To Military and Corpsman

bulgethetwine · Mar 22, 2007

Actually, I was disappointed to find this thread was closed. I think it was a legitimate concern brought up by Corps, and I agree fully. I had the same frustrations.

I would suggest this to Military and the others, though -- the truth is somewhere in the middle.

Point well taken, Military, that you might find it dangerous from a liability standpoint. But I think you're overreacting -- it's not like your own anesthesia interns come into the residency with experience built in. Hell, your story of being summoned to the ED actually reinforces the need for the EM trained to get some experience in the controlled environment of the OR.

But I can see your point about not wanting it to just be intubation camp, too. I mean, even when I did have days of intubation camp, although I did relish the experience, I was kind of sheepish that I wasn't doing more. But that didn't mean I wanted to titrate sevo! Surely there is other worthwhile components to anesthesia....

WAIT! THERE IS!

Why not call upon the EM world and the anesthesia departments to collaborate better in terms of rotations? Guess what, both worlds are super heavy in critical care. Why not make an anesthesia month a "critical care month" -- EM residents could get experience tubing multiple patients in different rooms, doing vascular access (swans, A-lines, etc.) and helping the transition for patients from OR to PACU to SICU which often involves sedatives, pain control medications, epidurals, pressors, etc. Now THAT would be a worthwhile rotation. The EM resident gets some practical training that is useful to his/her field, and the anesthesia department, I believe, would certainly feel as if the EM residents are active participants.

Military, I really do appreciate your perspective, but I think both specialties have a way to go to make this particular cross roads of medical practice better for everyone involved.

Cheers Corps, sorry for hijacking your thread back to life, I just thought it was a little premature to jump out, and I kinda wanted to hear what Military had to say to this because I don't think he/she is anti-EM so much as anti-intubation camp. And I think we EMers are kinda sheepish about it too, but I'd rather be sheepish that s^*% deep in sevo!

corpsmanUP · Mar 22, 2007

From anyone else I might have cringed, but my old buddy and pal BTT makes great points. Where the last thread went awry was the casual observer stepping in and making some unfriendly comments. Anyone who knows me realizes I won't sit back and be sniped. But I'll be a big boy and try to keep the thread alive in this manner, despite the PM's from militaryMD with the abusive language and all.

What gas passers don't understand is that we as EM docs in 99% of hospitals in the country have no anesthesia presence after hours and on weekends. Even in academia, by the time anesthesia would come to the department it would be way too late. So the reality of the situation is that we have to become competent in airway management. In an ideal world, there would be enough time to learn about the finer aspects of anesthesia as well as airway management on one rotation. But there is not.

We are not anesthesiologists and are not pretending or desiring to be. We only want and need to become proficient at airway management so that we can bring people back from the gallows of death, or prevent an untimely demise. The bottom line is that it takes a minimum number of "looks" to feel and function competently as someone who manages the airway, and in my opinion is is pointless to learn the finer points of anesthesia administration until you have crossed that threshold of "enough looks". I don't know what that number is.

I would be curious to see what an anesthesia response to this problem would be? I guess they want us to have minimal looks, but a finer grasp on the gases and drugs we will rarely use if ever. Does that make sense? As Navy corpsmen, we are taught to recognize basic trauma injuries and react with appropriate interventions. We spend less than 6 months in high speed Navy/Marine schools to get a basic grasp on techniques that we NEED to be able to perform to save someone's life in seconds. It's not like we had to spend a month in pulmonary medicine watching bronchs in order to be allowed to do chest tubes. It's not like we have to assist 2 dozen rhino/septoplasties in order to be allowed to drop an oral airway, and I assure you we never saw or met an anesthesiologist before being taught and allowed to intubate.

If flight training included minimal simulation time and maximal amount of time working navigation questions, you could not be expected to fly very well.

bulgethetwine · Mar 22, 2007

corpsmanUP said:
From anyone else I might have cringed, but my old buddy and pal BTT makes great points. Where the last thread went awry was the casual observer stepping in and making some unfriendly comments. Anyone who knows me realizes I won't sit back and be sniped. But I'll be a big boy and try to keep the thread alive in this manner, despite the PM's from militaryMD with the abusive language and all.

What gas passers don't understand is that we as EM docs in 99% of hospitals in the country have no anesthesia presence after hours and on weekends. Even in academia, by the time anesthesia would come to the department it would be way too late. So the reality of the situation is that we have to become competent in airway management. In an ideal world, there would be enough time to learn about the finer aspects of anesthesia as well as airway management on one rotation. But there is not.

We are not anesthesiologists and are not pretending or desiring to be. We only want and need to become proficient at airway management so that we can bring people back from the gallows of death, or prevent an untimely demise. The bottom line is that it takes a minimum number of "looks" to feel and function competently as someone who manages the airway, and in my opinion is is pointless to learn the finer points of anesthesia administration until you have crossed that threshold of "enough looks". I don't know what that number is.

