cool/rare procedures you've seen/done

[Andy Kahn]

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please feel free to add anything I have left out...

How many of the following have you done/seen?

PROCEDURE:
cricothyrotomy
thoracotomy
pericardiocentesis
interosseous line
venous cutdown
retrograde intubation
lateral canthotomy
post-mortem C-section
others

MY EXPERIENCE:
cricothyrotomy=cadaver lab
thoracotomy=cadaver lab
pericardiocentesis=none
interosseous line=none
venous cutdown=observed 1 (unsuccessful)
retrograde intubation=cadaver lab
lateral canthotomy=cadaver lab
post-mortem C-section=none

 

[edinOH]

I&D abscess: 1,566

 

[Seaglass]

I've seen one thoracotomy done of the bed of the CT scanner. Don't see cric's much these days with the advances in airway mgmt we have.

C

 

[DrQuinn]

First pericardiocentesis done on a code a few days ago (with my PD).
Tons of intubations.
Seen two thoracotomies, assisted one.
Several chest tubes (can now do them on my own)
did a cric on a pig
lateral canthotomy -> since we have Optho residents its not even in the realm of possibility.

Q, DO

 

[Apollyon]

The peri-mortem C-section is, as one of our attendings called it, the "Holy Grail of EM".

 

[DocWagner]

Internal defibrillation is pretty cool (after thoracotomy that is)...

It is my sincere hope to never do a perimortem c section.

 

[IMGforNeuro]

I have been a neurosurg resident in my country and have done some venous cutdowns in emergency and also some spinal extradural catheterizations.
I have also had the opportunity to do paramedian lumbar punctures in ankylosing spondilytis pts with subarachnoid hemorrhages. Actually the usual LPs failed so had to resort to paramedian.

 

[beyond all hope]

I have done tons of intubations, central lines. Haven't done a thoracotomy yet.

Did float a Swan, that's a cool procedure to add to your list. Also transvenous pacing. And shoulder reductions are very satisifying. (POP! you're in). You've also left out umbilical catheterizations, but those aren't very exciting. Nerve blocks are cool and relatively easy. Taking out FBs from the eye, another fun and satisfying one.

Suturing arterial bleeds is one of the toughest things (and scariest) you can do.

Lots o' procedures.

 

[mikecwru]

Originally posted by Andy Kahn
please feel free to add anything I have left out...

How many of the following have you done/seen?

PROCEDURE:
cricothyrotomy
thoracotomy
pericardiocentesis
interosseous line
venous cutdown
retrograde intubation
lateral canthotomy
post-mortem C-section
others

crich = been involved two
thoracotomy = been involved with one
pericardiocentesis = been involved with 2
interosseous = not yet
venous cutdown = seen one
airways = ive seen all kinds of difficult airway stuff down
lateral canthotomy = one of our third years did one just recently
post-mortem C/S = heard of it happening years ago
no lack for the minor procedures

The most lifesaving procedure I've seen is the crich and the one pt walked out of the hospital 5 days later.

mike

 

[Andy Kahn]

IMGforNeuro, can you tell me more about the spinal extradural catheterizations (indications, technique)? Is this going into the epidural space? I assume you are not talking about epidural anesthesia. As for the paramedian lumbar punctures, I assume you still go in at the L4 level, but do you go between the spinous processes and the paraspinous muscles? Besides ankylosing spondylosis, are there other indications? I guess maybe surgically fused vertebrae?

beyond all hope, you mentioned umbilical caths. How long after birth that is still an option? So there are 2 umbilical arteries and 1 umbilical vein (had to recheck the diagram in 1st Aid for Step 1). Can somebody tell me if the vein vs. arteries look obviously different in real life (color, size, etc)? It's been awhile since my Ob/Gyn and nursery rotations. You cath the umbilical vein, right? Also, I assume Swans and transvenous pacers are mainly done in the unit, but do they get done in the ED sometimes if the units are full and when those pts are stuck in the ED for awhile?

Anybody done a retrograde urethrography when finding blood at the meatus of a trauma pt or a suprapubic cath?

Thanks everyone for the other procedures I left out. Please bring up any other ones I have forgotten about.

