Waiting4Ganong said:
I wonder if some kind Pulmonary Fellow, Resident or 4th yr Med Student who has done a "pulmonary consult rotation" would care to comment on what a visiting medical student can expect from this and what would be expected of them?
Specifically if they could break it down for me in terms of essential skills and knowledge either expected or useful (eg: already slick with ABGs?, Spirometry details?, Evidence base for investigations etc?) before starting versus what could reasonably be picked up while on the rotation.
Also useful would be an idea of the typical hours/schedule on a Pulmonary Consult month and what the responsibility/role of a MSIV on the team would likely to be. Features that would differentiate a passing student from an excellent one would also be greatly appreciated.
Am happy to go look up information if pointed in the right direction (and you don't feel like typing) but first hand information/expectations would be particularly valuable.
Sorry if this sounds hopeless naive but I'm coming from a different medical school education system (UK) for just a single month rotation and want to:
a) get the most of it I can and
b) hopefully not stand out for any of the wrong reasons.
Thanks very much,
Ganong,
I did 3 weeks of pulmonary during my core medicine rotation as well as a 4 week elective. My rotations were "Pulmonary Critical care" so knowledge of acid base was slightly more important, but it is important on a pulmonary rotation nevertheless. Also pulmonary function tests are important to understand. The term pulmonary function test includes spirometry plus diffusion capacity. The key things to know are what classifies as airway obstruction (a lot of people define this as FEV1/FVC less than 80% and/or FEV1 less than 70% predicted). If there is obstruction, you have to know whether it is reversible, and many people define reversibility as a change of 12% and/or 200cc in FEV1 after administration of bronchodilator. When we talk about predicted values for spirometry, that is based on age, gender, race, and height (NOT weight). Reversible disease = asthma, nonreversible = COPD. Also, if there is a decrease in the diffusion capacity, then there is an emphysematous component to the COPD. Know your asthma/COPD meds, mechanisms of action, side effects, uses, and evidence for using certain agents. Anticholinergics - ipratropium(short acting)/Tiatropium(long acting) for COPD. Albuterol(short)/Salmeterol(long)/Xopenex(purified L-enantiomer of albuterol I think) for asthma. Also, Singulair (leukotriene modulator), inhaled corticosteroids, and rarely, mast cell stabilizers like cromolyn. A common pimp question might be that Singulair can unmask Churg-Strauss vasculitis in predisposed patients. Understand the role of inhaled corticosteroids in asthma and COPD. In asthma, they decrease chronic inflammation and airway scaring, which can lead to fixed, permanent obstruction. In COPD, they have some studies coming out that are showing a decrease in mortality with use, and also a decrease in morbidity - people with multiple exacerbation history benefit with decreased hospitalizations. Also, it wouldn't hurt to learn the classification systems used for COPD and asthma - the definitions used in each. Oh yeah, and know an exact pathophysiologic textbook definition of COPD and asthma, because I was asked that and I couldn't give one, so I felt rather silly.
Also, another great thing to read up on is sleep apnea... it is EXTREMELY common in the states. One risk factor that it might be interesting to know is neck circumference, 15cm for women and 17cm for men I think - but it's been a while so I would double check that. Also, it might look slick if you bring a measuring tape with you and measure neck girth on a patient. Know that it is one of the causes of pulmonary hypertension, as well as systemic hypertension - which can lead to heart failure. Treatment can include CPAP, BiPAP, or even surgery.
Also, if there is going to be a critical care portion of the pulmonary consult rotation, then I would try to read up on ventilator management because that was always a confusing topic for me.
The top 3 causes of chronic cough are post-nasal drip, asthma, and GERD in that order I believe. ACE inhibitors are also a consideration, 20% or as some reports say up to 50% of people on them experience cough, and the cough can start any time, like 1 day after taking a med, or even a couple years after taking it. The incidence of cough with ARBs is a lot less, 6-8% I think, or even less.
Another good topic to read would be venous thrombo-embolic disease. Along the same lines, learning to read and interpret plain chest films and chest CTs would also be an impressive skill to demonstrate.
Finally, lung cancer basics - find a concise review somewhere of the staging and basics of treatment and just learn that stuff as best you can.
I could go on and on, but I think those are a few good places to start.
With regard to hours, there were no pulmonary fellows at the institution where I did my rotation, and I was a 4th year student. This combination led to me coming in at 8am and leaving at 5pm on most days, and staying til 7-8 on a few days occasionally. The hours will probably be a little bit longer if you are working with fellows I would imagine.
Hope some of the information here is useful and please excuse the verbosity. Best of luck and take care.
-Gharfunkle
