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Hi all,
I just graduated this June 2015 from Im and looking for a hospitalist positions in midwest. A few hospitals are requiring central lines and Intubations!
I was definitely not trained in them during residency and even our pulmonary fellows barely did it. It was mostly anesthesias responsibility.
Has anyone been able to negotiate either not doing them with their hospital or demanding a salary >220K for it?
Please help!
 

chessknt87

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Probably can't negotiate it away if it is explicitly mentioned since nobody else qualified is there to do it. The hospital probably wouldn't even credential you to do them if your experience is so limited. Even if they did--someone dieing because you dont know wtf you are doing is opening you up for a lot of stress and medmal. Don't apply for those jobs.
 

Gpan

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Hi all,
I just graduated this June 2015 from Im and looking for a hospitalist positions in midwest. A few hospitals are requiring central lines and Intubations!
I was definitely not trained in them during residency and even our pulmonary fellows barely did it. It was mostly anesthesias responsibility.
Has anyone been able to negotiate either not doing them with their hospital or demanding a salary >220K for it?
Please help!
How did you not even trained in those basic medicine procedures? Intubations and central lines are the backbone of hospitalist medicine, maybe a little less intubation but definitely central lines. What kind of residency doesn't train their residents in these? I had to do 3 of these on my first day of intern year.
This is not a knock at you. I am just curious which residency this is or where is it located. And PULM FELLOWS BARELY do these? omg I'm scared now lol
 
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IM2GI

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Central lines are a core competency of an IM training program. Not sure how you did not get enough exposure on your ICU months.

That said, the vast majority of jobs will not require you to place them, and especially not intubate. Sounds like you are looking at a small hospital with an open ICU.

Look for a different job.
 
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Crayola227

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There are ways to address these deficiencies, but it's not easy, and I don't know if the hospital will be any help to you.

I've heard of docs addressing this with the hospital where they basically put you with another attending who can train and supervise you to do these before you're out on your own.

Don't give up, it's just if you want these jobs or to do these procedures you'll have to do some problem solving and I know it isn't easy but is possible.

ABIM requires you to do some number of procedures in residency, but I don't know when those standards started or all the rules.
 

gutonc

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Central lines are a core competency of an IM training program. Not sure how you did not get enough exposure on your ICU months.
No it's not. It used to be, but hasn't for some time.

To the OP though...if you want to take a job where dropping tubes may be required, then take an airway course (on your own time/dime of course). If you don't, find another job. There are a ton of them out there.
 

IM2GI

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No it's not. It used to be, but hasn't for some time.

To the OP though...if you want to take a job where dropping tubes may be required, then take an airway course (on your own time/dime of course). If you don't, find another job. There are a ton of them out there.
Interesting. Still, I can't imagine training at a program where you did not at least get in enough central lines...what did he/she do on their ICU rotations?
 

Raryn

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I have friends at programs (academic programs of all places) where a central line being done by an internal medicine resident is a rare event people talk about for a while after. OTOH, I've done ~40 of the things so far and am only 2 months into my third year. It really is institution dependent, and the ACGME only requires you be able to explain the procedure, not do it. Presumably those internists who graduate unable to do one have ER/anesthesia/IR do all their lines, but not every hospital has someone free to do a line when a patient is crashing and needs pressors.

Intubations are a little different. I've done a few dozen, but I hear there's lots of programs where even the pulmonary fellows/attendings call anesthesia to do all the intubations, especially up in the northeast. I think it's an important skill to have when **** hits the fan, but what do I know?

(What I find interesting is that one of the ACGME required compentencies is to be able to place a peripheral IV. I did something like five of the things as a medical student, none as a resident. If a nurse calls me to place an IV, it's going in the IJ/subclav/fem.)
 
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TimesNewRoman

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No it's not. It used to be, but hasn't for some time.

To the OP though...if you want to take a job where dropping tubes may be required, then take an airway course (on your own time/dime of course). If you don't, find another job. There are a ton of them out there.
I respectfully think this is terrible advice. I think the thought of taking a weekend airway course then attempting an intubation is putting you and your patient at significant danger. If you attempt an intubation and cannot secure an airway or appropriately oxygenate, you have killed a patient. Not only that, but even if you are able to secure an airway but not do so skillfully, you are likely hurting patients (there is good literature directly correlating the number of intubation attempts with adverse events). Even with a video scope (which a hospital that requires internists to intubate likely wouldn't have), your first pass success as a novice would be unacceptably low.

