Procedure turf war / controversial case

[airwaycart169]

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I am a PGY-2 who prefers inpatient/acute care/open ICU/EM type setting, fast paced and high octane environment and also wants to do his own procedures (central/arterial lines, intubations, thora/paracentesis, LP etc, I’ve tailored my elective rotations accordingly and sought out exposure to these procedures. However I’ve come to realize a lot of these things require heavy aggression. Nobody is going to come “pull” me for a procedure. If you snooze, you lose. Often times I’ll get the “watch this one and you’ll do the next one” thing which is pointless as i can watch any procedure on YouTube and gain nothing from watching a mid level PA/NP scrub who went to school/training for 2 years do it. I’ve always learned by doing, not watching.

So a medical resuscitation was called for a decompensating patient on the PCU floor (initially admitted from the ER, spent maybe a few hours on PCU) whose chart had “acute hypoxic respiratory failure due to COPD exacerbation and severe sepsis secondary to CAP, hypovolemic shock due to GI bleed, Hgb 5.5”, in it…..transfusion RBC was done, trial of BiPAP was done…ABG’s going the wrong way, acidotic/hypercapneic, obtunded, maxed out 100% FiO2 yadayadayada you get the point…getting moved over to ICU.

CRNA was paged by lead attending to intubate, however once she got down i told her that I was the primary and I’m doing the intubation but that she’s welcome to back me up. She did not agree to it, saying this was a very high risk intubation, but i previously purchased my own McGrath video laryngoscope (separate from hospital provided equipment) for these specific situations. After several minutes of disagreement, i eventually physically pushed her out of the way so i could get the intubation, as there was no other way I’d get this opportunity. Did not go as planned and there was blood everywhere, couldn’t really see. I shoved the ETT somewhere but didn’t really have any clue what i was seeing. I wasn’t worried cus i have like 50+ intubations under my belt and some of those i got lucky not really seeing the vocal cords clearly. Anyway got the ETT in and all was good, made my way over to put in invasive line monitoring.

Turns out the ICU-PA who’s been working here for 20+ years was doing the arterial line (R side) without notifying me, at which point i smacked the Arrow out of her hand mid procedure (she had already hit the radial artery and got blood back) and it landed on the floor, contaminating it completely and also losing access on the right.

During all this chaos i was somewhat getting yelled at by these people but didn’t care as I’m trying to get my procedure numbers, so scrubbed myself in to do a left arterial line instead. I told the PA to kick rocks (polite translation for the more R-rated language that was used) as she has significantly less education than i do as a physician, and has no right to supersede me on procedures.

Anyway the ultimate outcome was ok, airway secured and lines placed. How else should I have handled this situation in order to get my procedures while at the same time doing what’s right for the patient?? How can i, as a resident, override mid-levels for my procedure numbers, especially since i plan to do them when i am on my own? Also keep in mind there isn’t all the time in the world to discuss these things. Rapid sequence intubation (RSI) is a rapid fire procedure, no time to waste.

And especially because once I’m on my own, I don’t have any business doing these dangerous procedures unless I’m comfortable doing them, aka I’ve DONE (not watched) enough of them as a trainee/resident, where the medico-legal risk / liability etc isn’t entirely on me?

Thx.

 

[CliveStaples]

 

[Jabbed]

Wow that’s kind of pathetic that you needed to use a McGrath and didn’t DL or cric the patient…

You also completely missed the opportunity to put in a BlakeMore.

I’m not sure that you’re going to get your critical procedure numbers at this rate.

/s

 

[airwaycart169]

I’ve tried DL and have been told I should be comfortable doing them as many institutions won’t have videos, but I don’t like the feel of them and have a much higher success rate doing VL’s.

I’m not opposed to getting in on some of the rarer and lower yield procedures like cricothyrodotomies and Blakemores but am also not naive enough to believe I’ll have enough exposure to them to be credentialed. They may come around once in a blue moon.

I absolutely, however, want to be credentialed in the more common procedures.

 

[Tiger26]

Here's the chatgpt answer, but in short, when you've lost AI, I don't know what else to say (assuming the first post wasn't a parody or joke):

You’ve got the hustle, but bulldozing your team isn’t the move. Shoving a CRNA and slapping a PA’s hand mid-procedure isn’t assertive—it’s reckless. Want more procedures? Earn trust, talk to your attendings, and be someone people want to hand the laryngoscope to. You’re not just here to rack up numbers—you’re training to lead. Skills matter, but so does not being a walking HR incident.

