procedures as student?

Discussion in 'Clinical Rotations' started by larryj, Sep 9, 2002.

  1. larryj

    larryj Member
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    What is an average (or minimum) number of the following procedures that a student should do/ have done by the end of 4th year, before starting residency:

    LP
    vaginal deliveries
    flex sig
    other endoscopies
    casting
    central line placement
    arterial line
    intubation
    vaginal exam/pap
    chest tube


    Feel free to add to the list.
    I realize there may be a great deal of variation from school to school. This is why I am asking for averages, or what is felt to be the minimum acceptable level.

    If you would prefer to just share your personal experiences/numbers that would be great as well.

    thanks.
     
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  3. droliver

    Moderator Emeritus 10+ Year Member

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    Its been a few years but I prob. did

    - 10 central lines
    - 30 central line changes over wire
    - 3 arterial lines
    - 5 Swann-Ganz catheters
    - 2-3 chest tubes
    - 5-6 vaginal deliveries
    - 3-4 intubations
    - 10 closed reductions and castings
    - 2 infusaport placements in the OR
    - 1 BKA
    - 2 breast biopsies
    - 10-14 vaginal exams with colposocopy
    - no endoscopy as such
    - 3-5 LP's
    I think some of my numbers are higher than usual b/c I did essentially 3 AI months of surgery my 4th year including one late in the year where they turned me loose in the ICU. I really had little interest in OBGYN & passed up as many deliveries as possible
     
  4. tussy

    tussy Senior Member
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    Hmmm, I probably did:

    5 LP
    30 vaginal deliveries
    5 flex sig
    5 other endoscopies (got to back the scope out of the colon and look around the stomach)
    40 casting
    1 central line placement
    0 arterial line
    40 intubations
    50 vaginal exam/pap
    1 chest tube
    2 carpal tunnel releases
    few biopsies of skin lesions
    3 thoracocentesis
    5 paracentesis


    I probably did more than most as i did a lot of surgery electives. AS for what students should do before graduation .. I would think that the list should include LPs, vag deliveries, casting, intubation, chest tubes. The rest is just gravy!
    Feel free to add to the list.
    I realize there may be a great deal of variation from school to school. This is why I am asking for averages, or what is felt to be the minimum acceptable level.

    If you would prefer to just share your personal experiences/numbers that would be great as well.

    thanks. [/B][/QUOTE]
     
  5. DocWagner

    DocWagner Senior Member
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    I think you will find that procedure numbers will vary...regardless of true numbers or the "not so true numbers".
    Exposure to all procedures are nice, because it really doesn't count till they are performed independently as an intern etc. And it will be absolutely amazing how quickly you will forget how to the basics by the time you start up again as an intern. One would like to think it isn't true...but it is.
    Just try to do a little of each, in as many different formats as possible.
    Example: If you are able, do an LP in sidelying and seated.
    Try an intubation (in the OR) with a straight and curved blade.
    Try a femoral, IJ, and subclavian central line. etc etc

    Good luck
     
  6. droliver

    Moderator Emeritus 10+ Year Member

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    DocWagner,

    Just a technical point, but I wouldn't reccomend practicing femoral approaches for central lines except as a last resort, your infection rate is just too high to do these except in the most extreme cases. I also no longer do subclavian approaches if I can avoid them b/c I think 1) the anatomy is less predictable and 2) you never know who might need dialysis down the road & you will predictably casuse stenosis of the subclavian veins with central lines which can preclude upper extremity fistula or shunt creation (and literally take years off someone's life who is in ESRD & not a transplant candidate as you run out of access for dialysis)
     
  7. DocWagner

    DocWagner Senior Member
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    Though your comment is greatly appreciated, i will state the following.
    According to the Ohio Academy of Emergency Medicine educational guide for invasive procedures in the Emergency Dept, it is the preferred site for emergent lines.
    Why? Allows others to be at the head of the bed during an emergency (rather important point)...if used for short durations (1 week) there is no longer infection rate than at other sites...if the patient is on unknown meds (ie possible coumadin), better to hit the femoral artery than the carotid! Overall, it produces less anxiety to the conscious patient than the IJ.
    But common IM practice usually states that the "femoral line has higher infection"...not sure if i really buy into it, if you take care of your site.
    Overall, the IJ is a great site, and is often the preferred.

