002 Mark Klimek

The speaker discusses the psychological aspect of alcoholism, focusing on denial as the main issue in abusive situations. Denial hinders treatment as abusers refuse to acknowledge their problem. Confrontation, not aggression, is key to addressing denial by pointing out the inconsistency between what they say and do. The lecture emphasizes using "I" language rather than "you" when addressing conflicts to avoid aggression. Denial differs in abuse vs. loss and grief situations, where support is needed. Dependency and codependency are also highlighted, with the abuser seeking a life without responsibilities while the significant other gains self-esteem from fulfilling their needs. Setting and enforcing boundaries is crucial in treating these dynamics. Dark, very dark. Okay, alcoholism. Page four, alcoholism. Going into some psych and some medical statistics. I want to talk about the psychological aspect of alcoholism. It's called psychodynamics. The number one problem in alcoholism, psychologically, is the same as the number one problem in any and all abusive situations. The number one problem in abuse is denial. Denial. Abusers have an infinite capacity to deny. In fact, an abuser has to deny in order to continue the behavior. And what does denial allow that abuser to do? Keep doing it. Keep doing it without having to answer for it. They just deny they have a problem with it. Now, I want you to understand, the title of this lecture is what? Alcoholism, but the first part is you can use the alcohol rule for any abuse. So what's the number one psychological problem in child abuse? What's the number one psychological problem in gambling? What's the number one psychological problem in cocaine abuse? What's the number one psychological problem in spouse abuse? Elder abuse. Denial is the number one problem in all abusive situations. Why is it number one? How can you treat someone that denies they have a problem? Right? So until they admit they have a problem, you've got a problem. Okay, definition. A, definition. What's the definition of denial? It is refusal, that goes in the first blank, refusal to accept the reality of a problem. They refuse to accept the reality of it. They say, I'm not an alcoholic. I can quit any time I want. I'm not a spouse abuser. We just have a really physical relationship. I'm not a child abuser. I'm just a really strict parent and my kids aren't spoiled. You see what I'm saying? I'm not a gambler. I like games of chance. I'm not a food abuser. I'm a poor mom. You know, they have all these denials about their problems. So how do you treat denial? Letter B. You treat denial by confronting it. You confront it. Con-front. You confront it by pointing out to the person the difference between what they say and what they do. So how do you confront someone is this. You say, okay, you say you're not an alcoholic. It's 10 o'clock in the morning, you already drank a six-pack. You know what I'm saying? You know what I'm saying? You just confront them. What did I point out? The difference between what she said, which was what? I'm not an alcoholic. And what she did, which was? Drink a six-pack before 10 o'clock in the morning. You say you're not a spouse abuser, but she has a restraining order against you. Do you see the confrontation? You say you're not a child abuser, but protective services has your children. You say you're not a food abuser, but you're 400 pounds and you're 5'1". Do you see what I'm saying? It's my thyroid. Okay, it's your thyroid. But the point is that they will deny what they have. And you confront it by pointing out the difference between what they say and what they do. That's confrontation. Now, don't get thinking that confrontation is the same as aggression. Confrontation is aggression. Don't get those two things mixed up. Because aggression attacks the person. And aggression says, you are too an alcoholic. You jerk. You have to admit it. You see, what did I attack? What did I attack? Her. You. Jerk. Admit it. When I confronted, did I attack her? No. You what? Say you're not an alcoholic. Okay, you say you're not an alcoholic. Did I attack you? No, I said you say you're not an alcoholic. But, it's six pack gone by ten. I mean, did you, you know, you're just saying, you're just saying, hey. You're not saying right, wrong, good, bad, horrible, wonderful. You're just saying, hey, this is what it is. This is what I see. You confront. So don't get confrontation mixed up with aggression. Aggression attacks the person. Confrontation attacks the problem. On boards, never attack a person. Just another little note. They have these questions where you're dealing, you're interacting with staff. And they'll say something like, you're dealing with a staff nurse that has more seniority than you on your first job. And they just find fault with everything you do. You understand the scenario? Well, how do you handle that? What do you say? Does anybody know what you say? What's bad to say? And think about pronouns. What was bad, what pronouns would bad answers have and what pronouns would good answers have in that scenario? You versus I. So, explain that to me. What do you mean? What's the good and what's the bad? The good answer has what answer? I. Bad answer has you. So, what don't you say then? Why don't you say that? Why don't you like me? Why are you so mean? The right answer is, I seem to be having a, I seem to be frustrated. I seem to be having a problem or we are seeming to not get along well. You see what I'm saying? Always, when you're dealing with psychodynamic problems with staff, say to your, use the I. I'm, I'm, I'm, not, you, you, you. Do you understand that? That's a real big thing they are testing a lot now. Okay. Same thing with physicians. Physicians, when you question them on the phone, don't say, you wrote the order incorrectly. You say, I'm having a difficult time interpreting exactly what you want. Do you see the difference? Okay. So, when they are in denial, what do you do? Confront. Deny, confront. Deny, we're going to link that in your mind. Deny, they deny, you confront. They deny, you confront. However, be careful because there's another place where denial is opposite and that is loss and grief. Don't people go through denial and loss and grief? Have you heard of those cases of death, denying, loss and grief? Yes. What are they? Dabs. Dabs. D-A-B-B-A. D-A-B-B-A. Denial, anger, bargaining, acceptance, depression, I mean depression, acceptance. Denial, anger, bargaining, there's your dabs. And depression, acceptance, there's your dabs. So, denial is an accepted, healthy, normal, first reaction to grief and loss. So, what do you do for the denial of loss and grief? Do you confront it? What do you do? Support it. The word is support, you want to support it. So, my point is this, when you get a patient in denial, what do you have to pay attention to to get the question correct? Is it loss or abuse? Is it loss or abuse? With abuse, you what? Confront it with loss, you support it. I've been in college of 3,000 in a town of 3,000, where there's one student for every person in the town. But we were basically a farming community with a college, and we have a lot of one-handed men in our town. Why? Bailer accidents, the bailers amputate their hands. So, we have a lot of farm machinery, one-handed bailer accident guys. Can you imagine a guy, a farmer comes in, his hand gets amputated, and it's all wrapped in a bandage. The next morning, you're taking care of him, and he says, I can't wait to go home and play piano. Problem. He only has one hand, right? So, he's in what? What is he refusing to accept? The reality. Is that denial, refusing to accept the reality? So, he's in denial. What would you never say to him? You say you're going to play piano, but you only have one hand. That's called what? Confrontation. Now, is confrontation okay for denial? Yes, as long as it's abuse, but not if it's loss. And this guy is lost. So, what do you do? You say, oh, well, how long have you played piano? What's your favorite kind of music? Did you take lessons? What are you allowing that denial to continue? You're supporting it, because it serves a function. Does everybody get the difference? So, if you've got an alcoholic, and the alcoholic says, well, I'm not an alcoholic. I can quit any time I want. He's in what? What's the strategy? Confront. What would be really