Tuesday, December 6, 2011

Let's Boil Some Water and Make Coffee. . .II

“Let’s Boil Some Water and Make Coffee. . .”
(script for podcast I)
Hallelujah. . .
Good morning from Ranger Camp where all the Rangers are working hard and preparing for a decisive Victory over Boards—Written, Oral, Pain, and MOCA Boards. 
The top Ranger T-shirt today is easy to read as we begin our daily Ranger Run, a quote from Edward Anderson, a contactor who worked at the White House when President Truman lived there.  Truman was doing a personal inspection of work completed when he happened upon these lines.  For a President then fatigued by a very unpopular war in Korea, a bad economy, a myriad of problems, the prospect of returning home to his simple roots enticing.  This President was ready to go home.  Here the lines which spoke most to him, it’s Recitation #9 in Little fRed:  Recitations, Pearls, Perils, and Passages for Working
Harder and Smarter to Pass Boards:
"Every man's a would be sportsman, in the dreams of his intent,
A potential out-of-doors man when his thoughts are pleasure bent.
But he mostly puts the idea off, for the things that must be done,
And doesn't get his outing till his outing days are gone.
So in hurry, scurry, worry, work, his living days are spent,
And he does his final camping in a low green tent."  (Reuben Anderson)

Ranger Run here for Podcast. . .
I’d like to thank the nice people from Documentary recordings who have kindly given us permission to use brief snippets of our Ranger Runs.  The complete set can be found at their website, documentary recordings.com. 
Let’s now to an important Lock’nLoad topic of interest to passing Boards.  These topics are relevant for all Boards—Written, Oral, Pain, and MOCA as these are the selected topics the Board has identified which more than 50% miss on the primary Written examination.  The Boards wants us to shore up in these areas and sends these 10-12 topics each year to training programs.  They are not answered, I’ll do that here, they are sometimes distributed merely as statements by training programs, but often nothing much comes of them at all.  Then they appear again. . . and again. . . and again.  So topics missed by more than 50% become strike-out pitches.  Our job is to get our bats off our shoulders, see them early, and hit them hard.  In this way, these are not nightmare unhittable strike-out pitches, missed by more than 50%, but competitive advantages for our guys.  Along with Big Blue, and most Lock’nLoads are in Big Blue, this territory is at the very top of our priority list to command and control. 
Ranger Lock and Load!
From The Joint Council on In-Training Examinations
American Board of Anesthesiology-American Society of Anesthesiologists
"The following responses on the ITE suggested misconceptions in specific areas of the knowledge domain of Anesthesiology. . . based upon the performance of CA-3 residents taking the examination for ABA credit."
According to the Board:  The majority of either CA2 residents (in the case of the ITE) or graduating CA3 residents (in the case of the ABBA Part 1 exam) in the United States did not know that. . . myotonic dystrophy type 1 increases the likelihood of heart block.
1.  Recitation command of Big Blue is greatly beneficial here. “Besides muscle weakness (especially respiratory), the most important symptom s are cardiac abnormalities, including cardiomyopathy, cardiac dysrhythmias, and cardiac conduction abnormalities. . . Anesthesia can also worsen cardiac conduction defects.  It is not infrequent to encounter RBBB or even sudden third degree heart block.”  So there you have it.   
2.  Don’t panic when you encounter something like “Type 1,” or the like; the Board loves to distract with jargon.  Under fire, and this is a shortcoming I suffer, exercise your synapses and apply what you know!  Further, over and over it’s clear, it all starts with memorization and recitation learning.  As the Oracle of Omaha Richest Man Warren E. Buffett says, “It’s when the tide goes out that the skinny dippers get caught,” and the tide here is memorization of Big Blue. 
3.  Again, with regard to myotonic dystrophy, “Besides muscle weakness (especially respiratory), the most important symptom s are cardiac abnormalities, including cardiomyopathy, cardiac dysrhythmias, and cardiac conduction abnormalities. . . Anesthesia can also worsen cardiac conduction defects.  It is not infrequent to encounter RBBB or even sudden third degree heart block,”—exactly to the point of the Lock’nLoad.
If you liked this podcast and found it helpful, I hope you join the Band of Brothers, which is a monthly newsletter with a CD, longer and more detailed.  The cost is reasonable, I spend a lot of time focusing upon, summarizing, writing, and re-writing the information so it has maximal firepower for recall in your synapses, and you can sign up for that on the ordering page at www.boardprep.com. 
Farewell now from Ranger Camp where all the Ranger Warriors are working hard and preparing for a decisive win.  We don’t know much at times, but we do know a few things in the marrow of our bones.  One is this:  “Victorious warriors win first, then go to war.  Defeated warriors go to war first and then seek to win.”  Onward now to Victory!
We are the champions. . .

