Procedural Skills and Interventions
Every procedure follows the same skeleton
Indication and alternatives, contraindications, informed consent (implied in a true emergency), a time-out confirming patient, site, and side, positioning, anesthesia, sterile technique, the procedure itself, confirmation of success, and documentation of complications and follow-up. Competence includes recognizing when to stop and call for help.
Details that get tested
- Central venous access: ultrasound guidance and site selection by indication; confirm tip position and exclude pneumothorax after internal jugular or subclavian placement.
- Lumbar puncture: measure opening pressure; commonly used thresholds are platelets below about 50 ×10⁹/L or INR above about 1.5, and you must assess herniation risk and image first in the appropriate patient.
- Paracentesis and thoracentesis: ultrasound marking reduces complications; avoid a distended bladder and use real-time guidance for small or loculated fluid.
- Procedural sedation: cardiorespiratory monitoring including capnography; fasting status does not justify delaying urgent sedation.
- Arterial lines, joint aspiration, nerve blocks, and suturing all hinge on landmark accuracy and sterile technique.
Traps
Skipping the time-out or consent because the patient is in pain; failing to reverse anticoagulation when the procedure cannot wait; forgetting to document both the attempt and the complications; assuming a landmark technique is safer than ultrasound.
Rule of thumb
Stop before you start: pause, confirm the side and site out loud, state the plan for failure, and name the person who will manage the airway.