What is the Medicine Procedure Service at UNC, and how does it benefit patients? In this episode of Chair’s Corner, Dr. Ria Dancel highlights the procedures provided at UNC and how this helps resident training as well as patient care. Dr. Dancel is an Associate Professor of Medicine and Pediatrics in the Division of Hospital Medicine and the Department of Pediatrics, and is Director of the UNC Medicine Procedure Service.
“When we walk into a patient’s room and we say, “Good morning, we are about to do XYZ procedure on you.”
The question we usually get is, ‘Well how many of these have you done?”
– Ria Dancel, MD
Falk: Hello, this is Ron Falk for the Department of Medicine at the University of North Carolina. Welcome to the Chair’s Corner.
Today we welcome Dr. Ria Dancel who is an Associate Professor of Medicine and Pediatrics, and holds dual appointments in our new Division of Hospital Medicine and the Department of Pediatrics. Our conversation is going to concentrate on her passion, which is the Medicine Procedure Service, so we’re going to discuss what this service is, how it benefits resident physicians, but just as importantly how it is of benefit to patient safety. Welcome, Dr. Dancel.
Dancel: Thanks, Dr. Falk.
Falk: What is the Medicine Procedure Service, and why would I as a physician, or more importantly, as a patient, actually want to know what it is?
Dancel: The Medicine Procedure Service is a small consultative service of one attending physician and one trainee physician that does bedside procedures for other teams in the hospital to help them take care of their patients, either for diagnostic purposes, or therapeutic purposes. The attending physician – there are very few of us who call ourselves “proceduralists” has a lot of experience in performing these procedures. There is good evidence that shows that these procedures are safer for patients when they’re done by physicians who have some regularity in performing them.
Any department in the hospital can ask us to help them with any of their patients. The most common procedures that we do are paracentesis, where we remove fluid from a patient’s abdomen, thoracentesis, where we remove fluid from a patient’s chest, central venous catheterization, where we place a special IV in one of the larger veins that leads to the heart, and lumbar punctures, also known as spinal taps.
Falk: So the goal is to have highly competent physicians who do these procedures all the time, be in charge of or do the procedure themselves. Why is that important to a patient? If I’m a patient, why do I want somebody who is a proceduralist to do my spinal tap, rather than somebody else?
Dancel: We get that question a lot. When we walk into a patient’s room and we say, “Good morning, we are about to do XYZ procedure on you.” The question we usually get is, “Well how many of these have you done?” It’s the very first question and it’s a very understandable question. You want to have someone who has done many of these procedures because they understand what is going to be uncomfortable for the patient. They can walk the patient through every step of the way. And again, there’s been evidence that shows the more you do these procedures, the fewer complications the patient will have.
Falk: If I’m a patient, I want somebody, as in any invasive procedure, I want somebody who’s done a lot of them, and that I’m not the first person that the individual has ever seen.
Dancel: Or the first person that they’ve put a needle into.
Falk: Practice makes perfect.
Dancel: Practice absolutely makes perfect. We have seen that over the past three years that the Medicine Procedure Service has been doing these procedures on patients. We have seen that our complication rates are frequently one percent or less, and I’m very proud to be able to talk to a patient and say, “These are the risks of your procedure. However, these risks are very, very low because we do these procedures all the time.”
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Falk: Let’s pretend that it’s a lumbar puncture or a spinal tap. You have some discomfort about this procedure – somebody’s putting a needle in your back. How do you make sure that you calm the person down?
Dancel: I think anticipation is the worst part of the patient experience. How is this going to feel? What position am I going to be in? Am I going to know what you’re doing behind my back? The biggest question is, “Is this going to hurt?”
Falk: Does it hurt?
Dancel: I don’t lie. The lidocaine part – the numbing part of any procedure actually does burn and sting, and I tell them it feels like a bee sting. Some patients have told me it’s a very large and very mean bee. But that’s the part that is the most uncomfortable. For example, if I were doing a lumbar puncture, I would absolutely counsel them that the lidocaine part will probably be the most uncomfortable bit. After that, I will tell them every step of the way, knowing that they have their back turned to me, and that’s a very vulnerable position for a patient to be in.