 

[IMGforNeuro]

I was the junior most resident in neuro surg when i learnt about spinal extradural cath. The indication which i learnt was for some patients postoperative to drain CSF . Post craniotomy CSF drainage is done to flush the blood from subarachnoid space which always enters during surgery. The most commonly done procedure for this is a simple LP drainage in which you drain CSF ,usually about 60 to 90 ml because by this time the csf becomes clear. But spinal extradural cath is used uncommonly in selected pts for this purpose . It is also done preoperative in certain craniotomies ( i have seen for certain vascular skull base tumors ) to provide csf drainage during surgery. The trocar of this needle is slightly curved unlike the LP needle which is straight.
The disc space is same as for LP , L 3-4 , L 4-5 . The patient positioning is same as for LP. The curved end is up when the needle is inserted and then we check for csf. Once the needle is in the space , the needle is rotated so that the curved end is up. This is to facilitate the pasage of the catheter in the space. After rotating the trocar is removed and the tube is passed through the cannula into the space for some length and then fixed to the skin and cannula is removed. This is the spinal extradural cath . I am not sure of the other indications of this procedure.
The para median LP was done because there were 2 or 3 pts of ankylosing spondylitis with CNS disease needing LP. same disc space. The LP needle is inserted about one finger space lateral to midline and inserted pointing a little inwards. It should not be too lateral because it may damage spinal nerves. The rationale is to bypass the calcified thick interspinous ligament. Honestly i am not sure of other indications of paramedian LP.

 

[*Wing of Zock*]

My List:

LP x 4
intubations lots on anesthesia, 3 in ED
Pericardiacentesis: watched one
Lots of shoulder reductions on ortho (great MS IV rotation)
assisted with chest tubes
Lots of central lines, but no S-G caths
Arterial ligation (by myself when we got slammed on the trauma service--my proudest moment)


No Cric's, difficult airway procedures, interrosseus lines, cutdowns or lat canths. I missed a perimortem C-section that came in hour after my shift ended, but it was done by a senior OB resident.

I also just missed a thoracotomy with internal defibrillation where the dude survived! .

and I've also done about 700, 000 pelvics

 

[Seaglass]

Yeah, I didn't think to add NICU procedures. I got a tube there and UA and UV lines x2.

To answer the UA/UV line question.

Yes, they look obviously different, but are somewhat difficult to find as the UA's kinda corkscrew through the umbilical cord. The UA's are usually at about 4 and 8 oclock and the UV is at about 12 o'clock. The lumen of the UV is 3-4x the lumen of the UA's. I think you can get lines into them up to ~2 hours after birth.

Casey

 

[SMW83]

Originally posted by Andy Kahn
please feel free to add anything I have left out...

How many of the following have you done/seen?

PROCEDURE:
cricothyrotomy
thoracotomy
pericardiocentesis
interosseous line
venous cutdown
retrograde intubation
lateral canthotomy
post-mortem C-section
others

MY EXPERIENCE:
cricothyrotomy=cadaver lab
thoracotomy=cadaver lab
pericardiocentesis=none
interosseous line=none
venous cutdown=observed 1 (unsuccessful)
retrograde intubation=cadaver lab
lateral canthotomy=cadaver lab
post-mortem C-section=none

wow....i wish ya luck!!

 

[Scrubbs]

I don't know why, but I find thoracentesis to be really satisfying. I've done 4-5 of them, and they're just cool... 😎

Reductions are all fun... I did a patella a few months ago which was just funky.

I haven't been in a thoracotomy yet, but they always seem to happen just before or just after my shift. It'll happen... I have no fear.

 

[mikecwru]

Originally posted by Scrubbs
I don't know why, but I find thoracentesis to be really satisfying. I've done 4-5 of them, and they're just cool... 😎

Reductions are all fun... I did a patella a few months ago which was just funky.

I haven't been in a thoracotomy yet, but they always seem to happen just before or just after my shift. It'll happen... I have no fear.

I've done then on off service. Only one in the ED.

mike

 

[ERMudPhud]

Here are my approximate numbers from a 4 year residency. Even at a busy institution you probably won't see/do everything before you graduate. A friend of mine did his first cric on his first day as an attending. Also it should be noted my institution had a fairly liberal policy about procedures on DOA's

