Advice for applicants

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Graduating senior here. Just thought i'd share some personal thoughts that I wish I knew better when I was an applicant..
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[FONT=DejaVu Sans, serif]1)Vacation. All programs give you vacation, but some places want you to do the same number of shifts that month. For example if you have a week off during a month they might want you to work extra during the rest of the 3 weeks. Some places just give you the time off. Period..[FONT=DejaVu Sans, serif]
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[FONT=DejaVu Sans, serif]2)It's much more important than you think for you to go to a hospital where EM is much stronger than medicine/surgery..[FONT=DejaVu Sans, serif]
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[FONT=DejaVu Sans, serif]3)A lot of programs(even the big names) don't teach their residents how to do blind central lines. It' much easier for them to teach you ultrasound guided IJs and less liability for them. There are quite a few residents out there that are graduating without knowing how to do subclavian or blind IJ lines. You NEED to know how to do those more than comfortably..[FONT=DejaVu Sans, serif]
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[FONT=DejaVu Sans, serif]4)Trauma is overrated and medical resuscitations are much more important for your training. Applicants don't know that trauma in fact is a money losing service and places that get a lot of trauma depend on residents to do the work and it does not contribute as much to your overall training as you think. After a certain amount of trauma, any more than that hinders your training.
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[FONT=DejaVu Sans, serif]5)There are more people at 4 yr programs than we admit that wish we could have gone to a 3 yr program and have the choice to either graduate a year earlier or do a fellowship. Overall, we defend our programs and tell applicants otherwise.
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Other graduating residents feel free to share your advices also.
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[link2swim06]

How do you know relatively how their EM and med/surgery programs compare? I dont really see ranking for residency programs like their were for med schools.

 

[Apollyon]

Why are there two different typefaces? Copied from someone else?

 

[Flopotomist]

I have to disagree with the whole 'blind central line' arguement. The standard of care is quickly becoming ultrasound guided lines, and after having seen with the US a few people with anatomy that didn't comply with Netter, I would be scared to start an IJ blind now. Why would you NOT use the US?

 

[Arcan57]

I have to disagree with the whole 'blind central line' arguement. The standard of care is quickly becoming ultrasound guided lines, and after having seen with the US a few people with anatomy that didn't comply with Netter, I would be scared to start an IJ blind now. Why would you NOT use the US?

Because you don't have one.

 

[DeadInside]

How do you know relatively how their EM and med/surgery programs compare? I dont really see ranking for residency programs like their were for med schools.

Not so easy at some programs, but a huge clue would be if their EM program is not its own department, but a division within the dept of surgery or medicine. Not to say these programs are bad programs, but being the ugly stepchild of another dept can get old at times.

My two sonts.

 

[xaelia]

If all else fails, the femoral is a compressible site.

They may make fun of you for putting a triple lumen in down there, but, well, anatomic landmark subclavians have a 5-10% complication rate - probably similar for blind IJs.

Then again, other than a cordis, vascath, or pacing line, you could always drill an IO into both knees and you have debatably better access.

 

[MSmentor018]

If all else fails, the femoral is a compressible site.

They may make fun of you for putting a triple lumen in down there, but, well, anatomic landmark subclavians have a 5-10% complication rate - probably similar for blind IJs.

I completely agree U/S is going to be the standard of care and wouldn't do an IJ without it but there are community places that don't even have a cheap ilook. I completed a study that showed a potential 34-44% complication rate for blind IJ if the head was turned 80 degrees. these were randomized 100 ER pts and purely anatomical U/S, no lines were inserted.

groin line are great except they're being phased out due to the "higher infection rate", plus at our shop there's a checklist w/ a check box that you have to justify and answer why you didn't put a sc or ij. and yes if you blow it off, in a few weeks ID does contact your program, who then finds you to document all this

 

[la gringa]

subclavian is the expected line at the shops where i work. like msmentor said, you'd better have a reason to do a femoral. last one i did was on a lady on coumadin w/ an INR of 4 and absolutely no access, and she was about to be transferred. that was over a year ago.

