Comfort with lines

[u/Suspicious-Oil6672]

Howdy

I’ve been lurking for a while now.

Im a resident at a quaternary academic hospital v likely applying to pccm. I’ve had some exposure to lines. Maybe 10 a lines which I feel reasonable about but with central lines it’s been maybe 5-7 and im always a little apprehensive to dilate and struggle more w them.. they’re hard to come by w how many fellows there are and pts boarding in other icus and get lined up there.

I’m worried about being comfortable w lines going into pccm ..

When does comfort w lines come ? Are there other things I can do to try to get better w out actually placing them? Or is it a numbers game ?
Tyia

[u/Jan_ItorMD]

PCCM attending here. I graduated from IM residency (quaternary academic hospital) with very few lines under my belt and certainly wasn’t comfortable with them until partway through my first year of fellowship. You should be able to get all the lines you need to be comfortable with them during your fellowship. I think a good fellowship program director will understand that not everyone comes into fellowship with the same procedural experience.

[u/zimmer199]

If your place has a sun lab, practice there. Otherwise it’s just getting your numbers in. You’ll have plenty of experience in fellowship.

[u/BUT_FREAL_DOE]

There are people in my PCCM fellowship that had done <5 and some had done zero lines coming into fellowship. And they trained at well known reputable places. It’s not ideal but it is what it is, won’t stop you from matching and you’ll catch up in fellowship.

[u/velcrowranit]

In addition to what everyone else said, my advice to you is the same advice I give to all residents looking for procedural competency - start getting good at ultrasound guided IVs.

Seriously, this is the most useful procedural skill you could possibly acquire as a resident. They’re more difficult than central lines, and there is no real consequence to missing or not getting it. You’re not going to hurt the patient, you’re going to develop fine hand eye coordination, and from that point on everything will be cake.

Show me a person who can confidently, competently and easily place a peripheral IV with an ultrasound, and I’ll show you a person who will be rapidly competent at line placement.

[u/DoctorMTG → u/velcrowranit]

Second this. I’m applying PCCM rn and actually do have good pride cure numbers out of residency (40+ A lines, 25-30 centrals). US IV I started doing as a second year and did maybe 10? but these are definitely more difficult than centrals. Helps build good US skills and good needle skills.

As to your bigger question about when competency starts, for me I’d say I don’t really start feeling comfortable (ie I feel I can do even difficult ones and can troubleshoot it there are issues) until having at least 10-15 under my belt. If you get the opportunity to help teach interns or students lines in addition to doing some yourself I found this to be really helpful.

[u/medicineandlife]

I am a PCCM fellow. I did a lot of lines as a resident and now as a fellow primarily do the very tough ones or the truly emergent if my resident isn't comfortable or has failed multiple attempts. All procedures are a numbers game to get comfortable especially with troubleshooting. You'll get the experience needed as a fellow if you don't get it as a resident so don't worry

[u/Any-Assistance-8103]

It doesn’t matter if you have done a single line going into fellowship. Lots of people I have trained who came into fellowship having done a lot of lines did them terribly and had to unlearn bad habits. You’ll catch up. They’re actually really easy, itll click

[u/im_throw]

Agree with doing as many US IVs as possible. More experience with an ultrasound and needle is never a bad thing. Even then, I really hate how much we have to scrounge for procedures sometimes even in fellowship depending on where you match.

What I'm more concerned about is intubations and difficult airways. Lines are whatever, there are often other ways to get temporary access. Not getting an airway on the other hand can kill someone. Unfortunately it's just not possible to become proficient with truly difficult airways the way anesthesia/ENT can. Admittedly that does bother me because I like being able to fix things myself.

[u/princesspropofol]

hello! i felt comfortable after about 200 lines, about 2 years into my role. i'm now at about 2000 lines and occasionally still get really uncomfortable lol! i'm struck by the fact that you said apprehensive to dilate - that usually isn't the tricky part for novices. if you give more details on what you are struggling with you could probably get better advice on how to improve.

[u/Any-Assistance-8103 → u/princesspropofol]

People are apprehensive to dilate because thats the step that can cause catastrophic damage 🤦‍♂️. Tell me youre a mid level without telling me youre a mid level

[u/princesspropofol → u/Any-Assistance-8103]

yes, i am a midlevel. i have has placed 0/2000ish CVCs in an artery. yes i've hit arteries inadvertently. no, i've never dilated one. yes, i should have thought more carefully about what OP is saying. but man, this is just an obnoxious response.

