Procedural Skills

This chapter was reproduced from the Emergency Medicine Clerkship Primer, 2008, Chapter 20, with the permission of the Editor, for ease of viewing on mobile devices.

If you feel that you are not yet experienced in performing basic medical procedures, you are not alone. Graduating medical students have a wide variety of procedural skill experience. A number of medical students complete their core third-year clerkships without performing venipuncture, peripheral IV access, urethral catheterization, or ABG sampling. Your emergency medicine clerkship may help alleviate some of these is-sues by providing you with exposure to a wide variety of procedures that may not be as readily encountered on other clinical rotations. You should take advantage of this opportunity and perform as many procedures as possible to build confidence in your skills before graduation.

Although your clinical experience will vary day to day and between clinical training sites, ample opportunities often exist to perform procedures throughout your emergency medicine clerkship. The procedures most commonly performed by students are peripheral IV access and phlebotomy. Even though many medical schools do not have a formal process to ensure that a student is competent or proficient in performing these skills, they are nonetheless very important. Many students, interns, and residents will be called on to perform these basic yet necessary skills. Regarding procedural instruction, it is equally important to understand which patients truly need IV access and the various options available for crystalloid fluid administration (e.g., normal saline, half-normal saline, D5 normal saline). Students should also gain experience in procedurally related tasks such as connecting IV fluid tubing, troubleshooting a clogged IV, maintaining proper technique for collecting blood cultures, and determining which color blood tubes are required for specific chemistry or hematology testing. The same can be said for other procedures that are performed by students and house staff: NGT insertion, ABG sampling, urethral catheterization, and laceration repair, to name a few. It is important to remember that the psychomotor skill involved with performing many procedures improves with repetition. However, it is essential that you become familiar with the indications and contraindications for performing specific procedures.

Categories of Procedural Opportunities in the Emergency Department for Medical Students

  • Procedures typically performed independently with direct supervision: IV access, phlebotomy, NGT insertion, ABG sampling, urethral catheterization, simple laceration repair
  • Procedures typically performed in an assist role, but sometimes playing an independent role: arthrocentesis, central venous access, incision and drainage of a cutaneous abscess, lumbar puncture
  • Procedures typically observed: orotracheal intubation, tube thoracostomy, transvenous pacemaker insertion

Procedural opportunities in the emergency department can often be categorized into one of three different groups. The first group includes procedures you will likely perform independently with direct supervision: IV access, phlebotomy, NGT insertion, ABG sampling, urethral catheterization, simple laceration repair, and the like. The next group includes those procedures that you will likely assist with, but at times may have more of an independent role: arthrocentesis, central venous access, incision and drainage of a cutaneous abscess, and lumbar puncture. The final category includes those procedures that because of the complexity and urgency of the situation, you will likely observe: orotracheal intubation, tube thoracostomy, and trans-venous pacemaker insertion. Your direct participation in performing or assisting with any procedure is always up to the discretion of the attending physician. This decision is often based on a number of factors, including the student’s experience with performing the procedure, the complexity of the procedure, the comfort level of the patient, and the inherent risk to the patient. That being said, it is still likely that you will have the opportunity to be involved.

Procedural Skills Web Sites

How Can I Become More Comfortable in Performing Procedures?

One of the first steps in becoming more comfortable is to familiarize yourself with the procedure(s) that you would like to learn to perform. These can be procedures that you have a high likelihood of performing, or they can be selected procedures that are uncommon or that you are less familiar with. Couple this choice with your career interests, and you have a good place to start. You can easily take advantage of the wealth of information available to you in hardcopy textbooks or on the Internet. Three excellent resources are as follows:

  • Roberts and Hedges, Clinical Procedures in Emergency Medicine, 2004
  • Rosen and Chan, Atlas of Emergency Procedures, 2002
  • Custalow, Color Atlas of Emergency Department Procedures, 2004

The Roberts and Hedges text is available in full-text version through MD Consult for which some medical schools have institutional subscriptions. The New England Journal of Medicine publishes an online series titled “Videos in Clinical Medicine” (http://content.nejm.org/misc/videos.shtml?ssource=recentVideos). These procedural videos highlight a number of common and advanced procedural skills and are accompanied by a summary PDF article further reviewing the topic. McGraw-Hill’s “Access Emergency Medicine” is another Web-based resource that contains a broad range of emergency cases with accompanying procedural videos (www.accessem.com/public/about_aem.aspx). Elsevier also offers an online educational resource titled “Procedural Consults.” This resource reviews a number of basic and advanced procedures (http://app.proceduresconsult.com/Learner/Default.aspx). A number of these online resources require individual or institutional subscriptions to fully access the educational material. The University of California San Francisco/San Francisco General Hospital emergency medicine residency Web site contains a number of educational procedural videos (www.emresideny.ucsf.edu). Additional advanced procedural videos can also be found on the University of Maryland emergency medicine residency Web site under the section of procedural videos (www.umem.org/ res_student.php).

Remember, each student will have a different procedural experience throughout his or her emergency medicine clerkship. This is in part because of the variety and complexity of patients encountered and, to some extent, the interest or proactiveness of the student. It may be more important for some students, based on career aspirations, to partake in certain procedures. Communicate your interests with your supervisors and the nursing staff to further enhance your procedural opportunities. Again, we recommend not focusing solely on the technical skill required to perform a particular procedure but also emphasizing the rationale of why a particular procedure needs to be performed.

Suggested Reading

  • Coberly L, Goldenhar LM. Ready or not, here they come: acting interns’ experience and perceived competency performing basic medical procedures. J Gen Intern Med. 2007;22:491–494.
    • This prospective survey of fourth-year medical students on an internal medicine rotation found that students do not perform basic procedures during their subinternship rotations and that procedural performance correlates with feelings of competency.
  • Custalow C. Color Atlas of Emergency Department Procedures. Philadelphia, Pa: Elsevier Saunders; 2005.
    • This text provides a comprehensive review for more 65 emergency procedures.
  • Fincher RM, Lewis LA. Learning, experience, and self-assessment of competence of third-year medical students in performing bedside procedures. Acad Med. 1994;69:291–295.
    • This survey of 100 third-year medical students found that students performed procedures on patients infrequently.
  • Roberts JR, Hedges J. Clinical Procedures in Emergency Medicine. 4th ed. 2004. Philadelphia, Pa: Elsevier Saunders; 2004.
    • This text provides a comprehensive evidence based review on a multitude of procedures performed in the emergency department.
  • Rosen P, Chan TC, Vilke G, Sternbach G, Mass EW. Atlas of emergency procedures. 2nd. St. Louis, Mo: Mosby Press; 2004
    • This text provides a comprehensive review of more than 100 commonly per-formed emergency procedures.
  • Wu EH, Elnicki DM, Alper EJ, et al. Procedural and interpretive skills of medical students: experiences and attitudes of third-year students. Acad Med. 2006;81:S48–S51.
    • This survey of 171 third-year medical students from seven institutions found that a majority of students had never performed important procedures, such as lum¬bar puncture, thoracentesis, paracentesis, or blood cultures.