in residency though - you need exposure to all of them. my program was pushing US guided IJ's, but i knew by mid senior year that my new job didn't have US privileges in the ED. so i did a lot of subclavians when i rotated to the community sites.

as far as gauging med/surg power - inquire about how pts are admitted. big "name" programs will have big name med and surg, period. whether the turf battles have already been fully worked out will probably not be obvious when you're interviewing. i interviewed at mostly county/public sorts of places and it was not really a concern. i did get the idea one place the the ED was not top dog, but i didn't really like that place.

 

[Groove]

I try to go with whatever I'm least comfortable with as a challenge. We never use UTZ for subclavian or femorals and I'm most comfortable with those. Most of our IJ's are at least UTZ guided or I'll at least view the IJ first just to check for anatomy, volume, stricture, scarring, anatomical variant, etc... I have one attending that challenges us to not use the UTZ as a crutch for IJ's because you may not have one available and I'm comfortable doing them but call me crazy...I really like to know if the IJ is sitting smack on top of the carotid before I stick. Any volume down patient that's hypotensive, even in trendelenburg makes me nervous doing an IJ without UTZ to at least view first, but that's me.

 

[MSmentor018]

all me crazy...I really like to know if the IJ is sitting smack on top of the carotid before I stick./QUOTE]
you mean if the CA is sitting on top of the IJ like this? 3/100 pts had this variant. how frustrating would this be on a blind stick?

 

[Kris1]

all me crazy...I really like to know if the IJ is sitting smack on top of the carotid before I stick./QUOTE]
you mean if the CA is sitting on top of the IJ like this? 3/100 pts had this variant. how frustrating would this be on a blind stick?

Ehhh so what if you stick the carotid. Pull out and hold pressure. Let IR fix the pseudoaneurysm.

 

[MSmentor018]

Pull out and hold pressure.

yeah that's a good technique, or you can just think baseball and keep truckin. bring your A game for the golf course tomorrow!

 

[Groove]

all me crazy...I really like to know if the IJ is sitting smack on top of the carotid before I stick./QUOTE]
you mean if the CA is sitting on top of the IJ like this? 3/100 pts had this variant. how frustrating would this be on a blind stick?

LOL, wow.

Can you link me to the stats on that anatomical variant? Was that an internal study at your institution? I briefly pulled this up but didn't see it.

 

[Venko]

Because you don't have one.

As someone who has placed blind IJ lines many times 5-6 years ago, I can say in my opinion it has no role in today's care. If you don't have an ultrasound machine or its too time sensitive to get it, or your department does not have privileges to use ultrasound, I believe the patient should have a subclavian or femoral line as other posters have suggested. If I didnt have an ultrasound machine and I think that an IJ line is the best for the patient, it would be even more motivation to have the ICU / Floor etc take the patient faster so that best possible care can be delivered.

Just my thoughts.

 

[Venko]

I disagree with the idea that EM should be "stronger" than other services. Its a sad feeling when I don't want my upstairs colleagues to take a patient because I am worried that the patient will not receive good care (this is the situation, I currently experience at a local county hospital).

My personal opinion on this is that since a large percentage of the residency is spent in critical care, surgery, and along-side medicine, it is important that all departments are equally motivated to be high quality clinicians and are dedicated to resident education. This is best gauged by asking the residents in a given program details about their off-service rotations.

I trained in an environment where EM, medicine, and surgery (along with all other specialties) were truly top-notch, and I'll tell you this keeps you on your toes. There is nothing wrong with a very knowledgeable discussion, you shouldn't be afraid to sit at a table with very smart people in other specialties; who wants to be part of a hospital where you are not challenged to be better every day? I have no idea what is to gain by being the smartest fishes in the hospital by a large margin....if you want to be the best, work with the best.

