Procedure legends?

[The Knife & Gun Club]

Hit an IJ dialysis line in the ICU after 3 NPs had attempted every other site and deemed the line “un-gettable”. Walked off to jay-Zs 99 problems in my head

Mismanaged a bunch of chronic GERD and other nonsense, but hey. Gotta take the wins as they come.

Anyone else have any good procure stories? I’m not gonna have a job in 2.5 years so hey, gotta live it up.

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[turkeyjerky]

The thought of an NP trying a subclavian HD cath is horrifying imho...

Personally, nothing is as gratifying as placing a TV pacer and seeing a corpse reanimate, but my favorite procedural memory is from residency. On a traumatic arrest I was supervising a med student doing a chest tube (right sided—they didn’t do clamshells at my center) I told her not to be shy about the incision, and, in the 5 sec or so that I looked away to grab a Kelly, she had made a 5 in. incision straight into the thorax! I couldn’t help but be impressed.

 

[alpinism]

Lol at ICU NPs being allowed to perform dialysis lines.

It's funny how people think critical care is safe from midlevels.

 

[Rekt]

Hit an IJ dialysis line in the ICU after 3 NPs had attempted every other site and deemed the line “un-gettable”. Walked off to jay-Zs 99 problems in my head

Mismanaged a bunch of chronic GERD and other nonsense, but hey. Gotta take the wins as they come.

Anyone else have any good procure stories? I’m not gonna have a job in 2.5 years so hey, gotta live it up.

Mid-levels should not even be doing any central lines, let alone a dialysis line. And in the neck? If its for emergent dialysis, there's no reason not to do a fem trialysis. Significantly more easier to compress than an IJ as these patients usually have non-existent platelet function and are likely on anticoags for some other reason. Playing with fire for no reason to look like a bad ass.

 

[dadaddadaBATMAN]

The thought of an NP trying a subclavian HD cath is horrifying imho...

Personally, nothing is as gratifying as placing a TV pacer and seeing a corpse reanimate, but my favorite procedural memory is from residency. On a traumatic arrest I was supervising a med student doing a chest tube (right sided—they didn’t do clamshells at my center) I told her not to be shy about the incision, and, in the 5 sec or so that I looked away to grab a Kelly, she had made a 5 in. incision straight into the thorax! I couldn’t help but be impressed.

Well, after that it’s hard to say they didn’t do clam shells at your residency. Might as well have her complete the job

 

[Fox800]

Midlevels in the ICU...not even once.

 

[Dr Mantis Toboggan]

Midlevels in the ICU...not even once.

Sad to see.

 

[bravotwozero]

Mid-levels should not even be doing any central lines, let alone a dialysis line. And in the neck? If its for emergent dialysis, there's no reason not to do a fem trialysis. Significantly more easier to compress than an IJ as these patients usually have non-existent platelet function and are likely on anticoags for some other reason. Playing with fire for no reason to look like a bad ass.

At my shop, when they first allowed mid levels to place central lines, we had 3 pneumothoraces in 1 week. One of them coded in the ICU that I had to respond to and then place a chest tube. That came to an abrupt end.

 

[YCAGA]

Midlevels in the ICU...not even once.

Do you all work in academia? I go to school/live in a top 30 metro area and the big community hospitals have only NPs in-house covering the ICU for 18-20 hours a day. The critical care physician comes in for 4-6 hours in the morning to round, puts in orders, maybe does some procedures, and then bounces. Any code or procedure after 2-3pm is going to be run by either the EM if they don't have a crashing patient of their own or the NP. Sometimes the CC doc on call will answer pages quickly, sometimes not. Now, all of this is horribly unsafe and I am not sure how it isn't malpractice, but they have been getting away with this system for years. The NPs just say they are "practicing at the top of their licenses."

 

[CCM-MD]

Lol at ICU NPs being allowed to perform dialysis lines.

It's funny how people think critical care is safe from midlevels.

Things are excellent now but future looks very questionable for CCM.

 

[YCAGA]

Things are excellent now but future looks very questionable for CCM.

