"Nuts & Bolts 2" - A Guide to the Clinical Years Section 3: Insider's Guide to Inpatient Settings Table of Contents Daily Agenda Prerounds Every morning you will visit each of your patients and check their events overnight (prodecures, consults, acute changes in status), subjective status (e.g., How are you doing this morning, better/worse, resolution/appearance of symptoms, etc.) and objective status (e.g., vital signs, a brief PE of pertinent systems and laboratory results: make sure that you have all of the lab results from the day before). Plan some extra pre-rounding time on your first few days to become familiar with the various kinds of charts/records (bedside, ICU, hospital chart, labs, etc.) as they change from hospital to hospital. While the information they present as a whole does not change, their format, data sets and location can vary greatly (computer, bedside, nurse's station, etc.) The morning labs are drawn around 6 A.M. and may or may not be back by the time you are finished pre-rounding. Also, you should review the nurses' notes (or talk to the night nurse regarding the patient's status and changes) and the patient's chart for new notes (consults, cross-cover and orders). In addition, reviewing any new orders on your patient will alert you to any new developments. Allow approximately 15 to 45 minutes per patient to pre-round. This amount of time will vary according to the complexity of your patient's case and your level of experience. This is a great time to start your note (at least the SO part). Work-Resident Rounds After you and the interns have finished pre-rounding, the resident and the ward team (the attending is not usually present) proceed from bed to bed to discuss patient status and treatment plans. What residents know about patients is what you tell them! When the team arrives at your patient's room, the resident will expect you to give a SOAP-format presentation by presenting your Subjective and Objective findings as well as an Assessment and a Plan. Students often say too much in the subjective section. Literally a one sentence summary is enough. Also, after the first few days, do not say the normal physical exam each day on rounds; just the pertinent positives or unchanged. For vital signs, some people say to read them as a range, while others want one number unless there is wide variation. On the first day with each team, ask your resident how he/she prefers that you do your presentations on work rounds. While you may not be certain as to the optimal assessment and plan, it is important to consider the possible alternatives and choose the one which seems reasonable. Note: while thorough gathering of the subjective and objective data make you a good medical student, it's the Assessment and Plan that make you shine. You can discuss your plan with the intern following the patient with you prior to your presentation. During these rounds, people will make suggestions about what needs to be done that day for each patient. These suggestions should be written down and comprise your daily "scut sheet" (e.g., Mrs. Smith: check x-ray results; Mr. Jones: change diet from regular to nothing-by-mouth <NPO>). It's generally regarded as poor form for one medical student to "pimp" (ask questions of) another medical student; that's the resident's job. Attending Rounds All new cases (those patients admitted the night before the team was on call) are presented in detail with a follow-up on current patients. Medical students are expected to present very detailed reports on new patients. Practice! Aside from this time, your attending does not have much opportunity to see you in action. Prepare carefully for these presentations because part of your evaluation is based on them. Read up on the basics of your patients' illnesses. Your resident may also recommend articles about more recent therapies. If you have time, you should do Medline searches and get articles yourself. On Medicine, try to bring in an article every week. The general categories to cover in your reading are: clinical presentation, DDX, DX (P.E., labs, imaging studies, etc.), complications, RX, and prognosis. If time permits, your attending will make didactic presentations. Never, ever present literature on another student's patient without explicit direction and permission of your fellow classmate it's just poor form. Evening Rounds Surgery teams may also have rounds in the late afternoon or evening. This is to check in on all the patients after the surgeons have been in the OR all day. "Sign Out" Rounds Interns and medical students "sign out" their patients to the "cross covering" interns on call by conveying important patient information to the physician who will be covering their patients at night. This includes: "Does your patient need to be cultured if s/he spikes a temp?"; "Is your patient a DNR (do-not-resuscitate) or a full code (full resuscitation)?"; "Does your patient need an IV replaced if it infiltrates or falls out?"; etc. Be sure not to go home without notifying your resident. Third-year students should check with their interns and residents about their sign-out responsibilities. For the most part, third-year medical students do not sign out, but should check with interns and your resident when you leave each