 

[ORL10]

I disagree about putting in central lines without ultrasound guidance being a critical skill and I also disagree that femoral lines result in significantly higher infection rates. It is true that the cochrane review found higher rates of line colonozation but not increased clinical infection rates (which really is what we care about isn't it??). Thrombosis is more common with a femoral line, but you also don't get PTX with a femoral line. Also remeber the people in NON randomized studies that had CVC placed in femoral lines also had them placed while at higher risk (codes, sick patients requiring immediate access) and may lead to the slightly increased infection rate seen, and following the checklist may prevent CLABSI. if you are an EBM kinda guy the ref are Merrer et al in JAMA 2001, and Hamilton et al 2007 is the cochrane review that said there was a statistically increased colonization rate.

Also I love putting in CVC, but to be honest in most patients they don't need them. (CVP is a crappy monitor of intrvasculr volume if thats why you do it to follow EGDT, if your pt is intubted and NSR do PPV or use an US). Central acting drugs or difficult access usually the reason I place a central line otherwise two large bore peripherals are pretty good.

There are times when it is difficult to put in an IJ, and then we will move to a subclavian line. The argument that putting in blind IJ's over US guided IJ's to me sounds ludacris (think of the last time you had the US and saw a sliver of an IJ next to a bulging carotid.) Most ED's have US and those that don't should soon ( because it is probably the standard of care.)

I also disagree with trauma not being helpful, as yes the w/u is pretty protocolized. However, at our shop trauma patients roll in left and right with unstable pelvic fx, GSW's, open fx and require lots of ED interventions. (dosing PCC's for ICH on coumadin, MTP, thoracotomies, chest tubes, intubations, cordis catheter, intubating hypotensive unstable patients.) I wouldn't pick a residency on trauma alone but it definitely is an important part of residency development.

As for 3 vs 4 year I think that will always be a debate. I want to do a 2 yr CC fellowship so 4 years + 2 sounds so much longer than 3+2 ( not sure why but it does).

I like being the strongest residency at the hospital, although I think you definitely have to be a go getter when on off service as I find other residents less helpful and knowledgeable (ICU months in particular).

Good discussion though, and deifnintely appreciate the thoughts from the OP.

 

[Arcan57]

As someone who has placed blind IJ lines many times 5-6 years ago, I can say in my opinion it has no role in today's care. If you don't have an ultrasound machine or its too time sensitive to get it, or your department does not have privileges to use ultrasound, I believe the patient should have a subclavian or femoral line as other posters have suggested. If I didnt have an ultrasound machine and I think that an IJ line is the best for the patient, it would be even more motivation to have the ICU / Floor etc take the patient faster so that best possible care can be delivered.

Just my thoughts.

My go-to line is a subclavian, but I'd do a blind IJ before a femoral if I really needed access. There's a generation of residents that has been raised on U/S IJs and it's been drilled into their head that blind IJs will kill at least 50% of the patients that you attempt them on. Of course that's hyperbole, but so is MSMentor saying there's a 40% complication rate from doing blind IJs. And a number like that gets propagated and maybe somewhere down the line a patient doesn't get a needed triple lumen because the now attending never figured out how to do landmarks if needed. And if you're waiting for the patient to get to the ICU to get a line, you can kiss EGDT goodbye in >90% of community hospitals.

If you've got the U/S then do an U/S guided IJ. If you don't, you should be really damn good at subclavians. But you should know how to do a blind IJ because someday that may be your only choice. I have 2-3 dialysis players whose only access is an IJ (chronic ileofem dvts and stenotic subclavians that even IR can't get).

Also, for everyone quoting the femoral line as being inferior because it's "dirty" that's only a little bit true. The main driver in complication rates on femoral TLCs is DVT, which are much higher than their SVC traveling counterparts.

