Procedures during MS3

[a_ditchdoc]

I am currently training in Israel, at what I consider a great program, but I sometimes question the differences in training philosophy here compared to the US. More specifically, I have a question concerning procedures during rotations. Although I have only completed Peds and IM rotations thus far, I have noticed that procedures for students (lumbar punctures, umbilical catheterization, central lines, IV's, etc) are a bit lacking. We will undoubtedly be world champion venipuncturists, as we did this every morning on internal medicine rounds, but some procedures are for the most part hands off for students (this varies with the attending, but seems to be the general concensus). The attendings and residents remark that we will obtain these skills during our prospective residencies. I find it a bit frustrating that I was trusted to do more as a paramedic prior to medical school.

I would appreciate some of your experiences in this area. I am planning on multiple rotations in the US during MS4 and would like to know what is expected of me in regard to technical skills. My program is very receptive to student input, and would perhaps expand our training in this area if necessary, but I would like to know if it a realistic expectation or simply the way that MS3 is structured everywhere.

Any input would be greatly appreciated...

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[Smurfette]

I am currently training in Israel, at what I consider a great program, but I sometimes question the differences in training philosophy here compared to the US. More specifically, I have a question concerning procedures during rotations. Although I have only completed Peds and IM rotations thus far, I have noticed that procedures for students (lumbar punctures, umbilical catheterization, central lines, IV's, etc) are a bit lacking. We will undoubtedly be world champion venipuncturists, as we did this every morning on internal medicine rounds, but some procedures are for the most part hands off for students (this varies with the attending, but seems to be the general concensus). The attendings and residents remark that we will obtain these skills during our prospective residencies. I find it a bit frustrating that I was trusted to do more as a paramedic prior to medical school.

I would appreciate some of your experiences in this area. I am planning on multiple rotations in the US during MS4 and would like to know what is expected of me in regard to technical skills. My program is very receptive to student input, and would perhaps expand our training in this area if necessary, but I would like to know if it a realistic expectation or simply the way that MS3 is structured everywhere.

Any input would be greatly appreciated...

I never did any of those procedures as a med student except for IVs. Most of my residency classmates didn't do any IVs as med students. And I doubt I will EVER do a umbilical catheterization or LP given that my chosen specialty is surgery.

 

[footcramp]

doctors aren't trained to do those things because it's not what doctors do, unlike paramedics. if you are eager to be a doctor then start reading and thinking about patient management, not how to stick a needle into someone's arm.

 

[a_ditchdoc]

doctors aren't trained to do those things because it's not what doctors do, unlike paramedics. if you are eager to be a doctor then start reading and thinking about patient management, not how to stick a needle into someone's arm.

Cramp,

I am eager to be an EM physician, and plan on EM rotations. I just wanted to be sure I wasn't behind in technical skills compared to the US medical students when the time came for my rotations. By the way, in Israel, only physicians start IVs, administer medication boluses, or give blood products. And certainly they are the only ones to do lumbar punctures and central lines. It is just how the system evolved. It is all relative I suppose, hence the question.

Thanks for the input...

 

[orientedtoself]

If you want experience doing procedures as a medical student, think about doing an anesthesia rotation. I got to do several central lines and arterial lines, and many intubations during my anesthesia month. Also, I was able to do a couple of spinal blocks, which are basically LP's with injection of anesthetic.

 

[pillowhead]

I also second doing an anesthesia elective if you want more hands on experience in these procedures.

At my school, medical students are generally expected to know how to do ABGs by graduation and should have an LP and/or a central line or two under their belts. You should just have a feel for the motions but are not expected to be an expert or to even do these things (except maybe ABG) without direct resident supervision.

 

[raspberry swirl]

if it makes you feel any better, im half way through my 3rd year, and i haven't done any procedures either. i haven't even drawn blood.

