[BigBri.net] The official Brian Fields site

3Mar/100

How [not] to Intubate

right mainstem

A common mistake - the ETT was 24cm at the lip.  I heard diminished breath sounds on the left, we pulled it back and taped it.  After the CXR came back, we rechecked - it was 28cm at the lip.  No wonder the vent was alarming high pressures.

right_mainstem_tight

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4Mar/090

ED Mnemonics

Here are a few mnemonics I picked up that helped me out...

HAD CLOTS: PERC Rule - Risk factors for PE
Hormone use
Age >50
DVT/PE History
Coughing Blood
Leg Swelling - Unilateral
O2 Sat < 95%
Tachycardia
Surgery/Trauma History - Recent

AMPLE: Important history items in trauma patients
Allergies
Medications
Past Medical/Surgical History
Last Meal/Last Menstrual Period
Events/EMS/Environment

PHAILS: Toxins that cannot be decontaminated with charcoal
Pesticides
Hydrocarbons
Acid/Alkali
Iron
Lithium
Solvents

DUMB BELSS: Cholinergic Toxidrome
Diarrhea
Urination
Miosis
Bronchospasm
Bradycardia
Emesis
Lacrimation
Salivation
Sweating

ME DIE:
Differentials for Osmolar Gap
Methanol
Ethanol
Diuretics (Mannitol, Sorbitol)
Isopropanol
Ethylene Glycol

MUDPILES: Differentials for Anion Gap Acidosis
Methanol
Uremia
DKA
Paraldehyde
INH, Iron
Lactate
Ethanol, Ethylene Glycol
Salicylates, Starvation, Solvents

AEIOU:
Indications for dialysis
Acidemia
Electrolytes (Potassium)
Ingestion (Drugs)
Overload (Fluid)
Uremia

I STUMBLED: Toxins that can be removed by hemodialysis
Isopropanol
Salicylates
Theophylline
Uremia
Methanol
Barbiturates
Lithium
Ethylene Glycol
Depakote

AEIOU TIPS: Differentials for Altered Mental Status
Alcohol
Endocrine
Insulin
Opiates
Uremia
Toxins, Trauma, Tumor
Infection
Psychosis
Stroke, Seizure, Shock

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23Feb/090

COMLEX II Percentile Table

The three-digit COMLEX score is often difficult to interpret.  This table converts your score to a percentile so you can gauge your performance against that of your peers. This table is based upon the 1995 to present three-digit score with a  mean of 500 and a standard deviation of 83.  Passing score is 400.

2Aug/070

COMLEX I percentile table

Here's another percentile table - this time for the COMLEX I. They list the mean as 500, the SD as 79, and the SEM as 18-25.

SCORE Percentile
674 99
670 98
666 98
662 98
658 98
654 97
650 97
646 97
642 96
638 96
634 96
630 95
626 95
622 94
619 93
615 93
611 92
607 91
603 90
599 89
595 89
591 88
587 86
583 85
579 84
575 83
571 82
567 80
563 79
559 77
555 76
551 74
547 73
543 71
540 69
536 67
532 66
528 64
524 62
520 60
516 58
512 56
508 54
504 52
500 50
496 48
492 46
488 44
484 42
480 40
476 38
472 36
468 35
464 33
461 31
457 29
453 27
449 26
445 24
441 23
437 21
433 20
429 18
425 17
421 16
417 15
413 14
409 13
405 12
401 11
397 10
393 9
389 8
385 7
382 7
378 6
374 6
370 5
366 5
362 4
358 4
354 3
350 3
346 3
342 2
338 2
334 2
330 2
326 1
23Jul/073

USMLE Percentile Table

Here's a little table to help you interpret your USMLE scores. The scores reported are hard to decipher, and it sometimes helps to think of your score in terms of percentiles to see how you performed relative to your peers. This table is based on the most recent administration of the test in which the mean was 218 and the standard deviation was 23 for first-time test takers in the US and Canada. A score of 185 is passing. Keep in mind that the SEM for this measure was 6 points, so you should think of your percentile as a range. For example, someone who scored a 210 should add 6 and subtract 6 to look at the percentiles between 204 and 216. This gives us a range of 27th to 45th percentile.

USMLE 3-digit score Percentile
267 98
266 98
265 98
264 98
263 97
262 97
261 97
259 96
258 96
257 96
256 95
255 95
254 94
253 94
251 93
250 92
249 91
248 91
247 90
246 88
244 87
243 87
242 86
241 84
240 82
239 82
238 81
236 79
235 77
234 77
233 75
232 73
231 70
230 70
228 68
227 66
226 63
225 61
224 61
223 58
221 55
220 55
219 53
218 50
217 47
216 45
215 45
213 42
212 39
211 39
210 37
209 34
208 32
207 32
205 30
204 27
203 25
202 25
201 23
200 21
198 19
197 19
196 18
195 16
194 14
193 14
192 13
190 12
189 10
188 10
187 9
186 8
185 7
184 7
182 6
181 5
180 5
179 5
178 4
177 4
175 3
174 3
173 3
172 2
171 2
170 2
169 2
167 1
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9Mar/070

Lara’s Neck

Lara's Neck MRILara was having some shoulder pain for a few weeks, and it wasn't going away.  I took her to see a doctor at the clinic, and she also had a few visits with a doc at school that did some manipulation, but she was still hurting.  We went back to the clinic for some injections, and got some xrays.  When the radiologist's report came back, there were some abnormal findings, so we ended up getting an MRI.  Lara has a few disks that are herniated dorsally (the arrows on the right).  Lots of people get these, and although it looks bad - it's usually no big deal.  Same thing with the Chiari Malformation (left arrow).  This is where the cerebellar tonsil protrudes through the foramen magnum at the base of the skull into the spinal canal.  Also not a huge deal.  The problem seems to be a combination of a reversal of the normal lordosis (the spine should have a natural backwards curve), and also a slight narrowing of the disk heights.  She also has some mild osteophytes (bone spurs).  All of these things are leading to a narrowing of the foramen that the nerve roots pass through as they exit the spinal canal.  C5 and C6 serve the back of the shoulder and also go into the brachial plexus - eventually leading to the median and radial nerve.  This is causing her some pretty intense pain and muscle spasms in her shoulder, as well as some tingling sensations down her arm.  Right now her doctor is recommending some conservative treatment including physical therapy and accupuncture.  We're really hoping that she will be able to avoid surgery.  Keep her in your thoughts and prayers.

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5Jan/073

The ‘Ashley Treatment’

Biomedical Ethics has always intrigued me.  This groundbreaking case has shocked and amazed me.  When I mentioned it to one of my professors, he exclaimed: "THIS HAPPENED IN AMERICA?" 

Ashley is a 9 year old girl with static encephalopathy, an idiopathic condition that renders her permananently disabled.  Her doctors removed her breasts, uterus, and ovaries at the request of her parents.  They also used high-dose estrogen to force her growth plates to fuse and stop the growth of long bones.

Many people are outraged, accusing the parents of orchestrating the treatment to maintain a more "portable and manageable" child. 

Her parents claim that the treatment was done to decrease Ashley's discomfort by eliminating menstrual cramps and bedsores.  They also claim that there is a family history of breast cancer, but there is no mention of BRCA testing.

Here's a link to the story on CNN.

Here's a link to the family's blog.

What do you think?  Please comment below...