Notes: Table of Contents

Transcription

1 Notes: 16

2 Table of Contents Table of Contents... 2 Schedule of Activities... 3 Cytopath Rounds Memo... 4 NIMV Project... 5 Call Room Assignments Department of Medicine... 6 Leave Request Procedure... 7 Overview of Pulmonary Rotation... 8 Pulmonary Ward CanMEDS Objectives & Rotation Specific Objectives Pulmonary Consult CanMEDS Objectives & Rotation Specific Objectives List of Bronchodilators Pulmonary Staff Contacts Additional Information Website Notes Area Written by Dr. Lawrence Cheung Formatted by Casandra Nero Notes: 15

3 Staff Contacts Schedule of Activities Physician Phone Pager Secretary Physician Details Dr. Lawrence Cheung Sue Falconer 2E4.34 WMC Day Time Type Location Dr. Irv Mayers Dr. Godfrey Man Val Lubbers Admin Dianne Chaba Clinical Dianne Chaba 2E4.26 WMC Mondays General Pulmonary Clinic - (for residents rotating through the consult service) 2E Medicine Clinic Dr. Hari Vliagoftis Dr. Dilini Vethagayam locating Iris de Guzman irisd@ualberta.ca Iris de Guzman irisd@ualberta.ca 550A HMRC harissios.vliagoftis@ualberta.ca dilini.vethanayagam@ualberta.ca Pulmonary Lecture 5C1.06 Dr. Ben Chiam Dr. Mohit Bhutani Raegan Kelly raegan.kelly@ualberta.ca Giselle Prosser gprosser@ualberta.ca bchiam@ualberta.ca mohit.bhutani@ualberta.ca Tuesdays Multi-disciplinary Ward Rounds 5D Conference Room Dr. Ron Damant Dr. Eric Wong Zuzana Turakova-Baran zuzana.turakova-baran@ualberta.ca Sue Falconer sue.falconer@ualberta.ca rdamant@ualberta.ca eric.wong@ualberta.ca Cytopathology Rounds Classroom F Dr. Neil Skjodt Dr. Neil Brown Raegan Kelly raegan.kelly@ualberta.ca Giselle Prosser gprosser@ualberta.ca neil.skjodt@ualberta.ca neil.brown@ualberta.ca Seminar (Ward Resident Presentation) Classroom F Dr. Dale Lien locating 6191 Sheila Roth sroth@cha.ab.ca dale.lien@ualberta.ca Dr. Justin Weinkauf Dr. Brian McNab Sheila Roth sroth@cha.ab.ca Tanya Ducharme tanya.ducharme@ualberta.ca justin.weinkauf@ualberta.ca 8327 Aberhart Ctr 1 brian.mcnab@ualberta.ca Wednesdays Radiology Rounds (NB: if no seminar is scheduled, radiology rounds will occur immediately after Cytopath Rounds) Classroom F Casandra Nero Residency Program Administrator casandra.nero@ualberta.ca 2F2.33 WMC Respirology Resident Seminar Classroom F Additional Information: Please see our website at: Pulmonary Research Rounds (every second week) Classroom F Fridays Grand Medical Rounds Classroom D 14 3

4 Memo: To: R2s Rotating through Pulmonary (Consults) From: Pulmonary Division Date: February 28, 2007 RE: CYTOPATHOLOGY ROUNDS To the Consult Residents, Cytopathology rounds take place at noon Wednesday. The format of cytopathology rounds is as follows: Three cases over minutes. You present the clinical features of the case (the history, pertinent physical exam, pertinent lab data) Each case presentation is supplemented by Radiology +/- Pathology (i.e. the radiologist reviews the relevant CT s and CXR s and the pathologist reviews the relevant pathology, if any). At your discretion, you can flesh out a focused, specific topic within the cases. For example, if one case reveals a pulmonary AVM, you could do a few (4 to 6) slides on a specific topic regarding AVM (but don t do a whole presentation on everything about AVM). Or, in a case of Sarcoidosis, you can focus on "what is the role of ACE level?, or in a case of pleural effusion, you can focus on "how do you manage an undiagnosed pleural effusion? etc. One technique may be to simply raise questions and direct them at the audience, (i.e. "Dr. Long, what do you think about this patient's risk of TB reactivation?") Naturally, you've already read up on this and can knowingly nod your head when he speaks for the next 5 minutes. Or you can ask the radiologist to provide learning points (for your benefit, as well the audience) about the CXR or CT scan. *The names and hospital ID numbers of the patients should be given to Sheila Roth (one of the Pulmonary secretaries located at 2E4.31) at least one week prior to your scheduled Cytopathology Round. She will then distribute this information to Radiology and Pathology so they will know what the cases are. Sheila s is sroth@cha.ab.ca and her phone number is The data projector is located in 2E4. 36 and you should bring it to the classroom for the rounds. 4 13