Just to play devil’s advocate, is anything really safe from midlevel encroachment when you have online degree NP’s with a 6 month on-the-job “residency boot camp” intubating, doing lines, and managing an entire ICU without supervision? The only ones that seem remotely safe are fields like cardiac surgery and neurosurgery where bad outcomes are very immediate and dramatic and the procedures themselves are highly technical.

It’s just a matter of time before NPs are doing heart caths while an interventional cardiologist is “supervising” 1:2 or 1:4 like anesthesia. So the commonly repeated belief on this forum that specialities that “bring in patients”/make the hospital money are safe from encroachment doesn’t hold up to scrutiny either.

 

[CCM-MD]

Just to play devil’s advocate, is anything really safe from midlevel encroachment when you have online degree NP’s with a 6 month on-the-job “residency boot camp” intubating, doing lines, and managing an entire ICU without supervision? The only ones that seem remotely safe are fields like cardiac surgery and neurosurgery where bad outcomes are very immediate and dramatic and the procedures themselves are highly technical.

It’s just a matter of time before NPs are doing heart caths while an interventional cardiologist is “supervising” 1:2 or 1:4 like anesthesia. So the commonly repeated belief on this forum that specialities that “bring in patients”/make the hospital money are safe from encroachment doesn’t hold up to scrutiny either.

Nothing is probably safe except for actual surgery. Cardiac cath is already being encroached upon. Meet your "nurse angiographer/nurse cardiologist".

Safety, effectiveness and quality of nurse diagnostic coronary angiography - The British Journal of Cardiology

Introduction Coronary artery disease (CAD) remains among the leading causes of premature death in the UK, as well as the leading cause of death worldwide. In the UK, one in seven men and one in 11 women will die from CAD, which, on average, is one death every eight minutes.1 Despite advances in...

bjcardio.co.uk

 

[Groove]

I work in the community and in my last job we had some extremely well trained NPs running the ICU at night and doing the majority of the work during the day for the Pulm group. In fact, two of them are being sent over to a new hospital to run the ICU with minimal attending involvement. I trained two of them in the ED before they went upstairs and joined the ICU. I wish I could say terrible things about them but they really know their stuff and I'd let them take care of me before I'd let some of my old colleagues. I got called up twice for airway disasters and both were legit. One turned into a cric in a rotoprone bed and another one was a guy who had so much vocal cord edema that I could barely get the bougie through and had to muscle a 6.0 tube so hard I thought I was going to dissect his trachea.

We all like to assume that NP/PAs can't learn to do this stuff as well as we can. As if our training or innate skill, talent, smarts, whatever...precludes them from mastering our skillset and that's where you are flat wrong. It's GREED and LAZINESS that will ultimately destroy us. Training them to staff the ICU/ED at night, work the odd/less desirable hours, ease the workload, cut a doc here, cut a doc there, pay the NP/PA less so that the senior partners can make more money. Destroying and eroding our future in the process. The irony is that we watched anesthesia drive themselves off a cliff and here we are doing the exact same thing. If we lose our salaries and specialties to MLPs, we have only ourselves to blame.

I had an ICU PA last shift asking me to teach him how to do a subclavian line because NSGY fellow had requested one for their SAH pt with an EVD because he didn't want venous outflow obstruction from an IJ CVL. (WTF?) I kindly turned him down on a bedside teaching opportunity and stated I would take care of it for him. When he left, I popped one in by myself. I closely guard my skillset and as much as I respect and genuinely enjoy working with MLPs, hey...this is business and I'd like to keep my job thank you very much!

 

[Groove]

Hit an IJ dialysis line in the ICU after 3 NPs had attempted every other site and deemed the line “un-gettable”. Walked off to jay-Zs 99 problems in my head

Mismanaged a bunch of chronic GERD and other nonsense, but hey. Gotta take the wins as they come.

Anyone else have any good procure stories? I’m not gonna have a job in 2.5 years so hey, gotta live it up.

10 years from now you'll realize that you probably just got lucky on that one. However, for now...it was 100% skill and something I would definitely tell my mom about.

