I posted a reader take on kevinmd this weekend. With a fake story about witch doctors and socialized medicine, how can you go wrong?
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Looking over my previous post about how to conduct yourself on surgery, I realized that I left out an important point about pre-rounding and presentation on rounds. Part of your job as a medical student will be to wake up all of the patients first thing in the morning so you can ask them about their pain level, bowel habits, and any overnight events. You will also conduct a very short physical exam. Depending on which service you’re on, you might have as many as six patients that you have to see and write notes on in one hour. Since timing is so important, I used the following lines of questioning with every patient:
How did you sleep last night?
How’s your pain right now? Can you rate it on a scale from 1-10? Where is it located?
Any nausea, vomiting, or diarrhea? Have you passed gas?
How’s your appetite?
Did you get out of this bed yesterday to walk around?
Are you using the incentive spirometer? (You should have the patient demonstrate that he knows how to use the spirometer.)
Next, listen to the patient’s heart, lungs, and abdomen. You’re looking for any chance of atelectasis, new murmurs, and bowel sounds. If the patient is on the first postoperative day and had abdominal surgery, you may very well not hear any bowel sounds—hence why it’s so important to ask if the patient has passed gas since the operation. And make sure to do a real physical exam. That means that you will have to set the patient up in bed, if possible, to do a proper lung exam. I’ve seen many residents claim that the patient is healthy when they’ve only listened to the anterior chest. They later get burned when they discover that the patient has a lower lobe pneumonia. Don’t let that happen to you. Getting an immobilized patient to sit up—or even roll over—takes only a few extra seconds.
Finally, check to see what the patient is getting via IV. While the orders may say that the patient is to receive 100 mL per hour of 1/2 normal saline, you might be very surprised to see that he is now receiving 150 mL per hour of 0.9 normal saline. Also make a note of the color of the urine in the Foley bag—whether or not it has any blood, as well as look at any drains. The color of the fluid in the JP drain should be either clear, pink, or green if you are expecting bile. The output in a drain should never contain frank blood, but a serosanguinous fluid is acceptable. I also knew a few attendings that wanted us to change the patients’ dressing before rounds each day. Check with former students to learn the attending’s preferences.
Whenever I’m pre-rounding on a patient, I usually try to find the nurse who took care of him the night before to ask about any overnight events. While your patient might tell you that he slept well throughout the evening, your nurse may tell you that he was up vomiting all night. If the nurse is unavailable, then try to find her notes.
You should be able to complete all of the above steps in less than three minutes.
Now you need to look up all of the patient’s overnight lab work, including any new imaging studies. You should write your note by detailing what the postoperative day is, what was the surgery, all the information that you gathered earlier, and what day of antibiotic treatment the patient is on. Leave out any past medical history. An example note looks like this:
S) Mrs. Smith is a 67-year-old female who is postoperative day number three for a gastrojejeunostomy. There were no acute events overnight. The patient states that she currently has a 2/10 pain level and is well controlled by current medications. Clear liquid diet is well tolerated. No N/V/D. Patient is ambulatory.
O) List your physical exam findings as well as any new labs.
A/P) Give a very short assessment and plan, but focus more on the plan. Examples might be “Advance to soft diet” or “Chest x-ray to rule out pneumonia.”
When you give your presentation on rounds, recite the information from the subjective part, list the vitals, mention only pertinent findings from physical exam—otherwise just say, “heart and lungs sound normal”—and then give your plan for the day.
Rounds stop being nerve-racking around week two.
Addenum: Someone pointed me to the surgical review by Pestana. It looks good, but given that I don’t know the copyright status of the outline, I’m hesitant to post it here. You’ll have to do a search for it.
All around the country premeds everywhere are anxiously awaiting the start of medical school at the beginning of August. They will bring with them many hopes and aspirations as they begin their careers toward becoming future MD’s. They will have many questions such as which organizations to join, whether or not to go to class, and who is going to kill the first patient. But nothing is more anxiety provoking at this time then trying to decide which stethoscope to purchase.
While there are many options to choose from, I would caution fresh medical students to stay away from the electronic stethoscopes. I have never use these devices. While I’m sure that their built-in microphones will help listeners catch even the faintest heart murmur, there is something to be said about learning the physical exam the old fashion way.
First and foremost you must buy a cardiology grade stethoscope. That includes a diaphragm, a bell, and a dual lumen tube. Instantly disqualified are the nursing-grade stethoscopes that your parents got you as a gift when you were accepted to medical school. You should plan to spend at least $100 on a quality model.
