So you need to do a portfolio for your rotation ….
What is it?
The portfolio is a document (like a diary) detailing your experience, your progress, feelings, and reading during the assignment.
The most important aspect of the portfolio is that it should reflect your thinking about your cases (Practice-based learning and Improvement):
Could I have done this case another way?
Would I do it differently next time?
What does the literature say?
How could I handle the clinical, interpersonal, staffing problem better? (Interpersonal and Communication Skills)
How should it be presented?
Please submit your entire portfolio as a word document, with the pertinent articles “imbedded” as icons in the text. Each entry should reflect your thinking about the article, and its applicability to your patient.
Example:
Today I was responsible for Jason Mouzake’s list. We did 23 tonsillectomies. All had terrible post op pain, despite having been given opiate analgesia. Thank goodness I was with Dr Crnkovic who had each patient tee’d up and ready. There is a recent article on NSAID s and ped tonsillectomy, which addresses the bleeding issue, but unfortunately does not address the issue of post op pain. In the Finnish study, Ketoprofen was effective in treating post operative pain. In the review by Katri Hamunena, Vesa Kontinen, NSAIDS were as effective as opioids in controlling post op tonsillectomy pain in children.
Technique for imbedding articles in a Word Document
Word Toolbarà Insertà ObjectàCreate from FileàBrowseàClick on relevant file àcheck box “Display as icon” àOK
Saving your Portfolio Word Document on New Innovations
Log into NIàMainàPortfolioàLog a (drop down box) Portfolio for (drop down box) for you or your residentàlog the activityàfill out the boxesà”save and upload files”àselect the fileà”upload. Your completed portfolio is then kept safely on NI.
The document should also be sent to the Attending on the rotation for comment.
Down below are excerpts from the pediatric portfolio of one of our former residents. Note that instead of just commenting “did an obese child for T&A – see article below”, she actually questioned the seemingly inappropriateness of just treating a condition surgically and not recommending life-style changes in the patient. In addition, please don’t hesitate to reveal some of your feelings about the cases you were doing – do they make you sad? Frustrated that room turnover can take so long? Angry that your attending didn’t respect your opinion on a case? Overall our goal for the portfolio is to have a permanent document for your folder that demonstrates at least some insight into the core competencies:
Patient Care - Gather data; order diagnostic tests; interpret data; make decisions; perform procedures; manage patient therapies; work with others to provide patient-focused care
Medical Knowledge - Fund of knowledge; active use of knowledge to solve medical problems
Practice-Based Learning & Improvement - Analyze practice performance and carry out needed improvements; locate and apply scientific evidence to the care of patients; critically appraise the scientific literature; use the computer to support learning and patient care; facilitate the learning of other health care professionals
Interpersonal & Communication Skills - Develop a therapeutic relationship with patients and their families; use verbal and non-verbal skills to communicate effectively with patients and their families; work effectively as a team member or leader
Professionalism - Demonstrate integrity and honesty; accept responsibility; act in the best interest of the patient; demonstrate sensitivity to patients' ethnicity, age, and disabilities
Systems-Based Practice - Demonstrate awareness of interdependencies in the health care system that affect quality of care; provide cost-effective care; advocate for quality patient care; work with hospital management and interdisciplinary teams to improve patient care
Please follow something similar to the format below (you don’t need to list every case that you did on a certain day, but list at least one of them and make appropriate comments) and please put this into Microsoft Word. When you have an article to “attach” (aim for at least one article per week) please embed it in the text with a hyperlink (see above directions).
In order to make sure that you are compiling an appropriate portfolio, please forward a copy of what you have done so far at the end of each month to Dr. Melissa Ehlers by email:
Please try to look at the positive aspects of this exercise and not view it as just another piece of paperwork to get done each day – enjoy!
Date: 10.11.2007
Procedure: T&A in 8 y/o male
Comments:
This patient was already on CPAP/BIPAP
So… isn’t there something wrong with a child needing CPAP/BIPAP for OSA?? Maybe they should also try… losing weight??
