Procedures and Skills
Procedures and Skills evaluates whether you can select, perform, and document bedside procedures safely, and recognize complications early. Items typically ask for the next step when a procedure is contraindicated, the finding on bedside ultrasound, or the documentation element that protects the patient and the clinician.
Core rules across procedures
- Confirm indication, rule out contraindications, obtain informed consent (emergency exception applies when the patient lacks capacity and delay would harm).
- Know your coagulation thresholds: routine correction before most bedside procedures is not required, but severe coagulopathy changes site and technique.
- Use ultrasound guidance where evidence supports it - vascular access, arthrocentesis of deep joints, abscess localization, and lumbar puncture in difficult anatomy.
- Document indication, consent, technique, findings, complications, and post-procedure monitoring.
High-yield specifics
- Arthrocentesis: send cell count with differential, crystals, Gram stain and culture; avoid intra-articular steroid when a prosthetic joint or overlying cellulitis is present.
- Lumbar puncture: obtain CT first for immunocompromise, focal neurologic deficit, papilledema, altered mental status, new-onset seizure, or known CNS mass. In suspected bacterial meningitis, give antibiotics before imaging - never delay treatment for the scan.
- Extended Focused Assessment with Sonography in Trauma (eFAST): include pleural windows; ultrasound detects pneumothorax more sensitively than a supine chest radiograph.
- Procedural sedation: preoxygenate, use capnography, confirm rescue airway and reversal agents are at the bedside, and document pre-sedation risk and post-sedation recovery.
Worked example
A 24-year-old with fever, headache, and neck stiffness is scheduled for lumbar puncture. They are confused and have a new seizure. Reasoning: altered mental status plus new seizure are CT-first criteria, so imaging precedes the tap; however, blood cultures and empiric antibiotics plus dexamethasone are given immediately, because the CT is for procedure safety, not for diagnosis.
Traps that cost marks
- Delaying antibiotics to complete imaging or the lumbar puncture.
- Forgetting the posterior lung windows on eFAST and missing a pneumothorax.
- Injecting steroid into a joint with overlying cellulitis or a prosthesis.
- Performing a procedure without documenting consent and complications.
- Ignoring post-procedure reassessment, which is where complications are caught.