 

[Venko]

My go-to line is a subclavian, but I'd do a blind IJ before a femoral if I really needed access. There's a generation of residents that has been raised on U/S IJs and it's been drilled into their head that blind IJs will kill at least 50% of the patients that you attempt them on. Of course that's hyperbole, but so is MSMentor saying there's a 40% complication rate from doing blind IJs. And a number like that gets propagated and maybe somewhere down the line a patient doesn't get a needed triple lumen because the now attending never figured out how to do landmarks if needed. And if you're waiting for the patient to get to the ICU to get a line, you can kiss EGDT goodbye in >90% of community hospitals.

Arcan, I generally agree with your posts, but I continue to disagree with you on this point. It is possible that I am not as well read on this topic and would love to know from what foundation you believe that a blind IJ is safer for a patient than a temporary femoral?

As for the dangers of blind IJ placement, there is plenty of evidence (some of which I will list) which suggests that the complication rates can be four times as great 16.9% vs 4.6% with landmark techniques compared with ultrasound (Leung et al. Ann Emerg Med 2006; 48:540-547). There have been meta-analyses on this issue such as the one by Keenan (Journal of Critical Care, Vol 17, No 2 (June), 2002: pp 126-137), which show reductions in failure rates, number of attempts required, complication rates (including arterial puncture), etc and that when further analysis is performed the reductions are most prominent with regards to IJ sites of insertion. There is a cochrane piece in the works on this issue as well.

With regards to your case of the Sepsis patients, Subclavian lines will suffice for CVP / ScVo2 monitoring. If you simply need fluids and medication administration, I still contend that a femoral insertion is safer for the patient than a blind IJ, and can later be removed when an ultrasound machine is available.

Again, Arcan, it is certainly possible that I am not aware of all the facts, but at least based on what I have reviewed there is overwhelming and consistent evidence toward decreased complication rates, number of attempts, and failure with ultrasound guided IJ placement. Comparing the risks associated with blind placement (i.e. 17% risk of complication) vs. 20% arterial punctures with femoral lines (Hilty et al. Ann Emerg Med 1997 29:331-336), I would much rather have the complication in the groin than at the neck especially with the critically ill patient. I agree that SC lines are fantastic and the complication rates for blind SC lines are consistently lower than either of the others blindly approached.

So, would i teach my residents on live patients to do blind IJs because I think they need to learn it?

Nope.

 

[Arcan57]

Arcan, I generally agree with your posts, but I continue to disagree with you on this point. It is possible that I am not as well read on this topic and would love to know from what foundation you believe that a blind IJ is safer for a patient than a temporary femoral?

As for the dangers of blind IJ placement, there is plenty of evidence (some of which I will list) which suggests that the complication rates can be four times as great 16.9% vs 4.6% with landmark techniques compared with ultrasound (Leung et al. Ann Emerg Med 2006; 48:540-547). There have been meta-analyses on this issue such as the one by Keenan (Journal of Critical Care, Vol 17, No 2 (June), 2002: pp 126-137), which show reductions in failure rates, number of attempts required, complication rates (including arterial puncture), etc and that when further analysis is performed the reductions are most prominent with regards to IJ sites of insertion. There is a cochrane piece in the works on this issue as well.

With regards to your case of the Sepsis patients, Subclavian lines will suffice for CVP / ScVo2 monitoring. If you simply need fluids and medication administration, I still contend that a femoral insertion is safer for the patient than a blind IJ, and can later be removed when an ultrasound machine is available.

Again, Arcan, it is certainly possible that I am not aware of all the facts, but at least based on what I have reviewed there is overwhelming and consistent evidence toward decreased complication rates, number of attempts, and failure with ultrasound guided IJ placement. Comparing the risks associated with blind placement (i.e. 17% risk of complication) vs. 20% arterial punctures with femoral lines (Hilty et al. Ann Emerg Med 1997 29:331-336), I would much rather have the complication in the groin than at the neck especially with the critically ill patient. I agree that SC lines are fantastic and the complication rates for blind SC lines are consistently lower than either of the others blindly approached.

