Hi everyone,
The first time I tried to place an IV, I almost killed my patient. It was during my medicine clerkship in the mid-1980s. I’d watched residents place IVs, and in the grand tradition of “see one, do one,” I decided to do one, on an actual human, alone.
I collected the equipment: catheter, alcohol swabs, bag of fluid, tubing, and tape, and I arranged them neatly next to the patient, a gray-haired man with bulging, purple veins. Step-by-step, I punctured the bag, clamped the tubing, swabbed his arm, inserted the IV, hooked everything up, and unclamped the line to let the fluid flow.
Seconds later, beside the vein, a lump appeared, swelling rapidly like a balloon. My heart pounded and I began sweating, suddenly realizing I hadn’t primed the tubing and air was flowing into the man’s arm. Somehow, I had the presence of mind to re-clamp the tubing, remove the IV, and tell the patient that someone would return to try again. On my first IV, I nearly killed a man. He only survived because of my incompetence; I’d missed the vein.
During residency, I placed hundreds of IVs, central lines, a-lines, and NG-tubes. I drew blood every day, and I performed countless paracenteses, thoracenteses, arthrocenteses, and LPs. Back then, residents taught each other how to do these procedures, and attendings were rarely involved. With volume came expertise. I don’t remember causing complications, but we all knew residents who had dropped lungs and punctured major arteries.
Today’s residents have far less procedural experience. Several years ago, the ABIM decided to stop requiring specific procedural training. Instead, residents are expected to learn general skills like adhering to sterile technique and obtaining informed consent. Individual residents could pursue technical skills, depending on their interests and career goals.
Most procedures are now performed by expert clinicians with formal training. Nurses place IVs and feeding tubes, techs draw blood, and respiratory therapists do ABGs. Pulmonology owns thoracenteses, rheumatologists and orthopedists do arthrocenteses, and if your patient needs an LP, you can usually find a neurologist or interventional radiologist to help. The hospitalist procedure team can do almost anything. Most Yale residents still master paracenteses because our huge liver service provides many opportunities, but with so many experts around, residents can easily miss out on other skills.
Patients benefit from the expertise, but the downside is that we depend on a limited number of capable clinicians, many with competing responsibilities. If qualified people are unavailable, we risk delaying care, for example if no one is around to place a feeding tube or difficult IV.
Several years ago, in an attempt to make residents more self-reliant, we created a Resident Procedure Team (RPT), which was intended to resurrect the tradition of qualified residents teaching residents. Trainees on the RPT were skilled and enthusiastic, but the team eventually became more of a procedure service, rather than the teaching service we’d envisioned.
As Kevin Wheelock showed in his recent Grand Rounds, most residents want more procedure training, and such training would be both educationally and clinically valuable. So, what should we do next? We can’t and won’t resurrect the chaotic, dangerous, and sometimes traumatic “see one, do one, teach one” days, but we do need to ensure that residents who wish to master procedural skills have the opportunity.
I propose dividing procedures into two categories: required and optional. For example, we should require all traditional residents to master core procedures like venous and arterial blood draws, peripheral IV placement, NG tube placement, and paracenteses. In contrast, interested residents would have the option to seek training in advanced procedures like a-lines, central lines, thoracenteses, arthrocenteses, and LPs. I’m less certain about mandating CorTrak and PowerGlide training for all residents and welcome your thoughts.
We’ve started speaking with hospital medicine colleagues to see how we can tap into their expertise, perhaps by developing a new procedure elective. During orientation, all interns will get central line simulation training and introductory PowerGlide and CorTrak training. I encourage all of you to capitalize on opportunities that are already available. You can easily master ABGs in the MICU and paracenteses on Klatskin. You can ask qualified attendings, fellows, and residents to call you when their patients need procedures so they can teach you. If your patient needs a procedure, use the opportunity to get trained. Under no circumstances should you do a procedure independently if you’re not signed off and comfortable.
Ideally, all rising PGY2s should master ABGs, peripheral IVs, NG tube placement, and paracenteses by the end of internship. Over the next year, we plan to develop a more structured approach to teaching procedures so residents can gain skills. I’m thankful to the many of you who have offered feedback, encouragement, and ideas, which will take training and patient care to the next level.
Enjoy your Sunday, everyone. I’m heading to Acadia today for a picnic and more beautiful views.
Mark
P.S. What I’m reading:
- King: A Life by Jonathan Eig (recent Pulitzer Prize Winner)
- Elmer Gantry by Sinclair Lewis
- In Medicine, the Morally Unthinkable Too Easily Comes to Seem Normal by Carl Elliott
- The age of Discovery is Only Beginning by David Von Drehle
P.P.S. Happy Mother’s Day to all who celebrate.
P.P.P.S. Vacation pics!