Hesitant to go into IM due to vagal episodes. Advice appreciated.

[VeryOldSpice]

I've always been interested in another specialty, but after doing my IM rotation I realized how much I love the problem solving and continuous learning. My main reservation is that I occasionally get vagal episodes, usually from long needles but sometimes in generally stressful situations or when patients are screaming in pain. I've had to step out of the room for both a Nexplanon insertion (contraceptive implant, very thick needle) and an unsuccessful lumbar puncture on a larger patient where the doc tried retracting and advancing the needle multiple times. I also once had to step out when we woke a patient up from a nap and she started seizing. I've seen patients seize before but the unexpectedness of it and the uncertainty of what was happening freaked me out. I had no issues during my surgery rotation but it didn't bother me because it was in a controlled environment and the patient was always knocked out so they weren't in pain.

I am worried that:
1) It will be difficult for me to do the required procedures in residency (mainly thoracentesis, paracentesis, LP, central line)
2) I might not get over the vagal episodes that I get in emergency situations

Has anyone ever experienced this or have any insight for me? Will I get used to it? Thank you guys.

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[CatFactorial]

I've always wanted to do psych, but after doing my IM rotation I realized how much I love the problem solving and continuous learning. My main reservation is that I occasionally get vagal episodes, usually from long needles but sometimes in generally stressful situations or when patients are screaming in pain. I've had to step out of the room for both a Nexplanon insertion (contraceptive implant, very thick needle) and an unsuccessful lumbar puncture on a larger patient where the doc tried retracting and advancing the needle multiple times. I also once had to step out when we woke a patient up from a nap and she started seizing. I've seen patients seize before but the unexpectedness of it and the uncertainty of what was happening freaked me out. I had no issues during my surgery rotation but it didn't bother me because it was in a controlled environment and the patient was always knocked out so they weren't in pain.

I am worried that:
1) It will be difficult for me to do the required procedures in residency (mainly thoracentesis, paracentesis, LP, central line)
2) I might not get over the vagal episodes that I get in emergency situations

Has anyone ever experienced this or have any insight for me? Will I get used to it? Thank you guys.

Be more aggressive than the other studs about doing procedures if available for this very reason. Try asking nurses if they’d let you start IVs.

You will probably be fine but if it’s a real issue, CBT?

Alternatively (and my preferred option), you could just label any more needle averse patient a betch and then promptly pass out at the start of the procedure.

 

[IM2GI]

I would guess if you immerse yourself and become comfortable you could overcome it. Make sure as you are first exposing yourself that you have eaten and are well hydrated.

 

[epicandprivate]

I've always wanted to do psych, but after doing my IM rotation I realized how much I love the problem solving and continuous learning. My main reservation is that I occasionally get vagal episodes, usually from long needles but sometimes in generally stressful situations or when patients are screaming in pain. I've had to step out of the room for both a Nexplanon insertion (contraceptive itimplant, very thick needle) and an unsuccessful lumbar puncture on a larger patient where the doc tried retracting and advancing the needle multiple times. I also once had to step out when we woke a patient up from a nap and she started seizing. I've seen patients seize before but the unexpectedness of it and the uncertainty of what was happening freaked me out. I had no issues during my surgery rotation but it didn't bother me because it was in a controlled environment and the patient was always knocked out so they weren't in pain.

I am worried that:
1) It will be difficult for me to do the required procedures in residency (mainly thoracentesis, paracentesis, LP, central line)
2) I might not get over the vagal episodes that I get in emergency situations

Has anyone ever experienced this or have any insight for me? Will I get used to it? Thank you guys.

I use to have a similar problem with doing procedures although to a lesser degree. Now, I'm almost through internal medicine residency. I enjoy procedures and I'm going into cardiology. Over time you will become desensitized. I wouldn't let this affect your decision to go into IM. Most likely you'll get over it too and even if you don't residency is short and you can pick a non procedural or low acuity specialty.

 

[VeryOldSpice]

Thanks everyone for your feedback. Hope to hear some more success stories! I approached my attending about this situation and he's throwing me into the ICU tomorrow to see how I handle it. Hope all goes well lol.

 

[IM2GI]

Thanks everyone for your feedback. Hope to hear some more success stories! I approached my attending about this situation and he's throwing me into the ICU tomorrow to see how I handle it. Hope all goes well lol.

Eat a hearty breakfast!

I passed out a few times when I was younger with shots and stuff and now I do an interventional subspecialty. Don't count yourself out.

 

[AlexMack12]

Haha wow I read OP’s post and it sounded like I could have written it. I had zero issues on surgery and ob/gyn, but like OP, I found myself struggling when I perceived a patient was in pain. So yes, a smoothly placed central line doesn’t bother me a bit, but if I’m watching someone have a bit of an issue placing it and the patient starts screaming, I can feel the beginnings of a vasovagal episode coming on.

I’ve found that I’m far more likely to feel that way when I’m strictly observing (as we often do as students). Although as a medical student I’m certainly not placing lines or doing bone marrow biopsies, when I’m directly assisting, it’s much easier for me to really focus on the task at hand and not feel woozy. When I’ve drawn blood, placed IVs, and done ABGs myself, I’m usually so focused on successfully completing the task that I’m able to really focus and not think too much about anything else.

I also find that chewing mint gum helps a lot during a procedure (it’s rude to chew gum while talking to patients, of course- I do it when I’m gowned up and wearing the mask so as long as I do it quietly, no one is the wiser, and of course I get rid of the gum once the procedure is over.
I’ve also had some success clenching and releasing leg and hand/arm muscles when I feel a bit lightheaded and it’s worked!

That being said, if you can’t get the feeling to pass, excuse yourself and sit down immediately, out of everyone’s way. I’ve seen residents and fellows battle this occasionally too. No one will be upset as long as you don’t (1) fall onto the patient or (2) wreck the sterile field.

Good luck!

 

[GastriqueGraffin]

Many internist are very hands off and go into it because it’s a “cerebral speciality”. Don’t let the few required procedures throw you off. Most of the ones you mentioned are not even required. The few that are lke IVs, ABGs, and even central lines can be done on nice or sedated patients with supervision so if you struggle someone else will take over. I say if you like IM then go for it!