Not naturally good at procedures

[Eder]

Like the title says, I feel that I don't have the talent some of my co-residents do when it comes to procedures. This made me shy away from them early in the residency, which made the situation worse.

I'm in my second out of three years now. I know there's enough time to practice, especially if I seek out procedures during shifts. It's demotivating though, not getting LPs a few times in a row, struggling with chest tubes, messing up central lines.

My question is, is it worth worrying about this? Would it be stupid to just get a job after residency that doesn't require me to do many procedures (such as the standard at a place being to defer them to ICU or surgery)? Should I get a job with double attending coverage so that the other attending would be potentially able to bail me out if I'm in trouble? What would you do in my position?

Of course, I might be exaggerating the problem, but I've always been better at thinking that doing something with my hands. And naturally, I'll keep working on getting better during residency.

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[Angry Birds]

Hey Eder,

I was in your exact same boat. I too fell into this vicious cycle during residency:

I feel that I don't have the talent some of my co-residents do when it comes to procedures. This made me shy away from them early in the residency, which made the situation worse.

I'm still not good at procedures, but I've mastered the ones we absolutely need to know, which are very few: intubation, LP, central lines, chest tubes, etc. You can count them on your fingers.

I wish I had indeed thrown myself at procedures more during residency. The problem is going to get worse as you become a senior resident. I remember during a trauma, the attending told me to teach the intern how to do a chest tube. I was thinking "f*** maybe he can teach me." It was a cluster. Every time I did a central line it was also a cluster. I still am haunted by a senior nurse who told me during my 2nd year of residency, "It's always a mess when we do a central line together." (Yeah, 'cuz I royally sucked at them.)

BUT, the flip side of this was that I failed so many times that I can say that I now know 24,000 mistakes to make and fail in your procedure. So, during a central line I am literally at each step cognizant of what NOT to do. I then follow the advice Michael Scott gave to Dwight: "Don't be an idiot" to which Dwight replied "If an idiot would do it, I do NOT do that thing."

Now, I think I am one of the best to teach these few procedures to others, since I can warn them of what NOT to do. Make sure that every time you fail you think about WHY you failed and next time make the necessary adjustment.

Bottom line is that: you will EVENTUALLY get this down, if but from failing so many times. Unfortunately, it took me two years OUT of residency to get them down. So yes, you should throw yourself NOW at these procedures, instead of shying away--even though for me, the shyness got worse through residency. It was harder as a third year to suck than a first or second year.

Procedures ARE hard and require TONS of finesse that people who are naturally gifted at procedures don't realize. Every time I see a video of a new procedure that is 3 minutes long and the person says, "This never fails," I think to myself, "yeah watch me show you how it will fail." But yeah, each time you fail is a new adjustment to be made.

As for what job you should get out of residency, I would suggest a single-coverage facility at a mid-acuity community shop. Don't work at a crazy trauma center nor at a place where you will never get any procedure. You don't want to throw yourself in the deep end nor never jump in the water at all.

Just my thoughts. I'll post more if I think about it, since I was also in your position. In fact, I was honestly considering IM due to this fear and distaste of procedures. But alas, rounds were too killer.

Lastly, just as a reassurance to you, people at my current shop think I'm the procedure guy, lol. My intubations are smooth as butter, because I take so many precautions and spend SO much time in set up. Same with the other procedures. It's all from failing so much and making so many adjustments. So yeah, there is hope.

P.S. How are your intubation skills? How do you feel about this procedure?

 

[GonnaBeADoc2222]

You're probably over estimating the problem. Your residency mates are also likely over estimating their own success.

I would keep throwing myself at what I think are the 3 critical EM procedures: vascular access (peripheral >>> central...i don't see many reasons to put in a central line in the ED in 2018, however you still need to be proficient at them...ultrasound guided peripheral is a much more useful skill imo), chest tubes, and intubation.

LPs can be deferred to the inpatient team in most cases.

You can't rely on your future coattendings to bail you out every time. That's just not right. You gotta get better, and you will.



Sent from my SM-G928V using SDN mobile

 

[Angry Birds]

You're probably over estimating the problem. Your residency mates are also likely over estimating their own success.

I would keep throwing myself at what I think are the 3 critical EM procedures: vascular access (peripheral >>> central...i don't see many reasons to put in a central line in the ED in 2018, however you still need to be proficient at them...ultrasound guided peripheral is a much more useful skill imo), chest tubes, and intubation.

LPs can be deferred to the inpatient team in most cases.

You can't rely on your future coattendings to bail you out every time. That's just not right. You gotta get better, and you will.



Sent from my SM-G928V using SDN mobile

I agree with you about focusing on the three critical EM procedures, but I would include LP in the mix as a necessary fourth. Also, I think central line is way more important than peripheral access. Also, it is an ultimate back-up and actually easier to master for those who naturally suck at procedures like me and the OP. U/s guided peripheral IV is insanely hard to master, especially with such a smaller target and high degree of variability.

I agree with your last sentence (bolded)!

 

[Birdstrike]

Like the title says, I feel that I don't have the talent some of my co-residents do when it comes to procedures. This made me shy away from them early in the residency, which made the situation worse.

