Otolaryngology-Head and Neck Surgery Service

University of North Carolina Otolaryngology-Head and Neck Surgery (OTO-HNS) Service Medical Student Information

Welcome to the OTO-HNS service! We look forward to an educational and productive experience for each of you in caring for patients with diseases of the head and neck. While on our service, you will have the opportunity to learn about a wide range of problems while participating as a member of the team in the clinic, on the wards, and in the operating room. The fourth year residents will be your primary resource persons for questions regarding the schedule, end of rotation test, oral presentation expectations, call, and any problems that may occur during the course of the rotation (Josh Demke, Jeff Lacour, Steve Lee and Karen Kolln).

Medical Student Clerkship Director: Marion Couch MD PhD 843-3627 Pager 347-0052

Surgery Medical Student Ombudsmen: Marion Couch MD PhD 843-3627 Pager 347-0052

Timothy Weiner MD 966-4220

The Department of Otolaryngology – Head & Neck Surgery and the Department of Surgery in The School of Medicine are both committed to fostering a respectful educational environment. If a student has concerns, the student is encouraged to meet with the Ombudsman for Students. This is a confidential meeting where a student may discuss a concern and learn about resources and procedures available to them. Education A. The primary goal of your rotation on the OTO-HNS service is for you to learn about the diagnosis and treatment of patients with diseases of the head and neck. Our academically - inclined staff and residents have a commitment to excellence in education and consider teaching students a top priority. Your interest in learning will facilitate effective teaching. B. One of the most effective teaching methods in medicine is asking questions, whether this is on morning rounds, in the operating room, in conference, or in clinic. We use this method liberally, so read and be prepared. 2

C. Additionally, we may ask students to look up articles or general information from textbooks to present succinctly on morning rounds. At the end of the rotation each student is expected to give a concise 5 minute oral presentation to the team at morning rounds on a topic of their own choosing. D. Your mandatory conferences take precedence over work on our service. Please excuse yourself to attend these at the appropriate time, however, there may be a rare occasion when you are an essential member of the operating team and are asked to stay for completion of a procedure. E. You are encouraged to seek out information from sources such as the textbooks in our library, and journal articles regarding more in-depth information on patients you see in the operating room and clinic. Here is a list of some online resources available to you:

 American Academy of Otolaryngology – Head & Neck Surgery Foundation (AAO- HNSF) http://www.entlink.net/ . Click on Clinical Otolaryngology OnLine (COOL) to learn about:  Epistaxis  Hoarseness  Nasal Obstruction  Otitis Media  Rhinosinusitis  Sensorineural Hearing Loss  Tinnitus  Vertigo  Neck mass . Click on Core Education Curriculum as well. This is a curriculum designed especially for medical students. There is good, basic content about many subjects.

 Head & Neck journal http://www.interscience.wiley.com/ A premiere journal with free online access.

 Archives of Otolaryngology – Head & Neck Surgery http://archotol.ama-assn.org/ A premiere journal with free online access.

 The University of Texas MD Anderson Cancer Center Head & Neck Cancer Web Book https://www2.mdanderson.org/sapp/headneckbook/book/index.cfm A superb, free online web textbook that has evidence-based information for head and neck cancer management.

 National Comprehensive Cancer Network http://www.nccn.org Here you will find evidence-based guidelines for the management of cancers in all sites, including head and neck, thyroid. There are also algorithms for management of cancer pain, nausea, and anemia. You can order a free CD-ROM online at this site. A must see site for all oncology-related education.

 Archives of Facial Plastic Surgery 3

http://archfaci.ama-assn.org/ A premiere journal with free online access.

 Internet Resources Available to Otolaryngologists http://www.annals.com/Resources/index.html

 Atlas of Head and Neck Pathology Department of Otolaryngology – Head & Neck Surgery Ohio State University Medical Center William H. Saunders, MD http://medicine.osu.edu/oto/atlas.html

 Otolaryngology/ Head & Neck Surgery University of North Carolina http://www.unc-ent.org/ Great links for learning more about the field of OHNS.

Schedule A. A general schedule grid (Section I) is provided and breaks down the service for two, three, or four medical students. This should provide each student with roughly equal exposure to our staff in clinic and the operating room. If an attending is on vacation or absent for any reason ask the fourth year resident what activity would be most educational for that day. B. The administrative chief resident may request your presence/help in the operating room or elsewhere if the need or a particularly educational experience arises regardless of the schedule.

Call A. In general, you may expect to take home call. The junior resident on call will contact you for admissions, emergent operations, and ED cases that have educational merit. B. The students should rotate call so that each day and night, including the weekend, is covered from the first day of the rotation to the last day of the rotation. C. The student on call should contact the junior resident on call late in the day to find out when afternoon rounds will take place. On the weekends, contact the junior resident the night before to find out the time for morning rounds. Pre- rounding is not expected on the weekends.

