全科医生应掌握的操作和手术
Kim Potter, MD
In His Image Family Medicine Residency Program
Tulsa, Oklahoma
我们为什么要做操作？
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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
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
做什么操作？
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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
皮肤科操作
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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
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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
眼、耳、鼻、口操作
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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
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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
心血管操作
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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
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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）
呼吸系统操作
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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
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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
胃肠道操作
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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
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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
妇科操作
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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
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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
产科操作
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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
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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
泌尿系统操作
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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
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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
矫形外科和骨骼肌肉操作
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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
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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
麻醉和镇痛
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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
我们一直在看什么？
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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
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
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
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
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
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
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
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
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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。
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Your can now teach the fine points. 现在你可以教授细节。
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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？
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Arrange for a follow-up session. 安排一个随访的阶段。
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
有问题吗？