# goose ca staging
# goose layers
The submucosa is highly vascular, and contains loose connective tissue. It contains oesophageal glands, that secrete mucus to help ease the passage of swallowed food.
The muscularis externa layer in the top third of the oesophagus contains skeletal muscle, in the middle, it is a mixture of smooth and skeletal muscle, and in the bottom third it is entirely smooth. This photograph shows an example of the muscle layers from the upper oesophagus.
# GI anatomy
# To do for lists:
(early morning) Review plans/signout for each patient
Print the list
RR, recent: Any special labs
MAR – Standing Meds
MAR – Drips/fluids
Flowsheet: IO breakdowns
Secondary survey = head to toe xm:
Head eye mouth
Push on face
Turn patient and look at back
CT non-con of head
Thorax + contrast, (look for aneurysms, ligamentous aterteriosum )
CT Abd Pelivs
CT neck – contrast (+ if seatbelt sign, neuro signs, jumpted facets, lefot 3 (face fracture)
If negative, CT head
# neck anatomy
Lower leg arteries
# layers of tissue abdomen
- Eyes: 4eyes
- Motor think Engine (V6)
# Spinal cord
# DERMATOMES Myotomes
# Really good advice
I got H in all clerkships, and can share some keys to success that worked for me. Apologies for the incoming wall of text. This is something I wrote months ago in a word doc like halfway through 3rd year, and now I guess is the time to drop it. To answer your question, I would have done things pretty much the same, I’d just worry a little bit less.
I guess this is about rotations in general. The way I have been navigating the hospital is by treating it like a game, where the ultimate goal is getting honors. You can use skills in your toolbox like medical knowledge and social engineering/EQ to score points with your evaluators. If you keep your radar on, you can find so many ways to not only get the most out of your learning, but also to be always on point.
Any time you first start working with a new intern/resident/attending (preferably one you’ll be sticking with for a while), be attentive to what scut work they do. Be proactive in taking some of it over for them! But tread carefully because you want to avoid creating extra work for them. So for example, my first day with a certain intern I saw that she had to copy and paste a bunch of stuff into a discharge summary, and call the PCP. Easy stuff, but tedious, therefore it is practically made for an M3 on a silver platter. So the next day, I came in a few minutes early and started on that for a patient who I knew would be leaving that day. For the things that aren’t so easy to just do on your own after watching it done once, ask them if you can do that task for them. Worst case they say no, but are appreciative of you asking.
Also, any time you are working with someone new, pay attention to their habits, no matter how small. I pay attention to the glove sizes people use so that I can pull them if I’m closer to the glove boxes than they are. I also pay attention to where a person moves when they are in a patient room, and it helps me predict where the doc will go next. This way I can smoothly move out of the way before I am actually in the way. Also if a doc does the same procedure often, figure out in what order they do it, so that you can hand them things or get out of the way when needed.
Read all the time. Specifically, read directly about your patients. This may be controversial, but don’t study for the shelf during downtime. I only study for the shelf when I go home. During the day, whenever there is a lull in patient care, I’m always on UpToDate about whatever is going on on the floor that particular day. This is the best way to nail pimp questions, and also interns/residents/attendings do notice that you are reading about patients. I’m of the strong opinion that attendings couldn’t care less about whether you are studying for your shelf or not – that’s why the shelf grade exists in the first place, to take care of that aspect. Reading about relevant things shows that you care about what you are leaning in the hospital. (Maybe I’m wrong and overthinking it, but studying for the shelf in plain view has always felt like a no-no to me. Somehow it feels to me like I am not present and in-the-moment).
Every time you have a patient, look up some research on their condition. Even if it is bread-and-butter, most cases have something unique about them, or have research that is very recent that the team might not be aware of. Then take the article, summarize the pertinent facts in a little paragraph in an email, and attach the paper. Send to everyone on the team. I’ve been given advice by upperclassmen/interns to do presentations to the team on this kind of research, but I’ve found that in reality there may be no time to do that, and sending out an email with your commentary accomplishes that much easier. And it can be done from home.
