Small Group Session 17

SMALL GROUP SESSION 17

January 16th or January 18th

ETHICS CASE AND EYE WORKSHOP

Readings:Review your lecture notes on ”Discussing an Ethics Case” and “Ethics of Being a Medical Student.”

Readings: “The Eye Exam” at:

Watch: The “Ophthalmoscopic Exam” video at:

Prepare by:

Charging your scope handle.

Bring:Charged scope handle

Brief Outline:

Section 1: Touch base (15 min)

Section 2: Ethics case (80 min)

Section 3: Ophthalmoscopy workshop (75 min)

Section 4: Evaluation (10 min)

A PATIENT WITH PLEURAL EFFUSION:

You are a third year medical student on your surgery rotation. You enjoy surgery, though so far your rotation has consisted mainly of scut work (collecting and recording lab data, getting X-rays, drawing blood, getting coffee for the residents) and holding retractors in the operating room.

This morning, the residents and attending physician are headed for the OR (operating room) to do an operation that will take several hours. As you all leave the ward, a nurse approaches your team and says that Ms. Sanchez is short of breath again.

Ms. Sanchez had emergency cholecystectomy (removal of her gall bladder) five days ago. Since surgery, she has had recurrent right pleural effusion (fluid in the pleural space) large enough to compress her lung and make her short of breath. The residents have drained the fluid twice using a needle (thoracentesis), which relieved her symptoms; but each time it re-accumulated within 36 hours. You watched the thoracentesis both times and feel you probably know how to do it, though you have never done one before.

Ms. Sanchez is 42 years old and was healthy before her gall bladder infection and surgery. She is Mexican and understands English fairly well, though she is reluctant to say much in English. She is not your patient, so you have seen her on rounds but don’t know her well. She works at a local chicken processing plant, and though no one asks, your team believes she is an undocumented worker (lacks a green card).

Hey! says your intern. Do you want to do a thoracentesis?

You are eager to have hands-on procedure experience and go with your intern to see Ms. Sanchez. She is sitting up in bed and looking uncomfortable, breathing 28 times per minute. Your intern asks for her permission to do the thoracentesis; she consents and signs the form for the procedure. The intern writes on the form and reads to her the risks of thoracentesis, including pneumothorax (air in the pleural space causing a collapsed lung), bleeding and infection.

The intern then tells her that you will do the procedure. She nods. Neither the intern nor you tells her that this is your first thoracentesis.

The intern stays with you in the room as you prepare to do the thoracentesis.

Part 1: Ethical Issues:

Write on the board or sticky poster paper:

AutonomyBeneficenceJustice

Decide as a group how each of these issues may apply to Ms. Sanchez’s case.

Part 2: Give your opinion:

Your small group is now the ethics committee responding to the student who asked about Ms. Sanchez’s case. Each of you should give their opinion on the ethical issues facing the student and what you advise the student and/or supervising physician to do. Go around the room and ask everyone to speak.

Section 3: Ophthalmoscopy workshop: (75 minutes)

Goals:

To learn to use the different lenses of your ophthalmoscope
To learn to focus on the anterior structures of the eye
To learn how to look for the fundus and optic disc

Objectives:

to understand the use and properties of the short and long focal length lenses
to use the short focal length lenses to look at the anterior chamber of the eye
to position yourself correctly to see the optic disc (and, we hope, see the disc)

EXERCISE 1: Using the Ophthalmoscope Lenses (20 minutes)

The ophthalmoscope has two colors of lenses: the green or black lenses (used to look at anterior chamber structures - those in front of the lens) and the red lenses (used to look at the retina, which is behind the lens). Get to know it first.

1. The skin exercise: use of short focal length lenses (10 minutes)

The green or black- numbered lenses look at things up close – at 1 to 5 inches or so from your eye. They are usually numbered up to 40; the closer up you look, the higher the number.

Hold your hand 3 inches from the scope and look with a green lens at your hand. Find the number that gives you the sharpest image. Then, move your hand 1 ½ inches from the scope and dial the lens to focus again. What number lens is best now?

2. The wall exercise: use of long focal length lenses (10 minutes)

The red lenses require an intact patient lens to focus on the retina. The correct number for you is a function of your own lens’s refractive power - and the patient’s.

This exercise lets you find the correct number for each of your eyes. The lens of this number is the one you will use first to look for a patient’s retina. In patients with refractive errors, you may need to move one or a few lenses away from this to focus best - but always start with your unique number, which you can find with this exercise.

Look at a distant object on the wall and dial the lens that gives you the sharpest number. Make a mental note of this number. Now, do the same with your other eye. This is your unique number for viewing the retina.

EXERCISE 2: POSITIONING FOR EYE EXAMINATION (5 minutes)

In the ideal position, the examiner is 1 ½ to 2 inches from the patient’s cornea. To do this, and to stabilize your relationship to the patient, you will need to hold the scope in the same hand as the eye you are examining and to “find” the patient with your other hand.

So: to look in the patient’s right eye, hold the scope in your right hand and look through it with your right eye. Put your left hand on the patient’s head with your thumb just above the eyebrow. For the left eye, reverse everything.

Get as close to your patient as you can without bumping into his or her eyelashes or eyebrows. The closer you are to the patient, the wider your visual field.

EXERCISE 3: LANDING ON THE DISC (50 minutes)

For this exercise, keep the room as dark as you can - only enough light so that the patient can see something to focus on.

Dial your unique red lens for your dominant eye.

Have the patient look straight ahead at a fixed object behind you. Approach the eye from 20 to 30 degrees to the side of the patient in the sagittal plane, with the ophthalmoscope at a low level of light intensity. Move in to the ideal viewing distance. Make sure your patient can keep looking straight ahead.

The disc is a light-colored circular area with blood vessels converging into it. Try to see it. If you find a blood vessel, try to follow it to the disc. If you are in the correct position, the disc should be nearby.

Section 4: Evaluation

How did this session go? What could make it work better in the future?

O:\Practice of Medicine1\2006-2007\Spring Sessions\Final versions\Session 17\Session 17_ethics case and eye workshop_spring 2007_student_nov21.doc