    It is always good Karma to have as many options as possible, and I can absolutely say that I need to practice them all!

    thank you for your point.
     
  8. droliver

    Moderator Emeritus 10+ Year Member

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    DW,

    there are multiple studies showing large differences in the rate of line infection by site (femoral >>> Jugular > subclavian) as well as by the choice of topical agent to prep the skin (Hibiclens preps have lower rates of infection than Betadine). There have been a # of antibiotic or antimicrobial (silver) impregnated catheters on the market purported to lower the infection rate, but they seem not to make much difference in a # of studies I've seen & are a lot more expensive (I think bone-marrow & burn ICU's would be the logical places for them if you did it selectively). I'm pretty sure that even @ 1 week there statistically signifigant differences in infection rates for groin lines versus the other sites. The location in the hospital where the lines are put in also has an affect for both lines & chest tubes with the ER having the highest complication/infection rate -> floor -> ICU -> OR. Each episode of line sepsis with septicemia costs several thousand dollars in abx. (even more for MRSA or VRE) alone to treat and adds days to hospital stays

    Another reason to avoid femoral lines I saw published last year is that when ACLS drugs are introduced this way, they don't reach high enough levels to work well (and unfortunately codes are where I've had most occasion to need to access the groin :confused: ). I'm not sure whether you get much less anxiety via a groin approach, frequently I've found them much harder to identify landmarks in & you end up doing more probing around in than the neck (I think a fat neck is much easier than a fat groin any day). In people that are anti-coagulated I would still prob. go neck over groin, I just wouldn't let someone without a lot of experience do it & I think most of my colleagues would agree.
     
  9. DocWagner

    DocWagner Senior Member
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    I think it would stand to reason that if lines are performed in the ED (emergently as they enter the door), chance of survival/complication rate ...or even making it to the ICU or the floor for that matter is dramatically reduced, regardless of line placement. Those people are as bad off as you can get.
    And as you know your ABC's, airway before circulation, typically the head of the bed is a busy place and the inguinal area becomes a practical approach. These are recommendations by the Ohio College of Emergency Physicians...not making them up.

    I am not feverishly arguing, just stating that I have yet to see these high infection rates for the emergent line... If I had the choice in an immunocompromised patient, I certainly would choose anything that was on my side.
    Regarding ACLS drugs...if peripheral access is needed during a code, you take what you can get. I have a hard time believing femoral access decreases availability of epi (etc), especially considering you can administer epinephrine, narcan etc via orotracheal intubation tubes and you simply double the dose (as per ACLS protocol). Poor cardiac distribution has more to do with C.O. (chest compressions etc) than with where you administered the epi.

    Regardless, it is certainly very valuable to practice as many approaches as possible.
    Your points are certainly well taken and I believe the IJ approach to be wonderful and one of the many tools in the ole toolbox.

    I am sure we have answered the question that was originally asked. I appreciate your input and your comments. Take care, I have a meeting.
     
  10. droliver

    Moderator Emeritus 10+ Year Member

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    ethan,

    the ? of bioavailability of acls drugs via femoral lines is out there in the literature, it doesn't mean that we shouldn't use them in a pinch, its just a phenomena that I guess we have to recognize when we do QC for ACLS protacols.

    As for line infection rates in the ER (emergent or otherwise), this is another well-recognized risk-factor & these are removed ASAP in the ICU here & many other institutions

    cheers!
     
  11. LaCirujana

    LaCirujana Smoking Gun
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    In answer to the original question, something in the neighborhood of:

    10+ central lines
    30-35 line changes over a wire
    5 Swan-Ganz catheters
    2 chest tubes
    2 thoracenteses
    2 adult LP's; 8 pediatric LP's
    8-10 art lines
    0 endoscopic procedures
    1 lap chole
    1 AKA
    3 appys (open)
    1 umbilical hernia repair
    >50 vag. deliveries (I went to med school in Utah--very high birthrate)
    1 PD catheter placement
    5-7 permacath/portacath placements
    way too damn many pelvic exams/Pap smears
    25 or so intubations
    0 castings
    multiple skin ditzel excisions (in-office type procedures)

    I notice that those of us who've responded probably have higher numbers than most, and all of us are surgery residents, so we had more procedure-oriented sub-I's and/or SICU rotations. I doubt most medicine/less procedure-oriented specialties would have quite as much hands-on exposure as we did.

