Match list due soon be careful

[WilcoWorld]

So art lines facilitate pimping...I knew we used them for something.

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[The Knife & Gun Club]

You don't understand, man... I may get pimped about the art line wave form and what I am supposed to tell the attending, "I was too much of a **** to force the ED to place one prior to admission?"

My go to if I actually need an A-line for some reason is the femoral double prep. Open both trays, one sterile field, needle into artery, wire, fem art line, second needle into femoral vein for femoral CVC. Only adds about 30-60 seconds to my line time.

But I agree outside of ICH or cardiogenic shock the a-line usually doesn’t add much if the BP cuff works.

 

[southerndoc]

If a patient is on >1 pressor, they need an art line. I find them most useful for salvageable patients who are post-arrest that remain in a peri-arrest state. No mucking around trying to feel for a pulse. Lose the a-line wave form, and you're doing compressions again.

 

[BoardingDoc]

If a patient is on >1 pressor, they need an art line. I find them most useful for salvageable patients who are post-arrest that remain in a peri-arrest state. No mucking around trying to feel for a pulse. Lose the a-line wave form, and you're doing compressions again.

Yep. I've placed one a line in the past 2 years and it was for exactly that scenario. Don't see the point otherwise.

 

[GonnaBeADoc2222]

Any need for pressors requires an A line in my book. Pressors are a high morbidity medication (gut / limb ischemia) etc and the A line lets you titrate the pressors to the minimum amount needed. Cuff pressures are often inaccurate.

 

[WilcoWorld]

If a patient is on >1 pressor, they need an art line. I find them most useful for salvageable patients who are post-arrest that remain in a peri-arrest state. No mucking around trying to feel for a pulse. Lose the a-line wave form, and you're doing compressions again.

Seems reasonable.

 

[BoardingDoc]

Any need for pressors requires an A line in my book. Pressors are a high morbidity medication (gut / limb ischemia) etc and the A line lets you titrate the pressors to the minimum amount needed. Cuff pressures are often inaccurate.

I can only assume that you work in academics, or are on the lower end of pph if working community. I don't mean any disrespect by that. I do mean that if I had to place an a-line in every patient I had on pressors I'd never get anything done. Hell, I don't put central lines in 90% of the patients I have on pressors. They can go to the unit on peripheral norepi.

 

[WilcoWorld]

Any need for pressors requires an A line in my book. Pressors are a high morbidity medication (gut / limb ischemia) etc and the A line lets you titrate the pressors to the minimum amount needed. Cuff pressures are often inaccurate.

If that's your practice, that's fine. But I'm unconvinced that arterial lines decrease extravasation risk. Any evidence for that?

 

[Tipsy McStagger]

I can only assume that you work in academics, or are on the lower end of pph if working community. I don't mean any disrespect by that. I do mean that if I had to place an a-line in every patient I had on pressors I'd never get anything done. Hell, I don't put central lines in 90% of the patients I have on pressors. They can go to the unit on peripheral norepi.

Most often in the unit if they're on low dose levo I never place a central line or a-line. I just let them coast with peripheral pressors. I use art lines mostly for ARDS and frequent need of ABG. Otherwise, I'll place them for high risk intubations prior to induction (group 1 pHTN, severe aortic stenosis), dissections, cardiogenic shock if I have them on an infusion of nipride or cleviprex, and some multipressor shock. But I don't think that any pressor is an indication for an art line, though I am a firm believer in "less is more."

 

[BoardingDoc]

If that's your practice, that's fine. But I'm unconvinced that arterial lines decrease extravasation risk. Any evidence for that?

I'm assuming you were inferring limb ischemia = extrav? I don't think that was the intent of the post. I think they were simply stating that downtitraing pressors decreases the chance of limb ischemia.

 

[BulgeDaTwine]

Sounds like your program sucked. I started training in 2006 and we had US training then and multiple video scopes. One thing I notice which is interesting is that the current residents and students expect 0 scut. No doubt I did too much but the coddling of some of the current residents is extreme.