Find out what unique things you can do to help out the team. Most recently, I was at a community hospital where the interns and residents rotate through as well, so they are not caught up on all the protocols that the hospital has. We had a patient once who was on a protocol that spanned a whole packet, like 15+ pages. I overheard the intern and resident talking about how they should go through that protocol once they wrap up things for other patients. So while they did that, I went through the protocol myself and created a 1-page Word document where I essentially summarized the most important points in the protocol that the medical team was responsible for (there was a bunch of other stuff for other teams too, so I didn’t include any of that). Then printed out copies for everyone on the team. They kept referring to my document the whole week. I’m not saying do exactly that, just saying that it’s helpful to always be on the lookout for ways to make things easier for people – medical students have more time than anyone else in the hospital, so we can do this kind of stuff no problem. Many times I have done something and it ended up being totally useless. But this one time I hit a jackpot. You miss 100% of the shots you don’t take. As long as what you’re doing isn’t going to create more work for someone else, go for it full force.
If you’re at an outpatient setting, figure out how to get a hold of the EMR and the patient records. If I am ever at an off-campus site with a different EMR than the one I have access to, I talk to a nurse or MA – 100% of the time if you are polite and approachable, they will help you out and may even let you hop on to their account. Then I print out the most recent note for every single patient I might see that day, and read them ahead of time to learn about the patients. This is not a HIPAA violation. You are a medical student whose job it is to learn from every single patient, such that you can then provide the best level care. This way, when an attending says “would you like to see the next patient?” you can go into that interview armed with a lot of knowledge about everything pertinent to their follow-up. This scores major points imo.
Also another thing about outpatient settings – I’ve heard lots of people complain about how working one-on-one with an outpatient doc is too much like glorified shadowing. Obviously that’s the way it is – PCPs and specialists are very pressed for time, so they don’t have the time to let you ask questions or do the interview. Two things help with transforming your glorified shadowing into actual clerkship material. First, is being informed as I said above. Once the doc realizes that you are caught up about their patients, they may let you actually lead part of the interview because you won’t be slow. Second, nothing is stopping you from examining the patient while there is a lull in the visit. If the doctor is charting in their computer, or if it is a pediatric patient and the doc is talking to the parent, you can start listening to the heart and lungs, and do whatever else is pertinent to the visit. Feel this out, but most of the time the docs that I have been with have been very welcoming to that, and have commented to me that it shows that I care about learning while respecting the busy nature of the visit.
In the OR, be cool, stay quiet, and don’t ask too many questions. Keep your back straight. If you are retracting for a long time, use the weight of your body to retract rather than your arm muscles – this helps prevent strain. Always be aware of your body positioning. Walk around the OR slower than you think you need. Move your hands a little slower than you think you need. Doing these things will allow for greater precision, and you will appear much more composed and relaxed in the OR, which is a good thing in terms of showing clinical competence.
Never say no to anything. Any time you are offered to go down to talk to radiology/go in with a consult to the pt/offered to see a new procedure/asked to do an errand/asked to get food for a patient/literally anything, always say yes and do it.
Along the same lines, volunteer for everything. If you are rotating with a group of students, gauge the situation – if people are being hesitant when the attending asks “Which one of you wants to be the first to do ____,” jump in and raise your hand! But always gauge the situation first. Which brings me to my next point.
Don’t step on anyone’s toes and don’t make anyone look bad. While this includes interns/residents/attendings, there usually isn’t much of an opportunity to mess that up because their responsibilities don’t often overlap with yours. So this rule mainly applies to peers – medical students, PA students, nursing students, etc. Don’t do stuff for their patients. Don’t answer their pimp questions. Also, my modus operandi is to talk everyone up who deserves it. If I enjoyed rotating with someone, I’ll always make sure the team knows why I thought they were a great person to work with. If another medical student or PA student teaches me something, or if they did something that I really liked for their own patient, and it somehow comes up, I’ll absolutely make sure that they get the credit they deserve. Especially if the student isn’t particularly outgoing or assertive.
Treat everyone as your work colleague. Keep the relationship very professional, but part of a professional and cooperative work environment involves the interpersonal stuff like work-appropriate small-talk. This is the same across any industry. Your interns/residents/attendings/nurses aren’t your friends, but I’ll absolutely remember if one of them goes away for the weekend, and I’ll absolutely ask them how it was/did they enjoy it/etc. Being liked doesn’t mean you are everyone’s friend, it just means you navigate the relationships just like you would in any other professional team.