horrible to do? Support. You wouldn't say, oh, how long have you been drinking? What's your favorite beverage? Did you take lessons? Did you ever go to have that hurricane over there at MacGyver's Bar? You don't support it. So, you see where you've got two totally different answers for denial. Just pay attention to that. Okay, let's talk about the number two psychological problem that a man has. And that is dependency, codependency. Dependency is when the abuser gets the significant other to do things for them or make decisions for them. In other words, the abuser says, oh, would you call my boss? Would you go do this? Would you do that? And they do it. So, who is dependent? The significant other or the abuser? The abuser is dependent. Now, codependency, on the other hand, is when the significant other derives positive self-esteem from making decisions for or doing things for whom? The abuser. So, the abuser says, call my boss, tell him I'm sick. That's an example of what? Dependency. Dependency. The significant other calls the boss, says he's sick, he can't come to work, hangs up, says, oh, aren't I a wonderful spouse because I did that because I don't know anybody else would do it for that jerk. What are they? How do you know they're codependent? Did they get positive self-esteem? Yeah, what did they say? Oh, aren't I a wonderful spouse because I did that? See, they have this rather pathologic yet symbiotic relationship. You know, one is dependent, the other gets positive self-esteem from meeting those dependency needs and they just feed off the other. What does the abuser get out of a relationship? What does the abuser get out of a relationship? Well, that's what you're doing. Yeah, a life without responsibilities. He gets to keep doing whatever he wants, abusing. What does the significant other get out of it? They feel good. Positive self-esteem out of it. And then we sit there and we say what from the significant other? Leave it. What are you doing in that relationship? Get out of it. Right? But they can't get out of it because they're what's tied up in that whole thing. Their self-esteem. So, you know, I mean, it's really kind of tough to treat. Well, then how do you treat it? How do you treat it? Well, number one, you set limits and enforce it. You set limits and enforce them. That goes fill in the blank. Set limits and enforce them. In other words, you start teaching the significant other to say the two-letter word, no. And then they have to keep doing it. Would you call my boss? No. Would you go buy me some? No. Would you drop me off at the track? No. Would you get me a ham sandwich out of the refrigerator? Well, see, that would be okay. Now, I'm not saying say no to everything. I'm saying say no to those things where you're feeding into everything. All right? But that's not good enough. That alone will not work because you must work on the self-esteem of the codependent person or it will never work. Because as soon as the codependent starts saying no, what will the dependent abuser start saying? You don't love me anymore. You're a mean, nasty old whatever because you are just horrible. You're horrible. And what's that person playing right at? Self-esteem. They know what side the bread's buttered on. And they go right at that person's self-esteem and within 10 minutes they got them emotionally manipulated right back into the whole system. So, in order for this to work, what does the codependent person have to say? I'm saying no and I'm sticking to it because I'm a good person because I'm saying no. Oh, you're nasty. I don't care what you say. I'm a good person. And that's how you can work on it. The thing is I worked at Lafayette Clinic in Detroit, Michigan for a couple of years and it's mostly alcohol rehab and seizure. And we found that when we treated codependency dependency successfully, when we treated this problem, guess what we lost? The relationship. You know, the codependent person goes, I'm a good person. I don't need you and why am I here? And they leave. So, you know, we solve the problem but lose the relationship. Real problem. Okay, turn the page. Let's talk about manipulation. What's the definition of manipulation? It's when the abuser gets the significant other to do things for him or her that are not in the best interest of the significant other. The nature of the act is dangerous or harmful. What goes in the blank is interest and harmful. Interest and harmful. So, how is this life dependency? How is manipulation life dependency? Yeah, in both situations the abuser is getting the other person to do something for them. Then how in the world do you tell the difference between those two things? What's that? Well, neutral versus negative. Look at what they're being asked to do. If what the significant other is being asked to do is neutral, no big deal, no harm done, no harm, no foul, it's simply dependency codependency. If what the significant other is being asked to do is inherently harmful or dangerous to the significant other, that person is being manipulated. So, let me give you two examples and you tell me which one is denial, I mean, which one is dependency and which one is manipulation. A 49-year-old alcoholic gets her 17-year-old daughter to go to the store and buy alcohol for her. That is what? Lying. Well, because a 17-year-old going to buy an alcohol is illegal in the state of Ohio. So, it is illegal. So, she's being asked to do something illegal. Now, what about this? A 49-year-old alcoholic asks her 15-year-old husband to go to the store and buy alcohol for her. Of what is that an example? Why is it dependent? It's the same thing, buy an alcohol. I mean, well, in terms of age, how harmful is it for a 50-year-old man to go to a store and buy alcohol? Any harm? No. So, that's simply dependency. But when the 17-year-old goes to buy alcohol, that's illegal, there's harm, that's manipulation. Let me give you an example. Tuesday evening or last Friday evening. Remember Tuesday, last Friday, around here? Yeah. Okay. Your neighbor calls you. No, your brother calls, sister-in-law calls you. Would you pick up little Billy from basketball practice at school? So, he could spend the night at your house because of the snow. Now, you have a... What's a four-wheel drive what? Hummer Jeep. Hummer Jeep. What's best in the snow? Not ice, but snow. What? Four-wheel drive, some big... Okay, you got a big Earth Mover, four-wheel drive. Okay. And you live three blocks from the school. And you say, okay, sister-in-law, I'll do that. You are being what? She is being dependent on you. You're being co-dependent because you'll say, oh, aren't I a wonderful brother-in-law for doing this, right? What if your sister-in-law calls you? She's got the four-wheel drive all-terrain vehicle. She lives three blocks from the school. She asks you to pick up her son and take him to your house. You have a Kia Sophia with ball tires and it starts every other time. It leaves soil, got no heat. You see what I'm saying? And you live 20 miles from the school. And what's happening here? You're being what? Manipulated. Manipulated because it is inherently dangerous for you to get in that car and go that distance when she could do it easily, safer, better herself. Whereas in the first one, it was safer and better for you to do it than... You see what I'm saying? Dependency and manipulation are similar. It's just the only way you tell the difference is one, you're being asked to do something which is bad for you. That's manipulation versus something that's neutral, best, dependency, codependency. Can you tell the difference now? Okay, good. All right. How do you treat manipulation? You set limits and enforce them. Please start saying what two-letter word. No. Number two, it is easier to treat them dependency, codependency because nobody likes being manipulated. I have never heard a person say, oh, I must be a wonderful person for being manipulated. Do you know what they all say? I must be an idiot for falling for that. Do you hear any positive self-esteem going on? No. So there's no positive self-esteem issue going on with manipulation like there is with dependency, codependency. You see why it's easier to treat? Okay, let's just summarize. How many patients do you have with denial? If Bob is in denial, how many patients do you have? One, two, or three, or four? Bob is in denial, how many patients do you have? One, two, or