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