So, would i teach my residents on live patients to do blind IJs because I think they need to learn it?

Nope.

If you have an U/S, you should use it for IJs. Period. If the U/S isn't available, then you should do what you have the most comfort doing. If that site is not available, you should do another site. The data for where to place the line (in the absence of obvious contraindications) is not robust. Subclavian vs. IJ TLCs was based off a Cochrane review that only found 1 randomized trial. I tend to buy the increased risk of thrombosis argument for femorals, and I can transduce a CVP off of a IJ. I'm not at all convinced that the complication rates for femorals vs. IJs is significantly different. And I don't think every complication is equal. If the carotid artery is stuck with a finder needle, that's a complication but what does it actually mean for the patient? My gut is that arterial insertion of a TLC is far more common in the femoral artery than the carotid (I'll try and pull up the review when it gets less busy).

If the U/S was not available and the patient had contraindications for a subclavian line, I would walk a senior resident through a landmark IJ. If it were a new intern, I'd probably have them do the femoral.

 

[AmoryBlaine]

Things I wish I knew as an applicant:

1. Agree with trauma. Just not that critical. The tough cases when you are a senior resident are not the B/L PTX with a GCS of 6 after a car accident, they are the endless string of belly/chest/head pain.

2. There are real differences in what programs consider to be adequate procedural training. There are residents graduating from established, reputable programs who have only done 20-30 tubes and 20-30 central lines.

3. Most people in ER are relatively benign but you will see some true incompetence and personality disorders.

4. The big names in the field are often terrible on shift.

5. One of the most important things to learn in residency is how to deal with the urgent care patients. They can be a surprisingly challenging and risky population.

6. The responsibility for your education will be 85% on you now and forever.

7. Whiny medical students turn into whiny residents then turn into whiny attendings. If you can't find happiness at one stage of life you won't find it at another.

7.5. No one ever complained their way into greatness.

8. If you go into ER for the lifestyle you will never be happy.

9. You will establish a speed/rhythm for yourself and this will be a set point. Be wary of situations that demand that you work far above this point. When you are you are making mistakes whether you are catching them or not.

10. You cannot overestimate the value of getting along with your fellow residents. If you are friendly and appreciative of your consultants they'll be putty in your hands.

11. 40% of your job as a senior is managing your attending.

 

[AmoryBlaine]

A note on central lines:

The u/s has become a terrible crutch for many people. Even if you are never away from an u/s machine for your whole career you need to know how to put in other lines.

The 5-10% complication rate for SC depends on how you define complication. If you define it as arterial puncture/PTX it's clearly not that high. You have to look at the methodology of those studies because they will lump things like >2 attempts and failed line in with dropping a lung.

In the hands of an experienced operator I think the PTX rate for SC is more like 1-2%. The problem is that we train people first on USIJ and so when you try to move them to LMSC it's so terrifying to not be able to see the vein.

 

[MSmentor018]

LOL, wow.

Can you link me to the stats on that anatomical variant? Was that an internal study at your institution? I briefly pulled this up but didn't see it.

it was a study I did at my hospital but I presented at acep/saem last yr. the abstract is in the oct annuals of EM supplement and this month's SAEM supplement. I beleive the papers' already been submitted but haven't heard anything yet. author J newton in NJEM had similar results, which is who i used for my comparisons. also the wang paper is a popular one. PM me your email and I can send you the data table and pic

 

[gman33]

Things I wish I knew as an applicant:


7. Whiny medical students turn into whiny residents then turn into whiny attendings. If you can't find happiness at one stage of life you won't find it at another.

7.5. No one ever complained their way into greatness.

 

[RustedFox]

A note on the 'blind IJ' and landmarks.

I learned both methods. Landmarks and US. I love my US, I really do. However, I feel that you cannot reliably identify landmarks in a lot of cases because people are just so fat. I also have difficulty with femorals for the same reason; I hate swimming through six inches+ of adipose.

