What PCCM procedures should we be well prepared for after finishing a PCCM fellowship?

[pccm_guy]

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[Nephro critical care]

That's terrible. I am a CC fellow and by the end of my fellowship I had logged 150 bronchs , 25 EBUS , 20 perc trachs and even 5 navigational bronch ( which I thought were too tedious ) . I even did a few PEGs . We had a IP attending but no IP fellows so the fellows got all the procedures.
Though I will say that EBUS skills are easy to learn . My brother in law had not done any major EBUS prior to starting it in clinical practice and he has picked the skills up as an attending. Maybe you could talk to your PD as a group and discuss about your concerns.

 

[chessknt]

Some of that probably depends on how the fellowship is set up. If most of your pulm is later it isn't unreasonable that your exposure to those procedures isn't great yet.

 

[Vigileo]

Hopefully your procedural numbers will pick up with more pulmonary time. TBBx, endobronchial bx, airway exams are bread and butter pulmonary procedures. I would argue, though some IP disagree, that EBUS is/should be a general pulmonary procedure and is standard of care, so I believe fellows should be trained in it. Navigational seems hit or miss from what I can tell in the private world, as are other procedures like perc trachs and PleurX placements. The senior guys may disagree, but I would think focusing on the standard bronchoscopic procedures in the pulmonologist wheelhouse along with EBUS would be a first priority.

 

[Dark Hoarse]

I'm a second year Pulm/CCM fellow at an Osteopathic institution. I feel the same way about feeling deficient in procedures in some regards. What I have done this year is attend the ACCP Bronchoscopy and EBUS course. This course was great to get my hands on some tools that my PD isn't letting me use much: foreign body retrieval systems, Cryo probe. It is also a good review of anatomy needed for EBUS proficiency. I would agree with those above, getting your hands on an EBUS scope will likely make you more marketable when applying for jobs.

As a basis of comparison, here are my procedural numbers so far.
Bronchs (including diagnostic, TBBx, brushing, EBBx): ~120
EBUS: 30 (mostly done during second year)

My PD is Interventional Pulmonary trained, and tends to do a lot of Super-D bronchs. I can tell you that after doing a dozen of these with him and hearing what they actually reimburse compared to the procedural time, I don't think that I will be doing many when I start practice. Previous fellows at my program have said that the reps from the navigational bronch companies will send you to courses and set you up with mentors to help you with proficiency.

 

[mochief2000]

I have a year left. Does any attending have any advice on procedures that we should focus on for the real world. i feel pretty comfortable with my training at this point, but a heads up "you would be expected to do this" would be nice. I do know that jobs vary from place to place. Thanks for replying.

PS: to the above poster. I haven't done any percutaneous trachs. Mixed feelings on that one. I feel like you are taking aways ENT bread and butter procedure, will they come and bail you out if there is a complication?? Has that happened at your institution?

 

[maverickdoc]

I have a year left. Does any attending have any advice on procedures that we should focus on for the real world. i feel pretty comfortable with my training at this point, but a heads up "you would be expected to do this" would be nice. I do know that jobs vary from place to place. Thanks for replying.

PS: to the above poster. I haven't done any percutaneous trachs. Mixed feelings on that one. I feel like you are taking aways ENT bread and butter procedure, will they come and bail you out if there is a complication?? Has that happened at your institution?

I am in private practice (8 physician owned single specialty group ). We offer
Bronchs with biopsy
EBUS ( very useful skill to have)
Nav Bronch ( Olympus offers a hands on training for free if your hospital has the equipment)
Chest tubes
Chest Ultrasounds
Perc trachs ONLY if you are interested in them
Bread and butter ICU procedures

 

[mochief2000]

thats intriguing, people are doing more perc trachs than I expected. Only like 1-2 attending do it at my institution, but we are not trained. We also really don't do surgical chest tubes, mostly pigtails. I heard about the nav bronch course through Olympus is good.

Thanks for you input!!

 

[maverickdoc]

thats intriguing, people are doing more perc trachs than I expected. Only like 1-2 attending do it at my institution, but we are not trained. We also really don't do surgical chest tubes, mostly pigtails. I heard about the nav bronch course through Olympus is good.

Thanks for you input!!

We do pigtails only but can / have done surgical chest tubes in the past .
Don't do perc trachs imho without surgical backup

 

[Dark Hoarse]

The way my program is set up, we cover SICU during our MICU rotations (20 beds total between the two of them). Our SICU attending is a fairly new grad, and is the one training us for our perc trachs. We will typically do them in the OR, but will occasionally perform at bedside. The number that's actually done is variable, tho. I think I've only logged about 5-6 assists for per trachs over the past 2 years. Since I've been interviewing, one of the places has asked specifically about my ability to do perc trach. They have stressed that this will be required, and have offered to train me until I can get privileges.

 

[maverickdoc]

The way my program is set up, we cover SICU during our MICU rotations (20 beds total between the two of them). Our SICU attending is a fairly new grad, and is the one training us for our perc trachs. We will typically do them in the OR, but will occasionally perform at bedside. The number that's actually done is variable, tho. I think I've only logged about 5-6 assists for per trachs over the past 2 years. Since I've been interviewing, one of the places has asked specifically about my ability to do perc trach. They have stressed that this will be required, and have offered to train me until I can get privileges.

I am glad such places exist , it is a straightforward skill to master....You just need surgical backup in case **** hits the fan
Just a tip, the next time your attending tries to convince you to hold the bronch while he does the cool stuff cos " visualization is the most important part of the procedure", don't