to be RH positive?

Well, if you've been sensitized because of a blood transfusion in the past and you now have anti-RH antibodies, remember, those antibodies can be IgG antibodies and they can cross the placenta and cause him, you know, hemolytic 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 they registering their minds at the classic situation that, oh, this woman is RH negative and, you know, the first pregnancy, you may not have hemolytic disease of the newborn, but from that first pregnancy, you're going to make anti-RH antibodies. And then the second pregnancy is going to 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 USML Es, you can have hemolytic disease of the newborn with a first pregnancy, because mom could have met anti-RH antibodies 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 RH positive blood in a different setting. So just be careful that first pregnancy, no problem. Second problem, pregnancy problem. No, that's, that is an overtly simplistic way to think about it, right? Trust me, the USML Es have kind of moved well, well, well beyond that. So just be kind of, kind of careful with that.

All right. What if they give you a question about a patient that 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 which of the following, which of the following will be 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 elevation and blood pressure. Like the person's blood pressure is catching up, or they can see reduction in heart rate, or they can say reduction in respiratory rate, or whatever. And then they can give you an answer that says you're in output. You want to pick the answer choice that says you're in 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 onto fluids, right? But think, just 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 would want to be letting go of extra fluid? No, right? Because you're not proficient in your GG cells. Well, you're going to make a ton of running, you know, a lot of outdoosterone and jotensin and whatnot. And outdoosterone and EDH, they make you keep fluid, right?

So if, wow, you're in a trauma situation, you're getting fluids and you're barely pee in. So the body is still like, I mean, 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 is like, hmm, 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, a place of 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 ill things about fully catheters, right? So the thing is, there are certain trauma situations where you don't place fully catheters, right? I'm sure many of you are yelling in your room, so in your cars, as you work out right now, ooh, divine, blood, I do your rhizromyritus and that's true, right? If you have blood, I do your rhizromyritus, you absolutely, positively should not do a fully catheter, right? Because if a person has blood at the rhizromyritus, it tells you that they have urythrolingery. It'll be very, very, very unwise to try to place a fully catheter in that circumstance, right? What should you do to people that have blood at the urythromyritus?

Typically, for those people, you want to do a rhizrograde, urythrograde, a retrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, urythrograde, but again, our friends at the MBM is, they are not stupid. They know that everybody that has the blood, the job description, not blood description, we're talking about blood groups here, but job description medical student, have memorized, blood at the urythromyritus, 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 sclerodohymatoma, right? You see a person's scrotum, it's a trauma situation, it looks bloody, looks positive. You see like a blood collection, 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 trauma in a acoustic stem, that the person has a high riding prostate. 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 USM Ls anymore. These days the USM Ls are very descriptive, this is one of those things I talk about quite extensively in my test taking strategies class, and in many of my classes, like people that have attended my 20 hour class, 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 see 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 see 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 digital rectal exam, pretty close to the anus. 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 anus than is normal. So instead of using the term high riding prostate, you may say, oh, on digital rectal exam, the patient's prostate is observed to be like, you know, more than X centimeters from the anoverge or whatever. When you see something like that, that's the USM Ls talking about a high riding prostate, right?

And if people that have a high riding prostate, a scrotal hematomas or whatever, or blood at your ethro meters, it probably tells you that man 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 image. 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, 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 non-descript as possible. So to give you a patient, the person's blood pressure is like one, nine, you over one ten. 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 management? Well, the thing is, I would really hope that you're saying you're going to pick some answer that involves trying to lower the intracranial pressures, involves doing what? Trying to lower their intracranial pressures.

This person has 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 the cushions reflex, right? So hypertension, pretty cardiac irregular respirations, right? Those are signs of increased intracranial pressures, okay? Those are signs of increased intracranial pressures. And the thing is, as we go along, I'm going to talk about how to, actually, let's go ahead and just talk about it right now, right? So how do we lower intracranial pressures, right? So what is the fastest way actually to lower a person's ICP? 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 podcasts. 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 strategies should you apply in this circumstance? The thing is, content alone is no longer enough on the USML Es. 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 classes. I have a series of classes starting next week that I think you'll really benefit from.