 

[deuist]

you mean if the CA is sitting on top of the IJ like this? 3/100 pts had this variant. how frustrating would this be on a blind stick?

I learned that taking a detailed history from the patient is also important. As I was setting up my central line equipment, an elderly lady with no obvious neck scarring suddenly remembered that she had a carotid endarterectomy years earlier. The ultrasound showed the carotid was placed on top of the internal jugular.

 

[ORL10]

New article this month in critical care medicine ultrasound guided vs landmark subclavian line. Fragoue et al. CCM July 2011

Landmark group: arterial puncture in 5.4%, hemothorax 4.4%, pneumothorax 4.9%, brachial plexus injury 2.9%, phrenic nerve injury 1.5% and tamponade 0.5%.

Ultrasound group: Artery 0.5%, hemothorax 1.5%, PTX 0.0%, hemothorax 0.0%, no brachial plexus, or phrenic nerve injuries or episodes of cardiac tamponade.

All statistically and clinically significantly reduced in ultrasound group

Avg time to cannulation and success rate also reduced.

This again adding to the evidence that US guided CVC insertion is much safer and more efficient method of placement.

This obvious not done with compression but rather with real-time US guidance.

Caaveat: done in critically ill patients under non-emergent conditions. Which I still think placing any line (for me femoral) is fine in an emergent conditions as these lines are coming out on day 1 in the unit. I know a lot of people will say I do not have those high of complication rates, but just ask your ICU freinds who see your patients after they go up, you do.

This evidence is done in skilled physicians hands > 6 years experience and does not agree with AmoryBlaines statement on 2% PTX rate from below:



"A note on central lines:

The u/s has become a terrible crutch for many people. Even if you are never away from an u/s machine for your whole career you need to know how to put in other lines.

The 5-10% complication rate for SC depends on how you define complication. If you define it as arterial puncture/PTX it's clearly not that high. You have to look at the methodology of those studies because they will lump things like >2 attempts and failed line in with dropping a lung.

In the hands of an experienced operator I think the PTX rate for SC is more like 1-2%. The problem is that we train people first on USIJ and so when you try to move them to LMSC it's so terrifying to not be able to see the vein. "

 

[Arcan57]

Those numbers don't pass the sniff test. I'm a "skilled physician with >6 yrs experience" who follows up on every patient I put a line in for the first 48 hours and my complication rate isn't anywhere close to that. And I don't think I'm anything special in terms of ability. Where are these brachial plexus, phrenic nerve and cardiac tamponade complications coming from? I'm going to call shenanigans.

 

[deuist]

Just what the hell are you doing if you're hitting the brachial plexus and phrenic nerve during a subclavian line placement? Also, faster placement with a U/S? I can reasonably hit the subclavian vein in 1-2 seconds after I enter the skin. I'm not sure you can improve on that.

 

[Venko]

Just what the hell are you doing if you're hitting the brachial plexus and phrenic nerve during a subclavian line placement? Also, faster placement with a U/S? I can reasonably hit the subclavian vein in 1-2 seconds after I enter the skin. I'm not sure you can improve on that.

I do not know the study intimately, but brachial plexus and phrenic nerve injury are known complications of supraclavicular approaches to the subclavian vein cannulation.

 

[Venko]

A note on central lines:

The u/s has become a terrible crutch for many people. Even if you are never away from an u/s machine for your whole career you need to know how to put in other lines.

The 5-10% complication rate for SC depends on how you define complication. If you define it as arterial puncture/PTX it's clearly not that high. You have to look at the methodology of those studies because they will lump things like >2 attempts and failed line in with dropping a lung.

In the hands of an experienced operator I think the PTX rate for SC is more like 1-2%. The problem is that we train people first on USIJ and so when you try to move them to LMSC it's so terrifying to not be able to see the vein.

AB, increased number of attempts and a failed line are complications. If any technique can reduce the occurrence of these events it is necessary to do so as these are certainly patient centered outcomes.