The airway is one of the few things that messing up can quickly kill a patient. This isn't like placing a central line, art line or chest tube; this is infinitely more important. No one should be doing them unsupervised after a handful and a few hours of training.
 

jdh71

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Hi all,
I just graduated this June 2015 from Im and looking for a hospitalist positions in midwest. A few hospitals are requiring central lines and Intubations!
I was definitely not trained in them during residency and even our pulmonary fellows barely did it. It was mostly anesthesias responsibility.
Has anyone been able to negotiate either not doing them with their hospital or demanding a salary >220K for it?
Please help!
If you're the only doc around, like rural critical access hospital, you need to be a doc and give it a shot if it's the best shot a patient has, but if you're at a hospital that's big enough to have anesthesia or ED support on airways and they just won't . . . don't work there, you simply don't need that horse****.
 

Crayola227

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I respectfully think this is terrible advice. I think the thought of taking a weekend airway course then attempting an intubation is putting you and your patient at significant danger. If you attempt an intubation and cannot secure an airway or appropriately oxygenate, you have killed a patient. Not only that, but even if you are able to secure an airway but not do so skillfully, you are likely hurting patients (there is good literature directly correlating the number of intubation attempts with adverse events). Even with a video scope (which a hospital that requires internists to intubate likely wouldn't have), your first pass success as a novice would be unacceptably low.

The airway is one of the few things that messing up can quickly kill a patient. This isn't like placing a central line, art line or chest tube; this is infinitely more important. No one should be doing them unsupervised after a handful and a few hours of training.
While I agree with you in theory, what is the difference between doing 5 supervised intubations spread through residency and getting signed off to do that on your own and doing a course that provides the same amount of experience?

I think "see one do one teach one" mentality in medicine is often idiotic, unavoidable, and does even makes sense a lot of the time.

At my institution, you get signed off on 3 central lines and you're good to go. Obviously you're still expected to know when to ask for help and your ass is still on the line after being signed off.

I don't know what are the exact numbers for sign off on intubations, and I agree ****ing them up is unacceptable, but once you've abided by whatever rules theoretically allows you to do something in medicine, I don't see the benefit of just not participating at that point. I mean, there is CYA and patient well-being to consider, just being devil's advocate that in general we get a certain amount of training, a pat on the ass, and a go get 'em tiger, so I don't see why this poster shouldn't take @gutonc 's advice. And I don't say that often.

Receiving the amount of training we're told is going to cut it and then sitting on the bench doesn't seem like a great or even viable option most of the time.
 
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Gpan

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By the time I was in my 3rd year in residency I had done somewhere close to 300 IJ/fem and close to 80 subclavian, and maybe 60 intubation. We had open icu and everyone was welcome to come and help out. Some of us who love procedures were the regular contacts for the icu nurses. We even had nicknames like "gunners", "snipers", "ninjas" because whatever lines they needed we were there in a second to help putting them in. I think back of the experience and feel very grateful now knowing that there are other residencies that don't offer that kind of opportunities. No wonder when I offered to put in an IJ as an attending nowadays, the nurses looked at me like they thought I was joking, lol.

So lessons for all of us is that we, as Hospitalists, should keep up with our crafts and practice these on a regular basis. I know it could take more time than seeing 2, 3 or 5 patients depends on how good you are with lines but these procedures can really prove our worth as a goup of specialty in medicine. Who needs intensivists or IR , pffffffftttt This hospitalist got this. I GOT THIS!!!!! ;)
 

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FWIW I know of pulm/crit programs where fellows never learn procedures or do extremely few because they are so heavily academic and focused on research, with the intent that their fellows all end up going into some sort of academic position, that they simply never learn to do things like intubate or place lines. I personally find that incredibly bizarre and completely undesirable in a program, but there you have it.

In my residency I've done something like 35 to 40 central lines and as a medical student I did a bunch of intubations on an anesthesia rotation. That being said, I also enjoy procedures immensely and I have colleagues who have done the absolute bare minimum required for their procedural competencies (which as gutonc mentioned do not include central lines) because they absolutely hate procedures and never want to do them. So even in high procedure residencies I think it varies person to person. I would not have been happy at a residency where we don't get that experience or where it's farmed out to consultants.

OP - I would get comfortable at placing lines and intubating just for your own sake, because it'll help out in a situation with a crashing patient. On the other hand I probably wouldn't take that job though if you're not comfortable with it.
 