5 Non-Invasive Mechanical Ventilation Project The Problem: Patients presenting to hospital with respiratory failure may require endotracheal intubation and mechanical ventilation as life-saving interventions. Noscomial infection (sinusitis or pneumonia) is a recognized risk of endotracheal intubation. Ventilator-associated infections prolong hospitalization and markedly increase mortality. Projections are routinely published showing that COPD and lung cancers are becoming the world s largest killers. The Background: Over the last 10 years, Non-Invasive Mechanical Ventilation (NIMV) has evolved from a research curiosity to an established clinical practice. NIMV consists of mechanical ventilation delivered by mask rather than endotracheal intubation. It is now clear that for patients presenting to the Emergency Room (ER) with acute exacerbation of COPD, early institution of NIMV (within 14 hours of arrival in ER) can prevent endotracheal intubation and reduce mortality. There are two recent randomized, controlled studies clearly showing the clinical benefits of NIMV in COPD patients (documented 50% relative reduction in mortality). The Initiative: We have created a program to deliver NIMV in a rapid, life-saving manner. The NIMV program interfaces between Emergency Medicine, Pulmonary Medicine, and Intensive Care Medicine. We deliver a consistent, state of the art ventilatory support for COPD patients admitted through the ER. An integral feature of this program is an ongoing evaluation of service delivery including the institutional and individual costs associated with delivery of NIMV. We also evaluate specific clinical outcomes including hospital stay and health related quality of life following discharge. We will then be able to assess the full impact of this treatment on Albertans suffering from COPD. The Expectation: We expect that by creating this comprehensive NIMV service we will decrease in hospital mortality due to COPD by 50%, reduce ICU bed utilization, and decrease total hospital length of stay. Check out our Intranet web site for lot of information: index.htm From Intranet Home Page ( go to Sites tab, University Hospital (left side of page), Programs and Services, and NIMV Project link. 12 5

6 Call Room Assignments Dept Medicine Pulmonary Division Call Room Code 3H2.32 Used by seconded Residents while on Pulmonary (for RadOnc, Anesthesia, OccMed) Code 1722# Pulmonary / Gastro 5H1.14 Pulmonary / GI Code 2115* Hematology GIM Cardiology Hem/Neph 3H2.47 Used by seconded Hematology Residents 5D1.17 Residents Reading Room 5D1.16 Staff Discharge Room Code 5441# Code 8829* 3H2.36 Medical Students Code 1811* 5H2.07 Medical students Code 7025* 5H2.08 Medicine Junior A Code 7025* 5H1.12 Medicine Junior B Code 2115* 5H1.10 Senior Med. Resident Code 6662# (not working) Code 0115* 5H2.11 Cardiology Junior Code 9025* 5H2.12 Cardiology Senior Code 9025* 5H1.16 Hematology/ Nephrology Code 6115* Neurology 5H1.18 Neurology Code 6115* Core Internal Medicine Pulmonary Consult Objectives Revised March, 2007 Medical Expert Collect appropriate information from history and physical exam. Generate an appropriate differential diagnosis. Establish an appropriate management plan. Demonstrate knowledge of the following areas: Approach to COPD Approach to Asthma Approach to Sleep Disordered Breathing Approach to Pleural effusions Approach to Interstitial Lung Disease Approach to Hemoptysis Approach to Lung Masses and Nodules Approach to Non-resolving Lung Infiltrates Interpretation of ABG s and PFT s Interpretation of Chest X-rays. Communicator Generate clear and effective consult notes or letters. Communicate effectively with patients and / or families. Collaborator Effectively address the referring team s questions or concerns. Manager Complete tasks efficiently and proficiently. Utilize resources effectively. Health Advocate Identify aspects of preventive health care important in respiratory system disease (e.g. smoking, vaccination, obesity, issues impeding compliance, etc). Scholar Demonstrate an effective self-learning strategy. Help others learn (e.g. presentations, etc) Professional Exhibit appropriate professional behaviour befitting a consultant. Seek advice where appropriate and be aware of limitations Rotation Specific Objectives: 1. Assessment and management of COPD 2. Assessment and management of lower respiratory tract infections 3. Assessment and management of asthma: acute and chronic 4. Assessment and management of pulmonary thromboembolism 5. Assessment and management of interstitial lung disease 6. Assessment and management of masses and nodules 7. Assessment and management of sleep disorders 8. Assessment and management of hemoptysis 9. Approach to lung infiltrates in the Immune Compromised Patient 10. Approach to pleural effusions 11. Interpretation of arterial blood gases and pulmonary function studies 12. Interpretation of plain chest x-rays 13. Approach to end of life care in patients with chronic lung disease 14. Use of invasive and non-invasive ventilatory support 6 11

