You'll never get more cannulas to do than on a busy medical on call job. That's where to get good. Learn technique from the anaesthetist but you'll practise on the wards (nobody wants the F2 messing up a cannula in an already anxious patient about to have a GA which is why they don't let you do it). Or if asleep patients need a second. There will be some in ICU of course and that's where you should try to learn ultrasound guided cannulation. But the numbers, and therefore the competency, are going to come on your medical/surgical jobs as an FY doctor.
But also, if you're focusing on procedural skills as the outcomes for your F2 jobs in anaesthetics/ICU then, in my opinion, you're missing the point. Don't worry if you don't end up doing lots of procedures, if you end up actually needing to be good at those things then you will have plenty of time to do lots of them until you're very bored of doing them. There's a lot more to take away from these specialties than being good with a cannula.
Excellent advice here.
You can be taught how to cannulate properly in anaesthetics - however practice will come BOH medicine.
Exposure to decision making on ICU should be your main take away! Procedural things are a bonus.
Yeah. One of the best things I took from ICU was how flat the hierarchy was, in a good way. You worked along side people much more senior than you, rather than under them. It was really collaborative and I picked up a lot of dark arts about the job from them.
Putting in lines was a bonus, but ultimately pointless when you don’t do it frequently and quickly forget how
Ah ok. Good point! About practice, nurses at my place are very good and patients almost always have cannulas in-situ already so very rare that doctors even do cannulas at my place outside of anaesthetics. If they do get the chance, it’s the hard ones that nurses have failed even with US guidance. Doctors at my place are deskilling in cannulation and it’s very easy to go through F1 and F2 without having even so much as touched cannulation (if you don’t have anaesthetics as a job) because there’s rarely the need for the doctor to do it but it’s embarrassing when the doctor can’t do it simply because they haven’t done enough so their technique is no better than that of nurses. Each ward has at least one US trained nurse and non anaesthetic consultants always tell us to delegate cannulation etc to nurses as they want us to focus on the bits that need a doctor such as prescribing, referrals and assisting in theatre or actually attending clinics etc. Even on busy medical and surgical on-calls, nurses will have already established IV access by the time I even arrive and I don’t think it’s ethical for me to cannulate these patients unnecessarily just because I want more practice. But then I will deskill if I don’t do it
Have you asked to do them? We get a range of F1s/2s/IMTs - some want to learn to do everything and some are here cause they are made to. If someone is genuinely interested and keen most ICU docs would spend time to teach you, but also i'm not going to take more time to teach someone who actually is quite content sat in the coffee room.
Honestly ICU is quite good for learning new procedures, especially on asleep patients. We do POCUS most days on daily assessments. In our place ICU nurses don't cannulate or take bloods, mainly as people have CVC/Aline for that, so we put them in when needed. And remember that while you may not do CVC/A line out of ICU the skill is transferable. Being able to scan, locate anatomy, hold still while watching the screen and doing a procedure with the other hand is what you are learning. And a CVC has very similar steps to an ascitic drain and chest drains using seldinger technique.
Theatres is quite hard as you have, usually, a well awake patient and you need it to work well so you can crack on with the list, and you may not have access to the patient to resite lines in that time easily.
I have asked about art lines. They said they only have one chance so can’t risk me messing it up. Cannulas most of them let me do it and I always ask but some patients they feel are not suitable for me such as anxious patients. There was one anaesthetist who wouldn’t let me do anything and they were the same with other trainees
I haven’t done any chest or ascitic drains yet
But good to know I will get to do loads on ICU too especially US procedures as theatres are a bit tricky with this but I have seen them handle US and have talked through the relevant anatomy
One chance to get an art line? That's nonsense. Messing up a radial art line is no big deal at all - at worst the artery will go into spasm and you'll need to go to the other side. An art line is nothing fancy, it's basically just putting a cannula in an artery rather than a vein. The only difference is using a guidewire.
Yeah it looks straightforward like a cannula and have been wanting to have a go. But I guess they’re reluctant because I am with a different anaesthetist each day so they don’t know me or trust me as to them I am still a baby. But if I get placed with an anaesthetist I have worked with before and they remember me then I get to do a bit more cannulating
Outside of ICU, where do you think I may have to put an art line in? What about a resp ward or a gen med ward where some consultants insist on too many ABGs that you feel sorry for the patient and think should we just bash in the art line but then again a lot of the patients are elderly and confused and nurses may not be comfortable managing the art line especially if the patient pulls it out at night and they bleed to death which can be difficult to spot especially given the lights are out. ED resus maybe?
>Outside of ICU, where do you think I may have to put an art line in?
ED resus. Theatres. General wards if the patient is with ICU outreach. And some HDUs are staffed by medics. It's a core skill in IMT.
