Episode Transcript
Before your First Day on the Wards…
Welcome to Before your First Day on the Wards! The inpatient wards are one of my favorite places in the hospital, and whether or not you are interested in pediatrics, the inpatient setting offers such an in depth and immersive learning experience that I am absolutely positive it will be a huge milestone for you in your pediatric experience, and a core memory of your third year of medical school.
In this episode, we will go over 4 major topics. First, we will talk about what to do or know before the rotation, in other words a few quick tips to make sure you hit the ground running. Next, we will go over how to preround on a patient. After that, we will talk about how to present a patient. And finally, we will wrap up by going over some pointers about how to be an effective team player.
Before the Rotation
First, let's talk about some tips before you even begin your wards experience.
Reach out to your team: I always think that it is important to have an idea of who you will be working with ahead of time, and sometimes sending an email to the residents on service ahead of time can make sure you receive the most up to date information about where and when you should report.
Understand what first day expectations are. Most rotations will likely mean listening to rounds on the first day, but it's possible that others may expect you to come in ready to round on a patient. Clarifying this ahead of time will lead to less stress on your first day.
Peruse the patient list if this is something you have access to: while not an expectation, gaining an understanding of the list of patients ahead of time can help you know what topics it might be helpful to start your studying with or to review the night before
Identify what study materials and resources will help you excel–it's a good idea to ask your clerkship directors, attendings, or residents on service if there are any key resources they would recommend for this part of the rotation. Having this information handy ahead of time can help streamline your studying
Come ready to learn and have fun! Being an enthusiastic learner will always lead to other more senior members of the team wanting to help you learn and grow, and you are more likely to be delegated more responsibility and privilege if you demonstrate that you are a team player that is prepared and ready to work hard.
How to Pre-round
The specifics of pre-rounding can look different for every team and hospital set up, but in general this means coming in well ahead of rounds to collect information on overnight events, vitals, labs, and doing a brief interview and physical exam on your patient.
For overnight or interval events: make sure to touch base with your resident on overnight events from the night team. As med students, verbal change of shift sign out information is not always readily accessible to you unless you are present for sign out. Additionally, make sure to read all of the notes from the day prior which also might have information on interval events. This may include notes from consultants, nursing team, speech/physical/or occupational therapy teams, social work, or case management. This is an incredibly helpful way to stay up to date on the most recent events from a broad multidisciplinary perspective.
Next, sift through your patient's vital signs. Keep in mind that in pediatrics, vital signs change greatly based on the age of your patient. Remember that because of these age specific ranges, there are vital signs that can be abnormal that may not flag or alert as such: for example a heart rate of 70 in a baby is very abnormal, but might not flag in your EMR since this would be a normal adult HR. Vice versa there are vital signs that are normal, that may alert as critical: for example a blood pressure of 80/50 may be normal for an infant, but may flag as hypotensive. Interpretation is key! It is helpful to keep a printed out copy of normal vital signs by age range in your pocket to have handy.
Next, make sure to look at your patients “Ins and Outs”. We will talk more about interpreting these later in our “how to present a patient” section.
After going through overnight or interval events, vitals, Ins/Outs, next make sure to look through your patients lab, microbiology, and radiology data if it is available. Having an idea of these results can help you target what parts of the physical exam or questions you may want to ask the patient or family. Next, I recommend reviewing the medications that your patient is on, and making note of how often they required any medications ordered “PRN” or as needed.
Alright so you have all of your objective data, and now it's time to go see your patient! Make sure you are clear what the expectations are and if your resident needs to accompany you or if it is acceptable to see the patient on your own. Before you physically see your patient, I would strongly recommend checking in with their night nurse who can be helpful in recapping important events the MD team may have not been aware of. Just make sure that you aren’t interrupting our nursing colleagues sign out to their own day team!