Currently, the most popular stethoscope amongst medical students is the Littman Cardiology III. there is no shortage of users willing to sing its praises. It comes in numerous colors, drug companies give away accessory products specifically designed for it, and it has the appeal of being able to say, “I went with the Littman.”
I don’t like it. I haven’t been able to hear as well with it as the marketing propaganda would claim. The fans will instantly cry out, “But it has a tunable diaphragm.” To which I would respond, “Do you even know what a tunable diaphragm is? And furthermore, if you pay any attention to the research that was conducted on stethoscopes beginning over 50 years ago, you’d realize that a tunable diaphragm is the exact feature that a stethoscope should not have.”
I prefer the Welch Allyn Tycos DLX. The sound quality is much, much better compared to the Littman. It has interchangeable ear pieces that come in various varieties of stiffness so that the user can choose based on comfort level. Finally, the diaphragm can be easily changed to a pediatric version. All I have to do is unscrew the adult version and then replace it with a pediatric one to convert my stethoscope into a listening device for the kids.
Take a look at the pictures below:
What now bitches? I’d like to see you pull that off with a Littman. Its users will be required to buy two stethoscopes to follow both adult and pediatric patients. I know several people who purchased new stethoscopes just to go through the peds rotation. I took a more sensible approach.
I was sent this article about workers in Japan. I’d like to see them work American residency hours. What’s more, I’d love to see if anyone outside of medicine cares if a resident dies from “overwork.”
I wanted to kick off this series by discussing surgery. Few rotations are as anxiety-provoking as this one. You can expect to be at the hospital by 5:00 a.m. every morning with plans that you’ll stay put for the next 12-14 hours. You’ll have to come in almost every day on your rotation, and that includes weekends. Expect to spend 80 hours a week in the hospital. You should kiss your loved ones goodbye because as far as they’re concerned, you’re going to be gone for the next eight weeks.
To excel on surgery the first thing you need to do is become very familiar with the reasoning behind the procedures. Attendings don’t care if you know how to remove a gallbladder. They will, however, expect you to know what are the indications for taking one out. If a patient has right upper quadrant pain, what’s the differential diagnosis? How would you know that someone has cholecystitis versus pancreatitis? What do you look for on ultrasound? What are the findings on the physical exam? What labs should you order, if any? How urgent is this procedure? Are there any alternatives to this procedure, including medical ones? What are the risks to a cholecystectomy? If the resident in the case prematurely cuts the bile ducts, what do you do then? What’s some of the relevant anatomy in that area? That is, what do you have to watch out for during surgery? Once the gallbladder is removed, is there any chance for recurrence of disease?
Those are just some of the questions you should be able to answer any time you go into an operation. And if you’re dealing with cancer, you should know all of the relevant tumor markers as well as their half-lives. The half-life is important to know because it gives us an indication of how long to wait before retesting the patient.
The second expectation that attendings will have is that you can manage hospitalized patients. You should do some reading on fluids and electrolytes because those issues become very important once a patient comes out of surgery and cannot eat for several days. You should also be aware of your patients’ conditions at all time, including urine output, feedings, any fevers, relevant labs, ambulatory status, and pain level, just to name a few. Some attendings are also very big on wound care—so you should always carry gauze, tape, suture removal kits, staple removal kits, and a pair of scissors.
In addition to the general etiquette that was discussed earlier, there are several new behaviors you will have to acquire on this rotation. First, you should address everyone as “ma’am” or “sir.” That includes the nurses, the techs, and all of the residents and attendings. For some reason, surgeons believe that medicine should be run like the military. Granted, none of them had ever served in the armed forces, but I certainly heard a lot of attendings say, “This is just like the military.”
Second, do not speak unless spoken to. If you have a question, you should keep it to yourself and look up the answer later. I cannot stress this point enough. Do not ask your attendings any questions regarding any disease is that you may encounter. You’re attending will very likely turn the question around and either pimp you or force the resident to answer. Then you’re going to be stuck with the resident that dislikes you and a comment on your evaluation that says “The student needs to read more.”
Finally, you’ll have to start introducing yourself to everyone in the OR. Whenever you head into a case, immediately let the circulator know who you are. You should also introduce yourself to the scrub tech, as he/she will be passing you instruments throughout the operation.