Falk: How did you get into this profession? How did you get into wanting to do these procedures? It’s absolutely clear that you’ve become expert in them. What drove you in that direction?
Dancel: I was a resident here from 2006-2010, and I found that I really liked being in the critical care units, where a lot of these procedures were being done. Over the years, I also became very passionate about doing bedside ultrasound, or point-of-care ultrasound, and actually went as far as getting a certification through the American College of Chest Physicians in bedside ultrasound. Those two passions go hand in hand. A lot of our procedures are ultrasound-guided, so they play into both of my passions.
The other thing that I really like about doing procedures is the one-on-one teaching with the residents. There are few times and few teams that have one resident and one attending, and the education piece I’m very passionate about. Finally, a lot of the procedures that we do— at the end of the procedure, the patient feels a whole lot better.
Falk: Especially with the paracentesis, getting rid of fluid from the abdomen. How did you learn? You learned the process “See one, do one, teach one.” But now with the advent of simulation labs, one can actually practice a lot of this before one ever does it on a patient.
Dancel: Yes, and that is where the patient safety and quality improvement aspect of what I like to do comes into play. “See one, do one, teach one” is a very time-honored way of teaching, but it doesn’t take into account that every resident, every trainee has their own learning curve. And no patient wants to be on the other end of a needle where the resident has not had any prior training on how to perform the procedure. The simulation environment actually allows trainees to go through the procedure, get comfortable with it, and even make mistakes in a way that doesn’t compromise patient safety in any way whatsoever.
Falk: Pilots have been doing this for years with simulation experiences so they learn how to fly jets, before they’re actually flying a jet with one of us in it, so this is the same sort of process.
Dancel: Absolutely the same sort of process.
Falk: What can you see in an ultrasound that’s different than what you’re seeing otherwise?
Dancel: An ultrasound is amazing, the things that you can see on it. For example, for a paracentesis, our physical exam skills for finding large pockets of fluid, aren’t so great. The patient doesn’t have a whole lot of interaction while you’re performing your physical exam, so they’re not feeling what you’re feeling, they’re not hearing what you’re hearing. When you put an ultrasound probe on a patient’s abdomen, they really get excited – they can see their liver, they can see the fluid, and how much fluid is in there. For patients who get paracenteses fairly really regularly, can actually tell me if there’s a lot of fluid in there and they need to have the procedure done, or there’s not that much fluid in there and they’re okay going home.
Falk: The same is true for thoracentesis or taking fluid out of the lung, where there’s actually a risk of hitting the lung, and causing what would be known as a pneumothorax. What can you see by ultrasound when you’re doing those?
Dancel: I always tell residents that they must show me the boundaries of the effusion before they can think about sticking a needle into the chest. The boundaries are where the lung is sort of moving inside that pocket of fluid, the chest wall, and the diaphragm which is the muscle that typically would allow the patient to breathe. Within those boundaries, you should see a very large black space that’s indicative of a large amount of fluid that would make the procedure safe.
Falk: Why don’t I want these procedures to be done in radiology with other kinds of x-ray modality such as fluoroscopy? So if I have a choice between getting a central line, or a thoracentesis, or even a lumbar puncture, why don’t I want to have other kinds of visualization approaches?
Dancel: That’s a very good question. For paracenteses and thoracenteses, they use an ultrasound in radiology just like we do on the floor, so there’s not much of a difference there. When placing a central line they also do an ultrasound-guided; they use fluoroscopy to ensure that the catheter ends up where it needs to end up. That isn’t usually something that causes a complication. And for lumbar punctures, yes for more difficult lumbar punctures it is appropriate to go down to radiology.
I think the biggest reason to have our procedure team do these procedures, rather than go down to radiology, is the efficiency that we can bring by coming to the patient’s bedside.
