Procedures

[Pili]

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I have had very little experience with procedures. I have been elbowed out of the way by residents and fellows. I am worried about internship.
I have only done:
1 central line
2 NGTs
2 Foleys
Stapling
Removing stitches
Only 3 stitches of suture
2 paracentesis
1 arthrocentesis.

No LPs, no arterial lines, no IVs, no intubation, NO suturing!!!!

 

[jpro]

Where are you at in TX?

 

[unk_fxn]

I have had very little experience with procedures. I have been elbowed out of the way by residents and fellows. I am worried about internship.
I have only done:
1 central line
2 NGTs
2 Foleys
Stapling
Removing stitches
Only 3 stitches of suture
2 paracentesis
1 arthrocentesis.

No LPs, no arterial lines, no IVs, no intubation, NO suturing!!!!

Mmmm, should have gone to a DO program, actually gotten some clinical experience.

Sorry, couldn't resist. Now for something actually constructive.

Buy or Borrow a good procedure book, like Robert and Hedges or Procedures for Primary Care. Review all the major procedures you are concerned about. Understand the indications and contraindications for all of them, and the anatomy. Then reherse the technique in your mind, step by step. Start with what equipment you will need, how you will position the patient, what you will have your assistant do, and do the procedure in your mind over and over again. Do the same thing right before you actually do the procedure. Then think positive... its a lot like shooting guns or basketballs in that if you think positive, you tend to hit what you are aiming at.

Other good advice:

Primary procedural indication is MEB = maximal educational benefit.

Watch as many as you can. You can learn a lot of good technique that way.

The "Airway Cam" videos will really help you will intubations, you might be able to get those at the library, probably even more helpful than manniquin practice.

The way to get good at a-lines is to get good at abg draws.

Sutures. Everyone says practice on pig parts. This is gross. I think anything nerf works just as well, sometimes the drug reps give away foam heart and crap like that - these work well.

Good luck!

 

[Fantasy Sports]

Mmmm, should have gone to a DO program, actually gotten some clinical experience.

Hard to get that experience when you might have to move to another city just for a specific rotation since you lack a stable academic hospital. 🙄

 

[hemoglobin]

I have had very little experience with procedures. I have been elbowed out of the way by residents and fellows. I am worried about internship.
I have only done:
1 central line
2 NGTs
2 Foleys
Stapling
Removing stitches
Only 3 stitches of suture
2 paracentesis
1 arthrocentesis.

No LPs, no arterial lines, no IVs, no intubation, NO suturing!!!!

Hey Pili! Long time no see!!! Where did you end up matching???
Keep in touch! 👍

Hb

 

[ak1978]

Pili, don't worry-we all start out at different points but we'll all end up at the same place after 3 years. Here is a decent book w/step-by-step instructions & lots of pics.


http://www.amazon.com/exec/obidos/t...002-6245473-3008806?v=glance&s=books&n=507846

There's a sample chapter on the blackwell site on LPs & epis:

http://www.blackwellpublishing.com/...ample_chapter/1405103884/marbasbpclinproc.pdf

 

[AJM]

Pili - you will certainly not be alone in your lack of procedural experience when you start internship. I have supervised more interns than I can count in their first central lines, first a-lines, first LPs, first thoracenteses, etc... I think a lot of people are in the same boat as you -- they just don't speak up about it.

If you really are worried about getting a few more procedures under your belt before you start, you might want to consider doing a last-minute anesthesia or ER rotation. Anesthesia would be good to do given the specific procedures you're lacking -- since you'll be able to intubate, place lot of IVs, do art lines, and possibly central lines (although they like to do the central lines fast, so you probably won't be able to do those).

You'll have to rotate through the ED as an intern as well as in your 2nd and 3rd years -- that will be the only place that you'll have to suture anything, and usually there will be med students around dying to sew up those lacs. You can trump the med students if you want the practice, but you don't have to do too many of them to get the hang of it. I let the students take all the lacs if they want them, because I did more than enough as a student myself, and I'm sick of them. 🙂

The IVs are straight-forward to learn, but you probably won't have to do too many of them, unless you're going to a hospital with no ancillary services. If I get called because all of the staff have tried to place an IV in a patient and no one can get one, I won't be the 5th or 6th person to try to do the IV --that patient buys a central line instead (it's either that or an EJ). I've done way more central lines than IVs during residency.

