You know, some of the questions that we have, like we said, they were not good questions. But the subjects are important. So if it's there, just review the subject. Like we're talking about global. I don't mean specifically global child, but there were some other ones in review the subject and just go and read it without dissecting the question. And I have one trivia question. I heard Dr. Zimmerman taught me this. And I want to see what you guys know. Do you like, do you guys like cherry pie? Yeah. Yeah. Kendall Bialas. Kendall Bialas, we have your credit card at the customer service. Please go back. Kendall Bialas, we have your, oh, the driver's license. I mean driver's license. We have a driver's license. Okay. Yes. Study questions or class questions. Are there any particular questions that you recommend or it's advised and where are the sources we should be looking for good quality questions? I'm not aware, are you aware of any, I hear somebody was talking about something that's called class machine, but I really don't know. For, I don't know if it's, Teresa, is the SCCM boards, question boards still available? Yes. They are. You can, you can get those and there's also a practice test on the learning module that you can take and an extra 30 questions plus all of these. So there's a lot of practice questions. Yeah, so you'll get, everything that we're doing here, you'll get an extra 30 questions and there are resources through SCCM. That's what I used to use, the SCCM practice questions. Again, the questions are good, they're not perfect. So, you know, don't argue with the questions, just learn from them. The class machine has a huge question. Yeah, I don't know if somebody mentioned that. Was that the pass machine? It's called, yeah, some. The thing is, you know, some of the things that we mentioned is like, as you're doing questions, try to not like, oh, you know, trying to figure out only what the, of course you need to know what the correct one is, but try to do what, you know, what we were saying, dissect a little bit the answers and say, this is, this makes no sense, this makes no sense. So then you are in between two questions, two answers. And then, of course, you have to have the knowledge to answer which one is correct. Any other questions that we missed? Sorry. Okay, I want to hear about the cherry pie. So, the cherry pie, I mean, that's my trivia question. Okay, so I, which cherries are the best to make a cherry pie? What type of cherries? I will show you the background. I didn't grow up clearly in the United States, and for me, cherry pie is too sweet. And, but I, Dr. Zimmerman educated me the other day when we were having dinner. So, it looks like I was eating the wrong cherries. That's why it was too sweet. Okay. Nobody knows. Sour cherries, okay, good, good. Excellent. From where? Where? No. You see, Dr. Zimmerman is an expert. What else? Okay. Anyone from Michigan here? Yes. So, from Michigan, yeah? Okay, and what are the best apples? Oh, okay, and Wisconsin, yeah. There you go. And what are the, and the best apples for apple pie, what type of apples? Macintosh, okay, pass. Okay. Okay. Okay, well, guys, thank you so much. We really enjoy these almost three days here. I hope you're not exhausted. You have our emails. Feel free to send us an email with any questions and also feedback, because we want to hear and see what things we need to modify or what things really work very well. Best of luck with the exam. You'll do well. It's just a test. Painful test, but it's just a test. And safe travels, everyone, and it was great to have you here. What do I do? Oh, oh, we're going to keep more, oh, we're going to do more questions. I'm sorry, I didn't realize that. That's not the plan. Should I do the questions again? I got it. Okay, I got it. Okay, sorry. We have this all planned out, and she totally went off script. So if anyone needs or wants to leave, you're welcome to. But as I said, we're going to go to 1.30 and get you all the questions that we didn't get through on the first day. So I'm watching the time. What's your flight? Okay. Okay. It is great, though, to see a course like this that everyone is still here at the very end, because you go to any other conference and half the room's empty by the last session. So thank you. All right, we're going to go through these super fast, just to at least get you the information. We'll go about, whatever, 15 minutes, and that's it. So long stem, let's read the question. Which of the following best explains acute decompensation? Look at the choices, they're all respiratory. It's not going to be a sepsis question. It's not going to be a metabolic question. At least frame your mind on what this is. 16-year-old boy with Ewing's undergone chemotherapy. You know, you can skip a lot of these words because they're going to be irrelevant. Uncooperative with incentive spirometry. He's been immobile since surgery. A rapid response call finds the patient cyanotic and encephalopathic. Vital signs, he's tachycardic, 155. Blood pressure's normal. Tachypneic at 30. Desaturated with a pulse ox of 70% and a low-grade temp. He's given 100% oxygen by face mask, doesn't improve. Is orally intubated. Tube is confirmed by capnography and the patient's transported to the PICU. Auscultation shows symmetric breath sounds. Chest radiograph shows the endotracheal tube's in good position. Remains desaturated at 85% despite hand ventilation. His end tidal CO2's 35. Blood gas, 732, 55. PO2 of 15 and a bicarb of 27. What explains his decompensation? So before we even go through this, just in terms of teaching, what do you think this is gonna be? What's the key here and what they're giving you? You know it's respiratory, and you've got an end tidal CO2 that's notably lower than the PACO2. So with that, it's gonna be shunt physiology. So which of those choices does this essentially have to be? So let's go for 100% with that kind of leading you. Okay, it's gonna be pulmiambuli. So all that stuff about the chemotherapy and the radiation, all red herrings just to kind of throw you. That's the key difference here is that the end tidal CO2 is 20 lower than the PACO2. Thus, you have dead space ventilation. And the one entity here that's gonna give you that. You know it's not malfunction because the patient was handbagged. Probably not a pneumothorax. It's not gonna cause that. Atelectasis and pleural fusion, same thing. So you know what this has to be. All right. Next one. Okay, this comes out of some of the talks earlier today, some of Ed's talks yesterday. This