procedures for hospitalists working at nights

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Seriously. Jesus h christ everyone has their own comfort level and way of doing things. I manometer every line unless it's a crash line. It also depends on your training and skill set.

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It is n00bz who hit big red using ultrasound. Artery and vein look completely different if you know what you are doing.
 
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This is one of the big reason I would feel uncomfortable doing a nocturnist position. I am not the best on procedures, while I would like to do them, I am pretty bad with hands-on activities and procedures are my Achilles heel. If I know that there is support in case of an emergent intubation or central line, that would at least make me feel a bit comfortable. Otherwise, I fear I would be too dangerous to be alone at night :(
 
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Not much to add, but completely varies based on the culture and what sort of coverage your hospital has so you would need to ask around.

I did IM at a smaller community program so we got plenty of lines/tubes. We didn't have any in house attendings besides whoever was in the ER and they did NOT like coming to floor to help out so we were expected to get comfortable with US guided central lines and intubations early on.

I agree with a comment about experience with intubations. True, most may be fairly straight forward, but if they go bad they can go REALLY bad quickly.
 
The IM residents at my program get really crappy procedural training. The EM/IMs run the invasive procedure team and end up doing pretty much all of the LPs, midlines, paras, etc that the IM residents should be doing on their own. We got so overwhelmed with calls for US guided IVs that we had to just flat out stop doing them. While it initially was great training for me, now it is just a time suck and an annoyance.

IMO every IM resident should be comfortable doing basic procedures on the floor like paras, LPs, IVs, paras, etc.
 
The IM residents at my program get really crappy procedural training. The EM/IMs run the invasive procedure team and end up doing pretty much all of the LPs, midlines, paras, etc that the IM residents should be doing on their own. We got so overwhelmed with calls for US guided IVs that we had to just flat out stop doing them. While it initially was great training for me, now it is just a time suck and an annoyance.

IMO every IM resident should be comfortable doing basic procedures on the floor like paras, LPs, IVs, paras, etc.
Well that's what happens when you don't share... If your em/im program decided to take all the procedures on then you can't complain about getting asked to do said procedures... Maybe the shift needs to be that either the invasive procedure team supervises the resident with the procedure or only the failed or complicated procedures go to the procedure team.
 
The IM residents at my program get really crappy procedural training. The EM/IMs run the invasive procedure team and end up doing pretty much all of the LPs, midlines, paras, etc that the IM residents should be doing on their own. We got so overwhelmed with calls for US guided IVs that we had to just flat out stop doing them. While it initially was great training for me, now it is just a time suck and an annoyance.

IMO every IM resident should be comfortable doing basic procedures on the floor like paras, LPs, IVs, paras, etc.

Wait so you guys steal all the procedures and now you're mad that no one else can do them? LOL

Not their fault that they can't do paras or paras
 
Wait so you guys steal all the procedures and now you're mad that no one else can do them? LOL

Not their fault that they can't do paras or paras

Haha. Reminds me of an EM intern that rotated with us when I was in the MICU as an intern. Never wrote notes and would be the first to jump in on any lines or procedures whether or not it was his patient. Needless to say people didn't take kindly to that
 
Wait so you guys steal all the procedures and now you're mad that no one else can do them? LOL

Not their fault that they can't do paras or paras

We do this on top of our regular floor months so it is not exactly a good time. Managing 20 patients and having to do everyones procedures sound like a good time to you?
 
Haha. Reminds me of an EM intern that rotated with us when I was in the MICU as an intern. Never wrote notes and would be the first to jump in on any lines or procedures whether or not it was his patient. Needless to say people didn't take kindly to that

Wrong I manage an entire medicine team WHILE doing the entire bloody hospitals paras, LPs, etc. Im more than happy to teach, but the medicine residents for the most art are not interested. They just want me to do the procedure for them.
 
Haha. Reminds me of an EM intern that rotated with us when I was in the MICU as an intern. Never wrote notes and would be the first to jump in on any lines or procedures whether or not it was his patient. Needless to say people didn't take kindly to that
It's like an EM intern during my TRI year. Patient was in hepatic encephalopathy and just barely protecting his airway. Instead of joining the senior, other intern, and ICU fellow at the foot of the bed, she just assumed that the patient would be intubated any positioned herself at the head of the bed assuming she would get the intubation (granted, this is what the program director told them to do... poach procedures instead of working as a team). The look was priceless when we ordered some lactulose instead. By AM, the patient was A/Ox4.
 
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We do this on top of our regular floor months so it is not exactly a good time. Managing 20 patients and having to do everyones procedures sound like a good time to you?
I think we all agree this is a terrible setup. But it sounds like somebody in your program decided at some point that it was a good plan. Instead of (or perhaps in addition to) kvetching about it here, consider bringing it up with your program leadership.
 
Wrong I manage an entire medicine team WHILE doing the entire bloody hospitals paras, LPs, etc. Im more than happy to teach, but the medicine residents for the most art are not interested. They just want me to do the procedure for them.

