So.... by 60% of the way, I take it you are a PGY-2. You may be "credentialed" in airways, chest tubes, TV pacers, PACs and IABP, but that is in a residency training license i.e. under the supervision of an attending. You might *THINK* you can do these - and I don't doubt you can for straight-forward ones - but for a PGY-2 to give the impression that he/she is capable of doing these independently including managing their complications and knowing how to do the ATYPICAL ones, well, that's just laughable.
The worst unknowns are the unknown unknowns.
Incorrect. I have been supervised for maybe 5-6 of > 100 lines. For maybe 5-6 of 40+ airways. For the first 5-6 chest tubes. For the first 4-5 LPs. Yes I still in general am supervised for pacers and the rarer more difficult things, but YOU are the misinformed one if you think because I have a resident training license and because my procedure note has "attending X" listed as being present and supervising, that any of them in fact are. I have put in more lines then every one of our 15 hospitalists, probably more than most of them combined. If you look at my note, they supervised it, so it can be billed for. I havent seen an attending in the room in over a year, maybe 80-90 lines ago. By the time they show up to the airway I am long done with it. And with good reason, as studies show procedure complication rate is a direct function of the number performed. If I have put in 50-60 more than my supervisor, they are not of much use are they?? Do I come across more difficult procedures that require me to call the surgeon who I know has more experience, sure. Do I call the CRNA/anesthestiologist on call when I forsee a difficult airway to peak over my shoulder and back me up, of course I do. This isnt a pride issue. It is a skill issue. And to assume because I am a PGY-2 I do not possess skill to do these is wrong in my mind. Being a fellow or even an attending does not make you more qualified to do a procedure. Attending X who has floated 15 swans during their residency and attending years is not more profficient than a current resident who has floated 30. Procedures are not like general medical knowledge. There success rate/complicatin rate is not related to the number of years you have been practicing, they are related to the number performed and experience of the operator. I am not trying to say I run around throwin in pacers and swans or anything like that. But If I have a pt that is suddenly in 3rd degree block in my MICU and symptomatic not responding to atropine I will, and have done, had the nurse page cardio,or text them quick myself, and tell them to get here stat while I get access in the neck and start getting ready to float. If I am done before they get there, great. In the past they have showed up midway through and guided me through the rest. Would I have done anything different had they not shown up? no. When I first dropped a lung putting in a subclav, the only one I have ever had, I called surgeon and said Hey man i dropped a lung can you come help me put in a chest tube I am not credentialed yet. He said sure. If it happened at this point or more likely, if the intern I am watching dropped a lung, i would just put in a chest tube.
And as for the license thing and so forth, when I go to a new hospital as an attending, my first 2 years will be here, i will just show my logs, which are signed by attendings, for privledges. Beautiful thing new innovations. Heres my 200 lines signed off by attendnigs I have completed over the years. privledge granted.
And I guess I should furthur clarify, In every case, if I have a patient that needs, a CVC, Aline, Airway, LP, Thora, Para, I do them immediately with a text to the attending, " I am doing X". There response is, "let an intern do it and supervise them", to help enhance others skills, if one is available and it isnt emergent, or "ok let me know if you have any problems". I have had notes left for me when I was on nights by a daytime hospitalist, " hey i admitted so and so with ascites and severe abdominal pain at 6pm, too late for IR to tap them today, can you tap them tonight for me if you get a sec, I already wrote all the orders for the fluid". For pacers that are urgent, I treat them like a cric and do what is best for the patient so they dont code. If they are responding to atropine or pads I will wait for cardio as they usually say bring them to the lab so we can do it under fluoro from the groin, and they supervise me there. For swans, which are never urgent, there is usually someone there, but again, because it isnt urgent and the attending is usually around anyway. The others I did preop for CTS and the attending was there prepping the chest and legs and such while I was doing it. IABP are obviously in the presence of cardiologist, as I previously mentioned.
My general point was for any of the above procedures, I have done enough and feel comfrotable enough that if a patient needed one emergently, I would have no hesitation in doing it regardless of who was present. And I have yet to meet an attending who was upset with me for doing it.
Yes the worst unknowns are the unknown unknowns, but those of us who dont train in academia with a huge heirarchy of experienced people, we learn by doing. and we learn complications when they arise and do our best to figure out why they happened and how to prevent them from happening in the future and better manage them if they do.