Transcript 为什么学习操作?
全科医生应掌握的操作和手术
Kim Potter, MD
In His Image Family Medicine Residency Program
Tulsa, Oklahoma
我们为什么要做操作?
Patients need these procedures病人需要这些
操作
We enjoy doing them我们喜欢做这些操作
They bring good sources of revenue这些操作
是好的收入来源
做什么操作?
Based on training, interest and community needs建立在
培训、兴趣和社区需要基础上
Out patient care门诊照顾
In patient care住院病人照顾
Common procedures常见操作
Rare procedures少见操作
Emergent / Urgent procedures急诊/紧急操作
Specific procedures requiring additional training要求
额外培训的特殊操作
Procedures frequently needed in the community社区
经常需要的操作
做什么操作?
Dermatologic Procedures皮肤科操作及小手术
Eyes, Ears, Nose, and Mouth Procedures眼、耳、鼻、口
操作
Cardiovascular Procedures心血管操作
Respiratory Procedures呼吸系统操作
Gastrointestinal Procedures胃肠道操作
Gynecologic Procedures妇科操作
Obstetric Procedures产科操作
Urinary Procedures泌尿系统操作
Orthopedic and Musculoskeletal Procedures矫形外科和
骨骼肌肉操作
Anesthesia Procedures麻醉操作
皮肤科操作
Skin Biopsy1 皮肤活检
KOH examination
氢氧化钾检查法(真菌
检查的一种方法)
Soft Tissue Aspiration
软组织抽吸
Incision and Drainage2
切开和引流
Wound care: Bites,
Burns
伤口照顾:咬伤、烧伤
Skin Closure3皮肤缝合
Ingrown Toenail
Removal嵌趾甲去除
Foreign Body4 Removal
异物去除
Skin Lesion Removal5
皮肤病损去除
Subungual Hematoma
Excision
指 (趾)甲下血肿切除
Topical Hemostasis
局部止血
眼、耳、鼻、口操作
Tympanometry鼓室压测量法
Ophthalmoscopy and other
eye exam1检眼镜检查和其它
眼部检查
Visual Evaluation视力评估
Corneal Foreign Body
Removal角膜异物去除
Eye Irrigation眼部冲洗
Eye Trauma Stabilization
眼外伤处理
Eyelid Eversion睑外翻
Eyebrow Laceration Repair
眉撕裂伤修复
Auricular Hematoma
Evacuation耳血肿清除
Cerumen Impaction Removal2
耵聍堵塞去除
Epistaxis control鼻出血控制
Nasopharyngoscopy鼻咽镜检查
Removal of Foreign Body
异物去除
Frenulotomy for Ankyloglossia
处理舌系带过短的舌系带切开术
Lip Laceration Repair
唇部撕裂伤修复
Tongue Laceration Repair
舌部撕裂伤修复
心血管操作
Doppler Technique
多普勒超声技术
Electrocardiogram心电图
Exercise Treadmill
平板运动试验
Holter Monitor
Holter心电检测
Telemetry 遥测术
Cardioversion and
Defibrillation心脏复律和除颤
Needle Thoracostomy
针刺胸腔造口术
Thoracentesis胸腔穿刺术
Tube Thoracostomy
插管胸腔引流术
Central Venous Catheter
Placement中心静脉导管置入
Intraosseous Infusion
骨内输液
Umbilical Vessel
Catheterization
脐血管导管插入
Arterial Puncture and
Cannulation
动脉穿刺和套管插入
Unna Boot Application
Unna靴应用(用氧化锌的一
种绷带)
呼吸系统操作
Chest X-ray Interpretation
胸部X线片解释
Nebulizer Administration
雾化器应用
Peak Flow峰值流量
Basic Airway
Management基本气道管理
Intubation1气管插管
Cricothyroidotomy
环甲膜切开术
Transtracheal Aspiration
经气管吸引
Chest Tubes胸管
Flail Chest Stabilization
连枷胸固定
Stab/Penetrating Wound
Stabilization
刺伤/穿透伤处理
胃肠道操作
Abdominal X-ray
Interpretation腹部X线片解释
Anoscopy肛门镜检查
Rigid Rectosigmoidoscopy
硬管直肠乙状结肠镜检查
Flexible Sigmoidoscopy
软管乙状结肠镜检查
Abdominal Paracentesis
腹腔穿刺术
Nasogastric Tube Insertion
鼻胃管插入
Gastric Lavage洗胃
Diagnostic Peritoneal Lavage
诊断性腹腔灌洗术
Thrombosed Hemorrhoid
Removal血栓性痔去除
Internal Hemorrhoid
Banding内痔套扎疗法
External Hemorrhoid
Excision外痔切除术
Prolapsed Rectum Reduction
直肠脱垂复位
Rectal Foreign Body
Extraction直肠异物摘除
妇科操作
Papanicolau Smear巴氏涂片
Cervical –Vaginal Sampling1
宫颈-阴道取样
Colposcopy2阴道镜检查
Vulvar, Cervical,
Endometrial Biopsy
外阴、宫颈、子宫内膜活检
Bartholin’s Marsupialization
前庭大腺造口术
GYN Lesion3 Removal
妇科损伤去除
Cervical Cryotherapy
宫颈冷冻疗法
Loop Electrosurgical
Excision环形电切除术
Cervical Cap Fitting
宫颈帽放置
Diaphragm Fitting, Insertion,
and Removal
阴道隔膜放置和取出
Intrauterine Device Insertion
宫内节育器放置术
Pessary Insertion子宫托置入
Sexual Assault Examination
性侵害检查
Culdocentesis后穹窿穿刺术