Falk: Because the patient doesn’t have to move?
Dancel: They don’t have to move.
Falk: And they don’t have to move after the procedure.
Dancel: They’re in their bed the whole time in an environment that they are comfortable with, so there’s a lot of efficiency. They don’t have to wait hours to get these procedures done. Especially important if that’s all they’re waiting on before they can go home.
Falk: So if I’m a patient, what questions should I be asking you, before you do any procedure, or anybody does a procedure?
Dancel: The risks of the procedure is something that they absolutely should know and understand. The benefits of the procedure, and alternatives to what we are about to do. Those are all of the things that we discuss before we do the procedure, and those are questions that every patient should ask.
Falk: And a patient should feel comfortable asking, “Well, doc, how many of these have you done?”
Dancel: I think so. I think it’s necessary for us to be transparent. We are a teaching institution, so we have trainee residents, but I don’t think that we have to compromise patient safety because we have proceduralist attendings that are there and making sure that everything is being done safely, being done according to standard of care, and best practices.
Falk: So what happens as a patient as I’m sitting there or lying in bed and I get anxious about this procedure, and I’m not sure that I should have it done, or the person who’s doing it might not be as competent as I’d like them to be? What are my options?
Dancel: You can always say “stop.” Anytime, unless it’s a point in the procedure where stopping would actually cause more harm. If the patient is not comfortable at any point in time, they can say stop.
Falk:Patients should feel comfortable participating in every aspect of this.
Falk: After a procedure’s done, how do you make sure that patients are actually doing okay?
Dancel: We make sure that if there is a follow-up image that is appropriate to do after that procedure, that that image is done, and we ourselves review that image. For example, if we’ve done a thoracentesis, we make sure that there wasn’t any inadvertent damage to the lung. We also follow up on all laboratory results, and we help the primary team interpret these results and the images. If it’s appropriate, we recommend that they consult another team. If the thoracentesis shows that the fluid surrounding the lung is infected, we actually will call the interventional pulmonologist ourselves and discuss the case.
We regularly follow up within 24-48 hours after the procedure is done to make sure there weren’t any complications that weren’t immediately obvious, and then on a more systematic level, I have reviewed every procedure, which is almost 2,000 procedures, over the past three years to ensure that there aren’t any patterns that we need to go back and look at and maybe improve our practice.
Falk: Your quality assurance project. In other words, you as a physician, if you needed a central line—other than in an emergency situation—you would want to have somebody know where they were putting the needle under ultrasound, rather than just probing around. If there was an option, ultrasound or fluoroscopy-guided procedures should always happen before blind central line placement.
Dancel: Absolutely. That is the standard of care. The Centers for Disease Control actually have guidelines on reducing complications when central lines are being placed. One of the major guidelines is that it needs to be done ultrasound-guided, whether it goes in the neck, or in the chest, or in the groin, an ultrasound should be used. That sounds fairly simple, to be able to use an ultrasound, in order to guide the tip of the needle where it needs to go, but there is a learning curve for that as well. Before the Medicine Procedure Service, our residents did not have any formal training in using ultrasound in order to guide procedures.
Falk: That’s a wonderful service.
Dancel: As far as patient safety is concerned on a more hospital-wide level, this is the first collaborative effort with four other departments, to train the residents in one single way in doing a central line.
Falk: And how did you do that?
Dancel: The five departments that are involved are Internal Medicine, Surgery, Anesthesiology, Emergency Medicine, and Family Medicine. These are all departments that place central lines on the floor. We got together as a collaboration and found out that we all train our residents very differently, and that we weren’t very educated ourselves on what the Centers for Disease Control guidelines were. Using those guidelines, we came up with a four-hour simulation course. In this course, residents have knowledge-based testing of why we do the things that we do before and after the course. They get formal ultrasound training, and they actually at the end of the course have to place a central line in an anatomically correct mannequin that the Department of Surgery has created.
Falk: It really is a tremendous advance from an era that happily has gone by when people would just put lines in without this kind of formal training.