1. Dismiss Notice
  2. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice

central line

Discussion in 'Clinical Rotations' started by OpalOnyx, Aug 2, 2011.

  1. OpalOnyx

    2+ Year Member

    Joined:
    Aug 15, 2008
    Messages:
    561
    Likes Received:
    2
    I read an article online by a medical student talking about central lines and it sounded like she had practiced doing quite a few. I've observed one done by a resident in the ER, it looks pretty involved/potentially dangerous. Is it common for med students to practice central lines? And if so, which rotations could this be expected in?
     
  2. Note: SDN Members do not see this ad.

  3. Smurfette

    Smurfette Antagonized by Azrael
    Administrator Physician 10+ Year Member

    Joined:
    Jun 6, 2001
    Messages:
    4,240
    Likes Received:
    2,286
    Status:
    Attending Physician
    It varies from school to school as to how much students get to do. I didn't do any as a student, and my residency classmates had done between 0 and 2 prior to starting a surgery residency.

    Rotations were you are more likely to get to do one: surgery, ICU, trauma.
     
  4. Droopy Snoopy

    7+ Year Member

    Joined:
    Apr 3, 2006
    Messages:
    1,847
    Likes Received:
    11
    Status:
    Resident [Any Field]
    I did an ICU rotation in Nov/Dec of 4th year, got at least 4 or 5 each of A-lines, IJs, subclavians, and femorals. If you're lucky you'll also get some chest tube practice with your first couple of subclavians :laugh:
     
  5. ZagDoc

    ZagDoc Ears, Noses, and Throats
    10+ Year Member

    Joined:
    Jul 12, 2007
    Messages:
    1,411
    Likes Received:
    23
    Status:
    Resident [Any Field]
    Did none as a MS3, three as a MS4. All during my TICU/SICU month.
     
  6. ZagDoc

    ZagDoc Ears, Noses, and Throats
    10+ Year Member

    Joined:
    Jul 12, 2007
    Messages:
    1,411
    Likes Received:
    23
    Status:
    Resident [Any Field]
    Dude, jealous. Rule #1 at my school was if you down the lung you don't get the chest tube.
     
  7. OpalOnyx

    2+ Year Member

    Joined:
    Aug 15, 2008
    Messages:
    561
    Likes Received:
    2
    Ok please explain to me how the student whose blog I was reading indicated she did 20 +. She was a 3rd (or maybe 4th) year at US medical school! I kind of panicked b/c I couldn't imagine.... Maybe she was just a rockstar?
     
  8. bioteach

    bioteach MSIV
    7+ Year Member

    Joined:
    Apr 9, 2007
    Messages:
    836
    Likes Received:
    0
    Status:
    Medical Student
    It's not standard that all med students (or even most) get one done. I didn't do any 3rd year and based on my planned rotations, I won't do any 4th year either. But, I also never asked to take part in one. I'm sure if you are interested and find the right resident...it's probably not too difficult to get some experience.
     
  9. drizzt3117

    drizzt3117 chick magnet
    10+ Year Member

    Joined:
    Oct 29, 2006
    Messages:
    14,647
    Likes Received:
    28
    Status:
    Resident [Any Field]
    I did a couple a-lines and central lines. It depends on when in the year your rotation is too. If it's in July they'll be trying to get the interns dialed in, while doing it in may/June will get you more chances.
     
  10. turkeyjerky

    Physician 7+ Year Member

    Joined:
    Sep 27, 2008
    Messages:
    1,705
    Likes Received:
    94
    Status:
    Resident [Any Field]
    Don't make the mistake that thinking she was a rockstar just cause she got procedural opportunities. Most of that is situational and depends more on your residents/attendings comfort levels and being in the right place at the right time, rather than your quality as a student (no matter how much some people might say that they'll give you a chance once you prove yourself at other tasks--these people are lying).
     
  11. OpalOnyx

    2+ Year Member

    Joined:
    Aug 15, 2008
    Messages:
    561
    Likes Received:
    2
    thank you, that's really helpful advice to keep in mind
     
  12. OpalOnyx

    2+ Year Member

    Joined:
    Aug 15, 2008
    Messages:
    561
    Likes Received:
    2
    good info, thanks everyone! I'm so much looking forward to third year :) Just gotta clear this year and boards........
     
  13. jbar

    jbar Senior Member
    10+ Year Member

    Joined:
    Dec 18, 2005
    Messages:
    949
    Likes Received:
    14
    Status:
    Resident [Any Field]
    I have a co-intern who did an ICU rotation where there were no other students, so she did lots of procedures like lines, chest tubes etc.
     