is, we'll go again backwards here. So which of the following most likely lead to extubation failure? You're looking at markers of extubation success. And you can see in the choices here, it's kind of a potpourri of different options. So this is a 12-year-old girl with myotonic dystrophy, no prior lung disease, is intubated for staph pneumonia with ARDS. She's been ventilated for eight days. She's weaned to a PEEP of five now with a peak pressure of 18. Her TOT of IM6 per kilo and her vent rate's only eight. Her PAO2's 80. Her PCO2's 45. She's off vasoactive agents. She's appropriately awake for a point of extubation. So which of these are most likely to lead to extubation failure in this patient? So NIFM of 15, an endotracheal cuff leak of 20, an increase in heart rate during a spontaneous breathing trial, a TOT of IM of five per kilo, an admitted ventilation of seven and a half per kilo, again on a spontaneous breathing trial, or a PF ratio of 250. Oops, we'll move quickly there. So it's the NIFM. If we go back up here, it's a neurologic entity, so the most likely thing here that's going to lead to a failure is going to be a NIFM. That's not adequate. You've heard numbers of minus 15 to minus 20. They're not going to test you on whether it's minus 15 or minus 20, something in that area. But her negative inspiratory force is not adequately negative. Endotracheal cough leak of 20 is reasonable. The data on that is very controversial. They're probably not going to test you on that. A heart rate increase of 70 to 90 doesn't really get your attention, and the total volume of 5 per kill in a period of ratio of 250 should not preclude extubation. So you can also do this by process of elimination. This one we're going to skip because it's a repeat of the earlier one. Initial treatment of pulmonary hypertension, what, oxygen, right, done. OK. We'll go through this one here. A 7-year-old boy presents to the ED with a rash, multiple areas of bruising, his energy levels down. He has a petechia rash and echemotic lesions, his tachycardic to 145, his respiratory rate is 37, punch line, his white count is 443, his hemoglobin 7 with a platelet count of 21, and which of the following is most appropriate? And don't argue with the question that A you're going to do anyway. So just don't choose A, OK? What would you do first? Essentially, PAC transfusions, leukophoresis, or nothing until you get a definitive diagnosis. OK. So leukophoresis, as most of you chose, with the white count of 443, the risk's now with a white count that high, regardless of whether it's ALL or AML, you're in the risk zone, and you would do leukophoresis. Would you admit to the ICU? Of course you would. It's not a choice there. You would do both. But one of the keys here, the high white counts, is in general, PAC transfusions are contraindicated because you don't want to further increase the viscosity. So PAC cells is clearly a wrong choice here, and with a white count that high, you would not wait for a diagnosis. But the last one you had, he or she was symptomatic. I mean, you still picked P.D. from the last one before, but that one was more straightforward because it was symptomatic. Yeah. It has a regulatory error. That doesn't matter, right? Right. But once you exceed, the general teaching is exceed 400,000, even if it's ALL. And I forgot what the AML is, 200 or 300. It's not an area I have. It's just so high. And often in these kids, I agree, this isn't a great question. They'll probably give you some subtle symptom. Yeah. Because they're not going to test you on that. What's the absolute white count cutoff? All right. Let's skip that one. It's straightforward. Just trying to get through the... All right. This is pretty much the same questions. And we've done... These are the statistical ones that have already been done. I think we're... Oh, actually, this... All right. We'll do this one. This might be the last one. This is actually a good question. So this is long-stem again. So the signs and symptoms are most consistent with what? ARDS with pulmonary contusion, transplantation. ARDS with pulmonary contusion, transfusion-related lung injury, diffuse axonal brain injury, fat emboli syndrome, or cardiogenic cerebral emboli. So this was a 16-year-old who was driving, broadsided by a log truck. She was extracted from the vehicle. She sustained multiple long bone fractures, received two units of PAC cells by ortho. 36 hours later, on the general pediatric floor, she had an increasing O2 requirement, student alteration in mental status. She had a new petechial rash. She was tachycardic at 132, slightly tachypneic at 29. She was desaturated to 88%. Her Y count's 18, CRIT's now 26, and the platelet count of 60. And at this point, her brain MRI is unremarkable. So what does she have? ARDS, transfusion-related lung injury, diffuse axonal brain injury, fat emboli syndrome, or cardiogenic cerebral emboli. You can say she may have more than one of these things, but what's most likely that ties together all of her symptoms? All right, we're going to end on some positive notes here. There we go. Fat embolized syndrome. Does she have ARDS? Probably. But the key here is what's going to cause pulmonary, skin, and brain changes at the same time. It's going to be acute fat embolized syndrome with a showering of fat. MRI will become abnormal. This was done immediately, but you will see some changes over time. But the key here is when you see those three things after an orthopedic injury and procedure, it probably is related. Good. It is exactly 1.15, so I'm going to stop there and turn it back to Annalia and Mike so you guys could actually really close out. Do you guys have any questions? Okay. Well, I already said goodbye to everyone, so again, good luck. One comment, in addition to what Ira said and what we discussed over the last few days, read the question because, again, you know more than, sometimes it's like, oh, that's not what I would do. I would just go and tap the pericardial effusion because that's what I need to do. But just read what they are asking you. How do you solve 100% of the problem, or what's the best next step? So be careful reading the question to be able to answer the correct answer. Anyway, again, thank you, everyone. It was great to have you here. Let us know if we'd like to hear the feedback. There are some evaluations. We would like you to complete the evaluations and let us know how, you know, things work out for everyone. Safe travels and best of luck with the exam.

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