I'm in my second out of three years now. I know there's enough time to practice, especially if I seek out procedures during shifts. It's demotivating though, not getting LPs a few times in a row, struggling with chest tubes, messing up central lines.

My question is, is it worth worrying about this? Would it be stupid to just get a job after residency that doesn't require me to do many procedures (such as the standard at a place being to defer them to ICU or surgery)? Should I get a job with double attending coverage so that the other attending would be potentially able to bail me out if I'm in trouble? What would you do in my position?

Of course, I might be exaggerating the problem, but I've always been better at thinking that doing something with my hands. And naturally, I'll keep working on getting better during residency.

There is no procedure in EM that can't be mastered by doing enough of them. Maybe you need a few more than the next guy, but do enough and you'll eventually be good enough to be confident. I wouldn't worry about picking jobs based on what your perceived weak spots are this early. Procedures are one of those thing you sometimes struggle and struggle, until one day you don't and it just clicks, for that procedure. Then you don't worry anymore. Just keep working, keep doing as many procedures as you can. Seek out those you find most difficult knowing that each one you do, means you're one closer to that magic and elusive number you need for it to click. What seems impossible today, will be old hat at some point in the future.

I remember a time I struggled learning LPs in the ED. I now put 10 gauge needles inside peoples' vertebral bodies injecting cement to fix their fractures, as well as put neurostimulators in spinal canals, with confidence. You can do this.

 

[miacomet]

My guess is it's more nerves than competence. Agreed the only absolutely critical procedures are intubations and maybe lines. At my shop the nurses exceed any and all docs with PIVs, regular or ultrasound, and we generally go to IOs before central lines, which I think will be obsolete in a decade.

Remember procedures are dynamic- when I was a resident there it was RSI and a bougie, no fancy video laryngoscopy. US IVs were rare, and we didn't have IOs. Some shops the RTs do a lot of intubations, others it's just you. My nurses would laugh at me if I tried to put in a PIV, but we do all our own reductions. So there's a learning curve wherever you go and whatever you do.

 

[RustedFox]

Add "chest tube" to list of critical procedures.
Needle decompression.

 

[Eder]

Thank you so much, everyone!

Hey Eder,

I was in your exact same boat. I too fell into this vicious cycle during residency:



I'm still not good at procedures, but I've mastered the ones we absolutely need to know, which are very few: intubation, LP, central lines, chest tubes, etc. You can count them on your fingers.

I wish I had indeed thrown myself at procedures more during residency. The problem is going to get worse as you become a senior resident. I remember during a trauma, the attending told me to teach the intern how to do a chest tube. I was thinking "f*** maybe he can teach me." It was a cluster. Every time I did a central line it was also a cluster. I still am haunted by a senior nurse who told me during my 2nd year of residency, "It's always a mess when we do a central line together." (Yeah, 'cuz I royally sucked at them.)

BUT, the flip side of this was that I failed so many times that I can say that I now know 24,000 mistakes to make and fail in your procedure. So, during a central line I am literally at each step cognizant of what NOT to do. I then follow the advice Michael Scott gave to Dwight: "Don't be an idiot" to which Dwight replied "If an idiot would do it, I do NOT do that thing."

Now, I think I am one of the best to teach these few procedures to others, since I can warn them of what NOT to do. Make sure that every time you fail you think about WHY you failed and next time make the necessary adjustment.

Bottom line is that: you will EVENTUALLY get this down, if but from failing so many times. Unfortunately, it took me two years OUT of residency to get them down. So yes, you should throw yourself NOW at these procedures, instead of shying away--even though for me, the shyness got worse through residency. It was harder as a third year to suck than a first or second year.

Procedures ARE hard and require TONS of finesse that people who are naturally gifted at procedures don't realize. Every time I see a video of a new procedure that is 3 minutes long and the person says, "This never fails," I think to myself, "yeah watch me show you how it will fail." But yeah, each time you fail is a new adjustment to be made.

As for what job you should get out of residency, I would suggest a single-coverage facility at a mid-acuity community shop. Don't work at a crazy trauma center nor at a place where you will never get any procedure. You don't want to throw yourself in the deep end nor never jump in the water at all.

Just my thoughts. I'll post more if I think about it, since I was also in your position. In fact, I was honestly considering IM due to this fear and distaste of procedures. But alas, rounds were too killer.

Lastly, just as a reassurance to you, people at my current shop think I'm the procedure guy, lol. My intubations are smooth as butter, because I take so many precautions and spend SO much time in set up. Same with the other procedures. It's all from failing so much and making so many adjustments. So yeah, there is hope.

P.S. How are your intubation skills? How do you feel about this procedure?

I haven't missed a tube in a while, but when I was start out, it was a disaster. We learn cric next year, but I'm fairly comfortable with most tubes at this point.

I'm curious why you recommend a single coverage shop. That sounds scary, not having any backup? Or am I missing something here? I know it's probably a bit early to think about this, but I know a couple of third years who already had jobs at this point last year.

 

[Angry Birds]

Thank you so much, everyone!



I haven't missed a tube in a while, but when I was start out, it was a disaster. We learn cric next year, but I'm fairly comfortable with most tubes at this point.