 

[YCAGA]

I work in the community and in my last job we had some extremely well trained NPs running the ICU at night and doing the majority of the work during the day for the Pulm group. In fact, two of them are being sent over to a new hospital to run the ICU with minimal attending involvement. I trained two of them in the ED before they went upstairs and joined the ICU. I wish I could say terrible things about them but they really know their stuff and I'd let them take care of me before I'd let some of my old colleagues. I got called up twice for airway disasters and both were legit. One turned into a cric in a rotoprone bed and another one was a guy who had so much vocal cord edema that I could barely get the bougie through and had to muscle a 6.0 tube so hard I thought I was going to dissect his trachea.

We all like to assume that NP/PAs can't learn to do this stuff as well as we can. As if our training or innate skill, talent, smarts, whatever...precludes them from mastering our skillset and that's where you are flat wrong. It's GREED and LAZINESS that will ultimately destroy us. Training them to staff the ICU/ED at night, work the odd/less desirable hours, ease the workload, cut a doc here, cut a doc there, pay the NP/PA less so that the senior partners can make more money. Destroying and eroding our future in the process. The irony is that we watched anesthesia drive themselves off a cliff and here we are doing the exact same thing. If we lose our salaries and specialties to MLPs, we have only ourselves to blame.

I had an ICU PA last shift asking me to teach him how to do a subclavian line because NSGY fellow had requested one for their SAH pt with an EVD because he didn't want venous outflow obstruction from an IJ CVL. (WTF?) I kindly turned him down on a bedside teaching opportunity and stated I would take care of it for him. When he left, I popped one in by myself. I closely guard my skillset and as much as I respect and genuinely enjoy working with MLPs, hey...this is business and I'd like to keep my job thank you very much!

I don’t really disagree with any of that—it’s just blind arrogance for physicians to think an NP/PA can’t be trained to competently intubate or do cardiac caths or whatever procedure we want to pick. It’s not like having a high GPA in college gives us some superpower in terms of manual dexterity. Now, will NP/PAs know WHEN and WHY to do these procedures is another question.

I am confused about one part though. You say in the past you helped train NP/PA’s that basically run ICU’s themselves now but also you refuse to train a PA because he might take your job one day?

 

[Groove]

I don’t really disagree with any of that—it’s just blind arrogance for physicians to think an NP/PA can’t be trained to competently intubate or do cardiac caths or whatever procedure we want to pick. It’s not like having a high GPA in college gives us some superpower in terms of manual dexterity. Now, will NP/PAs know WHEN and WHY to do these procedures is another question.

I am confused about one part though. You say in the past you helped train NP/PA’s that basically run ICU’s themselves now but also you refuse to train a PA because he might take your job one day?

I agree for the most part.

In those cases, the CMG dictated that they work independently and they also dictated that I sign and attest their charts at the end of the day. So, unless I wanted them to kill someone and pull me into a lawsuit, I was forced to train them in EM. They were interested in learning, smart, competent and I didn't mind. I did not teach any procedures beyond basic laceration repair and I&D. They primarily handled fast track patients.

Sometimes you are forced to set aside your ideological goals in order to put food on the table, keep patients safe, avoid lawsuits and fund your retirement IRA. That's not the same thing as what I was describing earlier.

 

[CCM-MD]

If we truly get to a point where midlevels essentially independently care for the sickest and most complex patients in the hospital, the question is going to be: what do we actually need physicians for?

 

[GeneralVeers]

If we truly get to a point where midlevels essentially independently care for the sickest and most complex patients in the hospital, the question is going to be: what do we actually need physicians for?

Welcome to ICU care in Vegas. Several community hospitals have 40+ ICU beds staffed after 7PM solely by an NP......who can't do lines, intubate, or ACLS.
It's truly terrifying the poor care that these hospital mega-corporations are willing to accept.

 

[CoolDoc1729]

I remember doing a right femoral art line as a PGY-2 after the fellow and attending had tried. The patient was like 97yo (yikes) and I felt three distinct crunches before i got into the vessel. It was pretty gross

 

[gutonc]

I think this thread deserves legend status for going OT in post #2.

 

[dadaddadaBATMAN]

If it has the word np or pa in the post in any form we’ll be discussing the merits of a fm attending vs an em experienced pa in solo Rural coverage by the end of the first page

 

[YCAGA]

If it has the word np or pa in the post in any form we’ll be discussing the merits of a fm attending vs an em experienced pa in solo Rural coverage by the end of the first page

Ha, trick question. The correct answer is an NP with 500 hours of shadowing and an online degree.