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TimesNewRoman

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While I agree with you in theory, what is the difference between doing 5 supervised intubations spread through residency and getting signed off to do that on your own and doing a course that provides the same amount of experience?
That's exactly my point, there is no difference. It you have only done 5, 10, 20 intubations, you are still a novice and have no business doing them. You will have an unacceptably high failure rate and when failure means dead patient, it's a procedure that should be done by those with more experience.

You wouldn't put in a EVD after a weekend course, would you? Just because a hospital says it's ok for you to do something doesn't mean you should.
 

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If you look at two relatively similar hospitalist jobs, and one expects you to do procedures like lines and intubations and the other doesn't, would you expect the one requiring procedures to pay more and how much more? I definitely have done procedures (20-30 central lines, ~ 20 intubations), so as I am starting to look for hospitalist gigs for next year, I am wondering if it's really worth finding a job where you'll keep up with those skills?
 
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Thank you all for your replies. I think I miss spoke when I said I haven't done central lines. Its intubations we never did in my northeast residency. It was solely anesthesia. But yes, as it was mentioned we need only 3 central lines to get certified (ACGME no longer requires any procedures), and even after certification, sheesh, its been 6 months since I did my last icu and hence procedures..i'm not sure I want to put my career on line for it now. Our programs emphasis was mostly research/fellowship.
@Gpan, good for you to have so many procedures under your belt lol
@gutonc..i agree with you.
I think procedures is not for me and i don't think Im in the minority. ACPs survey points to only 3% hospitalists doing all procedures. None of the hospitalist in CT south/southeast area where I did residency from, ever did procedures bec the hospitals are large and plenty of help. Even if i learn and intubate 1 per week, thats still not a good count to make a an expert and help save lives (or me from medmal)!.
I will have to keep looking..
 
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Raryn

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It really varies program to program. Mine makes us do 10 IJ/fems (combined, not each) supervised before we can do them independently. To do subclavians we need to be signed off on IJ/fems and have done 5 additional subclavs supervised. Not sure why of that one, IMO a subclav is easier than an IJ.
 

rokshana

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How did you not even trained in those basic medicine procedures? Intubations and central lines are the backbone of hospitalist medicine, maybe a little less intubation but definitely central lines. What kind of residency doesn't train their residents in these? I had to do 3 of these on my first day of intern year.
This is not a knock at you. I am just curious which residency this is or where is it located. And PULM FELLOWS BARELY do these? omg I'm scared now lol
how long ago did you train...IM residents are not trained to do intubations anymore...and not one place that i have worked as a hospitalist has required intubations...and you can easily do hospital medicine without having to do a line .
 

Gpan

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how long ago did you train...IM residents are not trained to do intubations anymore...and not one place that i have worked as a hospitalist has required intubations...and you can easily do hospital medicine without having to do a line .
Just graduated last year. Why not? IM is such a broad spectrum of medicine. I think this is a big miss if they don't require training in intubation. That's sad!!!!!
I have seen hospitalist gig posting that asking hospitalists to run code, intubate (albeit with er as backup if needed), and CERTAINLY central lines. These tend to be in smaller cities but still. What are we? note writing monkeys? jeez
 
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Crayola227

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My program is ICU heavy, no fellows.

They have us do a shot ton of lines, run a lot of codes, and intubations (at least first shot at it). My first week as intern I attempted intubation with visual scope (under close supervision of intensivist). Intensivist took over after my one try and then had to call ED or anesthesia, not sure which (maybe both to get whoever could get there faster I dunno).

When I did an ENT rotation anesthesia let me try a few.

I don't know why we wouldn't train hospitalists to tube, plenty of times we were first on the scene of a code and running it.

I don't know much, but it came up at places I interviewed open ICUs and places without fellows or a great number of ED or anesthesiolgists twiddling their thumbs. I dont know what percentage of all hospitals are smaller community places, but it's nice to have a bunch of docs trained up to work anywhere out of residency IMHO, what with the general doc shortage.
 
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Why would a hospitalist spend time to do them when the reimbursements are so small. Call those hospitals for me and ask the billing department how much you can charge for intubating someone, compare the money you make from seeing patients.
 

Crayola227

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Why would a hospitalist spend time to do them when the reimbursements are so small. Call those hospitals for me and ask the billing department how much you can charge for intubating someone, compare the money you make from seeing patients.
If the hospital isnt big, hires more hospitalists amd less intensivists, sure they don't get a lot of reimbursement for the tube and line placement, but dead patients get less reimbursement so I guess there's that trade off.