I'm curious why you recommend a single coverage shop. That sounds scary, not having any backup? Or am I missing something here? I know it's probably a bit early to think about this, but I know a couple of third years who already had jobs at this point last year.

I feel the only reason why I mastered these procedures AFTER residency was because I was the only doc on and I HAD to do them. I was it.

By the way, if you feel like you're good with intubations, you're gold and ahead of me when I was in your spot. Now, it's just central lines you gotta get good at. Chest tubes are very rare in community practice, but yeah those still scare me to be honest but I can do them. LP is actually super easy and I don't know why everyone has a hard time with them, but I guess it's my one procedure I was good at from the get go, so I might be biased.

 

[NITRAS]

I want to re-iterate some of the earlier points. Your fellow co-residents are not as good as they think they are. At least you know you have a deficiency.

LPs are my favorite procedure, and I've done a lot more as an attending than as an IM resident. They require positioning, positioning, and positioning. The rest is anatomy (and playing with a spine model can help.) with visualization of where the bones are and your needle.

 

[r-e-l-a-x]

I've seen some residencies describe basically doing a "procedures" month as an elective, you could see if you can take or create something like that with any elective time you have left.

 

[miacomet]

I feel the only reason why I mastered these procedures AFTER residency was because I was the only doc on and I HAD to do them. I was it.

By the way, if you feel like you're good with intubations, you're gold and ahead of me when I was in your spot. Now, it's just central lines you gotta get good at. Chest tubes are very rare in community practice, but yeah those still scare me to be honest but I can do them. LP is actually super easy and I don't know why everyone has a hard time with them, but I guess it's my one procedure I was good at from the get go, so I might be biased.

I work in a single coverage shop and we do far more chest tubes than central lines or intubations. They are one of our most common procedures. Only tough based on habitus, and many places have a surgeon hanging around that will help out.

 

[s109442]

Like the title says, I feel that I don't have the talent some of my co-residents do when it comes to procedures. This made me shy away from them early in the residency, which made the situation worse.

I'm in my second out of three years now. I know there's enough time to practice, especially if I seek out procedures during shifts. It's demotivating though, not getting LPs a few times in a row, struggling with chest tubes, messing up central lines.

My question is, is it worth worrying about this? Would it be stupid to just get a job after residency that doesn't require me to do many procedures (such as the standard at a place being to defer them to ICU or surgery)? Should I get a job with double attending coverage so that the other attending would be potentially able to bail me out if I'm in trouble? What would you do in my position?

Of course, I might be exaggerating the problem, but I've always been better at thinking that doing something with my hands. And naturally, I'll keep working on getting better during residency.

I find going to the batting cages helps my hand eye coordination. Substitute target shooting, racquetball, ping pong.

 

[thegenius]

Another problem in residency is you have a pack of wolves ready to feast on your procedure if you don't get it on the first pass. Other ER residents, attendings, and sometimes even residents from other specialties like surgery. So that adds immense pressure.

I too had problems with procedures within years 1-3 of my 4 yr residency....and I was surprised by this because I'm generally quite adept with my hands and solving spatial problems, good procedural competency. (as a side note, some of you have rightfully teased my handle on this forum. I chose it over a decade ago and I probably wouldn't choose it now. my friends labeled me the genius because I fashioned a disco ball to the ceiling for a party we threw when I was younger and I didn't need any screws or bolts).

This happened to me several times. In residency had a tube. Say I was a PGY2. There was a PGY4, an attending, and others looking on. Lots of pressure. We paralyze the patient. Around the thirty second mark, everyone is itching to go. However the pt is not fully paralyzed yet, maybe 3/4 of the way. So DL is harder, passing the tube is harder...and I don't get it on the first attempt. I either goose it or I just can't see the cords. Then the PGY-4 says "pull out!" and we bag the pt and then he goes in and everything goes well.


It's so much easier doing procedures as an attending. You get to control everything...you get to order people around. You can go as fast and as slow as you need. You will get better. I agree with the above that it's mostly nerves as EM procedures are not technically difficult.

 

[Angry Birds]

I work in a single coverage shop and we do far more chest tubes than central lines or intubations. They are one of our most common procedures. Only tough based on habitus, and many places have a surgeon hanging around that will help out.

How in the world is that possible? More chest tubes than intubations!??! Forrealz homie?

 

[miacomet]

How in the world is that possible? More chest tubes than intubations!??! Forrealz homie?

I don't know the exact number, but yes, I'm pretty sure. We see a lot of blunt chest trauma.

 

[s109442]

Why is it hard for you to put in lines with ultrasound, i don’t get it

 

[Psai]

Why is it hard for you to put in lines with ultrasound, i don’t get it

Joke? If you're pulling out the ultrasound they're likely a vasculopathy. Lots of people with tiny vessels, crunchy vessels with atherosclerosis everywhere, veins that curve this way and that. Plenty of difficult lines even with ultrasound.

 

[miacomet]

Why aren't the nurses doing this? It's an IV.

