Miss that procedure? Good!

by Bob Stuntz


I have had a few cases recently where, while supervising a procedure with a resident, the procedure does not go perfectly smoothly, and I have had to step in and lend a hand.  This usually results in the resident beating themselves up.  I’m here to talk you down off the ledge. 

Remember, you are learning how to do procedures the attendings you are working with have done hundreds, or even thousands, of times.  We are naturally going to be more skilled procedurally because, as has been said, practice makes perfect.  If you compared my intubating skills to an EM attending who has been working for 15 years, they would probably have me beat.  It is the natural progression of things.  

Look at it as a learning experience.  As a resident, when I missed a procedure, it usually wound up teaching me some very good lessons about what I was doing wrong and what I could do better.  

So how can you turn these instances into positive learning experiences?

1. No matter how many times you have done a procedure, check your ego at the door.  I vividly remember the first intubation I missed as as resident.  I had had the good fortune of being successful for about 90 intubations in a row, with near half of those being on very carefully selected OR patients.  I was going in a bit cocky.  It was an obese status epileptics.  I jokingly told someone that I had done a tough intubation on a skinny guy earlier that week I thought would be easy, so this lady would probably wind up being the opposite of what I expected and be the easiest tube of my life. It was not.  I had not mentally prepared myself for the procedure, and when I got in and saw it was difficult, I panicked.  

2.  Ask the attending what they did differently, and make them give you a good answer.  On that same tube, my attending went in calmly, visualized structures, passed a bougie, and smoothly threaded the tube over that.  I asked the attending what they had done and why.  The attending jokingly responded, “I took my time, visualized my structures, and it was easy.”  I now use this as a joking phrase, but if you are an attending, explain to the resident what you did.  What did you see?  What kind of view did you get?  Why did you choose the bougie, and how do you use it?  What would you have done if that did not work?  Debrief the resident, and residents demand an adequate debriefing.  

3.  Do your own mental debriefing, and review the procedure step by step.  Did you position the patient appropriately?  Was your equipment positioned appropriately?  Did you have everything in the room that you needed?  What did you attending do differently that helped them get it?

4.  Identify where you went wrong, and make a mental note for the next time.  Maybe you had the US machine over your shoulder instead of line of sight during that central line.  Maybe the LP patient was not sitting correctly.  Perhaps you forgot a crucial piece of equipment.  Figure it out, note it, and don’t do it next time.  

5.  Take a deep breath, and relax.  This is how you learn, and you will miss procedures.  Murphy’s law dictates that your attending will come in and have a super easy time, leaving you to think they never miss procedures, and you are somehow incompetent because you do.  Everyone, at every stage in the game misses procedures.  I did an LP with a resident recently that went very smoothly for me.  A few weeks before that I had done an LP on my own when I was covering our ED during resident conference that was one of the more difficult ones I have ever done, and I had to throw in the towel.  We all miss sometimes.  

Do not freak out about these missed procedures.  Use them as a learning tool.  Approach it like a mechanic: break down every step, figure out where you went wrong, and fix it for next time.  Attendings, make sure that you talk your resident through your process and debrief them appropriately.  Making it seem easy and not explaining yourself only makes the resident feel worse, and winds up teaching them nothing.  This is a true learning opportunity.  Don’t miss it!