Absite Smackdown! · Episode 34: Top 5 Dumbest Absite Facts


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Dr. Kashmer:  Welcome back to The Absite Smackdown Podcast.  And today, Jessica and I are going to explore some of the most foolish Absite-related facts. In fact, we like to think of these as the top five dumbest Absite facts.

Jessica:  Hey guys, it's Jessica, the host for Absite Smackdown podcast. I'm just really excited today to do such a fun topic. It's interesting and silly, and we get to poke fun at not just ourselves, but pretty much all study guides. So as always, I'm excited to be here with Dr. Kashmer because anytime with him is a pleasure.

Dr. Kashmer: Number one on our list of dumbest Absite facts...well, before we even get into the list, let me share a couple things with you.  Even though these are on the list of what we consider the dumbest, most foolish, or least useful testable facts for the Absite...that doesn't mean you don't have to know them!

The test is what it is, and these all make the Absite Smackdown review book, and many other classic review books. So before we even get into the list of what we kind of nickname the dumbest Absite facts, guess what?  Still need to know them!

And number one in the list:  it's the indications for liver metastasis resection. You know, this is one of the funniest ones to me because every time I study or teach for the Absite, I think of this fact.  What it is, is basically the indications to do a liver metastasectomy.

"If the patient can tolerate it"...it's kind of a funny fact. I mean, what procedure do we do for patients that they're not going to tolerate?  Is there any elective procedure that we say, "Hey, signing you up for this procedure. Don't think you're going to tolerate it"?

It's sort of bad judgment to do that. And that makes this one of the most foolish facts. Jessica, what do you think? 

Jessica:  Can they tolerate it?  I mean, it just seems so silly to me. Obviously, if a patient isn't up for surgery, then you have to use your best judgment, but at the same time, what is your other option?  What surgical options do you have?  So this is definitely one of the facts that just seems a little redundant to me. So I don't know. That's just my opinion.

Dr. Kashmer:  Well, it turns out that there may be more behind this fact than meets the eye.  In cirrhotic livers, especially, you can only resect so much liver.  The parenchyma as a whole is dysfunctional.  You need very little functioning liver to do all the things the liver needs to do, like make sure your mental status is okay and allow your INR to be okay. And all the different things the liver needs to do. You actually need surprisingly little of it.

However, in patients who are cirrhotic, they cannot tolerate resections that are substantial. And so you have to use some judgment to say, "Hey, this metastasis is this large. I'm going to have to take this much of the liver. The patient may not tolerate it." So I think in some ways this is a deceptively simple fact, but on the face of it, it just sounds so foolish.  "If they can tolerate it." That's one reason to go ahead and do the resection. I mean, really? 

Coming in next on the list is very different fact from the first and that's number two, the classic saying quote, "-Osis bleeds and -itis perfs."

Well, what we're talking about here is diverticulitis. And as you know, as we get older blood vessels, the sites where blood vessels enter and leave the colon get progressively weak, and then we get these outpouchings in those areas and these little areas are called diverticulae. Don't need to tell you that. But what's interesting is the classic fact that diverticulosis bleeds. So if you have a lower GI bleed and it's owing to diverticulae it's diverticulosis.

Diverticulitis perforates.  So if you have a patient with a peri-colonic abscess, and it's because they have diverticulitis, that's how it works. But to me, really, the fact behind this fact is that the patient has diverticulitis and these are manifestations of it.

It's like, yeah, these are two different disease scenarios and they're treated differently, but really it's all owing to the diverticulae that are there. So is it a fact yes, but on the face of it, to me, it just sounds almost foolish to separate those in our heads so distinctly, although we do it all the time. So is this the worst of the bunch of facts? No, but to my mind, this is all owing to diverticulae.

One is where they're infected and we do a certain thing and we look at the Hinchey classification and we, you know, we've changed it so much. The treatment of this disease, diverticulitis with perforation now in the acute care surgery world it's just changed much.  Jessica, any thoughts on this classic -osis bleeds and -itis perfs? 

Jessica:  Well, with this one, it's kind of difficult because it seems to be the original cause is one thing. And then it deviates and to just a slightly different form of the original issue. And so it's just really breaking it down. And I don't know, I just, it seems almost unnecessary because it all goes back around to the single cause. But again, I'm not the professional in this. I do see why you would have picked this fact though. And I definitely agree with you. 

Dr. Kashmer:  Next up on the list is one that seems redundant. Sometimes we say funny things in medicine, and these are classics that are funny to me and sort of favorites of mine.

One of them is the word "etiology".  "Etiology" is the study of the cause. And yet we use it all the time in medicine to mean the cause.  Etiology is the study of the cause of something where people use it all the time to just mean the cause. Well, what's the etiology of this disease?  Yeah, but really we're talking about what's the cause of this disease.

And then there's another great one like "liver cirrhosis".  Do we really see cirrhosis anywhere else?  It's almost redundant to say "liver cirrhosis", but we do it all the time. Well, here's one in that same vein coming into number three:  "the watershed area at the splenic flexure is vulnerable to ischemia".

