Board stiff three pdf download

Get BOOK. Board Stiff Three. Author : Christopher J. Board Stiff Three Book Description:. Gallagher's signature humor and engaging writing style make this. Board Stiff Three E-Book. Board Stiff. The world of Xanth is a wacky one full of offbeat heroes and surprising journeys.

In these three volumes of this hilarious series, characters bumble their way through many misadventures to find their happy ending on the other side, aided and hindered by puns along the way. Board Stiff: Thanks to a mental typo and. Every fall, hunting season in Sorenson, Wisconsin, leads to some accidental injuries. But somebody seems to have declared open season on land developers. That might be. Deputy coroner Mattie Winston knows a thing or two about dead bodies. That's why she's on the case of Derrick Ames, a high school math teacher stabbed to death with a barbecue fork straight to the heart.

Sure, she's turned up some motives and a few suspects, but nothing adds up. Especially when the evidence points to Ames's teenage son. Newly pregnant Mattie can't believe it, even as her own long-estranged father may be following her.

But one thing's certain,. First published in this edition in , this book is a dictionary of the past, exploring the language of the criminal and near-criminal worlds.

It includes entries from Australia, New Zealand, Canada and South Africa, as well as from Britain and America and offers a fascinating and unique study of language. The book provides an invaluable insight into social history, with the British vocabulary dating back to the 16th century and the American to the late 18th century.

Each entry comes. A Buick Regal with , miles on it can get you to work. Do you need a ft2 house overlooking the lake? The ft2 house around the block will provide you shelter from the storm. However, you paid extra for those items because those were things you wanted. The same principle applies to a review course. It may be one luxury you choose to pay for, so which one is best? Board Stiff Live provides the smallest student-to-teacher ratio.

Board Stiff Live gives you the most individualized attention. Board Stiff Live gives you the most private exams. You tell me! Which one do you think is best? What is the bottom line? If I sailed through a good residency and had plenty of confidence and time to practice, I would not take a review course. If I were having trouble passing, lacked confidence, or just wanted a focused time dedicated to nothing but oral board study, I would take a review course, and I would take the best one.

It is a good idea to know what is down the river before you dip your oars in the water. This chapter describes the examiners, the exam criteria, and the exam format. It is a good idea to see things from their perspective as you roll into the exam and before you pitch over the waterfall.

Examiners are not superheroes. They are not clinicians beyond the reach of mere mortals. They are practicing anesthesiologists, just like you and me. They look up stuff, ask around, have someone nearby in a jamall the regular things that regular people do during the daily grind of operating room work.

Examiners receive the exam questions the night before and are specifically told they cannot look up anything. This means that they must draw on the knowledge they already have, just as you will have to draw on the knowledge you already have. That makes the exam fair, and it should set your mind at ease, at least a little bit.

The examiners cannot dig deep in Millers Anesthesia to find some obscure tidbit about infrared plasma vortex intracraniographic positron interactions with lipophilic ameboid capsules in the pseudohypoparathyroid patient with Munchausen syndrome. They know what they know. You know what you knowso have at it.

The examiners invest a lot of time and effort to do these exams, and they are paid peanuts. They are aware that they have been entrusted with an enormous responsibility. How can our specialty be recognized unless we make sure board certification means something? That is serious stuff, and that is what guides the examiners.

They do not wake up in the morning thinking, Who can we get today? Lets nitpick the next person to death. They just want to make sure that the American Board of Anesthesiologists imprimatur is valid.

They will pass you if you know how to do anesthesia. One examiner summed it up quite nicely, and his words are worth keeping in mind as you prepare for your exam: If I ask a candidate how to handle malignant hyperthermia, and he or she tells me the right way to handle it, then on what grounds am I going to flunk this person?

Apply that to everything 7. On what grounds are they going to flunk you If they ask you how to manage a preeclamptic patient, and you tell them the right way to handle a preeclamptic patient? If they ask you how to manage an intravascular injection of local anesthetic, and you tell them the right way to manage an intravascular injection of local anesthetic? If they ask you to diagnose and treat myocardial ischemia based on electrocardiographic changes in the middle of a case, and you diagnose and treat myocardial ischemia appropriately?

If they ask you about fluid management in a burn patient, and you correctly describe the protocol? If they ask you about intracranial pressure issues in a head-injured patient, and you explain the issues and appropriate management? If they ask you about failed intubation, and you explain the correct approach?

If they ask you about hypotension in a patient with a bleeding aneurysm, and you describe the right way to handle the patient? If they ask you about hypoxemia in a patient with acute respiratory distress syndrome ARDS , and you tell them the correct way to handle the case?

