12 April 2009

Do I really NEED to take an MCAT Review Course?

You have completed your pre-med coursework with no grade less than B+ and a majority of A grades. You feel that you have a solid grasp of the material and the concepts presented in your pre-med courses. Do you really “need” to take a review course for the Medical College Admissions Test (MCAT)? The answer to that question depends on whether or not you are good at solving the types of problems that are presented on the MCAT. If your knowledge base is good, then taking a review course that emphasizes knowledge refreshment is largely going to be a waste of money for you. If it’s been a few years since your pre-med coursework, then getting your knowledge base up to speed is your first priority and thus a knowledge upgrade type of review course may be the key to a strong score on this very important admissions test.

How are your problem-solving skills?
You can quickly find out how well you solve MCAT-type problems by downloading one of the retired exams and working the problems under actual testing conditions. If you are finding that you are struggling with these types of problems, then try to find a review course that gives you plenty of strategy and experience with problem-solving. Problem-solving is often the main gap in the education of most pre-med students. With many undergraduate institutions placing more emphasis on “rote memorization” rather than application of knowledge to problem-solving, pre-med students may have earned high grades in science coursework with little training in how to apply those skills to new situations. Even the so-called “ranked” universities can be seriously lacking in terms of making sure that students have problem-solving skills. Many times these skills are utilized most in coursework like Calculus and applied Differential Equations; courses that many students avoid because of rigor or lack of math background.

How are your reading skills?
In this age of electronic media at every corner, many students have lost the ability to produce (and evaluate) good writing. Many students view the analysis of literature, primary resources and scientific papers as the torture of producing research papers and as a “necessary evil” of obtaining an education. Many professors routinely pass out PowerPoint lecture slides that contain the bare minimum of facts/information that students attempt to memorize verbatim without regard to analysis or research beyond what they have been handed. These processes have tended to rob many students of the skills needed to evaluate information sources and information. While Wikipedia may give starting points for a wide variety of subject matter, many students will often use the “cut and paste” function for research paper writing rather than spend some time evaluating a cross section of resources. Reliance on quick media resources is a great starting point but this reliance can’t be the end point of your information evaluation and gathering skills. Learning how to evaluate the primary literature is a valuable skill that you should have acquired in your undergraduate training regardless of major course of study.

The sections of the MCAT – Biological Sciences
This section will test and evaluate your mastery of General Biology with some Organic Chemistry thrown in. While it may seem strange to put these two subjects together, organic chemistry is largely the most concept application course that is taught in chemistry. Organic Chemistry relies on your understanding of the chemical properties of carbon as an element to solving problems across a wide variety of conditions. Many students hit a major roadblock with organic chemistry because there are many problems that can be created to test your knowledge of carbon chemistry. Trying to sit and memorize every problem that you were presented with in organic chemistry is not going to be very helpful but making sure that you know the concepts of carbon and its chemistry will enable you to solve any problem that you are presented with.
In addition, many student mistakenly believe that they must “take a course” in every type of subject matter that is covered on the MCAT. This could not be further from the truth. A good comprehensive General Biology course will give you the knowledge foundation to apply concepts to the problems that the MCAT will present in Biology. You don’t need specific coursework but you DO need to be able to do some creative thinking in the application of your concepts to novel experiences. A good comprehensive General Biology course will cover physiology, botany, zoology and ecology. Thus, you don’t HAVE to be a biology major to have exposure to the subject matter but you do need to have a grasp of the concepts of a good comprehensive General Biology course. Being able to synthesize and build upon a basic knowledge base are the types of skills that you will use in medicine thus your ability to do these types of problems will be measured by the Biological Sciences section of the MCAT.

The sections of the MCAT – Physical Sciences
This section tests your ability to solve quantitative problems using concepts that you learned in General Chemistry and General Physics. These types of problems are often answered by being able to apply order of magnitude type strategies rather than working though an entire problem. Students who thoroughly know quantitative relationships presented in their coursework will tend to do well on this section. Between General Chemistry and General Physics, the quantitative relationships of many concepts can be probed and tested. It is practically impossible to rote memorize every type of problem that can be presented in these courses but having a sound knowledge of quantitative relationships in addition to being able to apply those relationships can bring success in this section.

The sections of the MCAT – Verbal Reasoning
This section of the MCAT can often be very difficult to improve or prepare for. Being able to analyze critically the reading passages from a wide variety of sources and disciplines generally takes years of careful practice and skill building. Preparation for this section should have been occurring over students previous years of study in practically every subject. College coursework in the humanities with strong achievement can also hone these skills. In addition, good readers are always good writers and thus, the writing section of the MCAT is likely going to mirror the Verbal Reasoning section of this exam. Can you consistently read and learn from your text books and journals? This is a very valuable skill to take into medical school with you as medicine will require a lifetime of learning and the acquisition of new knowledge that will be outside of a classroom.

