Learning to Perform Procedures
Learning to competently and compassionately perform procedures is one of the most challenging skills to master in pediatric training. At CHOP, multiple approaches are used to gain competency in performing procedures.
Didactic sessions and workshops are utilized as early as Intern Orientation to develop competence and confidence in the procedural skills residents need to master. Pediatric Advanced Life Support (PALS) and the Neonatal Resuscitation Program (NRP) are offered during orientation. Basic, life–saving procedures such as bag-valve-mask ventilation, intraosseous access and endotracheal intubation are first performed on simulators during these courses. Additional dedicated sessions early in the first year include suture and splinting workshops provided by the Division of Emergency Medicine.
Ongoing procedural practice is provided in a variety of settings. The pediatric chief residents facilitate skills workshops as part of the weekly Friday morning Mock Resuscitation Curriculum. These are held on the regular inpatient units, and the participation of individual house officers in a preset curriculum is tracked throughout the year.
During PICU, NICU and ED rotations, there are regular mock resuscitations, including the practice of procedures for the house staff which utilize the high fidelity simulation resources of the CHOP Center for Medical Simulation. There are set goals and objectives, and feedback is provided in both group and individual settings. Transport-specific procedures and mock resuscitations are also reviewed during elective rotations in transport medicine.
The Division of Emergency Medicine holds an annual resuscitation day for first-year residents. This day-long event focuses on procedural skills and resuscitation scenarios using didactic, small group and workshop settings. The goal is to reinforce and refresh these concepts before undertaking the large number of acute care (ED, PICU and NICU) rotations that are part of the second-year curriculum.
Formal procedure learning incorporated into some inpatient rotations as well as a procedure elective provides residents with the opportunity to gain additional experience in minor pediatric procedures in a variety of settings making use of the wide variety of resources and teachers that the Hospital can provide. Procedures taught include:
- Intravenous line insertion
- Urinary catheterization
- Casting and splinting techniques
- Advanced sedation practices
As part of these experiences, faculty from the Division of Emergency Medicine have served as preceptors for residents interested in learning how to use point-of-care ultrasonography to facilitate some of these procedures. These are especially valuable experiences for house staff planning on pursuing careers in primary care pediatrics and hospitalist medicine.
The chief residents and faculty from the Divisions of Emergency Medicine and Neonatology, in partnership with faculty members from the Department of Anesthesiology and Critical Care Medicine, have developed an Airway Curriculum that includes online, didactic and hands-on experiences for residents to develop airway skills that match their future career goals and work settings. A variety of skills are taught from bag-valve mask ventilation and use of simple airway adjuncts, to spending time in the Operating Room learning to intubate older children in a controlled setting.
Delivery room experience and resuscitations are an integral part of the NICU rotations at the Hospital of the University of Pennsylvania (HUP). The management of minor trauma, including laceration care and splinting, is taught in the ED. Residents actively participate in and perform procedures during resuscitations in the ED, PICU and NICUs. The opportunities to perform lumbar punctures, procedural sedation, intravenous line insertion and the entire gamut of routine pediatric procedures occur throughout a residents’ training.
As critical procedures become rarer in pediatric practice, reliance on simulation technology as a means of providing valuable experiences will continue to increase.
Sessions on how to teach procedures are being developed for and offered to senior house staff. As with much of the training that occurs in residency however, a majority of what we learn about procedures we learn at the bedside of our patients through the teaching of our mentors. In a variety of rotations, house staff are instructed in procedural skills and supervised by experienced nurses, senior house staff, fellows and attending physicians as they perform procedures. Primary care sessions, ED, inpatient unit, PICU, NICU, transport and sedation service rotations expose residents to a wide range of minor and complex procedures throughout their training.