If they ask you something about anesthesia, and you say the right thing no tricks here or plot twists , you are in clover. Do the examiners make it tough? Yes, but consider it from their point of view. If they did not make it tough, the test would be meaningless, and board certification would be meaningless. You walk in and shake hands. You sit down. An examiner says, Good morning. How would you anesthetize a healthy young man with no medical problems for a hernia operation? You respond, Uh, general anesthesia with a laryngeal mask airway.

The examiner says, Okay, thats fine. Thank you for coming to your board exam. Well be sending your certification in about 6 weeks. Have a nice day. It is safe to say that is not going to happen. You will have some tough and thorny problems. People coming back from exams tell me all the time about their questions, and some are doozies!

However, one theme has held true for the past 20 years: The exams are tough, but they are always fair. That bears repeating. The exams are always tough, but they are always fair. They always cover topics that we should know. No returning examinee has ever accused the examiners of playing unfair. Four criteria are used in grading your exam: judgment, adaptation, clarity, and application. A simple example illustrates these four criteria in action.

Your patient is a year-old man about to undergo transurethral prostatectomy TURP. What kind of anesthetic will you use? A spinal block provides a good, dense block and gives you information about TURP syndrome and bladder rupture, because the patient can communicate with you.

Your good judgment tells you to do a spinal. The patient is on Plavix for eluting stents placed 3 months ago. This introduces a clotting issue, and a spinal block is not such a good idea.

Your adaptability tells you to do this procedure under general anesthesia. Should you use an endotracheal tube or laryngeal mask airway LMA? The patient is at no risk for aspiration and has had nothing by mouth NPO , so your notion of clarity says that you will use an LMA. You do not waffle or debate the two options endlessly; you make a clear decision and go with it. Halfway through the case, you see green liquid in the LMA. Plan A has not worked. A new complication has arisen, and you have to apply your knowledge of anesthesia to manage this situation.

You go head down, suction, and secure the airway with an endotracheal tube. Lets go through the four grading criteria again and address a recurrent theme in your oral board preparation. The examiners want to hear the voice of a consultant in anesthesia.

A consultant has sufficient knowledge to pick the right course of action. A consultant is not bound to one course of action. A consultant knows that different circumstances here, Plavix call for different plans.

A consultant is not a memorizer of long lists, ready to dredge out every bit of possibly relevant information. A consultant gets to the point with a clear, concise plan or response. A consultant is sufficiently nimble after the case has started that he or she can apply accrued knowledge to changing situations. Most often in the exam, the situation is a complication or failure of the original plan. Do not worry if this happens! It does not mean you did wrong and are now in this jam due to your foolishness.

It means the examiner has a sheet of paper with a question that asks what happens when the local anesthetic goes intravascular, the spinal goes high, or the teeth get chipped. Apply your knowledge and answer! You now know about the examiners and the criteria.

We next consider the exam format. Look it over. Talk about getting stuff straight from the horses mouth! Here it is laid out for you. In room 1, you face two examiners, with a possible third in the room.

The third person is grading the examiners, not grading you. You are given a long stem question, with all the preoperative information provided and taken care of. Your exam consists of a long section on intraoperative questions, followed by a shorter postoperative section, after which you are finished with the stem question. The examiners then shift gears and ask you two or three shorter questions on other topics this section of the exam has earned the sobriquet grab bag and is labeled as such in later chapters.

Someone knocks on the door at the end of 35 minutes it will seem as if you just got there! Out into the hall you go, and you are given a second stem question in the next room. In room 2, there are again two examiners, with a possible third person to grade them, not you. Your stem question is short this time, and the examiners start by asking you preoperative questions, and they then lead into the intraoperative questions; the longest section in both rooms covers intraoperative topics.

There is no postoperative section in room 2. The examiners finish with the stem question and do two or three grab bags before the knock comes. To summarize, the long stem question has intraoperative, postoperative, and grab bag sections. The short stem question has preoperative, intraoperative, and grab bag sections. You have about 5 minutes to look over the stem questions before they let you in the room.

Most people scribble furiously on the paper, hoping to put down a flurry of reminders and things they absolutely must have down. There is nothing wrong with this, and it may even do you some good. However, many people have told me that after the examiners blast the first question at you, your mind goes gazoinkel, and you never even look down at your carefully constructed notes.

That is what happened to me, but by all means, write notes if that makes you feel better. What the hell are you supposed to do in those 5 minutes anyway? Pull out a Sodoku puzzle and fill that in? So there you have the exam, with all its component partsthe examiners, the criteria, and the format. Theyve been there.