 

[JacobMcCandles]

Here's the chatgpt answer, but in short, when you've lost AI, I don't know what else to say (assuming the first post wasn't a parody or joke):

This is why AI sucks. It gets fooled by an obvious troll post.

 

[airwaycart169]

No, it really isn't even though I can see how it can be interpreted as such by people who haven't seen these types of things done or this type of behavior displayed in real clinical practice. It's really not that different from what I've seen done by some surgeons, except this is more EM/ICU type setting.

Reality is, I've been on the other side, as a medical student/PGY-1 - displaying interest, asking to do stuff, sometimes being told yes but often times being asked to watch this particular one and perhaps get in on the next one (often times the "next one" not actually existing). Difference is now as a PGY-2 I realize how fast time flies and how limited my time is to get what I want. I'm not a medical student anymore. In barely over a year I'm going to be doing this **** on my own.

You can only play nice in the sandbox so many times before you sometimes have to just say f**k it, I'm doing this and don't give a f**k if you approve of it or if it's the conventional way things are done.

The sad reality is many, many residents who actually have interest in being certified in these things ultimately won't due to passivity. It's one thing if you don't care to do them in practice, which is totally fine and in which case you don't need to be aggressive or show interest. But if you want to do them, sometimes this is the way.

 

[Lexdiamondz]

Trolllllolololol

Just for education's sake - folks, this is exactly how a junior resident should *not* act.

 

[RockClimberMed]

Trolllllolololol

Just for education's sake - folks, this is exactly how a junior resident should *not* act.

You may be underestimating the lack of interpersonal skills that, unfortunately, lots of healthcare professionals exhibit.

 

[airwaycart169]

I’m not an EM resident also btw even though I do EM and ICU rotations as part of my residency. If I was an EM resident I suspect these things would be less of an issue as they are required to get certified / hit a minimum # of procedures as part of the program’s requirement. However I still believe it can be done in other specialities without fellowship, but as I said, require serious aggressiveness.

 

[throway134]

2/10 troll 🧌 🧌 post
If 💩 post more like 6/10

No view intubating because of 50 under your belt was a pretty funny line though, got a good chuckle , as was smacking the art line in after blood return and potentially lacerating the artery

this behavior could legitimately get you fired as a resident for any med students: it’s really hard to do, but visibly failing to follow the chain of command (attending requested crna and you ignore them) and prioritizing #s over safety of a patient, as well as directly harming them with the aline —-> pretty crazy.

I also really liked the bit about how they were focusing on getting that life saving a line in. A cvl might have been more believable but less funny, especially in the age of ios

 

[airwaycart169]

Again, we had no idea what the patient’s real time BP was and how much he was bleeding out / how hypotensive he was…there were all kinds of variable and fluctuating reads via the manual cuff…hence the need for the urgent A-line. It’s not that uncommon at all or perhaps it’s just an institutional thing where I train…but A-lines very frequently get done before any other procedure for critically ill patients.

 

[throway134]

Again, we had no idea what the patient’s real time BP was and how much he was bleeding out / how hypotensive he was…there were all kinds of variable and fluctuating reads via the manual cuff…hence the need for the urgent A-line. It’s not that uncommon at all or perhaps it’s just an institutional thing where I train…but A-lines very frequently get done before any other procedure for critically ill patients.

If we wanted to engage as though this weren’t fiction, when you get variable readings from an automatic cuff, you do a manual one.

If you have more than one person in the room who can do it, it’s reasonable to get the a line in while someone else is placing the cvl or more likely two ios. Of course, in a troll post this would apparently be the time to slap it out of their hands, since apparently doing procedures any monkey can do is more vital than learning how to take control of a situation, calm and direct a room, lead or make clinical decisions like a physician.

 

[airwaycart169]

It's a real case. Again, perhaps just an institutional thing/difference. For a 60+ BMI patient with arms as wide as tree trunks, I don't know how successful the nurses would be getting a manual read (not sure if they even tried but there was so much chaos going on that i don't know). I'm well aware manual reads are more accurate than automatic cuffs but here where I'm at, if someone's BP is tenuous or unclear and they are very sick, they get an arterial line. Who knows if it's the right or wrong thing to do, but its the way stuff works at my facility.

Thankfully for us after i got the A-line in and saw the persistently sub 55 MAPs (instead of the fluctuating reads of 120s/70's followed by 80's/40's) I was able to appropriately start Levophed and vasopressin, something I wouldn't have known was required without the A-line.

