CA 1, not great at procedures

[pillowhead]

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So it's April of CA-1 year, and I am definitely not as good at procedures as I would like to be. The first half of the year, I was at a hospital where the preop nurses started our IVs while we were in conference so I didn't get much IV experience on awake patients. Now I'm at a hospital where we start our own IVs every morning, and I'm taking two attempts or worse, having to get help, way more often than I would like. I'm just blowing way too many veins at this point.

Arterial lines are also hit and miss. I'll get several in a row and then just miss several in a row. I can't really figure out what I'm doing differently between the ones I get and the ones I don't.

Central lines haven't really been a problem. Nor has regional stuff. Airways in the OR have been fine but I've had two not so great airway experiences on call recently outside the OR (one was an ENT disaster that I'm not sure anyone could have intubated.) My in service exam scores are above average and my evals. have been fine to date.

The problem now is that I'm starting to get very anxious whenever I go to do a procedure, and I think it's starting to become a self-fulfilling prophecy that I'm not going to get that IV or line or whatever which creates a vicious cycle.

Anyone have any advice or suggestions about how to handle this? Technical advice or otherwise? Is this normal CA-1 stuff, am I on the left side of the bell curve but not that bad for a CA-1, or do I need to find a new specialty (half joking) 😳

 

[idaknow]

Not a doc, but you sound like you are coming along fine, A-lines are a bitch IMHO the only thing to do is to keep swinging nervous or not. We all have been there remember "don't let the bastards wear you down"

 

[GasEmDee]

Don't rush these procedures if at all possible. At this stage you, if you are having trouble, you should be taking your time to optimize your chances of success. Give yourself as much time as possible, and save time in other areas to stay efficient with starts and turnovers. I have found that with procedures, I actually decrease my procedure time quite a bit by slowing down. One well set-up attempt that results in success takes a lot less time than multiple, frantic, failed attempts. For example, when doing an arterial line, really convince yourself of the trajectory and points of maximal impulse before sticking the catheter in.

Each failed attempt makes you and the patient (if awake) less and less confident. So again, take your time. The first attempt is the best attempt. Ask for input from folks with more experience who can actually stand there and watch what you are doing. Good luck, and keep at it!

 

[rsgillmd]

Hard to say anything specific without watching you, because I'm sure you know the general technique by now. I would recommend asking your attending or one of your colleagues to observe you so he/she can give specific feedback.

One thing I found with A-lines was if I sit down, my 1st stick success rate goes up to almost 100%. I didn't believe it because I felt comfortable in the positions I was attempting the A-line. However, during one downslump (struggling for 3 patients where I didn't think I should be struggling) my chairman (my attending for those times) suggested sitting. Having nothing to lose, I tried it and I was sold. So when I can, I sit to do the A-line.

You are probably right about the anxiety causing a self-fulfilling prophecy. When I was a CA-1 my attendings would comment that my hand would shake when I was intubating, although I was saying I was feeling relaxed. When I deliberately slowed myself down and talked myself through each step, this stopped. Also, force yourself to go into the procedure with confidence. Your patients can pick up on the nervousness, as well as the surgeons. Sometimes surgeons want/need to see the anesthesiologist operating in a smooth/calm manner.

Hang in there.

 

[Jeff05]

now that you know how to do the procedures - optimize positioning.

place your aline in holding - pre-induction, so you don't have everyone starting at you in the OR. just put a big old slug of lido in the wrist with a 27G/25G needle. if you're not slick enough to hit, drop and thread, just go through and through and wire the line in.

many people believe that through and through is the way to go for all a lines. for me, i decide based on quality of flashback and general state of vasculopathy. if i get a so so flash and the patient is an 80 year old with PVD i go t and t. a 20 year old with a nice flash - just drop your angle and thread.

once you have enough fine control and experience you can throw these in under the drapes backhanded. for now, optimize positioning and SIT down.

as far as IVs, it's all about a very very narrow angle. your entry should be almost parallel to the skin. that makes a big difference. also try to sit for these.

