Tuesday, October 26, 2010

"Dark and early" at the Trauma Burn Center

Posted by Zhe Han at Tuesday, October 26, 2010

Last Friday, I completed my first inpatient rotation- Trauma Burn. My main reason for choosing to take this rotation was because of my PharmD investigations project which looks at the use of an anabolic steroid in burn patients. If there's one thing I hear frequently about this rotation, it is "rounds are early". Indeed, rounds are very early; starting at 6am on most days and at 5.30am every Thursday. Hence, before I go to bed the night before, I need to have a good idea of the issues I like to bring up on rounds. On most days, I would arrive ~15 minutes before rounds begin to look up some labs that came back overnight. This is also the time when the intern on-call last night gives report to other interns, so sometimes I can get an idea of what happened to my patients overnight even before rounds begin.

In many ways, this was the hardest rotation I've had so far. Yet, it was also my favorite because I gained so much clinical knowledge and developed a more systematic way of looking at patients. Here are 3 main learning points that I hope to share:

1) Be at where things happen.

When you are on inpatient rotations, try to be on the unit as much as possible. There are "COWs" (computer on wheels) along the hall which you may use to work up your patients. In this way, you see what happen to patients, you hear what interns/residents say, and you get the latest updates. When the interns see you around, they ask you questions (eg. antibiotic dosing). You feel involved and they see you as part of the team.

2) Be ready when you make a recommendation.

Whenever you make a recommendation, give a rationale. If you propose adding a new drug, have the dose ready and be sure you can explain your choice and give your reference (if applicable). By being ready, you sound more credible and that increases the likelihood of your recommendation being accepted.

3) Persistence counts.

If your recommendation is not accepted the first time, keep bringing it up when similar situation arises. I encountered a situation on BICU rounds where the chief resident changed IV ranitidine to PO omeprazole whenever patients were able to tolerate oral medications. The reason being PPIs are "innocuous" and Zegerid can be dissolved in water and be administered easily down a tube. It wasn't until the third time that I bring up this issue that he was willing to listen to my explanation of why the H2RAs are first line for stress ulcer prophylaxis (VAP, C. difficile, etc.) plus ranitidine comes as a liquid. He was convinced! So persistence counts and being able to explain the rationale behind your recommendation counts. Even if your recommendation was never accepted, take it as an opportunity to educate and demonstrate your knowledge!

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