central line

[OpalOnyx]

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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?

 

[Smurfette]

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.

 

[Droopy Snoopy]

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

 

[ZagDoc]

Did none as a MS3, three as a MS4. All during my TICU/SICU month.

 

[ZagDoc]

If you're lucky you'll also get some chest tube practice with your first couple of subclavians

Dude, jealous. Rule #1 at my school was if you down the lung you don't get the chest tube.

 

[OpalOnyx]

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?

 

[bioteach]

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.

 

[drizzt3117]

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.

 

[turkeyjerky]

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?

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).

 

[OpalOnyx]

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).

thank you, that's really helpful advice to keep in mind

 

[OpalOnyx]

good info, thanks everyone! I'm so much looking forward to third year 🙂 Just gotta clear this year and boards........

 

[jbar]

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.

 

[jdh71]

good info, thanks everyone! I'm so much looking forward to third year 🙂 Just gotta clear this year and boards........

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.

 

[nothingman]

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.

 

[ztaw15]

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.

 

[sylvanthus]

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.

 

[45408]

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.

 

[sylvanthus]

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.

 

[Rendar5]

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.

 

[DeadCactus]

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...

 

[Rendar5]

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...

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.

 

[The Angriest Bird]

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.

 

[jdh71]

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.

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.

 

[Rendar5]

Meh. Ibuprofen can cause acute renal failure, profound lower extremity edema, anaphylaxis, upper GI bleeding, and MI. Listing off the severe but uncommon complications of a procedure is what the lawyers do, not us...

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.

 

[jdh71]

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.

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.

 

[SLUser11]

A lot of the complications simply aren't fixed by experience....

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.

 

[turkeyjerky]

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.

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?

 

[SLUser11]

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?

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.

 

[mrwesticles]

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.

 

[turkeyjerky]

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.

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.

 

[deleted6669]

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.

 

[SLUser11]

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.

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.

 

[isoquin]

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.