 

[Dr Mantis Toboggan]

Fuhrman Pleural/Pneumopericardial Drainage Set and Tray | Cook Medical

This kit is money for putting in small bore chest tubes. Not for big trauma cases obvi. Seldinger technique, way better than the trocar based systems.

I don't know the exact number, but yes, I'm pretty sure. We see a lot of blunt chest trauma.

 

[deleted109597]

Why aren't the nurses doing this? It's an IV.

Hahahahahahahahaha
In some institutions nurses can put in US guided IVs. It's not universal, and remember, there are many EDs out there that don't have US in the department.

 

[enalli]

During my first two years of residency I had very little confidence in my procedural skills. "Yeah, the blood pressure is a little soft, but they've only had 2L of fluid and their baseline is likely low anyways"; "yeah, it's a bad headache outside the 6 hour window, but it's not the worst headache of their lives and not really thunderclap-like". I would try not to sign up for patients who I thought might need certain procedures.

When third year was near, I switched to a "year of yes" mentality. I didn't purposefully do this as a way to better myself at the time, but rather in a resigned sort-of fashion. What this meant is that I really followed the adage of "thinking about an LP is an indication to do an LP" for every procedure. The patient's SBP went down to 95 once? I was already gathering up the central line supplies. A 1 month old checked in with tactile fever? I signed up for it before the nurse was out of the room. I have to admit my pendulum swung a bit too far at times and my attendings had to reel me in to reasonable-land. But you know what? by the end, I had become a lot more confident. I was by no means some sort of procedure rock-star, but I had basically faked it until I (sorta) made it.

If you're anything like I was, I encourage you to do a complete 180 on saying yes to procedures regardless of your confidence. Obviously don't go LPing every migraine or putting in central lines before giving fluids, but whenever you start talking yourself out of doing a procedure, consider doubling down on it instead.

 

[thegenius]

If you're anything like I was, I encourage you to do a complete 180 on saying yes to procedures regardless of your confidence. Obviously don't go LPing every migraine or putting in central lines before giving fluids, but whenever you start talking yourself out of doing a procedure, consider doubling down on it instead.

Yea....well...that is one way to do it! I find as an attending though, in a busy ER, doing procedures just slows you down so much. I'm regularly talking myself out of a procedure.

 

[TheComebacKid]

I'm in a fairly procedure heavy residency program and I struggle A LOT with certain procedures.

I've heard variations of the same speech regarding LPs: "Do it THIS way and you'll get it 100% of the time!" What a crock of BS. I couldn't get an LP to save my life at this point in the game. But I'm going to keep trying.

I remember as an intern I hit approximately 20-30 intubations in a row. I was on top of the world.Then as a second year during a code I couldn't pass an airway. It messed with me. I probably did everything exactly the same as before, but for whatever reason, it just didn't work. The attending took over and in typical attending fashion, threw the ETT across the room and it landed in the patient's trachea. Nothing but net. It was like watching Michael Jordan shoot a free throw with his eyes closed. It shattered my confidence.

I agree with the person above who said that it's probably harder as a junior resident because the second you mess up everyone will be chomping at the bits to take over. In addition, they are watching you struggle and taking mental notes so when they go ahead and do it, they make adjustments and look way better than you do. Regarding LPs, the first LP that I ever hit was when I was on my own as a second year resident and the attending stepped out of the room to manage another critical patient. I had my own time and I got it. But when people are breathing over your neck, not only is there a lot of pressure, they can be extremely impatient and take over after 1 try.

We are supposed to be procedure cowboys and the best proceduralists in the hospital. But we also deal with screaming patients (versus sedated patients in the OR) and high pressure situations in a training environment with lots of other cooks in the kitchen. You can bet that if I am struggling with a chest tube in a hypotensive GSW patient, someone is pushing me out of the way.

Things I've learned that help with procedures:
1. Even if you are scared, exude confidence. 1month old comes in and needs to be intubated? You tell the attending that you can handle it. If you show any hesitation, someone else more senior will take the procedure away
2. While it's hard to learn how to do procedures unless you actually physically do them, it's very easy to learn how to set up for procedures. If you want a procedure and want to be better at them, you need to learn how to set up. As an intern I took home central line kits and looked at all the moving parts. Become a medical paraphernalia junkie, i.e. what kinds of catheters, needle gauges, tubing comes in what kit etc. KNOW your equipment
3. If you are lucky to have strong and friendly consultants, suck up to them for their skills and ask them to show you how to do stuff. I did my first hematoma block with an ortho resident. Swallow your pride. The orthopedist may be better at reducing than you are, so let them show you what's in their bag of tricks.

If all else fails and you want to prove to yourself that you are good at procedures: watch a medicine resident try to intubate in a code, or an ortho resident try to get an IV, or a surgeon try to place an ultrasound guided femoral line. You will realize how much better your skills actually are than you think.

 

[Perrin]

Three things I repeat in my head when doing procedures and teach to residents and others.
1. Slow is smooth and smooth is fast. Remember your training.
2. Prepare
3. Anticipate

1. Take your time to properly dissect into the pleural space. Putting the chest tube into the morbidly obese pt's sub-Q axillary fat and then re-doing the procedure correctly takes more time. Visualizing the cords and watching the tube pass through them is much faster than, "I saw part of the cords and pushed the tube in."

