Are subclavians necessary in private practice?

[Dinkyconductor]

I'll be finishing my anesthesia residency in June, and I already have a great job lined up. As I'm working on honing my skills over these last few months, though, it occurred to me that I've never really done a subclavian line. I've done two femorals and maybe 100+ IJ's, we do IJ's exclusively for every procedure requiring a central line. I tried two subclavians (unsuccessfully) in the ICU last year.

Is this a skill that is considered a necessity in private practice, i.e. will they laugh at me when I say that I haven't done enough subclavians to be comfortable? Or is it enough to be able to do IJ's and femorals?

Any thoughts?

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[militarymd]

I doubt people will laugh at you....but all lines I place in the ICU are subclavians first..

1) lower infection risk ...probably
2) more comfortable for patients who are awake over the next few days

 

[Planktonmd]

Most anesthesiologists in private practice don't do subclavians because they were trained like you did.
I do alot of subclavians because that was how I trained prior to anesthesia Residency.
I think you can get by doing IJ's and Femorals.

 

[EtherMD]

I'll be finishing my anesthesia residency in June, and I already have a great job lined up. As I'm working on honing my skills over these last few months, though, it occurred to me that I've never really done a subclavian line. I've done two femorals and maybe 100+ IJ's, we do IJ's exclusively for every procedure requiring a central line. I tried two subclavians (unsuccessfully) in the ICU last year.

Is this a skill that is considered a necessity in private practice, i.e. will they laugh at me when I say that I haven't done enough subclavians to be comfortable? Or is it enough to be able to do IJ's and femorals?

Any thoughts?

I got news for you. You will learn new skills in private practice. Let me list a few I learned AFTER Residency:

1. Subclavian Central Lines- I did TWO in Resdiency. I have now done several thousand and about 9,000 IJ's.

2. Retrobulbar Blocks- did ZER0 in Residency. I have now done several thousand with only one minor complication

3. Nerve Blocks- I learned Axillary, Interscalene and Femoral. I now do them all routinely including InfraClavicular, Sciatic, Popliteal, Lumbar Plexus (I like this one a lot), Supraclavicular, Paravertebral, etc.

Your leaning doesn't stop after Residency; it is just beginning.

 

[militarymd]

I got news for you. You will learn new skills in private practice. Let me list a few I learned AFTER Residency:

1. Subclavian Central Lines- I did TWO in Resdiency. I have now done several thousand and about 9,000 IJ's.

2. Retrobulbar Blocks- did ZER0 in Residency. I have now done several thousand with only one minor complication

3. Nerve Blocks- I learned Axillary, Interscalene and Femoral. I now do them all routinely including InfraClavicular, Sciatic, Popliteal, Lumbar Plexus (I like this one a lot), Supraclavicular, Paravertebral, etc.

Your leaning doesn't stop after Residency; it is just beginning.

Unfortunately for some...it stops before residency starts.

 

[johankriek]

I got news for you. You will learn new skills in private practice. Let me list a few I learned AFTER Residency:

1. Subclavian Central Lines- I did TWO in Resdiency. I have now done several thousand and about 9,000 IJ's.

2. Retrobulbar Blocks- did ZER0 in Residency. I have now done several thousand with only one minor complication

3. Nerve Blocks- I learned Axillary, Interscalene and Femoral. I now do them all routinely including InfraClavicular, Sciatic, Popliteal, Lumbar Plexus (I like this one a lot), Supraclavicular, Paravertebral, etc.

Your leaning doesn't stop after Residency; it is just beginning.

9000 IJs holy moly..
what do you do an IJ on every patient instead of an IV
several thousand retrobulbar blocks... holy moly.. are you an eye doctor

sorry if i sound facetious but i really wanna know how you managed 9000 Ijs.. I am really busy and do some big cases and i only manage about 50 per year.. are you a cardiac attending? ICU attending?

 

[johankriek]

Unfortunately for some...it stops before residency starts.

ask yourself this question. was that comment necessary?

 

[militarymd]

9000 IJs holy moly..
what do you do an IJ on every patient instead of an IV
several thousand retrobulbar blocks... holy moly.. are you an eye doctor

sorry if i sound facetious but i really wanna know how you managed 9000 Ijs.. I am really busy and do some big cases and i only manage about 50 per year.. are you a cardiac attending? ICU attending?

