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Surviving the Clinical Years Slide 2 What to Expect From the 3 rd and 4 th year clerkships: Long hours, lots of standing, system of hierarchy Rewarding, exhilarating experiences Clinical education/Learn! Youre still paying for it! Basis for choosing a lifelong career Slide 3 Team Players: Ward/unit secretary Dieticians Pharmacists Therapists: OT, PT, RT Social workers Techs/RMA Nursing Physician ancillary staff Medical students, Interns, Residents, Fellows Attendings Custodians Third Party Reviewers Slide 4 Unit Secretary Also known as ward secretary or clerk Organizes everything Knows where every patient is Arranges transport Knows about incoming admissions Day to day operations Notes orders Slide 5 Pharmacy Pharm.D: doctors of pharmacology Sometimes round with the team Monitor expensive and dangerous meds Helpful with hospital formulary Slide 6 Therapists Respiratory: vent settings, ABG specimens Occupational: help impaired pts function more independently Physical: focus on mobility and strength Slide 7 Social Workers Help plan for discharge Solve non medical problems related to pt care Big role in psych, peds, gero Slide 8 Third Party Reviewers lurk around the hospital preying on unsuspecting newbies Be careful! Slide 9 Technicians EKG Phlebotomy Radiology Can teach you tricks of the trade/clinical skills Slide 10 RMA Registered Medical Assistant Perform routine administrative and clinical tasks to keep the offices and clinics of numerous health professionals running smoothly. Accredited Medical Assisting Programs are offered in postsecondary vocational schools, junior colleges and in colleges and universities. Postsecondary programs usually last either one year or less which results in a certificate or diploma or two years with an associate degree. There is no licensing for Medical Assistants, however, some states require them to take a test or course before they can perform certain job duties. Slide 11 Nurses CNA LPN RN NP Nursing students Slide 12 CNA Certified nursing assistants (CNAs), also known as nurses aides, orderlies, patient care technicians, and home health aides, work under the supervision of a nurse to provide assistance to patients with daily living tasks. CNAs are responsible for basic care services such as bathing, grooming and feeding patients, assisting nurses with medical equipment, and checking patient vital signs. In addition to a high school diploma or GED, you'll need to complete a 6-to-12 week CNA certificate program at a community college or medical facility. Slide 13 LPN Also Licensed vocational nurse (LVN) Working under the direction of physicians and registered nurses (RNs), LPN nursing schools and educational programs typically involve one year of study and training at a hospital, community college or technical vocational school. After earning a nursing degree through a state- approved program, graduates must pass the National Council Licensure Examination (NCLEX-PN). Slide 14 RN Credentials can be acquired by completing one of these three programs offered at many registered nursing schools: Associate's degree in nursing Bachelor's of science degree in nursing Nursing diploma The most popular program is the associate's degree in nursing, which takes an average of two-to-three years to complete. Going straight for the bachelor's program takes four years, and a nursing diploma can take three-to-five years. After completing any of these programs a nurse must pass a national licensing examination (NCLEX-RN). Slide 15 Nurse Practitioners Education: graduate, advanced education and clinical training beyond their registered nurse preparation. Most have masters degrees and many have doctorates. Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) degree. Job duties: Order, perform and interpret diagnostic tests such as lab work and x-rays Diagnose and treat acute and chronic conditions Prescribe medications and other treatments Spend time counseling/educating patients Slide 16 Prescribing Rules for NP Oklahoma Advance Practice Nurses are authorized by the Board of Nursing to prescribe as Advanced Registered Nurse Practitioners, Clinical Nurse Specialists, or Certified Nurse Midwifes subject to the medical direction of a supervising physician. They have prescribing authority and may obtain a mid-level DEA number to prescribe CDS, Schedules III, IV and V, limited to a seven day supply. The nurses have an Exclusionary Formulary a list of drugs they cannot prescribe. The name of the Advance Practice Nurse will be placed on the prescription label. Slide 17 Nursing staff They provide the bulk of one to one pt care Can be an invaluable source of information Read the nurses notes First to observe changes in pt status ICU nurses are the best Slide 18 Physicians Assistants/PA/PAC Physician assistants (PAs) are health professionals licensed to