There are many west coast programs including "established" ones whom i have no respect for. I worked with residents from a pretty well known program and had a 3rd year resident who trained at this trauma center tell me he had only put in 2 chest tubes.

I think one key point in your above post is that many of your attendings being new grads. Experience matters. In my opinion a good program has a mix of experience. The old guys know some cool tips and tricks that they picked up over time or learned years ago. The young guys are similar but often they feel pressure to either move the meat, still want to do a bunch of procedures themselves etc.

I doubt many EM residents could place an IJ using only landmarks. From my experience with some residents they clearly never paid attention to it as they are so beholden to US they forgot basic anatomy. Similarly, I am a huge video fan but DL skill is a must. Yes US IJ is the gold standard and it is IMO malpractice to do it without but learn the landmarks, learn the basics of the skill.

I can go on and on but the point is some residencies suck and abuse their residents. The issue with HCA land is they dont even care and what they practice is extraction of money from patients without care for the quality of care (or apparently cleanliness of their facility).

I will never hire an HCA grad. Hard stop.

You had me until you decided to throw those of us who ARE WELL TRAINED under the bus by demanding that to put in a central line without ultrasound is malpractice. I HOPE you are just referring to IJs. I've probably put a few hundred lines in (EM/Critical Care) and the vast majority were no-ultrasound subclavians. Sometimes, they were in crashing patients and so we were infusing the things that matter less than 120 seconds after the package was cracked while the nurse was looking for the vascular ultrasound in the back of the supply room.... or we were waiting for the thing to boot up... or we were looking for a probe cover....

My point is, I think the ultrasound is complimentary to your practice, not a malpractice-mandated appendage.

Definitely reflects my training, though. When I was an attending in academics, the residents would specifically ask me if they could put in a subclavian on-shift because so many of the others weren't comfortable doing it and, by extension, wouldn't let them try. It's not that I'm particularly good or bad at them... just numbers, yo.

 

[BulgeDaTwine]

Does anyone use the subclavian as their go to approach for central access? I’m pretty facile at all three, but love the subclavian.

Yes. 100% my go-to. Speed and consistency of landmarks make it totally safe sans u/s, IMO - plus ultrasound gives you ****ty images in even thin patients let alone bog-standard Amurican' BMI patients....

 

[BulgeDaTwine]

Subclavian is nice if you are doing a blind line but if there’s an US I can do a femoral just as quickly. I almost never need access so much that I can get an US in the room. If they are that sick and no one can get a line honestly I place an easy IJ/IO then place a central line later. My concern is always if you accidentally drop a lung people will ask why you chose that site. US guided subclavian is safer since you can use rib protection but takes longer. An US IJ also only takes 5-10 minutes. Dunno I love the mechanics and simplicity of placing a subclavian but the rate of PTX is quoted at 10-20%

YMMV based on your site as regards if you really NEED the skill of doing a rapid line (trauma center?) but you definitely cannot do an u/s guided femoral as fast as an experienced pit doc can whap in a subclavian, and yes I'm still doing it sterilely which means I get central delivery right into the heart (ok, the SVC) of life saving meds (let's see your IO do that) it isn't gonna get infected as readily as your femoral and/or I'm not gonna have to just rely on the Intensivist to fix my mess and convert the line later.

If you're doing it right, you won't drop a lung. The trick is to start far enough away inferiorly from the clavicle such that you can take a shallower route heading cephalad, then as soon as you're under the clavicle, drop your hand and re-direct toward the opposite shoulder, almost parallel to the clavicle. Using this method you need to be closer to the sternal notch than the text books. Almost uncomfortably so. But I've never dropped a lung in over 15 years (knocks on head, turns around 3 times, and goes outside and spits on the ground)

 

[WilcoWorld]

I'm assuming you were inferring limb ischemia = extrav? I don't think that was the intent of the post. I think they were simply stating that downtitraing pressors decreases the chance of limb ischemia.

Ah, that makes more sense.

