How long does it take to acquire basic ER procedural skills?

[MedicineZ0Z]

So here in Canada some family Drs staff ERs that are outside of the city (but not necessarily very rural or remote) and get a decent volume of patients. I always wondered how long it takes to acquire the procedural skills to do ER work confidently?
Like we have family Drs with only 2 years of residency training working as full time ER physicians. Those 2 years barely give enough time to practice intubating (assuming you did an anesthesia elective or something). What about placing chest tubes? Or anything of that level? Can someone get enough reps in during some elective time to do it confidently? And how long does it take an ER resident to gain reasonable confidence and proficiency?

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[Angry Birds]

For me, one to two years after EM residency.

 

[namethatsmell]

So here in Canada some family Drs staff ERs that are outside of the city (but not necessarily very rural or remote) and get a decent volume of patients. I always wondered how long it takes to acquire the procedural skills to do ER work confidently?
Like we have family Drs with only 2 years of residency training working as full time ER physicians. Those 2 years barely give enough time to practice intubating (assuming you did an anesthesia elective or something). What about placing chest tubes? Or anything of that level? Can someone get enough reps in during some elective time to do it confidently? And how long does it take an ER resident to gain reasonable confidence and proficiency?

In my opinion there's a lot more to being procedurally-savvy than "doing enough" of the procedure itself. Putting plastic in a hole (intubating) is pretty straightforward, but becomes a bit more nuanced when there's a massive UGIB, or the patient has a SBP of 60, etc. If somebody is literally crumping in front of me from a tension ptx I'm doing a thoracostomy and going from there, not waiting for a chest tube kit to be set up. Same thing with lines and most other "major" procedures we do. Being an expert with procedures is not just about knowing the steps of a procedure, it's about knowing when to do it and how it should be performed in the context of all the acute pathology affecting the pt.

IMHO, resuscitative procedures are one of the easiest aspects of our job and is only a tiny part of what being a good ED doc is all about.

I trained in the US and I think the ideal length of training would be 3.5 years. I went to a 3 year program FWIW.

 

[MedicineZ0Z]

In my opinion there's a lot more to being procedurally-savvy than "doing enough" of the procedure itself. Putting plastic in a hole (intubating) is pretty straightforward, but becomes a bit more nuanced when there's a massive UGIB, or the patient has a SBP of 60, etc. If somebody is literally crumping in front of me from a tension ptx I'm doing a thoracostomy and going from there, not waiting for a chest tube kit to be set up. Same thing with lines and most other "major" procedures we do. Being an expert with procedures is not just about knowing the steps of a procedure, it's about knowing when to do it and how it should be performed in the context of all the acute pathology affecting the pt.

IMHO, resuscitative procedures are one of the easiest aspects of our job and is only a tiny part of what being a good ED doc is all about.

I trained in the US and I think the ideal length of training would be 3.5 years. I went to a 3 year program FWIW.

Interesting.
Any insight or idea on how some doctors are able to do ER work without all the training? It's been confusing for me to understand.

 

[namethatsmell]

Interesting.
Any insight or idea on how some doctors are able to do ER work without all the training? It's been confusing for me to understand.

Nope.

 

[Angry Birds]

Interesting.
Any insight or idea on how some doctors are able to do ER work without all the training? It's been confusing for me to understand.

From my observation, they underperform and are unable to do some critical measures. For example, I have seen they will order CT head's all the time, but never do a lumbar puncture (because they don't feel comfortable in their skills). They will avoid or never do central lines, etc.

 

[MedicineZ0Z]

From my observation, they underperform and are unable to do some critical measures. For example, I have seen they will order CT head's all the time, but never do a lumbar puncture (because they don't feel comfortable in their skills). They will avoid or never do central lines, etc.

I see. So how does that affect outcomes? Is it possible a lot of these ERs (where they work) see few truly acute cases and hence outcomes are fine overall because most patients are stable?
I mean this isn't even a Canada thing cause there are family doctors in USA that staff ERs. My guess is they had a few total months of elective time at best during residency.

