Teaching and Doing Procedures in the ICU

Placement of a central venous catheter is a core skill on most medical specialties. Emergency physicians, surgeons, internal medicine doctors, anesthesiologists, and pediatricians all have to learn to place a "central line." In principle, it's easy: place a needle into a central vein, thread a wire through that needle, and place a catheter over that wire. But in practice, there's a learning curve, and as an ICU fellow, I have to shepherd residents through that learning curve by supervising their procedures.

This has taught me a lot. I've learned where obstacles seem to crop up for trainees. Some are simply nuisances, inefficiencies, but some can be potentially harmful. I quickly learn to recognize how comfortable a medical student or resident is in the process; some just need a nod of reassurance, and some need me to scrub and hold their hand; some don't recognize how little they know, and some don't recognize how skilled they actually are. I spend a lot of time thinking of how to best teach a particular trainee; inundate a newbie with too much information and they will be overwhelmed, but even a proficient proceduralist (including myself) has things to learn. For example, if someone has done a hundred lines, I still find things to teach. How do you do the line completely solo with no assistance? (How do you adjust the ultrasound knobs or place the probe cover when you're already sterile?) How can you maximize efficiency? How can you do the line without a drop of blood touching the patient's bed? My background as an anesthesiologist really helps me in this setting; I've had my share of pressure for efficiency in the OR and learned many tricks from placing regional nerve blocks.

The learning curve is steep at first and then plateaus. After doing a couple dozen lines, most physicians can handle straightforward central lines with ease. However, we occasionally have very high risk clinical situations, and that's when for patient safety, I do the lines myself. Trauma, obesity, prior lines and surgeries, altered anatomy, inability to tolerate usual positioning are all reasons a central line can be scary, but my most challenging line (and the one I'm most proud of) was for a dying liver patient.

The patient, who already had multiple neck central lines, needed emergent dialysis. He was extremely prone to bleeding from disseminated intravascular coagulation with an INR of 6. Cognizant of following my own advice, I set everything up carefully. Once I started, I had to move quickly because bleeding would start immediately, and a hematoma might make the procedure impossible. The patient's abdominal ascites from cirrhosis made femoral access difficult, but it was the best vein I had. With one quick stab into the femoral vein, the patient started oozing blood, even with a small 18 gauge finder needle (1.3mm diameter). With two quick dilations, I managed to slip the 12.5 French (4.2mm diameter) trialysis catheter into place. I was pretty sweaty as I did it. I am no surgeon, but sometimes I like that feeling when a challenge is presented and I use all my skills and experience to conquer it.

Image is in the public domain.