cricothyrotomy=watched a fair number (mostly on DOA'S), did one on a pig, one on a DOA, and one on someone who lived
thoracotomy=watched or assisted on a fair number. did one on a DOA
pericardiocentesis=>10 including one succesful placement of pericardial catheter for a patient who eventually survived the OR
interosseous line=chicken bone and manikin lab. Never even seen one done on a real kid and hope never to need to.
venous cutdown=observed lots. I had one attending who loved them but I've always been able to get large bore central lines so I haven't needed to try much on cutdowns
retrograde intubation=cadaver lab
fiber optic intubation=a few
nasotracheal intubation= observed lots done none
LMA= done a few in OR
lateral canthotomy=cadaver lab
post-mortem C-section=none
central lines, LP's, pelvics, intubations, chest tubes, ortho reductions, paracentesis, thoracentesis, arthrocentesis, lacs, abcesses, rectal and vaginal foreign bodies, removal of taser darts, BB's, fishhooks, and other assorted soft tissue foreign bodies= I lost count
S-G catheters= 5-10 while on assorted ICU rotations
retrograde urethrograms= 2 or 3
Suprapubic catheter= 1 ultrasound guided 😍
Transvenous pacers= 3 or 4 but nobody who survived to leave the ED
🙁
Smallest intubation= 30 week premie born in ambulance to crack addict with twins-probably my best/happiest resuscitation
Ultrasound guided removal of toothpick from someones foot(pretty much the only way to visualize toothpicks and very satisfying when it works)=2

 

[basementbeastie]

cricothyrotomy: nope.
thoracotomy: 4 observed, none successful.
pericardiocentesis: nope
interosseous line: one on an infant while coding her in the back
of a medic unit while bringing her back to the
mothership.
venous cutdown: one in the peds ED.
retrograde intubation: none.
fiberoptic intubation: several on anesthesiology elective.
nasal intubation: many as a paramedic before and during
medschool.
lateral canthotomy: no.
post-mortem C-section: no

 

[Tenesma]

imgforneuro: it isn't a spinal extradural catheter if it drains CSF - it is subdural or even better intrathecal, except we call it a lumbar drain 🙂

indication for paramedian approach: unsuccessful midline approach...

 

[EMIMG]

One of my fellow classmates just did his 4th ED thoracotomy last the other day and the second where they opened up both sides of the chest. However, i don't think any one of them has lived.

Most of the residents in my program get at least one thoracotomy by the time they are done.

 

[Galaxian]

Is a perimortem C-section referring to the mom or the baby?

 

[docB]

I've heard that if you have a coding pt who has a pacemaker that is not firing and you can't float a TV pacer you can externalize the pacemaker wires and pace with those. None of the guys in my group have done this and most say they'd never try it. Anyone else ever heard of this?

 

[ERMudPhud]

Originally posted by Galaxian
Is a perimortem C-section referring to the mom or the baby?

Its a C-section on a dead mother (often but not always due to trauma) in order to save the baby.

 

[ERMudPhud]

Originally posted by docB
I've heard that if you have a coding pt who has a pacemaker that is not firing and you can't float a TV pacer you can externalize the pacemaker wires and pace with those. None of the guys in my group have done this and most say they'd never try it. Anyone else ever heard of this?

It makes sense and is probably faster and easier than floating a TV but I don't ever recall seeing a coding patient with a pacemaker that wouldn't fire. How scarred down are the wires do you think after they've been in the patient for a few years? Do you think you could just scrape a little flesh and insulation of the wires and then clip you external pacer wires to the exposed metal?

 

[Apollyon]

Originally posted by Galaxian
Is a perimortem C-section referring to the mom or the baby?

The baby. From what I've heard, it's pretty gory - CPR on dead mother, cutting mother umbilicus to pubic symphysis, on top of whatever (probable) traumatic injuries the mother had sustained.

 

[Tenesma]

externalizing wires is not as easy or as quick as you think - first of all they are endothelialized, and on top of it the wires are covered by thick/tight plastic insulation.... usually if a pacemaker isn't firing it is not because of the pacemaker but rather because of the leads ... so wasting time to excise the leads isn't worth it...

instead float TV leads and in the meanwhile pace them thrans-thoracic...

 

[IMGforNeuro]

Originally posted by Tenesma
imgforneuro: it isn't a spinal extradural catheter if it drains CSF - it is subdural or even better intrathecal, except we call it a lumbar drain 🙂

indication for paramedian approach: unsuccessful midline approach...

--------
quite true , it is subdural .
Unsuccessful midline LP could be an indication for paramedian.
But you can always use a higher disc space or a lower disc space ie L3-4 instead of L4-5 and vice versa. Paramedian is not very common and in good hands LP midline is almost always successful . It is only under very different circumstances that paramedian LP is approached at the first attempted.

 

[Galaxian]

The baby. From what I've heard, it's pretty gory - CPR on dead mother, cutting mother umbilicus to pubic symphysis, on top of whatever (probable) traumatic injuries the mother had sustained.

Christ, that sounds awful...