OKAY, now we are officially ready for the most exciting part, seeing our patient! Enter the room and state your role as the medical student. Remember when pre-rounding: these are patients already admitted to the hospital. This is NOT the time to re-do the entire H&P. Instead, I encourage every student when outside the room to identify the 2 most important questions they want to ask the patient or their caregiver, and the 2 most important things they want to make sure they do on physical exam. Your interactions with patients in the early morning (usually at 6am after what likely was not a great night of sleep) should be problem focused. It is always okay (and encouraged) to come back again later in the day to ask further questions and start building a stronger relationship with the patient and family. For example, for a patient admitted with dehydration secondary to viral gastroenteritis, we would want to make sure we ask detailed questions about what their stool looked like, how much they vomited, and how much PO intake the parents felt like they were about to keep down, and we would likely want to make sure we did a good abdominal exam, as well as assess signs of dehydration with evaluating mucous membranes, capillary refill, and skin turgor. This does not mean that we won’t do the rest of the physical exam, but making a point to identify the key elements beforehand will make sure you don’t forget to perform them in the room, or report them on rounds. In general, for each patient at minimum you should make note of their general appearance, listen to the heart and lungs, do a basic abdominal exam, and make sure to examine all lines and drains. As a rule of thumb, it is better to be more thorough than you anticipate is needed than to have an inadequate exam. We will discuss this more in our “how to present a patient” section. After you finish pre-rounding, it is time to sit down and collect your thoughts, interpret your data, and formulate your assessment and plan. If you have time, beginning to prepare your note can be especially helpful in organizing your thoughts, and is an efficient way to make sure your notes are done at a reasonable time.
Alright, you’ve made it so far already through your first day. You just finished pre-rounding, now let's move on to…
How to Present a Patient on the inpatient wards service
All presentations should begin with a one liner that includes the patient's age and gender, any relevant medical history or conditions, and their main problem that is keeping them in the hospital. For example, “Thomas is a 3 month old male with a history of prematurity born at 31 weeks who is currently admitted with viral bronchiolitis due to his high flow oxygen requirement and need for IV fluid repletion”. At this point, you can move into our SUBJECTIVE portion, with interval and overnight events. When reporting significant clinical events, you should get in the habit of reporting the event itself, followed by any clinical intervention, followed by the patient's response. For example, let's say overnight our patient desatted to the low 80s several times. Reporting this event is helpful, but even better would be to report “Thomas had several desats to the low 80s during which he reportedly looked like he was working harder to breath with worse retractions. The night team got another chest x-ray, and increased his flow from 5L to 8L/min with improvement in his saturations and work of breathing.” See how this paints a better picture? Think EVENT→ Intervention —> Response. Next, you can go into more detail about any questions you might have asked the patient this morning. If there were truly not any significant interval events, it is okay to report “no significant overnight events” but I generally recommend finding at least one clinical event or patient or caregiver concern or question noted on subjective interview.
Next, we can report Ins and Outs. Ins and Outs are variable, and some patients require very carefully logged I/Os like our cardiac patients, versus others we may not log or follow to an exact amount. In general, Is and Os should be reported in ml/kg, since volumes are difficult to interpret based on age/weight. This can seem intimidating at first, but I promise we can do it together!
First, let's talk about “ins”. This includes the fluid that the patient took enterally (or through the gut) either by mouth, by NG tube, or a G tube. Ins should always be reported in ml/kg/day. Additionally, if the patient is a baby or is there for any nutritional concerns, it is important to note how many kcalories/kg/day they received and of what type of formula this was. These calculations are easier than they look and get better with practice. I recommend asking your resident to help you and compare your numbers the first few times. In addition to reporting total volume, calorie amounts, and formula types, sometimes it can also be important to note what portion of our “INs” were done by mouth (instead of by NG tube) or what portion of our INs were enteral nutrition vs. what was given IV. For example, for our patient we could say “Thomas was IN at a total of 120ml/kg/d. Enterally, he took in 100 ml/kg/d of 20kcal/oz standard term formula by mouth, which equates to 66kcal/kg/day. He also received 20ml/kg/d of IV fluids running at half maintenance rate.” Calculations with lots of unit cancellations are difficult to walk through in a non-visual podcast, so I recommend sitting down with your resident to do these for the first few times and compare your numbers. To calculate ml/kg/d divide the total mls in by the patient's weight. To obtain the total caloric intake, multiply the amount they took in in ml/kg/d by the calories/oz in their formula, then divide this number by 30 to give you the appropriate kcal/kg/day.