Some final thoughts…
Finally, the review courses are expensive and time-consuming. You have already paid thousands of dollars in tuition and book purchases in order to master your coursework. Do you actually NEED to pay a few thousand more for a review course of that work? If you didn’t master what you needed the first time around or if you find from doing a few practice retired MCAT exams, you are struggling with this test, and then perhaps a review course can make a difference for you. You should thoroughly investigate the materials offered and you should thoroughly understand what the courses are offering for the fees that they charge. You should also be prepared to master some of the material on your own as many of these courses are taught by people who have a variable ability to teach others. Doing well on the Medical College Admissions Test may not translate into being able to teach others to do well on this exam.
The Medical College Admissions Test is one aspect of your application to medical school. This test requires solid and thorough familiarity with the mode of testing and a solid knowledge base that must be applied to the problems asked on this test. Several retakes of this test do not bode well for medical school admissions. You want to be prepared and take this test one time. With this test being administered 22 times annually, you also have more options in terms of being able to time your preparation for this exam. The important thing to realize is that you don’t want to take this test unless you are thoroughly prepared at your own pace. This is not the time to listen to your peers tell you how much or how little time they needed but the time to set the study schedule that works for you.

11 April 2009

Burn Surgery

I was the resident in charge of the burn unit and working on my daily notes for the patients that were currently residing there. There was a 19-year-old who had suffered severe inhalational burns and brain damage after the carburetor that he was cleaning with gasoline caught fire from a static electricity spark. There was a 70-year-old who had fallen asleep with a lit cigarette and sustained 25% full thickness burns to his upper torso. There was a mother who had burned her hands and face when she opened the door to her house, smelled gas and pushed her children to safety just before her house exploded. All of these patients require intensive care, intensive wound management and attention to every detail of their progress and condition. Also, some of these patients were in the process of being grafted which required operative timing and preparation.

The call came in just before lunch that a 39-year-old highway construction worker was being flown in with 96% partial and full-thickness burns to his body. This man was working in a manhole when he accidently hit a steam pipe that ruptured. He was wearing steel-toed boots which kept his feet and lower legs from the burns but just about every place else on his body was burned. This would be a major trauma to this young man and this would predict months of recovery if he would be able to recover from such a traumatic blow. In the case of burns, the patient doesn’t stop in the Emergency Department but come immediately to the Burn Unit where the staff can start treatment as soon as possible. At stop in the Emergency Department would delay initiation of the treatment unnecessarily and would expose this patient to infection because the Burn Unit is far cleaner than an open Emergency Room. He would arrive in less than 30 minutes.

The nursing staff set up one of the evaluation rooms: scrubbed stainless steel tables lined with sterile liners and warm water for removal of any clothing that might be adherent to the skin. In the field, most paramedics know that burned clothing will hold heat and continue the burn process unless removed from the skin. They will make sure that any smoldering clothing is removed and will wrap the burns in sterile dressings and drapes. The patient’s airway will be protected and two large bore intravenous lines will be inserted so that fluids can be infused as quickly as possible. The paramedics had indicated that they had inserted three 16-guage lines into this patient and has already infused 1.5 liters of fluid. The patient was intubated, stripped of clothing and wrapped completely to prevent fluid and heat loss because of the burns. They had done an excellent job in the 15 minutes since the patient has been burned. They were 15 minutes out from the hospital.

The man arrived and we quickly set to work debriding any scorched skin and clothing from his wounds. I inserted a cordis intravenous line into his internal jugular vein for even more fluid infusion and extra IV access. We also induced a pharmacological coma for pain relief (about 60% or his burns were painful partial thickness and the other 30% were full-thickness (not painful but devastating). His face was swollen and red; his hair was gone; singed by the steam. It appeared that the pipe exploded, he inhaled the hot gas and turned to his left while covering his face. His left arm and back had the full thickness burns but his eyes were in good condition. I used an ultraviolet light with dye to assess corneal damage and found none. His ears were singed red with large blisters that wept fluid. His chest and legs had partial thickness burns that needed to be debrided too. Three nurses helped me start the initial debridement process while the respiratory therapist made sure that his ventilation was taken care of.

Full-thickness burns cause the skin to take on a leathery appearance. Since all layers of the skin are totally destroyed, this leathery eschar would need to be removed. Just under this layer would be a layer of ischemic damage that would be lost unless proper fluid resuscitation had been undertaken. Our patient had an IV rate of 1,950 ml/hr in the first 8 hours because of massive fluid loss. We didn’t want to get behind and cause further damage. After the first 8 hours, we cut the IV fluid rate back to 980 ml/hr for the next 16 hours. Overall, our estimate was that our patient was 31,000 ml of fluid down because of the extent of his burns. In addition, his body was massively stressed by the injury to his lungs and fluid loss from there. He was fortunate in that he had been in excellent health before this accident. We were able to hold blood pressure and urine output adequate in the first days after his accident.