day. Similarly, if someone has covered your patient overnight, either you or your intern should receive signout from that covering resident in the morning. Conferences Throughout the week, often at lunch time, residents or faculty give lectures: • Grand Rounds: Weekly lectures given by professors (UC or visiting), often on the subject of esoteric research topics. All of the biggies attend these lectures. • Morbidity and Mortality (M & M) Conferences: Attendings, house staff, and students meet weekly to discuss difficult and complex cases. This is where the house staff are often grilled (a.k.a. "pimped") but you won't be. Sometimes you may actually be asked to present the case if your patient is to be discussed. Present it well, for this is a rare moment to shine in front of the entire department. • Radiology Rounds: Review x-rays with the radiologists. Depending on the service you are on, it may be a formal weekly teaching event with presentation of cases or it may be completely informal with students meeting with their residents in the Radiology Department to review patient films. • Morning Report/Resident's Report: The Chief of Service and all of the residents get together in the morning, at which time the resident on-call the night before discusses his/her admissions. • Medical Student Presentations: You will make presentations for the team on topics relevant to your patients. This may happen during rounds or at a different time. The frequency of these presentations varies according to your resident and your attending. Do not be discouraged if you are asked to do a presentation and then no one asks you to give it. Just politely remind your resident and ask when would be a good time to present. Early in your rotation, it is important that you ask your resident and attending about the frequency and format of presentations. Work Aside from rounds and conferences, the rest of your day is spent writing your notes, reading about your patients, and doing "scut" work (e.g., checking lab or other results, ordering and/or calling for consult services, performing procedures, etc.). In addition, you should consult with your patients, answering their questions and practicing the "art of medicine." It is important to keep up with your reading because this is part of what you are evaluated on. Students who spend too much time doing "scut" are not necessarily rewarded with Honors, but neither are those who read all the time to the exclusion of providing good patient care. "Scut" is often considered part of the entire medical/surgical team's responsibility and many residents feel that "scut" helps keep students involved in patient care. If you feel you are being "over-scutted," talk with your resident, but don't whine. On most services, your job is NOT to try to be "mini-intern." However, note especially on the surgical rotations that the "good" students are often the ones who ask for scutwork, get it done, and come back asking for more. It is often helpful to talk to your intern and go over the scut list designating what each of you will do. (Sometimes medical students are not supposed to call consults or private medical doctors (PMDs); check with your intern.) Trauma at SFGH or Fresno There may be little else during your third year to compare to a 911 trauma activation. For your own safety/student well-being, bear the following in mind: • on your way to the trauma, ask your resident/intern what you can do • wear FULL protective gear (eye shield, face mask, lead vest, gown, long booties/shoe covers) • don't get stuck, and don't stick anybody • volunteer to do the rectal exam, foley, & exposure (cutting clothes off) • have rectal kit (lube and hem occult) and foley kit ready • be ready for chest compressions • don't agree to do anything that you don't know how to do (unless the person asking knows this, and he/she needs to guide you) Admission Notes Admission notes are similar to Foundations of Patient Care write-ups. They include pertinent detailed histories, a complete PE, and a well thought-out assessment and plan. Remember, these are legal documents. The student's admission note is often the most complete in the chart and should contain a complete family history, social history, review of systems, and past medical history. • Find out when admission notes are expected to be in the chart. They usually need to be in the chart within 24 hours of the patient's admission. • Don't "white-out" mistakes. Draw a single line through errors and initial them. • Many attendings request that students on the team photocopy admission notes so that they can read them carefully and make recommendations. Admission Orders Admission orders should be written as soon as possible following the admission of a patient because the nursing staff cannot do anything for your patient without signed orders. Each set of admission orders should have the date, time (military time, i.e., 3:00 P.M. = 1500 hours), and the physician's signature with a beeper number where s/he can be reached. The orders should be legible, complete, and organized. Most house officers end the orders with specifications for conditions for which they want to be notified. If you can write the orders, even if they need to be modified, you can save intern time which is always appreciated!