 

[jennyboo]

lumbar punctures - Heh. Most medical students I know have never done one, or have gotten to try their hand on just one or two. Most of the IM residents I worked with, as well (although one intern said she got familiar with LP's as a medical student after having a patient who needed to be tapped repeatedly). The EM residents learn as interns and get all the LP's they need to get good at them.

umbilical catheterization - Never seen it done, much less done one,

central lines - Got my hands involved in changing a couple of lines over wires as a third year medical student, and start one under direct supervision with lots of help. But now that I'm about to graduate and am all done with my core requirements, I can tell you I (and most US students) wouldn't feel comfortable doing it by myself. Most people learn to both change and start 'em as residents.

IV's - These you can possibly do as a medical student (I've done more than most students), usually if the hospital has poor ancillary staff or if student is pro-active. In my teaching hospital, the residents were "blessed" by having strong ancillary support. Students, of course, therefore have to be proactive if they want to learn.

The attendings and residents remark that we will obtain these skills during our prospective residencies. They're exactly right. Lines and LPs generally fall under the list of procedures you "get" as a resident, not as a student.

I find it a bit frustrating that I was trusted to do more as a paramedic prior to medical school. Yeah, I can understand how that would be frustrating.

I would like to know if it a realistic expectation or simply the way that MS3 is structured everywhere. Not all realistic expectations. But one can introduce a limited experience by doing practice workshops.

 

[a_ditchdoc]

Thanks for all the input. Our schools does have classes to teach us how to insert central lines, chest tubes, etc. And many students have done ABG's. As for Iv's and intubations, I have done many of both of these, it is more the issue of keeping in practice. I was just a little concerned that we were not getting procedures because of a philosophical difference in training. This thread has made me feel somewhat better.

Perhaps the rotation in anesthesiology would be a great idea. I'll strongly consider it...

 

[Telemachus]

For procedure experience I recommend doing anesthesia (lines and airways), EM (lines, airways, LPs, and suturing), Peds EM (LPs and suturing), and Family medicine (skin biopsies, joint injections) during your 4th year.

As for whether or not American med students get a lot of procedures during their 3rd year, it is highly variable. Aggressive students will get more than passive, but nowhere near the experience one can get as a 4th year or of course intern or resident.

 

[Adcadet]

I got to agree - an anesthesia rotation is where you get a lot of procedures - especially i.v.s and intubations, but also some a-lines and PACs if you're a bit lucky. I really think luck has a lot to do with it. I "got" to do chest compressions on a code today, but only because the intern happend to know me. Meanwhile the student on the team caring for the patient just watched. I apologized afterwards, but I wasn't going to start a conversation about who's BLSed or not during a code.

But we're training more to think than do. Any monkey can learn to intubate and we will if we need to do it a fair amount. They key is knowing the when/where/why of the procedures. Just my $0.02.

 

[nutmegs]

I've heard SICU and MICU rotations are good for lines, too. As a 3rd year at my school I've done sticks, IVs, ABGs, dobhoffs, and intubations but I am pretty pro-active in seeking them out. I also chose my school because it has a rep for being procedure-friendly. I know at the ivy-league school in town 3rd AND 4th year students are not allowed to do lines at all... pays to pay attention to these things

 

[carrigallen]

I am eager to be an EM physician, and plan on EM rotations. I just wanted to be sure I wasn't behind in technical skills compared to the US medical students...

Don't worry, ER doesn't tend to do many procedures here anyway - usually they consult surgery or medicine to have basic procedures done. You probably don't even need to learn how to put down an NG tube.

For ER residency just learn - if it involves getting up out of your chair, then you consult another service.

 

[quideam]

Don't worry, ER doesn't tend to do many procedures here anyway - usually they consult surgery or medicine to have basic procedures done. You probably don't even need to learn how to put down an NG tube.

For ER residency just learn - if it involves getting up out of your chair, then you consult another service.