three, or four? One. Bob is dependent, how many patients do you have? One or two? Two because you've got to get the codependent. Bob is a manipulator, how many patients do you have? One or two? One. One. You see what I'm saying? Because you don't have to do anything with the person who's being manipulated because there's no self-esteem issue. So with denial, you've got one patient. With dependency, you have two patients. With manipulation, you have one patient. Does that make sense? Okay. Let's talk now about things specific to alcoholism. Let's talk about Wernicke or Corsica. Wernicke and Corsica. Typically, they are separate, but Bortz often lumps them together. Wernicke is an encephalopathy and Corsica is a psychosis. But they tend to go together. You find them in the same patient. So Wernicke-Corsica is, number one, psychosis induced by vitamin B1 or thiamine deficiency. This is a scenario where you lose touch with reality. You go insane because you don't have B1. What's it mean? Psychosis. Psychosis, which means insanity or loss of touch with reality. These are psychotic people, not just a little bit emotionally disturbed. These are psychotic people. The primary symptom, number two, is amnesia with confabulation. Amnesia with confabulation. Amnesia means memory loss. Confabulation means making up stories. Why do they make up stories? Because they forgot. Well, in that case, then I'm psychotic. Because I often make up details that I have forgotten. Right? So then why are they psychotic and me not? Fair question. Why? So everybody that forgets something and makes up a story to fill in what they forgot is insane psychotic. True or false? False. Well, then explain to me the difference. Why? Why are these poor people called in as psychotic and we're not? Because they believe it. See, when I fill in details because I forgot, I know it's not really true. But they really believe it. The lie is just as real as reality. And their memory loss is not, Oh, I forgot what I did last night when I was drunk. No. It is, What happened to the 90s? They don't remember anything in the whole 1990s. They'll lose entire decades of their memory. So what will they do? Make up stories as to what they were doing during the 90s. I had a guy that was working. Oh, he was Ronald Reagan's national security advisor during the 80s. The guy had never made it past third grade. Now, whatever you thought of Reagan, he wasn't that bad that he went out of third grade to run in the national security. You know what I'm saying? So he definitely was never Reagan's national security advisor. He thought he was. He could tell you meetings, dates, times, people. He had this whole psychotic reality built around Ronald Reagan's terms in office. And he believed it. He literally believed it. He believed that that was as real as anything that was happening right then and right there. So, how do you deal with that? How do you deal with that? How do you deal with that? You've got a Wernicke's, Korsakoff guy who thinks he is Obama's secretary of defense. And so he's got to get up and go to a cabinet meeting right now. How do you deal with that? What would probably be a bad way to deal with that? What's that? Okay, we don't usually agree or disagree. We don't confront why. Why? Right. And it's due to brain damage. So are they ever going to learn what's true and what's real? So is this permanent or not? Typically permanent. So you don't present reality because they can't learn it. So what do you do? See, there's the questions they ask you. They give you a person with Wernicke's and they say that Wernicke's says he's going to a presidential cabinet meeting at 8 o'clock this morning. How do you deal with that? Okay, distract is known as, give a word as redirect. Redirect is a really good word. And that means to take what he's all about that you can't do and rechannel it into something he can do. So can he go to Barack Obama's cabinet meeting this morning? No. So what you do is you say something like this. Well, why don't we go, why don't you then get a shower. When you're done, we'll go watch CNN to see what the news of the day is in Washington, D.C. You see that? Is he going to do that? Probably, because he, you see what I'm saying? And you don't get into a fight with him about, no, you're Joe the milkman. You're not Ronald Reagan's national security advisor. You see what I'm saying? Because that's fruitless and pointless. So when somebody has Wernicke's and Korsakoff's and they talk crazy, what do you do? Redirect. You don't present what? Reality. Because presenting reality is for those people that you think can learn it and these people can't learn it. So redirecting them is the way. Now let's talk about characteristics. Number one, it is preventable. You never have to get this in the first place. How can you prevent getting this in the first place? Take vitamin B1. By the way, vitamin B1 is a coenzyme necessary for the metabolism of alcohol. You don't have to know this. It's necessary for the metabolism of alcohol. So if you don't have B1, you won't metabolize alcohol. It won't go into Krebs cycle. Does that sound familiar? It won't get burned up for energy. So what will it do? Accumulate. And where will it go? Brain. And it will destroy brain cells. That's how this happens. So all they need to protect their brain is to take vitamin B1. And any alcohol they drink will be what? Metabolized. So they don't have to stop drinking. Stop drinking. All they have to do is take their one a day with their vodka in the morning and they'll be fine. They will be perfectly fine. You get a lot of good compliance with this. B, it is arrestable, which means you can stop it from getting worse. How can you stop it from getting worse? Take B1. Stop drinking. Stop drinking. They stop drinking necessarily. No. C, it is irreversible. Now, not everybody that's irreversible, but it's about 70% irreversible, so you always say irreversible. Do you understand on boards you always answer with majority? If something is majority of the time fatal, you say it's what? Fatal. Fatal. You don't say, well, you know, 5% of the time it's not fatal, so I'm saying it's not fatal. No, don't do that. Go with the majority. So it is irreversible. So it's preventable, it's arrestable, and it's irreversible. Two good news, one bad news. All right, let's turn the page and talk about some drugs that have to do with alcohol. Antibiotics or Revia. Antibiotics or Revia. Does anybody know the generic name for this new drug? Disulfiram. Disulfiram. Number one, it is aversion therapy. Aversion therapy. It's a form of aversion therapy. Now, what aversion therapy is, is this. The word aversion means a really strong hatred for something. A gut hatred for something. What we want alcoholics to develop is a gut hatred for alcohol. That's what we're trying to do here. Well, how do we do it? Well, we give them this drug. Now, you don't have to write this down, but just sort of listen to this for a second. When you take this drug and it gets to a blood level in your blood, if you drink alcohol, it will interact with that chemical in your blood and make you super sick to your stomach. Not like, I mean, really super sick. Horribly ill. Let me ask you, have you guys ever been to a restaurant and gotten sick afterwards from eating at that restaurant? Anybody? Will you eat at that restaurant anymore? Now, if you go, you probably won't order, you may order something else, but you're not going to order what made you sick, because you have developed a what? A what? Aversion to that restaurant. Okay? Because if I gave you a $20 bill right now and said, go eat at that restaurant and buy that meal, would you do it? No. Would you take my $20? Yeah. You'd go somewhere else and buy something else, but you wouldn't go there. So, I couldn't even pay you to eat there, could I? Well, we want the alcoholic to have that same reaction to alcohol. In other words, we couldn't even pay him to what? Drink. So, you couldn't even pay an alcoholic to drink. That's pretty much a cure. Now, the only problem with this drug is it works in theory better than it works in reality. Or else we'd have had a cure for alcohol years ago. So, it really doesn't work as well as they say it does. But you still need to know how it's supposed to work and whatnot. So, the thing the boards want to know is how long does it take to get into their system