FPs do Procedures!

FPs do Procedures! Kim Potter, MD In His Image Family Medicine Residency Program Tulsa, Oklahoma 全科医生应掌握的操作和手术

Why do we do procedures? 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

What Procedures? 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

What Procedures? 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

Dermatologic Procedures 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

Eyes, Ears, Nose, and Mouth Procedures 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

Cardiovascular Procedures 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）

Respiratory Procedures 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

Gastrointestinal Procedures 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

Gynecologic Procedures 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

Obstetric Procedures 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

Urologic Procedures 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

Orthopedic and Musculoskeletal Procedures 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

Anesthesia And Analgesia 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

What have we been seeing? 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

How do we learn? 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

Cognitive Phase: See One! 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

Cognitive Phase: See One! 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

Cognitive Phase: See One! 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

Developmental Phase: Do One! 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

Developmental Phase: Do One! 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

Automated Phase: Teach One! 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。

Automated Phase: Teach One! 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

Questions? 有问题吗？

FPs do Procedures!