Article: “Identification and Evaluation of Obstructive Sleep Apnea Prior to Adenotonsillectomy in Children: a Survey of Practice Patterns”
Date: 10.11.2007
Procedure: General anesthesia
Comments:
4 y/o female with facial swelling, history of multiple fungal infections throughout her body, scheduled for fungal cultures from the oropharynx and adenoidectomy.
- uneventful inhalation induction, IV placement
- failed laryngoscopy x 1, able to mask ventilate the patient, but she was slow to reach 100% SpO 2 (from 92% after laryngoscopy) despite obvious good ventilation
- intubated on second laryngoscopy, but patient had desaturated quickly, and SpO2 remained low, to the point of questioning and rechecking tube placement
- HR 120 80s, given glycopyrrolate 0.1 mg, atropine 0.1 mg HR 110s with BP 50s/-, given neosynephrine HR 80s, then 3rd degree HB with HR 46 atropine 0.1 mg HR 160s, no HB
- peds cardiology called to OR, TEE brought into room
- echocardiogram hypokinetic RV, ? echogenicity near the pulmonary valve – was it air or vegetations?
- upon reflecting later, with the facial swelling, did this patient have SVC syndrome? But CT head earlier had shown no signs of this, and u/s of neck later showed normal sized vessels
- patient was placed on epi gtt for HR and BP and remained on gtt in PICU
- CT showed dilated PA
- felt like I was under water. I wasn’t moving very fast, wasn’t zoning in on what needed to be done next, whether it be set up for a much needed A line or central line or even another IV access.
- I think I did have a passing thought of SVC syndrome when I first laid eyes on this girl – why didn’t I say anything??
- how does one even manage pulmonary HTN in the OR, whether it be known prior to anesthesia or discovered intraop? Is milrinone available to children?
- the surgeon had gone to talk with the parents afterward, and I really wish I had gone along as well. I’m not sure if my attendings had gone – but this case was in the middle of the day, we still had several cases to go, and I was just trying to go on with the day.
- what was going on with this little girl??
Articles: “Communicating Sad, Bad, and Difficult News in Medicine”
“Pulmonary Arterial Hypertension in the Pediatric Age”
“Perioperative Complications in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheterization”
Date: 10.30.2007
Procedure: cardiac catheterization
Comments:
Balloon valvuloplasty for pulmonic stenosis
must! Pay attention to the case. Surgeons are notorious for not communicating with anesthesia! Is anesthesia the one who is supposed to develop the communication, or is this the way it is in a teaching facility where the anesthesia personnel changes every day there are cases? Anyway – even though the initial readings need to be taken at 21% O2, definitely need 100% for the balloon inflation, as there is no blood flow to the lungs at that time!! (also good to make the SpO2 tone loud enough for Dr. Velvis to hear)
Date: 11.21.2007
Procedure: inguinal hernia repairs x 2
Comments:
Did ileoinguinal blocks for the first time! These were 12 and 14 y/o patients, so a caudal was not an option
ASIS 2 cm medial, 2 cm inferior, insert needle at 90 degree angle to skin
Unfortunately, it was really difficult to determine if I had actually performed a successful block used Bupivacaine, and the surgeons started the case within 10 minutes of the block. Great.
Date: 1.8.2008
Procedure: debridement of face
Comments:
This 10 y/o still had gravel in his skin after an injury several months ago! Apparently the wound had not been washed out properly, so tissue was now growing around the foreign bodies and someone needed the patience to go back and re-explore every inch of his face.
Discussion with the surgeon was important, as not only did he need the OR table to be positioned away from me, but the ETT also needed to be different. Sigh… finally learning the whole communication thing… very slowly.
Date: 1.18.2008
Procedure: EGD
Comments:
This kidney transplant patient was coming to rule out graft versus host disease. I know I’ve sympathized for these younger children who were so familiar with the operating room and its routine. Then this patient was, in an odd way, a little refreshing. She knew what medications would work for her nausea, and how to give them. Perhaps it was that she was suggesting it and was open for discussion, not ordering us to behave in a particular way. Perhaps it was also that she was actually doing well, now that she had had a kidney transplant, where as many frequent OR patients still battle their problems.