Life just keeps getting better. The attending is starting to leave me to finish some cases (ie close up afterwards, but still it’s a responsibility; and I don’t know whether or not I’d like to know what the OR staff think as they watch me slowing down even more to do things meticulously in his absence).
The chief remarked, “I’m tired of doing these cases. I’ve had enough to last me a lifetime. You go do the next one.” More laparoscopic experience there. I think that attending is starting to run out of patience with my awkwardness. I hope he can stand to have me around a couple more times this month, because I’m starting to hit the learning curve, and get a little more comfortable with the instruments.
Then, we had an ICU patient with very poor venous access. Everyone else was ready to place a central line, but I wanted to try a tricky peripheral iv. I’ve never started an iv since medical school, and I’d never tried this location before, but I figured I ought to learn sometime, and this man seemed to have a good vessel. To my extreme surprise, I got it the first time, and then didn’t know what to do next to hook it up. (Yes, pathetic, but that’s what you get when the rest of the staff are very good at ivs. I hate to go around practicing on people, subjecting them to my attempts, when they could have it done, quickly and properly, by an experienced person, since it’s a skill I don’t absolutely need to have.) I was surprised to find myself being that much of a cowboy, pushing to do something when the attending and senior didn’t want to. Fun, when it works.
I’m enjoying this month to the hilt, because I know it won’t be this good again until at least July. But this is so tremendous, I think I can last four months on the strength of it. (Only four months till July! I find if I don’t think about it for a while, it makes time go faster, and then I’m surprised again by how close the end of the year is.)
February 14, 2008 at 4:49 pm
Excellent news – I’m really pleased you’re getting to do so many things! But I was astonished by what you said about IVs. When I was a house officer (the UK equivalent of internship), siting IVs was an absolute staple of our day-to-day life. We’d do hundreds over the year. And this was 1995 – 6, not quite the Dark Ages. Is this just something that’s different in the US? Who does do them normally – the nurses?
I also agree that if you don’t need to learn a procedure it shouldn’t be something you do just for the sake of it, but I’m surprised at the idea of a hospital doctor not needing to know how to site IVs – especially since I seem to remember you saying you were planning to work in the Third World for a bit. Has that plan changed? And, regardless, aren’t there going to be times when you’re, I don’t know, having to travel with a critically ill patient being transported, or part of a first response team, or in some situation where you really might have to get an IV in? It’s hard for me to picture how a doctor whose specialty is going to include quite a bit of urgent stuff could get by without needing to be able to put IVs in easily – but I honestly don’t know because I’m not in your line of things at all, so maybe I have that completely wrong!
Anyway, kudos to you for getting that one in. I was completely hopeless at IVs. (I did eventually become good at them through sheer amount of practice – that in itself speaks volumes about the number we had to do as junior doctors!)
February 14, 2008 at 9:18 pm
YIKES, is it really only 4 months until July?!?!? I think Harrison’s Textbook of Medicine and I need to have a date this weekend…
February 14, 2008 at 9:50 pm
My hospital probably takes it farther than some others. They have a team of nurses for starting ivs, and allow no other needles whatsoever to be on the regular floors. So if I want a needle, I have to either go down to the ER, or page the iv nurses – either way it’s faster to just have the iv team do it.
But yes, in the US it’s now a sign of the hospital being poverty-stricken and trapped in the dark ages if there are not enough good ancillary staff to do the ivs, so that the residents still have to do them. Even in the ER, there are medics whose major job is to draw labs and start ivs efficiently.
Yes, I do plan on being in places where I ought to know how to start an iv. I need to work on that, sometime, somehow. 😉
(Plus, there are picc lines, so we’re no longer forced to choose between trying for a peripheral line yet another time, or proceeding all the way to a central line, except in emergencies.)
February 15, 2008 at 12:24 am
Would the IV nurses give you a couple of catheters to carry with you if you asked nicely?
Well hydrated people with just enough subcutaneous fat to keep the veins from rolling too badly, but not enough to obscure them are ideal for redeveloping that skill.
If you find yourself facing a little old lady with huge purple marks from other people’s IV attempts, don’t use a tourniquet. Use your thumb to occlude the vein and to pull the skin fairly taut so the vein doesn’t roll. Use the smallest catheter you can justify. Release the vein when you get a flash and slide the catheter off the stylet into the vein. People will be truly impressed.
February 15, 2008 at 1:27 pm
Do you know about the external jugular as site of access. I got really good at this as a house officer- and it really paid off. Nurses are not allowed to assess here, and it works great. Always use a 18F catheter, and have a 10 cc syringe of saline ready to assist with floating it into the vein. If you can do this nurses will love you. Good luck in the OR….. JC