When a code happens I'm guessing the hospital would rather you tube the patient for $15 and transfer to ICU for $3000 per day than wait for an understaffed EM doc to make it upstairs while the patient dies.

Hospitalists are cheaper to employ than intensivists. So maybe it makes sense to have an open ICU where the hospitalist can manage some of the "easier" ICU patients themselves. DKA at my program always went to ICU while on drip (they wouldn't need a central), psych OD's w/ AMS +/- intubation frequently went there, iffy on monitoring if they would need a central for norepi or intubation depending on their cocktail, they usually needed babysitting but sometimes a line and tube would need to be placed while you waited to see what the cocktail would do, so why not have an open ICU where the internists do lines and tubes?

There's times you have to move o
your patient from floor to ICU just because of nursing needs related to a line placement, so wouldn't it be cheaper for the hospital for the hospitalist to transfer, place line, and manage in ICU while still billing for ICU level of care, while the intensivist can have a greater number of sicker patients? If I have 20 ICU beds, with 1 intensivist doing 10 patients and the hospitalists managing the other 10, rather than 2 intensivists to cover all 20 beds (I'm not pretending any of this makes sense) couldn't that be better financially for hospital?

I mean this as a question, I can't pretend to know how the whole thing works by any means, just with resident experience at one institution.
 
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I do see your point, in the small rural areas where I work, the intensivists are more valuable. What happens here is that we just transfer the pts to another center, it's sad but true. Actually we first get the interventional people, then the surgeons, and if they are not available we transfer.
 
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If there's one thing I feel I can trust a hospital to do well, it's reimbursement. I can't imagine they would want a hospitalist to do tubes and lines unless it had something to do with improving the bottom line. I may be naive and place too much faith in the hospital admin to know how to squeeze a buck....
 

jdh71

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That's exactly my point, there is no difference. It you have only done 5, 10, 20 intubations, you are still a novice and have no business doing them. You will have an unacceptably high failure rate and when failure means dead patient, it's a procedure that should be done by those with more experience.

You wouldn't put in a EVD after a weekend course, would you? Just because a hospital says it's ok for you to do something doesn't mean you should.
Do you call anesthesia to do all your intubations in the ED?
 

TimesNewRoman

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Do you call anesthesia to do all your intubations in the ED?
No, but I'm also supervised by attendings and I've done about 200; I've listened to hours and hours of lectures on airway, intubation drugs, peri-intubation hemodynamics, intubation complications; I've done sim-labs on intubation; I've lectured med students and paramedics on intubation; I understand the utility and limitations of my airway adjuncts; I've done many sims on surgical airways and I know exactly where everything in my surgical airway kit is.

No, I'm not an anesthesiologist, but I've received really good training on airway and I'm comfortable with it.

I'm not at all advocating that only anesthesia or EM or crit care intubation. I realize there are some hospitalists that are probably very competent with airway - I just don't think that anyone with limited exposure to intubation should go to an airway course then start intubating.

And you'd better believe that if I get a bad angioedema or something else of the sort, you'd better believe I give anesthesia a call. I don't think airway is the time for machismo.
 

jdh71

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No, but I'm also supervised by attendings and I've done about 200; I've listened to hours and hours of lectures on airway, intubation drugs, peri-intubation hemodynamics, intubation complications; I've done sim-labs on intubation; I've lectured med students and paramedics on intubation; I understand the utility and limitations of my airway adjuncts; I've done many sims on surgical airways and I know exactly where everything in my surgical airway kit is.

No, I'm not an anesthesiologist, but I've received really good training on airway and I'm comfortable with it.

I'm not at all advocating that only anesthesia or EM or crit care intubation. I realize there are some hospitalists that are probably very competent with airway - I just don't think that anyone with limited exposure to intubation should go to an airway course then start intubating.

And you'd better believe that if I get a bad angioedema or something else of the sort, you'd better believe I give anesthesia a call. I don't think airway is the time for machismo.
You are correct airway should never have any chest thumping associated with it. You seemed to be arguing that only the "best" should ever do anything and I was arguing that maybe anesthesia should do ALL intubations then?? However you have further cleared up your position and I agree.

Five in residency and a weekend course are likely a potential recipe for disaster. Though most tubes do not require expert level hands. The key is knowing before hand if you need help and multiple level back up plans until the cavalry arrives.
 
