Resident procedures

[narcusprince]

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Junior attending here. How long do you guys wait before you take a procedure from a resident? I usually wait 5 min for the a-line while also making suggestions. I let the residents get two passes at a FOI then daddy takes over. I came from a very grabby residency where if you blew your procedure the staff took over very fast. I feel like as I progress I have started reading the surgeons and feeling when they cannot wait anymore.

 

[KCBarbarossa]

Look, I get it. I'm not saying a CA2 resident has the numbers to even compare. However, part of learning is learning to make that subtle readjustment. To "angle off" just a bit during an epidural. To allow yourself to LEARN just how much more medial that radial artery is in reality...... etc etc

I agree with airway stuff in terms of not causing trauma with repeated attempts. I also do get that some residents just suck at procedures and that's that. Also, that there's a fine line on some of this and you do need to read the patient/patient's loved ones (husband of a laboring woman) and indeed the surgeons.

BUT, this is residency and we have one or two (thankfully only about that many) who are super grabby and never let you experience some subtleties of getting things down. Fortunately, we have many more attendings whom exercise patients w/r/t this stuff than not. One guy gloves up, STILL (and for all of us residents), on almost ALL labor epidurals. It's ridiculous. And, trust me, I'm not a fumble f.cker with procedures at all. Only point is that if EVERYONE were grabby, then we'd have whole crops of new attendings not deft at anything.

Kinda playing the devil's advocate here.

 

[dhb]

I think it's often possible to give active help without taking over completely

 

[neusu]

I'm a neurosurgery resident so take this for what it's worth. We, as a field, tend to be resident driven. While I realize this may not suffice for anesthesiology, but for us it seems to work out. That being said, when I walk junior residents through procedures I typically use the "see one, do one, teach one" mentality. I show them how I do it, verbalizing at every step what I'm doing and why. I scrub in to assist them doing one, and redirect them if they need it. Often, this step is difficult because they are inexperienced and unsure of themselves. It helps to reiterate the fundamentals and reassure them during the procedure. Likewise, instead of "stealing the case" actively help. In our unit we intubate our patients if they need it (among other things such as line/swan/trach/peg). In the right patient, I'm more than comfortable standing behind a junior and holding the laryngoscope over his hand and showing him the motion he needs while passing the ET tube holding his other hand.

 

[Doctor4Life1769]

CA-1.

We have some grabby attendings here. Really hurts resident education.

I ended up doing my first nasal rae intubation while on call and luckily i did not have a grabby attending. the only other time i had this experience was with a grabby attending. the moment resistance was felt, attending took over. that was on first attempt.


luckily, we have more attendings who aren't grabby.

 

[gasattack3]

My tolerance for grabby attendings diminishes by the day. As a CA2 whom again, does not fumble around with most procedures (there's always the outlier) and has good technical skills, it's really annoying to have to put up with that crap.

Fortunately it's still the rare few who do that, but still.....

 

[pgg]

I don't work with residents but this is when I think I'd elbow in

- patient at risk, you simply can't let the resident dig a hole so deep you can't climb out yourself (obviously)

- resident mucking around so much that my odds of success after taking over a non-elective procedure are significantly diminished

- awake patients reaching the end of their rope

All of this is very subjective.

I wouldn't put absolute time limits or attempt limits on anyone, unless it was clear they were totally inept, unprepared, or just not going to get it no matter how much time they had.

The surgeon will let the med student close, and who cares if anyone else gets impatient? The surgery resident will fumble after the gall bladder for 90 minutes, and the scrub-in-training will contaminate 6 instruments. I'm not going to rush my resident.

 

[urge]

If only resident opened books with the same zeal they have when doing procedures...

 

[Idiopathic]

they have to give up on an art line for me to take it over. if i get the impression that they dont know how to do a procedure such as a central line of FOI, then we walk though it together (i.e. ill put gown and gloves on). epidurals/spinals/airways are toss ups. sometimes i see something in the patient or the technique that causes me to intervene quicker, but its rare that I havent given someone the chance to fail twice.

 

[Gern Blansten]

I don't work with residents but this is when I think I'd elbow in

- patient at risk, you simply can't let the resident dig a hole so deep you can't climb out yourself (obviously)

- resident mucking around so much that my odds of success after taking over a non-elective procedure are significantly diminished

- awake patients reaching the end of their rope

I like these points, especially the awake patient. You really have to be in tune to how the patient is tolerating things.
That being said, I think I rarely jump in to help other than offering suggestions without being scrubbed in. I will frequently glove up for residents and help set up the tray while they position the patient to help speed things along. Then I take off the gloves, sort of symbolically saying that I do not expect them to need my help. For epidurals, I usually wait for them to ask me to give it a try, unless the above criteria are met.
I think most attendings where I am are similar in their thinking and allow the residents ample opportunity to take a couple of attempts. There is one glaring exception on our faculty, and I always hear about it.

 

[Gern Blansten]

The other thing to mention is the attendings own confidence level that they can bail you out of whatever mess they let you get into. Brand new attendings may take a bit of time to develop their own level of confidence in themselves. Their behavior may also hinge greatly on what was the usual behavior of attendings where there did residency.