and how long does it take to get out of their system? In other words, what's the onset and duration of its effectiveness? And that answer is two weeks. Two weeks. So, how long do they have to be on the drug before it starts to work? Two weeks. And how long do they have to be off the drug before they can safely drink again? Two weeks. So, usually the way it happens is doctor prescribes antibiotics. You sort of have to live sort of like a transition, like a recovery place, a transition home, where for two weeks they make sure you take the pills. And then you're let out into the community. And it will work. And every time you drink, you'll get deathly ill. So, but if you decide you want to drink at a high school reunion, when do you have to stop taking your antibiotics? Two weeks before the reunion, or you're not going to be able to do it. Alright, now, number three, patient teaching. Teach these patients to avoid all forms of alcohol. To avoid nausea, vomiting, and possibly death. Now, death isn't what we're going for. That would cure the problem. But it's not what we're going for. Now, do you suppose you have to teach an alcoholic, hey, hey, let me tell you what has alcohol in it. Whiskey does. Wine does. Beer does. Tequila does. They know that. What you have to teach them to death avoid is stuff that they wouldn't think that they have to avoid that they do. And number one, mouthwash. They need to avoid mouthwash. Even if they swish and spit, they're still going to get sick. Number two, aftershave. Even if they put it on topically, they're going to get nauseated. Now, they won't get violently ill from that, but it will make them nauseated. Perfumes and colognes should not be used for the same reason. Insect repellent, like mosquito spray, off, deep woods cutter. Those are all bad. They'll make you sick. Any over-the-counter that ends in the word elixir. E-L-I-X-I-R. Because what do all elixirs have in them? Alcohol. Alcohol. Diamond cap elixir, robitussin elixir, day quill elixir, night quill elixir, Tylenol PM elixir, Benadryl elixir. Alcohol-based hand sanitizers. In Greene County, about six months ago, we had our first case of alcohol hand sanitizer poisoning. This alcoholic got into Bob Evans and drank every single bottle of hand sanitizer he could get his hands on to keep himself clean. Every single bottle of hand sanitizer he could get his hands on to keep the shakes away. Because he knew what that alcohol was. In fact, I've heard that they've taken out, the guys are learning how to distill it themselves. Another thing they're not allowed to have is uncooked icing. Remember those uncooked, those no-bake icing that you make? What do no-bake icing have in it? Vanilla extract, which is powerful. That's granny's way of getting it. Alright, and remember this one. Here's the one that everybody gets suckered in on. Do not pick the red wine vinaigrette. They can have the red wine. Why are they trying to sucker you in on there? Wine. Do you see what I'm saying? They can't have red wine vinaigrette, they just can't have the cupcake with the unbaked icing on it. Okay, is that all the blanks filled in there, guys? Now let's talk about overdoses and withdrawals. Bad news. You've got to know all your drugs, all the overdoses, and all the withdrawals. Good news, you only have to answer two questions to get them all correct. It's an easy way of knowing them. So here we go. Every abused drug, did I say every drug? Every abused drug is either an upper or a downer. Would you agree with that? Yes. Why are drugs that are not uppers nor downers, why are they not abused? That's what I'm saying. Right? Although, there is an exception. What is the number one most abused class of drug that's not an upper or a downer? Laxatives in the elderly. The elderly abuse laxatives. But that is an upper or a downer. That's inner or outer, I guess. But every abused drug is an upper or a downer. Correct? Have you ever had anybody come up to you on the street and say, Hey, do you want to buy some Nexium? Is this not an upper or a downer? So, letter A, do you see in the box letter A? When you get an overdose or withdrawal question, what's the very first question out of your mouth? Is the drug an upper or a downer? That's the very first thing you must establish. That is the first step you take in getting the question correct. Now, let's talk about uppers versus downers. The names of the uppers are caffeine, cocaine, PCP-LSD. What are those? PCP-LSD, what are those called? Glycodelic hallucinogens, sounds like up to me. And then, another class are the methamphetamines. M-E-T-H-amphetamines, methamphetamines. Crystal meth, all that stuff you buy at the grocery store. You know, you buy the student fed, all the coffee, the decongestants, and you cook it down. That's the upper meth. New, that you're going to have to know, is Adderall, which is the ADD drug, the attention deficit drug. And, a lot of kids with ADD are selling their Adderall to their friends at school rather than taking it. ADD is the first three letters of Adderall. But, that's another upper, and that's going to be tested probably starting April 1. It's going to be a new one. Now, that's only five drugs. Caffeine, cocaine, PCP-LSD, methamphetamines, and Adderall. Those are uppers. Well, what do you think the signs and symptoms are when you're on an upper? Think, Joe. Up, because you're on an... Upper. Upper, figure that out. You know, uppers make you go up. Yeah, that's pretty hard to remember. So, what are they going to have? Give me some signs and symptoms. Principles. Euphoria. Euphoria. Tachycardia. Restlessness. Irritability. Bowels. What are you going to... What's the bowel test going to be? Borborygmi. Diarrhea. What are the refluxes going to be? What numbers? Three and four. Flaccid or spastic? Spastic. Spastic. Are they going to respiratorily arrest your speed? Should you have a suction machine or an ambu bag? Are you getting this idea? Uppers make things go up because they are uppers. Alright? Downers. What are the names of the downers? Am I going to memorize anything? No. Why? Everything that's not an upper is a downer. Because every abused drug is either an upper or a downer. There's no such thing as a tweener, so you can't get that. Now, if they want a tweener effect, what do they take? An upper and a downer together, but there's no one drug that gives you a tweener effect. Now, there are how many uppers? Five. Five. Do you know how many downers there are? A hundred and thirty-five. You know, the laudan, mf-tocosin, morphine, sulfate, codeine, demerol, fentanyl, guabaine, nubane, thorazine, stelazine, sofenazine, piperazine, clopromazine, prolixin, Ativan, Xanax, Valium, Librium, phenobarbital, penobarbital, secobarbital, heroin, hashish, marijuana, alcohol. Do you know what I mean? It's all what? Downers. Downers, because it's not an upper. So, only memorize. I hate lists, right? But if we can memorize a short one and know everything else is a... That seems like some payoff for me. So, what do downers make you do? Go what direction? Down. Because they are? Downers. Downers. So, what are you going to see there? Lafarge. Lafarge. Everything that we said, just flip it and what's going to be the big danger? Respiratory depression. Respiratory? Depression. Arrest. Depression and leading to arrest. What do you think about this? Your patient is high on heroin. No, high on cocaine. What's critically important to assess? And one of the answers is B, which says making sure that the respiratory rate is above 12. What do you think? He's high on cocaine. Is a critical measurement making sure that the respiratory rate is above 12? No. No, why? There's no way he's going to be close as well. You've got the wrong patient. But they're trying to sucker you into thinking, oh, respiratory rate. No. You know what I mean? Yeah, respiratory rate's important, but not in this patient because this patient wouldn't have a respiratory arrest because they're high on and upper, which makes everything go up. You'd rather check their reflexes. You see what I'm saying? Oh, ABCs. Did you hear that? Airway. Oh, respiratory rate less than 12. ABCs is not a great rule, guys. If you've been living by ABCs, you've been smart change for a very long time. It's a very poor rule. I will show you better rules than ABCs. ABCs is a vast oversimplification. How many have used ABCs to get answers? How many have