 

[bravotwozero]

We went from HCA crap residencies to central lines…

 

[EctopicFetus]

You had me until you decided to throw those of us who ARE WELL TRAINED under the bus by demanding that to put in a central line without ultrasound is malpractice. I HOPE you are just referring to IJs. I've probably put a few hundred lines in (EM/Critical Care) and the vast majority were no-ultrasound subclavians. Sometimes, they were in crashing patients and so we were infusing the things that matter less than 120 seconds after the package was cracked while the nurse was looking for the vascular ultrasound in the back of the supply room.... or we were waiting for the thing to boot up... or we were looking for a probe cover....

My point is, I think the ultrasound is complimentary to your practice, not a malpractice-mandated appendage.

Definitely reflects my training, though. When I was an attending in academics, the residents would specifically ask me if they could put in a subclavian on-shift because so many of the others weren't comfortable doing it and, by extension, wouldn't let them try. It's not that I'm particularly good or bad at them... just numbers, yo.

Yes. I do blind subclavians myself with no ultrasound. Trained that way. I don’t know why it was that way. I imagine because we were a super busy trauma center. So ijs off limits generally due to c collars. So fem lines and subclavians were the go to. All trauma icu patients got those as the old way was that femoral lines were dirty and frankly SCs are most comfortable for patients.

It’s funny cause I end up doing subclavians with my residents cause so few other attendings do them.

 

[Pudortu]

Regarding A lines…I thought there was no good literature showing an improved mortality. Can anyone show me different if I’m wrong? I’d be happy to change my practice patterns if there’s a good indication to do it.

 

[GonnaBeADoc2222]

Regarding A lines…I thought there was no good literature showing an improved mortality. Can anyone show me different if I’m wrong? I’d be happy to change my practice patterns if there’s a good indication to do it.

How many things do we do show decreased mortality? Not much.

W reference to above posts, yes I'm in a low PPH environment; definitely wouldn't be doing all the A lines that I do if i were seeing 2+ pph.

I like the real time reliable data an A line gives you. Pressors are harmful as a result of the tissue ischemia they produce (not referring to extrav). Nurses and cuffs are unreliable in my experience. Id rather the patient be on the lowest possible pressor dose.

 

[Mount Asclepius]

Regarding A lines…I thought there was no good literature showing an improved mortality. Can anyone show me different if I’m wrong? I’d be happy to change my practice patterns if there’s a good indication to do it.

Is there literature showing a mortality benefit for using a manual blood pressure cuff?

There isn't literature showing a mortality benefit for a lot of what we do in medicine.

Use an arterial line because it makes life easier. You really want to spend time mucking around trying to feel for a pulse rather than just look to see if there is a waveform. You titrate vasoactive medications in a more fine tuned manner with arterial monitoring. No, you don't need an arterial line for every critically ill patient, nor everyone receiving vasopressors. There are times though that they are incredibly helpful.

In residency we placed arterial lines in everyone. As an attending my use of them has fallen off considerably in a busy community ED, but I still place about 1/month. I often place femoral arterial and central venous catheters at the same time. Typically in patients post cardiopulmonary arrest or that are critically ill medically. Occasionally in trauma. I'm not sure radial arterial lines provide as significant an advantage compared to a more centrally placed arterial catheter. I don’t place radial lines much anymore. I'll take any arterial line though if a patient codes.

This line discussion should probably be a separate thread though. Unless of course it’s helpful for HCA graduates who don’t ever place lines during residency (sarcasm, although probably sadly true).

 

[EctopicFetus]

YOu know what is most interesting about this HCA thread devolving into critical care/pressor/central line/A line discussions? Those crap-tastic residencies wont be worried about this. It will be have you met the metric some Noctor set? Did you click the boxes in the right order at the right time? Did you make sure to hit the door to doc time of 5 mins even while coding someone?

Yeah avoid the hCA residencies at all cost. hard stop.

 

[cyanide12345678]

I can only assume that you work in academics, or are on the lower end of pph if working community. I don't mean any disrespect by that. I do mean that if I had to place an a-line in every patient I had on pressors I'd never get anything done. Hell, I don't put central lines in 90% of the patients I have on pressors. They can go to the unit on peripheral norepi.