With that said, I am not entirely convinced that ultrasound assists in subclavian line placement. I am still trying to formulate my opinion on this issue.

BTW, there are some real gems in your advice list.

Cheers!
TL

 

[Arcan57]

I do not know the study intimately, but brachial plexus and phrenic nerve injury are known complications of supraclavicular approaches to the subclavian vein cannulation.

Ah, that makes sense. It also makes the study significantly less relevant to my practice. I do landmark subclavians infraclavicularly, which I believe has significantly fewer complications then the blind supraclavicular approach. Give me a study that compares complication rates of U/S guided supraclavicular lines vs. landmark guided infraclavicular and then I'll be interested.

 

[AmoryBlaine]

AB, increased number of attempts and a failed line are complications. If any technique can reduce the occurrence of these events it is necessary to do so as these are certainly patient centered outcomes.

With that said, I am not entirely convinced that ultrasound assists in subclavian line placement. I am still trying to formulate my opinion on this issue.

BTW, there are some real gems in your advice list.

Cheers!
TL

They are complications but they don't have the same ramification as dropping a lung.

My point, which I think is still valid, is that when you look at a study that describes complications of a procedure you have to first look at the methods and ask what they mean by complications.

Personally if I was designing a study I would not put "catheter malpositioned in soft tissues" in the same category as "hemopneumothorax" and "death."

 

[Venko]

They are complications but they don't have the same ramification as dropping a lung.

My point, which I think is still valid, is that when you look at a study that describes complications of a procedure you have to first look at the methods and ask what they mean by complications.

Personally if I was designing a study I would not put "catheter malpositioned in soft tissues" in the same category as "hemopneumothorax" and "death."

The implications of a malpositioned catheter in soft tissue can be equally if not more grave in a critical situation as a hemopneumothorax. Tissue necrosis from vessicant medications, lack of life saving pressers or other interventions dispensed into the tissue are very serious complications. I would argue that I can treat a hemopneumothorax easier than I can treat vessicant related skin and deep soft tissue necrosis...

 

[Venko]

Ah, that makes sense. It also makes the study significantly less relevant to my practice. I do landmark subclavians infraclavicularly, which I believe has significantly fewer complications then the blind supraclavicular approach. Give me a study that compares complication rates of U/S guided supraclavicular lines vs. landmark guided infraclavicular and then I'll be interested.

Certainly. Also in my personal experience, landmarks for subclavian is easier than US guided. The images aren't as crisp as with an IJ. I haven't read the other article though, so I don't know if it is supraclavicular approaches they are discussing...I just put it out there.

As I mentioned, I am NOT advocating against or for US for subclavians...I still haven't created my own opinion.

 

[turkeyjerky]

Thought I would bump this thread (for more advice to applicants, not discussion on central line placement)

 

[nycqqe]

My advice would be to place a litte more focus on serving yourself during residency.

A lot of applicants have this overly naive image of seeing themselves training at a "hardcore" place where it lacks resources, has poor ancillary staff, and serves an under-served population where no doubt there is plenty of sick patients, but often there is a lot more scut, placing ivs, transporting patients, dealing with BS presentations like drunks, trauma drama, abscess I&Ds, drug seekers, malingerers...etc. I'd advice applicants to look for places where they could miminize exposure to such scut and maximize exposure on sick, complicated medical patients, which is generally agreed by all EM physicans as the more challenging part of EM. Serve yourself well by exposing yourself to sick medical patient after sick medical patient. All the other stuff, like dealing with drunks, gang-bangers, medication refills..etc you really don't need years and years of training in doing while being paid a resident's salary. The best way to serve the under-served population is to serve yourself first and maximize your training on the difficult stuff, and then go back as a solid attending and serve whoever you want to serve later. I agree there's definitely value in learning to deal with scut and low acuity patients, but let's be honest a lot of it is also hype due to the medical student's over-idealization and the residency's over-selling it because they need the warm bodies to do the work.