Central line was placed as well...AFTER the intubation and arterial line.

I agree any monkey can do the procedures, but not if they haven't done enough of them. As with everything from the days of med school to my current level - repetition is the key. More reps = more proficiency. I can't be proficient in lines and intubations if i've only done 4 of them. I also can't control when these types of situations (med resuscitation, stat intubation/line necessity) arise.

I can go a f***ing week on a rotation without any of these situations happening. Or i can get 3 of them in 1 day. So when the situation arises I make my presence known cus it's the stuff I want to get comfortable with when I'm the person (not my supervisor) who can get sued next year if things go wrong.

 

[Powdermonkey]

I really hope I never have to work with you. You sound like you suck as a human. And a teammate. That is, if you're real.

 

[dozitgetchahi]

I really hope I never have to work with you. You sound like you suck as a human. And a teammate. That is, if you're real.

I think it’s entirely possible that this is a real resident lol. If I’ve learned anything in dealing with folks in this profession, it’s that a surprising number of them have poor self awareness and/or crazy beliefs etc. So this may not have been a story.

 

[airwaycart169]

Not crazy at all. Just want to get good. Sick of the "get the next one" or "this one's too risky" stuff. Dealt with enough of it as a student and intern. Your training time is limited (few yrs) and your areas of expertise are dependent on how much you physically did, not passively watched on the sidelines. I also have nothing against midlevels but part of my motivation stems from the fact that if they (lesser educated/lesser trained providers) can do these things, I should be able to do them in my sleep.

 

[EctopicFetus]

Not crazy at all. Just want to get good. Sick of the "get the next one" or "this one's too risky" stuff. Dealt with enough of it as a student and intern. Your training time is limited (few yrs) and your areas of expertise are dependent on how much you physically did, not passively watched on the sidelines. I also have nothing against midlevels but part of my motivation stems from the fact that if they (lesser educated/lesser trained providers) can do these things, I should be able to do them in my sleep.

Ill pretend this is real but if it is and not a troll post you need help.

1) you picked the wrong residency. I had a ton of procedures in residency. So do my residents. Acting like a little snot (lack of better language) is never appropriate and is never appropriate during a legit resuscitation. If this happened and i was around I would throw your butt out of the room. Call security etc. Selfish behavior should not be accepted. Sure it exists to some degree but your “numbers” are secondary to you know.. the patient..

Again, the way you told the story and the story itself sounds so far out of reality it has to be a troll post. If it isnt you need help cause you will have an exceedingly short career.

 

[airwaycart169]

You are incorrect. I picked my residency fine but am tailoring/customizing it to include skills that I want to have in my toolbox for when these situations arise. Hate to break it to you but EM isn’t going to be doing procedures for every patient on the floor, PCU, ICU etc. Most places they’re only required to do it for patients physically in the ER. I just want to be prepared for anything as a real physician, which isn’t residency - it’s attending life.

I didn’t compromise patient safety either. I got the airway secured via VL but more importantly didn’t interrupt someone else doing the intubation. Plus you can bag forever anyway as they all keep saying in the event that I did mess up someone else’s intubation.

Arterial line is not a central line…way lower risk procedure. Not going to hit the carotid or cause a pneumothorax or a vascular catastrophe or something messing up someone else’s A-line.

 

[WhatJobDoIPick]

At first I thought this was a troll but not I think it's a psychopath

 

[TooMuchResearch]

You are incorrect. I picked my residency fine but am tailoring/customizing it to include skills that I want to have in my toolbox for when these situations arise. Hate to break it to you but EM isn’t going to be doing procedures for every patient on the floor, PCU, ICU etc. Most places they’re only required to do it for patients physically in the ER. I just want to be prepared for anything as a real physician, which isn’t residency - it’s attending life.

I didn’t compromise patient safety either. I got the airway secured via VL but more importantly didn’t interrupt someone else doing the intubation. Plus you can bag forever anyway as they all keep saying in the event that I did mess up someone else’s intubation.

Arterial line is not a central line…way lower risk procedure. Not going to hit the carotid or cause a pneumothorax or a vascular catastrophe or something messing up someone else’s A-line.

By your own account, you shoved someone who your attending called to intubate a patient so you could do it.

If this isn't a troll post, I suspect you may be unemployed soon.

I am blocking this account and will not check the thread again.

 

[airwaycart169]

Like most in this thread you’re not interpreting the situation correctly. It’s standard protocol that Anesthesia gets at least called to intubate in these situations. It generally goes to some CRNA pager. The attending never said “I don’t want my resident intubating”.