Dont trust the bastards, but do listen to them. Here are the four most important, time-tested, this really helped me tips amassed from helping people through these exams since the late s. Times have changed, therapies and drugs have changed, and our thinking about anesthesia has changed, but these four tenets hold true: 1. Do not ask questions. Do not complicate things. Think head to toe. Break down questions into their component parts.

Learn to suppress this reflex. Better yet, train yourself through practice to suppress the reflex. Examiner: The blood pressure drops. You: Whats the heart rate? Dont do that! Examiner: The heart rate goes up. You: Whats the blood pressure? What did I just say? Do not bounce questions back to the examiners. What should you do?

Make your assumptions, cover the bases, and give an answer. You: Assuming this is related to blood loss from an injury, I would give fluids, send a gas, and decrease potent inhaled agents.

Thats more like it! You: If the heart rate is up and the blood pressure is up, this could be light anesthesia, so I would deepen it; but if the heart rate is up and the pressure is down, it would be typical of hypovolemia, and I would replace volume.

You gave a complete, concise answer that covered all the major things that could be going wrong, and you did not waste a lot of time asking useless questions.

There is no need to tack pathology on pathology. Examiner: This man is 1 year out from a myocardial infarction MI. You: Well, he could have had arrhythmias and might have an automatic implantable cardioverter defibrillator AICD.

His ejection fraction could be severely impairedheck, he might be about to arrest right now! I would intubate him in the preoperative clinic and set up extracorporeal membrane oxygenation! This is a bit over the top, wouldnt you say? Examiner: This man is 1 year out from an MI. You: Assuming he has fully recovered and is doing well clinically, with cardiology following him and adjusting his medications, I would induce him with standard induction agents.

You do not need to drag in problems that are not there. Make an assumption that the patient is healthy, and answer the question. The examiners may up the ante and make the patient sick. This is not a problem. You prove your adaptability and your skill at application see Chapter 2 , and you adjust accordingly. I then would induce for his hernia repair, aware that the AICD is off, and I would be on the lookout for dangerous rhythms because I will have to jump in and shock the patient.

So you throw your hands up in the air and yield to despair. But wait! Think about what makes a human being, go from head to toe, and you will understand that no matter how you slice or dice it, there are only so many things that can go wrong. There are only so many areas the examiners can focus on, because we humans have only so many pathologic conditions:. Abdomen: baby preeclampsia is the biggie in this department ; obesity; liver dysfunction; renal failure; aortic aneurysms; severe third spacing and fluid losses with obstructions and long operations Extremities: blocks and attendant local anesthetic problems; trauma causing fat emboli and blood loss ; burns; peripheral vascular disease Age: very young systems all immature, childhood differences from adult conditions ; very old everything goes to hell, as one look at me can confirm.

A great tip, based on a lot of experience with a lot of examinees, is to go over the head-to-toe review and ask yourself a simple question: Can you answer questions pertaining to these head-to-toe problems?

Unless examiners start asking us about parakeets or Martians, the previous list is pretty much everything that you could ask about anyone. There is no need to despair because the list is quite manageable! Hang onto your hat. A pregnant woman at term is in a motor vehicle accident on her way into the hospital. You are in the elevator, taking her up to the operating room, and the endotracheal tube gets pulled out. Your laryngoscope has a burned out light bulb.

I almost fell out of my chair when I heard this. At first glance, determining what to do seems impossible. So now it is time to be systematic.

Airway, Breathing, and Circulation Checking the airway, breathing, and circulation ABC is always a good place to start! You have a suboptimal situation here, so you manage the ABCs as best you can with what you have.

You cannot intubate, so mask ventilate. As soon as the elevator door opens, call for help, and get to a place where you can resecure the airway. Keep a finger on the pulse to monitor circulation. Emergency, Urgent, or Elective Management Emergency means life, limb, or sight are at risk. Urgent means delay can cause damage to life, limb, or sight.

Elective means action can wait. This case is an emergency. A GCS score of 8 means serious neurologic trouble and an inability to protect the airway. You move to resecure the airway and to determine a need for neurosurgical care, such as for an epidural or subdural hematoma or cervical spine injury. Concomitant Conditions What else does the patient have? This is where you can run into clashing objectives. In this case, the woman is pregnant, and you would like to avoid instrumenting the airway, because there is a higher fatality rate for cesarean sections under general than under regional anesthesia.

However, she has a GCS score of 8, and you need to protect the airway. You do not want to intubate, but you do want to intubateclashing objectives. That is what makes it a board question! These damned if you do, damned if you dont dilemmas are a test of your understanding of complex problems.