If you do one case at a time...and sit on the stool most of the day....then numbers like this will seem high to you...

In another thread on regional anesthesia ....someone was talking about doing hundreds of blocks at a GOOD regional program......I do hundreds in a couple of weeks.

However, if you do one case at a time....your experience will be limited.

 

[militarymd]

ask yourself this question. was that comment necessary?

Yes, absolutely.....the last 5 anesthesiologists that I had to squeeze out of my practice fall into that category....along with a number of others that I have encounter here...

It is no wonder our specialty is in shambles.

 

[Planktonmd]

I got news for you. You will learn new skills in private practice. Let me list a few I learned AFTER Residency:

1. Subclavian Central Lines- I did TWO in Resdiency. I have now done several thousand and about 9,000 IJ's.

2. Retrobulbar Blocks- did ZER0 in Residency. I have now done several thousand with only one minor complication

3. Nerve Blocks- I learned Axillary, Interscalene and Femoral. I now do them all routinely including InfraClavicular, Sciatic, Popliteal, Lumbar Plexus (I like this one a lot), Supraclavicular, Paravertebral, etc.

Your leaning doesn't stop after Residency; it is just beginning.

Ether, do you still do retrobulbar blocks or did you switch to peribulbar?

 

[johankriek]

If you do one case at a time...and sit on the stool most of the day....then numbers like this will seem high to you...

In another thread on regional anesthesia ....someone was talking about doing hundreds of blocks at a GOOD regional program......I do hundreds in a couple of weeks.

However, if you do one case at a time....your experience will be limited.

i always knew you were the best.. everyone else on this board pales in comparison

 

[UTSouthwestern]

Back to the original question. Yes, it is a necessary skill. You will see patients with cervical infections, recent carotid surgery, indeterminate cervical landmarks, fat necks, short necks, no necks, etc.

All of my hearts get a R IJ cordis and a R SC 2L CVP cath and I place them at the head of the bed, not from the patient's right.

 

[militarymd]

i always knew you were the best.. everyone else on this board pales in comparison

nooo...not everyone else....just you...


I can't do subclavians from the head of the bed....I need to do them from the side of the bed.....but then, I do my IJ's from the side of the bed....the CRNA is at the head of the bed doing their thing.

 

[johankriek]

Back to the original question. Yes, it is a necessary skill. You will see patients with cervical infections, recent carotid surgery, indeterminate cervical landmarks, fat necks, short necks, no necks, etc.

All of my hearts get a R IJ cordis and a R SC 2L CVP cath and I place them at the head of the bed, not from the patient's right.

i agree.. I do subclavian lines routinely. I hate for you to be one of those anesthesiologists who defer to the surgeon whenever there is a subclavian line to do. You have a few months left in residency. Go to the ICU and put them in. Have them page you whenever there is a subclavian to do. Or do it in the heart room.

 

[militarymd]

i agree.. I do subclavian lines routinely. I hate for you to be one of those anesthesiologists who defer to the surgeon whenever there is a subclavian line to do. You have a few months left in residency. Go to the ICU and put them in. Have them page you whenever there is a subclavian to do. Or do it in the heart room.

How routine can it be...when you only do 50 IJ's a year??????

I am really busy and do some big cases and i only manage about 50 per year

 

[johankriek]

How routine can it be...when you only do 50 IJ's a year??????

listen jerky I know what you are trying to do. I consider 50 lines a year a lot. for someone who doesnt do cardiac at the moment. Thats mroe than 5 per month. one or so per week on average.. Thats routine in my opinion.

Let me pose this question to you smarty pants.

what are the indications for central line placement in non cardiac anesthesia?

answer the question and dont dance around the issue by trying to be witty because you are not capable of that.

 

[EtherMD]

Ether, do you still do retrobulbar blocks or did you switch to peribulbar?

