Technology slave

[Nephro critical care]

Have a severe inferiority complex at my ineptness at doing any procedures without an ultrasound or glidescope. When I started out fellowship I was initially trained to use Mac blade or glide. Mostly if I couldn't get with Mac the attending would jump right in. Never learned Miller blade . Same with vascular access or thora/ para I was gunshy about complications and did every single procedure with U/S. Had close to zero complications but meant I was not doing many subclavians or arterial lines by palpations or femoral / IJs by landmark technique.

And now as an attending obviously even more paranoid about complications so everything goes in by Glidescope or ultrasound . My success rate is very good but technology dependent . So far I have survived but one day it's going to catch up with me courtesy a broken technology device.

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[engineeredout]

How are we supposed to learn to do procedures without technology when if you do them blind, and you get a complication that could have been avoided with U/S, you get chewed out?

Especially when it comes to lines. Airway is a different discussion

 

[mimelim]

Have a severe inferiority complex at my ineptness at doing any procedures without an ultrasound or glidescope. When I started out fellowship I was initially trained to use Mac blade or glide. Mostly if I couldn't get with Mac the attending would jump right in. Never learned Miller blade . Same with vascular access or thora/ para I was gunshy about complications and did every single procedure with U/S. Had close to zero complications but meant I was not doing many subclavians or arterial lines by palpations or femoral / IJs by landmark technique.

And now as an attending obviously even more paranoid about complications so everything goes in by Glidescope or ultrasound . My success rate is very good but technology dependent . So far I have survived but one day it's going to catch up with me courtesy a broken technology device.

I always pick where I'm going to stick based on landmarks, then I use an ultrasound to watch my needle tip from skin to vessel. I force myself to pretend that I'm sticking blind so that in the rare instance that I need to, I can. ~85-90% of the time I am dead on. Probably 97-98% of the time it wouldn't matter if I had stuck where I planned blind, but it was less than perfect.

I have cleaned up conservatively 40-50 arterial/venous access cock ups in my residency. The vast majority of which were done without ultrasound. I have seen people maimed and killed by it. It will become standard of care, give it time. Now, that having been said, in a crashing patient where you don't have an ultrasound on the floor or in the room? Yes, you should have your femoral/subclavian anatomy down so that you can do crash lines. That is all about practice and doing the same thing over and over and over. I always map out where the inguinal ligament is before I do a femoral line. I always setup as if I'm doing things blind and mentally commit to a puncture site/angle before putting the ultrasound on sterile. I force our interns to do the same when I do lines with them.

 

[sluggs]

Your fear of "getting chewed out" for a complication that could have been avoided by the use of ultrasound is ridiculous. You should have, instead, a fear of harming your patient! Using ultrasound for IJs is safer than doing them blind. There is now data to support doing (albeit 'lateral") subclavians with ultrasound. Patient safety and avoiding harm is paramount, and if you have a device that facilitates this, use it when available!

 

[CCM-MD]

Should always use an ultrasound when possible - there is no need to put patients in harms way for no reason. In an emergent setting blind femoral/subclavian or intraosseus.