Here are other examples of common clashing objectives: Asthma want to intubate deeply and a full stomach no time to intubate deeply Difficult airway want to intubate while the patient is awake and asthma intubating while the patient is awake may trigger asthma No venous access in a mentally challenged adult patient want to breathe down and obesity do not want to breathe down Asthma want to give -agonists and cardiac ischemia want to give -blockers.

What laboratory or other studies are needed before you proceed? What monitors specifically, which invasive monitors are needed? What are your plans for induction, maintenance, and emergence? Does the patient require placement in an intensive care unit ICU? We can apply these questions to our unfortunate mommy-to-be who just got extubated in the elevator.

After she is out of the elevator and her airway is secured, you want to make sure you have blood available type and crossmatch but can use O negative if she crashes first. Computed tomography CT scans of the cervical spine and head CT should be obtained if vital signs allow.

Blood gas determinations should be made. Place an arterial line need for frequent blood gas determinations and for beat-to-beat blood pressure measurement given her precarious state and large-bore intravenous catheters for access. Use a fetal heart rate monitor. Because the patient is unstable, induce with etomidate.

For maintenance, use intravenous agents, depending on her vital signs. Alert the pediatric department that if a cesarean section occurs, they may need to support the infants ventilation.

Until the neurologic picture is clearer, keep the patient on a ventilator at emergence. The next chapter considers our very reason for existencemanaging problems with the vital signs.

I made up that quotation, but it makes a good point. When you cannot feel a pulse, and someone has been buried for years, you have good prima facie evidence that they are, in point of fact, dead. This underscores the importance of vital signs.

This chapter was originally written in the first edition of Board Stiff, and it is so good, we are going back in time to revisit that chapter from long, long ago, because it covers the topic as well today as it did then. Yes, but in a good way. Prepare yourself to handle every aberration in vital signs. That is the essence of every anesthesiologists job. In the intraoperative part of the oral exam, you will have to handle vital sign aberrations. Work on and have clear responses to the following situations:.

Primary tachycardia i. Supraventricular arrhythmia 2. Ventricular arrhythmia Secondary tachycardia i. Hypoxemia 2. Hypercapnia 3. Decreased oxygen delivery a. Anemia b. Decreased cardiac output 4. Pain usually associated with hypertension a. Somatic e. Visceral e. Sympathetic e. Hypovolemia usually associated with hypotension a. Absolute e. Relative e. Unusual possibilities a. Inotrope running wide open b. Pheochromocytoma leaking an inotrope c. Carcinoid syndrome. Primary bradycardia i.

Sick sinus syndrome 2. Complete heart block Secondary bradycardia i. Drug-induced a. Digoxin i. Narcotics i. Anticholinesterases Oops! Forgot the glycopyrrolate! Dexmedetomidine i. Calcium channel blockers 2. Vagal stimulation a. Oculocardiac reflex b. Traction on viscera e. Laryngoscopy d. Baroreceptor reflex e. Patients have primary hypertension i. Primary hypertension 1. Long-standing hypertension called primary hypertension 2. Hypertension associated with a specific disease entity a.

Preeclampsia b. Kidney failure Secondary hypertension i. Pain usually associated with tachycardia a. Carcinoid syndrome The widespread use of -blockers can confuse the picture. A patient under light anesthesia may not manifest a tachycardic response in conjunction with tachycardia. We have to put on our physiology hats and break blood pressure down into its basic parts: 1.

Preload can be insufficient: There is not enough e. There is enough, but it cannot get back to the heart because of tamponade, positive-pressure ventilation, PEEP, tension pneumothorax, aortocaval compression, a vessel pinched during surgery, or bent and twisted heart during off-pump coronary artery bypass grafting CABG.

The heart itself can be insufficient: The muscle itself is not strong enough e. The muscle is fine, but it is not able to deliver enough blood because of bradycardia, tachycardia i. Afterload can be insufficient: It is too low e. The blood can be insufficient: There is not enough of it e. Wait a minute! Where does anesthesia fit into all of this? We cause hypotension all the time. Why is not part of the differential diagnosis of hypotension?

Anesthesia is there, in that an excess of anesthetic can affect the afterload e. If you are going to be board certified in anesthesiology, you damned well better be able to diagnose and treat hypoxemia! What follows is a geographic approach to nailing this question. Go from the wall to the tubing to the endotracheal tube to Then go from outside to inside on the patient: chest wall to parenchyma to pulmonary vasculature to the heart itself.