  14. jdh71

    jdh71 epiphany at nine thousand six hundred feet
    Physician 10+ Year Member

    Joined:
    Dec 14, 2006
    Messages:
    66,069
    Likes Received:
    39,332
    Status:
    Attending Physician
    First, what everyone else said.

    Second, part of the problem for students is that we are doing fewer and fewer central lines this days as they are often completely unneeded. I like procedures and now that I'm a fellow I get to teach procedures which is cool for everyone involved, but I need to be convinced the procedure is necessary.

    Third, there is less tolerance these days for what were accepted complications in the past, and more documented procedures are being required of trainees in order to be "signed off" or "credentialed", and this means that dibs goes from the top to the bottom of the food chain. For instance in the MICU if there is a need for a surgical chest tube (rare for the MICU as smaller chest tubes are normally all the is required), as the fellow I have dibs on that large bore tube, and I would take it as I've not gotten to do many (one total in all of my training), BUT if I had my numbers and felt good at teaching one, the next senior resident on the team would get the chance to do the tube, and on down the line.
     
  15. nothingman

    nothingman We're getting there.
    Physician PhD 10+ Year Member

    Joined:
    Jul 10, 2003
    Messages:
    129
    Likes Received:
    1
    Status:
    Resident [Any Field]
    For the opposite extreme, there is a very highly ranked medical school in eastern PA where medical students are explicitly forbidden from touching, drawing blood from, and most certaily placing/participating in placing central lines.

    A little while ago this also extended to Foley catheters, although as I understand it that policy has since been discontinued after increased sim training.
     
  16. ztaw15

    5+ Year Member

    Joined:
    Oct 5, 2007
    Messages:
    131
    Likes Received:
    0
    Status:
    Medical Student
    This kind of thing makes me love my school. I'm about halfway done with my second rotation (medicine, now surgery) and I've been able to do a ton of stuff already. One subclavian, one IJ, one chest tube, a thoracentesis and a paracentesis, a million foleys (yay), some NG tubes, a bunch of IV's, femoral vein sticks, femoral/radial ABGs, a few intubations, a ton of laceration suturing... I even got to do a surgical abscess drainage the other day - granted the resident was standing over my shoulder directing me the whole time, but it was neat to feel like the surgeon a little bit, even on a small case. I'm starting family medicine next, so I'm pretty hopeful that I will get some good delivery experience there, plus on OB/Gyn.

    I think the main thing is to ask, and to be a little confident - most of it isn't that hard really, you just have to be aware of the potential complications. I mean the way I got to do my first central line was that when my resident asked me if I wanted to watch her do one I just said "not really, I've seen a bunch of them already, but I would like to try it" and she said okay. After that I just tell people I'd like to do the line, and that I've done it before and I want some more practice.
     
  17. sylvanthus

    sylvanthus EM/IM/CC PGY-6
    Physician 10+ Year Member

    Joined:
    Sep 9, 2008
    Messages:
    2,874
    Likes Received:
    594
    Status:
    Fellow [Any Field]
    Wow, nice job to the poster above me. That is freakin' awesome. I thought it was cool that on my first rotation I did one central line and 2 abdominal paracentesis, but I have just been schooled. It seems it is extremely variable, which can suck if you end up doing zero procedures.
     
  18. 45408

    45408 aw buddy
    7+ Year Member

    Joined:
    Jun 13, 2004
    Messages:
    16,978
    Likes Received:
    43
    Status:
    Resident [Any Field]
    I did none in med school. I did around a dozen in my intern year, and 6-7 chest tubes. Dozens of arterial lines, and probably 75 intubations.
     
  19. sylvanthus

    sylvanthus EM/IM/CC PGY-6
    Physician 10+ Year Member

    Joined:
    Sep 9, 2008
    Messages:
    2,874
    Likes Received:
    594
    Status:
    Fellow [Any Field]
    Seems like it is one of those things we will knock out in residency for sure, but it could help if we get exposure as a 3rd/4th year. Though, not required by any means. Just can be a plus.
     
  20. Rendar5

    10+ Year Member

    Joined:
    Nov 12, 2003
    Messages:
    6,940
    Likes Received:
    557
    Status:
    Attending Physician
    It's a plus, but I will say that I personally would not have a med student do one under my supervision. At a 5% complication risk, I would want to assume all the risk myself. other procedures just don't carry that same complication risk and I would not want it to be on the student when the pneumo happens or the septicemia occurs a few days later.

    If you're in a situation where you have someone do one with you and you get to perform the procedure, all the power to you. gratz.
     
