The Pre-brief
The intern’s technique seemed perfect, but on the grainy screen of the ultrasound, we could not find the needle tip. Meanwhile, outside the room, the emergency department sounded busier than it had when we first entered the room about thirty minutes prior. The patient was becoming restless and the monitor continued to beep. I could sense the intern’s frustration because I had once been in her shoes.
“Damn,” she muttered. The wire for the midline had kinked. We would need another kit and have to restart.
I took a step back and surveyed the scene. I was supervising the procedure but I was also her assistant. And I needed to optimize her for success. Now the intern was getting rid of her sharps, shoulders slumped.
“Hold on, I have an idea,” I said, slipping out the room. “I’ll be right back.”
The Education of a Proceduralist
Dr. Scott Weingart, an emergency critical care physician at Stony Brook University and host of the EMCrit podcast, espouses that if you want to be a master resuscitationist, you need to know how every single role is performed and how every single piece of equipment works. When it comes to procedures, this means not only being able to do them efficiently, but also being a great assistant.
The education of a proceduralist often begins in medical school when students, acting as observers, watch what seems like the dark arts of medicine as the resident places catheters, chest tubes, and endotracheal tubes. This is the perfect chance for medical students to learn how the procedure is performed and stand out in their rotations. By learning how the procedure is completed, how to set up the senior resident for success, and how to anticipate problems, you can help the team move a lot faster through procedures.
As a resident, you start by performing a majority of procedures, progress to doing them independently, and ultimately graduate to supervising them. This is when you should be volunteering for as many lines and tubes as possible. The more you do, the better you will get. At the same time, you will also encounter more challenges, which will give you a valuable education at troubleshooting them.Â
Unless you go into community practice, the opportunities to do procedures once you become an academic attending with trainees dramatically decreases. You will primarily teach and assist with procedures, and will only be called to perform them when previous attempts have been unsuccessful. Sure, you can turn to simulation or mental visualization, but actually performing procedures are much more valuable. This is why getting your reps in during residency is so vital.
How to be a Better Assistant
Being a great assistant is a valuable skill. There have been times when I have become so tunnel-visioned in trying to perform a procedure, that I miss the one detail that is preventing me from success. And then an astute co-resident or attending will remind me to optimize my view, adjust my position, or to just relax. Ultimately, excellent assistants allow for procedures to be completed efficiently, help root out problems before they arise, and provide valuable support to the proceduralist.Â
The most important aspect of being a great assistant is that it will teach you to be a better proceduralist. Not only will you be able to think of the direct actions that must be completed in order to place a line or a tube, but you will also be able to think of the intangibles. You will not always have the luxury of having an assistant, so by learning to troubleshoot a situation from other perspectives, it will make you a much better resuscitationist. Here are five ways you can be a better assistant:
1) Know Where All the Equipment Resides
Make sure you know where all the kits and materials are located. Sometimes extra probe covers, sterile gel, or different needles are needed. If you know where to find it, you can help grab them so your proceduralist does not have to break sterility. You should also know which equipment is best. Sometimes the difference between an easy line and a hard line is not the provider but the equipment.
2) Optimize the Conditions for the Proceduralist
Where should the table be set up? How high should the bed be? Is the proceduralist left-handed or right-handed? Does the family need to leave the room? Can you help transduce the line or set up the a-line bag and tubing? As the assistant, your job is to minimize distractions (turn off the TV, set the bed to the right height, make sure the monitor is not beeping, relax the patient), ensure ideal ergonomic conditions, and then let the proceduralist work. If a procedure has to be performed quickly, you want the proceduralist to get into the zone while you worry about everything else.
3) Practice Implicit Coordination
Dr. Chris Hicks, an emergency medicine physician and trauma team leader, emphasizes the importance of implicit coordination when leading resuscitations. This occurs when members of a team can focus on their own tasks with minimal overt communication, yet everyone can anticipate the needs of the other and can adapt accordingly. The same idea can work on a smaller scale with procedures. In order for this to work, you need to understand how the procedure is completed so that you can be ready with the next item without being asked. My favorite procedures are when the proceduralist can work uninterrupted, just once step seamlessly flowing into the next, without having to look for equipment or reorient themselves. As Dr. Weingart also likes to emphasize: “Slow is smooth. Smooth is fast.”
4) Anticipate Problems
The best assistants can anticipate problems before they escalate. Sometimes the proceduralist is too locked in to the task at hand to think about the blood pressure or the noise in the room or the patient’s anxiety. Sometimes it is only after three missed tries that she realizes her back hurts and her angle was off because the patient was poorly positioned. The best assistants ask themselves what might be missing and then take the initiative to solve the problem.
5) Recognize When to Stop and When to Get Help
One of the most essential roles of the assistant is to serve as a check on the proceduralist. Frustration breeds mistakes and, in the worst cases, ego takes over. The desire to complete a successful procedure and the reluctance to admit failure is more likely to lead to patient harm. The assistant’s job is to monitor the temperature in the room and recognize when the law of diminishing returns applies — when more attempts will lead to a decreased chance of success. This is when the assistant needs to step in and gently ask the proceduralist to take a break or to tactfully call for backup without causing offense.
I stepped out of the room and spotted my favorite ultrasound machine: an old but reliable Mindray M9. I grabbed it and wheeled it back into the room, picking up another midline kit along the way.
“You got this,” I told her. “Stay sterile. I’ll set everything up. Let’s knock this out in five minutes.”
I unplugged the original ultrasound machine and plugged in the new one so it was sitting directly in her line of sight. Next, I raised the bed so she wouldn’t have to hunch over. Then I slid the procedure table from her left side to her dominant right hand. I thanked the patient for her patience. Finally, I made sure to silence the monitor and I opened the midline kit.
Together we replaced the probe cover, found the target vessel, and optimized the view. She quickly injected lidocaine at her entry site. I felt confident in her skills, so I let her know that as I put on a pair of sterile gloves to assist her. I didn’t want her to think I was going to steal the procedure.
“Wow, this ultrasound is way better,” she remarked. We could clearly see the tip of the needle slide towards the blood vessel. As she prepared to puncture the vein, I readied her supplies: first the wire, scalpel next, then the dilator. I flushed the catheter, pushed the air out of the saline syringes, and had the blue caps at hand.
At this point the room was quiet and we did not have to speak. The intern knew what she had to do and as she completed each step of the process, I was ready with the next item. In practiced movements, she made her nick, pushed in the dilator, removed the wire, and slid the catheter through. The syringes showed flashbacks of blood and her eyes showed relief.Â
“Nice work! You were perfect.” I said as I doffed my gloves. The second attempt took less than five minutes. Before I walked out, I looked back to see that the intern was standing tall, her head up, and her shoulders pulled back.
The Debrief
- In order to be a great proceduralist, one must also learn to be a great assistant.
- The best assistants take care of the intangibles in the room that the proceduralist might be too busy to think about: Is the bed at the correct height? Is the ultrasound in the proper position? Is there unnecessary noise? Is the patient comfortable?
- The ideal assistant knows to anticipate problems before they arise and where to find more equipment should it be required.
- An essential task of the assistant is to recognize when to stop the proceduralist or to call for backup if the proceduralist is having trouble and letting his ego get the best of himself.
- By practicing how to be a great assistant, proceduralists will become better at performing interventions when they do not have help readily available.
