What ARE good procedure numbers?

[The Knife & Gun Club]

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Now that I’m on the other side after doing all those residency interviews and having residents throw random procedure numbers for various thing at me (35 airways? 75 airways? 150 airways?)...what are the actual procedure numbers for the common ED procedures you think make for a respectable, middle of the road residency?

Things I’m thinking of are:
Intubation
Central line
Chest tube
Maybe some others...

 

[dadaddadaBATMAN]

For the most part I think the acgme guidelines have reasonable procedure numbers. The 35 intubation seem way too light to me, I think some old anesthesia literature showed an asymptotic success curve for residents at around 100-150 tubes, maybe a little less. More is always better, and more difficult (bloody, vomit filled, crashing) is ideal. You can probably never have too much airway experience, and especially Peds numbers can be really hard to come by if you don’t have a dedicated rotation or other experience (emergent Peds intubations just aren’t as common).

The number of reductions isn’t that many on acgme requirements, but distal radius fxs aren’t often fatal, although you can certainly see some significant disability if you f up. More is better there too.

However, I don’t think chest tubes, central lines, lps etc are rocket science and if you get the required numbers it’s probably fine.

What would matter more is things like your level of autonomy in making decisions, if you are forced to see the patients in the department at reasonable volumes to prep you for being an attending, and if you get to make complex decisions regularly. Also whether you are having patients stolen by mid levels or having Attendings who regularly rescue you/decompress things.

Just my two cents.

 

[deleted547339]

The problem is that is entirely individual dependent. Some people have poor spatial understanding and are all thumbs. Some people are naturally gifted gamers who can think in 3D.

There’s also the concept of focused practice. Mental reps with independent study and focused feedback is different than just doing something wrong 1,000 times.

35 for intubation is a joke. For tubes, you learn the basics somewhere between 20 and 50. You then get to the “get almost all” step somewhere between 100 and 300, then mastery at some higher number.
I did probably 30-50 in med school, 200-300 in residency and another 100-200 in fellowship and maybe 25-50 as an attending (when residents are in conference/can’t get a tube, rapid response teams or fellow not around/can’t get a tube in the icu).

Central lines are largely a function of natural ability and US skills. If you’re super slick with US and can do US IVs really well, probably only a handful of IJs and fems. I felt good with subclavian lines around 20-25.

Surgical tubes are easy. I dunno, 5? Pneumocaths? Probably a lot more than you’ll do. I’ve seen some nasty complications from good doctors.

Procedures aren’t what make you a good ER doc or intensivist, but are table stakes. Go somewhere that had sick patients and enough autonomy to make mistakes in a safe place.

 

[gamerEMdoc]

I agree. I have residents who get crazy high numbers, others closer to the minimum with some areas. Part of it is a logging issue. Part of it is some residents seek out sick patients and other residents are more passive.

I think intubations are usually easily exceeded. I feel like LPs are becoming less and less common now that not every r/o sah needs an lp. Chest tubes may be difficult to get a ton of depending on if you work in a place that is way more blunt than penetrating trauma but still not hard to get the minimum usually. Lines usually you will exceed easily. Crics and pericardiocentesis are likely going to be sim/cadaver cases.

 

[thegenius]

The problem is that is entirely individual dependent. Some people have poor spatial understanding and are all thumbs. Some people are naturally gifted gamers who can think in 3D.

There’s also the concept of focused practice. Mental reps with independent study and focused feedback is different than just doing something wrong 1,000 times.

35 for intubation is a joke. For tubes, you learn the basics somewhere between 20 and 50. You then get to the “get almost all” step somewhere between 100 and 300, then mastery at some higher number.
I did probably 30-50 in med school, 200-300 in residency and another 100-200 in fellowship and maybe 25-50 as an attending (when residents are in conference/can’t get a tube, rapid response teams or fellow not around/can’t get a tube in the icu).

I've been an attending for 6 years, and including 4 years of residency I have not done 300 tubes.

I'm just fine intubating. Not sure what you're talking about above. I'm not railing on ya, but intubating isn't THAT hard. Challenging at times yes, but there are procedures I fear more.