  21. DeadCactus

    DeadCactus SDN Lifetime Donor
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Oct 28, 2006
    Messages:
    2,510
    Likes Received:
    568
    Status:
    Resident [Any Field]
    I never understood the attitude that there is some magical transformation between 4th year and residency that suddenly makes one capable of trying an invasive procedure. The need for an MD in most procedures is to decide the procedure is warranted and to recognize/handle any complications, a need fully met by having the physician in the room guiding the trainee.

    The actual procedure is a physical skill that requires nothing more than practice. Yet there seems to be more and more of a push to delay that practice until later and later levels of training. Granted some of this is driven by the more pressing need for experience by people higher on the totem pole...
     
  22. Rendar5

    10+ Year Member

    Joined:
    Nov 12, 2003
    Messages:
    6,940
    Likes Received:
    557
    Status:
    Attending Physician
    a fresh intern is as likely to screw it up as a 4th year med student. But it simply looks like more blame worthy that a non-doctor did it than a doctor. Some non-medical person will see it as due to inexperience as opposed to unavoidable complication even though we know better. This doesn't really matter in my mind if it's a procedure with a low risk of complication, but when a procedure is known to cause complication even in a skilled provider's hands, my supervision is not going to prevent this complication. By the 20th med student central line, statistically I'm gonna run into the complication at least once.

    that said, i did none as a medical student and did enough my first year of EM residency to be accredited to perform them without direct supervision and to supervise others. There was no detriment to my education to not learn this skill in med school. There would've been a detriment to not learn suturing, foley insertion, IV insertion, a-stick, etc.
     
  23. The Angriest Bird

    10+ Year Member

    Joined:
    Sep 24, 2007
    Messages:
    422
    Likes Received:
    5
    Status:
    Resident [Any Field]
    Central line is a very NON-BENIGN procedure. Pneumothorax is just one of the few dreadful complications. You can cause carotid-IJ fistula. The tip of the catheter may end up in a large intercostal vein, thrombosing that and cause cardiac tamponade. Hemothorax is also possible.

    The learning curve is probably 10 lines placed. After that, you become quite proficient. The problem is that rarely a medical student can have 10 lines under his belt before graduation.
     
  24. jdh71

    jdh71 epiphany at nine thousand six hundred feet
    Physician 10+ Year Member

    Joined:
    Dec 14, 2006
    Messages:
    66,069
    Likes Received:
    39,332
    Status:
    Attending Physician
    I don't know. I think the central line is very benign for the most part, especially an IJ with U/S in the hands of an experienced operator. I also think that it takes around 10 lines to feel comfortable with the A-Z of the procedure basics, but many, many more lines than that to be comfortable with the many varied kind of things that can happen or go wrong during the procedure, and that number is probably closer to 100.

    Though your point about some of the more serious aspects of complications is well taken, but I've never seen them myself thank god.
     
  25. Rendar5

    10+ Year Member

    Joined:
    Nov 12, 2003
    Messages:
    6,940
    Likes Received:
    557
    Status:
    Attending Physician
    number needed to harm (NNH) is much higher for central lines than those rare side effects of ibuprofen. there are well-established complication rates for the different central line complications. I agree with above that u/s guided IJ is the safest of all, especially if you use current checklist guidelines for full sterility, but it's still got a fair rate of complication. I myself have done an arterial puncture with an IJ while using u/s guidance. A lot of the complications simply aren't fixed by experience, so they'll happen even if there's good supervision of the lines. No need to expose a med student to that liability.
     
  26. jdh71

    jdh71 epiphany at nine thousand six hundred feet
    Physician 10+ Year Member

    Joined:
    Dec 14, 2006
    Messages:
    66,069
    Likes Received:
    39,332
    Status:
    Attending Physician
    Just because you go through the jug and get into big red, doesn't mean you've had a "complication". Pull the needle out. Put it in the jug.
     
  27. SLUser11

    SLUser11 CRS
    10+ Year Member

    Joined:
    Feb 22, 2005
    Messages:
    2,878
    Likes Received:
    759
    Status:
    Attending Physician
    I disagree. As JDH pointed out, it takes 100+ lines to really be good at them.

    It's not just about memorizing the anatomical landmarks and basic steps to the procedure, it's about troubleshooting, and knowing when you're in trouble.

    The IJ is a safer line, but the subclavian tends to be easier for the nursing staff to take care of, and has a lower infection rate....so really it's a balance of risks, and the proceduralist should be able to do both effectively....and know when to give up on one approach and try another.