 

[Angry Birds]

I see. So how does that affect outcomes? Is it possible a lot of these ERs (where they work) see few truly acute cases and hence outcomes are fine overall because most patients are stable?
I mean this isn't even a Canada thing cause there are family doctors in USA that staff ERs. My guess is they had a few total months of elective time at best during residency.

I’ve worked in a critical access hospital where acuity is normally low but this doesn’t mean that every shift there won’t be one or two real sickos. So, I think they end up having ok outcomes on many/most patients but often drop the ball on the sickos.

Even simple stuff like being aware of the fact that vital signs are vital. This isn’t necessarily engrained in the heads of non-EM trained folks. Shrug.

 

[CanadianEM]

Takes a few years I would suspect. At my level 1 trauma, University hospital, we have a few FM trained folks who work and function quite well in the ED doing many of the same procedures as anyone else. Presumably, their procedural competence has been obtained through the years. The folks who did the FM plus the year of EM fellowship are all competent procedurally as well. The only thing I see different is that the FM guys might not as readily put in a central line, but would start peripheral pressors and consult ICU sooner whereas the 5 year guys might start the line and then call ICU. As well, the 5 year guys might more readily do awake fibreoptic intubations whereas the FM guys might RSI that same patient.

For the most part however, at our site, it is pretty much indistinguishable between who is 5 year trained vs FM+ER or FM trained. Some are better than others, but with enough time and motivation and continuous learning, most anyone can do this job if they are a generalist (at least in Canada). I know of some of my FM colleagues who have gone and done OR days with anesthesia, outside of their clinical time, to help with intubations and central lines. The real difference is in who is ready from the get go to make tough decisions or to run the department or to run tough resuscitations. The 5 year guys are pretty much ready to go after training, while the FM+ER guys take about a year or so to get their bearings, and the FM guys take maybe 1-2 years to get their bearings.

 

[alpinism]

Remember being confident =/= being competent with regards to procedures.

As an emergency doctor you should be able to manage any airway including that 400 pounder with no neck who's actively vomiting during chest compressions.

 

[shoal007]

Remember being confident =/= being competent with regards to procedures.

As an emergency doctor you should be able to manage any airway including that 400 pounder with no neck who's actively vomiting during chest compressions.

Had one of those the other day minus the vomiting. Pulse ox went from 98 to 9 in 30 seconds. Neck was prepped. If anyone thinks a person's, who weighs 400+ lbs, airway is easy -- is crazy.

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[MedicineZ0Z]

Takes a few years I would suspect. At my level 1 trauma, University hospital, we have a few FM trained folks who work and function quite well in the ED doing many of the same procedures as anyone else. Presumably, their procedural competence has been obtained through the years. The folks who did the FM plus the year of EM fellowship are all competent procedurally as well. The only thing I see different is that the FM guys might not as readily put in a central line, but would start peripheral pressors and consult ICU sooner whereas the 5 year guys might start the line and then call ICU. As well, the 5 year guys might more readily do awake fibreoptic intubations whereas the FM guys might RSI that same patient.

For the most part however, at our site, it is pretty much indistinguishable between who is 5 year trained vs FM+ER or FM trained. Some are better than others, but with enough time and motivation and continuous learning, most anyone can do this job if they are a generalist (at least in Canada). I know of some of my FM colleagues who have gone and done OR days with anesthesia, outside of their clinical time, to help with intubations and central lines. The real difference is in who is ready from the get go to make tough decisions or to run the department or to run tough resuscitations. The 5 year guys are pretty much ready to go after training, while the FM+ER guys take about a year or so to get their bearings, and the FM guys take maybe 1-2 years to get their bearings.

Interesting info. Very good to know.

Remember being confident =/= being competent with regards to procedures.