Monday, November 7, 2011

Let's Boil Some Water and Make Coffee. . .

A favorite recitation from Little fFred:  Passing Boards--Recitations, Pearls, Parables, and Passages is this:  "Suspicion of prior atrocities drives men to surpass report in their own cruel innovations, either by subtlety of assault or extravagance of reprisal." (Thucydides) (Recitation #36)  BTW:  I awarded my first shirt for completion of the recitation trail last week.  It was fun!)

It sometimes seems that those writing questions for Boards, whether Written, Oral, or Pain, desire to make this process progressively more difficult, and way beyond what they themselves encountered and with all due respect.   

An example of this is a keyword I was working upon this morning, namely activated protein C.  To me, at least, it seems a bit esoteric for a Board exam--a definite, "How Many Nits on a Gnat's Nut. . ."  First a question, then some summarized content.

Single best
Activated protein C (APC) is which of the following:
a)  Thrombocytopenic
b)  Anti-fibrinolytic
c)  Anti-thrombotic
d)  Anti-thrombocytopenic
e)  Fibrinolytic

Activated protein C
1.  Activated protein C (APC) inhibits factors V and VIII in the coagulation cascade and in this way inhibits the conversion of prothrombin to thrombin which in turn inhibits the conversion of fibrinogen to fibrin and thus inhibits clot formation.  Therefore, since the conversion of thrombin leads to fibrin and clot formation, also known as thrombosis, APC could be described as being anti-thrombotic.  

2.  Fibrin is formed clot, resulting from fibrinogen activation, through the clotting pathway.
a.  Fibrinolysis is the breakdown of clot, and it results from the conversion of the fibrinolytic enzyme plasminogen being converted to plasmin.  “Fibrinolysis” is the breakdown of clot therefore the term “anti-fibrinolytic” refers to the preservation of clot.  

3.  Patients with severe sepsis have systemic inflammation resulting in coagulation abnormalities that range from thrombosis to DIC; initially there is often thrombosis and this ultimately leads to low factors, low platelets, and low fibrinogen—DIC. 

4.  One, of many, pathophysiologic factors involved with sepsis might be low APC levels, leading to the initial thrombosis mentioned.  Indeed, recognition of sepsis caused micro-thrombosis and the presence of low levels of circulating APC led questions about the possible need for APC supplementation in sepsis.
a.  Because of the crucial role that protein C plays as an anticoagulant, those with either deficiencies in protein C, or some kind of resistance to APC, suffer from a significantly increased risk of forming dangerous blood clots (thrombosis). On the other hand, medical research into protein C's clinical and pharmacological effects has demonstrated that patients with severe sepsis, ischemic stroke and other serious medical conditions may benefit from treatment with recombinant human activated protein C (rhAPC) in the form of drotrecogin alfa-activated (branded Xigris by Eli Lilly and Company).  However, studies since have questioned the drug's overall benefit, and its use is now controversial, given the risk of serious bleeding associated with treatment.  However, it should be noted, another reference through MD Consult stated:  “Recombinant human APC is the first pharmacological drug that has demonstrated efficacy in the treatment of severe sepsis.”  A third source states:  “APC is recommended in the setting of severe sepsis with reasonable life expectancy beyond sepsis.  The cost is high and use remains controversial. A new randomized placebo controlled trial is currently under way.”

5.  As can be imagined, the most severe adverse effect of APC is serious bleeding, hemorrhage, as would be expected due to its anticoagulant effect.

6.  In summary, APC is a naturally occurring anticoagulant that inactivates factors Va and VIIa and prevents the generation of thrombin (and is therefore anti-thrombotic).  Best answer C.
(Reference:  MD Consult)

I hope this was helpful and, as you know, I'm with General George Smith Patton:  "The highest honor I have ever attained is having my named linked to yours in these great events."  Passing Boards is a Great Event, and it's fun being on your team.  Thanks, Niels F. Jensen, M.D.