The Presentation Series (The Plan)

Hi everyone:

We end our Presentation Series today with “The Plan.” This is literally the bottom line, and your goal is to be clear and concise. Here’s how:

• Delete the junk: It’s a common rookie error to litter the Plan with assorted facts, updates, and random observations. Historical points (“s/p chest tube placement”), test results (“echo with LVEF 35%”), and commentary (“proning didn’t help”) don’t go in the Plan. They belong in the history, data, and assessment sections.
• Organize by Problems or Systems: For less complicated patients, you can organize by problem (fever) or diagnosis (pneumonia). In the ICU and SDU especially, you should organize by system (cardiovascular, pulmonary, renal, etc.), because multiple systems need to be addressed individually. For example, a patient with pneumonia complicated by septic shock and multisystem organ failure may need fluids and pressors (cardiovascular), mechanical ventilation (respiratory), dialysis (renal), antibiotics (ID), insulin (endocrine), transfusions (heme), and so on.
• Copy Forward (Carefully): If there’s any part of the note where you might want to copy forward it’s the Plan, since you don’t want to forget details, like how many days of vancomycin the patient has gotten or whether the ANCA has resulted. But be careful- review and update every line every day. Don’t get caught planning to extubate a patient who’s already off the ventilator. Completed plans aren’t plans- they’re history.
• Address all concerns: All concerns raised in the history (cough), physical (thyromegaly), or data section (anemia) must be addressed, either by you or your designee (“Microscopic hematuria be addressed by Dr. Bernstein in the NHPCC”).
• Be consistent: By following a consistent system, you’ll become more efficient and have an easier time remembering details. It will also help your audience follow your plan. I’ve followed the same order in the MICU for years (see attached)
• Provide a brief, targeted assessment: This is distinct from the comprehensive assessment discussed last week. You want to provide context for your plans:
  • Problem-based:
    • Pneumonia: defervescing, oxygen requirements decreasing, cough subsiding
    • Gout: Left big toe less painful, swollen, red
    • Diabetes: Still hyperglycemic, likely due to persistent stress from infection
  • Systems-based:
    • Cardiovascular: Blood pressure remains low despite triple pressors; euvolemic
    • Pulmonary: Gas exchange improving on current vent settings; plateau and driving pressures acceptable
    • Renal: Hyperkalemia and metabolic acidosis resolved with CVVH
• Use bullets and action words: This is the “boom, boom, boom” of your presentation:
  • Check blood cultures
  • Consult ID
  • Start ceftriaxone/doxycycline
• Show the workup, then the treatment: By outlining the plan in this order, you’ll show how evidence drives treatment (draw cultures before starting antibiotics, check a CBC before transfusing, etc.).
• Make it attractive: Make your Plan inviting and easy to follow: Here are two examples, one problem-based, one systems-based:
  • Pneumonia: Most likely community acquired, mildly hypoxemic on RA
    • Check chest x-ray
    • Check blood and sputum cultures
    • Check urine legionella and pneumococcal antigens
    • Begin ceftriaxone and doxycycline
    • Begin O2 2LPM by nasal cannula, titrated to maintain SpO2 >90%
  • Cardiovascular: Vasodilatory shock most likely secondary to sepsis, though can’t rule out adrenal insufficiency, sedation side effect, volume depletion, or cardiac dysfunction
    • Obtain POCUS to assess cardiac function and IVC diameter
    • Straight leg raise test to assess preload
    • Check random cortisol
    • Follow lactate
    • Place a-line
    • Depending on POCUS and straight leg raise results, give additional LR or begin norepinephrine, aiming for MAP >65 mmHg
    • Stop propofol (see below for further sedation plans)

Well, everyone, we’ve completed the Presentation Series. I hope you agree that as internists, we strive to be master communicators, which is epitomized by the care we take to create succinct, coherent, compelling presentations. I encourage all of you to dedicate your careers to honing this essential skill.

Wishing everyone a restful Sunday,

Mark

PS Our hearts go out this morning to our neighbors in Haiti following yesterday’s devastating earthquake.

MDS