Becoming a Rural Doctor, Part 5: Procedures for the Rural Doctor

Now that we've addressed medical school and residency for the rural physician, it's time to discuss common procedures with which rural physicians should be comfortable. In earlier posts in this series I've mentioned one effect of fewer specialists in rural areas: the broadening of rural primary care physician's scope of care. One element of this wide scope is performing procedures many primary care doctors might not do in a metropolitan area.

Teaching and learning medical procedures is a hands-on process, so I'm not expecting to provide you with everything you need to know to go out and do these procedures. What follows is a list of recommended procedures to go after during your training so you'll have experience under your belt by the time you enter practice. Some items are merely mentioned, others have references for you to consider.

Just to give you a flavor of what I do in my practice, I've marked the procedures I do regularly with one asterix, ones I do in an emergency if no one else is around with two asterixes, and ones I know how to do but defer to more skilled/experienced hands with three:

INTERNAL MEDICINE: DIAGNOSTIC PROCEDURES

• Lumbar puncture^*: very important for family/internal medicine doctors to know how to do. Here's a good write-up of the technique, and here's a video of the technique.
• Diagnostic paracentesis^*
• Diagnostic thoracentesis^*
• Arterial blood gas sampling^**
• Punch and excisional biopsy^*

INTERNAL MEDICINE: THERAPEUTIC PROCEDURES

• Therapeutic (large volume) paracentesis^**: It's nice to be able to make a patient more comfortable with this procedure, but I do far more diagnostic taps than large-volume taps. Here's a write-up of the technique, and here's a video.
• Therapeutic (large volume) thoracentesis^**: Same comment as for therapeutic paracentesis. Video.
• Suprapubic urinary bladder catheterization^**: This doesn't come up very often, but boy is it useful when you have a patient with a bladder up to his belly button and no urologist willing to come in at 2am. Here'sa write-up.
• Tube thoracostomy^***
• Splinting and casting^**
• Laceration repair^**

INTERNAL MEDICINE: CRITICAL CARE PROCEDURES

• Central line insertion
• • Internal jugular^**: Not very practical in a code, but best location for most critically-ill adults because you can obtain central venous pressures accurately through an IJ, and it doesn't risk pneumothorax as much as a subclavian, especially in a COPD patient. Video.
  • Subclavian^**: A little easier to get in. Be careful in COPD patients who can have tons of bullae in the apices of the lungs. This video shows the landmarks nicely. Technique is same as for internal jugular.
  • Femoral^**: Best site for central access during a code, because you can get one in while everyone else is up at the patient's head working on the airway.
• Endotracheal intubation, adult^**: You've seen it on TV, now watch the video.
• Arterial line insertion^***
• Advanced Cardiac Life Support (ACLS) certification^*

PEDIATRIC PROCEDURES

• Neonatal Resuscitation Program (NRP) certification^*
• Endotracheal intubation, neonatal^** and pediatric
• Umbilical artery^***/vein^** catheterization
• Pediatric Advanced Life Support (PALS) certification
• Circumcision^***: My least favorite procedure. I don't do them now.

OB/GYN PROCEDURES

• Spontaneous vaginal delivery^*
• Vacuum-assisted vaginal delivery^*
• External version
• Intrathecal labor analgesia^*: I haven't found a good Web resource for this technique, so I plan to write it up one day.
• Pudendal block for labor analgesia^*
• Repair of 2nd degree^*/3rd degree^*/4th degree^*** perineal lacerations
• Cesarean section, primary surgeon
• Advanced Life Support in Obstetrics (ALSO) certification^*
• Dilation and curettage^*
• Colposcopy^*
• Endometrial biopsy^*

OBTAINING PROCEDURAL EXPERIENCE

1. In Medical School

Every medical student wants to do procedures, but so does every summer/fall intern. Residents are invested in teaching their interns procedures, much more than teaching their medical students. You're much more likely to get experience at a hospital with large volume than one with only moderate volume. Consider doing electives in ER and ICU if you're hoping to get some medical procedures under your belt. If you're interested in OB, you'll get more deliveries at a high-volume community hospital than at a large tertiary care hospital, where volume is lower and acuity of illness greater.

When it comes to GYN procedures, the honest truth is that you probably won't get any significant experience until you get to residency. It is hard enough to get enough Pap smears during med school, let alone do EMBs, colpos or D&Cs.

2. In Residency

How many of the procedures listed above you end up doing depends on your specialty. Obviously, internists don't do pediatric procedures, but family doctors might perform procedures on both lists.

Some residents are procedural animals, others dodge procedures like poison oak. Overall I recommend overtraining rather than undertraining. You never know when you're going to need the skill. For example, I trained to do intrathecal analgesia in residency, believing I would never do one after I graduated. Lo and behold, when I got up to Rural I found they were much in demand. If I'd avoided doing them in residency, it would have been that much harder to slip into OB practice here.

Express your interest in procedures. Be willing to hang around the ER when you're on call to pick up lines, intubations, lacerations, splinting and casting from the ER doctors. You have to be present to win.

Finally, consider doing a procedural elective. At my residency hospital, this meant running around from the OR (intubations, central lines, arterial lines) to the casting room to the ER. I didn't do enough OR time, so I still wish I were better at those types of procedures, but you can learn from my mistakes.

A couple of excellent books:

• John L. Pfenninger's Procedures for Primary Care covers office as well as ER and inpatient procedures. Well-illustrated and clearly written.
• Frm the department of surgery at Johns Hopkins, the now out of print Manual of Common Bedside Surgical Procedures provides a relatively portable reference for interns and residents to carry around on hospital rotations. Excellent bullet-style presentation, line drawings, all-around useful book.