 

[CajunMedic]

Do you all work in academia? I go to school/live in a top 30 metro area and the big community hospitals have only NPs in-house covering the ICU for 18-20 hours a day. The critical care physician comes in for 4-6 hours in the morning to round, puts in orders, maybe does some procedures, and then bounces. Any code or procedure after 2-3pm is going to be run by either the EM if they don't have a crashing patient of their own or the NP. Sometimes the CC doc on call will answer pages quickly, sometimes not. Now, all of this is horribly unsafe and I am not sure how it isn't malpractice, but they have been getting away with this system for years. The NPs just say they are "practicing at the top of their licenses."

Where I'm at, our ICU beds (68 in total) are split between a private Pulm/CCM group and our IM residents/Pulm CCM fellows. The private group is almost exclusively PA/NP 24/7 with 3 supervising docs in-house during the day shift. We spend a month with them in our PGY-2 year. If a resident is there, we perform all relevant procedures (except intubation, for some reason only anesthesia is allowed to intubate outside the ED), run the codes, and perform death pronouncements. At night, they page the resident/fellow ICU team for codes, etc. with their attending.


On the original topic:

My personal best is having to intubate and central line 3 patients in a row during a 10 hr shift. Our patient population is sick as hell, and don't really come out of the holler until they're mostly dead...

 

[alphaholic06]

The NPs just say they are "practicing at the top of their licenses."

What does this even mean?

 

[turkeyjerky]

What does this even mean?

They practice “healthcare”

 

[Siggy]

Large patient coded on the telemetry unit while in a chair. Nursing staff moved the patient to the floor. Intubated with a Mac 3 while laying on my side without interupting compressions. I followed that show up later in the week by intubating a paitent in resp arrest in the psych unit while he was sitting up. The sofa he was sitting on only went part way up his back, so his head was maximally extended.

 

[Siggy]

The NPs just say they are "practicing at the top of their licenses."

I always hate that phrase because I know no physician that "practices at the top of their license." I hold an unrestricted license to practice medicine. I can perform brain surgery if I wanted to under my license. I don't because it's dangerous and I'm not trained to do it. Same reason I don't treat kids.

 

[Zebra Hunter]

The most difficult procedure I ever did was place a radial A-line in a 6 week old. It was like trying to thread a wire through the eye of a very small needle.

I also usually feel pretty pumped when I help a colleague get a tube without any issue on someone they have made 3 or 4 attempts on without success.

 

[AlmostAnMD]

Second week at a new hospital, don't know the staff or resources very well

900-year-old dehydrated altered whale with sandpaper tongue comes with afib rvr and a temp around 102

Nursing home, as usual, knows "nothing" about the patient and just has squad kindly leave this warm cadaver at my foot with a BP soft but not crashing

Many nurses try for IV, all fail even with US

I look up in the neck, don't see much

I turn her essentially upside down and sort of see R IJ

I ask for central line kit (this part is MY fault, I just ~asked~ for a kit, didn't look at it)

I run through usual line stuff, a nurse is sterile next to me handing me stuff as I ask for it

I eventually find venous gold through a field of neck blubber under US and pass guidewire. I ask for the rest of the kit and see this is a 13 Fr trauma line. Appalled, I asked for a 3 port 7 Fr central line. They look for a while but no one can find one, just this massive trauma steak knife thing

Eventually I'm like F it, whatever. So I put this massive behemoth in her neck and it looks like I'm murdering her with an ice pick. Procedure goes well

2 things happened afterward.

1) One nurse hung fluids as "bolus" I ordered but the line is fully opened and within 10 seconds half a liter is in her before I realize it in time to slow the flow. Nothing bad happened but watch a bag empty like that was interesting.

2) 20 minutes later got blood results from labs I drew when I placed the line INR was "undetectably high" meaning for our assays > 20. Glad I knifed her good

 

[RustedFox]

@dchristismi will attest that I straddled a patient while riding a bed on the way to the cath lab, doing chest compressions.