Same. Peripheral pressors. Transfer for real ICU that isn’t my critical access hospital. Only if there are huge transfer delays and otherwise really poor vascular access, that’s when i think central line. Otherwise this is an ICU issue.

 

[MechEDoc]

Use an arterial line because it makes life easier.

Working in a critical access hospital. Trying to use an arterial line would make my life infinitely harder due to nursing issues...

 

[Mount Asclepius]

Working in a critical access hospital. Trying to use an arterial line would make my life infinitely harder due to nursing issues...

When I work in those settings I only place when transferring and I think it’s helpful.

You should be familiar with how to do the setup yourself and troubleshoot it completely without any nursing support as they won’t be able to reliably help.

 

[RustedFox]

When I work in those settings I only place when transferring and I think it’s helpful.

You should be familiar with how to do the setup yourself and troubleshoot it completely without any nursing support as they won’t be able to reliably help.

Sounds like a good teaching point for a spinoff mini lecture. Go.

 

[Mount Asclepius]

Sounds like a good teaching point for a spinoff mini lecture. Go.

I think it’s probably got to be hands on. You bring the beer, I’ll bring the tubing, and we’ll zero it together.

If I can make something simple and helpful once I get off this stretch of shifts, I’ll throw it up here.

 

[wareagle726]

I can only assume that you work in academics, or are on the lower end of pph if working community. I don't mean any disrespect by that. I do mean that if I had to place an a-line in every patient I had on pressors I'd never get anything done. Hell, I don't put central lines in 90% of the patients I have on pressors. They can go to the unit on peripheral norepi.

My problem is they never go to the unit so I get bugged about putting in the CVL because they've been on peripheral levo for 18 hours. I just go ahead and do them. I like doing lines still. Gives me 5 mins of not signing EKGs/transfer forms or answering stupid questions.

 

[EctopicFetus]

My problem is they never go to the unit so I get bugged about putting in the CVL because they've been on peripheral levo for 18 hours. I just go ahead and do them. I like doing lines still. Gives me 5 mins of not signing EKGs/transfer forms or answering stupid questions.

Central lines intubation reductions and chest tubes I still enjoy 10+ years out. Lps, lacs and I and ds I can do without.

 

[CoolDoc1729]

Central lines intubation reductions and chest tubes I still enjoy 10+ years out. Lps, lacs and I and ds I can do without.

Reductions are so fun. It’s nice to actually feel like you actually accomplish something.

 

[WilcoWorld]

Reductions are so fun. It’s nice to actually feel like you actually accomplish something.

One of the two greatest moments of my medical career was when I reduced my neighbor's shoulder, in my kitchen, using the Cunningham method.

 

[RustedFox]

One of the two greatest moments of my medical career was when I reduced my neighbor's shoulder, in my kitchen, using the Cunningham method.

- and the other?

 

[WilcoWorld]

- and the other?

It's a long story that's better told in person. Maybe I'll hit you up when I'm in FLA next month.

 

[gro2001]

I similarly eye roll when my residents get all up in arms (pun unintended) about an art line on a patient with reliably measurable blood pressure.

That's one of the things I changed my mind about the most during the course of fellowship.

There is no such thing as a reliable blood pressure cuff measurement.

Anyone in whom blood pressure is at all an important component of resuscitation, needs an art line.

 

[WilcoWorld]

That's one of the things I changed my mind about the most during the course of fellowship.

There is no such thing as a reliable blood pressure cuff measurement.

Anyone in whom blood pressure is at all an important component of resuscitation, needs an art line.

Really? I'm willing to be convinced by evidence, so please educate me.

I'm thinking of my most recent case where we had a patient with MAPs in the mid to high 50's with consistent readings on serial measurements. Placed a CVL and started levophed and then had MAPS in the high 60s to low 70's with consistent readings on serial measurements. So I didn't feel a need for an art line.

Tell me what I'm missing, I'm genuinely open to learning.

 

[Tipsy McStagger]

The MAP is accurate, the systolic and diastolic are derived from proprietary algorithms. When functioning properly the MAP on BP cuff and art line will correlate, though often the systolic/diastolic are different.

