The other day we had a patient come in for a CABG. Aside for some coronary artery disease, hypertension, and chronic kidney disease, the patient was pretty healthy. They were not on anticoagulation prior to the procedure.
After I gave full dose heparin for going on bypass (41,000U in this case), the ACT only came up to 422. An additional 10,000U of heparin was given with a repeat ACT of 457. Still, our surgeon was not quite comfortable with that number and requested an additional 10,000U heparin. The ACT came to 477.
If the ACT stayed in the low 400s, would you go on bypass? What if the ACT had not responded to the repeated heparin dosings?
Management of coagulation during cardiopulmonary bypass. Continuing Education in Anaesthesia Critical Care & Pain, Volume 7, Issue 6, 1 December 2007, Pages 195–198, https://doi.org/10.1093/bjaceaccp/mkm036.
Antithrombin III concentrate to treat heparin resistance in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2002 Feb;123(2):213-7.
Would you give antithrombin III or plasma?
Treating Heparin Resistance With Antithrombin or Fresh Frozen Plasma. The Annals of Thoracic Surgery. June 2008Volume 85, Issue 6, Pages 2153–2160.
Is there evidence that fresh frozen plasma is superior to antithrombin administration to treat heparin resistance in cardiac surgery? Interact Cardiovasc Thorac Surg. 2014 Jan; 18(1): 117–120.
We ultimately decided to go on bypass. Repeat ACTs on bypass were in the 500s. No antithrombin was given. After separation from cardiopulmonary bypass and administration of protamine, repeat ACT was 111. Protamine was dosed accordingly to heparin administration and ACTs while on bypass.
Recommendations for the use of antithrombin concentrates and prothrombin complex concentrates. Blood Transfus. 2009 Oct; 7(4): 325–334.
Thrombate (antithrombin III) package insert
A friend of mine’s son is just about to graduate from high school. He’s interested in medical school, and his mom asked me what advice I would give to help him pick a college knowing that he has an interest in medicine.
Keep in mind: I am not a counselor or an advisor. I am a physician, and this is what worked for me.
- If you’re interested in medicine…. start early.
- The college and medical school application process are getting more competitive. Students are bright, prepared, and eager. Let’s start with the basics. Are you sure you’re interested in medicine? Like really interested? Sure, the media portrays some glamour lifestyles for physicians… but it’s not all glitz and glam. You’ll put in at least a decade of extra work vs. your peers who get a job right out of college. While they’re building their nest egg, you are not.
- Luckily, I stumbled upon my interest in medicine at an early age when my family practice physician encouraged me to pursue it. He proved to be a great mentor as I was able to shadow him and really get a feel of his day and what he does.
- Once you’ve decided medicine in your passion… solidify that decision.
- Volunteer at the hospital. Observe your physician. Volunteer to help people. If this excites you, you’re on the right track. Put yourself in situations where you can get involved in medicine. Read and research what medical school is like. Reach out to a medical school and see if you can get more information: chat with a medical student, find out if anyone needs help with a research project.
- Do well in school.
- This is a must. Applicants are incredibly competitive and intelligent with tons of extracurriculars on their resumes. Get good grades. Do well on your SAT/ACT and then do well on the MCAT. Your grades and your test scores are the most basic comparison tool for schools to compare applicants. Doing well gets you noticed.
- Get involved and signup for extracurricular activities.
- Once you’ve put in the work for good grades and test scores… get involved. This could be anything: sports, clubs, arts/music, babysitting/caring for loved ones, volunteering, job in a lab, travel/cultural growth. The key is to show that you’re well-rounded and multifaceted all while achieving the good grades. Once the colleges and med schools have seen your test scores, they’ll next use your extracurricular activities to help separate out the different applicants. The key is maintaining good grades while all these other activities are happening. AAMC fact sheet for medical schools.
If you’re in high school and interested in medicine:
- Get good grades and do well on SAT/ACT (consider college prep courses to help)
- If you’re able to take honors classes or AP classes and do well, definitely sign up for these. It’s another way to separate yourself from other applicants.