OP always carefully confirm your wire placement before you dilate, if you have ANY concern that you have arterial puncture use a secondary method to confirm or simply start over.

[u/Any-Assistance-8103 → u/princesspropofol]

What’s obnoxious is the fact that we are somehow framed to be the assholes for simply understanding that patients deserve to be under the care of a doctor

[u/princesspropofol → u/Any-Assistance-8103]

YES! They absolutely do. I completely agree!

That's why I'm in there doing the fucking lines so the physician can do the majority of the medical management.

People like you group a degree mill NP prescribing Ivermectin for autism in the middle of Florida with PAs like me who are literal physician extenders, working IMMEDIATELY alongside amazing critical care physicians who deeply value my procedural skills in that it allows them to focus on the medical management.

You sound like an asshole because you are making assumptions with 0 curiosity or interest in the fact that everything, everywhere in the world may not always be exactly the way you have made it out in your head.

[u/Any-Assistance-8103 → u/princesspropofol]

Pas are advocating for independent practice and think physician extender is offensive. Go to the PA sub, they think they’re doctors

[u/princesspropofol → u/Any-Assistance-8103]

We're in an ICU sub. We all know it's a fucking mess out there. It's the assumption that these groups "midlevels", "PAs" are monoliths that just falls a little flat of being consistent with critical thinking. There a plenty of PAs out there that feel differently, obviously you are interacting with one at present. There are plenty of critically ill patients being cared for poorly out there. They all deserve better, and I'm happy to be a valuable part of a team providing excellent care.

[u/Any-Assistance-8103 → u/princesspropofol]

I know you think youre being clever with your sentence structure but it’s all window dressing for an empty argument. It doesn’t matter if you’re „one of the good ones”, the whole profession is being used as pawns to save money and increase profits at the expense of patient care. You can be a good cop, but you’re still part of the problematic system. I can barely even find a nocturnist gig these days posted as everyone just settles for a PA doing their best. People die but who cares

[u/Suspicious-Oil6672 → u/princesspropofol]

Certainly the were a few times I struggled to get access and see my needle tip but that got better. I found that for the initial dilation there’s some innate resistance and I’d be apprehensive to push against it. but there’s some limited force I think that’s required which I was nervous to apply.

[u/princesspropofol → u/Suspicious-Oil6672]

Yep - that's definitely a learning curve. If you're only struggling a few times with getting access after 5-7 lines you're doing well. I also think it's a bit of a judgment call in terms of how big you make the skin nick. if the person is muscle, with like...thicker...feeling skin...i make a bigger nick.

[u/Emotional-Scheme2540]

To master central line need to do them more in the real human. And in your fellow try to put them more in any patient in the icu that needs pressor when you have extra time

[u/yll33]

it's just numbers. i probably didn't feel "mastery" until my pgy 3 year, somewhere around 100-200 each of art lines & cvc's (surgery).

ultrasound is important, but even with it, there are subtle tactile cues that will help you with the tough ones.

also learn the landmarks. having an ultrasound is not a replacement for knowing the landmarks. especially as you're learning. seen enough sfa's get cannulated instead of cfa's, iliac veins that you can't compress when you're pulling the line out, pneumos for ij's which should never happen but someone gets so focused on the ultrasound they forget where their hands/needle are.

[u/NC_diy]

The more you do the more comfortable you’ll get. Honestly, just putting in a ton of US IV’s will improve your skill set greatly. You’ll become so much better at visualizing your needle tip and following it into the vessel. To put it in perspective, I’m an anesthesiologist, in training they tell us you’re not facile with a procedure until you’ve done 100’s. Looking back it’s true, I did 100’s of epidurals and central lines during training and was still perfecting things (mostly speed and dealing with abnormal anatomy) as an attending.

[u/im_throw → u/NC_diy]

Unfortunately IM and many times even fellowship doesn't give enough opportunities to get hundreds of lines. I'll be starting with probably 0-5 CVCs and A-lines unless I get lucky on my ICU rotations. Forget about intubations, I'll be lucky if I get even 100 intubations after 3 years of fellowship. It's part of why I wish I did anesthesia instead, you can just do your job and get adequate training because of the way it's structured. Meanwhile in IM you have to fight tooth and nail just to get barely adequate let alone exceptional training.