EDIT: The patient arrested en route to the cath lab, so I jumped up on the bed and started doing compressions for the elevator ride up. Got his cath. Can't remember if he made it thru.

 

[YCAGA]

What does this even mean?

Well in many states NPs can do anything a physician can do as long as they are “supervised” and their hospital credentials them for the procedure/task. I think that’s what they mean. Couldn’t tell you for certain, I’m not an NP...

 

[EMhawkeye]

@dchristismi will attest that I straddled a patient while riding a bed on the way to the cath lab, doing chest compressions.

EDIT: The patient arrested en route to the cath lab, so I jumped up on the bed and started doing compressions for the elevator ride up. Got his cath. Can't remember if he made it thru.

Did this en route to the unit. The intern who witnessed it likes to recount the story that I rode a little old lady around the hospital hard and put her away wet.

 

[thegenius]

I had an ICU PA last shift asking me to teach him how to do a subclavian line because NSGY fellow had requested one for their SAH pt with an EVD because he didn't want venous outflow obstruction from an IJ CVL. (WTF?) I kindly turned him down on a bedside teaching opportunity and stated I would take care of it for him. When he left, I popped one in by myself. I closely guard my skillset and as much as I respect and genuinely enjoy working with MLPs, hey...this is business and I'd like to keep my job thank you very much!

yea i heard this regularly during my NICU rotation in residency. I asked about the evidence behind it and they said it was poor, but they do it anyway.

 

[Groove]

yea i heard this regularly during my NICU rotation in residency. I asked about the evidence behind it and they said it was poor, but they do it anyway.

Weird. I’ve never even heard that one before.. I put a supraclavicular line at the brachiocephalic “pocket shot” (basically a distal IJ) out of spite.

 

[dadaddadaBATMAN]

yea i heard this regularly during my NICU rotation in residency. I asked about the evidence behind it and they said it was poor, but they do it anyway.

...then they should place a femoral.

 

[The Knife & Gun Club]

Weird. I’ve never even heard that one before.. I put a supraclavicular line at the brachiocephalic “pocket shot” (basically a distal IJ) out of spite.

How difficult are these to do? I’ve been wanting to learn forever but haven’t found an attending who can teach me yet, since none of ours were ever trained in it

 

[Groove]

How difficult are these to do? I’ve been wanting to learn forever but haven’t found an attending who can teach me yet, since none of ours were ever trained in it

So, here's my 2 cents. If you wait for attendings to teach you how to do something, you'll never learn anything new. What you need are attendings in residency that are fine with letting you try new stuff. I think the latter is much easier to find than the former if you just make a good case for the procedure. After all, that's how I learned a lot of the tricks that I do today. For instance, I didn't necessarily come from a strong regional anesthesia EM residency, I just happened to be interested in doing them and would jockey to perform any block I got the chance to do. Most of my attending would shrug and say fine. Over time, I got pretty good at them. Even then, I picked up new ones after residency just by researching and trying them. Interscalene blocks are a good example. I spent some time researching and learning about them, watched countless videos, picked the safest patient population and finally just did one. Now, I'm pretty proficient at them and teach my colleagues how to do them. The nice thing is that we live in the YouTube age and just about everything is on YouTube these days. Hell, I picked up the Captain Morgan hip reduction technique from a fellow colleague who explained it and then I watched the YouTube video and then went and did one. I guess my point is that you just have to be proactive. Learn on your feet. Always be open to learning new techniques and don't be afraid to try them. That's how you improve over time.

Pocket shot supraclavicular is just one variant of several supraclavicular subclavian line techniques. All of which can be easily done with or without ultrasound. I would recommend using ultrasound the first few times but challenge yourself to imagine the anatomical landmarks as you approach the target area on ultrasound. You'll come to appreciate the relative large size of the target window and how it's not the axial/sagittal axis adjustments that can get you into trouble as much as the adjustment around the coronal axis (diving too deep or shallow).