My attending burn surgeon arrived after the patient had been in the unit for about 20 minutes. He helped with the debridement and wound evaluation. Our patient was fortunate that he didn’t need an escharotomy (incisions made to release burned skin so that the patient would be able to breathe/be ventilated). After 35-minutes, we had infused several liters of IV fluid, placed the patient in a pharmacological coma for pain relief, undertaken mechanical ventilation and cleaned/dressed his wounds. My preceptor surgeon and I sat down with the nurse assigned to the patient to plan for covering this patient beginning the next day. We also had antibiotics started and had placed a feeding tube for liquid nutrition which is so vitally important in burned patients. This young man would be in a hyperdynamic state with the ultimate demands on his body both physically and nutritionally. In addition, we would need to start to cover his burned skin as quickly as possible. Our first cover would be donated cadaver skin.

Cadaver skin would be a good cover to start with but the patient’s own skin would have to be harvested slowly as he healed. As soon as donor sites would become available, we would use them and would harvest. On our first assessment, the backs of both calves were not burned along with his right upper posterior thigh. These would be harvested first. We would start on hospital day 2, harvesting skin from the donor site and covering the full thickness burned areas with cadaver skin. The patient’s own skin would be meshed and would be used to cover the partial thickness areas. We would also perform a tracheostomy as he would require mechanical ventilation at least two week and possibly three or more. He had been fortunate in that he had not inhaled carbon monoxide but he did inhale heated gases which had caused some lung damage. We hoped that this would heal and we would come to see that this damage was minimal in the next week.

At the first surgery, our team consisted of seven people: the attending surgeon, the chief resident, an intern, a nurse practitioner and three medical students. Our attending surgeon set about further debriding the burned areas after anesthesia had been induced. I performed the tracheostomy creation while the intern and nurse practitioner harvested and meshed skin for beginning the coverage. Once the recipient sites had been properly debrided and prepared, the meshed skin was applied with everyone having an opportunity to do some suturing. In the coming weeks, he would undergo more of these coverage procedures as his body rejected the cadaver skin and the donor site would allow more harvest. In all, it took about three weeks to get his would covered with his skin and to keep the donor sites healthy and thriving.
In addition to coverage, keeping infection at bay and nutrition, we had the challenge of pain relief. At first, we kept the patient strongly sedated. As his lungs began to heal, we gradually cut back on the sedation to allow him to breathe on his own. After 2 ½ weeks, he was doing well and we removed mechanical ventilation. At this point, he was able to talk with his family by covering his tracheostomy tube. With is grafts and tubes, we could see that the greatest joy for this young man was having his family gathered round for encouragement. When he was pharmacologically comatose, his wife made tapes of their children singing for their father. The nurses would play these during the daily would care and dressing changes. Any person who entered his warm room (to prevent heat loss) would have to dress in sterile garb and wear a mask. In addition, the massive facial swelling started to resolve after about a week so that his children could see him from the door. His wife had carefully prepared them for the sight of seeing their father in bandages from head to toe.

When I left my burn rotation after two months, I would stop in to see him from time to time. He said some of his first memories had been of my voice and the staff speaking with him and encouraging him. During his dressing changes, we had sung (recommended by our music therapist) along with his children and that this had been of great comfort to him. He also said that he didn’t remember having a huge amount of pain until near the end of his recovery when he started to have difficulty with some mild contractures. He continued physical therapy and when I saw him one year later, he looked fantastic. One could tell that his arms and torso had been burned but the plastic and reconstructive work that had been done on his face and ears was very nice. He was upbeat and looking forward to changing careers. He had decided to go back to school to get a degree in counseling so that he could help other burned patients. The staff in the burn unit said that he would often visit young men who were burned to tell them his story as he was recovering. He said that he thought that recovery for a younger man was especially difficult.

I still remember what this gentleman looked like when he came in and often had to look at the portrait that his wife had supplied so that we knew what he had looked like before his accident. We also saw the incredible love and support that came from his family and parents. He had brothers and sisters who took turns sitting with him and reading to him while he was comatose. This was a very close-knit family who prays for and supports each other. We saw the incredible determination in this patient and in others that have undergone this type of extreme stress and life adjustment. All of these patients taught me the value of appreciating how easy it is for me to do something as simple as walk across a parking lot or sip a cup of coffee in the morning. Often it takes weeks and months for a burned patient to even get out of bed.

And finally, taking care of burned patients is the ultimate team effort. The surgical procedures take multiple hands and personnel who have the goal of getting the burned patients covered as soon as possible. In addition, the nurses, nursing assistants and environmental services personnel in the burn units are invaluable. They have some of the strongest work ethics of any area of the hospital. If the environmental services folks were not dedicated to their jobs and doing a job well, the infection rate in these units starts to climb. Every single person “counts” when it comes to getting this massively injured patients back to health.