Rounds A. Rounds begin promptly at 7AM on Mondays, Wednesdays, Thursdays, and Fridays. On Tuesdays, rounds begin at 6:30AM. Pre-round on your patients and be there on time. **Be sure to ask the residents on Thursday afternoon about rounds on Friday, as the time is sometimes switched to 6:30 if there is an extra-long tumor board list.** B. You will present your patients on cue from the administrative chief resident. Presentations will follow the SOAP format and should cover pertinent positives and negative only. There is no time for superfluous information on morning rounds. Take this opportunity to hone your presentation skills into 4

providing concise, accurate, and necessary information. A sample presentation is provided in Section II. C. All patients on the service should be covered by the students. Each evening divide the patients on the service up so they are all covered. If you attend a patient’s operation you should follow that patient for the length of their hospital stay. At the end of the operation ask the resident what the pertinent exam findings will be to present on rounds the next morning. Expect to formally present your two most interesting patients on morning rounds, but know and write notes for all of them. D. Pre-round on patients and have your note in the chart before rounds. This allows the resident to read your note and provide you with feedback on your exam and note writing. It also makes the chart available for the attendings who also round on their own patients each morning. E. Be sure to check lab work and look at radiographic studies for your patients. Don’t rely solely on RTAZ for X-ray interpretation; this is the time to start reading films, not your first night on call as an intern. F. Green sheets – Completing a green sheet is an excellent way for the students to summarize the patients’ hospital course and synthesize the pertinent information. It also helps save the housestaff time on morning rounds. Fill the green sheet out as completely as possible prior to the day before discharge. G. Feel free to ask questions of the residents at anytime, especially on morning rounds. If you have a question chances are your fellow students are wondering as well. H. Attending rounds are held every Tuesday at 7AM. Be prepared to present your patient to the attending with a brief disease history, operative indication, operation, and post-operative course. See example in section III.

Conferences A. You are expected to attend all mandatory medical student conferences. Attend our conferences when there is not a schedule conflict. B. Conferences generally will be held in the 7th floor conference room. C. Monday 7AM morning rounds 6th floor Neuroscience 5PM resident conference 7th floor Neuroscience Tuesday 6:30AM morning rounds 6th floor Neuroscience 7AM attending rounds, children’s hospital cafeteria Wednesday 7AM morning rounds 6th floor Neuroscience 7:30AM postoperative conference 7th floor Neuroscience 5PM resident conference 7th floor Neuroscience Thursday 7AM morning rounds 6th floor Neuroscience 4:30 PM preoperative conference 7th floor Neuroscience Friday 7AM morning rounds 7:00AM Multidisciplinary Head and Neck Tumor Conference, Basement Gravely Building 5

Clinic A. The clinic is set up in 3 “pods” each of which has 5-7 patient rooms. On any given day 2-3 clinics will be simultaneously occurring each with 2-3 nurses. B. Ask the attending at the beginning of clinic how they would like you to interact with patients in terms of seeing them together, versus seeing them first and presenting them to the attending. C. Please treat the nurses and ancillary staff with an appropriate degree of respect and courtesy. They will do the same. D. Teaching heads are available for flexible fiberoptic laryngoscopes; ask the attending if you may use them for endoscopies. Several rooms have microscopes, video towers available as well. We also have a video stroboscopy machine that will be utilized. Don’t be afraid to use the otoscopes to look in patients ears. Ask one of the residents to show you how to perform an indirect mirror laryngoscopy. E. If you don’t know where something is, ask the fourth year residents. F. The computers in the resident room are for the residents to perform clinical activities on as well as preparation of presentations and papers. Please abstain from using them.

Questions A. If any questions, conflicts, or problems arise please notify the fourth year resident or Dr. Couch immediately.

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Section I

Assignments:

Week One Student A Monday Tuesday Wednesday Thursday Friday Couch OR Drake (Dental) Drake OR Buckmire Senior OR

Student B Monday Tuesday Wednesday Thursday Friday Weissler Weissler OR Pillsbury OR Shores OR Shockley

Student C Monday Tuesday Wednesday Thursday Friday Shockley OR Shores Drake OR Weissler OR Zdanksi

Student D Monday Tuesday Wednesday Thursday Friday Buchman Buchman OR Senior Zdanski OR Shores

Week Two Student A Monday Tuesday Wednesday Thursday Friday Shockley OR Couch Pillsbury OR Shores OR Shockley

Student B Monday Tuesday Wednesday Thursday Friday Couch OR Shores Zdanski Buckmire Senior OR

Student C Monday Tuesday Wednesday Thursday Friday Buchman Buchman OR Senior Zdanski OR Rose

Student D Monday Tuesday Wednesday Thursday Friday Rose ACC Pillsbury OR Drake OR Zdanski

***PAGE DR DRAKE THE DAY BEFORE TO DISCUSS HER CLINIC SCHEDULE. 7

Section II

Example presentations:

A. (3yo s/p tonsillectomy and adenoidectomy for obstructive sleep apnea) S: Overnight no desaturations, or bleeding. The child is taking PO liquids well. O: AVSS with RR 16 and Sat 98% on room air Bilateral tonsillar fossa have eschar without blood clots, there is no epistaxis. There is no stridor, retractions, or use of accessory muscles of inspiration Lungs are clear to auscultation bilaterally, and the heart has a regular rate and rhythm A: s/p tonsillectomy and adenoidectomy doing well P: D/C home

(56yo s/p total laryngectomy for larynx cancer) History: Mr. Jones is a 56yo male who presented with a 6 month history of odynophagia, and progressive hoarseness. He underwent a pandendoscopy 2 weeks ago that revealed a T4N1M0 squamous cell carcinoma of the larynx. 4 days ago he underwent a total laryngectomy with a right selective neck dissection levels 2, 3, and 4, and a left modified radical neck dissection sparing the spinal accessory nerve. His postoperative course has been complicated by ETOH withdrawal for which he is being treated with benzodiazepines. He is scheduled to have a gastrograffin swallow study on postoperative day 5.