# County phone numbers
8A 97651 8B
ED NORTH 96707
Chief google: 213 375 4455
Chief Office: 323 226 7644
Office Ed Affairs: 226 7556
Galaxy 323 226 2206
Long-distance code: 2112039280
Dictation Line: 888 201 8590
Cards c/s: 226-4238
Stress Lab Marci: 97468
Cath Recovery: 95284
Echo scheduling: 97444
Echo tech 97445
Echo Read x97520
EKG tech office: 97466
Medtronic (800) 328-2518
St. Jude’s 800.681.9293
Boston Sci 508-650-8000
GI & Liver c/s: 97974
GI Lab/Sched: 95530
GI recovery: 95530
GI Fellow work rm: 92679
ERCP room: 97275
Heme c/s 226-6969
Heme fellow: 888-218-6789
Onc: c/s &appts: 226-6395
Rand Schrader 323-343-8255
Bronch Suite: 94730
PFT lab: 91266
Sleep Lab 92859
Renal consult: 226 7307
HD nurse VOIP: 93243
Neuro inpt svc VOIP: 94537
Stroke hotline: 7-7455
Derm consult: 213-717-2626
Endo 442-2807, c/s voip: 93987
Palliative Care: 98532
Psych ED: 97085
Psych c/s: 226-7976—97976
Psych VoIP 96353
Rheum 226-7889, c/s voip: 93998
ACS consults: 97728
ACS non-trauma VOIP 97769
Trauma VoIP 97767
ACS A 919 8751
ACS B 919 8752
ACS C 919 8755
ACS D 919 4529
OMFS: 213-217-0215, 95051,97309
Ortho intern 2132081193
Ortho ID x97227
Podiatry – outpt 226-4172
SICU 91817 – c/s PEG/Trachs
Surg Onc 226-4981
Urology lab 92821
Vasc Lab 94618
CT scheduling: inpt: 97202
FNA biopsy: 94615
IR consult: 94100
Angio suite room: 94099
Neuro reading room: 94149
Nuc Med: 97855
MRI: 91289, 90, 91, 92, 93
MRI msk 91293
MRI MSK reading: 96104
U/S: scheduling: 97207
US Reading room: 94386
DC pharmacy: 97165
Chemo 97551, DEA 9271
ID approval 213-717-0039
Blood Bank 97134
Heme Path 91804
Manual CBC 97177
Bed Control: 95321
Jail liaison 98685
Nursing sup: 92965
Page operator 94906
PICC scheduling – 226 7516
Sched Admit (Grace, UR 96412)
Skin Care 213-919-0407
SW ER – 96883
SW office: 95253
SW wkds/nts: 91 7063
TB control:226 7962
TB liaison: 226 28 66
Pierre induced sputum: 91825
Surgical Wound Care 95269
UR ER: 95001
UR InPt: 92962
Rancho liaison office: 91674/5
Rancho – Shirley pgr 562 446 2347
Deputy room 4563
Sleep study 91266
Vein mapping appt 94618 ( order: cv vas arterial duplex UE, CV vas vein mapping, order for future, location:usc)
Med consult 91644
Res room on 8A – 91385
CCU A C 93980
CCU B D 93981
Heme on call 93991
MICU I – 93984
MICU II – 93986
Faculty in house 93999
Melissa (sW) 2132081687
Ed pharmacist 91604
My health LA
- Inspect breasts with patient in sitting position.
- Ask patient to perform maneuver to accentuate skin dimpling (must do 2 of 3 maneuvers: lean forward, pectoralis contraction, raise arms above head).
- Perform axillary exam with patient in the sitting position (holds elbow and encourages arm relaxation).
- Examine for supraclavicular nodes.
- Perform quadrant sweep maneuver to localize and elicit discharge only if spontaneous nipple discharge is present.
- Palpate breasts in a systemic fashion using the strip or circle method. Must be done with patient in supine position with arm raised over head. Must cover all breast tissue including tail.
- Cover breast not being examined.
- Male breast should be examined and palpated as well.
- Ask patient to sit up for exam (or roll on side if seriously ill).
- Ask patient to breathe with mouth open.
- Inspection performed (respiratory pattern, increased AP diameter, barrel chest, asymmetry, masses, lips and nails).
- Palpate chest wall for tenderness, crepitus, respiratory excursion.
- Percuss anterior and posterior chest wall.
- Rotate back and forth from right to left chest for comparison in percussion.
- Check bilaterally for diaphragm excursion.
- Auscultate anterior and posterior chest wall.
- Rotate back and forth from right to left chest for comparison on auscultation.
- Auscultate apices in supraclavicular areas.
- Place patient supine with head on pillow. Remove all clothing from abdomen.
- Inspect abdomen (shape, scars, distension, color) before auscultation or percussion.