Often times the CRNA will be ok with me intubating if I ask. Not always but many times yea. This was my patient anyway and I assumed responsibility as I was taking over as the primary service.

CRNA’s aren’t that advanced either. They’re basically like PA’s and NP’s. No reason they should get dibs on a procedure especially if it’s on my own patient. Sry but that’s how it works (or at least should work).

 

[EctopicFetus]

Like most in this thread you’re not interpreting the situation correctly. It’s standard protocol that Anesthesia gets at least called to intubate in these situations. It generally goes to some CRNA pager. The attending never said “I don’t want my resident intubating”.

Often times the CRNA will be ok with me intubating if I ask. Not always but many times yea. This was my patient anyway and I assumed responsibility as I was taking over as the primary service.

CRNA’s aren’t that advanced either. They’re basically like PA’s and NP’s. No reason they should get dibs on a procedure especially if it’s on my own patient. Sry but that’s how it works (or at least should work).

Im gonna try to remain nice.

Every attending one here thinks you are out of your mind. If you arent an EM resident why are you on the EM forum. Talking to the experienced attendings here like we are college sophomores leads us to believe this is a BS post. Again, why on this forum? My guess you are yourself a low skilled noctor trying to troll us. Again, if you arent an actual physician you will have a very brief career based on your post.

“, i eventually physically pushed her out of the way so i could get the intubation, as there was no other way I’d get this opportunity.” “smacking” an A line.. touching people at work will get your ass fired. Touching someone like this during a peri-arrest situation will get your medical license taken away.

You took over as primary service.. what does that mean? What kind of resident are you? IM? FP?

 

[JacobMcCandles]

You’re a troll or an idiot. Maybe both.

 

[airwaycart169]

Im gonna try to remain nice.

Every attending one here thinks you are out of your mind. If you arent an EM resident why are you on the EM forum. Talking to the experienced attendings here like we are college sophomores leads us to believe this is a BS post. Again, why on this forum? My guess you are yourself a low skilled noctor trying to troll us. Again, if you arent an actual physician you will have a very brief career based on your post.

“, i eventually physically pushed her out of the way so i could get the intubation, as there was no other way I’d get this opportunity.” “smacking” an A line.. touching people at work will get your ass fired. Touching someone like this during a peri-arrest situation will get your medical license taken away.

You took over as primary service.. what does that mean? What kind of resident are you? IM? FP?

Look, I'll try to explain this nicely to you as well. I posted it on this forum cus I just got off my EM rotation and segued into ICU now (patient was also in the ER initially). EM is where I learned the bulk of my procedural / resuscitation skills. I don't claim to be an expert, but I am better than average given the interest level I show on EM where I get a lot of intubations and lines, and extra time I spend with Anesthesia on elective rotations. F***, I even come in on days off /weekends on occasion to the ER to get procedures.

I respect the **** out of EM. It's one of my favorite rotations in my residency. Yes, IM resident (picked IM over EM as I prefer longitudinal and chronic care over initial triage/stabilization/dispo to another department) with hopes to either do a critical care fellowship or more preferably given the financial/economical benefits of skipping one and going straight into practice, just work in acute care/inpatient/open ICU internal medicine doing all my own procedures. I know attendings both FM/IM who do all their own procedures and given the difficulty of getting #'s in a non EM/critical care residency/fellowship, I asked them how they did it and they said it was just by being *AGGRESSIVE* and seeking these procedures out, spending extra time in ER specifically. Though I am aware this is the minority, however it absolutely can be done. I'm also fairly convinced I can do a better job at EM itself than most of the PA's and NP's who are working there.

There is no EM residency where I'm at, in fact it's a fairly unopposed program in terms of residencies so when I'm on EM or even ICU there's not the same competition for procedures (at least with residents) as there would be if there was an EM/Anesthesia residency, ICU fellowship, etc. I get top evaluations from all my EM supervising attendings when I'm on that rotation. They all say I'm great to work with.

I smacked the A-line away from the PA, didn't smack her personally. Again - reading is key.

I'll once again pose the alternative situation which many of you may agree with - just stand there and do nothing. Just watch from the sidelines. Let lesser degree having and lesser trained people do what I want to do with far more education and training. If that's the way you think things should be done, that's fine. Personally i'm not leaving any stone unturned during my training.

I know far too many attendings who told me they wish they had done more and been more assertive during their residency.