2. Prepare. For an emergent airway. You, RT, bag while we get ready. You, nurse, draw up med X in dose Y. You, tech, get the glidescope. You, nurse, get a 7.5 ETT with a rigid stylet and 10cc syringe and test the bulb, I still test it myself. You, nurse, be ready to hand me the tube and hold cricoid pressure if needed. I usually am adjusting the bed and patient while setting up the suction behind me and placing the yankauer where I don't need to look to grab it. Organizing and leading your team builds your confidence and theirs.

For an LP, know the order of operations. Find your landmarks. Sterilize the skin. While it dries, set up your drape and your equipment. I put mine in the order it will be used. Make sure the stop-cock and column are in the right position. Double check your landmarks through the steril drape and make sure pt is comfortable. Inject local anesthetic. Recheck landmarks a final time and insert the LP needle.

3. Anticipate what may go wrong or change. Emergent intubation and the pt vomits, you have suction at hand. Light or video goes out on glidescope, you have DL already set up. Can't get tube to pass, bougie is ready. Cuff leak b/c bulb cut while inserting, tube exchanger/bougie is ready. Nothing is working, cric kit is ready to be opened.


As others have said, your fellow residents are likely not as far ahead of you as they let on.

If you feel you need to work on intubations, ask the anesthesia resident or attending if you can hop over to the OR for a few mornings. When the ORs start up, you can usually hop from one to the other just doing intubations for them and get in a few each morning. Sometimes you also can do an art line. Few EM attendings would balk at a resident acknowledging a percieved deficiency and wanting to improve.

For LPs, find the neurology residents and ask if they can let you know when they need an LP. When I was in med school, the neuro residents hated to do LPs and would consult IR frequently. I asked if I could try and after a few successes, they would let me attempt before calling IR. It's nice to get out of hour 3 of neuro rounds to go do an LP on room 304.

For central lines, have a low but appropriate threshold for doing this. Nearly all intubated, septic, or trauma patients can meet this threshold. They're going to need sedation, fluids, blood, abx, or other meds. In the ED, I've found few residents rotating through the ICU who would balk at us putting in their central line. Heck, most of them will ask you to put one in before transfer to the ICU.

We've all walked in these footsteps and you too will become proficient.

 

[n2b8me]

As for what job you should get out of residency, I would suggest a single-coverage facility at a mid-acuity community shop.

100% agree! Excellent learning in the first couple years, with some scary moments.

 

[anbuitachi]

do as many as possible. now is the best time to learn when you still are somewhat supervised. dont be confident in your procedural skills. i remember reading a paper a while ago that looked number of times one need to practice intubating to be considered an expert (dont remember what they used as endpoint), but it was something like 300 with MAC3s..

 

[enalli]

Yea....well...that is one way to do it! I find as an attending though, in a busy ER, doing procedures just slows you down so much. I'm regularly talking myself out of a procedure.

You're absolutely right. I think this strategy is only feasible in residency where by definition you have at least one other person to cover for you and where you are nominally still a learner, so people won't harp on you (as much) about your efficiency.

 

[vector2]

Thank you so much, everyone!



I haven't missed a tube in a while, but when I was start out, it was a disaster. We learn cric next year, but I'm fairly comfortable with most tubes at this point.

I'm curious why you recommend a single coverage shop. That sounds scary, not having any backup? Or am I missing something here? I know it's probably a bit early to think about this, but I know a couple of third years who already had jobs at this point last year.

Just my two cents as as a cardiac anesthesiologist / intensivist: always stay humble when it comes to procedures, no matter how good you think you are as a resident. Even hundreds of central lines and thousands of a-lines and intubations later, I still occasionally run into situations where a combination of overconfidence, challenging anatomy, and lack of optimization/positioning made a procedure harder than it had to be. Like Lombardi said, *perfect* practice makes perfect. Don't get complacent with setting up your kit precisely, positioning the patient precisely, mentally rehearsing the exact steps you're to perform, preformulating a plan B and C etc, just because you've nailed the last 5 in a row and you think this next one looks easy.

 

[Groove]

If you get anxious during procedures and your hands shake a lot, get a low dose Rx for propranolol. My dad used to take that on days he did surgery. I've also tried it though I don't have much of a problem with steady hands but damn... you could sew butterfly wings together in a room full of 3rd trimester women all giving birth at the same time with husbands, pt's and L&D nurses screaming to the top of their lungs AND full c-suite set of admin standing over your shoulder with ease.

Just randomly happened to be the first high stress situation that popped in my head!

 

[turkeyjerky]

Just my two cents as as a cardiac anesthesiologist / intensivist: always stay humble when it comes to procedures, no matter how good you think you are as a resident. Even hundreds of central lines and thousands of a-lines and intubations later, I still occasionally run into situations where a combination of overconfidence, challenging anatomy, and lack of optimization/positioning made a procedure harder than it had to be. Like Lombardi said, *perfect* practice makes perfect. Don't get complacent with setting up your kit precisely, positioning the patient precisely, mentally rehearsing the exact steps you're to perform, preformulating a plan B and C etc, just because you've nailed the last 5 in a row and you think this next one looks easy.

