The Pre-brief
There are a few procedures in emergency and/or critical care medicine that are both rare and life-saving. For instance, central line placement could be considered a life-saving procedure, but most providers who regularly work in a critical care setting place central venous access regularly enough that they feel comfortable with the procedure. On the other hand, some procedures may be rarely performed but are not truly life-saving, such as perhaps rectal foreign body removal or nailbed repair, and thus have less pressure associated with performing the procedure. It can be challenging to teach those procedures that are both rare and life-saving (ED thoracotomy, transvenous pacing, perimortem c-section to name a few), because there are fewer opportunities to actually do the procedure, and when the need arises, it’s critical that the procedure happens as smoothly as possible.
In this two-part series, we’ll review some keys to teaching the rare and life-saving procedure. Let’s use transvenous pacing as an example.
Open a kit before you need it
This is one of the most important aspects of teaching rare procedures. Frequently, the most intimidating factor for a provider to overcome when doing a procedure that they haven’t done many times is unfamiliarity with the contents of a kit and how they piece together. Being comfortable with the contents of a transvenous pacing kit, and having gone through the steps of connecting each piece, is vital to the comfort level and confidence of the physician getting ready to float a pacer on a patient in third-degree heart block. A great way to justify the cost of opening a kit “just for teaching” is to make it a hands-on portion of a lecture or a station at an active learning session during resident conference. I recommend becoming your department’s go-to provider for inheriting expired kits when they get pulled from shelves, and put them to educational use, rather than have them thrown away. A brief lecture followed by the opportunity to explore the kit will allow learners to simulate the process of setting up the kit. This should make them more confident when it’s actually time at the bedside! Don’t forget to keep the kit to use for teaching again – take a picture of the kit when you open it so you can easily reorganize the pieces at the conclusion of your educational session, and wrap it back up for another day.
Emphasize prep work and gathering supplies
When I was a resident (cue the old-timey music and sepia photography) I always rolled my eyes on the inside when an attending would insist that we spend time gathering supplies and going over the prep work for a procedure, as I was ready to get right to the cutting/stabbing/sewing portion of any procedure. Of course, my attendings were right, and anyone who’s attempted to float a pacemaker only to discover mid-procedure that they forgot to grab the lidocaine or battery pack can fondly recall standing sterile and motionless next to the patient while you wait for someone else to run and grab said item. So, as the circle of education returns to the start, I now highly encourage the medical educator to emphasize how important it is to be thoughtful about all the moving pieces needed to prepare for a procedure, from monitoring to pain control and anxiolysis to the setup and wrap up of any procedure. Pumping the brakes on your learner’s enthusiasm to get cutting will pay dividends in the smooth success of the execution of a procedure, particularly one that is truly emergent and life-saving.
The Debrief
Plan ahead when considering how to teach the rare and life-saving procedure. Highlighting the importance of effective preparation and using the procedure kit as a teaching tool are helpful ways to up your med ed game! Keep your eyes peeled for a few more tips in the next part of this series!
