Performing Interventions as an Intern

[1stYearGunner]

I am an M4 in interview season. One of the practice questions I was asked was the following:

You are on call and a patient needs a lumbar puncture. You have never done one on a patient. But you have practiced on simulation models and have seen attendings do LPs.

The physician on call at home asks you to do the LP. Do you do it?

Is this a skill interns should be able to do without direct supervision?

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[Chemist0157]

1. Don't do it. Find help, or it will wait until help is available.
2. No. Maybe there are some wild wild west programs, but for the most part, hospitals and physicians do not like being sued.

 

[gutonc]

Ah hellz nah!

The correct answer for those reading along at home is:

"Can you cite the data that an urgent LP, in the middle of the night, by an unsupervised intern that has never done an LP, will change this patient's treatment and not put the patient at risk for complications?"

Would you get raked over the coals in the morning for treating this patient for presumed meningitis without an LP? Probably. But the patient would be unlikely to be significantly harmed, assuming you remembered to ask about drug allergies.

Would you get hung out to dry if you did the LP unsupervised and there was a complication resulting in patient harm and a subsequent lawsuit? Absof***inglutely.

 

[deleted480308]

Attending gas money and sleep isn’t an intern problem. You don’t do anything you aren’t qualified to do just so they don’t have to drive in

 

[rokshana]

I am an M4 in interview season. One of the practice questions I was asked was the following:

You are on call and a patient needs a lumbar puncture. You have never done one on a patient. But you have practiced on simulation models and have seen attendings do LPs.

The physician on call at home asks you to do the LP. Do you do it?

Is this a skill interns should be able to do without direct supervision?

No...as an intern you are not alone overnight...call your senior to either supervise you or do it.

In fact, you should not be the one to call the attending on call...that’s your senior’s job.

If, for some reason, your senior is not cleared for LPs, then there is generally a neurology resident or someone in the ED that can do it.

 

[1stYearGunner]

Thanks everyone. I stumbled upon another interview question : You are on the code team and you see the senior resident slip a bottle of fentanyl in his pocket. What do you do?

Do we have to talk to the resident, explain him the reasons why. Or is this enough evidence to suspect drug diversion and call the anti-drug diversion team of the hospital?

 

[psychapp121]

If you see someone slipping fentanyl in their pocket you tell your senior or attending

 

[1stYearGunner]

I have never worked on a "code team" and I also have had no training on this subject matter in my med school. Is this behavior blatantly outside the regulations? Could the resident not have put it for the purpose of using it for the patient in the room close to the bedside for example?

I know that suspicious activity should be reported to the committee on call at the hospital (Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention). But is this suspicious activity or is it jumping to conclusions?

@psychapp121

 

[wholeheartedly]

I have never worked on a "code team" and I also have had no training on this subject matter in my med school. Is this behavior blatantly outside the regulations? Could the resident not have put it for the purpose of using it for the patient in the room close to the bedside for example?

I know that suspicious activity should be reported to the committee on call at the hospital (Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention). But is this suspicious activity or is it jumping to conclusions?

@psychapp121

Lets put it this way, my hospital has a chain of custody for fentanyl and similar meds. If it changes hands/locations it's being documented. It requires two people to sign off on any before leftovers get put in waste disposal system. Pocketing would be a sign of drug diversion.

 

[Vandalia]

Answers and some general advice:

1. The answer to the question would depend on the supervision policy for the institution. I would be almost certain that the first LP must be done with supervision. Here is the general advice: The correct answer in any testing situation - all the way up to the oral exams for board certification - is the "textbook - by the book" answer. This is never the setting to display the originality of your thought.

2. In any situation such as the fentanyl example, the correct answer is to follow the chain of command and/or get the advice of an experienced attending. As a med student I often heard attendings say, "I will handle it, that is why they pay me the big bucks", and I later used the same line with students/residents. In any unusual situation, never act on your own until you have your own practice with board certification. Even then, always "load the boat" with any advice you can get - and document. General advice: As soon as you land in a new environment, starting with residency, look around and find someone who is well respected, trustworthy, and hopefully wise who you can go to with delicate situations. Even when I held that role for many physicians, I still had my list of people who I could trust. Start looking for that person the first day you start residency and keep doing it for the rest of your career.

 

[psychapp121]

Answers and some general advice:

1. The answer to the question would depend on the supervision policy for the institution. I would be almost certain that the first LP must be done with supervision. Here is the general advice: The correct answer in any testing situation - all the way up to the oral exams for board certification - is the "textbook - by the book" answer. This is never the setting to display the originality of your thought.

2. In any situation such as the fentanyl example, the correct answer is to follow the chain of command and/or get the advice of an experienced attending. As a med student I often heard attendings say, "I will handle it, that is why they pay me the big bucks", and I later used the same line with students/residents. In any unusual situation, never act on your own until you have your own practice with board certification. Even then, always "load the boat" with any advice you can get - and document. General advice: As soon as you land in a new environment, starting with residency, look around and find someone who is well respected, trustworthy, and hopefully wise who you can go to with delicate situations. Even when I held that role for many physicians, I still had my list of people who I could trust. Start looking for that person the first day you start residency and keep doing it for the rest of your career.

this. Always ask for help in all situations..it’s better to be asked later why you did something and say “my attending and chair told me to do this” versus “oh I thought this would be the right move and I didn’t tell anyone about it”

 

[Dave1980]

I've done many LPs and they really aren't that dangerous. If the person isn't anticoagulated you can't really hurt someone as long as you aren't grossly negligent (attempting one at T12-L1).

 

[rokshana]

I've done many LPs and they really aren't that dangerous. If the person isn't anticoagulated you can't really hurt someone as long as you aren't grossly negligent (attempting one at T12-L1).

That is not the point

 

[Dave1980]

That is not the point

What's the point then? I am saying that attempting a low risk procedure on a patient without Attending supervision is fine as an intern.

 

[gutonc]

What's the point then? I am saying that attempting a low risk procedure on a patient without Attending supervision is fine as an intern.

Did you even read the thread?

 

[rokshana]

What's the point then? I am saying that attempting a low risk procedure on a patient without Attending supervision is fine as an intern.

Except that it’s not...the supervision part, doesn’t have to be an attending...

 

[deleted950463]

There’s the correct answer above...and then there’s the real life answer

- call IR

 

[WheezyBaby]

There’s the correct answer above...and then there’s the real life answer

- call IR

Ah yes, the 0200 IR LP, seen many