Starting from the test-taking class to the bio-stats class, to the social science class, to the last minute review, to the 20-hour class, to the step one class taking place next month, and to the 50-hour class for step two and step three taking place in June. You're going to 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 going to get from those classes. Why those classes, maybe, what you should expect to get from those classes over my podcast. Just check those podcasts, I'll tend. Should be an email through the website, I can give you some more information. Let me explain something here. Let me explain something here. The thing is, this thing I just said about, if a person has high ICP, the quickest way to reduce their ICP is to hyperventilate. I'm sure many of you have memorized that. If you've not memorized that, hopefully you know it now from what I just said. But the thing is, the USMLE is, again, literally, I've done this now, thankfully, thankful to God for many years. I can almost promise you that this is a mini-onkey decks. Hyperventilate, hyperventilate, hyperventilate. The USMLE is, 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 archedeck known to mankind, there is the fastest way to reduce elevated ICP is by hyperventilating. Great.

So what do they do these days on the exam? They'll 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 anarchy deck, you're just looking, what am I supposed to do? 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, what do you think that that's going to be the correct answer? Just let me ask you this. How do you hyperventilate a trauma patient? How? Do you tell the person, hey, you slapped the person, breathe faster, breathe harder, my friend. You slapped the person, you hit the head. I said, breathe faster. No, that's not how you achieve hyperventilation. The person is obtundate. The person is altered. They're not going to hyperventilate like that. No, you're going to ram a tube down their throats, right? An endotracheal tube. And then you're going to set the respiratory rate on the ventilator to the setting that you want. So, tell them to, hey, you need to hyperventilate, right? So, just something to keep in mind for exams. Then you 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 a monitor. Remember, a monitor is a non-reabsorbable sugar. So, it's going to stay in the lumen of your GI tract, I mean in the lumen of your blood vessels, 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 example. All right. Now, what if they give you an ethics situation on your test? I don't know, for whatever reason, with emergency medicine, they love to give a bunch of ethics actually. So, for example, they give you a question about a person that is like in a bad emergency, right? You know, they're altered, they can barely respond, you know, you can't get anything out of them. 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 not advanced directive or whatever. And then, they'll say what's the next best step in management. Again, I would really hope on you exams that you're not worried about consent. It's an emergency situation, just jump in and see 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 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 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 ethics situation, you see on your exams, right? So what if they give you a question about a patient that was pretty much found trying to commit suicide, you know, and the patient, you know, stabbed themselves, you know, and the patient was found, brought to the emergency room. And the patient is conscious. The person can repeat oral backwards. He can name the last seven presidents or 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 USM is in their great wisdom. They will give you an answer that says to respect the patients wishes and not treat and all those things. Let me tell you this. What I was supposed to do, absolutely, not that patient and treat them. Literally, you know 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 oh, wait, we need to save those persons life. This person stabbed themselves or this person was trying to hang themselves and the person is lucid. The person is conscious and present saying, I do not want treatment. Doctor do not treat me. Literally, let me tell you what you should do on your exams. Absolutely. Ignore those people and treat them. Ignore those people and treat them. Again, you may think that while divine, this person is where violating the patients wishes, well, this is a very good exception to that role, 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 shot, you know, in like gang violence, gone wrong or whatever. And persons brought to the emergency room and the person is hypotensive, the person is tachycardic, the person is owner responsive and they ask, what is the most appropriate next best step in management? 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 going to do an X-lap, right? But again, the NBM is know that everybody knows the indications for X-lap these days, right? So I think you're looking through your answers and you're looking for X-lap, I 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 you're picking the answer that says to inform law enforcement, right? So obviously, you're going to fix the person's emergency situation. But whenever you suspect a kind of a crazy situation, right? Like the person was shot, gone shot, won't. Right? Gone shot, won't yeah, it could be suicide, right? Gone shot, but gone shot, who could also be your homer's side. So maybe I've been trying to kill that person. You absolutely need to let law enforcement know, right? So if a suicide was attempted, law enforcement also has to know, right? Whenever something happens on the usual circumstances and you suspect that criminal or suicidal activity, law enforcement has to know. Right? But especially in the case of like homicide, like gone shot, won't you suspect a crime? You got a little enforcement know. Again, you may see those kinds of answers on your exams, right? You know, all these things about like, oh, again, that's the thing about the USM at least. And again, you don't have to believe me. You can check out my free 120 series. You can check out my free 137 series, right? You notice that many of the answers you see these are just kind of like novel or usual answers. It's not like they're suddenly testing things they've never tested before.