Here's a video on how to do them using US. There are several videos, some of which demonstrate going more proximal in the subclavian. I typically aim for the brachiocephalic vein because I think it's an easier and larger target window and farther away from the lung. They are super easy lines. Easier than IJs or Femorals IMO. Once you get a good feel for the line, you can try one in a code or blind. When doing blind, I was trained to always use the finder needle first to get a flash of venous blood. I then follow that with the larger needle. (If I'm using US, I don't use the finder needle.) Now, in my defense, I learned these in residency blind, but I still don't think that should keep anyone from picking up the technique. It's super simple. I typically will use US these days for these lines because...why not? The only ones I still do blind anymore are subclavian infraclavicular lines and that's because I can't see the vein very well with US and end up getting frustrated and going back to blind technique. Anyway, long winded answer to your question.

Trick of the Trade: Ultrasound-guided supraclavicular central line

Trick of the Trade: Ultrasound-guided supraclavicular central line

www.aliem.com

 

[DocEspana]

In the grand scheme of things this isnt "impressive" as much as it is my favorite story by far: There was a double stabbing that made headlines (briefly) in NYC. I guess for hipaa reasons I cant say what the news called it, but the newspaper name for it itself is pretty funny. Leave it at they both got stabbed under highly unique circumstances and a million bystanders got it on video. anyway, fire rescue calls in two stabbed people 5 minutes before shift change. One is reported as a single wound to the chest and doing fine except for pain. One is reported as a ton of stab wounds and vitals signs are bad over bad. So we prep both trauma rooms and I tell the incoming guy that I'll take the single stab wound because it sounds simple and we have a trauma team who will basically take over for me so I can get out quickly. He can go and get the complex sounding one.

no one shows up for like 10 minutes. Its odd. Way too long a time frame. First fire rescue finally shows up with single stab wound guy. They seem to think the other truck arrived before them so they are all chill and assume we know the whole story. Are shocked the other truck isnt there yet and its clear theyve been not paying *a ton* of attention because when I ask them what the vital signs are they (twice!) say "whatever it says on the monitor, doc". Except the monitor facing me says 0, 0, ---/---. The next words uttered by the fire rescue was "WHAT? he was alive in the truck." So I go and grab a thoracotomy kit. Crack a chest. Realize that the single stab wound was right under the clavicle and sliced the aorta so.... yeah.... he was likely dead for a while and they figured one small (at skin level) chest wound wasnt a big deal.

I go to the other room where the other victim had finally arrived. My buddy is there and put in a chest tube already. Apparently had a something thorax on the left, I wasnt there for that part. tons of stab wounds all over this one, though. But because the closest thoracotomy kit (for me) was the trauma cart he had pulled out for his case, I had also taken his intubation tray away from him. So he asks me to give BVM support to this girl who is still gasping for breath while he goes over to my trauma bay to get the intubation tray back. In the 15 seconds he is gone she suddenly codes and he comes back to me with a new scalpel cutting the ribs and yelling for another thoracotomy tray. This one had a slight knick on the pericardium/myocardium and I got to delivery a heart and she suddenly came back to life.

As if two thoracotomies in 10-12 minutes wasnt enough (and my buddy getting zero of them. this was back in residency, these were golden opportunities)...... Im working about 7-10 days later and the second patient checks in. because somehow she isnt in the SICU still. Had "**** to do" was her answer. Which, with more time and wisdom, I am realizing is a fully valid answer. Why did she check in? To get the 100-ish staples holding her chest wall together taken out.

 

[bravotwozero]

If I did a thoracotomy on someone and they survived, I would consider that to be the absolute pinnacle of my career.

 

[DocEspana]

If I did a thoracotomy on someone and they survived, I would consider that to be the absolute pinnacle of my career.

I got 2 survivals (afaik). she was one of them. But my stats sort of equal out what the survival should be. like 4-for-20 making it to the OR and 2-for-20 surviving long term and generally fully intact (minus some WICKED scars) at discharge.

Edit: found the old email with how many I have done in residency plus the one I did as an attendant. 2-for-16 survived well to DC, but I'm sure if I did four more they'd all be dead and id be 4-for-20 to the OR and 2-for-20 to the door.

 

[YCAGA]

I got 2 survivals (afaik). she was one of them. But my stats sort of equal out what the survival should be. like 4-for-20 making it to the OR and 2-for-20 surviving long term and generally fully intact (minus some WICKED scars) at discharge.