Dr. Kashmer: Well, that's the same thing twice. We're talking here about Griffith's point and the way we write this in review books is really pretty redundant. The watershed area at the splenic flexure, aka Griffith's point, is vulnerable to ischemia. Well, that's what a watershed area is!

Probably one of the funniest facts to me because it's redundant. It always kind of makes me laugh. And I guess that's the kind of comedy you appreciate when you've read too many review books, but there you go, Jessica, what do you think about this maybe redundant fact?  Any thoughts about it? 

Jessica:  Honestly, the redundancy of this kind of reminds me how we say "tuna fish". I mean, it's a kind of fish. We don't go around saying "chicken bird" or "steak mammal". And so I'm not sure why we have to say "liver cirrhosis" because I mean, like you said, cirrhosis only happens in the liver. And so just these small little things where, like you said, it's redundant,

Dr. Kashmer:  Coming in at number four, some facts that are almost misleading in some ways. And that's why I think this is probably some of the dumbest or most foolish Absite facts.  This one centers around the colon. And we teach residents over and over that the colon absorbs five liters of water per day.

It's dramatic and its primary job is to absorb water. And so when you're asked on the test, "Hey, what's the primary, what, area of the bowel absorbs the most water?" or something like that while your mind immediately goes to colon because it's dramatic. It's five liters of water per day and its primary job is to absorb water!

But guess what?  The nasty little fact that flips things on its head is that the small bowel, the jejunum actually, absorbs 90% of water that's absorbed. And that kind of makes sense. The colon gets the leftovers of everything, including water, but we don't typically think of it that way because of fact number four that makes us feel the colon absorb so much. And it's so dramatic and it's five liters a day...but guess what?  The jejunum beats it out. So Jessica, what do you think about that one?

Jessica:  I actually remember when I posted this fact on our Insta daily.absite.fact and remember I thought it was weird because I also thought it was the colon.  I later learned that it was the jejunum, which is a weird word to me. I just thought it was really interesting. 'Cause I feel like even common knowledge wise, most people think of the colon.  

Dr. Kashmer:  Last on the list is Fothergill's sign. And this is filed under the obscure, almost-historic-interest-only signs that we all learn. They are important when we do physical exam to kind of have a sense of what's going on from our differential diagnosis. But under the heading of "let's get real" let's talk about fothergill's sign. This is related to abdominal wall hematoma. And when at lesion in the abdominal wall is more prominent where the abs are clenched that really tells you that there's something in the abdominal wall. Now sometimes it's a hematoma from Lovenox or some similar, you know, sub Q injection. It can be other things too and things other sub Q injections can give it. So it's typically associated with a lesion that's more prominent when you kind of sit up or clench the abs because it makes it more pronounced.

And that can be an abdominal wall hematoma or a soft tissue mass in the abdominal wall. What makes this fact so funny to me is that this isn't really how we typically find.  Internal medicine will consult us on a patient with a large abdominal wall hematoma, and they've typically gotten a CT or the patient is morbidly obese. So you can't really see it too well from the outside.

Anyway, really Fothergill's sign is one of those signs that you're never going to hang your hat on for which problem the patient has, but we teach it and we learn it.

And for that reason, although it's something to know.  We're not going to say don't learn it. It's still tested. It's still in the books. But come on, let's get real. This is not how we typically discover a patient has an abdominal wall hematoma, except maybe looking backward on the situation. It's one of those remnants of physical diagnosis before we really have more effective and efficient tests. So those are the five that we came up with. And Jessica, any thoughts about father you'll sign and kind of these, historic interest signs What are your thoughts on that?

Jessica:  Fothergill's sign?  I I just feel like it's helpful maybe in the old school way before we had technology and CT scans and everything.  Then it was a good way to deduce things. And I think there's a lot of stuff like that that which maybe we don't use as much anymore, but if you were to go overseas to a third world country, or if you're a military medic or something like that, then those kinds of things could still be helpful. And yeah, we may not use them every day in today's world because we don't have to and we've evolved past it. But just having that base, common knowledge seemed sort of helpful to me.

Dr. Kashmer:  Hey, everyone we hope you enjoy the five dumbest or sometimes least useful, or misleading Absite facts. We hope you enjoyed kind of thinking about those with us today. Those are some of my personal favorites and it doesn't mean that we don't learn them. It just means as we read it, we tend to be critical readers and critical thinkers. And we say, "come on."

And I think there's a value to that even as we study for Absite reviews.

Again, whether it's doing the liver metastasectomy and thinking to yourself, "You know, I should only do this if the patient can tolerate it." Well, of course!

Or whether it's a thinking that the watershed area at the splenic flexure, Griffith's point, is vulnerable to ischemia...well, of course it is!  It's kind of redundant!

Or whether it's "The colon absorbs so much water...it's five liters a day!"...but really the jejunum is doing most of the job.

We hope you enjoyed thinking about some of the five funniest, silliest, and dumbest Absite facts with us today.  Have a great day and good luck in your Absite prep!  And we hope that Absite Smackdown can help you out with it. #AbsiteSmackdown!

Jessica:  Guys thanks again for tuning in for another session with me and Dr. David.  And like he said, #AbsiteSmackdown.

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