used ABCs? How many have gotten about as many right using it as you get wrong using it? How many you get quite a bit wrong using it? How many get it all right when you use it? Are you understanding? How many would say ABCs doesn't really work that well for me? It doesn't. It shouldn't because it doesn't. Okay? So, it's a vast oversimplification. We'll get to that later. All right. B. You see where we're at? B. After you know whether the drug is an upper or a downer, the second thing you ask yourself is, are they talking about overdose or withdrawal? Because they're opposites and you've got to know which one you're talking about. You have to pay attention if the question's talking about overdose, which is too much, or withdrawal, which is not enough. If you don't pay attention to that, you will miss the question. So, what's the first thing you have to pay attention to in a drug overdose question? Is the drug an upper or a downer? What's the second thing you have to pay attention to? Overdose or withdrawal. Once you do those, you've got your answer. Your answer is so simple, it's the best. Let's look how it works. Under letter B, you see where it says overdose or intoxication? You see that? You have what? Too much. Now, put it together. Put the answers to the two questions you asked together and you get your answer for the question. In other words, if they say overdose on an upper, you have too much what? Upper, and everything goes up. So, you're going to take those up things because you have too much upper. But what if they say downer and intoxication? In that case, you have too much downer, which makes everything go down, and it's going to go the opposite of what the other one did. Do you see the point here? However, what if they talk about withdrawal? In withdrawal, you don't have enough. You have too little. So, let's put it together. If you have withdrawal, downer, you don't have enough downer. If you don't have enough downer, everything goes... Okay, I'm doing it backwards. On your page, it says you don't have enough upper, right? So, too little upper makes everything go down, and then too little downer or not enough downer makes everything go up. Does everybody see the logic in that? So, upper overdose looks like what other situation? Upper overdose looks like what other downer withdrawal? And downer overdose looks like upper withdrawal. So, in what two situations would respiratory depression and arrest be your highest priority? In which two situations would respiratory arrest and depression be your highest priority? Downer overdose and upper withdrawal. Exactly. Which two would seizure be your biggest risk? Upper overdose and downer withdrawal. Do you see what I'm talking about? So, what's the first question you ask yourself? Upper or downer? Second question. Overdose and withdrawal. Too much or not enough? Put it together? Just pick the obvious answer. Let me show you how I went and worked it. Squad calls you and says they're bringing in a patient. They're 10 minutes out. He's an overdose on cocaine. Cocaine. What would you expect to see? Select all that apply. Excuse me. First is overdose on cocaine. Coming into your ED, what would you expect to see? Select all that apply. What's your first question? Upper or downer? The answer is? Upper. Second question. Overdose or withdrawal. In this case, you would have what? Which is? Putting two and two together. Too much, upper. Right? So, answer your question. Remember, this is an essential nervous system drug, not an odd and novel. Talk to your buddy. See what they think. That's one. Yeah, but who knew? I wish I could deal with the twins right now. Yeah, there's four of you. I could deal with the twins, huh? Yeah. There's four of you. Four of you. Overdose. Overdose. It's a hyperactive drug. Okay, how many did you select? Four. You should have selected four. Okay. So, first task. What came to your head? Upper. Overdose means? Too much. Yeah, too much upper means you're going to go one direction. So, draw your arrow up. Then go hunt. What about irritability? Plus four reflexes. Repetition less than 12. Just pull four out. Four breathing. You're correct. One, four. You're caring for a client who's withdrawing from cocaine. What are you going to answer? Now you're going to say respiration is under 12 and difficult to erupt. They start doing that on you, you start moving. They need some Narcan. Good. Are you seeing the idea? So, you have to memorize all these drugs. No. Turn the page. Let's talk about drug abuse in the newborn. Or drug addiction in the newborn. Is this a hot topic? Because we have a lot of babies born nowadays to addicted moms. Always assume, here's the blank, always assume intoxication, not withdrawal, at birth. Always assume intoxication, not withdrawal, at birth. So, if they say you have a baby at birth or in the first 24 hours, what would you assume the baby is in? Intoxicated. After 24 hours, after birth, you'd assume he's in what? Withdrawal. So, how old does the baby have to be before you go withdraw? 24 hours. And how do you work this? Well, what about this question? You're caring for an infant born to a Kweilu that they've used, addicted mom. Nobody uses used anymore. A Kweilu's addicted mom. 24 hours after birth, select all that applies. So, you got a Kweilu's addicted mom, you're caring for this infant 24 hours after the baby's been born. Select all that applies. Difficult to console. Low core body temp. Exaggerated startles. Reflex. Respiratory depression. And seizures. Talk to your baby. Breathe. And you're in withdrawal. Anything that goes down. Is that awesome? That's a real high-pitched cry. How many did you collect? Two. You should have selected three. Okay, so, Kweilu's. What are they? Downers. How do you know they're downers? It's not on the upper list. Not caffeine, not cocaine, not PCPLC or Adderall or methamphetamine. You don't know what it is. How many did you know what it was? What did you expect? Downers. Downers. When you don't know what it is, pick downers. You've got a 100 to 1 chance of being right. I mean, 100 to 1. 99 to 100 chance of being right. So, we would say this is a downer. And the baby is what? Withdrawing. Withdrawing. It's been 24 hours. So, he's starting into withdrawal. So, he doesn't have enough downers. The baby's going to go up. So, difficult to console. Yes. There is more. I'm sorry. There's one. Okay. Both for a body test. No. Exaggerated steroids. Yes. Respiratory infections. No. Teetering. Yes. I'm sorry. I didn't. I wasn't thinking. Now, how many of you are really good at Quaalude newborn situations? How many thought you were? Do you see what I'm saying? It's not that hard. In fact, boards doesn't really expect you to know this. They just want to see if you know some what? Principles that central nervous system depressants 24 hours after birth make the baby go the opposite way. Does that make sense? And they'll pick these things, and you're going, Oh, I don't know Quaalude. No, I don't know Quaalude. No, I don't know Quaalude. Shut up and answer the question. If you don't know Quaalude, you should know the answer. If you don't know the answer, it's a downer. And then go with it. The guys with the good test figures do it. They're going, they're putting their money on the best bet. And that ain't the point. Okay, alcohol withdrawal syndrome versus delirium fetus. Alcohol withdrawal syndrome versus delirium fetus. You have to know the differences between them. They're not the same. Sometimes people think DT, delirium tremens, is alcohol withdrawal syndrome. No, they're totally different things. When boards says alcohol withdrawal, they mean you're withdrawing from alcohol. When they say delirium tremens, you're in delirium tremens. They're very different. Do not think they're the same. Letter A, every alcoholic goes through alcohol withdrawal. They all do, 24 hours after they've stopped drinking. So when an alcoholic stops drinking alcohol, within 24 hours, they will all go into withdrawal syndrome. Every single one of them. However, only a minority gets delirium tremens. You don't have to know the percentages. It's under 20%. By the way, when do you go into delirium tremens after you stop drinking? You know what time frame? 