I find this a little bit amusing :p
 
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Wrong I manage an entire medicine team WHILE doing the entire bloody hospitals paras, LPs, etc. Im more than happy to teach, but the medicine residents for the most art are not interested. They just want me to do the procedure for them.

That sounds like a systemic issue that your hospital needs to fix. I've also had medicine residents/interns "not interested" in these procedures. To which my response is generally, "too bad, this is your patient and you need to learn how to do this". I don't tolerate the "oh I'm going into nephro/ID/endo/nonprocedural subspecialty" excuse. I'm a cardiology fellow and will never have to do a para or thora in practice again but I still did my damn job and learned them because it was a valuable part of my training.
 
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It's like an EM intern during my TRI year. Patient was in hepatic encephalopathy and just barely protecting his airway. Instead of joining the senior, other intern, and ICU fellow at the foot of the bed, she just assumed that the patient would be intubated any positioned herself at the head of the bed assuming she would get the intubation (granted, this is what the program director told them to do... poach procedures instead of working as a team). The look was priceless when we ordered some lactulose instead. By AM, the patient was A/Ox4.

So you didn't intubate a patient that was encephalopathic and had a questionable airway? Yea, the proactive intern who thought they would intubate and learn a skill valuable for their practice as well as gauruntee the safety of the patient is the jackass....
 
So you didn't intubate a patient that was encephalopathic and had a questionable airway? Yea, the proactive intern who thought they would intubate and learn a skill valuable for their practice as well as gauruntee the safety of the patient is the jackass....


The patient was still protecting their airway to the point where even the ICU fellow was comfortable with some initial monitoring and we treated the encephalopathy that showed quick resolution while avoiding the dangers with putting a patient into respiratory arrest, introducing a plastic tube that bypasses multiple immune processes and avoiding subjecting the patient to mechanical ventilation. Intubation and mechanical ventilation is not exactly harmless.

Meanwhile the only thinking that the EM intern did was "Less than 8, intubate" instead of, you know, evaluating the patient, looking for reversible causes of altered mental status, and treating said reversible causes. ...but you know, screw appropriate medical practice and subjecting a patient to all sorts of other dangers if it means you get to do cool, ultimately unnecessary procedures to the patient, right?


BTW, all of the drunks with EtOH levels of 300-400 should be intubated because they're difficult to wake up and have a GCS <8*... because procedures are cool, harmless and we don't have to think past simple assessment tools!

*Because if I try to push you to wake you up and you just roll over, don't open your eyes, and mutter something, then the GCS is going to be terrible, regardless of whether you're protecting your airway or not.
 
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The patient was still protecting their airway to the point where even the ICU fellow was comfortable with some initial monitoring and we treated the encephalopathy that showed quick resolution while avoiding the dangers with putting a patient into respiratory arrest, introducing a plastic tube that bypasses multiple immune processes and avoiding subjecting the patient to mechanical ventilation. Intubation and mechanical ventilation is not exactly harmless.

Meanwhile the only thinking that the EM intern did was "Less than 8, intubate" instead of, you know, evaluating the patient, looking for reversible causes of altered mental status, and treating said reversible causes. ...but you know, screw appropriate medical practice and subjecting a patient to all sorts of other dangers if it means you get to do cool, ultimately unnecessary procedures to the patient, right?


BTW, all of the drunks with EtOH levels of 300-400 should be intubated because they're difficult to wake up and have a GCS <8*... because procedures are cool, harmless and we don't have to think past simple assessment tools!

*Because if I try to push you to wake you up and you just roll over, don't open your eyes, and mutter something, then the GCS is going to be terrible, regardless of whether you're protecting your airway or not.

It would teach them a lesson
 
I think it is very unfortunate that programs do not put more emphasis on procedural competence. I have been an attending all of three and a half months now, and have already been in the position where I was the only one available to tube a patient, needed to do a crash line, and had several times when procedures were really quite emergent and patient care would have been compromised had I not done them myself. Yes, I put myself in a job where this kind of thing happens. But, if you're going to be working in the hospital, you're going to occasionally find yourself in situations where you have to perform life saving procedures. The reality is that two good months, one on a procedure service and the other with anesthesia, if those months are good and serious about teaching the residents, can prepare you very well for the times when these things happen. I didn't get the amount of training I want--airways still scare the crap out of me even though I am credentialed to do them--and I'm continually working on improving my skills--but if I had one thing I could change about my residency, it is that I would want the training to be much more rock solid on procedures. Whenever I discussed it in residency, I felt that many people considered them to be a box that gets checked on your way to graduation, and not necessarily a core part of the job. My opinion is that a good internist should be able to handle the first 24 hours of any critical illness (with phone support for the exotic cases--i.e. obviously if I have a crumping pHTN patient on a vent, I'm gonna need some advice....). Reason being, for a large swath of our country, your patient is a good 24 hours away from the service of an intensivist. If we don't keep them alive, they don't live. Yes, its great if the ER doc will come do your lines for you. See how you feel arguing with a busy ER doc about whether your patient really needs a line at 3:00 AM.
 