- Volunteer at your local hospital and/or doctor’s office
- Get a job at a research lab or hospital
- Get involved in extracurricular activities
- Talk to your high school counselor about career paths
- Attend career fairs (my school offered a career night in medicine where we got to go into the operating room) and college fairs on getting into medical school
- Ask a college pre-med what they’re taking and how to do well in college
- If you’re torn between two schools on your college list, consider taking a good look at the college that may also be linked to a medical school. There’s a good chance that some of the medical school professors will be teaching some of the upper level physiology or anatomy college courses. Some of the professors may also sit on the admissions committee to medical school. Lastly, it may be easier to get involved in clinical research or scientific studies that the medical school professors are working on… and that would be a great way to introduce yourself to medical school staff as well as get a stellar recommendation letter to show off your work ethic and dependability.
If you’re in college and interested in medicine:
- Get good grades and do well on the MCAT (consider prep course to help)
- Get a major in something you’re interested in (you do NOT have to be a pre-med major… you just have to take the pre-med prerequisites to take the MCAT and apply for medical school). Even though I majored in biomedical science (a pre-med major at Texas A&M), I would have done biomedical engineering if I had a do-over. Science and math have always been my interests…the engineering major would have given me a nice background beyond my pre-med major.
- Talk to your college counselor/advisor early (freshman year)
- If you get into an honors program in college (usually based on your SAT/ACT scores), go for it. Typically the honors classes are smaller and are a fantastic way to build report with your professor as well as get deeper into the subject matter. Plus, being in the honors program will further help you standout on your application to medical school.
- Volunteer at the local hospital. Although you may start out as a volunteer, see if you can get into the OR (operating room) as well as outpatient clinics. This will expose you to a wide variety of practices: surgery, anesthesiology, pathology, internal medicine, family practice, OB/GYN, specialties, etc.
- Get involved in extracurricular activities in college. There are a ton of clubs and interest groups in college. If you don’t find one you like, start your own!
- Need a job in college? Consider getting one in the research lab or at a medical school or in a hospital.
- Consider doing summer school to get some credits out of the way. When I was in college, 12 credits was a full-time student. I always took 15 credits because I thought I could handle it. (Now I cannot recommend the following…) My junior year in college, I signed up for 21 credits to see if I could handle a medical school work load. It was a tough semester, but I did it and got a 4.0. I wouldn’t recommend that route because you need to focus on grades… but it worked for me.
- Apply to a lot of medical schools (in-state and out-of-state). I grew up in Texas and at the time they had a Texas match with 7 medical schools. I only applied to the Texas (in-state) medical schools because I knew that was all I could afford. Keep in mind your debt burden: a $9,000/yr education vs a $30,000/yr is a big difference. I chose an option that made the most sense to me — I didn’t want to be in debt forever. In fact, I highly recommend reading this book: The White Coat Investor: A Doctor’s Guide To Personal Finance And Investing. If I had that available to me, I would’ve read that in high school… re-read it in college… read it again in medical school… and read it again throughout life. Yes, I’m constantly revisiting this book because it is that good.
- Interviews: honestly, I can’t remember if I interviewed for medical school or not (geez that makes me sound old!). If you do have interviews… put your best foot forward and practice interviews with your friends/parents/professors/etc. Be positive, engaging, and professional. Interviewers DO judge a book by its cover.
- Once you’ve applied to medical school, sit back and wait for your results to roll in. Honestly rank the schools you would like to go that caters to your learning style/goals/etc. My medical school (UTMB) was one of the first in the country to incorporate systems-based learning and problem-based learning.
- Systems-based = learn subject material based on the different organ systems vs. separate anatomy, physiology, pharmacology, pathology, etc. (I learned based on the cardiovascular/gastrointestinal/genitourinal/neurological system, which included the anatomy, physiology, pharmacology, pathology, etc related to that system. I thought it was a more intuitive way to learn medicine) .
- Problem-based learning involved small groups where we would discuss medical cases, labs, clinical problems, etc. It was a nice environment to express yourself as well as work together in a team. This is how the real-world works where you talk to your colleagues to work through various medical issues. It supports professionalism and engages a teamwork mentality.
- Lastly, thank the people who helped you get here. It’s easy to overlook your mentors, friends, professors, and family. As you enter the medical school/medicine world, your family will learn along the way that you made a commitment to a profession that will take priority over them. You will miss weekends, evenings, date nights, holidays, anniversaries, etc. Not only will you sacrifice a lot to get to medical school… you’ll continue making sacrifices once you’re out practicing medicine in the real world.
AAMC fact sheet for medical schools