7 Core Internal Medicine Pulmonary Ward Objectives Revised March, 2007 Medical Expert Collect appropriate information from history and physical exam. Generate an appropriate differential diagnosis. Establish an appropriate management plan. Demonstrate knowledge of the following areas: Approach to COPD Approach to Asthma Approach to Pleural effusions Approach to Interstitial Lung Disease Approach to Hemoptysis Approach to Respiratory Failure Approach to Lung Masses and Nodules Use of bronchodilator therapy & oxygen therapy Interpretation of ABG s and PFT s Interpretation of Chest X-rays Use of invasive & non-invasive ventilatory support Communicator Write chart notes which are legible, timely, and problem based. Communicate effectively with health care personnel. Communicate effectively with patients and / or families. Collaborator Work with and utilize expertise of the appropriate interdisciplinary team members. Manager Complete tasks efficiently and proficiently. Utilize resources effectively. Health Advocate Identify aspects of preventive health care important in respiratory system disease ( e.g. smoking, vaccination, obesity, issues impeding compliance, etc). Housestaff Leave Request Form ALL Residents requesting a day(s) off their assigned rotation (including seconded residents) for any given reason (stat or personal day, conference leave, etc), MUST ensure this form is completed and duly signed. STAT days worked and being taken in lieu MUST be taken on the same rotation that the stat was worked. This should be arranged at least 14 days in advance of the stat day taken. Leave requests for conferences or personal days MUST be applied for 30 days in advance. Divisions MAY refuse the resident's application if appropriate notice (30 days) is not given. The MAXIMUM number of working days for conference leave per year is 5 (also refer to the Travel Guidelines document). Leave taken that has not been approved will be recorded on the resident's file as "unexplained absence" and may result in the resident having to make up the missed days. PERSONAL DAYS: During the months of December and June, requests for 2 to 3 personal days taken together may not be approved. INTERVIEW ABSENCE REQUESTS: Residents will be allowed a MAXIMUM of 5 working days only for interviews when applying to subspecialty training programs. FINAL APPROVAL AUTHORITY FOR ALL LEAVE IN THE DEPARTMENT OF MEDICINE IS GRANTED BY THE DIRECTOR OF POSTGRADUATE MEDICAL EDUCATION. Leave forms can be found online here: forms.htm RETURN FORM TO: Doris Kurtz, Department of Medicine, WMC 2F1.22 Fax: WITH A COPY TO: Casandra Nero, Department of Medicine, WMC 2F2.33 Fax: Scholar Demonstrate an effective self-learning strategy. Help others learn (e.g. presentations, etc) Professional Seek advice where appropriate and be aware of limitations Apply appropriate ethical principles to patients with end-stage lung disease. Rotation Specific Objectives: 1. Assessment and management of COPD 2. Assessment and management of asthma 3. Approach to pleural effusions 4. Assessment and management of interstitial lung disease 5. Assessment and management of hemoptysis 6. Assessment and management of respiratory failure 7. Assessment and management of pulmonary masses & nodules 8. Use of invasive & non-invasive ventilatory support 9. Use of bronchodilator therapy and oxygen therapy 10. Interpretation of arterial blood gases and spirometry 11. Interpretation of plain chest x-rays 10 7