practice medicine with physician supervision. PAs perform a comprehensive range of medical duties, from basic primary care to high-technology specialty procedures. PAs often act as first or second assistants in major surgery and provide pre- and postoperative care. Programs offering baccalaureate degrees require a minimum two years of college credits, and virtually all require health care experience prior to admission. The average PA program takes 26.5 months to complete. The first year generally is composed of classroom studies the essential medical sciences such as microbiology, anatomy, and physiology followed by a year of clinical rotations in private practice and institutional settings. Slide 19 PA Oklahoma Physician Assistants have prescribing authority as set out by their supervising physicians. They may obtain a mid-level DEA number to prescribe CDS, Schedules III, IV and V. Prescriptions for CDS are limited to 40 dosage units with only (1) refill or a 10 day supply maximum (whichever is smaller). Non-controlled drugs are limited to a 34 day supply with (2) refills of a drug prescribed for the first time for the patient. A 90- day supply or 100 dosage units (whichever is greater) of drugs prescribed for chronic, stable conditions, may be prescribed. P.A.s have a Formulary that excludes certain drug categories. The name of the physician will be placed on the prescription label with a slash/P.A. (Dr. Jones/PA) Slide 20 Interns Doctors without prescribing privileges Longest hours in the hospital Most uncomfortable/possibly unfamiliar with the hospital Most sleep deprived Lonely, stressed Slide 21 Interns Take care of daily tasks as quickly as possible Discharge and transfer patients quickly Learn Sleep Wont do a lot of teaching More interested in how to accomplish practical tasks than have academic discussions. Broad, general approach to treatment/extreme thoroughness Slide 22 Residents 2 nd year post medical school Prescribing privileges Dont do intern scut work Have more time to teach students Rely more on experience that the intern broad- based approach More focused exams Slide 23 Fellows Are in subspecialty training Have completed residency Often on attending level of knowledge without the experience Slide 24 Attendings Leader of the team Responsible (maybe) for your eval/grade Concerned about patient care and teaching Responsible for everyone Slide 25 Consultants Subspecialty attendings and their team of residents, interns, students Called in to give expert opinion/answer a specific question. Do not write: Evaluate this patient. Verbal feedback and formal consult note Do not write orders on the chart May or may not follow the patient Slide 26 Med students Thats you! Even though you may feel like an unimportant, redundant part of the team, the more responsibility you take on, the more of an asset you will become. Your main goal is to learn and decide on a career in medicine. Your secondary goal is to get good grades and connections by making a good impression on your superiors You have to balance these 2 roles between scut work, feelings of inferiority, and competition. Slide 27 Med Students This will be the easiest time to learn from a book, but you also have the least amount of time available. Very tempting to quit at the end of the day. Opportunity to know your patients inside and out. Be proactive and speak up. Slide 28 Daily Routine Managing patients: leaving, coming, and staying (reviewing charts, writing notes, procedures, dictations, reviewing films) Attending lectures Learning/Presenting/Studying Slide 29 Daily Routine: Pre- Rounds 6 am: Interns and students arrive to see patients, review overnight events and admissions, write notes, order am labs/tests. Pay attn to overnight events: new meds/impt vitals/new symptoms and signs/new labs Talk to the nurses. Slide 30 Daily Routine: Pre- Rounds 630-7 am: residents arrive to see, patients, review intern and student notes, check orders. Interns usually present new patients but this can be handed off to students. Interns and students give an informal/formal reports to the residents. Slide 31 Daily Routine: 8am: Attending arrives to see all patients. Goal is to present each patient with a plan for treatment. Students, interns, and residents give formal presentations to the attending. Attendings will modify plans, write addendum notes, and teach. Slide 32 Daily Routine: Could attend morning report/department meeting with case presentations prior to attending rounds. Slide 33 Daily Routine The team may go to radiology to look at films or be called to the ER to see a patient. Depending on the length of rounds, the team may or may not have breakfast. Could work through until lunch. After rounds, the attending may leave for outpatient clinic or may join the team for breakfast. Slide 34 Daily Routine: If the attending does leave after breakfast, the team