First Aid for the USMLE

Many medical students have obtained the book First Aid or at least looked at a friend’s copy at some time during their board preparation. The book by itself is a good template but in no way strong enough to get you the desired score you are looking for. Here at WOLFPACC, we take your learning to the next level and help you reach your desired score. Let me take a minute and explain with the topic pharmacology as an example.

In medical school you have covered the class of drugs known as “STATINS.” They are a commonly prescribed drug to many patients who have a problem controlling their serum cholesterol levels. The uncontrolled levels may be due to poor diet choices, familial in nature and some just idiopathic. Students studying for their boards know they will be tested on this class drugs and add it to a long list of other drugs to remember.

Most students pull out their copy of First Aid to learn about this class of drugs…
“HMG-CoA reductase inhibitor that lowers cholesterol levels in patients”
“Side effects may include: rhabdomyolysis (from muscle toxicity), hepatotoxic ( increase in transaminases — AST, ALT, GGT), risk of toxicity if combined with Fibrates ( cholesterol lowering drug).”

Wow, great clues and definitely board relevant as you move onto the next class of drugs.

STOP! Here is the danger you face if that is your level of knowledge on “STATIN” drugs walking into the test, let alone the hospital wards. During my years in the hospital setting and now teaching, majority of students will regurgitate the above information when asked about “STATIN’s.”

WOLFPACC approach….

Drugs are broken down into two categories, lipid soluble (processed by the liver) or water soluble (cleared by the kidneys). Since statins work in the cell, they are lipid soluble and have a high volume of distribution. Therefore a greater risk of toxicity vs a water soluble drug having a low volume of distribution and lower chance of toxicity. If I need to clear the body of a water soluble drug, giving fluids (0.9 %NS) will help increase GFR and the patient will void the offending drug. Since lipid soluble drugs sit in the cells, administering fluids to the patient will have little effect on the drugs toxicity.

Lipid soluble drugs can and do enter the cells of our body, and can lead to cell toxicity everywhere. Statin drugs can enter the …

  • Muscle – rhabdomyolysis releasing myoglobin which is toxic to the tubules and interstitial tissue of the kidneys
  • Heart – leading to arrhythmias caused by loss of electrolytes from damaging the kidneys.
  • Brain – altered mental status form electrolyte imbalance
  • Liver – hepatotoxicity, elevated AST, ALT and GGT. Can progress to lower serum albumin levels and prolonged prothrombin time.
  • Bone marrow – destroys the cells generated here leading to…
    • Red blood cell count starts to fall leading to a V/Q mismatch and ultimately causing hypoxia. Since hypoxia causes pulmonary vasoconstriction, the right heart has to pump harder. This leads to a backup pressure in the right ventricle and right atrium which causes jugular vein distention on inhalation (Kussmaul sign).
    • White blood cell levels will drop leading to the risk of infections, most commonly pulmonary and urinary tract infections.
    • Platelet count will also drop leading and can lead to petechiae, purpura or ecchymosis.

In conclusion, if you have a patient on a “STATIN” drug who now presents to the Emergency Department with altered mental status, cardiac arrhythmia (electrolyte loss), shortness of breath (hypoxia), or even petechiae (bone marrow involvement), you now know your patient could have toxic levels of their statin drug. WOLFPACC takes the material you have learned and teaches you to apply the material. If you would have walked into the test just knowing statin drugs cause hepatotoxicity and rhabdomyolysis, you would be in trouble.

WOLFPACC is the only program who will show you how to apply the material you have learned in a clinical approach, organ system based. It is for this reason; students have ranked the program #1 in USMLE / COMLEX preparation regardless of the Step or Level you are challenging.

I have given you a chance to see what truly sets us apart from others. The choice is yours!


Hans Wolf MD