Edit: found the old email with how many I have done in residency plus the one I did as an attendant. 2-for-16 survived well to DC, but I'm sure if I did four more they'd all be dead and id be 4-for-20 to the OR and 2-for-20 to the door.

You did NINETEEN ED thoracotomies in residency?! Did you train in Fallujah in 2003-2004?

The ED attendings I used to work with had 0-2 at knife-and-gun club residencies and normally 0 in their careers. Either gen surg did it themselves or it was pointless to try because gen surg wasn't around to clean up the mess.

 

[DocEspana]

You did NINETEEN ED thoracotomies in residency?! Did you train in Fallujah in 2003-2004?

The ED attendings I used to work with had 0-2 at knife-and-gun club residencies and normally 0 in their careers. Either gen surg did it themselves or it was pointless to try because gen surg wasn't around to clean up the mess.

Harlem hospital for residency. It is the original knife and knife and more knife club. And it was 15 in residency and one out of residency (think you added my successes to the total. It's 2/4 OUT OF 16). And over there, until a big staff turnover during the last year of residency, our ED attendings *literally* blocked the surgery team from the kits with their bodies if there was an indication for an ED thoracotomy. Harlem was the wild west, then the staff turned over in a few departments and everyone agreed to share thoracotomy opportunities.

We all graduated with at least 8-10 just based on how many stab wounds we saw and how some of them would die soon after arrival. I just happened to be un/luckier than most.

 

[The Knife & Gun Club]

Second week at a new hospital, don't know the staff or resources very well

900-year-old dehydrated altered whale with sandpaper tongue comes with afib rvr and a temp around 102

Nursing home, as usual, knows "nothing" about the patient and just has squad kindly leave this warm cadaver at my foot with a BP soft but not crashing

Many nurses try for IV, all fail even with US

I look up in the neck, don't see much

I turn her essentially upside down and sort of see R IJ

I ask for central line kit (this part is MY fault, I just ~asked~ for a kit, didn't look at it)

I run through usual line stuff, a nurse is sterile next to me handing me stuff as I ask for it

I eventually find venous gold through a field of neck blubber under US and pass guidewire. I ask for the rest of the kit and see this is a 13 Fr trauma line. Appalled, I asked for a 3 port 7 Fr central line. They look for a while but no one can find one, just this massive trauma steak knife thing

Eventually I'm like F it, whatever. So I put this massive behemoth in her neck and it looks like I'm murdering her with an ice pick. Procedure goes well

2 things happened afterward.

1) One nurse hung fluids as "bolus" I ordered but the line is fully opened and within 10 seconds half a liter is in her before I realize it in time to slow the flow. Nothing bad happened but watch a bag empty like that was interesting.

2) 20 minutes later got blood results from labs I drew when I placed the line INR was "undetectably high" meaning for our assays > 20. Glad I knifed her good

This is exactly what I was envisioning when I posted here. Bravo.

 

[RustedFox]

EDIT: quoted message deleted

 

[RustedFox]

EDIT: original message deleted due to trolling

You... you just keep on talkin' about things that you know very little about, don't you?
Spoken like a true med-student.

 

[DocEspana]

EDIT: original quote removed; original message deleted due to trolling

thats complete nonsense. I'm never going to suggest that I CLOSE a chest, but I would take an ED physician (especially an ED resident) over a surgical physician (again, especially if resident v resident) for emergent thoracotomy 100 times out of 100. The training on "do it fast. do it dirty. and do what needs to get done" is rather antithetical to anything else surgeons do. Sure they get trained in this, but its a random outlier in their field where everything is done in a controlled manner and even their uncontrolled unexpected stuff is problem shot in a very regimented way. On the other hand, an emergent thoracotomy is just the peak example of stuff we do to a lesser extent with tons of stuff. I need it done fast and neither group is going to feel super comfortable doing it fast - but one group is at least extremely used to doing stuff 1) fast and 2) that they didnt feel comfortable doing but situations forced their hand.

and thats not hating on surgery, thats admitting that even though they clearly can improvise, their improvisations on a day-to-day basis are very different than what this asks of them while our improvisations are the exact sort of medical hail mary that this asks for.