72 hours. So what always comes first? Alcohol withdrawal within 24, then a couple of days after that you go into DT. Here's a statement. You do not have to write this down, but if you understand this statement, then you're good to go. You understand what I said. Alcohol withdrawal syndrome always precedes delirium tremens. However, delirium tremens does not always follow alcohol withdrawal syndrome. You got that? Okay. So if you have DT, if you have DT, you have what? Alcohol withdrawal. But just because you have alcohol withdrawal doesn't mean you're going to get DT. What was the second part of that? The alcohol withdrawal syndrome. Precedes delirium tremens. But delirium tremens does not always follow alcohol withdrawal syndrome. Okay. Next difference. Letter B. AWS is the abbreviation that I'm using for alcohol withdrawal syndrome. AWS is not life-threatening. DTs can kill you. C. Patients with AWS are not a danger to self or others. Patients with DTs are dangerous to self and others. The word are goes in there. A-R-E. They are a danger. So here are two really big differences. AWS won't hurt anybody. It won't hurt you. You're stable. You're fine. DTs, you're unstable. You could die. Second big difference. AWS, they are not going to hurt anybody. They're rather loud and obnoxious. Because they're withdrawing from a downer, which makes everything go up. They're going to be loud and obnoxious, yeah, but they're almost never going to hurt anybody. But in DTs, you have to assume it's dangerous, because they are dangerous. All right. Now, those differences will translate into differences in care, which we will outline in the table below. I'm going to fill in this table about the differences between AWS and the tremendously. First column, first row. Is everybody know what box I'm in? First column, first row under AWS. Regular diet. Next box down. Same column. First column. First column, second row. Semi-private anywhere. Semi-private anywhere. Which means they could be in a semi-private room anywhere on the unit. Same column. Third row, down. We're just going down that first column. Up, add, live. Up, add, live, which means they can go around anywhere they want to go. And last box in that column, no restraints. You do not restrain people because they are not a danger to themselves or others. Now, let's compare and contrast that with the DTs slide that we're in currently. Second column, middle column, first box, first row. NCO, clear liquid. NCO or clear liquid. Why? Why Caesar? Why us? Why us? Yeah. Because if we're drawing equipment down, everything's going to go up in the big outfitted Caesar. And with Caesar, you get aspirations. So, you want an NCO or clear liquid. Yeah. On boards, sometimes they'll say NCO. Sometimes they'll say clear liquid. They won't have them against each other because that would be too tough to pick. But it would be either one. The second box down, private near nurses' station. Private room near nurses' station. Why? They're dangerous and they're unstable. So, you can... Could you put an alcohol withdrawal patient on a pediatric overflow unit? Sure. He'll be known as Uncle Wally, but, you know, he'll be everybody's best friend. It's a terrible thing. But he won't hurt anybody. So, these DTs, you've got to watch these DTs. In fact, DTs probably should be in ICU. Why? Because they're dangerous and unstable. Dangerous and unstable. But no self-respecting head nurse of ICU will allow them through the doors. Why? Because they're screaming and yelling like banshees. You know, and they don't want that destabilizing the rest of their population. So, they usually get stuck on step-down units. But if you're going to... If you, as an LPN... As an LPN, would you accept the assignment of a DT client? You couldn't, no, because they're unstable. As an RN, would you accept the assignment? Yes. But what would you have to do with the rest of your assignment if you accepted DTs on med-surg? Decrease your workload. Somebody else may have to take seven while you take three. Okay? And remember, it's a perfect world on board. Everybody will be fine with that. The other nurses will be fine with that. Yeah, I'll take nine, you take two. You know, it's fine. So, what kind of reasoning is really efficient death on board? What minor reasoning? What kind of thought process that you would do in questions and answers would really be bad? Saying, oh, I wouldn't do that because what? I don't have enough staff. I don't have enough experience. I don't have enough time. I don't have enough money. We don't have enough resources. No. On board, you have what? A perfect world. You have all the money, all the time, all the staff. Everybody's cooperative. Everybody's happy. Everybody wants to make it happen. They even don't mind their assignments being changed every hour. Okay? Okay, let's talk about the next thing down. They are on restricted bed rest, which means no bathroom privileges. If they have to use the facilities, we have bedpans and urinals for them. And lastly, they must be restrained. Why must they be restrained? Because they are dangerous. Now, what would you restrain them? Certain types of restraints are futile and not useful. Some are appropriate. What would be some that would be appropriate and some that would not? Do you know? What about soft risks? Yes or no? No, they'll get out of that. That's not enough. That's not safe enough. What about four point stuff? No, that's not. They can get out of that. They need to be in a vest or two point, two point loft leathers. Now, what does two point mean? Two extremities. Which two extremities? No, not two arms. An arm and a leg. Which arm, which leg? Opposite. You always lock down one arm and the opposite leg in two point. That's what it means. That's what you're supposed to do. Now, you rotate that every two hours, so what do you do two hours later? You switch it. You switch it. Now, what would you do first? Their right arm's locked down, their left leg's locked down. What would you do first? Lock their left arm, then the right leg. Lock their left arm, then the right leg. Then release the... Yeah, don't release them first. You'll only make that mistake once. And then you'll go, oh, okay, I got it now. You'll remember. Now, what do they both get? Well, they both get an antihypertensive, a blood pressure pill. Why would they get an antihypertensive? Why? Why is everything going up? Perfect, guys. Excellent, excellent, excellent. You got it. You're getting it. Okay, they're both on a tranquilizer. Why do they both get a tranquilizer? Because they're up. And why are they up? Because they're withdrawing from a... Downward. And they both get a multivitamin containing B1. Why? Because they're in a key. Of course it costs. To prevent that, I always say, no B1, you B1. One of those phrases. No B1, you B1. And then that last box I shaded. And I shaded that so that you obsessive-compulsive two weeks from now, when you go over this lecture, there was nothing you missed. You don't need to call everybody in the class to find out what was in that last box, what was in the last box. Nothing goes in that last box. Alright, let's talk about some drugs. And then we'll take another break. Drugs. Aminoglycoside. This is a powerful, powerful class of antibiotics. As far as antibiotics go, there's a big gun. You know what I'm talking about? When nothing else works, pull out your aminoglycoside, you know? It's like the... Aminoglycosides are to infections like that scene in Indiana Jones when the big Arab guy comes out with a scimitar, you know, and he steps like this and Jones pulls out a gun and shoots him. But they're like the gun. You know, they're going to blow it away. But you don't use it unless what? Nothing else works. These are dangerous. Now, boards love to test these. Why do boards love to test these drugs? Because they're dangerous. And this is a test of safety. And do you know these drugs? They're in the top in my... From my experience, these show up probably in the top five most commonly tested groups of drugs on boards. You'll have to know this because I'll repeat it several times. Probably the most common group of drugs you have to know for boards are your psych drugs. And we'll get that on Sunday. The second most common are the insulin, which we'll talk about tomorrow. The third most common is anticoagulants, which we'll talk about tomorrow. The fourth is digitalis, which we'll talk about today. The fifth are the aminoglycosides. Then you've got to know your steroids, your calcium channel blockers, your beta blockers, your