 

[VA Hopeful Dr]

The MAP is accurate, the systolic and diastolic are derived from proprietary algorithms. When functioning properly the MAP on BP cuff and art line will correlate, though often the systolic/diastolic are different.

I thought systolic was the pressure needed to occlude a peripheral artery...

 

[2021Doctor]

For the medical students on this board. Do yourselves a favor and avoid any hca program. Similarly avoid any new program at this point. Anything with less than a 3 year track record is proof that this residency exists solely to enrich the hospital.

If you want to be a lemming go and work at an hca site as a trainee.

This is your PSA from EF.

Would you avoid all of these newly accredited programs?
Lakeland Regional Health Program Initial Accreditation 08/25/2022 Emergency medicine
NYU Long Island School of Medicine Program Initial Accreditation 08/25/2022 Emergency medicine
Geisinger Health System (Wilkes Barre) Program Initial Accreditation 08/25/2022 Emergency medicine
University of Texas Medical Branch Hospitals Program Initial Accreditation 01/12/2023 Emergency medicine

 

[EctopicFetus]

Would you avoid all of these newly accredited programs?
Lakeland Regional Health Program Initial Accreditation 08/25/2022 Emergency medicine
NYU Long Island School of Medicine Program Initial Accreditation 08/25/2022 Emergency medicine
Geisinger Health System (Wilkes Barre) Program Initial Accreditation 08/25/2022 Emergency medicine
University of Texas Medical Branch Hospitals Program Initial Accreditation 01/12/2023 Emergency medicine

Yep.

 

[RustedFox]

Would you avoid all of these newly accredited programs?
Lakeland Regional Health Program Initial Accreditation 08/25/2022 Emergency medicine
NYU Long Island School of Medicine Program Initial Accreditation 08/25/2022 Emergency medicine
Geisinger Health System (Wilkes Barre) Program Initial Accreditation 08/25/2022 Emergency medicine
University of Texas Medical Branch Hospitals Program Initial Accreditation 01/12/2023 Emergency medicine

Lakeland: Yep. I live and work nearby. You'll be used to make sure that HCA keeps that door-to-greet time down, while every other service keeps you out of the things you need to see/do/learn because that service wants to bill for it.

NYU: I mean, I would avoid all of NYC like the plague because Noo Yawwk.

Geisinger: My uncle (also a physician) used to be a department chair at the Geisinger Big House. I grew up not far from there. The Big House barely got enough traffic and acuity, and was more of a "regional academic center" than anything else. I can't imagine that Wilkes-Barre has even close to what you need.

UT "Branch Hospitals": Can't comment, but the clue is in the name.

 

[carbonizedeyesockets]

NYU has been a toxic dumpster fire insofar as their leadership which will certainly trickle down to residents, so I'd avoid their main site in Manhattan, too. But, yeah, them choosing to start another program? I guarantee you that idea was suggested and rammed forth by some butt plug with an MBA. It happened where I work and is happening all over. Big name, "prestigious" institutions are in no way immune to such BS and sometimes more prone to perpetuate it due to their ego and sense of superiority.

 

[trackrunner321]

Would you avoid all of these newly accredited programs?
Lakeland Regional Health Program Initial Accreditation 08/25/2022 Emergency medicine
NYU Long Island School of Medicine Program Initial Accreditation 08/25/2022 Emergency medicine
Geisinger Health System (Wilkes Barre) Program Initial Accreditation 08/25/2022 Emergency medicine
University of Texas Medical Branch Hospitals Program Initial Accreditation 01/12/2023 Emergency medicine

Absolutely avoid

 

[Dr Mantis Toboggan]

The problem with subclavian is it just doesn’t come up *that* often that I need central access RIGHT NOW to the point where I don’t have the 2 minutes it takes to set up the ultrasound and drop an IJ or do a blind fem which is a far safer blind site.

The last subclavian I did that wasn’t just for “hey let’s do a subclavian” was a young female who got a whole body liposuction + Brazilian butt lift at a surgical center in a strip mall. PA using the trochar didn’t know how to operate it and lacerated her iliac artery, injected subcutaneous free air throughout her entire body, and created a giant abdominal wall hematoma. So the free air in her neck prevented me from doing an IJ and the abdominal wall hematoma/lacerated iliac made a fem less ideal.