    In response to the groin line debate--we only put groin lines in in trauma situations or as an absolute last resort, when no other access is available. Trauma lines come out ASAP and get replaced under sterile conditions with either an IJ or subclavian line. That's how we did it where I went to med school (all 4 hospitals), as well as how we do it where I am currently training.
     
  12. DocWagner

    DocWagner Senior Member
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    OK I will say just once more...femoral lines, though not the ideal for all situations, are a valid and useful approach. Risk of minor infection is far safer than dropping a lung any day(especially in the short term), EXCEPT in the immunocompromised or those whom need a longer term triple lumen. I used them in critical care as they were preferred by the CC docs, and in most situations, the lines were gone shortly (a week).
    This really is a non issue and is probably more institution based DOGMA than anything else. Nonetheless, IJ is usually the best on the floors.

    As for ACLS protocol, I really do think it is nonsense. Sorry dude, if an "epi pen" used sub-q gives a systemic dose of 0.3 mg epinephrine, then I think 1 mg of epi given femoral line will do just fine. Perhaps you heard this regarding some atypical ACLS drug, but considering most ACLS drugs are given via peripheral lines anyway (via EMT), I think a femoral line will be dandy. Really if the patient is coding, any vein will do...like I said previously, orotracheal route via intubation tube is OK.
    ACLS guidlines state that since the IJ and subclavian lines are closer to the heart that perhaps it takes less time for them to reach the heart (page 39 of provider manual)... that stands to reason, and I would bet, that is where the true confusion lies. But puting in an IJ or subclavian DURING CPR or intubation is silly. And overlooking a femoral central line to start a NEW line during a code is certainly not recommended. Let's forget this issue.

    Anyway, lets shake hands and agree...learning varied techniques are "good".
     
  13. DOnut

    DOnut Senior Member
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    Dr. Wagner,

    There is no need to even discuss the issue with that guy. It's pointless. He just likes to argue. He was arguing with me about interview ethics in the pre-med form. He has nothing better to do. He fails to realize that some people actually try to get useful info out of these forms.
     
  14. droliver

    Moderator Emeritus 10+ Year Member

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    DOnut,

    has nothing to do with arguing, its teaching someone with years less clinical experience about something I've done 400+ times and know a bit more about. I don't mean for it to be patronizing or condescending if you felt it was such. Some of these things you don't learn unless someone takes an interest in telling you. It's really important I think for ER residents to get as much a sense of some of the later impact of some of the things they may do & never see follow-up on. (Oh and Wagner, do not get caught up in any glorification of nasal intubations, ER thoracotomies, or perc. tracheostomies without a bronchoscope as a good thing as they seem to here)

    As far as whether its ethical, as you seemed to argue, to be dishonest (or at least deceptive) to get into medical school during admissions interviews...... I'm just calling a spade, a spade

    http://www.studentdoctor.net/forums/showthread.php?s=&threadid=44789
     
  15. DocWagner

    DocWagner Senior Member
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    I appreciate your feedback, and I will continue to follow the standard of care in the ED as volumonously discussed with my attendings, program faculty, EM literature, and professional organizations.

    sincerely,
    EW
     
  16. DOnut

    DOnut Senior Member
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    Wow,

    I really hope you are not saying what I think you are.........be careful there buddy that can be taken many ways. I'm giving you the benefit of the doubt, however I don't know too many other meanings except in a deck of cards.

    If there are any comments like this again, I will move to have you ban from posting on student doctor again. I have also alerted the moderator.

    You better check yourself DOCTOR!!
     
  17. droliver

    Moderator Emeritus 10+ Year Member

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    I beg your pardon? :confused: . I don't know what context you're taking that expression in, but it's a very well known expression with Greek origins that means to essentially call something what it is.

    http://www.quinion.com/words/topicalwords/tw-spa1.htm

    Just do a word search & you'll find countless uses of it in day to day language.


    Washington post July 2002 "Calling a Fake Spade a Spade:
    Purse Counterfeiters Keep Diluting the Cachet of a Young Luxury Brand "

    Stands To Reason webzine editorial on abortion politics Summer 2002 "Calling a Spade a Spade"

    BBC UK profile of Irish first minister Seamus Mallom "Mallon: Calling a spade a spade"



    Methinks YOU better check yourself first Doctor..... oops!....student doctor :rolleyes: before firing from the hip on a charge like that
     
  18. DOnut

    DOnut Senior Member
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    This is why I gave you the, "benefit of the doubt". I'm glad to hear that you are not the type of person I almost assumed you to be. It's good to be wrong at times.
     