8 Overview of your Pulmonary Rotation Intro Welcome to the Division of Pulmonary Medicine. We hope to make your experience with us as fruitful as possible. Depending on your particular level of training, we hope to expose you to the many strengths our division has to offer. These include the following: A. We have a strong clinical component to our program with a wide variety of patients (including those with general pulmonary conditions, TB, cystic fibrosis, lung transplantation, mechanical ventilation, and non-invasive positive pressure ventilation). B. Many procedures might be performed while on one of the clinical rotations including thoracentesis, chest tube insertion, pleurodesis, closed pleural biopsy, bronchoscopy, fiberoptic intubation, transbronchial needle aspiration of mediastinal lymph nodes, and transbronchial lung biopsy. C. Our pulmonary function lab performs a variety of tests such as PFT s, cardiopulmonary exercise physiology tests, methacholine challenge, and CO 2 response. D. Many of our clinical members are certified in sleep medicine and there are opportunities to learn more about this rapidly expanding field affecting a significant portion of the population. E. Many of our faculty are engaged in interesting clinical research. Feel free to contact one of our divisional members if you might be interested in participating on a project of your own or joining a project already in progress. (A list of divisional members involved in clinical research is listed at the end of this section.) F. The Pulmonary Research Group is involved in cutting edge basic science research and maintains close ties to the clinical faculty. Divisional members involved in clinical research: Dr. Dilini Vethanayagam dilini.vethanayagam@ualberta.ca Dr. Justin Weinkauf justin.weinkauf@ualberta.ca Dr. Irv Mayers imayers@ualberta.ca Dr. Dale Lien dale.lien@ualberta.ca Dr. Eric Wong ewong@ualberta.ca Dr. Richard Long richard.long@ualberta.ca Dr. Neil Skjodt neil.skjodt@ualberta.ca Dr. Dick Jones rjones@cha.ab.ca Duties A. Ward Service: There are two pulmonary in-patient services. The Lung Transplant Service has approximately 6-10 in-patients managed by the Transplant Team. The General Pulmonary Service has approximately in-patients managed by an attending physician, our Advanced Nurse Practitioner (Maryanne Kolodjiez), the junior rotating resident(s), and occasionally a pulmonary subspecialty resident. Other important members of the health care team include the Pulmonary Ward clinical supervisor, the Pulmonary Ward nurses, dieticians, physiotherapists, occupational therapists, and respiratory therapists. There are approximately 4 patients on mechanical ventilation and usually a number of patients on non-invasive positive pressure ventilation. B. Consult Service: On the consult service, you will provide pulmonary consultations requested from the Emergency Dept., Cross Cancer Institute, Surgical/Medical/ Psychiatry wards, and the various adult intensive care units. The consultations usually involve determining need for hospital admission, providing medical advice, assessing the need for bronchoscopy/pleural biopsy/thoracentesis/chest tube insertion, or assessing the appropriateness of transfer of care to the Pulmonary Ward. You should attend the Pulmonary Clinic in 2E2 Medicine held every Monday morning during the rotation. If the rotation starts on Tuesday (after a holiday Monday), page the attending physician on the consult service to arrange an appropriate time to review consultations. Additional out-patient clinics will be scheduled (approximately one ½-day clinic per week). Non-urgent consults can be seen after the clinic. Urgent consults can be seen by the attending physician if possible. Approximately 1 to 2 ½-days during the rotation will be scheduled in the bronchoscopy suite. Some time will be scheduled to meet with Dr. Neil Skjodt to review pulmonary physiology and PFT interpretation. C. Bronchoscopy Service: For those residents rotating through the bronchoscopy suite, the bronchoscopies usually start at 0830 h, but this can vary depending on the attending physician. Call 6741 (endoscopy bookings) or 3166 (bronchoscopy suite) to find out the bronchoscopy schedule. Although the duties can be confined to performing bronchoscopies, residents are strongly advised to speak with Dr. Dick Jones (our pulmonary physiologist) at 6475, to arrange to spend time in the PFT lab and review pulmonary physiology. D. On Call Duties: When on call, the resident is expected to attend to consults from the emergency department or calls about the pulmonary in patients. Consults from the emergency department must be reviewed with the attending physician on call (or pulmonary subspecialty resident). If patients are admitted to the pulmonary service, they should be admitted under the attending physician currently on the ward service (this will not always be the same as the attending physician on call). For major changes in the management of the pulmonary in-patients, the ward attending physician should be notified. For the off-service (e.g. anesthesia, occupational medicine, radiation oncology) resident covering pulmonary call, your call room is 3H the access code is 1722#. E. Elective Rotations: An elective rotation can be arranged for those residents wanting greater exposure to Pulmonary Medicine including bronchoscopy, out-patient pulmonary clinics, pulmonary function lab including special physiology tests, sleep medicine, lung transplantation, cystic fibrosis and TB medicine. Feel free to contact Dr. Cheung (Residency Program Director, Respirology) at or lawrence.cheung@ualberta.ca, to find out more about the elective rotation. You should report to the Pulmonary Ward (5E3) on the morning of the first day of your rotation to receive the list of patients you will be looking after. 8 9