will continue assessing lab results, new patients, ER consults. Minus a break for breakfast, this type of work continues until noon conference. Noon conferences are usually some type of learning opportunity and food: grand rounds, student lectures Slide 35 Daily Routine: After lunch: New admissions continue to f/u up on labs/tests Go to department meetings/and or outpatient clinics Day could end at 4pm or, depending on if the attending wants to do afternoon rounds, go well into the evening. Check out to the night staff Slide 36 Daily Routine: Differences in surgery: bump everything up by 1.5 to 2 hours Day usually ends by 5pm for students Slide 37 Admissions Review old charts Orders/flag them ADC VANDALISM Slide 38 Admit to ? Service, ? Doctor, ? Contact number Diagnosis: list primary suspected/important secondary Condition: critical, guarded, poor, stable, air, good Slide 39 ADC VANDALISM Vitals: q shift, q hour, daily weights. Call house officer if temp more than 102F Allergies: NKDA, ASA, sulfa Nursing: FSBS q ac and hs, guaiac stools, isolation, Foley cath or in/out cath Diet: NPO, clear liquids, full liquids, soft mechanical, ADA, Renal, low sodium, low protein. Specify calories Slide 40 ADC VANDALISM Activity: ad libitum, bedrest, walk with assist, restraints, commode at bedside, self toilet Labs: fasting lipids, cbc, cmp, ua, lfts IV fluids: KVO, heplock with flushes, dextrose (D5W), normal saline (NS), potassium (K) Specials: RT, PT Meds: dont forget renal or hepatic dosing Slide 41 Other tips: STAT orders need verbal verification with the ward clerk Frequently review the MAR to see how often the prn meds are actually being given, if a patient is refusing meds, meds added or discontinued by the house officer Use only approved abbreviations Sign and date every order. Be overly clear by using words like change this to that or replace x with y Verify the correct chart Use generic drug names Slide 42 Other tips: TID means through waking hours vs. q 8 hrs means exactly that! Balance prn orders with close follow up. Check the MAR to see how often they are getting pain meds. Consider tylenol dosing when looking at pt temps. Ped meds need to be adjusted for body weight Be prepared to be pimped on the drugs you order. Know them well. Slide 43 Admit note: Informants CC: precise and to the point chest pain and nausea later ruled an MI in the ER HPI: chronological order/pertinent positives and negatives. no radiation or SOB PMH/PSH: Meds/All: Slide 44 Admit note: Developmental Hx and Immunizations (for peds) Psych Hx (for psych) OB/GYN (for OB/GYN) SH (include pets and home smokers in peds) FH ROS: often redundant if HPI is done well PE (include height in peds) Labs: ER, pending Slide 45 Admit note: Problem list/assessment/diagnostic impressions: can list differential diagnoses Plan Slide 46 Daily Progress Note: S ubjective: pt and nursing reports O bjective: vitals, i/os, PE, labs, meds A ssessment P lan Slide 47 Discharge Note Serves as temporary dictated d/c summary Dx Hospital Course: interventions, studies, sx D/c meds see orders D/c instructions Slide 48 Discharge Orders: Discharge to home, nursing home, etc Diagnosis Meds Follow up appt Instructions Slide 49 Surgery Before each case review the anatomy and pathophysiology Prepare for a potentially hostile environment Lots of pimping Touch as little as possible Surgery etiquette Slide 50 Surgery notes Preop note S:state the procedure O: labs, cxr, ekg, consent A: P: NPO, consider meds (insulin, blood thinners) Slide 51 Surgery notes PPP SAFES FCDD Operative note: Pre-op dx Post op dx Procedure Surgeon names Anesthesia Fluids Estimated blood loss Specimens Findings Complications Drains Disposition Slide 52 Surgery notes Daily progress notes S: pain reports, flatus, bm, diet O: VS (tmax/with meds), i/os, include wound on PE, labs especially WBC, hgb/hct A: post operative day # P: dont forget to d/c foley caths and change central lines Slide 53 OB Delivery note: Stage 1: 23 yo G1P1 at 38 weeks presents with PROM/document time of presentation to completion of Stage 1. Anesthesia/other drugs/quality of fluids Stage 2: Length of active labor/tools used in delivery/describe rotation of occiput and position of delivery (breech, footling), nuchal cord, baby wt, APGAR, sex Stage 3:placental delivery, EBL, episiotomy or degree of tear Slide 54 Neuro tips: Include more extensive cognitive exam: LOC, GCS Orientation, speech language, memory, cognition Cranial Nerves I-XII Motor function: tone, bulk, strength Coordination Sensory Reflexes Slide 55 Psych MMSE: General appearance LOC Attn/Conc Speech Orientation Mood/affect Thought form and content Memory Judgment Intellect Slide 56 Final Tips Use index cards with pt stickers Electronic options Reading list Procedure list Slide 57 Sources: How to be a Truly Excellent Junior Medical Student by Robert J. Lederman,MD Get this book!