  19. Tenesma

    Tenesma Senior Member
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    this conversation about central lines really bugs me...

    From an ID point of view (see CDC recommendations), a subclavian placed in a controlled environment (not the ER - unless it is done with fully sterile technique and in no rush whatsoever) has the lowest risk for infection. In the ventilated patient on the floor or in the ICU, the IJ is worse than a femoral line due to increased secretions from trachea or mouth. In the pediatric population, the femoral line has the lowest risk for infection.

    From a trauma point of view, a femoral line is the number 1 site for access - for multiple reasons
    1) easy anatomy
    2) minimal life-threatening complications
    3) patient is usually still in c-collar or moving the neck around or puking
    4) etc...
    There can be no good study stating femoral lines are less effective during ACLS, as a prospective study would be very risky, and from a logical sense it is a bit nonsensical: subclavians and IJs have the tip in right atrium, femoral line has its tip 10 cm inferior to the right atrium - how is that going to change anything to distribution (it is all dependent on cardiac output anyway)??

    From a Hematological point of view: femoral lines suck as 25% of them have been documented to cause DVT - and if the patient has an unknown greenfield (IVC) filter, the J-wire may get caught (just out of bad experience i always use the straight end of the j-wire anyway just to be safe)... also if you don't know their coagulation status things can get risky

    From a vascular point of view: it is much easier to repair a femoral fistula than a carotid one, plus i can remember a few airway emergencies because of botched IJ (IJ tear or carotid leak leading to tracheal deviation and subsequent compression) placed by both upper level surgical and anesthesia residents.

    so for trauma you get a femoral line, for ICU or long-term you get a subclavian, and if you are an anesthesiologist you get an IJ...

    by the way, if you look at the surgical literature that describes femorals as having a higher infection rate (there are only a few studies actually proving this) those studies never took into account that the femoral lines they were studying were actually placed usually under traumatic events, and intrinsically would have a higher infection rate. They have yet to do a randomized prospective study - and if any of you know of one please post a citation (i am very interested).

    droliver, we appreciate your input and the seasoned experience is always welcome - but please provide literature (all of my statements are backed by CDC and their literature citations)

    bottom line: new central line placement should be supervised by a senior resident or attending unless it is under traumatic circumstances and location should be based on considering all factors listed above... at my old institution lines couldn't be placed without getting the OK from a surgical attending (which really made you think about placing a line during the night) and/or having a the senior resident pretty much holding your hand.
     
  20. droliver

    Moderator Emeritus 10+ Year Member

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    Tenesma,

    Here are some references relavent to this. There are literally hundreds & hundreds of papers devoted to central line infection inserted under both emergent & elective conditions. There is an almost unanimous consensus that femoral lines have higher infection rates & this has been demonstrated prospectively multiple times. You can find a few studies however, that have similar (but rarely equivalent) infection rates.

    I am trying to find the paper I saw re. the delivery of ACLS drugs via the femoral route that nobody believes can exist, & yes it does have to do with low cardiac output states & the pooling of blood in the IVC & illiac veins during arrest. In re. to your assertion that this couldn't be looked at prospectively- as you can see below, there actually have been prospective papers comparing femoral & subclavian access during cardiac arrest & they found problems with the femoral approach due to frequent incorrect placement.

    In re. to line placement in tracheostomy patients, I have never heard anyone recommend femoral placement preferentially in these patients. We would typically try to place them in the subclavians & if unsuccessful would almost always go IJ over the femoral approach.

    The rate of pseudoaneurysm in the carotid or femoral artery is very,very low (even when you actually place lines as big as cardiac caths or dialysis catheters into them) & really not much of a concern. For what its worth (in a retrospective "study")I've seen one neck hematoma that required I&D in 5 years & probably about 5-6 groin hematomas.

