Procedures Curriculum
Internal Medicine Residency Program
University of Nevada School of Medicine (Las Vegas)
Educational Purpose:
Recognizing that the individual physician, upon completion of his or her training and
eventual practice type and locale, may or may not continue to perform procedures, does
not minimize the need to learn about various procedures, including their indication,
complications, and interpretations of fluids recovered.
Teaching Methods
Procedures will be learned on the inpatient rotations, and during Emergency Medicine
and ambulatory rotations. Knowledge competency will be attained via directed teaching
from supervising attendings or residents, and from self study, including the use of the
New England Journal of Medicine video series.
ACLS is taught during intern orientation and all residents are required to be certified
prior to beginning. There are also quarterly review sessions during the resident noon
conference series.
Procedures to be Learned
The resident will develop knowledge and performance competency of the procedures
listed below. The resident will develop the knowledge to understand and explain the
indications, contraindications, recognition and management of complications, pain
management, sterile techniques, specimen handling, interpretation of results, and
requirements and knowledge to obtain informed consent.
1.
2.
3.
4.
5.
6.
ACLS
Draw arterial blood (submit 5 procedure cards/notes)
Draw venous blood (submit 5 procedure cards/notes)
Place an intravenous line (submit 5 procedure cards/notes)
Pap smear and endocervical culture (submit 5 procedure cards/notes)
Central Line Insertion (submit 5 procedure cards/notes per type of access
obtained; i.e., internal jugular, subclavian, femoral) -- Residents must obtain
performance competency in at least one technique for central venous catheter
placement.
7. Paracentesis (submit 3 procedure cards/notes)
The procedures listed below require that a resident develop the knowledge to understand
and explain the indications, contraindications, recognition and management of
complications, pain management, sterile techniques, specimen handling, interpretation of
results, and requirements and knowledge to obtain informed consent.
1. Arterial line insertion
2.
3.
4.
5.
6.
7.
8.
9.
Arthrocentesis
Central Line Insertion
Incision and drainage of an abscess
Lumbar puncture
Nasogastric intubation
PA catheter insertion
Paracentesis
Thoracentesis
Residents will be provided the opportunity to achieve knowledge and procedural
competency in the following procedures if the resident identifies that the procedure is
relevant to future practice:
1. Arterial line insertion
2. Arthrocentesis
3. Central Line Insertion
4. Incision and drainage of an abscess
5. Lumbar puncture
6. Nasogastric intubation
7. PA catheter insertion
8. Paracentesis
9. Thoracentesis
10. Cryosurgical removal of skin lesions
Patient Characteristics
There is a diverse patient population, male and female, of all ages from adolescent to
geriatric, representing most ethnic and racial backgrounds, from all social and economic
strata. The resident will only perform procedures on patients on the teaching service
unless they are rotating in the Emergency Department, in a private physican’s office and
performing the procedure in that setting (e.g., arthrocentesis during the orthopedic
surgery elective), or in the setting of an ACLS protocol.
Reading lists and other educational resources to be used:

New England Journal of Medicine Series of Articles and Videos on Clinical
Medicine Series
o Paracentesis: N Engl J Med 2006;355:e21;
http://content.nejm.org/cgi/content/short/355/19/e21
o Central Venous Catheterization: N Engl J Med 356:e21, May 24,
2007; http://content.nejm.org/cgi/video/356/21/e21/
o Thoracentesis: N Engl J Med 355:e16, October 12, 2006;
http://content.nejm.org/cgi/content/short/355/15/e16