Before it up, take a quick peek at the brain. This systematic approach hypoxemic bases. From the wall to the endotracheal tube. Wrong gas composition: line crossover No gas delivery: disconnect, ventilator off, switch thrown the wrong way Endotracheal tube to lungs Endobronchial or esophageal intubation Kink, clog, aspiration of big things such as hot dogs and other stuff you can get at a county fair Disconnect Tube went subcutaneously i.

Central nervous system Apnea from inhaled or injected anesthetic drugs Damage to the respiratory center High cervical lesion impairing the patients ability to breathe. Thankfully, hypercapnia is a little less taxing. The patient is making too much, getting rid of too little, or rebreathing carbon dioxide. Making too much Malignant hyperthermia Thyrotoxicosis Sepsis Getting rid of too little Hypoventilation from your sub-optimal anesthetic You are setting the ventilator wrong, or if the patient is breathing on his own, you are overdosing him on the muscle relaxant, narcotics, or inhaled agent.

Because you know a vital sign aberration will appear on the exam, make sure you can recite chapter and verse on the following:. I am positive somebody said that, and as far as most anesthesiologists are concerned, the airway explains everything else.

Chapter 4 looked at vital signs, which are certain to be on the test. We now jump to the next topic sure to be on the test: managing the airway. What is more important than the airway in the realm of anesthesiology? We are the airway people, and board examiners expect us to know this airway business up, down, and every which way. In this chapter, we consider the airway in the preoperative, intraoperative, and postoperative realms. History When obtaining the patients medical history, ask whether he or she has had anesthesia.

On rare occasions, you will get the real deal straight up: They told me I was hard to intubate. They gave me this lettersomething about a fiberoptic awake something. Last time, they trached me in a big hurry. Responses such as these are rare in practice and unlikely to be handed to you on the oral board exam.

You may get some indirect clues about the difficulty: They chipped my tooth. My throat was real sore afterward. These responses indicate that someone was having a hell of a time getting that tube in. It is great if you can get old anesthetic records. On the boards, the examiners will probably say the old records are unavailable.

Even an old anesthetic record is not a guarantee of accurate information: The airway might have worsened since that anesthetic because of increasing obesity or worsening arthritis. The last anesthesiologist might have been the best laryngoscopist in the world. The last anesthesiologist might have had trouble but did not bother to write anything about the difficulty on the anesthetic record.

Specific conditions in the patients medical history may cause you to suspect a bad airway:. Physical Examination During the physical examination, look for the usual suspects that coexist with a bad airway:.

Large teeth Short thyromental distance Large tongue Mallampati glottic view of grade 3 or 4 Head in a collar or a halo unless you are good at bending steel Radiation or surgical scars or masses e. As you examine the patient, consider how hard it will be to ventilate the patient if you fail to intubate: Morbidly obese: difficult mask ventilation In a jungle gym orthopedic bed: hard to get at the airway On some burdensome radiology bed: hard to get the bed into reverse Trendelenburg so you can take weight off the diaphragm and aid oxygenation Full stomach: intubation better than mask ventilating a patient at risk for vomiting and aspiration Middle of the night, weekend, or holiday: lack of personnel to offer help as in the movie Aliens, no one hears you scream.

The following points apply to awake intubation: 1. Have a low threshold for doing awake intubations. The more you do, the better you get at them, and the less you fear doing it awake. The biggest problem about doing an awake intubation is gathering all the stuff to do the topicalization, so get it together ahead of time. What is the best sedation for awake intubation? Dexmedetomidine, hands down. Because the patient has to be dry, get anti-sialagogue in early.

Do not flounder in an ocean of saliva and local anesthetic. Is the patient uncooperative? You will be amazed how they calm down with dexmedetomidine. Is the patient extremely uncooperative? If you have someone who will not hold still e. Should you use a nasal or oral approach? Nasal gives you a better angle, and the tube can and sometimes does go in by itself. However, you risk hemorrhage, which is a potential disaster if you later give heparin e.

The oral approach does not provide as good an angle, but at least you do not risk nasal hemorrhage. What do you do if you only see pink in the fiberoptic scope? Pull the tube back. Keep pulling back until you see a kind of cave, which means you will have enough room to look around, find that epiglottis, and go for it.

What if you are through the cords and cannot advance the tube? Do not force it. Rotate it, try again, and keep rotating until you eventually feel it give. Use oxygen in the suction port to blow secretions and blood away. Do not use suction. The hole is too small, and suction pulls fluid up to the end of the scope and obscures your view.

By insufflating oxygen, you help with oxygenation.