 

[ProRealDoc]

now that you know how to do the procedures - optimize positioning.

place your aline in holding - pre-induction, so you don't have everyone starting at you in the OR. just put a big old slug of lido in the wrist with a 27G/25G needle. if you're not slick enough to hit, drop and thread, just go through and through and wire the line in.

many people believe that through and through is the way to go for all a lines. for me, i decide based on quality of flashback and general state of vasculopathy. if i get a so so flash and the patient is an 80 year old with PVD i go t and t. a 20 year old with a nice flash - just drop your angle and thread.

once you have enough fine control and experience you can throw these in under the drapes backhanded. for now, optimize positioning and SIT down.

as far as IVs, it's all about a very very narrow angle. your entry should be almost parallel to the skin. that makes a big difference. also try to sit for these.

Good advice. I personally never sit down for anything. There's no room in the OR with all the equipment around me to pull up a chair. Sounds like a good idea though. Most attendings I have worked with place them while standing or down on one knee.

 

[ProRealDoc]

Hard to say anything specific without watching you, because I'm sure you know the general technique by now. I would recommend asking your attending or one of your colleagues to observe you so he/she can give specific feedback.

One thing I found with A-lines was if I sit down, my 1st stick success rate goes up to almost 100%. I didn't believe it because I felt comfortable in the positions I was attempting the A-line. However, during one downslump (struggling for 3 patients where I didn't think I should be struggling) my chairman (my attending for those times) suggested sitting. Having nothing to lose, I tried it and I was sold. So when I can, I sit to do the A-line.

You are probably right about the anxiety causing a self-fulfilling prophecy. When I was a CA-1 my attendings would comment that my hand would shake when I was intubating, although I was saying I was feeling relaxed. When I deliberately slowed myself down and talked myself through each step, this stopped. Also, force yourself to go into the procedure with confidence. Your patients can pick up on the nervousness, as well as the surgeons. Sometimes surgeons want/need to see the anesthesiologist operating in a smooth/calm manner.

Hang in there.

This is priceless advice. Like planktonMD said "Act as if".

 

[sweetalkr]

I am not experienced enough to give advice on A-lines, and central lines are more common than obesity in the CVOR so you will learn then, but on the IVs, here is something you could try.
On easier cases, ASA 1/2s for cystos and low chance of transfusion, try to go with the smallest IV size that is acceptable with the case. Once you get comfortable placing 22's and 20's, and your technique gets better, the 18s and 16s will come. Also, do you take call and do IVs at night?

 

[pillowhead]

I am not experienced enough to give advice on A-lines, and central lines are more common than obesity in the CVOR so you will learn then, but on the IVs, here is something you could try.
On easier cases, ASA 1/2s for cystos and low chance of transfusion, try to go with the smallest IV size that is acceptable with the case. Once you get comfortable placing 22's and 20's, and your technique gets better, the 18s and 16s will come. Also, do you take call and do IVs at night?

we don't do IVs at night on the floor and ICU if that's what you mean. we've been specifically told by our department not to respond to consults for difficult IV access.

thanks for the advice guys.

 

[Impromptu]

4th year student who got some advice on this very subject today. In the ICU today I witnessed several failed attempts by the resident to land an arterial line. He had some flashes of blood, but couldn't get it in. The attending came in and got it on the first try. He gave some advice to our group which you can take or leave as you please.

1. He steadies his hand on the patient so that he has as much control as possible, thus he is able to stop right when he sees the flashback, or decide if he should go through and through.

2. He nicks the skin with the needle before actually going for the artery. He said that going through the skin can divert your aim, so having that nick really helps out.

3. What others have said here, learn to do the procedure correctly early on, go slowly and deliberately and you'll get better faster.

I've been watching the procedure videos from the New England Journal of Medicine, which you should probably have access to through your institution. Those are very, very helpful. Take notes. Run through a dry procedure in your mind before you go to sleep. I'm now just wishing for my own chances to actually put in some of these lines. I know the interns need practice, but this is why I took ICU later in the year.