How many lines should you have done before starting fellowship?

[FunnyDocMan1234]

Lines (especially central lines) are hard to come by at my residency because PICC nurses are almost always available and the ED also puts in a lot as well... What is a goal number of central lines, a-lines, etc that incoming fellows should aim to have by the time they start so that they can comfortably supervise and troubleshoot?

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[jdh71]

Lines (especially central lines) are hard to come by at my residency because PICC nurses are almost always available and the ED also puts in a lot as well... What is a goal number of central lines, a-lines, etc that incoming fellows should aim to have by the time they start so that they can comfortably supervise and troubleshoot?

Fellowship is also time to get the procedural experience you may need. Just pick up what you can. Take what you need during your fellowship.

 

[shaidx]

Depends on how many you need to learn the skill. I used to scrub in with the fellows and learn the streps and attempted a couple under their supervision. I think I had a total of 12 before I started fellowship and never had trouble putting one during

 

[TimmyH]

I have done almost 50 in 3 years of residency.

Fastest personal time was 8-9min.

 

[SpacemanSpifff]

Lines (especially central lines) are hard to come by at my residency because PICC nurses are almost always available and the ED also puts in a lot as well... What is a goal number of central lines, a-lines, etc that incoming fellows should aim to have by the time they start so that they can comfortably supervise and troubleshoot?

I am by no means an expert in line placement, but if they are scarce in your residency, think about seeking out US guided IV opportunities. These can offer a common and easy way to get reps that allow you to get acquainted with the relationship between the probe and needle, develop the ability to identify the needle tip, and familiarize yourself with the mechanics of the process.

 

[Lexdiamondz]

I am by no means an expert in line placement, but if they are scarce in your residency, think about seeking out US guided IV opportunities. These can offer a common and easy way to get reps that allow you to get acquainted with the relationship between the probe and needle, develop the ability to identify the needle tip, and familiarize yourself with the mechanics of the process.

Agreed.

Truthfully US guided IVs are technically more difficult than CVLs, especially in patients who are difficult sticks. if you can put in a PIV you can put in a CVL.

 

[siliso]

Oh, 5 or 10. That will get you the lay of the land. Try going down to the ED and volunteering if that’s what it takes.

 

[Kjbds1]

I am by no means an expert in line placement, but if they are scarce in your residency, think about seeking out US guided IV opportunities. These can offer a common and easy way to get reps that allow you to get acquainted with the relationship between the probe and needle, develop the ability to identify the needle tip, and familiarize yourself with the mechanics of the process.

Definitely this. And if your hospital is the kind that admits pts with a beating heart and a need for IV medications / fluids then there are anywhere from hundreds to thousands of IVs going in daily. Ask literally any charge nurse who needs an IV and they'll point you to a room. Peripheral veins are smaller and follow a more tortuous course than central veins, and peripheral IVs are generally 18ga and smaller so they're less echogenic than central line introducer needles. Put in a couple dozen 20ga IVs in janky peripheral veins and the next time you do a central line you'll just laugh when you see an IJ that takes up half the US screen with a needle tip that damn near glows.

 

[sluggs]

Depends on how many you need to learn the skill. I used to scrub in with the fellows and learn the streps and attempted a couple under their supervision. I think I had a total of 12 before I started fellowship and never had trouble putting one during

I'm gonna call "no way"! You've never had trouble putting in a central line? Ive done > 1500 and sometimes still see a tough one

 

[sluggs]

I will add, also, that at 12 CVLs you have a decent understanding of technique, but it is hard to say you are "proficient". There are vessels that are tough to cannulate. There is difficult anatomy with a carotid where you don't want it. Subclavians are usually easy, but can present challenges. How about the coagulopathic or thrombocytopenic patient where even going through the back wall by accident can cause bleeding.
I think it takes 30 - 40 at least to be proficient and even more to be good.