 

[deleted547339]

I've been an attending for 6 years, and including 4 years of residency I have not done 300 tubes.

I'm just fine intubating. Not sure what you're talking about above. I'm not railing on ya, but intubating isn't THAT hard. Challenging at times yes, but there are procedures I fear more.

There’s some data saying there are plateaus in skill level at different numbers I’m the anesthesia literature. Too lazy to look up specifics, but I think it’s something like you hit roughly 75-80%, 95, then>99.

 

[alpinism]

Generally speaking you want to get at least twice the minimum ACGME numbers in my opinion.

For some procedures its relatively easy but for others its extremely difficult unless you get lucky.

Specifically I'd say at least 100+ intubations and 50+ central lines are respectable numbers.

 

[Lexdiamondz]

I think the ACGME numbers are kind of arbitrary to be honest and in general for most of the common invasive procedures (intubations, cvls, chest tubes) you should get around double the minimum. Why the ACGME thinks we only need 35 intubations but 150 POCUS is pretty incomprehensible to me.

 

[Groove]

In general, the higher the procedure number...the better. The only exception is...cricothyrotomy. While it might translate to greater experience with crics, it does tend to put into question your airway skills. I haven't done a ton but I've done enough that I'm starting to feel a little self conscious...

 

[BoardingDoc]

In general, the higher the procedure number...the better. The only exception is...cricothyrotomy. While it might translate to greater experience with crics, it does tend to put into question your airway skills. I haven't done a ton but I've done enough that I'm starting to feel a little self conscious...

Lol, agree. Anyone who claims that (through experience) they are very good at crics is not someone who I would let intubate anyone I cared about.

 

[namethatsmell]

For central lines, having experience and comfort doing them at all 3 sites is much more important than raw numbers. IJ is not always the answer. And neither is ultrasound. Try to do at least some SCs and fems by landmarks/palpation during training.

 

[TheComebacKid]

I did probably 30-50 in med school, 200-300 in residency and another 100-200 in fellowship and maybe 25-50 as an attending (when residents are in conference/can’t get a tube, rapid response teams or fellow not around/can’t get a tube in the icu).

So you did an anesthesia residency?

 

[RustedFox]

For central lines, having experience and comfort doing them at all 3 sites is much more important than raw numbers. IJ is not always the answer. And neither is ultrasound. Try to do at least some SCs and fems by landmarks/palpation during training.

Sadly, this would be a lot easier if the vast majority of our patients weren't fat, disgusting, gelatinous masses who have obliterated all their landmarks with adiposity.

 

[TheComebacKid]

With respect to airway, you should do every single airway you can. I still can't wrap my head around the discussion in one of the other threads where people were suggesting it's okay to give them to medical students.

For central lines, you should also do as many as you can. But I think overall it's less important than airway. Many patients that get central lines in the ED probably don't need them downstairs, and there's fairly decent data that suggests you can run peripheral pressors for 24 hours without major complication, and in the community many patients wait until they get to the ICU before a line is placed. More important than the actual line is being facile with ultrasound guided venous cannulation.

The only exception is blind subclavian access. Most EM residencies will train you to be proficient at IJ and femoral CVC placement but I would argue blind subclavian is the most important tool we have (best resuscitative line for trauma, fast, don't need the damn US to get set up, lower infection rate, better tolerated by patients etc).

In terms of surgical airway, the only ones I did in residency were in cadavers. I've done an emergent pericardiocentesis twice on 2 patients (both died with type A dissections). Overall, some of these low frequency procedures you will never get to do on an actual patient (maybe ever in your career, which I'm okay with). But use SIM when available, cadavers etc to get the numbers for logging in residency.

 

[RustedFox]

So you did an anesthesia residency?

I had several hundred in residency (EM). I quit logging them after 100 or so, because why?

 

[deleted547339]

So you did an anesthesia residency?