Prolapsed Uterus Reduction
子宫脱垂复位
产科操作
Obstetric Ultrasound1
产科超声
Fetal Heart Tone
Monitoring胎心音监护
Normal Spontaneous
Vaginal Delivery
正常自然阴道分娩
Episiotomy会阴切开术
Episiotomy, Laceration
Repair会阴切开、撕裂
伤修复
Symphysiotomy
耻骨联合切开术
Shoulder Dystocia
Management肩难产处理
Breech Delivery臀位分娩
Vacuum Delivery
真空吸引分娩
Forceps Delivery
产钳分娩
Cesarean Section
剖宫产术
Postpartum Hemorrhage
Management
产后出血处理
泌尿系统操作
Vasectomy
输精管切除术
Suprapubic Bladder
Aspiration
耻骨弓上膀胱穿刺抽吸
Anesthesia Of The Penis,
Testicle, Epididymis
阴茎、睾丸、附睾麻醉
Neonatal Circumcision
新生儿包皮环切术
Priapism Management
阴茎异常勃起处理
Paraphimosis Reduction
嵌顿包茎复位
Phimosis Reduction
包茎复位
Testicular Detorsion
睾丸扭转矫正
Zipper Injury Management
拉链损伤处理
矫形外科和骨骼肌肉操作
Bones X-ray Interpretation
骨X线片解释
Common Fracture
Reduction常见骨折复位
Dislocation Reduction
脱位复位
Casting, Splinting, Crutch,
Sling Application
石膏、夹板、拐杖、吊带应
用
Lumbar Puncture腰穿
Arthrocentesis
关节穿刺术
Intra-articular1 and
Bursa Corticosteroid
Injection关节内和滑囊皮
质类固醇注射
Ganglion Cyst
Aspiration and Injection
腱鞘囊肿抽吸和注射
Trigger Point Injection
痛点注射
麻醉和镇痛
Topical Anesthesia表面麻醉
Local Anesthesia局部麻醉
Digital Nerve Block指(趾)神经阻滞
Paracervical Nerve Block颈旁神经阻滞
Regional Nerve Blocks1区域神经阻滞
我们一直在看什么?
Very little hands on experience很少亲自去经历
• Lecture, Lecture, Lecture讲座、讲座、讲座
Procedure Skills very lacking非常缺乏操作技巧
• Equipment装备
• Enable能力
• Encouragement鼓励
我们怎样学?
3 Phases: 3阶段
Cognitive – See One
认识-看一个
• Why为什么
• How怎样做
Developmental – Do One 进展-做一个
Automated – Teach One
提升-教一个
认识阶段:看一个!
Why: Why learn procedure? 为什么:为什么学习操作?
Has the learner done procedure before? What does
s/he recall about indications, risks, etc.? 学习者以前做
过操作吗?对于操作的适应证、危险因素等,他/她能
记起哪些?
Indications, Contraindications, Risks/complications,
Benefits, Alternatives适应证、禁忌证、危险因素/并发
症、益处、替代方案
认识阶段:看一个!
How: Demonstrate procedure step by step怎样做:
一步一步示范操作
Tools:工具
• Visual Learning (websites, books, etc)通过看来
学习(网络、书,等)
• Procedure Labs操作手术室
Ask for questions 提问
Ask learner to verbalize the steps要求学习者描述
步骤
认识阶段:看一个!
Role Model Patient-Centered Medicine角色模
式以病人为中心的医学
Model explaining the procedure to the
patient给病人解释操作的模式
Demonstrate the skill at normal speed while
talking to the patient和病人说话同时,以正
常速度示范操作技巧
进展阶段:做一个!
Residents to practice the procedure under close
supervision住院医师在直接监督下实践操作
Have resident demonstrate procedure, explaining
each step out loud让住院医师演示操作,大声解释每
一步骤
• Simulator/ Standardized patients模拟/标准化病人
• Patients病人
Provide guidance for each step为每一步提供指导
• Verbally 口头上说
• Physically亲自做
进展阶段:做一个!
Evaluate resident’s proficiency:评估住院医师熟练的程度:
Ask resident to self-evaluate要求住院医师自我评估
Give specific feedback: first, what did resident do right,
then wrong给出具体反馈:首先,住院医师做对的地方;
然后,住院医师做错的地方。
Ask for questions again再次提问
提升阶段:教一个!
Residents begin achieving proficiency and are ready for
independent performance住院医师开始达到熟练程度,准备独
立完成操作
Observe resident performance again, this time with minimal
interruption. 再次观察住院医师操作过程,这次要尽量不去中断过
程。
Your can now teach the fine points. 现在你可以教授细节。
Encourage self-directed learning: What are the learner’s future
learning goals, and how does s/he want to achieve them? What
have you read or done that helped you learn?鼓励自我导向的学
习:学习者将来的学习目标是什么?他/她想怎样完成这些目标?
你已经读了或做了什么来帮助你学习?
Arrange for a follow-up session. 安排一个随访的阶段。
提升阶段:教一个!
Next step:下一步:
Seniors to supervise Juniors doing procedures高年资医
生监督低年资医生做操作
有问题吗?