o Lumbar Punctures: N Engl J Med 355:e12, September 28, 2006;
http://content.nejm.org/cgi/content/short/355/13/e12
o Incision and Drainage of an Abscess: Fitch MT, Manthey DE,
McGinnis HD, Nicks BA, Pariyadath M. N Engl J Med 2007;357:e20,
November 8, 2007; http://content.nejm.org/cgi/video/357/19/e20/
o Pelvic Examination: Edelman A, Anderson J, Lai S, Braner DAV,
Tegtmeyer K. N Engl J Med 2007;356:e26, June 28, 2007;
http://content.nejm.org/cgi/video/356/26/e26/
o Orotracheal Intubation: Kabrhel C, Thomsen TW, Setnik GS, Walls
RM. N Engl J Med 2007;356:e15, April 26, 2007;
http://content.nejm.org/cgi/video/356/17/e15/
o Arthrocentesis of the Knee: Thomsen TW, Shen S., Shaffer RW,
Setnik GS. N Engl J Med 2006;354:e19, May 11, 2006;
http://content.nejm.org/cgi/video/354/19/e19/
o Nasogastric Intubation: Thomsen TW, Shaffer RW, Setnik GS. N
Engl J Med 2006;354:e16, April 27, 2006;
http://content.nejm.org/cgi/video/354/17/e16/
o Placement of an Arterial Line: Tegtmeyer K, Brady G, Lai S, Hodo
R, Braner D. N Engl J Med 2006;354:e13, April 13, 2006;
http://content.nejm.org/cgi/video/354/15/e13/
Attached supplemental readings
Up-To-Date is recommended as a concise peer-reviewed source for on-thespot information. Residents are encouraged to go to the original literature for
more in-depth learning.
Ancillary Educational Materials
Subspecialty Texts of Neurology, Pulmonary Medicine, Nephrology,
Endocrinology, Infectious Diseases, Rheumatology as well as General Medical
References (Harrison’s Principles of Internal Medicine, Cecil’s Textbook of
Medicine) are available 24 hours a day, seven days a week in the resident lounge.
Savitt Medical Library On-Line
Residents have access to the on-line services of Savitt Library (the main library of
the University of Nevada - Reno) via their computer in the resident room, Suite
300 of the 2040 W. Charleston Building. Access to this room is available 24
hours a day, seven days a week.
Full text is available for many peer-review journals including, but no limited to:
ACP Journal Club
Annals of Internal Medicine
British Medical Journal
Cancer
Circulation
Journal of the American College of Cardiology
The Lancet
New England Journal of Medicine
Stroke
Also available on-line:
Harrison’s Principle’s of Internal Medicine, 14th ed.
Merck Manual, 17th ed.
Guide to Clinical Preventive Services, 2nd ed.
The Cochrane Library
Medline and Grateful Med Databases
All of the Competency Milestones are pertinent:
Interns should be able to be able to develop a basic level of competence in the skills
listed. PGY-2s should be able to perform the skills with less supervision, at a higher
level (eg, elicit subtle physical findings), in multiple patients and in more complex
patients. PGY-3s should be almost independent in these skills, be able to deal with
unexpected events and ambiguous situations, and will demonstrate an increasing ability
to teach others
 Patient care
o Gather accurate information about patients, including performing a thorough
history and physical examination
o Synthesize data into a prioritized problem list and differential diagnosis, then
formulate diagnostic and therapeutic plans
o Monitor and follow up patients appropriately
o Know the indications, contraindications, & risks of some invasive procedures
and competently perform some invasive procedures

Medical knowledge
o Demonstrate an increasing fund of knowledge in the indications,
contraindications, risks, proper technique and interpretation of samples from:
 Arthrocentesis
 Lumbar Puncture
 Paracentesis
 Thoracentesis
 Central Venous Access
o Identify ultrasonographic, and laboratory markers of transudative, exudative,
and complicated effusions as well as empyema, and the indications for
consultation to obtain definitive management of these problems
o Identify the diagnosis and management of catheter- related thrombosis and
blood stream infections

Practice-based learning and improvement
o All interns and residents should understand their limitations of knowledge and
judgment; ask for help when needed; and be self motivated to acquire
knowledge
o Accept feedback, learn from own errors and develop self-improvement plans
o Use information technology to manage information and access on-line
medical information
o
PGY-2s and PGY-3s should learn how to use knowledge of study designs and
statistical methods to the critical appraisal of clinical studies and apply to the
care of patients

Interpersonal and communication skills
o Demonstrate caring and respectful behaviors with patients, families, including
those who are angry and frustrated; and all members of the health care team
o Counsel and educate patients and their families
o Conduct supportive and respectful discussions of informed consent
o Facilitate the learning of students and other health care professionals
o Demonstrate ability to convey clinical information accurately and concisely in
oral presentations and in chart notes

Professionalism
o Demonstrate respect, compassion, and integrity and appropriate concern for
the patient’s comfort
o Demonstrate a commitment to excellence and on-going professional
development
o Demonstrate a commitment to ethical principles pertaining to provision or
withholding of clinical care, confidentiality of patient information, informed
consent, and other aspects of clinical care
o Develop an appreciation for the ethical, cultural and socioeconomic
dimensions of illness, demonstrating sensitivity and responsiveness to
patients’ culture, age, gender, and disabilities
o Residents should display initiative and leadership; be able to delegate
responsibility appropriately

Systems-based practice
o Work effectively with others as a member of a health care team
o Advocate for quality patient care and assist patients in dealing with system
complexities
o Understand and appreciate the importance of coordinating care with other
members of the health care team
o Residents should develop proficiency in leading the health care team,
organizing and managing medical care including suggestions on improving
efficiency and safety within the hospital
o Learn the cost-effective use of diagnostic and therapeutic technology to
minimize harm, particularly minimizing bloodstream infections and iatrogenic
harm from correctable system-based problems.
Evaluation of Procedures and Resident Check List
1. All procedures requiring procedural competency require the submission of 5
procedures cards or a copy of the procedure note signed by the supervising
clinician for the resident file. The only exception is completing 3 paracenteses.
2. In order to receive independent certification for central line placement, you must
submit 5 procedure cards/notes of an individual technique (internal jugular,
subclavian, or femoral). You will then be certified to place central lines
independently using that technique only. You must complete certification in at
least one type.
3. When a resident has demonstrated procedural competency, University Medical
Center and the Lied Ambulatory Clinic will be notified.
4. Residents that have demonstrated procedural competency on a certain procedure
will be able to supervise and sign procedure cards for that procedure for other
trainees.
5. Documentation of ACLS certification is kept in the resident file.
6. Residents are expected to review the available NEJM training videos on each
procedure listed under knowledge competencies.