But like…stuff like that just doesn’t happen that often.

Did my first one in prob 10 years recently: morbidly obese pt with sepsis. Groins were infected, neck had a ton of redundant folds, really had no other option. He was so big I had to hub the needle with about an inch of indentation before the flash but it worked out OK.

 

[southerndoc]

Would you avoid all of these newly accredited programs?
Lakeland Regional Health Program Initial Accreditation 08/25/2022 Emergency medicine
NYU Long Island School of Medicine Program Initial Accreditation 08/25/2022 Emergency medicine
Geisinger Health System (Wilkes Barre) Program Initial Accreditation 08/25/2022 Emergency medicine
University of Texas Medical Branch Hospitals Program Initial Accreditation 01/12/2023 Emergency medicine

Lakeland Regional is the nation's busiest ED (single facility). They see 220,000 patients per year.

 

[RustedFox]

Lakeland Regional is the nation's busiest ED (single facility). They see 220,000 patients per year.

Yep.
It's a busy shop, indeed.
All the services. All infighting. All the time.

I know the shop well.
Very well, even.
No, I didn't work there. I didn't have to, fortunately.

The overwhelmingly most likely scenario I see for a resident there is to get that door-to-doc metric down, and have the PLP for the subspecialty service do the thing... because the hospital says "it's THAT service's thing".

 

[alpinism]

So I get that Lakeland is the retiree capitol of the world.

But 100K town and 200K visits??

 

[PianoMedic]

So I get that Lakeland is the retiree capitol of the world.

But 100K town and 200K visits??

Their website says 165k visits in 2020, I’d assume their volumes were down on the year like most everywhere else. Town I’m in is similar sized (Midwest), but we see around 110-120k visits per year between the EDs here. No clue why so many more visits there.

 

[CoolDoc1729]

Did my first one in prob 10 years recently: morbidly obese pt with sepsis. Groins were infected, neck had a ton of redundant folds, really had no other option. He was so big I had to hub the needle with about an inch of indentation before the flash but it worked out OK.

Good for you. I’d have given up before it was at that point and run whatever peripheral tbh

 

[RustedFox]

Good for you. I’d have given up before it was at that point and run whatever peripheral tbh

Honestly? Same-same.
These fat fuggers. It's out of control.

 

[Dr Mantis Toboggan]

Honestly? Same-same.
These fat fuggers. It's out of control.

Had 2 good U/S guided IV’s, but these were his infusions prior to transfer to an academic mothership: insulin (sugar>1000), Precedex (got tubed), norepi, bicarb, LR.

 

[Tipsy McStagger]

I thought systolic was the pressure needed to occlude a peripheral artery...

On a manual BP cuff yes. Automatic BP cuffs use oscillation to measure the MAP. Basically they occlude the artery and release pressure, as pressure in the vessel increases (with decreased occlusion) there are pressure oscillations against the arterial wall which increase in amplitude up to a maximum point and then decrease again. The maximal point of oscillatory amplitude is the MAP. Then the BP cuff will derive systolic and diastolic from that depending on how the manufacturer sets its algorithm. Only MAP is measured on an automatic BP cuff.

in practice we still use cuff SBP/DBP as cutoffs for PRNs, but in truth it's inaccurate.

 

[wareagle726]

On a manual BP cuff yes. Automatic BP cuffs use oscillation to measure the MAP. Basically they occlude the artery and release pressure, as pressure in the vessel increases (with decreased occlusion) there are pressure oscillations against the arterial wall which increase in amplitude up to a maximum point and then decrease again. The maximal point of oscillatory amplitude is the MAP. Then the BP cuff will derive systolic and diastolic from that depending on how the manufacturer sets its algorithm. Only MAP is measured on an automatic BP cuff.

in practice we still use cuff SBP/DBP as cutoffs for PRNs, but in truth it's inaccurate.

Learn something new every day