No. Most anesthesia residents do several thousand. I did probably 50 in my anesthesia rotation, 20-30 in my peds anesthesia rotation, then probably 1-3/week on average for all of my EM and ICU rotations. There were days where I did 3 tubes in an hour in residency. I’ve never done 10 in a day, but I’ve definitely done more than 5 tubes in a day more than once in residency. Heck, I did three in a single day in the unit recently (two in rapid response, one on one of my icu patients when the felIow was doing another procedure elsewhere. I logged every procedure as an intern and broke 100 as an intern, then got a lot less precise in my procedure log.

 

[deleted547339]

With respect to airway, you should do every single airway you can. I still can't wrap my head around the discussion in one of the other threads where people were suggesting it's okay to give them to medical students.

For central lines, you should also do as many as you can. But I think overall it's less important than airway. Many patients that get central lines in the ED probably don't need them downstairs, and there's fairly decent data that suggests you can run peripheral pressers for 24 hours without major complication, and in the community many patients wait until they get to the ICU before a line is placed. More important than the actual line is being facile with ultrasound guided venous cannulation.

The only exception is blind subclavian access. Most EM residencies will train you to be proficient at IJ and femoral CVC placement but I would argue blind subclavian is the most important tool we have (best resuscitative line for trauma, fast, don't need the damn US to get set up, lower infection rate, better tolerated by patients etc).

In terms of surgical airway, the only ones I did in residency were in cadavers. I've done an emergent pericardiocentesis twice on 2 patients (both died with type A dissections). Overall, some of these low frequency procedures you will never get to do on an actual patient (maybe ever in your career, which I'm okay with). But use SIM when available, cadavers etc to get the numbers for logging in residency.

Agree to disagree. I let several med students do tubes and lines as a senior resident. It’s about 1) patient selection and 2) rapidly taking over if there is any hiccup. In the days of VL and once you’ve done 100-300 tubes, another chip shot intubation doesn’t add a lot. It is probably more important to teach because you see your gaps. If youve only find 40 tubes, yea, you probably shouldn’t be teaching med studs.

 

[TheComebacKid]

No. Most anesthesia residents do several thousand. I did probably 50 in my anesthesia rotation, 20-30 in my peds anesthesia rotation, then probably 1-3/week on average for all of my EM and ICU rotations. There were days where I did 3 tubes in an hour in residency. I’ve never done 10 in a day, but I’ve definitely done more than 5 tubes in a day more than once in residency. Heck, I did three in a single day in the unit recently (two in rapid response, one on one of my icu patients when the felIow was doing another procedure elsewhere. I logged every procedure as an intern and broke 100 as an intern, then got a lot less precise in my procedure log.

That is an insane number of tubes, and perhaps you just trained at a place with good volume, but I can tell you that is not anywhere close to what normal places see. I trained at a busy, high volume, high acuity, level 1 trauma center >100K visits per year, 4 year program and my procedure log says I did 113 intubations. I know for a fact I didn't log a bunch, but even then, it's not putting me anywhere close to 300.

I also did a whopping 1 intubation in medical school on my anesthesia rotation. So total 114 tubes confirmed.

 

[namethatsmell]

Sadly, this would be a lot easier if the vast majority of our patients weren't fat, disgusting, gelatinous masses who have obliterated all their landmarks with adiposity.

True and can still be good for training. I remember as a student being shown how to use tape to displace adipose for procedures. Afterwards I was like "wow cool I'll remember that for the couple times it'll be useful down the line." Haha, ah when ignorance was bliss.

 

[Porfirio]

For me, it was never about number of tubes. It was about hard tubes and managing the complications. Number of tubes just comes with residency. Difference between 20 successful tubes and 100 successful tubes means nothing if they were all easy uneventful tubes.

 

[deleted547339]

That is an insane number of tubes, and perhaps you just trained at a place with good volume, but I can tell you that is not anywhere close to what normal places see. I trained at a busy, high volume, high acuity, level 1 trauma center >100K visits per year, 4 year program and my procedure log says I did 113 intubations. I know for a fact I didn't log a bunch, but even then, it's not putting me anywhere close to 300.

I also did a whopping 1 intubation in medical school on my anesthesia rotation. So total 114 tubes confirmed.

Was going to send a DM but it looks like they’re turned off.