- Auscultate in at least two quadrants. Listen for bruits – aorta, renal arteries.
- Auscultate before percussion or palpation.
- Percuss abdomen in four quadrants.
- Percuss liver and spleen.
- Assess for peritoneal signs before palpation.
- Palpate all four quadrants (painful quadrant last).
- Palpate superficially first, then more deeply.
- Attempt to define liver edge beginning inferiorly and progressing superiorly on the right side.
- Palpate liver edge during inspiration.
- Measure liver span.
- Palpate for spleen tip.
- Assess for CVA and Suprapubic tenderness.
- Palpate inguinal lymph nodes.
- If indicated test for ascites, abdominal wall defect, costovertebral angle tenderness, and palpate suprapubic area.
SPECAIAL MANEUVERS ABD
Psosas (top) is an active test: they need to flex at the hip against pressure
Obturator is passive: doctor flexes them at hip and externally rotates leg
- Perform exam seated in front of patient with patient standing.
- Ask patient to strain (cough, Valsalva, etc.) for exam of inguinal floor.
- Place fingers over inguinal floor during straining maneuver.
- Palpate inguinal floor without having patient strain.
- Place finger at external ring.
- Examine right external ring with right index finger.
- Examine left external ring with left index finger.
- Inspect penis.
- Inspect both testes.
- Inspect cord bilaterally.
- Examine medial thigh below inguinal ligament for femoral hernia with straining maneuvers.
- Palpate carotids superficially and separately.
- Auscultate both carotids with bell of stethoscope.
- Auscultate the heart in all four valve areas for S1, S2, S3, S4, murmurs, clicks and rubs with the diaphragm and bell of stethoscope.
- Palpate brachial arteries simultaneously for rhythm, grade and amplitude 0-4.
- Palpate radial arteries simultaneously.
- Palpate femoral arteries simultaneously and listen to both with bell of stethoscope.
- Palpate popliteal arteries with thumbs anterior, fingers in fossa and with knee flexion.
- Palpate posterior tibialis arteries simultaneously.
- Palpate dorsalispedis arteries simultaneously.
- Palpate aorta.
- Auscultate aorta for bruits.
- Auscultate renal arteries with bell of stethoscope.
- Inspect perianal area.
- Perform digital examination.
- Inspect stool, checks for occult blood.
- Palpate prostate.
# Opiates Chart / pain killers
Dr Phung’s 10 rules
Notes from Dr. Phung’s lecture: how to succeed in residency
- Trust but verify, aka trust no one, expect sabotage (you can always say: “Thanks… but I like to verify physical xm findings myself.” story: the night resident who kept giving lasix based on a nurse’s impression of crackles. Story 2: when the chief resident trusted somebody who said the baby was cephalic (but the baby was actually breech)
- Be proud of your documentation (be proud of your work, so they know what you did and what you were thinking (story: waking up the night resident at home and having them come in to correct the documentation)
- Take the complement. Story: 6 good deliveries, 1 bad delivery. Related: each time you remember one bad thing, force yourself to remember one good thing
- Learn from everyone and don’t burn bridges, even if they have personality disorders (story: the gyn/onc attending who was wrong about some medications. Dr. Phung corrected them, in a nice way. several years later, that attending helped Dr. Phong pass his Gyn/onc rotation)
- Take the high road and give kindness. The staff here are “petty” be extra nice to people who don’t like you (bc it annoys them). Story: the day he forgot his name tag and the nurse yelled at him and told him he was in the wrong OR even though he was in the right one.
- Remember names: if you know their names, you can hold them accountable. Story: waiting for a whole day to get the paracentesis stuff set up vs. almost immediately
- Pick your battles. Better to bring up issues as a group/as a class bc of solidarity. Story: the powerful surgeon who was kicked out of UCLA bc she pushed a resident while everyone in the OR watched. All the OR ppl subsequently refused to work with her
- Communicate to prep the team for success beforehand: story: tell the curb tech in advance who could be a crash c-section
- Utilize mentors – talk to ppl who just matched to your specialty of interest to get advice about what to do
- be good to your class and juniors – watch out for each other
- Teach: keep and use the powerpoint you make and teach your juniors when you have a spare 5-10 min
- Ask for expectations when you start a new rotation. Ask how to succeed and how to help
- Enjoy the journey. If each year = shit, then you’re in the wrong profession
- Perspective: remember how many ppl would kill to be here
- Get back on the horse. You will inevitably get knocked down, what matters is how your respond.