pain meds, and your OB drugs. Those are the big ten. And we hit all of them. Okay? So, these are real, real important to know. Now, here's the deal. For aminoglycosides, think the following. Aminomycin. When you see the word aminoglycoside, from now on, I do not want you to think aminoglycoside. I want you to think aminomycin. Do you hear the similar sound? Amino, amino. Amino, amino. So, when you see aminoglycoside, think what? Aminomycin. Okay, now, what does that tell you? Well, here's what that tells you. This letter B. They are antibiotics used to treat what? Well, if they are mean, old drugs, what kinds of infections would they treat? Serious or non-serious? Life-threatening or non-life-threatening? Resistant or susceptible? Gram-positive or gram-negative? Gram-negative. So, you've got the resistant, serious, life-threatening, gram-negative infections are treated by what? Aminomycin. So, you treat a mean, old infection with aminomycin. Do you hear what I'm saying? So, would you use these drugs to treat sinusitis? No. Why? It's not a mean, old infection. So, don't use aminoglycoside. What about tuberculosis? That's a mean, old infection. I use aminomycin. What about septic peritonitis? Is that a mean, old infection? Yes. So, I use a what? Aminomycin. What about otitis media? No. It's a nuclear infection. Is that a mean, old infection? No. Do I use aminomycin? No. What about bladder infection? No. What about fulminating pyelonephritis? Yeah. Yeah. Septic shock? Yeah. Infection of third-degree burn wounds over 80% of your body? No. Got it? What about viral pharyngitis? No. Strep throat? No. No. So, use a mean, old mycin when you got a mean, old infection. And never any other substance. So, mean, old tells you what it triggers. Mean, old infection. The mycin tells you what they end in. Good news. All aminoglycosides end in mycin. They all do. That's letter C. All aminoglycosides end in mycin. But do you know what the bad news is? Not all drugs that end in mycin are aminoglycosides. Correct. Wish that would work, but it doesn't. But don't despair, because most drugs that end in mycin are mean, old mycins. There are three of the mycins which are not these drugs. And the three mycins which are not mean, old mycins, not mean, old mycins, are erythromycin, zithromycin, and clarithromycin. What do all the mycins that are not mean, old mycins have in them? Pro. So I say, if it ends in mycin, it's a what? Mean, old mycin. But if it has pro, throw it off the list. Do you hear what I said? If it ends in what? Mycin. It is a mean, old mycin. But if it has pro in it, throw it off the list. It is no longer a what? Mean, old mycin. So would you use clarithromycin, zithromycin, and erythromycin for sinusitis? Yes. Would you use it for tuberculosis? No. No. Would you use streptomycin for hepatitis media, sinusitis? No. Would you use it for tuberculosis? Yes. So the mycins are mean, old mycins, except for thromycins, which are little, old, harmless, no big deal. So watch out for your thromycins, they're a little tricky. So if you see thromycins, do what with it? Throw it off. Throw it off what list? The mean, old list. The mean, old list, so it's just a little, old. Some examples, clindamycin, cleomycin, bleomycin, gactinomycin, adremycin, streptomycin, canamycin, bleomycin, you know, all these mycins. Now, what are the toxic effects? Letter E. This is what they really see in them. What are the two toxic effects? Now, what do all these drugs end in? Mycin. Mycin. What English word sounds like mycin? Mycin. Mycin. So when you see mycin, I want you to think mycin. What is the most famous feature of the world's most famous mycin? Ears. Ears. So that's to tell you these drugs are what? Drugs. When you see mycin, I want you to think of mycin. When you think of mycin, I want you to think of ears. And when you think of ears, I want you to recall, oh, they are ototoxic. Because oto means what? Ear. Oto means ear. What's ophthalmo mean? Ophthalmo. Oto means? Rhino means? No. Oro means? No. Very good. So what do you monitor? The toxic period, what do you monitor? Hearing. Ringing in the ears. What's that called? Tinnitus. Yeah. If you're saying tinnitus, that's wrong. It's tinnitus or tinnitus. That last letter is a u, not an i. Just saying t-i-n-n-i-t-u-a. Tinnitus or tinnitus. No, tinnitus. Everybody says tinnitus. That's wrong. I even heard it on a commercial on TV. Okay, and vertigo or dizziness. Why vertigo or dizziness? Equilibrium. Because the ear also has equilibrium. Doesn't it balance? So what are the three things you worry about with the ear? Hearing, ringing, and dizziness. But if you had to pick between those three, which one would you pick? Hearing. Hearing would be the other two. Okay, number two. Number two. The human ears, now we're thinking ears. Why are we thinking ears? Because of mice, right? Because of mice. Well, here's the human ear. You see the human ear? If we connect the dots, what's it shaped like? The kidney. The kidney. So just remember the human ear is shaped like the kidney. So the second toxic effect of these drugs is nephrotoxicity. Nephro, N-E-P-H for kidney. Nephrotoxicity. So what do we monitor? Hearing. Not hearing. They'll have that there, but don't go for it. Creatinine. Don't go for D-Len. Don't go for daily weight. Don't go for output. Go for creatinine. The creatinine is the best indicator of kidney function. The creatinine is the best indicator of kidney or renal function. If they told you serum creatinine versus 24-hour creatinine clearance, which one of those would win as the best? The 24-hour creatinine clearance would be better than the serum creatinine, but the serum creatinine would be second best and beat everything else. So you've got the 24-hour creatinine clearance, the best indicator of kidney function, serum creatinine number two, and everything else a distance, a distance third. Oh, by the way, I didn't tell you guys. Stop. I don't know. I knew I was missing something at the very beginning of this whole review. Please feel free to record. Okay, so if you want to record what I'm saying, feel free to record away. Okay? Sir. Thank you. Now, you see this ear, kidney thing here? I want you to have a visual of the number eight. You see how the number eight fits in a kidney real nicely? See how that shape fits? I want you to remember that the number eight, that's number three there, the number eight drawn inside the ear reminds you of two things about these drugs. Number one, they are toxic to cranial nerve number eight, which is the ear nerve, and you administer them every eight hours. You don't give them Q6, Q4, Q2, continuous drip. You give them every what? Q8 hours. Q8 hours. All right, let's turn the page. What's the route? IM or IV. IM or IV is the route. You give these drugs IM or IV. Next point. Do not give these drugs PO because they are not absorbable. Remember, do not give them PO because they are not absorbable. So here is a oral mycin. What will happen? It will go into your gut, dissolve, and do what? Go right through and you're making expensive stool. Because it's not going to be what? Absorbable. If it's not absorbable, it will have no systemic effect. That's why it has to be given IV or IM. Not because it's going to hurt you, it just isn't going to do anything. Now, except in two cases. There are two cases where we want to give these mean old mycins orally. And the first case is hepatic encephalopathy, called hepatic coma. Have you heard of liver coma or hepatic coma? I hope you've heard of it. At least heard of it a little bit. It's when your ammonia level gets too high. Remember that? The ammonia gets up there and it tickles your brain. You go into a coma and you can die. Well, what is the treatment goal in hepatic coma? Reduce what blood level? The ammonia. The goal in hepatic coma or hepatic encephalopathy is to get the ammonia down. That's the goal. Well, oral mycins will do that. Because what will oral mycins do? Well, they will dissolve in your mouth, right? In your gut. And go through your gut and kill gram-negative bacteria in your gut. So it will sterilize your mouth. Do you know what the number one producer of ammonia in your body is? The E. coli in your gut. And if I can kill the E. coli in your gut, what do I do to the ammonia level? I decrease it. And would that help here? Yes. And because these people have liver damage, we don't want this drug