 

[alpinism]

In general, the higher the procedure number...the better. The only exception is...cricothyrotomy. While it might translate to greater experience with crics, it does tend to put into question your airway skills. I haven't done a ton but I've done enough that I'm starting to feel a little self conscious...

Ehh I used to think this way until I started working internationally. Lots of end stage diseases where patients wait until the last possible minute. Things like massive neck hematomas and tumors where the patient has severe respiratory distress and stridor that you can hear across the room before you even get to the bedside. In those cases you really have no other choice no matter how good your airway skills. Anyway what I'm trying to say is that I think it really depends on where you work and your pathology. Now that's not to say I'm doing them on a regular basis when I'm working overseas but its way more common and sometimes I'll end up with multiple crics in a single month.

 

[Renaissance Man]

I think I ended up with just over 100 in residency. Probably had another ~10-15 as a medical student. I still think it is the scariest procedure we do because when it goes bad, it is real bad. Took until the after 50 make for me to really get a bit more comfortable. I feel like the glidescope has decreased the numbers of intubations required for competence (especially if have some video game background - no evidence for this just my opinion). You have to get dozens in order to run into a scary one, which is where the rubber really meets the road. Aim for at least double the ACGME requirements for sure.

 

[thegenius]

I think I ended up with just over 100 in residency. Probably had another ~10-15 as a medical student. I still think it is the scariest procedure we do because when it goes bad, it is real bad. Took until the after 50 make for me to really get a bit more comfortable. I feel like the glidescope has decreased the numbers of intubations required for competence (especially if have some video game background - no evidence for this just my opinion). You have to get dozens in order to run into a scary one, which is where the rubber really meets the road. Aim for at least double the ACGME requirements for sure.

Interesting I don't really consider them scary. But I know what you mean. There are some scary airways for sure. I think I've called for help 2-3 times in my attending life. One was angioedema of the tongue which occluded everything. Couldn't see jack shhit. He went to the OR and was tubed there, and apparently the anesthesiologist said it was "easy with a glidescope."

I generally don't consider them scary because I've done enough of them. The scariest procedures are probably those where the patient is 1) alive and will not really die on you instantly, and 2) you never do them. I've never transvenous paced anyone and that patient can die in 1-2 hours if not taken care of properly. Pericardiocentesis should only be done in the ED if you are dead or just died, and cric's well....my guess is the patient will thank you if they survive it.

 

[larpleston]

These numbers are pretty intimidating. I'd love to finish residency with 200 tubes but I'll probably end up with 60 (probably 20 of those were anesthesia OR tubes). This is at a 100k+ visit, high acuity place. Typically at any given time there are around 5 EM residents working in various parts of the ED and the tubes need to be divided up so it's rare to end up with multiple tubes a shift. I'll sometimes go a few weeks without one even though I admit people to ICU all the time. I feel like just in the past 5 years bipap/high flow use has expanded and so many patients that would've been tubed 10 years ago are able to make it up to the ICU without it. Without bipap I would easily have 150 tubes. It definitely concerns me - at the same time with VAL truly 'difficult' airways are becoming rarer and rarer and those are the ones that are really educational. Anesthesia rotations that pump the numbers up are good for learning the basic mechanics but my experience was that with proper positioning on an OR table and preoxygenation, even tubing someone who is ASA 3 and 400 lb was easier than tubing a normal body habitus person who was actively dying in the ED.

Similar story with central lines. I literally never have done one for access. I can do an US IV in 95% of difficult access patients and the ones that I can't I can do a peripheral IJ. All of these patients would have gotten central lines back in the day. I think this is a problem in EM training in general.. probably similar to the loss of open surgical skills that gen surg residents have these days.

 

[alpinism]

Procedure numbers have gone way down over the years.

Some of my old attendings in Detroit claimed to have done 500+ intubations and 250+ central lines in residency. Back in those days you didn't have BIPAP or US so everyone with respiratory distress or bad veins got tubed and lined. It was very common to have shifts where they basically spent all day in the resus bay doing procedures. Those shifts have unfortunately become few and far between nowadays.