Welcome to your procedure rotation! this rotation occurs at both the VA and at Shands. During intern year, the rotation occurs at the VA and is under the close monitoring of Dr. Kosboth. On the first day you can page the procedure team at VA 4364 or meet them in the Medical Day Stay unit (3rd floor back building) after morning report. 

As a PGY 3, the rotation occurs at Shands, in conjunction with the medicine consult service.  

Before the rotation, please review the thoracentesis, paracentesis and lumbar puncture articles to start learning the basics of the procedures. 

The online NEJM videos for each are also excellent and should be reviewed: NEJM Videos in Clinical Medicine

Highly Educational NEJM Clinical Videos on Common Internal Medicine Procedures:

• NEJM Radial Arterial Line Placement - https://www.nejm.org/doi/full/10.1056/NEJMvcm1213181

• NEJM Arterial Blood Draw - https://www.nejm.org/doi/full/10.1056/NEJMvcm0803851

• NEJM Intraosseous Line Placement - https://www.nejm.org/doi/full/10.1056/NEJMvcm1211371

• NEJM US Guided Peripheral IV Placement - https://www.nejm.org/doi/full/10.1056/NEJMvcm1005951

• NEJM Peripheral IV Placement (non US guided) - https://www.nejm.org/doi/full/10.1056/NEJMvcm0706789​

• NEJM US Guided IJ Central Line Placement - https://www.nejm.org/doi/full/10.1056/NEJMvcm0810156

• NEJM US Guided Femoral Venous Central Line Placement - https://www.nejm.org/doi/full/10.1056/NEJMvcm0801006

• NEJM Subclavian Venous Central Line Placement - https://www.nejm.org/doi/full/10.1056/NEJMvcm074357

• NEJM US Guided Subclavian Venous Central Line Placement - https://www.nejm.org/doi/full/10.1056/NEJMvcm1406114

• NEJM Paracentesis - https://www.nejm.org/doi/full/10.1056/NEJMvcm062234

• NEJM Thoracentesis - https://www.nejm.org/doi/full/10.1056/NEJMvcm053812​

• NEJM Lumbar Puncture - https://www.nejm.org/doi/full/10.1056/NEJMvcm054952

As the two weeks continue you should be making your way through all of the attached articles. They are mostly short and easy reads. All are extremely high yield both clinically and on exams. The following articles go together well: 

General Guidelines

1. Wash your hands: entering a room, leaving a room. 

   • To borrow from pulmonary ‘s indication to intubate: If you think about it – do it. 

2. Consent is a process whereby you educate your patient. 

3. Safety/Do no harm. 

   • Do not hurry. 

   • If something is not right, do not proceed until you are comfortable. 

   • Be always mindful of your equipment, sterility, and sharps. 

   • We are a potential mechanism of disease. 

4. Own your patient. 

5. If you cannot execute or the procedure is not indicated: 

   • Bring something useful to the patient. 

   • Be helpful, explain why, and try to provide alternatives. 

6. Ultrasound: 

   • If it moves down and towards you/into your field with inspiration – it is lung. 

   • If it moves away from you/out of your field with inspiration – it is diaphragm. 

   • If it is diaphragm and moving up with inspiration – call MICU. 

7. If you are getting intermittent flow that is respiration associated – you are done. 

8. Tell your patient what was accomplished. 

9. Nurses are helpful, but they do not clean up after us. 

10. Wash your hands after reading this. 

Required Reading