Remember, I have been in practice for quite a while and I supervise a lot of cases. My First 12 years in practice I covered the ICU and the entire hospital at night and on the weekends. During this time I averaged 6-9 Central lines a day. That's right, a day! I probably have done more than 15,000 during more career. I don't care whether you believe me it's the truth.
I no longer cover the ICU so my central line numbers are only 2 per day. The hospital hired Intensivists (finally) and these guys do most of the ICU/Floor central lines these days.

I have personally done more than 4,000 interscalene blocks and at least that many Femoral blocks. I am now doing Infraclavicular blocks and have quite a few of those as well. I have done the axillary technique transarterial, two nerves, three nerves and all the nerves with a stimulator. My experience agrees with the literature in published success rate except my transarterial is about 95%. Interscalene 99.5%, Femoral 99.5%, Infraclavicular (double stimulation) 95%, Lumbar Plexus 99%.

With experience and volume (lots of volume) you will get better. I work in a high volume practice with tons of cases. My hospital does abour 20-25 totals per week. Ortho is huge in my facility.

As for eye blocks, I prefer topical MAC. But, a few of the older eye surgeons still insist on an "immobile" eye and peri-bulbar just doesn't cut the mustard.
A sub-tenon's block works well but why should I start doing those for $75 Medicare cases? I learned Retrobulbar blocks to make the eye surgeons happy. This way they get two rooms and don't have to bother with the block. Most of the young MDA's don't have any interest in the technique these days.

My average supervision/solo case load per year is 3500. Many years I break 4,000 cases per year. That is the kind of volume that should make you rock solid clinically. The average "solo" MDA does 1,000-1,200 cases per year.

 

[EtherMD]

All my experience in line placement, spinals (boy have I done a lot of those), Epidurals, blocks, etc. does not mean a hill of beans to Medicare, the AANA or providers. In the end, the "cheapest" provider will win out unless we rise to the occasion and deal with the CRNA "independent" practice issue. I can do it better but I can't do it cheaper than they can.

Why are our academic programs trying to put us out of a job? Why do they train SRNA's to compete against Residents (upon completion of training)?
They do this because of GREED and their need to staff the OR's. They are selling you out for a few bucks!

Guys like me run a Medical direction/supervision practice like the academic programs. We hire the people that they train. If they train AA's we will hire them instead.

Imagine how you will feel five yeas from now when a newly graduated CRNA with little or no experience has the same legal right to practice as you do in all states. In addition, this newly graduated CRNA collects the same amount of money from Medicare. On top of all this YOUR program was responsible for training him!

So, all the procedure junk aside what new Residents need is a certificate with teeth, a subspecialty area and less SRNA's in training.

 

[Planktonmd]

Remember, I have been in practice for quite a while and I supervise a lot of cases. My First 12 years in practice I covered the ICU and the entire hospital at night and on the weekends. During this time I averaged 6-9 Central lines a day. That's right, a day! I probably have done more than 15,000 during more career. I don't care whether you believe me it's the truth.
I no longer cover the ICU so my central line numbers are only 2 per day. The hospital hired Intensivists (finally) and these guys do most of the ICU/Floor central lines these days.

I have personally done more than 4,000 interscalene blocks and at least that many Femoral blocks. I am now doing Infraclavicular blocks and have quite a few of those as well. I have done the axillary technique transarterial, two nerves, three nerves and all the nerves with a stimulator. My experience agrees with the literature in published success rate except my transarterial is about 95%. Interscalene 99.5%, Femoral 99.5%, Infraclavicular (double stimulation) 95%, Lumbar Plexus 99%.

With experience and volume (lots of volume) you will get better. I work in a high volume practice with tons of cases. My hospital does abour 20-25 totals per week. Ortho is huge in my facility.

As for eye blocks, I prefer topical MAC. But, a few of the older eye surgeons still insist on an "immobile" eye and peri-bulbar just doesn't cut the mustard.
A sub-tenon's block works well but why should I start doing those for $75 Medicare cases? I learned Retrobulbar blocks to make the eye surgeons happy. This way they get two rooms and don't have to bother with the block. Most of the young MDA's don't have any interest in the technique these days.

My average supervision/solo case load per year is 3500. Many years I break 4,000 cases per year. That is the kind of volume that should make you rock solid clinically. The average "solo" MDA does 1,000-1,200 cases per year.

