clinical pearl

ineedthatseat  asked:

Hi Dr. W, I don't know if you'd like to publish this for anyone who's starting out in medicine, from a professional patient who has met dozens of drs. The absolute best question I'm ever asked at first visit is, "What are your expectations of me as your physician? What goals do you have in mind?" It’s a lot better than the ususal "What brings you in," because it makes me feel this dr is genuinely invested in helping me. Whenever things start out like that it makes the rest easier.

This is an excellent question. So much confusion and irritation is caused by unclear expectations. Getting it straight from the beginning is very helpful for both sides.

COPD: Tips for step 2 CK and rounds

Hello! I have a pulmonary rotation going on and I thought I’d shed light on management of COPD :D

During rotations, you may be asked what you want to do for the patient. I have written “Plan” for what you might want to answer to impress your attending. I’ve included a few common brand names too :)

Inhalers: Remember inhalers only improve symptoms and have no mortality benefit and do not affect the progression of the disease.

For all patients with COPD: A short-acting bronchodilator (eg, beta-agonist, anticholinergic agent) is prescribed for use as-needed for relief of intermittent increases in dyspnea.
Albuterol PRN

COPDers in whom intermittent short-acting bronchodilators are insufficient to control symptoms or two or more exacerbations in the previous year: Add a regularly scheduled long-acting inhaled bronchodilator. The long-acting inhaled anticholinergic (muscarinic) agent (LAMA) is preferred to the twice daily long-acting beta agonists (LABAs).
Albuterol PRN
Tiotropium OD (Spiriva)

Important for step 2 CK: Inhaled anti-cholinergics are the most effective in COPD.
(Contrary to asthma, where you start Inhaled steroids if symptoms aren’t controlled by short acting bronchodilator like albuterol alone.)
Mnemonic: antiCholinergics are the Coolest in COPD.

For patients who continue to have respiratory symptoms or exercise limitations when using long-acting inhaled bronchodilator monotherapy, add a second long-acting bronchodilator from another class (LAMA or LABA), rather than adding an inhaled glucocorticoid. For patients who continue to have symptoms or have repeated exacerbations despite an optimal long-acting inhaled bronchodilator regimen, add an inhaled glucocorticoid (ICS). An inhaled glucocorticoid may be warranted earlier (ie, at the same time that the long-acting inhaled bronchodilator is initiated) if there are signs of inflammation or an asthmatic component to the COPD.
Personally, I have seen them prescribed together in clinical practice rather than one after the other.
Albuterol PRN
Tiotropium OD
Fluticasone / Salmeterol BD (Adavir)
Or Budesonide / Formoterol BD (Symbicort)

Stuff that has a  mortality benefit:
Oxygen therapy
Smoking cessation
Vaccination (Influenza, pneumococcal)

Clinical pearl: Always ask your COPD patient when was their last flu shot. If your attending asks, you’ll know it like a boss B)

When do you start O2? Start O2 when pO2 < 55, sat < 88%
(Silly question that I asked and answered myself: Why don’t we start O2 right away if it’s so awesomee? Because carrying an O2 cylinder around isn’t always feasible lol.)

Other things to shine on rounds:
Know that COPD is a systemic disease, not just a lung disease - Depression, osteoporosis, weight loss, etc are also a part of the disease.
Read about BODE index.
Know about the anti-inflammatory effects of macrolides in COPD exacerbations.

That’s all!
We rise by lifting others :)

Sepsis clinical pearl

ICU doc: “There is a simple bedside test you can do to see if additional fluid resuscitation would be helpful. Simply lift the patient’s legs and hold them at about a 45 degree angle and watch the monitor. This is roughly equivalent to a 300ml bolus. Of course this means actually touching the patient.

And they have to have legs. ”

Advice from my preceptor...
During second year, we had a class called simply “small group.” (I think technically it was “problem based learning” but that’s irrelevant because we called it small group). My group was made up of 8 med students and 1 physician preceptor. Part of the goal of this group was to work though digitally presented cases with guidance from our preceptor and hopefully learn a thing or two along the way. However, our group was lucky; we scored a preceptor who not only taught us some great clinical pearls, but prioritized communication within the group and personal growth. (Seriously sometimes class was like a mini therapy session :P).  Right before we finished up for the year, he sat us down and gave us this list of advice for third year. Now that we have all started, I thought I would share. He elaborated on each, but I’m just going to present a concise list for you/me to think about. Advice from my preceptor… 1. Do not trash your classmates; instead, watch their backs.  2. There will be times you will feel depressed. Have a buddy you can call or go see and talk to when this happens.  3. When it comes down to it, you can survive a month.  4. Don’t sweat the small stuff. 5. Set yourself 2-3 goals for every rotation. Each week check in; if they are too hard change them. Just have goals.  6. Try to get something out of every rotation, even if it’s not your favorite. Don’t think negatively about the whole month.  7. Keep the big picture in mind. 8. Be polite to Everybody… Everybody. 9. When you’re tired and stressed keep your cool, and let people see you keep your cool.  10. The only time you will learn more is your intern year.  11. When your friends say hurtful things, understand they are stressed to, and it will be OK. 12. Watch out for preexisting dysfunction on your team and steer clear or proceed with caution. 13. People will die. Just remember that if the team is depending on a 3rd year med student to save the patient then something is wrong. It’s not your fault.

Case Study.

Studying in the clerkship years is a challenging task. Study times gives way to working time; working time gives way to sleeping time. Somewhere in between we need to create time for ourselves to build our knowledge.

The transition into third year requires quick adaptation to studying on the go. Bring a pocket book or load an ebook onto your phone or tablet computer. If you have few minutes to catch your breath, take out your study material and read a little. 

The best way to maximize your learning in these circumstances is to read around the cases you see each day. Was there something you did not understand about the pathophysiology for patient A’s condition? Not sure what the management plan should be for patient B? Make a case study out of these patients and read around what you do not know or cannot remember. Not only does this help you relate your readings to an actual experiences that help solidify your knowledge, but it will help you manage that patient’s care better. It is a win-win.

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Teammembers from the women’s national U.S. Soccer team paid a visit to the NHCH Makalapa SMART clinic on Joint Base Pearl Harbor Hickam where they met with wounded military members and patients, Dec. 3, 2015.

Lt. Cmdr. Tracy Wirth and Petty Officer 2nd Class Tara Molle, crewmembers from the Coast Guard 14th District had the privilege of escorting the team to the base where Hope Solo, Megan Rapinoe, Julie Johnston Heather O'Reilly and Alyssa Naeher conducted meet and greets with the servicemembers.

Digital Confidentiality.

In this age, we rely on technology in our day to day lives to facilitate work and play. One of the important topics in medicine as more of our interactions become digitized is confidentiality.

Nowadays, it is not enough to simply be vigilant when talking to someone in person. We need to take measures to protect our work and the sensitive information of the patients we see. I would like to discuss specifically the instance of using the phone.

If you cannot speak directly to the person you are looking for, a voicemail should not contain any patient identifiers. The same goes for text messages between members of your team or beyond.

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This is an example of what not to do.

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This is an example of what to do.

While this may seem trivial, students and doctors alike have had close calls before where too many details were given over the phone to the wrong recipient that confidentiality was in jeopardy; in other instances, there have been actual breeches. 

For everything else digital, use your years of acquired digital common sense. In a public area equipped with computers, tablets, and USBs, sign out of your sessions, secure your patient files and password protect your accounts. 

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