interns doing thoracentesis solo

[surgical06]

i don't know how many of you watch hopkins, but i saw it thursday while on call and the intern was doing a thoracentesis solo, dropped the lung, and it was all down hill from there. i think it was a great example of how not to act, the patient was able to pick up on his discomfort as well as the mistake and the way he told her definitely didn't help...lol i wonder how that M&M went.

anyway, is this common practice or any programs you all know of that allow this.

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[ESU_MD]

thoracentesis is an intern level procedure, and I would expect an intern to be able to attempt one solo after seeing one. they arent that hard, and I have even performed them in the office on outpatients

pneumothorax is a known complication, and not a big deal if you get one- as long as you diagnose and treat it.

i didnt see the show on tv, but imagine it was over dramatized

 

[Blade28]

I was comfortable with doing chest tubes by the end of my PGY-1 year - that's what you need in case you drop a lung during a central line.

 

[tussy]

I don't think it's wrong for an intern to do a thoracentesis solo, as long as they know how to recognize and treat the complications (ie can put in a chest tube).

I always warned patients about the possibility of a pneumo so that when it happens it isn't a big surprise - just a recognized complication.

 

[...to_the_OR!]

I was under the impression that IR does almost all of the thoracentesis these days anyway - unless it's emergent, and in that case pt may need a chest tube anyway. At least that's how it goes at our program.

 

[Winged Scapula]

I only ever did them at the VA where even the medicine ATTENDINGS did not have privileges to place chest tubes (which was a requirement to be able to do thoracentesis). At my home residency hospital, the medicine guys apparently did them...can't say I had too many surgery patients that needed one.

I'd say if the intern was competent to be able to place a chest tube, he doesn't necessarily need to be supervised doing this procedure. We had a guy out at the VA when I was the Chief who came in nearly every week to have his malignant effusion drained (not sure he just didn't have a drain placed). My intern got pretty good at it.

 

[maxheadroom]

The only time that I ever tapped a chest was as a med student on the medicine service. It just never came up during the GenSurg portion of my training. I'm pretty sure that they are done by Rads at my place -- Medicine can't tie their shoes, much less put a needle in a cavity.

 

[surgical06]

hello all, good to hear from you.

i think by the 2nd month of intern year, u can do a chest tube blindfolded, i don't want to mix thoracentesis and a chest tube. my point, as evidenced in this thread is that thoracentesis aren't all that common, and therefore "intern comfort" is less likely. i think that lack of supervision is careless for both learning reasons and patient care.

pneumo isn't that big of a deal, lol, i think you can only say that after you have personally had a chest tube for one. some patients can have chronic pain there.

personally i preffered when a upper level or just someone extremley comfortable w/ a procedure relatively new to me is watching, thats when you learn tricks and how to adjust when things aren't going as they should. i.e residency

 

[Samoa]

We did two of them on my medicine rotation, both done by medical students without complications, and we did one my entire intern year in surgery, done by my R4, resulting in a dropped lung, a hemothorax and a chest tube. It just depends on where you are.

 

[BlondeDocteur]

incidentally my sister-in-law is in that dude's residency class at Hopkins and says he's a first-class *******. His co-residents all watched the show out of serious schadenfreude. Basically, he grabbed the cameraman who was aimlessly wandering down the hall, shouted "come with me! I have something amazing for you to record!" and of course proceeded to f the whole thing up royally.

I have no comments on thoracentesis, though I know our CT interns do some wild and wooly stuff that tends to scare them sh@tless on the rotation.

 

[Winged Scapula]

incidentally my sister-in-law is in that dude's residency class at Hopkins and says he's a first-class *******. His co-residents all watched the show out of serious schadenfreude. Basically, he grabbed the cameraman who was aimlessly wandering down the hall, shouted "come with me! I have something amazing for you to record!" and of course proceeded to f the whole thing up royally.

Schadenfreude or karmic equilabrium indeed.

 

[SocialistMD]

Basically, he grabbed the cameraman who was aimlessly wandering down the hall, shouted "come with me! I have something amazing for you to record!" and of course proceeded to f the whole thing up royally.

That, my dear, is awesome (not for the patient, obviously, but the, as you put it, Schadenfreude, of it all).

As far as performing any procedure, I don't like to let anyone do anything unless I've seen them do it before and am comfortable with how they do it. However, I think it would be perfectly okay for an intern (perhaps not this one) to perform a procedure unsupervised. We have a sign off sheet at our program; once you've done three of a particular procedure, you can do them solo; once you've done five, you can supervise.

 

[Neuronix]

Some of the Medicine Interns were doing them solo at one of my medicine rotation sites. Seemed like they hurt the patients terribly too. I was emotionally disturbed by them as a third year medical student.