Not every single one of your patients will need every single one of these calculations, so it's important to identify the main reason we are trending these values so we know what is most important to report. For example, if Thomas is a 3 month old with viral bronchiolitis and dehydration, we are likely more concerned about his overall fluid status and ability to take PO than we are about his ability to gain weight and calorie intake. For this reason, we could shorten his Ins to say “Thomas was IN at a total of 120ml/kg/d, 83% of which was PO with the remainder being his IV fluids running at half maintenance rate”. In other cases, we don’t have exact numbers for Ins and we may report the number of breastfeeding occurrences, or the estimated % of their meal they took in.
Now let's talk about OUTs. Stool is generally measured in number of occurrences, unless an ostomy is present in which case present this in ml/kg. Urine is the one exception to ins and outs where we don't report ml/kg/d, but instead report ml/kg/hr. If we are unable to log exact urine amount, again we would report occurrences. OUTs are also the section to report any episodes of emesis, as well as any output from drains.
Don’t forget when reporting INs and OUTs, you should also report weight here if this is relevant to your patients active problems. Generally, if you have a newborn, you should be reporting their weight gain or weight loss each day.
Alright, let's move on to the rest of the objective data, starting with vitals! A good tip for the objective section in general is that when you are starting out on a new rotation with a new team or attending, I recommend being thorough to demonstrate that you did an appropriate job of collecting all necessary information. It is better to “show off” a bit on the first go around to build trust, and then let your attending or resident guide you with their preferences about what you can trim off. Again, try to determine the most important vital sign pertinent to your patient, and be detailed for that and condense for others. For our example patient, we could report that he was febrile with appropriate HR and BP, and was satting >95% on 8L of high flow at FiO2 35%.
For your exam data, present in an orderly fashion starting with general appearance and then moving from there like you would with any other patient encounter. Try to emphasize the key portions that are relevant to their main problem and may influence your plan. So for example for our patient, we would make sure we want to give an in depth description of their work of breathing and lung sounds, as well as their cap refill and hydration status since this might influence what we do with respiratory support or IV fluids. As the week goes on and you build trust with your team, you may be able to generalize some of the other less relevant portions, but for now stick with a full and complete description. For example, for our patient on day 1 you might report their abdomen is soft, nontender and nondistended, but by Day 7 with the same patient and team you may be able to report that his abdominal exam was unremarkable or unchanged, after you have shown us that you know how to report normal.
Next move on to labs, microbiology, and radiology. For labs, it is helpful to note trends. For example, reporting that a CRP has downtrended from 8.5 yesterday to 1.0 today is more helpful than an absolute value. Try to identify ahead of time what the most pertinent lab values for your patient are that day, and focus your time on those ones. Much like vital signs, normal lab values ranges can be very different for children versus adults, so make sure you aren’t reporting a number just because it is flagged, and likewise, don’t assume a value is normal just because it isn’t highlighted. One common area I see students make this mistake is with white blood cell count, hemoglobin, bilirubin and creatinine which can vary based on the patient's age especially in the newborn period. For microbiology, reporting culture data is important, and specifying at what growth times these reflect: for example Thomas’s blood culture is negative at 48 hrs. For radiology reports, it is okay to read complicated reports verbatim, but make sure you know the significance and meaning of the report. Additionally, it is a good habit to alway open chest x-rays and review the images yourself. First for learning purposes, and also because you may get asked to look at the image on rounds. MRIs and CTs are another story, we can save these for your radiology rotation!