    For students, I used to occasionally let a strong MS3 place a line with a bunch of coaching, but not very often. I would routinely let MS4s place lines.

    As for non-surgery residents, the volume is typically not there, so they're less likely to let students do much. Also, it's sort of the blind leading the blind.
     
  28. turkeyjerky

    Physician 7+ Year Member

    Joined:
    Sep 27, 2008
    Messages:
    1,705
    Likes Received:
    94
    Status:
    Resident [Any Field]
    I just don't really understand that mentality. I get, but don't really agree with, the reasoning behind giving interns, but not med students, procedures. But what's the difference between a 3rd year and a 4th year student?
     
  29. SLUser11

    SLUser11 CRS
    10+ Year Member

    Joined:
    Feb 22, 2005
    Messages:
    2,878
    Likes Received:
    759
    Status:
    Attending Physician
    Well, if the interns need the experience, then they simply get preference. Training students to do lines (regardless of their chosen specialty) is a bonus, while training interns to do lines (which is a skill they need to perform their job) is a required part of our job.

    The difference between MS3s and 4s is student buy-in. If they are doing a surgery sub-I, then they are going the extra mile, and usually they are better prepared for a central line than a random MS3.

    Also, there is a very palpable difference in level of experience before and after the MS3 year. There are many green MS3s that really have no business sticking patients with a long 18 gauge needle because it's not safe.
     
  30. mrwesticles

    Joined:
    Jul 5, 2011
    Messages:
    162
    Likes Received:
    1
    Status:
    Medical Student
    As an MS3 I watched several and coached a fellow student through one (we were supervised)

    Supposed to do more in third year. I mean, you gotta learn someday.
     
  31. turkeyjerky

    Physician 7+ Year Member

    Joined:
    Sep 27, 2008
    Messages:
    1,705
    Likes Received:
    94
    Status:
    Resident [Any Field]
    I agree with the rationale that people higher up have priority on procedures. What I don't agree with is the thinking that "this isn't a student procedure" and not letting student get in on it. That passes sniff test for some procedures (I really don't have any business doing an ercp despite having seen a few), but not for anything that you can do 1st day of intern year. Also, wouldn't you rather have interns who've done a few already?

    As far a student buy-in and procedural prowess, I don't buy it--I've done two central lines, one as a third year and one a couple of weeks ago, and believe me, I fumbled every bit as much on the latter.
     
  32. emedpa

    emedpa GlobalDoc
    10+ Year Member

    Joined:
    Aug 25, 2001
    Messages:
    6,014
    Likes Received:
    299
    Status:
    Post Doc
    procedures as a student are very rotation dependent. if you are the only student on a busy service you will be wallowing in opportunities for procedures. if you are at an academic ctr with 5 other students you will get squat.
    one of our recent pa students went the extra mile in being available for procedures on her trauma rotation and had 13 successful central lines in one month . granted, she was the only student on the service and we had no residents on service this month. if she had not done them the trauma pa or one of the attendings would have. most of our er docs are too busy for central lines most of the time and let the consultants do them.
     
  33. SLUser11

    SLUser11 CRS
    10+ Year Member

    Joined:
    Feb 22, 2005
    Messages:
    2,878
    Likes Received:
    759
    Status:
    Attending Physician
    Of course I'd rather have interns who already have procedural experience....which is why I walk the MS4s through lines routinely.

    As for your second statement, I would like to think that a student's procedural skills improve with practice and experience.

    If I walk a brand new 3rd year through a line, they may not even be able to do simple suturing/knot tying, and they don't necessarily know the anatomy, or the steps to the procedure, or the possible complications, etc etc etc. I don't think a student is entitled to aim a big sharp needle at a patient's chest if they don't know those things. If they come to the procedure knowing those things, then I am happy to let them do it, but I will tell you that situation is not very common.

    I believe in graduated autonomy, so I will start MS3s out with skin suturing and work my way up the list from there. A central line is a morbid procedure, so it's higher up my list.
     
  34. isoquin

    isoquin Allopathetic
    5+ Year Member

    Joined:
    Jun 17, 2007
    Messages:
    468
    Likes Received:
    5
    Status:
    Medical Student
    It's really variable based on school. For most med schools, you can get through all four years without really doing any smaller procedures. Others will make them requirements, especially with respect to intubations on anesthesiology. Others still will have them available but only if you ask or make your desires well known. Thinking back, the only reason I got to do LPs, IVs, foleys, splinting, suturing, and other random things was because I asked. I expect central lines will be the same way when I hit the ICU.
     

Share This Page