to ever get to their what? Liver. Because it could hurt the liver. Will it ever get to their liver if taken orally? No. It will go in one end, sterilize the bowel, and go out the other end. Do you see where there's the perfect drug for this? It's going to kill the E. coli, reduce the ammonia level, and it won't harm the damaged liver, because it's not going to be absorbed. It's a designer drug. Plus it makes you have diarrhea, which makes you get rid of stuff, too. Which is double better. The other time they want you to give it is in pre-op bowel surgery. Why would you want to give an oral mycin? Why would you want to give an oral mycin before bowel surgery? Why? To sterilize the bowel. Clean it out. Better than aminos. So for a few days before bowel surgery, what might a patient take? An oral mean old mycin. Will we have any ototoxicity or nephrotoxicity with this? No. It's not absorbed. Now, if it went IM or IV, we would have ototoxicity and nephrotoxicity, but because it's not absorbed, we won't. So in both cases, the hepatic encephalopathy and the pre-op bowel, what did the oral mycin do? It sterilized your bowel. Did it not? So what is the number one action that an oral mycin will have? Sterilize the bowel. So these oral mycins are called the bowel sterilizers. Now, there are any of these drugs would do it, but there are two of them that are used exclusively for bowel sterilization, and they are neomycin and kanamycin. Neomycin and kanamycin. So what do I want you to remember about neomycin and kanamycin? That they're bowel sterilizers, right? Because that's all they're going to be used for. They're taken orally for the purpose of sterilizing your bowel. So whenever you see neo or kan, what did you think of? Bowel sterilization. Now, how do I want you to remember that? I have this. Do you see where it says, remember this military sound off? Do you see that? Do you remember, do you ever see or hear or experience a military situation where the troops are marching down the road or jogging down the road, and the drill sergeant says, da-da-da-da-da-da-da, and the troops go, da-da-da-da-da-da. You know what I'm talking about, like a cadence? Is that what I'm talking about here? Well, think of this military cadence. It's rather weird, but it will work for you. The question that the drill sergeant asks, do you see the cue there? The question the drill sergeant asks is, who can sterilize my bowel? And who can sterilize my bowel? That's what the sergeant asked. Well, the troops are going to shout something back. In answer to that question, the A, the answer will be, neo kan. Because he said what? Neo kan. So they say neo kan. Neo what? Misin. And kan? Misin. So neo misin, kan misin. So whenever you see neo or kan, what did you think? Who can sterilize my bowel? You'll know they are bowel sterilizers, and you'll know what you're talking about. All right? Now, don't look at your book. Don't look at your book. I say aminoglycoside. You say? Aminoglycoside. Okay, which shows you they treat what? Amenal infections. Like what? Serious, life-threatening, resistant, gram-negative things. They all end in? Misin. Except for the throat. Correct? When you see misin, you think of what rodent? My eyes. Which makes you think of? Ears. Which tells you they are? A lot of thoughts. So you monitor their? Hearing. Hearing. Right. And dizziness. And dizziness. And the ear is shaped like the? A-E. So they are also? Nephotonic. So you monitor their? Prion. Correct. And what number do you draw on the ear? Eight. So prion number eight is damaged, and you give it every? Three hours. What route? Nine. Do you give it PO? Yes. Why? Yes. But if you give it PO, what will it do? Sterilize your bowel. What two situations do you want bowel sterilization? Static encephalopathy and? Free off bowel. Free off bowel. Who can sterilize your bowel? Neomycin. Neomycin and? Chemo. Chemo. All right. So do you know those drugs? Yes. Get it from mean old? Neomycin. Neomycin. Okay. So you can know the whole shit mess. There isn't a question they would ask you about these drugs, but that does not cover. That covers it all. Okay. I had a nurse from, I was touring Miami Valley Hospital about four or five years ago, and a nurse comes up to me in the hallway and says, who can sterilize my bowel? I don't know how you say it. And she says, who can sterilize my bowel? And I said, I don't know. And she said, answer the question. And so I said, Neocan? And she said, yeah, I had your class a year and a half ago. And I felt like I said, honey, you can delete this topic. You don't have to keep this stuff forever. But everyone evidently had stuck with her. Maybe let me get rid of that. Okay. Let's talk about trough and peak and going to break. Trough and peak is over there at the bottom of the page. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. Trough and peak. So, I like to teach it to TAP. Trough administers peak. So, when is the peak drawn? After the administration. When is the trough drawn? Before the administration. TAP. T-A-P. Well, what's the reason for drawing TAP levels? What we call narrow therapeutic window. Have you heard that term? Narrow therapeutic window? And that means there's a very small difference between what works and what kills. So, if a drug has a very small difference between what works and what kills, that means there's a very small difference between what works and what kills. So, if a drug has a very small difference between what works and what kills, that means there's a very small difference between what works and what kills. TAPs. If they have a wide range, will we draw TAPs on them? No. So, let me ask you this. What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? What's the smallest dose of Lasix you ever gave or saw in it? Yes, they do this all the time. Two right answers. Write 115 after it's in, 130 after it's in. Isn't that the range? Which one are you supposed to pick? Eleven. Whenever you get two in the same correct range, whenever you get two values in the range and they're both correct, play the price is right. Who wins on price is right? Highest without going over. So who's the highest here without going over? Eleven. And that's who wins all the time. For example, let's show you how this works in every case. Do you remember antidepressant meds? Antidepressant meds. How long does it take the typical antidepressant med to work? Two to four weeks. If Board told you that the client had been on it for one week already, got it, been on it for one week already, and they're saying it didn't work and it didn't help and I feel horrible, what would you teach them? A, it may take another week to work. Is that true? Might it? Yes, that's the two. And then B says it may take three more weeks to work. That's also true. So you've got two right answers, one week and three weeks. Which one wins? Three weeks. Three weeks because you picked off the highest without going over. When would a child be able to be potty trained during the night? Three years or five years? Well, that's three to five years. Isn't that kind of potty training for you? So what would be your answer? Three years or five years? Five. Five, and you'd be right. You see what I'm saying? So always, whenever you're sitting there and you have two right answers, they both are correct numbers, pick the highest without going over, and that will always win. That's not just on this, but on everything. Okay, the IM? The IM is 30 to 60 minutes. You draw the IM peak 30 to 60 minutes after you get it. So if you were between 30 and 60, what would you pick? 60. See, they love to test it. You gave an IM emerald for pain. When would you check them for relief, in 30 minutes or in an hour? Well, it's going to peak in 30 to 60, so it's either going to peak in 30 or 60. What would you say? 60. Yeah, because you want to give it enough time. You could check them in 30, but you should at least check them within an hour. Okay, sub-Q? Here I want you to write the word S-E-E. C, S-E-E. C-Diabetes Lecture, which we'll talk about tomorrow, because the only subcutaneous peak they talk about are the insulins, and we'll just talk about a sense, okay? They don't talk about turbulence, sub-Q, or anything like that. And then in the PO box put forget about it, because they don't test the TOT. It's all two variables. All right, thank you. We'll come back at 7.20, and we'll finish up for the day.