As an emergency doctor you should be able to manage any airway including that 400 pounder with no neck who's actively vomiting during chest compressions.

What I wonder as a 3rd year student is.. what if it's just you (more rural ER) and you aren't able to intubate and are a fresh attending with little experience doing a crico? Do you just go for it and do your best? How's the liability in that case?

Seems like the residency trained EM Drs are almost always in a setting where there are other doctors who can back them up (for various complaints) whereas the rural Drs is more likely to be a family doctor with far less experience and no one to back them up.

 

[shoal007]

Interesting info. Very good to know.

What I wonder as a 3rd year student is.. what if it's just you (more rural ER) and you aren't able to intubate and are a fresh attending with little experience doing a crico? Do you just go for it and do your best? How's the liability in that case?

Seems like the residency trained EM Drs are almost always in a setting where there are other doctors who can back them up (for various complaints) whereas the rural Drs is more likely to be a family doctor with far less experience and no one to back them up.

I'm very involved with critical access hospitals (although don't work clinical shifts there). You are correct, these patients get a provider with less experience with no backup and have to deal with the same life threatening issues. You fail an intubation cannot ventilate by bvm and try a cric and the patient dies?

It doesn't look good but worse yet as a provider, you're scared and scarred for life.

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[TooMuchResearch]

Interesting info. Very good to know.

What I wonder as a 3rd year student is.. what if it's just you (more rural ER) and you aren't able to intubate and are a fresh attending with little experience doing a crico? Do you just go for it and do your best? How's the liability in that case?

Seems like the residency trained EM Drs are almost always in a setting where there are other doctors who can back them up (for various complaints) whereas the rural Drs is more likely to be a family doctor with far less experience and no one to back them up.

Your only alternative is to let the patient die, so yes, you intubate or go for the neck.

I work both at a large site with backup and places where I'm definitely the only emergency doctor and often the only doctor in the hospital. Further out from where I work, you'll find people with less EM training.

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[deleted109597]

People with inadequate training are scared of things they shouldn't be, and aren't scared of things they should be.
They might now how to do a procedure, but not when not to.
Anybody can do this job, but learning it while you do it just reinforces bad habits unless you're really up for introspection and self guided learning. I've learned that many physicians aren't. Thats why when you look around at attendings, you'll note that most haven't changed their practice habits since residency (barring a lawsuit or some other drastic change in medicine ie: laparoscopic surgery)

 

[MedicineZ0Z]

People with inadequate training are scared of things they shouldn't be, and aren't scared of things they should be.
They might now how to do a procedure, but not when not to.
Anybody can do this job, but learning it while you do it just reinforces bad habits unless you're really up for introspection and self guided learning. I've learned that many physicians aren't. Thats why when you look around at attendings, you'll note that most haven't changed their practice habits since residency (barring a lawsuit or some other drastic change in medicine ie: laparoscopic surgery)

How do attendings learn a procedure as they go? In an acute setting with no other attendings around. I'm curious.

 

[alpinism]

Interesting info. Very good to know.

What I wonder as a 3rd year student is.. what if it's just you (more rural ER) and you aren't able to intubate and are a fresh attending with little experience doing a crico? Do you just go for it and do your best? How's the liability in that case?

Seems like the residency trained EM Drs are almost always in a setting where there are other doctors who can back them up (for various complaints) whereas the rural Drs is more likely to be a family doctor with far less experience and no one to back them up.

There are very few doctors including EM residency grads with experience doing crics.

If your 2 choices are letting the patient die or attempting a cric you should attempt one every time.

 

[alpinism]

How do attendings learn a procedure as they go? In an acute setting with no other attendings around. I'm curious.

Youtube.

 

[CanadianEM]

Agree that confidence does not equal competence. Hard to debate that. And not suggesting that a fresh FM grad is competent to be working solo in an ED. Heck, at one of the places I work at, the new FM guys working in that ED can barely put on casts... and struggle with placing the right kind of cast or splint for a given fracture. But the some of the older, seasoned, and motivated FM guys in that same ED are better than some of the guys I work with in the ivory tower (most of whom are 5 year specialty trained).