Don't get me wrong, I think this is in general great advice. However in our field, I do think it's important to get comfortable doing procedures (and other tasks) in less than ideal circumstance. You're not going to get perfect positioning whole incubating a patient with ongoing CPR and you won't get a perfect setup for a chest tube on a crashing GSW.

Also, about the original question of having other attendings help you out with procedures. Don't do this. A colleague recently asked me to reduce a hip for him--even though I smiled and said sure, I was pissed off underneath that he interrupted my email time and you're damn sure that I've talked **** about him since. If you need to be bailed out more than a few times on standard procedures, you'll quickly get a rep for being weak

 

[Groove]

Don't get me wrong, I think this is in general great advice. However in our field, I do think it's important to get comfortable doing procedures (and other tasks) in less than ideal circumstance. You're not going to get perfect positioning whole incubating a patient with ongoing CPR and you won't get a perfect setup for a chest tube on a crashing GSW.

Also, about the original question of having other attendings help you out with procedures. Don't do this. A colleague recently asked me to reduce a hip for him--even though I smiled and said sure, I was pissed off underneath that he interrupted my email time and you're damn sure that I've talked **** about him since. If you need to be bailed out more than a few times on standard procedures, you'll quickly get a rep for being weak

Had he tried first? I'm a proceduralist and don't necessarily mind when colleagues ask me to help. I've bailed people out on difficult reductions and/or airways and am flattered when they ask me. After all, hopefully they are just trying to take care of the patient with as few complications as possible. As long as I can bill for the procedure (and don't have to write the note), it's no sweat off my back and I would want the same helping hand if I were in the same position. After all, there's no shame in needing help sometimes. Now, if they are asking you to do the procedure without even trying it first and for no good reason other than "because you can", then I have a real problem with that. Luckily, I don't work with colleagues that would abuse those types of requests.

 

[miacomet]

Hahahahahahahahaha
In some institutions nurses can put in US guided IVs. It's not universal, and remember, there are many EDs out there that don't have US in the department.

Our techs do US-guided IVs.

 

[Perrin]

Had he tried first? I'm a proceduralist and don't necessarily mind when colleagues ask me to help. I've bailed people out on difficult reductions and/or airways and am flattered when they ask me. After all, hopefully they are just trying to take care of the patient with as few complications as possible. As long as I can bill for the procedure (and don't have to write the note), it's no sweat off my back and I would want the same helping hand if I were in the same position. After all, there's no shame in needing help sometimes. Now, if they are asking you to do the procedure without even trying it first and for no good reason other than "because you can", then I have a real problem with that. Luckily, I don't work with colleagues that would abuse those types of requests.

Exactly! I like collaboration and dislike avoidance. I'm overall tall and strong and have been asked to help with a few difficult shoulder or hip dislocation. I don't mind at all. I've asked for one of my partners to just be in the room for an anticipated particularly difficult intubation, just in case. It's a few minutes of our time. They don't seem to mind either.

Years ago, I had a colleague ask me if I would mind putting in a chest tube in one of his trauma patients. I declined, because he is credentialed to do it. I said I'd be available if he needed help, but I wouldn't just do it for him.

 

[Psai]

Exactly! I like collaboration and dislike avoidance. I'm overall tall and strong and have been asked to help with a few difficult shoulder or hip dislocation. I don't mind at all. I've asked for one of my partners to just be in the room for an anticipated particularly difficult intubation, just in case. It's a few minutes of our time. They don't seem to mind either.

Years ago, I had a colleague ask me if I would mind putting in a chest tube in one of his trauma patients. I declined, because he is credentialed to do it. I said I'd be available if he needed help, but I wouldn't just do it for him.

Do the procedure, own the complications.

 

[gro2001]

Like the title says, I feel that I don't have the talent some of my co-residents do when it comes to procedures. This made me shy away from them early in the residency, which made the situation worse.

I'm in my second out of three years now. I know there's enough time to practice, especially if I seek out procedures during shifts. It's demotivating though, not getting LPs a few times in a row, struggling with chest tubes, messing up central lines.

My question is, is it worth worrying about this? Would it be stupid to just get a job after residency that doesn't require me to do many procedures (such as the standard at a place being to defer them to ICU or surgery)? Should I get a job with double attending coverage so that the other attending would be potentially able to bail me out if I'm in trouble? What would you do in my position?

Of course, I might be exaggerating the problem, but I've always been better at thinking that doing something with my hands. And naturally, I'll keep working on getting better during residency.

I occasionally have a resident or a medical student say that they are "bad at procedures". Almost always they are not actually distinguishably less competent than their peers. They just give themselves a harder time. I find that the folks who claim to be good at procedures fail as often, except when they do they don't mind ascribing it to difficult anatomy or other similar circumstances. So if you looked at things objectively, you might find that you are not nearly as bad or as far removed from your peers as you think. And as a supervisor I would much rather teach someone like you than someone who is gung-ho and over confident.