One common mistake I see students make when presenting their objective section is by skipping ahead to their assessment and plan. For example, it is okay to interpret trend by saying that a patient's CRP has down trended from 8.5 to 1.0, but don't skip too far ahead by saying something like “their CRP has down trended from 8.5 to 1.0 and their blood culture is negative so I think we can stop antibiotics”. This should be saved for your assessment, reasoning and plan! It can feel strange at first to be listing numbers and data and holding in our next logical thoughts and plans but part of 3rd year is training your brain to communicate and receive information in this standardized way. It will feel more natural with the more practice you get!
Moving on, your assessment should start again with a one liner. Remember, this one liner should likely be different than your opening one liner, because you are interpreting and incorporating the data you presented. For our example patient, remember our opening one liner? Let me say it again: “Thomas is a 3 month old male with a history of prematurity born at 31 weeks who is currently admitted with viral bronchiolitis due to his high flow oxygen requirement and need for IV fluid repletion”. Now let's make a new assessment one liner. A good opening one liner for an assessment will again include their age, gender, relevant medical history and principal hospital problem, but should include some assessment on their overall progress, stability, or clinical trajectory. For example “Thomas is a 3 month old male with a history of prematurity admitted with viral bronchiolitis who has overall been worsening from a respiratory perspective over the past 24 hours, requiring increasing amounts of respiratory support.” This paints a better picture about his clinical evolution, and how he has been responding to our interventions. It also sets the stage for the next parts of your assessment and ultimately your plan. Your plan should be organized by problem or by body system, ask your team what method they prefer and try to be consistent. Do not worry about presenting the wrong plan! Take your best shot at it. Remember, that a careful assessment really is where the “meat” of the presentation is. This is the “show your work” of the math problem. It proves to me that you know how to tie together relevant information, interpret that information, and give a differential diagnosis all while showing me your careful thought process! I would much rather have a student give an excellent assessment and an incorrect plan, than have a student give me an incomplete assessment and completely correct plan. A good plan (whether correct or not) will be phrased a clear and firm action item, and not as a question. For example, instead of saying “i'm not sure if we should try weaning his high flow”, try suggesting “lets wean his high flow from 8L to 7L, and I can come back and assess how his work of breathing looks with that”. It can feel scary, but try your best to, as they say, put your money down!
When giving a presentation, well, presentation is everything! Make sure you aren’t reading directly from your paper the entire time, try to make eye contact with team members and even the patient or caregivers, especially during your assessment portion.
Alright guys you did it! We are almost through your first day on the wards, lets next skip to my favorite topic, how to be an effective team member! Life on the inpatient service can very challenging: the hours are long, much time is spent on your feet rounding, we are constantly interacting with many new team members, and to add to that: we generally take care of very sick children and meet families on what is some of the toughest and most emotional days of their lives. In this kind of environment, learning how to be an effective team member is key, and it will set you apart from other students. In the mornings, try to make sure you make a concerted effort to touch base with a resident to run through your assessment and plan. Instead of asking the resident what the plan is, propose your own thoughts first. A good resident will do their best to make sure you feel prepared for rounds, but it is your responsibility to show the initiative and be the one to seek out your resident in the morning. Another piece of advice is to always be honest and direct. If you did not do a particular exam maneuver or ask a specific question, it's better to simply say “no, i didn’t do that” instead of making up an answer or beating around the bush. Answers like this can erode trust that can be difficult to regain. On rounds, make sure you are engaged listening to all patient presentations, not just your own. After rounds are over, the team will tackle tasks. Usually this is organized by “running the list”: a time where team members sit down and assign specific action items to one another. Throughout the day, try to follow up on tasks for your patient (or other patients on the team) and make sure they are carried through. Keep eyes out for pending labs, offer to call or touch base with consultants, and re-visit and reexamine your patient to give the latest updates on your interventions made during rounds. Ask your residents what time they prefer notes to be finished, and ask for feedback on your notes. Feedback on the wards can come in all sorts of forms: making sure you review changes made by the resident and attending to your note, listen to the follow up questions or clarifications asked after you give a presentation.
And on that note, I hope you feel just a little bit more ready for your first day on the wards! I hope you enjoy this immersive learning experience, and I’m excited for you to realize how even as a medical student you can make big differences in the care that our pediatric patients receive. Good luck!