    As an aside- I would be very reluctant to haphazzardly feed the back of one of those J-wires into a vessel. It is much stiffer than the tip & prone to backwalling the vessel. This is clearly outlined in the inserts for those wires & you are on the liability hook for off-lable useage if you get a complication

    I don't want it to get lost in this discussion that I think all groin lines are bad (I have put many of them in), instead I wish to highlight the fact that they are rarely your site of choice except as DWagner pointed out in some trauma patients (assuming they have no pelvic fx.) & in the neonatal ICU where an IJ placement necessitates a cutdown. A personal bias for me also has to do with the body habitus of the patient- I believe that the infection rate has to be higher for some of these fat patients that you have to have someone retract the panus out of the way for you to see their groin & I will go to extraordinary lengths to stay out of there. I think the ease of site maintainance in the kids makes the infection rate essentially equivalent in them until they get old enough to be obese


    One more thing they don't teach you in school: Do anything you can to not place subclavian central lines or (god-forbid) Shiley dialysis catheters in people that you think will need dialysis in the future. Subclavian stenosis will preclude a upper extremity AV shunt or fistula creation in the future.

    Cheers


    JAMA 2001 Aug 8;286(6):700-7
    Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial
    RESULTS: Femoral catheterization was associated with a higher incidence rate of overall infectious complications (19.8% vs 4.5%; P<.001; incidence density of 20 vs 3.7 per 1000 catheter-days) and of major infectious complications (clinical sepsis with or without bloodstream infection, 4.4% vs 1.5%.as well as of overall thrombotic complications (21.5% vs 1.9%; P<.001) and complete thrombosis of the vessel (6% vs 0%; P =.01);
    The only factor associated with infectious complications was femoral catheterization.Femoral catheterization was the only risk factor for thrombotic complications.
    CONCLUSION: Femoral venous catheterization is associated with a greater risk of infectious and thrombotic complications than subclavian catheterization in ICU patients

    Ann Emerg Med 1990 Jan;19(1):26-30
    A prospective study of femoral versus subclavian vein catheterization during cardiac arrest
    "We found that the success rate for femoral catheterization was 77% compared with a success rate of 94% for subclavian vein catheterization (P less than .05). There were no instances of pneumothorax with subclavian vein catheterization. There was no apparent learning curve leading to an increased success rate during the course of the study. We conclude that femoral vein catheterization should not be used except in those instances where attempts at peripheral and central venous cannulation are unsuccessful."


    J Emerg Med 1984;1(5):387-91
    Femoral venous catheterization during cardiopulmonary resuscitation: a critical appraisal
    "In 31% of the catheterizations the final position of the catheter was not in the femoral vein. We conclude that femoral venous catheterization by inexperienced operators is an unreliable technique during cardiopulmonary resuscitation."

    Infect Control Hosp Epidemiol 1998 Nov;19(11):842-5 Related Articles, Links
    Risk of infection due to central venous catheters: effect of site of placement and catheter type.
    CONCLUSION: Our data support an association between intravenous catheter contamination and insertion at a femoral site.
    Goetz AM, Wagener MM, Miller JM, Muder RR


    Rev Clin Esp 2000 Mar;200(3):126-32
    [The risk factors associated with colonization and bacteremia in non-tunnelled central venous catheters
    CONCLUSION: The present study documents the relevance of prolonged catheterization as a consistent risk for colonization of non-tunnelled central venous catheters. This risk increases independently in canalization at femoral site and particularly among severely ill patients.


    Pediatr Int 2002 Feb;44(1):83-6
    Central venous catheters in pediatric patients--subclavian venous approach as the first choice.
    CONCLUSIONS: We concluded that subclavian central venous catheterization is a safe procedure with minimal complications in pediatric patients. Arterial injury was the most frequent complication. In experienced hands, the success rate was 100%. Subclavian central venous catheter insertion may be considered as the first approach in critically ill patients.

    Nutr Clin Pract 1995 Apr;10(2):60-6
    Femoral catheters increase risk of infection in total parenteral nutrition patients


    Crit Care Med 1995 Jan;23(1):52-9
    Femoral deep vein thrombosis associated with central venous catheterization: results from a prospective, randomized trial
    "CONCLUSIONS: Based on the data from this study, we concluded that femoral vein catheterization is associated with a 25% frequency of lower extremity deep vein thrombosis compared with similar patients receiving subclavian or internal jugular vein catheters"

    .
     
  21. dr. strangelove

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    wow...don't you all think you're spending a little bit too much time about this?
     

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