I agree with what people above have said in terms of seeking out more procedures to do and analyzing your failures. But I would also urge you to seek out advice from your faculty. Be as candid with them as you have been here. There may very well be a few small things they can point out that will make you way more likely to succeed.

For central lines for example, the procedure is made up of several mini skills. Each has its own pitfalls, but also relatively easy fixes.

1) Hitting the vessel under ultrasound guidance: use long axis (aka in plane view). It is a little harder to get the view but oh so much easier to see where your needle is going. In my experience the majority of CVCs done under US with the short axis (out of plane) view are really not ultrasound guided at all because the operator does not have the needle tip in view.

2) Disconnecting the syringe without losing your spot: most kits will have two needles, one that you are used to using and one with the catheter over it (looks like a peripheral IV) that no one knows what to do with. Use that one. If you do, once you get a flash, just threat the peripheral catheter into the IJ. That will keep you from losing your spot. No syringe disconnection necessary.

3) Threading the guidewire: just go slowly, threading only 1 cm or so at a time.

4) Making the nick in the skin: most of the time because of a skin fold the cut you make is actually a mm or so away from the actual entry point of your needle/guidewire. Keep the skin taught and make the incision so its connected to wear the guidewire enters the skin. Alternatively, start the procedure by making a nick in the skin and inserting your needle through it.

5) Threading the dilator and threading the catheter: hold them near the tip/as near the skin as possible, go slowly, and twist them back and forth as you advance. Dont hold them midshaft.

There are other pitfalls, but they are more rare. The above eliminates the vast majority of trouble with lines.

 

[turkeyjerky]

Had he tried first? I'm a proceduralist and don't necessarily mind when colleagues ask me to help. I've bailed people out on difficult reductions and/or airways and am flattered when they ask me. After all, hopefully they are just trying to take care of the patient with as few complications as possible. As long as I can bill for the procedure (and don't have to write the note), it's no sweat off my back and I would want the same helping hand if I were in the same position. After all, there's no shame in needing help sometimes. Now, if they are asking you to do the procedure without even trying it first and for no good reason other than "because you can", then I have a real problem with that. Luckily, I don't work with colleagues that would abuse those types of requests.

Nope, didn't try. Came up to me and said he didn't have much experience with them and could I help *do it for him*. I truthfully wouldn't of minded that much other than he screwed of the sedation, wasted 15 min of my shift, then signed out the case at shift change then we had to go back in and do it for real. Yeah--this guy is pretty weak.

Obviously, I don't have a problem with helping others out with difficult procedures (and appreciate it when they help me) or lending a 2nd set of eyes to a funny EKG, etc. My point was that you don't want to graduate with the expectation of being incompetent at your job.

How do you bill without writing the note? I assume you write the procedure note and thale the associated RVUs and then the other persons does the rest and takes the general visit RVUs. We're not heavily RVU based so I generally just keep my name off the chart in these situations.

 

[Groove]

Nope, didn't try. Came up to me and said he didn't have much experience with them and could I help *do it for him*. I truthfully wouldn't of minded that much other than he screwed of the sedation, wasted 15 min of my shift, then signed out the case at shift change then we had to go back in and do it for real. Yeah--this guy is pretty weak.

Obviously, I don't have a problem with helping others out with difficult procedures (and appreciate it when they help me) or lending a 2nd set of eyes to a funny EKG, etc. My point was that you don't want to graduate with the expectation of being incompetent at your job.

How do you bill without writing the note? I assume you write the procedure note and thale the associated RVUs and then the other persons does the rest and takes the general visit RVUs. We're not heavily RVU based so I generally just keep my name off the chart in these situations.

I write a separate procedure note and just state that I was requested to assist with a difficult procedure but was not involved in overall clinical management of said pt. It’s a stand-alone procedure note separate from the clinical encounter note. That way they can’t screw me if they go “hey man, whew...thanks! I’ll put you down on that procedure!” only to go back and see that they’ve put themselves down as performing it. (Or better yet, stating that I “assisted” them in performing it.)

That dude sounds like weak sauce.

 

[alpinism]

Its all about practice.

Don't shy away from difficult or challenging patients.

If you can drop a central line in a 300 lbs agitated hypotensive septic shock patient then everyone else becomes a piece of cake.

 

[thegenius]

Also, about the original question of having other attendings help you out with procedures. Don't do this. A colleague recently asked me to reduce a hip for him--even though I smiled and said sure, I was pissed off underneath that he interrupted my email time and you're damn sure that I've talked **** about him since. If you need to be bailed out more than a few times on standard procedures, you'll quickly get a rep for being weak

Boo!!!! Not good advice

 

[SamtheWise]

I think that one thing I at least have struggled with early on doing procedures is the mindset. You have to place yourself into a no fail mindset, and that can be very challenging (I still struggle with it). You have to trust your skills and own that if you cannot rapidly and easily get the airway orotracheally then you have to move to more aggressive measures, whether that's removing the C-collar, breaking teeth, or committing to cutting the neck. If you can't get the chest tube easily then you have to make a bigger cut, dissect more aggressively, etc, or if nobody can get a peripheral IV, don't mess around with US and a peripheral vein, just put the angio cath from the central line set into the IJ. That's what I have noticed is the difference between the extremely experienced person who takes the final crack at a procedure and succeeds when others fail.

