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It is early July. As the first-year surgical resident on the thoracic surgery service, you are asked by the senior resident to remove the chest tube on a patient who recently had a pulmonary resection. You have been on the service for a few days and you have seen the problems that can occur if a chest tube is pulled without appropriate management—namely, the patient may have an air leak into the pleural space requiring replacement of another chest tube. Although you have seen one chest tube removed, you are uncertain of the appropriate steps to take to ensure that the patient does not have a pneumothorax as a result of the chest tube removal.

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1. How should you manage your lack of comfort with this procedure?

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2. Who would be the appropriate person to speak to in order to ensure that patient safety is maintained while you gain the experience that is required to proceed?

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Over Your Head

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Answers
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  1. When answering this question, it is critical to distinguish between feelings of inadequacy and the actual lack of training or experience with a procedure. It is not uncommon for surgical residents to have some concern about doing procedures with which they have little experience. Unfortunately, early in the first year of residency, many procedures fall into the category of “things I have little experience with.” Being self-critical is important for the resident to determine if he or she has been adequately trained in all of the steps of the procedure and has seen it done by others. Lack of such minimal training in a procedure is a clear reason to ask for help from a senior resident or an attending.

  2. Although there is a tendency for surgical residents to sometimes be hesitant to ask for help, doing so should never be seen as a “sign of weakness.” As a physician, a surgical resident has a responsibility to do everything possible to ensure the safety of the patient. If the resident has not been fully trained in a procedure, to proceed to do it on a patient without adequate training and/or supervision should be viewed as unethical. In some cases, surgical skills are formally taught and competency is assessed formally. However, in many cases, the individual resident is the only one who can assess whether he or she has the training needed to carry out the procedure. A more senior surgical resident or fellow or a faculty member should be asked for help in learning how to do a procedure before it is done on a patient. Depending on the skill in question, you can also ask for help from experienced nurses, physician assistants, or other health providers who are usually happy to teach, assist, or guide you.

  3. It is often challenging for surgical trainees to determine whether conveying information to a ...

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