As I mentioned earlier, the attendings aren’t looking for you to learn surgical technique. Very likely your experience in the OR will consist of holding retractors and cutting suture lines. If the surgeons take a liking to you, they might let you place the closing stiches. In that case, it pays to be knowledgeable in advance on how to tie knots. Hop on over to YouTube and watch a few videos on the subject. You can then practice at home using old suture line obtained from the scrub nurse.
In addition to all the amount of time you’re going to spend in the hospital, you should devote about 10-20 hours a week for reading. The most popular textbook for a surgery clerkship is Lawrence. However, I found the book very difficult to get through. Students generally like Surgical Recall because it preps them for all the pimping that they’ll inevitably receive in the OR. Unfortunately, there’s not a whole on out there that does a good job of preparing you for the Shelf. This exam is very difficult because it covers a wide range of topics on everything from breast cancer to skin cancer to electrolyte management to ethics. The good news is that there is no anatomy on the Shelf.
All across the country this week medical students are coming back from their Step I vacations, dusting off the collared shirts and neckties from the back of the closet, and putting on pristine white coats as they head onto the wards as new third years. I want to congratulate all of you M3’s on getting this far. If you’re like me, you’re probably totally lost at this point as far as what your responsibilities are on your clerkships. I’m creating a new series called The Life Raft where I will move step-by-step through each rotation to tell you about your responsibilities, etiquette, what books are useful, and some general tips that will make you shine.
Before accepting anyone’s advice you should look at his qualifications. So, I feel that a bit of self disclaimer is necessary. I went through eight clerkships this year and earned honors on several of them, including getting the highest grade in the class on one rotation. Out of the 30 or so evaluations that were filled out by residents and attendings, all but one of them were for honors. Consistently my biggest struggle has been with the Shelf exams. I won’t be giving out any advice on how best to prepare for the tests. Instead, my goal is to make you a star on the wards.
There are some rules you should observe regarding your interactions with your teammates and teachers. First, realize that you and the rest of the medical students make up a team. You are partners. And unless there are any glaring differences, you will all generally be looked upon with either the same high regard or disgust. Therefore, you should do whatever is necessary to make your teammates look really good. You should alert your teammates to any changes with their patients. An example is if you have to stay till eight o’clock because of a late surgery and discover that someone else’s patient suffered a code at seven, you should call your teammate to let him know what happened. He’ll need to be prepared when he pre-rounds next morning. He certainly doesn’t need to get caught off guard with any surprising information when he arrives to the hospital at 5:00 a.m. the next morning.
Second, give teammates credit when delivering presentations. Whenever an attending posed a question to the group and told us to look it up, I would present the information the next day and state that my partners and I all played a role in researching the topic. My teammates ended up paying back the favor and cited me to make me look good on rounds. What the attending sees is not a group of students who individually hunt for data; he’ll see a cohesive team where members teach each other and work well together. The end result is that everyone gets high marks. If you’ve ever heard of the prisoner’s dilemma, the same situation applies here.
In short, the prisoner’s dilemma states that the best result can be obtained by forgoing a large reward and helping yourself and your partners obtain smaller rewards. The reasoning behind this action is that if everyone is searching for the largest reward—e.g., “I want to get honors and no one else should”—teammates will begin stepping all over each other, will make each other look bad, and then no one gets a reward of any kind. I’ve had several attendings tell me at the end of the rotation, “Your team is so great. I’m going to give you all excellent evaluations. You’re much better than many of the other students I have seen around here.” In reality, I don’t consider us that much better at all. I think that we showed up on time, knew about our patients, and did our work for the day. The only difference is that my teammates felt the same way I did. I will say that I’ve been lucky in that regard. I’ve heard horror stories from my friends about lazy partners who make the whole team looked bad. Nothing is worse during third year than a dysfunctional team. I’m lucky enough to have been shielded from much of that.
The final piece of etiquette is that you should never say anything bad about other students, residents, or attendings. Even if you have the world’s dumbest intern—and your attending openly calls him that on rounds—you should never say the same thing. Remember what I said earlier about making your team look good? The same rule applies in a way that you treat the house staff.
You should also go so far as to never make fun of other specialties. While I admit to making a lot of disparaging remarks about different specialties on this website, you should realize that this is just an anonymous place for me to vent. I would never call a psychiatrist a fake doctor while I’m in the hospital. You just never know who you’re talking to. While you’re ragging on shrinks in front of your surgery attending, he might feel a little insulted if his wife happens to be a psychiatrist.
With that said, this concludes my introduction to The Life Raft. Hop on over to the downloads section and pick up a patient tracking sheet that you can use on rounds. Welcome to third year. You are now a Half M.D.