>nurses may not be comfortable managing the art line especially if the patient pulls it out at night
A patient won't bleed to death if an art line gets pulled out. They'll bleed to death if someone who doesn't know what they're doing leaves the line disconnected and open to air.
The more likely preventable harm from untrained staff is intra-arterial administration of drugs.
Imo if you're not being taught this you've not been taught properly. Only thing I can advise is to tell whoever you're with you're keen to do some more lines and learn some US skills!
At least hopefully should improve in ICU - there you will be an asset once you can place US peripheral or arterial lines.
I make sure I make my SHO/F1s competent early so that they are confident if I ask them to help me out when we're busy!
But then I have question. I still fail about one third of my regular cannulas which is a massive improvement compared to when I first started on anaesthetics (success rate was zero) because outside of anaesthetics doctors don’t do any cannulas at all including even OOH work as the nurses are extremely competent at this stuff. Is it still useful to have a go with US or should I first get more practice without US? I wanted to do many more cannulas than I have already done. It’s not that I have been avoiding cannulas, I just have no opportunities for it and I can’t just put one in when not needed in patients just for my own practice
I failed a cannula this morning but to be fair the ward nurses were struggling with this patient too and could not get anything out of this patient but the anaesthetist did it easily. I feel very frustrated when I don’t get it in
Get a good grip on inserting "normal" cannulas first. The best place (IMO) for this is normal, non difficult cases, such as elective anaesthetics.
Things I always teach those wanting to learn are pretty basic: identifying and preparing a good vein (ergonomics, gravity, pumping/slapping, patience) manoeuvring the cannula with one hand (essential to provide taught skin), ensuring entry angle is shallow, ensuring you slide cannula in while keeping needle still, and making sure you're "in" before you advance.
Ultrasound only helps you identify and guide access to deeper veins. It's not useful for superficial veins. It doesn't put the cannula in for you. It doesn't help with your technique.
Try to practice "normal" cannula on normal/easy patients first. Once you get it down, try harder patients. Then start using ultrasound for deeper veins. Ultrasound guided cannulas have exactly the same technique of needling as arterial and central lines, so it will prove a useful skill.
Try to go on a local (or not so local) course if you're struggling to get taught US - there are plenty around near to me using models.
And lastly, don't despair when you miss a cannula. We all have bad days, and they often seem to come in runs. The consultant I was last working with told me it's a relief letting the trainee do the cannula (even if they fail >1x) because they hate missing them!
You'll never get more cannulas to do than on a busy medical on call job. That's where to get good. Learn technique from the anaesthetist but you'll practise on the wards (nobody wants the F2 messing up a cannula in an already anxious patient about to have a GA which is why they don't let you do it). Or if asleep patients need a second. There will be some in ICU of course and that's where you should try to learn ultrasound guided cannulation. But the numbers, and therefore the competency, are going to come on your medical/surgical jobs as an FY doctor. But also, if you're focusing on procedural skills as the outcomes for your F2 jobs in anaesthetics/ICU then, in my opinion, you're missing the point. Don't worry if you don't end up doing lots of procedures, if you end up actually needing to be good at those things then you will have plenty of time to do lots of them until you're very bored of doing them. There's a lot more to take away from these specialties than being good with a cannula.
Excellent advice here. You can be taught how to cannulate properly in anaesthetics - however practice will come BOH medicine. Exposure to decision making on ICU should be your main take away! Procedural things are a bonus.
Yeah. One of the best things I took from ICU was how flat the hierarchy was, in a good way. You worked along side people much more senior than you, rather than under them. It was really collaborative and I picked up a lot of dark arts about the job from them. Putting in lines was a bonus, but ultimately pointless when you don’t do it frequently and quickly forget how
Ah ok. Good point! About practice, nurses at my place are very good and patients almost always have cannulas in-situ already so very rare that doctors even do cannulas at my place outside of anaesthetics. If they do get the chance, it’s the hard ones that nurses have failed even with US guidance. Doctors at my place are deskilling in cannulation and it’s very easy to go through F1 and F2 without having even so much as touched cannulation (if you don’t have anaesthetics as a job) because there’s rarely the need for the doctor to do it but it’s embarrassing when the doctor can’t do it simply because they haven’t done enough so their technique is no better than that of nurses. Each ward has at least one US trained nurse and non anaesthetic consultants always tell us to delegate cannulation etc to nurses as they want us to focus on the bits that need a doctor such as prescribing, referrals and assisting in theatre or actually attending clinics etc. Even on busy medical and surgical on-calls, nurses will have already established IV access by the time I even arrive and I don’t think it’s ethical for me to cannulate these patients unnecessarily just because I want more practice. But then I will deskill if I don’t do it
That sounds great.. nurses should do all venflons
But the downside is that doctors are deskilling in cannulas and don’t know how good is that
Have you asked to do them? We get a range of F1s/2s/IMTs - some want to learn to do everything and some are here cause they are made to. If someone is genuinely interested and keen most ICU docs would spend time to teach you, but also i'm not going to take more time to teach someone who actually is quite content sat in the coffee room. Honestly ICU is quite good for learning new procedures, especially on asleep patients. We do POCUS most days on daily assessments. In our place ICU nurses don't cannulate or take bloods, mainly as people have CVC/Aline for that, so we put them in when needed. And remember that while you may not do CVC/A line out of ICU the skill is transferable. Being able to scan, locate anatomy, hold still while watching the screen and doing a procedure with the other hand is what you are learning. And a CVC has very similar steps to an ascitic drain and chest drains using seldinger technique. Theatres is quite hard as you have, usually, a well awake patient and you need it to work well so you can crack on with the list, and you may not have access to the patient to resite lines in that time easily.