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visari

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Central lines and airways are two completely different things... I agree that a graduating IM resident should feel comfortable putting a line without any help... But airway training is not a big part of IM residency... yes we did intubations on our ICU months but getting 20-30 intubations or whatever is in no way equal to having airway training... If I were applying for a job that requires intubations I wouldn't ask myself how many intubations I've done but rather: "am I confident enough to deal with any unexpected airway issue that might come up or not? and if not, what is my back up plan?" if I can't answer those questions then I wouldn't apply period. patients shouldn't die because of my lack of skills.

And can we please not turn this into "how come you only did 50 intubations and a 150 central lines in your residency?! I've done several hundreds on my 1st month as an intern" kind of talk. We get it. you're the man.
 

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I understand the hesitancy of some others here to have people who have limited (say, 10 a year) experience doing intubations be THE GUY in the hospital placing tubes. However, most of these places who require hospitalists do it are asking hospitalists for a reason -- there usually isn't enough demand to keep an anesthesiologist in-house, and ED is probably staffed with non-EM guys due to mostly low acuity and low demand.. These places are mostly non-urban and are not in areas overflowing with people who want to be there.

To answer your question -- no, not all hospitalists are required to know how to intubate. If you're not comfortable (and it sounds like you're not), there are lots of other options out there where intubation is not required. Personally, I used to be very confident with my intubation skills out of residency, but not doing one for a couple of years I'd never take one where I am expected to be the guy to put the tube in to save the patient's life. Interestingly enough, in our hospital, the RTs place the ETT. If that doesn't work out, the ED or Anesthesia gets a call. I've only seen one where RT couldn't place it and anesthesia had to be called, but I have seen RT know enough to call anesthesia right away.
 

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A lot of non-anesthesiologists CAN become highly proficient at airways. You need to:
Do at least 2-3 months of anesthesia electives and intubate a lot in the OR.
Learn the pharmacology of induction/paralysis COLD. know when to use what and how to rescue a low BP.
Do a lot of ICU in residency and manage a lot of airways.
Learn approaches to difficult airways.
Become an expert at bag-mask, LMA, video laryngoscopy, bougie and fiber optics.
Learn to position optimally and maneuver for a better view.
This all takes a lot of time and dedication, as well as opportunity.
Then you have to start intubating a lot in practice so you don't atrophy.
Not a lot of hospitalists have the time or need to do this, but it is possible.
If you cannot do all of this with expertise, you should not intubate unsupervised.
In my CCM practice I intubate regularly and have no back up (no dedicated anesthesia in house).
I treat every airway as though it will be difficult!
 

Crayola227

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I don't know why we consider the anesthesiologists the master of the emergent airway.

(I guess that's when I'm thinking you want the hospitalist to be tubing while they wait for someone from the ED to toss it in, if we're going with the idea this is the kinda place intensivists and in-house anesthesiologists aren't roaming about, that we're talking about a really emergent need for advanced airway)

They're the ones throwing the tube down the people who are wiggling around out of it on PCP and magic fairy dust, drowning in their own blood and puke, lower jaw in three pieces
 

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The above discussion is one reason why, as an IM resident, I'm heading to a primarily office-based fellowship (rheum). I'm just sick of the neverending penis-measuring contest that inpatient medicine always seems to turn into, and general IM always seems to come out on the bottom.
 
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TimesNewRoman

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The above discussion is one reason why, as an IM resident, I'm heading to a primarily office-based fellowship (rheum). I'm just sick of the neverending penis-measuring contest that inpatient medicine always seems to turn into, and general IM always seems to come out on the bottom.
I think what you said is usually correct, but not with airway. Airway isn't the time to worry about having someone's feeling get hurt - it needs to be done by someone extremely well prepared.
 

jdh71

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The above discussion is one reason why, as an IM resident, I'm heading to a primarily office-based fellowship (rheum). I'm just sick of the neverending penis-measuring contest that inpatient medicine always seems to turn into, and general IM always seems to come out on the bottom.
The procedure meatheads probably lose a lot of blood to their brains for all the grabbing of erect penis and mouth breathing.
 
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dozitgetchahi

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I think what you said is usually correct, but not with airway. Airway isn't the time to worry about having someone's feeling get hurt - it needs to be done by someone extremely well prepared.
I don't disagree. For me, the frustration has been the inability for us to improve our airway skills outside of a few months in the ICU.

A lot of us would like to be able to become truly proficient with airways - we're just not given the opportunity to do this during residency. It's frustrating.
 