What they're doing is they're just testing these same things in unusual ways. All right. Now, as we begin to slowly wrap up, what if they give you when you suspect head injury of any sort? What are you supposed to do on your exams? Well, I would hope that you're getting a non-contrast head CT of some sort, right? As your initial test, right? So remember, non-conhead C Ts are not just for strokes. You should also do non-conhead C Ts when you suspect head injury and you're dealing with an emergency situation. And then I guess this 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 skull fracture, right? What are some signs of a fracture at the base of the skull? Well, you should think of things like racoon eyes, right? So like they have bruising around their eyes, right? Like parabotal bruising. Or you see blood in the middle ear on the ear drum, right? Himal tympanum. Or you see like, you know, you may see the term odorea, right? So you see or, you know, where you see like CSF coming out of the ears or CSF coming out of the nose. Or they have like a bruised mastoid process. You know, sometimes this is called battle sign. Right? If you see any of these stains, you're kind of worried about a basal skull fracture. For these people again, get that non-contrast head CT. 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 brain imaging and he may need some very serious neurological interventions. So I think this is a good stop in point. Let's go ahead and stop here. Again, I hope you found this podcast to be helpful. Again, if you're interested in any of my classes for a step one, two, three, olive one, two, three, shoot me an email through the website. I'll give you some more information. And then I have this podcast on Apple Google and Spotify. I have a You Tube channel. You can check out where I post all the podcast that I make. I mean, where I post the videos that I make. And then I offer one or one to learn for all the USML Es, for all the complex exams. And I help with your applications, mock interviews, personal statements and things of that nature. And then I have another website called divineinterventionlifelessens.com. Divineinterventionlifelessens.com. And 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 strongly encourage you to kind of check that out. So thank you for listening to me today. I will see you in a episode I guess 573. So have 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.

Crystalloids (e.g., Normal Saline) before blood products.

1) Patient remains unstable despite fluids, 2) Hemoglobin < 7 g/dL, and 3) Ongoing bleeding.

It lacks A/B antigens (universal donor for RB Cs) and Rh antigens (prevents sensitization).

"Raccoon eyes" (periorbital ecchymosis), otorrhea, rhinorrhea (CSF leak), or Battle sign (bruised mastoid process).

Increased urine output.

Endotracheal intubation and controlling the ventilator settings.

O negative blood.

Raccoon eyes, otorrhea (CSF from ear), rhinorrhea (CSF from nose), or Battle sign (bruised mastoid).

Blood at the urethral meatus, scrotal hematoma, or signs of pelvic/perineal injury.

Hypertension (high BP), irregular respirations, and bradycardia.

It suggests displacement or pelvic instability, making blind catheterization dangerous.

Hyperventilation (or controlled ventilation via intubation).

O negative blood.

Raccoon eyes, otorrhea (CSF from ear), rhinorrhea (CSF from nose), or Battle sign (bruised mastoid).

Blood at the urethral meatus, scrotal hematoma, or signs of pelvic/perineal injury.

Hypertension (high BP), irregular respirations, and bradycardia.

It suggests displacement or pelvic instability, making blind catheterization dangerous.

Hyperventilation (or controlled ventilation via intubation).