Ether,
You quoted me and then gave a broad answer about your experience, so I assume you are not responding to me but rather to previous posters.
The reason I asked you about Peribulbar vesus retro bulbar because although I don't have your kind of experience, I stopped doing retrobulbars and switched completely to peribulbar a couple of years ago, just because there is some data that shows more complications with retrobulbars.
One thing I wish you limit is your use of the abbriviation MDA, I think it is offensive to many people.
Thanks.

 

[Noyac]

Answer: yes SC's are necessary. You don't want to be calling for help b/c you can't get the IJ in. Some of the vascular pts you will see have had so many lines in their IJ's that you can't thread a wire through. Now what? You gonna call the surgeon? You had better be the best at getting lines in anyone. And that means deft at all sites. My surgeons will occasionally ask me to help them with portacath's when they can't locate the SC. That is, the ones without the big egos. Those with the ego's will struggles for an hour b/4 getting it by doing a cutdown. So the bottom line is be able to all of the sites very well b/c you will need those skills. I didn't do SC's for the hearts, I did an IJ cordis with a swan and a 16 or 14 g PIV. But my surgeons were top notch.

About some people not learning anything after residency and even b/4 residency starts. I have to agree. I have seen my fair share of extremely poor practitioners. Most just don't care but others are down right pittyful. Ether said it best, Your leaning doesn't stop after Residency; it is just beginning.

 

[militarymd]

listen jerky I know what you are trying to do. I consider 50 lines a year a lot. for someone who doesnt do cardiac at the moment. Thats mroe than 5 per month. one or so per week on average.. Thats routine in my opinion.

Let me pose this question to you smarty pants.

what are the indications for central line placement in non cardiac anesthesia?

answer the question and dont dance around the issue by trying to be witty because you are not capable of that.

geee.....my google went down...and I can't cut and paste answers from the variety of websites that talk about central lines....

http://www.spotboricua.com/foro/style_emoticons/emoticons/******ed.gif

 

[EtherMD]

Ether,
You quoted me and then gave a broad answer about your experience, so I assume you are not responding to me but rather to previous posters.
The reason I asked you about Peribulbar vesus retro bulbar because although I don't have your kind of experience, I stopped doing retrobulbars and switched completely to peribulbar a couple of years ago, just because there is some data that shows more complications with retrobulbars.
One thing I wish you limit is your use of the abbriviation MDA, I think it is offensive to many people.
Thanks.

I realize what the data shows about retrobulbar blocks. Peribulbar works fine for the case but the eye is NOT "immobile." This means that the patient is comfortable but the eye moves during surgery. The subtenon's block and retrobulbar block create an "immobile" eye for the surgeon. Unfortunately, some of our eye guys need this to do the hard cases.

The "better" optho dudes only need topical. No block required. If your eye guys are happy with peri-bulbar blocks that's great. Remember, we have to please both the surgeon and patient in private practice. Personally, I would not mind if I never did another another eye block.

 

[DrBom]

EtherMD,
any books that you would recommend for regional anesthesia?

I got news for you. You will learn new skills in private practice. Let me list a few I learned AFTER Residency:

1. Subclavian Central Lines- I did TWO in Resdiency. I have now done several thousand and about 9,000 IJ's.

2. Retrobulbar Blocks- did ZER0 in Residency. I have now done several thousand with only one minor complication

3. Nerve Blocks- I learned Axillary, Interscalene and Femoral. I now do them all routinely including InfraClavicular, Sciatic, Popliteal, Lumbar Plexus (I like this one a lot), Supraclavicular, Paravertebral, etc.

Your leaning doesn't stop after Residency; it is just beginning.

 

[hokie]

I like Hadzic's book... they give a good graphic description of most of the common blocks and have tips on catheters and ultrasound also. Check out their website (looking at it you really don't need the book).
www.nysora.com
Also to echo what some others have said about numbers... looking at my schedule for Monday I have (+/-) 16 blocks (not counting epidurals), a couple of a-lines, at least one central line (we don't do hearts), and then however many OB epidurals. This is not an unusual day (will sometimes have more, sometimes less).
I have learned TONS since finishing residency.