I think it is very unfortunate that programs do not put more emphasis on procedural competence. I have been an attending all of three and a half months now, and have already been in the position where I was the only one available to tube a patient, needed to do a crash line, and had several times when procedures were really quite emergent and patient care would have been compromised had I not done them myself. Yes, I put myself in a job where this kind of thing happens. But, if you're going to be working in the hospital, you're going to occasionally find yourself in situations where you have to perform life saving procedures. The reality is that two good months, one on a procedure service and the other with anesthesia, if those months are good and serious about teaching the residents, can prepare you very well for the times when these things happen. I didn't get the amount of training I want--airways still scare the crap out of me even though I am credentialed to do them--and I'm continually working on improving my skills--but if I had one thing I could change about my residency, it is that I would want the training to be much more rock solid on procedures. Whenever I discussed it in residency, I felt that many people considered them to be a box that gets checked on your way to graduation, and not necessarily a core part of the job. My opinion is that a good internist should be able to handle the first 24 hours of any critical illness (with phone support for the exotic cases--i.e. obviously if I have a crumping pHTN patient on a vent, I'm gonna need some advice....). Reason being, for a large swath of our country, your patient is a good 24 hours away from the service of an intensivist. If we don't keep them alive, they don't live. Yes, its great if the ER doc will come do your lines for you. See how you feel arguing with a busy ER doc about whether your patient really needs a line at 3:00 AM.
Advice on how one can get procedural experience in a large academic program?

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Advice on how one can get procedural experience in a large academic program?
Ask for it.

Trust me, there are plenty of procedures to go around, and relatively few people who want to do them (unless you're in a place with more fellows than residents, in which case you'll have to fight them for procedures). Don't push anyone aside, and don't neglect your own patients, but be available and it will happen.
 
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Advice on how one can get procedural experience in a large academic program?

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Yes, you need to ask for it. Make sure your attendings know you are interested. I got more comfortable with intubations after I made sure all the ER attendings knew I really wanted to do them. They would call me when they had one for me. Also, and this may make me sound like a dick, but in third year I just let it be known when I was on in the ICU that the interns would not get procedures. I took them all, with the exception of IJs since I had done so many of those. Sad but I had to do it to build the skills. Its horribly uncomfortable to do that, but people understood. And I got a lot of procedures from attendings who just knew I was interested and called me when I had one. Yes, it sucks when you're on call at 2Am and manage to get some sleep and the ER calls you to let you know there is an LP--but if you go there and do it, they take note, and more procedures come your way. And then, once you are an attending, you have to remain committed to doing the procedures to stay competent and get better.
 
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I'm an ED resident that moonlights at a pretty small, low volume ED, and smallish hospital where overnight its me and a hospitalist. Small 6 bed ICU (at best step down at my residency). If a code happens both I and the hospitalist respond which has happened twice (1 real code and 1 syncope). I have also been called by the IM doc once to come do an intubation and once to put in a central line. Not sure if I am in the minority but I actually like this setup. Granted if I am slammed in the ED, like at my place for residency, I cannot take the time to go to the floor. Still I think I have much better relationships with the IM docs where I moonlight because I have actually done something for them instead of just giving them work. Going to a hospital with a similar set up and I would like to think this is great for building relationships and I like doing procedures. I think it is a win win for both of us.
 
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I'm an ED resident that moonlights at a pretty small, low volume ED, and smallish hospital where overnight its me and a hospitalist. Small 6 bed ICU (at best step down at my residency). If a code happens both I and the hospitalist respond which has happened twice (1 real code and 1 syncope). I have also been called by the IM doc once to come do an intubation and once to put in a central line. Not sure if I am in the minority but I actually like this setup. Granted if I am slammed in the ED, like at my place for residency, I cannot take the time to go to the floor. Still I think I have much better relationships with the IM docs where I moonlight because I have actually done something for them instead of just giving them work. Going to a hospital with a similar set up and I would like to think this is great for building relationships and I like doing procedures. I think it is a win win for both of us.

Interesting that you feel this way. Awesome.
 
It may change as I go along and procedures are not as fun. Also realize that in a busy place this would be a huge pain if the waiting room is full. But seems like the hospitalists knowing if they don't feel comfortable they can call me has made a huge difference in our interactions. Worth it to be inconvenienced once in a while.
 
Honestly I kind of miss some of the procedures I did in residency, particularly intubations and IJs. I guess I've traded out for some cooler ones though. ;)

But I echo what's been said above. If you show your interested and ask then you'll get procedures. I think there's enough IM residents who are not interested in these type of procedures to balance it out but for the most part no one is going to go out of there way to track you down to do one.
 
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