Also, like I said. Wild west. But also eventually we had to play nice when new staff came around and agreed that the general surgeons need to do some of these emergently (they got plenty of urgent ones that we didnt crack because they stayed alive but still had intrathoracic injuries needing stat surgery).

 

[EMhawkeye]

You... you just keep on talkin' about things that you know very little about, don't you?
Spoken like a true med-student.

👏 yaaaasssss

 

[RustedFox]

ah the ol' "I don't have an argument to stand on but I am the attending and you are the med student" defense

Hey, I was an arrogant jackass as a student, too.
Don't let me stop you.

 

[DocEspana]

Second week at a new hospital, don't know the staff or resources very well

900-year-old dehydrated altered whale with sandpaper tongue comes with afib rvr and a temp around 102

Nursing home, as usual, knows "nothing" about the patient and just has squad kindly leave this warm cadaver at my foot with a BP soft but not crashing

Many nurses try for IV, all fail even with US

I look up in the neck, don't see much

I turn her essentially upside down and sort of see R IJ

I ask for central line kit (this part is MY fault, I just ~asked~ for a kit, didn't look at it)

I run through usual line stuff, a nurse is sterile next to me handing me stuff as I ask for it

I eventually find venous gold through a field of neck blubber under US and pass guidewire. I ask for the rest of the kit and see this is a 13 Fr trauma line. Appalled, I asked for a 3 port 7 Fr central line. They look for a while but no one can find one, just this massive trauma steak knife thing

Eventually I'm like F it, whatever. So I put this massive behemoth in her neck and it looks like I'm murdering her with an ice pick. Procedure goes well

2 things happened afterward.

1) One nurse hung fluids as "bolus" I ordered but the line is fully opened and within 10 seconds half a liter is in her before I realize it in time to slow the flow. Nothing bad happened but watch a bag empty like that was interesting.

2) 20 minutes later got blood results from labs I drew when I placed the line INR was "undetectably high" meaning for our assays > 20. Glad I knifed her good

My very first day as an attending I had such a similar story. We had a code and I got ROSC. I could give a whole long story on all the "cultural" things there that made that ROSC go poorly, but leave it at I was so worried part way through the CPR effort that I said "Okay just get me a central line and I'll get access right now so we can give pressors if they come back." I guess no one had ever asked for a TLC midway through cpr and the code rooms (in a mind blowing bit of oversight) didnt have any. So a tech is running across a big ED to find one and I just go "is that a central line right there?" and the tech sees a kit in a corner and tells me that it is and gives it to me.

It was the trauma cordis. I didnt realize until I had fully gotten the guide needle and guide wire in. So I just sheepishly continued forward as all the techs and nurses just were baffled at this crazy new doc putting in the firehose on the CPR patient. I thought maybe the culture here was cordis on everyone because no one told me that it was odd to see that monster IV go in. It took me a solid 3 months before I admitted to the tech who handed it to me that I had zero intention of putting that line in and that maybe we should stock regular TLCs in the resuscitation rooms.

 

[DocEspana]

If someone ever needs an emergency burr hole or an emergency cric, they should make sure they call you and not neurosurgery or ENT. Those specialists don't have a chance against a wildwest, improvising, "fast and dirty" EM doc like you!

I guess anatomical knowledge and technical skills go out the window when it is an emergency! Now that I think about it, it makes sense because everyone always says you would rather have an ED resident suturing a great vessel instead of a surgical resident.

You accidentally made a really good argument and didnt even realize it. I'd totally take an ED doc every time for a crich (which is not a trach. Just in case we are being fast and loose with terms) in an emergency over ENT. I think every poster here would. But thats not the good point, thats just an obvious one because we just plain see many more emergent crichs than them. The good point is that emergent burr holes have such an incredibly limited indication. Just. Like. Its such an insanely unlikely thing to need - largely because neurosurgery isnt really going to do them if theyre around, so the real indication is someone who is both about to evacuate their brain and is also in such a rural location that the benefits outweigh risks for going medieval on their skull rather than transporting them by whatever the fastest possible method is on every med out there to slow the process. And the only human beings I can think of who would even know how to do a burr hole are some old AF EM docs (cheers to the pioneers) and the neurosurgeons - who again, are not going to do a burr hole given how many better alternatives they have if they are actually there.