Bradley Rosen, MD, MBA, Sally Wang, MD, FHM, and Joshua Lenchus, DO, RPh, SFHM led a motivated group of hospitalists through hands-on training in bedside invasive procedures during two half-day sessions on Sunday during the HM12 “Medical Procedures for the Hospitalist” pre-course. With emphasis on ultrasound-guidance and evidence-based practices, Drs. Wang, Rose, and Lenchus, with the help of other faculty and trainers, provided the sold-out audience with lively discussion and small-group experiential education in central venous catheter placement, paracentesis, thoracentsis, lumbar puncture (LP), and other bedside procedures.
While bedside procedures have been long been a staple of internal medicine practice, the field of procedural medicine has increasingly become the dominion of hospitalists and now proceduralists. Nearly all procedures now can be aided by ultrasound guidance, and for many procedures, ultrasound guidance is standard of care.
“You think you’re a pretty good driver, but you wouldn’t drive down the road with your headlights off,” said Mark Ault, MD, director of the division of general internal medicine at Cedars-Sinai Medical Center in Los Angeles. “On your flight home, I’m sure you wouldn’t want your pilot flying with his controls off.”
• Performing bedside procedures safely requires specific training and steady experience that is well-suited to healthcare providers in hospital medicine.
• Ultrasound guidance is considered standard of care for central venous catheter placement, paracentesis, and thoracentesis.
• Widely accepted limitations in fluid removal thought to prevent re-expansion pulmonary edema (RPE) after thoracentesis may not prove to be valid.
• Arbitrary cutoffs for INR and platelet count in paracentesis are based on data that may not be valid in bedside paracentesis.
• Use of non-traumatic lumbar puncture needles, such as the Gertie-Marx and Sprotte needles, may reduce the incidence of post-LP headache.
• Fine-needle aspiration, punch skin biopsy, and arthrocentesis are bedside procedures that can be mastered by hospitalists and used regularly in their practice.
• Establishing a proceduralist group or center initially requires showing to hospital administrators benefits other than revenue, such as reduction in CLABSI and off-loading other procedural services.
Dr. Chang is a pediatric hospitalist at the University of San Diego Medical Center and Rady Children’s Hospital in San Diego, Calif.