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TimesNewRoman

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I don't disagree. For me, the frustration has been the inability for us to improve our airway skills outside of a few months in the ICU.

A lot of us would like to be able to become truly proficient with airways - we're just not given the opportunity to do this during residency. It's frustrating.
That's unfortunate. I always offer to let our IM rotators take any tubes they want in the ED. It seems like the ones doing PCCM always jump at the chance, the rest go back to checking their email, lol (IM residents rotate with us in their third year so most are pretty checked out)
 

Crayola227

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all I'm saying is yeah, if I'm in the hospital, if I'm on the verge of arrest or my sats are coming down to brain/heart damage land for the love of God I would like the person with the most training (even if it was ****ing mannequins) to throw a tube in if all the other stuff isn't working (O2 mask, bagging, OP airway, suctioning), hell take a pocket knife and a pen to me for a cricothyroidotomy

If that means the hospitalist did a weekend airway schtick and they've called the usual suspects (intensivist, ED, RT, anesthesia, surgery, Jesus) and they've come to my room, for ****s sake do whatever you want, get that sat up before my heart stops I'm gorked and die
 

Brigade4Radiant

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Dec 13, 2006
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How did you not even trained in those basic medicine procedures? Intubations and central lines are the backbone of hospitalist medicine, maybe a little less intubation but definitely central lines. What kind of residency doesn't train their residents in these? I had to do 3 of these on my first day of intern year.
This is not a knock at you. I am just curious which residency this is or where is it located. And PULM FELLOWS BARELY do these? omg I'm scared now lol
It depends on the hospital at my academic institution in the ICU the fellows intubate because they need the experience for the floors the anesthesiologist does the intubation. Also for central lines unless you really look for them most internal med people don't get them. A lot of the time they want the ED to place the line in before they come up to the floor.
 

Gpan

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It depends on the hospital at my academic institution in the ICU the fellows intubate because they need the experience for the floors the anesthesiologist does the intubation. Also for central lines unless you really look for them most internal med people don't get them. A lot of the time they want the ED to place the line in before they come up to the floor.
must be an academic program thing. Mine was a big community program so it was different. BTW I did not want to brag or anything. I was simply surprised to hear this. I guess my residency wasn't the worst one like I thought it was lol
 

Raryn

Infernal Internist / Enigmatic Endocrinologist
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must be an academic program thing. Mine was a big community program so it was different. BTW I did not want to brag or anything. I was simply surprised to hear this. I guess my residency wasn't the worst one like I thought it was lol
Academic and regional. Community programs (especially as you move west) are more likely to emphasize procedural skills. That said, most hospitalists in bigger cities don't do their own procedures anyway.

It's sad. I enjoy doing central lines and tubes. But I'm applying for a primarily outpatient subspecialty and am never going to do them after I graduate... But ICU is too grating on me after the first 7-10 days for me to do it as a career.
 

Old Grunt

2000 yard stare
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Aug 28, 2007
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I do see your point, in the small rural areas where I work, the intensivists are more valuable. What happens here is that we just transfer the pts to another center, it's sad but true. Actually we first get the interventional people, then the surgeons, and if they are not available we transfer.

Hey guys. I realize I am bumping an old thread, but wanted to share an idea for airway for any potential "sole house physician in a small rural hospital with a patient that needs an airway". I am EM and not IM but definitely moonlit at places like this during residency (We covered the ED, but were the only doctor in house for inpatient codes, etc...).

For the crashing patient that needs an airway, do the basic primary airway interventions and start bagging them (also, if you are in this situation you should spend a little bit of time familiarizing yourself with LMA and supraglottic devices and bagging - as long as you can oxygenate a patient with bagging, you can put off intubation for a bit) and -

Call EMS. All paramedics are trained in airway, and paramedics in rural areas are usually well adept at it. If nothing else, they can help with the airway and supraglottic devices and hopefully get the patient transferred somewhere where a definitive airway can be established (make sure in the heat of the moment you do a formal transfer via EMTALA rules).

Also consider asking a respiratory therapist if they are there (they train to intubate too generally) - though if it's like some of the hospitals I moonlit in, there isn't even a ventilator after 5 PM. Learned that the hard way after intubating a patient in the ED and then bagging them until we could transfer them and EMS arrived.

It's not a great or even a good situation, but it might save a patient from going into respiratory arrest. Like I said, probably not something you would think to do normally, but might save the patient if you are ever in that (somewhat rare and unique) situation that you might not think about.

Other than that, I'll step out of the thread.
 
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