 

[shaidx]

I will add, also, that at 12 CVLs you have a decent understanding of technique, but it is hard to say you are "proficient". There are vessels that are tough to cannulate. There is difficult anatomy with a carotid where you don't want it. Subclavians are usually easy, but can present challenges. How about the coagulopathic or thrombocytopenic patient where even going through the back wall by accident can cause bleeding.
I think it takes 30 - 40 at least to be proficient and even more to be good.

Of coarse there will be lines that are difficult to put. Once you learn all the essential steps you can make things work when you come across a challenge. There is no set number of lines one needs to be proficient. I know fellow who struggled with after doing 30 and I know people who learned quickly and were independent doing them after 10. I have done a lot more during fellowship, I was nervous doing the first few but it was easy sailing after that. I don’t put in subclavians, it’s against our hospital policy given frequent complications a couple years ago.

 

[CCM-MD]

Of coarse there will be lines that are difficult to put. Once you learn all the essential steps you can make things work when you come across a challenge. There is no set number of lines one needs to be proficient. I know fellow who struggled with after doing 30 and I know people who learned quickly and were independent doing them after 10. I have done a lot more during fellowship, I was nervous doing the first few but it was easy sailing after that. I don’t put in subclavians, it’s against our hospital policy given frequent complications a couple years ago.

It is unfortunate that you won't get to place them. Silly policy. I think subclavian lines are very important to learn. You will encounter situations where that is the ONLY available site. Also, trauma patients with collars etc. - I prefer subclavian > femoral.

If you get proficient, US guided subclavian is arguably the best line to place.

 

[NewYorkDoctors]

It is unfortunate that you won't get to place them. Silly policy. I think subclavian lines are very important to learn. You will encounter situations where that is the ONLY available site. Also, trauma patients with collars etc. - I prefer subclavian > femoral.

If you get proficient, US guided subclavian is arguably the best line to place.

Agreed.

The US guided subclavian (or technically it is an axillary vein cannulation) can take out the pneumothorax complication entirely in the hands of a skilled sonographer. I have begun doing it a little while back and have not had any complications yet after doing about 60 of these. Of course, this is all predicated on having a good long axis view of the axillary/subclavian vein and a good visualization of the lung sliding.

For any discouraged residents out there who do not seem to have enough central line placements (because EM residency does them or CCM does them), I will say that I also had similar concerns years ago in residency. Further, the hospital I trained out allowed most vasopressors (except vasopressin) be run through peripheral IVs as long as the IV was placed in via ultrasound via the long axis and confirmed in place. Needless to say central line placement (and CLABSI) were cut down.

The only central line access placement I would have a chance to do are in patients without any viable peripheral access, even with ultrasound, or for HD catheters.

At the end of PGY2 year maybe I only did 4? At the end of PGY3 year maybe I had 10 in my pocket?

But I did master the ultrasound guided 1.88cm peripheral IV placement.
This skill is immensely useful in general.
In fact, being good at this upper arm ultrasound IV placement also allows one to quickly adapt PICC line and midline insertion skills.
Also being able to place a needle under the long axis view of a vein is also crucial in having success and safety with the US guided subclavian catheterization.

 

[Soccer171983]

I came from an unopposed program so fortunately I got to start knocking out a lot of lines as a pgy-1 (You did solo call 3 months into residency for a small 200 bed hospital).I would estimate that from pgy 1-3 including moonlighting I easily hit about 1k lines.By the time i got into fellowship I let the residents do most of the lines and I did more complicated lines like vascath's etc. I would say That after about 20 successful solo unassisted lines I felt pretty comfortable and confident. We were not allowed to do lines unsupervised until we had 5 successful supervised central lines (IJ,Fem and SC) and that went along with thora/para art lines. We all had to hit those figures before month 3 when we would do our in house call. Now, where I work I do a couple of lines a week because our np's/pa's hustle for those procedures for productivity bonuses and its better for me to be able to see the complicated cases and supervise as well. To answer the question however, do as many as you can to gain the experience and comfort level to bail out a pgy-1

 

[jdh71]

1000 lines?