How do you become competent at uncommon procedures?

[Medic_90x]

Really anything you may do once-twice or never during residency on a real patient, is it something you feel comfortable doing as an attending later on? I know simlab and courses exist, but does it build confidence to do it on a real person?

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[Fox800]

Cadaver labs at conferences (ACEP, AAEM).

 

[gro2001]

Really anything you may do once-twice or never during residency on a real patient, is it something you feel comfortable doing as an attending later on? I know simlab and courses exist, but does it build confidence to do it on a real person?

It's a challenge, and truly rare procedures most people are just not going to be competent at. However, there is a hierarchy of comptency I think of in terms of maintaining procedural readiness:

1. Cross over skills: being skilled in a related skillset may have some carry over to a new procedure. It might not be enough, but it is your foundation. Once you know seldinger technique for central lines, you are not starting over completely from scratch for a lot of seldinger procedures.
2. Familiarity with the procedure: this is where reading up on the procedure (anatomy, steps involved, tips, complications, etc) comes in. This should not be underestimated. When you are performing a procedure you should be visualizing everything using your "X-ray vision" of anatomical knowledge. Procedural videos are good too, but it's important to do both. I feel both modes of learning are different and different aspects settle differently.
3. Task training: mannequins, cadaver courses, pig lab, and such are indispensable. Maximize your opportunity with these, even if you've used these trainers before. But do it properly. By this I mean using the actual equipment you will in a real scenario (are you going to have the entire cric kit available with the tracheal hook? Maybe practice with just a scalpel the next time), in conditions approaching real ones (wearing wet gloves for example, if not fully in situ), and perhaps have people time you (important for things like cricothyroidotomy, intubation, etc) not because faster is better at any cost, but because time is sometimes important and its good to know how long each individual step takes.
4. Mental models: for procedures like cricothyroidotomy, thoracotomy, lateral canthotomy, etc mentally walk yourself through the steps every once in a while at the beginning of your shift. Visualize each step. Starting from where you would get the equipment in your department, to what layers you will cut through, how long it will take, how the tissue will feel, what you will do with the sharps, etc.
5. After action reports: after you or anyone else performs a rare procedure, take some time to discuss what their experience was, what were unexpected challenges, what they would do differently next time (Plus/Delta debriefing). Even a person who has only done a procedure once may have something to teach you about it. Even if you've done it more times than them.
6. Experience: this is the experience of actually doing it on an actual patient and is the very tip of the process. By this time you should have gone through the rest of the steps.

 

[alpinism]

The only way to truly become competent is to do an elective rotation somewhere where the uncommon procedures are common.

 

[miacomet]

It's even harder to stay competent in rare procedures after residency. It's a problem in EM.

 

[Medic_90x]

It's even harder to stay competent in rare procedures after residency. It's a problem in EM.

I guess cause they mainly happen in busy centers, where you also have a residency.. and they get first dibs.