NCC training and beyond

[NeuroCC]

Hi all, long time lurker first time poster here.

I am currently a first year NCC fellow in a "Top 5" (whatever this means) NCC program. Its fairly rigorous in terms of fellow involvement (which is great), and we have great cases with great volume.

I am kind of concerned about the volume of procedures however. I am now 5 months in - have done about 30 bronchs, but only one intubation (not much chance to do these during service weeks as anesthesia takes all), and maybe 3 subclavians, 4 IJs and like 3 femorals, 1 thora and 1 para. I do not feel proficient.

How do other fellows feel in their respective programs, how is absence of procedures rectified? My faculty is awesome, so if I provide a plan to get more procedures they would do everything in their power to help.

Thanks!

PS: Has anyone done 1 year surgical critical care after NCC fellowship?

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[barzan]

I am actually surprised you manage to do 30 bronchs in 5 months.

 

[typhoonegator]

Maybe he/she is counting tracheostomy visualization bronchs. Those shouldn't count, though. Otherwise, that's a bronch rate in a neuroICU that is far outside the standard scope of practice. Maybe they're doing a lot of thoracic ICU rotations? At any rate, good for training, I guess, but you'll need to have an honest conversation with yourself about the diagnostic and therapeutic value of bronchoscopy in a traditionally low pulmonary acuity population when you rise to the attending level.

Otherwise, not much to be done. You can do day-surgery rotations shadowing the CRNAs to get more intubations, but those will be "soft-music-tape-the-eyelids" intubations and not anything close to the RSI you deal with in the unit. If you have an intubation team then you can do more electives with them if you really want.

The day of the PICC has come, and line rates are different than when I trained. You should talk to your PD, though, as I'm surprised you don't have more central lines in 4 months. Subclavian lines are fading, as the data for trainees is that IJs are safer and they're far easier to visualize. And the old neuroICU saw about protecting the jugulars for venous drainage might sound good, but we don't really have a lot of data to back that up, and the rest of the CC populations have great data on the relative complication rates of subclavian vs. IJ lines. I probably placed 70 subclavian lines during training, and fewer than 10 IJs, now that's reversed. A skilled practitioner can place SC lines as safely as IJ lines, but it's a catch-22 because you're never going to get skilled at SC lines if you never do them.