Also regarding crics, not really too difficult when that is your only option. I heard about a pretty newly minted FM doc working in a rural hospital out here who successfully did one on a bad trauma patient. The issue is... could that have been avoided if that airway had been managed by someone with more experience? Possibly.

 

[MedicineZ0Z]

There are very few doctors including EM residency grads with experience doing crics.

If your 2 choices are letting the patient die or attempting a cric you should attempt one every time.

Really? Why?

Is it due to complexity? Risks?

 

[TooMuchResearch]

Really? Why?

Is it due to complexity? Risks?

Because we put the endotracheal tube in through the mouth. With the combo of direct, video, bougie, hyperangulated video assisted, fiberoptic techniques available, the cric is a very, very, very infrequent occurrence.

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[Angry Birds]

There are very few doctors including EM residency grads with experience doing crics.

If your 2 choices are letting the patient die or attempting a cric you should attempt one every time.

I've never done a cric. Nor have I had someone die on me for not getting an airway.

On the other hand, I've had anesthesia come down and get the tube for me once or twice.

 

[WildcatS11]

Agree that confidence does not equal competence. Hard to debate that. And not suggesting that a fresh FM grad is competent to be working solo in an ED. Heck, at one of the places I work at, the new FM guys working in that ED can barely put on casts... and struggle with placing the right kind of cast or splint for a given fracture. But the some of the older, seasoned, and motivated FM guys in that same ED are better than some of the guys I work with in the ivory tower (most of whom are 5 year specialty trained).

Also regarding crics, not really too difficult when that is your only option. I heard about a pretty newly minted FM doc working in a rural hospital out here who successfully did one on a bad trauma patient. The issue is... could that have been avoided if that airway had been managed by someone with more experience? Possibly.

Forgive my ignorance - what is this “5-year trained” business - is this non-US?

 

[TooMuchResearch]

Forgive my ignorance - what is this “5-year trained” business - is this non-US?

My money is on Canada...

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[gro2001]

Confidence does not seem to correlate linearly with competence. Competence goes up linearly every year (with the steepness of the slope determined by the quality of training). Confidence peaks mid PGY-2, hits nadirs early in PGY-1 and first year out as an attending. In general, confidence tends to exceed competence early on, until the trend reverses somewhere around end of PGY-4.

 

[Apollyon]

EM residency in Canadia (sic) for the longest time was two years of family medicine, then one year of EM (for those inclined). The people that did that would have CCFP-EM after their names. I might be off by a year for the FM years.

More recently (although I don't know when), a straight EM residency paradigm arose - a 5 year path. The only one of which I know is at Toronto General. There may be others.

 

[Groove]

Difficult Airway Algorithm FTW.

The nice thing about crics is that statistically you have about a 95% success rate, even for someone who has never done one. They aren't that difficult. The difficult part is recognizing the failed airway and making a conscious decision to perform the emergency cric instead of wasting precious moments. Still though, I don't consider crics a boy scout merit badge or anything. You don't want to be the doc who's done tons of crics. I would start to worry about airway skills. Also, I suspect a relevant percentage of emergency crics could have been avoided with enough planning and familiarity with backup devices and alternate techniques.

I always tell residents to pick a backup device and practice using it a lot. Bougie, LMA, etc.. Always have plan B,C mapped out in your head. Even things as simple as proper positioning can make a big difference. I always have a bougie and an LMA beside me somewhere even if I rarely use them. Though I used the bougie other day with a beached whale cardiac arrest pt with a grade 4 airway. I can't count how many times a cheap gum elastic bougie has saved my ass.

 

[Jlaw]

Difficult Airway Algorithm FTW.
I can't count how many times a cheap gum elastic bougie has saved my ass.

patient ass >> your ass