 

[turkeyjerky]

Boo!!!! Not good advice

Huh? Do you you really feel it's ok to intentionally pursue incompetence?

I think that one thing I at least have struggled with early on doing procedures is the mindset. You have to place yourself into a no fail mindset, and that can be very challenging (I still struggle with it). You have to trust your skills and own that if you cannot rapidly and easily get the airway orotracheally then you have to move to more aggressive measures, whether that's removing the C-collar, breaking teeth, or committing to cutting the neck. If you can't get the chest tube easily then you have to make a bigger cut, dissect more aggressively, etc, or if nobody can get a peripheral IV, don't mess around with US and a peripheral vein, just put the angio cath from the central line set into the IJ. That's what I have noticed is the difference between the extremely experienced person who takes the final crack at a procedure and succeeds when others fail.

Agree big time--this is probably the biggest reason for the skyrocketing of LP success rate after graduation. Although I do have to quibble with your airway management--doubt breaking teeth is ever really necessary or helpful, and the c-collar should already be off before the first attempt.

 

[Angry Birds]

I think that one thing I at least have struggled with early on doing procedures is the mindset. You have to place yourself into a no fail mindset, and that can be very challenging (I still struggle with it). You have to trust your skills and own that if you cannot rapidly and easily get the airway orotracheally then you have to move to more aggressive measures, whether that's removing the C-collar, breaking teeth, or committing to cutting the neck. If you can't get the chest tube easily then you have to make a bigger cut, dissect more aggressively, etc, or if nobody can get a peripheral IV, don't mess around with US and a peripheral vein, just put the angio cath from the central line set into the IJ. That's what I have noticed is the difference between the extremely experienced person who takes the final crack at a procedure and succeeds when others fail.

Good advice. Except breaking teeth might be excessive. Why not dislocate their jaw too lol

 

[acadianvoyager]

Hey Eder,

I was in your exact same boat. I too fell into this vicious cycle during residency:



I'm still not good at procedures, but I've mastered the ones we absolutely need to know, which are very few: intubation, LP, central lines, chest tubes, etc. You can count them on your fingers.

I wish I had indeed thrown myself at procedures more during residency. The problem is going to get worse as you become a senior resident. I remember during a trauma, the attending told me to teach the intern how to do a chest tube. I was thinking "f*** maybe he can teach me." It was a cluster. Every time I did a central line it was also a cluster. I still am haunted by a senior nurse who told me during my 2nd year of residency, "It's always a mess when we do a central line together." (Yeah, 'cuz I royally sucked at them.)

BUT, the flip side of this was that I failed so many times that I can say that I now know 24,000 mistakes to make and fail in your procedure. So, during a central line I am literally at each step cognizant of what NOT to do. I then follow the advice Michael Scott gave to Dwight: "Don't be an idiot" to which Dwight replied "If an idiot would do it, I do NOT do that thing."

Now, I think I am one of the best to teach these few procedures to others, since I can warn them of what NOT to do. Make sure that every time you fail you think about WHY you failed and next time make the necessary adjustment.

Bottom line is that: you will EVENTUALLY get this down, if but from failing so many times. Unfortunately, it took me two years OUT of residency to get them down. So yes, you should throw yourself NOW at these procedures, instead of shying away--even though for me, the shyness got worse through residency. It was harder as a third year to suck than a first or second year.

Procedures ARE hard and require TONS of finesse that people who are naturally gifted at procedures don't realize. Every time I see a video of a new procedure that is 3 minutes long and the person says, "This never fails," I think to myself, "yeah watch me show you how it will fail." But yeah, each time you fail is a new adjustment to be made.

As for what job you should get out of residency, I would suggest a single-coverage facility at a mid-acuity community shop. Don't work at a crazy trauma center nor at a place where you will never get any procedure. You don't want to throw yourself in the deep end nor never jump in the water at all.

Just my thoughts. I'll post more if I think about it, since I was also in your position. In fact, I was honestly considering IM due to this fear and distaste of procedures. But alas, rounds were too killer.

Lastly, just as a reassurance to you, people at my current shop think I'm the procedure guy, lol. My intubations are smooth as butter, because I take so many precautions and spend SO much time in set up. Same with the other procedures. It's all from failing so much and making so many adjustments. So yeah, there is hope.

P.S. How are your intubation skills? How do you feel about this procedure?

Hey Angry Birds, thank you so much for the advice. I'm in the same boat and your story is reassuring.

 

[GeneralVeers]

Who leaves the C-collar on before intubation? Given a c-collar's dubious benefit in actual spinal cord fractures, why would anyone want to make getting an airway harder?

 

[thegenius]

Not I. Collar comes off!!!
Paralyze. Collar off. Intubate. Collar back on.

 

[enalli]

Not I. Collar comes off!!!
Paralyze. Collar off. Intubate. Collar back on.

One of my favorite attendings once said to me when I was hesitant about removing the collar: "You think the patient's family was perfectly holding his C-Spine while rescuing his limp body from the bottom of the pool?"

I never again hesitated to remove the collar for the intubation.