 

[SLUser11]

incidentally my sister-in-law is in that dude's residency class at Hopkins and says he's a first-class *******. His co-residents all watched the show out of serious schadenfreude. Basically, he grabbed the cameraman who was aimlessly wandering down the hall, shouted "come with me! I have something amazing for you to record!" and of course proceeded to f the whole thing up royally.

I have no comments on paracentesis, though I know our CT interns do some wild and wooly stuff that tends to scare them sh@tless on the rotation.

Every time I watch shows like these, (the discovery channel trauma shows as well), I start to play armchair quarterback a little too much.

I always think to myself, or announce to my wife, that I would never do xyz like that. As you sit there, you notice hundreds of little mistakes....

-breaks in sterile technique or complete lack of sterile technique
-poor organization or neglect of the ABCs in trauma (apneic pt laying there while the resident examines his belly/foot/whatever, then later decides to intubate).
-placing a subclavian on the opposite side of a PTX.
-etc etc etc.

However, I then start to wonder how many little mistakes I make on a daily basis that slide by because the Discovery Channel isn't filming in Wichita. That makes me want to give these residents a little latitude.


Still, what got me the most wound up was the Hopkins episode where the med student came home with his flea collar, and kept it on throughout the segment (in his apartment) while he played video games with his friends. no latitude there.

 

[SocialistMD]

...the med student came home with his flea collar...

Please, oh please, oh please tell me that means he wore his stethoscope around his neck at home. Fan-freaking-tastic! Seriously, I'm done. I'm not sure anything can top that today.

 

[AlloImmune]

...the Hopkins episode where the med student came home with his flea collar, and kept it on throughout the segment (in his apartment) while he played video games with his friends.

That was his apartment??? I thought they were in the med student lounge. That's terrible.

 

[radslooking]

I felt good about doing chest tubes on my own. Never did an unaccompanied thoracentesis on my own, but would've been happy doing it had it come up.

I do think though, that if you cause a complication, you should give your upper a call and not just treat it yourself without telling anyone.

lol, i'd say that'd be the understatement of the year. Oh, hey, yah, i dropped the lung with my thoracentesis, so I tried a chest tube, but I kinda messed that up too. think you could come check this patient out??

 

[tacoman2493]

incidentally my sister-in-law is in that dude's residency class at Hopkins and says he's a first-class *******. His co-residents all watched the show out of serious schadenfreude. Basically, he grabbed the cameraman who was aimlessly wandering down the hall, shouted "come with me! I have something amazing for you to record!" and of course proceeded to f the whole thing up royally.

I have no comments on thoracentesis, though I know our CT interns do some wild and wooly stuff that tends to scare them sh@tless on the rotation.

Before filming at Hopkins ever began, they talked to program directors and residents and picked a few people to follow around. They tried to get some of the really big attendings that are the Hopkins vanguard (e.g. Ben Carson, John Cameron) but they refused, so they had to settle for lesser known attendings. As for the residents, they approached a bunch of them BEFORE they started filming and did some kind of selection process to narrow it down to around 20 (they only ended up featuring a half dozen).

Then they had camera crews following those particular people around for the better part of 9 months. At no time, did they just follow random people around the hospital, that was not allowed as part of their contract. At no time did Oscar (the surgical intern who made the mistake) just pull some random camera guy out of the room and say "follow me!" They were ALREADY following him that entire time, they were literally glued to him on the on-call shifts. If somebody told you that Oscar just randomly pulled some camera guy on a spur of the moment opportunity to get his mug on TV, then they were lying to you or just ignorant of the facts and made stuff up.

The ABC crew was trying to highlight diversity which was one of the major reasons they picked Oscar--that should have been obvious from the way they featured Dr. Quinones (mexican illegal alien turned brain surgeon in the first episode), the black ER resident (never worked with him and dont know his name), and the Sikh med student.

 

[tacoman2493]

I always think to myself, or announce to my wife, that I would never do xyz like that. As you sit there, you notice hundreds of little mistakes....

-breaks in sterile technique or complete lack of sterile technique
-poor organization or neglect of the ABCs in trauma (apneic pt laying there while the resident examines his belly/foot/whatever, then later decides to intubate).
-placing a subclavian on the opposite side of a PTX.
-etc etc etc.

However, I then start to wonder how many little mistakes I make on a daily basis that slide by because the Discovery Channel isn't filming in Wichita. That makes me want to give these residents a little latitude.

Some of those "mistakes" were actually camera editing that didnt show the real sequence of events (e.g. trauma stuff).

 

[SLUser11]

Some of those "mistakes" were actually camera editing that didnt show the real sequence of events (e.g. trauma stuff).

When you watch someone roll in, and then see the A in ABCs neglected immediately, there's no "camera tricks" that can cause it.

Anyway, unless you were in all of those different trauma bays featured on the discovery channel, I don't know if you can comment on it.

But, still, props on settling the Hopkins dispute....

 

[sponch]

i just saw the hopkins thing. is it me or does that oscar guy seem to be really tickled by himself? a bit too much confidence for a tern.