So I wouldn't sweat it too much. Whatever skills you're lacking, you will quickly pick up. Just remember - if there's something you haven't done before, ask for help your first couple of times doing it, then you'll be good to go.

 

[unk_fxn]

Hard to get that experience when you might have to move to another city just for a specific rotation since you lack a stable academic hospital. 🙄

I only moved for electives, and since this isnt a big academic center, there arent residents and fellows to steal the procedures. As a senior, all the attendings know me by name and I get to do any and everything I want as procedures go.

Too bad that I am just a glorified chiropractor.

At least I wont be an internist - everyone knows they are terrible at procedures and if you want some real work done you call anesthesia, a surgeon or the ER doc.

Heh heh heh.

 

[neutropeniaboy]

I have had very little experience with procedures. I have been elbowed out of the way by residents and fellows. I am worried about internship.
I have only done:
1 central line
2 NGTs
2 Foleys
Stapling
Removing stitches
Only 3 stitches of suture
2 paracentesis
1 arthrocentesis.

No LPs, no arterial lines, no IVs, no intubation, NO suturing!!!!

Pili,

I wouldn't worry about it. Prior to internship, I had done 0 central lines, 0 paracenteses, and 0 arthrocenteses. (And I was a pre-surg student!) I got my Foley experience in the OR. To be honest, I don't specifically remember putting in any NGTs during medical school, but I'm sure I did. I didn't intubate anyone either.

Suturing is pretty uncommon in medicine, relative to surgery. So, don't be surprised about your lack of experience. Internship will set you straight.

Another thing you should realize is that many of these procedures take one shot before you understand the procedure. I'm not saying you'll get every intubation and every line done perfectly, but after the first or second time around, it's really pretty simple stuff.

 

[endo]

I don't think one is really comfortable with central lines, arterial lines or whatever until you've done 20, 30, 40 -- but hopefully your intern year will allow for all that. Our internal medicine residents don't get a whole lot of procedures -- when opportunities come up you should jump on them. Also, don't dismiss peripheral IVs, my opinion is that you should be very good at these. They will save you a whole bunch of time -- ie. no central line / confirmatory XR, ptx.

-Sven, Cinci EM-R2

 

[Pili]

Thanks y'all. I guess I am comparing myself to the surgs. They have done way more. Also some of the future internists have done more. It's the luck of the draw.

 

[pikachu]

Yes, but how many differential diagnoses have the surgeons generated? Personally I've never even started an IV but I can give you a differential of at least 20 for an active urinary sediment! 😀

I'm not bragging about my inexperience with procedures, just joking. I don't think my experience is uncommon at hospitals where there are good ancillary services (IV and phlebotomy teams) and tons of residents and fellows who get priority over students for procedures. Weirdly I did get to do a thoracentesis a few months ago, but I've still never drawn blood.

 

[irlandesa]

Hey Pili! Long time no see!!! Where did you end up matching???
Keep in touch! 👍

Hb

not to blow Pili's cover, but I think the answers are in the Texas match lists, there's a link to them on the pre-allo page.. good job! believe me hon, I know people who would kill to have the "limited procedural" experience you have AND to have matched where you matched. all I've done is put in a few IV's, Foley's, NGT's, and drawn ABG's on MICU; intubated with help a few times on surgery and taken out some A-line sutures; the interns always get to do the central lines, etc.. I think that's appropriate b/c they need to know how to do it STAT, we have some time.

 

[erichaj]

Don't worry, you will get tons of chances for this.
EH.

 

[sbf]

You will get so much practice once you graduate that you shouldn't worry about it too much as a student. Your residents and attendings will help you out.... we're not all dinguses. Just listen and learn, and then have a go yourself.

 

[Code Blue]

As with many have said here before, you will have plenty of chances for procedures in intern year (or at least you should), and as someone else had said, I've supervised a ton of guys on their first procedures as a second year.

One busy night in our MICU, and I had 6 central lines (2 fems, 2 subclavians, 2 IJs), 4 art lines, and 2 intubations.