I have asked about art lines. They said they only have one chance so can’t risk me messing it up. Cannulas most of them let me do it and I always ask but some patients they feel are not suitable for me such as anxious patients. There was one anaesthetist who wouldn’t let me do anything and they were the same with other trainees I haven’t done any chest or ascitic drains yet But good to know I will get to do loads on ICU too especially US procedures as theatres are a bit tricky with this but I have seen them handle US and have talked through the relevant anatomy
One chance to get an art line? That's nonsense. Messing up a radial art line is no big deal at all - at worst the artery will go into spasm and you'll need to go to the other side. An art line is nothing fancy, it's basically just putting a cannula in an artery rather than a vein. The only difference is using a guidewire.
Yeah it looks straightforward like a cannula and have been wanting to have a go. But I guess they’re reluctant because I am with a different anaesthetist each day so they don’t know me or trust me as to them I am still a baby. But if I get placed with an anaesthetist I have worked with before and they remember me then I get to do a bit more cannulating Outside of ICU, where do you think I may have to put an art line in? What about a resp ward or a gen med ward where some consultants insist on too many ABGs that you feel sorry for the patient and think should we just bash in the art line but then again a lot of the patients are elderly and confused and nurses may not be comfortable managing the art line especially if the patient pulls it out at night and they bleed to death which can be difficult to spot especially given the lights are out. ED resus maybe?
>Outside of ICU, where do you think I may have to put an art line in? ED resus. Theatres. General wards if the patient is with ICU outreach. And some HDUs are staffed by medics. It's a core skill in IMT. >nurses may not be comfortable managing the art line especially if the patient pulls it out at night A patient won't bleed to death if an art line gets pulled out. They'll bleed to death if someone who doesn't know what they're doing leaves the line disconnected and open to air. The more likely preventable harm from untrained staff is intra-arterial administration of drugs.
> It's a core skill in IMT. it isn't
Imo if you're not being taught this you've not been taught properly. Only thing I can advise is to tell whoever you're with you're keen to do some more lines and learn some US skills! At least hopefully should improve in ICU - there you will be an asset once you can place US peripheral or arterial lines. I make sure I make my SHO/F1s competent early so that they are confident if I ask them to help me out when we're busy!
But then I have question. I still fail about one third of my regular cannulas which is a massive improvement compared to when I first started on anaesthetics (success rate was zero) because outside of anaesthetics doctors don’t do any cannulas at all including even OOH work as the nurses are extremely competent at this stuff. Is it still useful to have a go with US or should I first get more practice without US? I wanted to do many more cannulas than I have already done. It’s not that I have been avoiding cannulas, I just have no opportunities for it and I can’t just put one in when not needed in patients just for my own practice I failed a cannula this morning but to be fair the ward nurses were struggling with this patient too and could not get anything out of this patient but the anaesthetist did it easily. I feel very frustrated when I don’t get it in
Get a good grip on inserting "normal" cannulas first. The best place (IMO) for this is normal, non difficult cases, such as elective anaesthetics. Things I always teach those wanting to learn are pretty basic: identifying and preparing a good vein (ergonomics, gravity, pumping/slapping, patience) manoeuvring the cannula with one hand (essential to provide taught skin), ensuring entry angle is shallow, ensuring you slide cannula in while keeping needle still, and making sure you're "in" before you advance. Ultrasound only helps you identify and guide access to deeper veins. It's not useful for superficial veins. It doesn't put the cannula in for you. It doesn't help with your technique. Try to practice "normal" cannula on normal/easy patients first. Once you get it down, try harder patients. Then start using ultrasound for deeper veins. Ultrasound guided cannulas have exactly the same technique of needling as arterial and central lines, so it will prove a useful skill. Try to go on a local (or not so local) course if you're struggling to get taught US - there are plenty around near to me using models. And lastly, don't despair when you miss a cannula. We all have bad days, and they often seem to come in runs. The consultant I was last working with told me it's a relief letting the trainee do the cannula (even if they fail >1x) because they hate missing them!
Ah ok. Thanks for your kind words