The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Thursday, June 21, 2007

Learning my Lines

... but not in the musical theater sense.

This month I've been in the ICU. A very intense rotation. I've been dealing with patients sicker than any I've ever seen before. I've seen medicine do things I didn't know were possible. I've seen countless people who were clinically dead brought back to life with electricity and drugs. I've seen people who should be dead kept alive for days, sometimes weeks, using medications, ventilators and a little luck. It's been a long month.

The reason I've chosen to do ICU (as a family medicine resident, it's not a required rotation) is for the procedures. Now I'll be doing another 2 months of it as an emergency medicine resident in the coming year, but I figured another month of it would be more helpful than my other choices (including palliative care, more internal medicine and more geriatrics). There are lots of procedures done on a daily basis in ICU that come in handy in the emergency room. Before this rotation I had superficial experience with most of them, but I figured this would be a good chance to hone my skills.

Not so much. I have had a horrible streak this month. If anything, I think I'm getting worse at the procedures I should be getting great at. Central lines have become the bane of my existence. Before this rotation, the only experience I had with central lines was one subclavian under close observation in a trauma situation. But technically, I was one for one. This month I've had two subclavian attempts. Although I got both, one gave the patient a pneumothorax (a known complication of subclavian lines, but I can't help but feel bad about it).

IJ's, the mainstay of central lines, should be routine for me by now. Instead, the only attempts I've gotten have been on patients who are awake. Now for those of you who have never attempted an IJ, imagine trying to perform a delicate procedure involving sticking long needles into people's necks in people who are combative, can't lie flat, won't stop touching the sterile drapes, keep turning their heads to see what you're doing and often don't understand enough English to follow simple instructions (Damn, I wish I spoke Italian!). In short, I am 0-for-three in IJ's, and frustrated to tears.

Femoral lines aren't often done in the ICU where I am currently working. I have seen one done, that's it. So according to the 'see one, do one, teach one' rule, I should be trying the next one. But there's not much chance of seeing another one in the two days I have left.

Chest tubes are another procedure that I've been eager to learn. In an entire month, I've done one. That's all. I was successful, but to put things in context it was a large pneumothorax in a small, thin, 40-ish woman. NOT the typical patient. I can only hope I'll be just as successful when I'm called on to do the same in people with much more tissue to cut through.

But the issue with the central lines has been really discouraging. Particularly for me, who apparently has placed far too much of my professional self-worth in my proficiency at various procedures-- after spending the first three years of medical school thinking I was going to be a plastic surgeon, I do tend to pick up things like this easily. And now I seem to have grown extra thumbs and some kind of gypsy curse, to boot.

Oh well, there's always intubations. Crap, now I've probably cursed those too.


Blogger doctor T said...

Don't be so hard on yourself! It's the end of your PGY2, you're pregnant and moving soon. You should be applauded for still standing!

11:42 PM

Blogger Julia said...

Sounds like my success stories with LPs. Or the time when I was exchanging an intubation tube and still managed to put it in the esophagus.

Yeah. I've volunteered for 2 ICU rotations this year, so that I could learn my procedures better.

Good luck!

12:01 AM

Blogger Liana said...

My friend is 2 for 2 for subclavians... if you're talking about giving the patient a pneumothorax, that is.

I guess you could look at it this way... at our acute care workshop, we were told that the average doc causes only 2 pneumothoraces in their entire career. So you're already halfway there. Best to get those pneumos out of the way early on in your career, don't you think? Yay! ;)

3:22 PM

Blogger Dr. J. said...

Maybe it's just me, but anytime I have one of those days where I walk into work whistling, feeling like I'm on my game, I'm slick, I'm the doctor, lets get this department humming, oh yeah....I get a boot in the butt....not a light gentle boot, but a full on kick that sends my face directly into mud that I'm unable to get out of until I'm throughly brought back down to earth...ahh humility, so we meet again...

5:45 PM

Blogger MedStudentGod (MSG) said...

Great. I elected for an ICU clerkship in order to get exposure to central lines and other procedures. It sounds like I'm going to be "assisting" a lot, but not doing much of them.

Oh well, got residency for that, I guess.

8:08 PM

Blogger The Rotten Correspondent said...

As a former SICU RN at a level one trauma center (and teaching hospital) can I just say that it is far more common to miss than to hit at this stage in your training. And I've seen more than one chief resident cause a pneumo. Don't psych yourself out - these procedures take time and lots of practice. You'll get it!

4:57 PM

Anonymous Anonymous said...

I'm a family medicine resident like yourself and I did two months of ICU as a med student Let me tell you though...I couldn't hit shit for my first month of icu. like 0 for 10. 0 for 5 art lines. In fact I've watched experienced people dilate up the carotid. I can say on a few occassions I was pretty sure the blood was venous and in fact I was in artery and only by someone else transducing the pressure did I realize I was in the wrong place.

Art lines and central lines are tough, but they get easier and you will be popping them in with no problem. I'm on my third month now and it is still tough, but much easier then when you first start. I certainly feel that it takes 3 months of ICU to feel somewhat comfortable, and I'm not even all that great at it after this much time.

So keep poking away!

6:48 PM

Blogger DrWes said...


Wanna look cool and succeed every time? Have your ICU get one of these.

Hope this helps. It helped me and hopefully will help your patients and ICU attendings, too.

10:17 PM

Anonymous Anonymous said...

Hi Dr. C,

I really enjoy your blog! I know nothing about the procedures you're describing, but I could not hold on to things to save my life in my second and third trimesters when I was pregnant with my daughter. I dropped at least five or six things a day. My husband's theory was that minor edema in my hands was interfering with prioception. I liked that better than my theory, which was that I was losing my mind. :)

Anyway, I second doctor t -- good for you for hanging in there, and best of luck both with your rotation, and with the move and the birth of your child!

1:57 AM

Blogger Doc's Girl said...

One day at a time....:) Hope you are feeling well!

9:08 PM

Blogger Couz said...

Thanks to all who commented. Particularly those who boasted of worse records than my own. :-)

You've all made me feel much better.

11:18 AM


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