To the OP - That guy was just being a jackass - ER physicians actually do many procedures and are very involved in patient care... but i'm sure you already knew that. Anyway, to answer your question, I think that as time goes by, you'll accumulate enough experience. Doing anesthesia or some of the more procedure-heavy rotations is sure to be a plus, though.

Quid

 

[bldavis11]

be very up front and tell the attendings and residents that you really want to learn how to do the procedures. you'll be golden.

also be noted that it's highly hospital dependent. i got experience at every procedure you listed prior to entering my 3rd year while "volunteering" at the Charity ER in New Orleans before it sunk. most places aren't as chronically understaffed as charity, so it's a different bag.

best of luck,
davis

 

[redwings54]

Hmmm...I am wondering if a lot of these procedures are largely dependent on what hospital you do your clinicals at, who the attendings are and how capable you appear in the eyes of the attendings. If any of you have read Malo's blogs about his rotations, it seems like he has done tons of stuff. Everything from C-sections and deliveries to central lines to intubations to assisting in surgeries. He goes to an osteopathic school so I dont know if that makes a difference. I am hoping to attend UNECOM and wonder how involved MSIII's and IV's are allowed to be during their clinicals. Anyone who has any ideas, I would really appreciate it if you responded. Thanks.

 

[Pollicis]

I'm halfway through my 3rd year and the only 'procedures' I've done is drawn blood and started a few IV's.

 

[Entei]

I haven't even gotten to draw blood or start IVs. 99% of the time, techs do them, and for the other 1%, this exchange happens: "Mr. So and So needs an IV. Want to start one?" "Sure! I've never done one before, but I'd love to learn." "Eh... we'll just find a tech."

The only "procedure" I've gotten to do is put in foleys.

 

[cabinbuilder]

I am 4th year now, I did way more stuff as third year. It really depends on the rotations and the hospital you are at.

Definitely do anesthesia: I was fortunate to be with the open heart surgery cases. I did a central line on every patient who needed one.(about 20)

Intubated everypatient (approx 75 over the month)

Started IV's

Put in NG for bowel surgeries.

During OB/Gyn I did the exams on every pt at the free clinic, did doppler/pelvic ultrasounds, assisted on every birth/C-section. Did all the cultures, sutures, suture removal, cut the cord, extracted the placenta.

In surgery I did countless sutures, ran the camera, put in mess, took out lipomas, stiched Sub-Q, closures, staples, etc.

put in foleys, done my own EKG's

Did autopsies in forensics.

In ER fast track I have more autonomy and do my own cases, suturing, etc.

 

[imtiaz]

it depends what setting youre in. ive rotated at both community hospitals and large academic centers and the experience varies drastically.

at community hospitals you wont get to do anything too invasive. all ive done at places like this is start IVs, a few intubations, and got to suture quite a bit (only subcuticular).

at big academic centers, you pretty much have free reign. you dont "get" to do procedures (especially in surgery), you have to earn them. ive done about 10+ central lines (subclavian and IJ) all with supervision, NG tubes, chest tubes (2), every suture you can think of (fascial, deep dermal, subcuticular), ive even gotten to put lembert sutures in bowel. ive stapled bowel numerous times as well.

your experience will vary based on where you are and how much the residents like you, honestly. the more they like you the more theyll trust you to do invasive things.

 

[Bobblehead]

We don't expect interns to have done any central lines, and if they have done any, likely not using proper sterile technique. As such we walk everyone through their first few central lines. Having some familiarity with the technique may be useful but not knowing anything about it won't cause you to be behind the curve really.

It seems that a lot of central line teaching is done during med school in a surgical situation where the lines don't stay in for long. As such there seems to be less of an emphasis on full barrier precautions and sterile prep. In a medical setting where lines are expected to stay in for a longer period and where line-associated bloodstream infections are a more frequent concern, everyone has to be retaught proper sterile technique.

There is also the matter of teaching the use of ultrasound for central line placement and the proper sterile technique for real-time visualization with the ultrasound.