0
Correspondence |

Real-time Sonography With Central Venous Access Response: The Role of Self-Training FREE TO VIEW

Albert F. Olivier, MD
Author and Funding Information

Affiliations: University Medical Center, Tucson, AZ,  Johns Hopkins Hospital, Baltimore, MD

Correspondence to: Albert F. Olivier, MD, FCCP, PO Box 41959, Mesa, AZ 85272-1959; e-mail: alfrol@aol.com



Chest. 2007;132(6):2061-2062. doi:10.1378/chest.07-1930
Text Size: A A A
Published online

The recent article in CHEST (July 2007)1 on internal jugular access with sonography establishes obvious benefits for the procedure despite the reluctance of present-day colleagues to recognize the decrease in multiple needle passes, cervical hematoma, and pain to the conscious patient. Whether it is comfort or pride in the “blind” technique among attendings, residents, and fellows, these traits beckon an opportune change for the patient’s sake.

Real-time sonography performed with a one-operator technique using either hand for needle insertion and probe support should be encouraged to develop ambidextrous skill for sonography of the right or left internal jugular and subclavian veins. In my routine, the probe is held but not set down, while the needle is inserted. The exceptions are obese patients with multifolded skin; short necks; and tracheostomies, severe heart failure, and orthopnea.2

Adjunctive measures have been suggested to promote safety and comfort with the procedure, namely: (1) routine use of a non-Trendelenburg position; (2) minimal anesthetic infiltration to offset iatrogenic vein compression; (3) use of a micropuncture set to reduce venous and perivenous trauma; and (4) use of the transverse view to probe the most central diameter of the vessel. These points were obtained from over 15 years of self-training in sonography for thoracoabdominal and peripheral evaluation, for difficult arterial insertion, and for venous entry into the internal and external jugular veins, subclavian veins, and innominate veins. The result of this experience became evident in the endomyocardial biopsy of cardiac transplants.2

Self-training in real-time sonography should be included as a benefit of recognition and certification, as given by the proctoring system of the American College of Emergency Physicians, the American College of Surgeons, and the American College of Chest Physicians. Though these entities don the recognized authority to initiate competency for quality assurance and to promote an undefined legal standing to perform the procedure, self training, once recognized as a self-willed earnest effort to achieve excellence, is implicitly regarded as an egocentric, deceiving, depreciative method of learning. Bravado without medical and legal appreciation!

In any specialty, self-training is the product of different concepts, the harbinger of new management, and a precursor of organized evaluation and acceptance. What role should it play in the formal education of a physician for an organized entity such as a hospital, the American Colleges, or other medical associations? Just as the proctoring system is recognized as a form of training for the physician by the accepted medical organizations, why shouldn’t self-training be afforded an equal stance in the eyes of the same medical organizations since: (1) both methods aim to achieve the same results: safety and competency; and (2) self-training in a new approach or technique when accepted by a medical organization allows for the development of a proctoring system to promote that approach or technique.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

The author has no conflict of interest to disclose.

Feller-Kopman, D (2007) Ultrasound-guided internal jugular access: a proposed standardized approach and implications for training and practice.Chest132,302-309. [PubMed] [CrossRef]
 
Olivier, AF, Copeland, JG Real-time sonography in central venous access for endomyocardial biopsy in cardiac transplanted patients.J Am Coll Surg2007;205,13-18. [PubMed]
 
To the Editor:

I thank Dr. Olivier for his comments regarding my article.1Although I appreciate Dr. Olivier’s recommendations to develop ambidextrous skill as well as his “adjunctive measures,” the purpose of my article was to propose a standardized approach for ultrasound-guided internal jugular access as opposed to offering “pearls” that develop with experience. As Dr. Olivier states, his “points were obtained over 15 years.” Clearly, self-training is integral to proficiency in all aspects of medicine. The astute physician constantly reviews their technique and style with an attention toward self-improvement. Self-training should, however, be used in conjunction with, and not instead of formal didactics and instruction from experts/mentors. In an article by Mey and colleagues,2when performed with the two-operator technique, the experience of the physician controlling the needle did not influence procedural success or complication rate, whereas both were significantly reduced when the physician manipulating the sonographic probe was experienced. This illustrates the fact that there is a learning curve associated with sonography, and that guidance based on misinformation can harm our patients. The responsible way to develop skills in any procedure is to understand the concepts of the procedure, learn the psychomotor skills, and integrate them with clinical judgment and experience. Medical simulation combines deliberate practice and feedback with the goal of achieving mastery.3 By combining didactics, simulation, and mentorship, the learning curve may be significantly reduced. It is the responsibility of our collective societies to develop formal training guidelines before they are imposed on us from third parties. Until these guidelines become available, it is my hope that the recommendations I proposed will lay some of the groundwork to improve training and education in ultrasound-guided central venous catheterization.

References
Feller-Kopman, D Ultrasound-guided internal jugular access: a proposed standardized approach and implications for training and practice.Chest2007;132,302-309. [PubMed] [CrossRef]
 
Mey, U, Glasmacher, A, Hahn, C, et al Evaluation of an ultrasound-guided technique for central venous access via the internal jugular vein in 493 patients.Support Care Cancer2003;11,148-155. [PubMed]
 
Kneebone, RL, Nestel, D, Vincent, C, et al Complexity, risk and simulation in learning procedural skills.Med Educ2007;41,808-814. [PubMed]
 

Figures

Tables

References

Feller-Kopman, D (2007) Ultrasound-guided internal jugular access: a proposed standardized approach and implications for training and practice.Chest132,302-309. [PubMed] [CrossRef]
 
Olivier, AF, Copeland, JG Real-time sonography in central venous access for endomyocardial biopsy in cardiac transplanted patients.J Am Coll Surg2007;205,13-18. [PubMed]
 
Feller-Kopman, D Ultrasound-guided internal jugular access: a proposed standardized approach and implications for training and practice.Chest2007;132,302-309. [PubMed] [CrossRef]
 
Mey, U, Glasmacher, A, Hahn, C, et al Evaluation of an ultrasound-guided technique for central venous access via the internal jugular vein in 493 patients.Support Care Cancer2003;11,148-155. [PubMed]
 
Kneebone, RL, Nestel, D, Vincent, C, et al Complexity, risk and simulation in learning procedural skills.Med Educ2007;41,808-814. [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543