I would be curious to see what an anesthesia response to this problem would be? I guess they want us to have minimal looks, but a finer grasp on the gases and drugs we will rarely use if ever. Does that make sense? As Navy corpsmen, we are taught to recognize basic trauma injuries and react with appropriate interventions. We spend less than 6 months in high speed Navy/Marine schools to get a basic grasp on techniques that we NEED to be able to perform to save someone's life in seconds. It's not like we had to spend a month in pulmonary medicine watching bronchs in order to be allowed to do chest tubes. It's not like we have to assist 2 dozen rhino/septoplasties in order to be allowed to drop an oral airway, and I assure you we never saw or met an anesthesiologist before being taught and allowed to intubate.

If flight training included minimal simulation time and maximal amount of time working navigation questions, you could not be expected to fly very well.

Incidentally, there is some data on this -- albeit it small sample size, in abstract form, and really a comparison of Miller vs. Mac blades then the "magic number" of intubations needed to be comfortable...

"Miller vs. Macintosh for Learning Intubations"
Maurice L. Kliewer, M.D., Jr., Lance L. Trahern, M.D., Joe A. Carrithers, Ph.D.
American Society of Anesthesiologists 2003

Essentially, what it says, is that for a Miller blade, failure rate plateaued after 12 attempts, and it was a few more for MAC. So one might reasonably say that if you got 40 attempts, split in roughly equal proportion between Mac and Miller blades (the two most common type of blades, for any newbies out there) your failure rate might plateau. It would at least give you some orientation to be able to identify the difficult airway, when to try a differnet blade, etc. (and when be able to start to know when anesthesia needs to be called urgently and pro-actively rather than emergently and under absolute crash circumstances).

militarymd · Mar 22, 2007

To anyone who is interested...read my post.

I offered an observation....about the type of rotations that exist.

I explained why what some would want out of a rotation is not something that anesthesia departments offer.

I made an observation that junior trainees (pgy 1's) can be overconfident.....I don't need to know the trainee...the simple fact is that is true 99% of the time regardless of what that trainee thinks of himself....overconfidence...knowing what they need to do ...etc.

This is followed by insults.....

As pointed out by the stone thrower...this is a PUBLIC forum......points of view are offered.....I would submit that my point of view is wider than a PGY'1's.....

which is then followed by insults from the PGY1....

hmmmm

corpsmanUP · Mar 22, 2007

militarymd said:
To anyone who is interested...read my post.

I offered an observation....about the type of rotations that exist.

I explained why what some would want out of a rotation is not something that anesthesia departments offer.

I made an observation that junior trainees (pgy 1's) can be overconfident.....I don't need to know the trainee...the simple fact is that is true 99% of the time regardless of what that trainee thinks of himself....overconfidence...knowing what they need to do ...etc.

This is followed by insults.....

As pointed out by the stone thrower...this is a PUBLIC forum......points of view are offered.....I would submit that my point of view is wider than a PGY'1's.....

which is then followed by insults from the PGY1....

hmmmm

1. 99% of 1st year residents are overconfident (any data here or just anecdotal based on your experience?)

2. Do anesthesia departments not offer high numbers of intubation attempts to offservice residents...everywhere? This has already been disputed by posters in the closed thread multiple times. Perhaps this is just another one of your anecdotal viewpoints that you are applying to the whole world. And you say I have bitemporal hemianopsia?

3. And thanks for again showing your obvious bias towards EM, towards residents in general, and towards those who would disagree with you. It seems no stone throwing is necessary when you place yourself at the bottom of a landslide of boulders.

Haemr Head · Mar 22, 2007

What we have here, is a failure to communicate....

Sometimes it helps to remember what we are all trying to accomplish: providing the best possible patient care now and in the future through the most optimal training for all residents from all disciplines. It's not about who is better but who needs the training and where it can be best provided. Training and patient safety need to be balanced. But if we start focusing only on service and risk, then the only providers who will intubate will be the most experienced attendings. Since I am counting on today's EM residents to save my life when I need it in the future, I selfishly will ensure that they get lots of practice on my watch. So to my anesthesiology colleague, I will simply argue that you aren't obliged to do anything you don't want to, but thanks for the help and teaching you can provide to the EM residents because it will make all of out patients safer in the long run.

Airway skills in the ED are different than in the OR, more than in better patient preparation. I say this from the perspective of someone who has lived both roles as an attending in both specialties although my anesthesiology days are far in the past. An anesthesiologist must know how to intubate fiberoptically but this skill is optional and potentially unnecessary for an EM specialist. On the other hand, an EM specialist must be comfortable in performing a cric in under 2 minutes. A rare anesthesiologist will feel comfortable performing a surgical cric. A few anesthesiologists I know would rely on the (shudder) percutaneous device if they ever were forced to a surgical airway. The remainder would yell for a surgeon or even call for back-up from the ED (I personally know of a good number of cases where this has happened).

EM physicians will probably not reach the same level of technical skills with a laryngoscope as someone who intubates 3 times a day, but they are the ones on duty at night when no one else is around to secure an airway. Finally EM physicians routinely have to do something anesthesiologists rarely do, namely decide to intubate someone they have had little time to assess and who has not yet fully shown that the tube is needed. Airway management is not an area for competition between EM and anesthesia but one where we need to recognize the different skill set and accept that each specialty complements the other. If I have a stable patient with an unstable cervical spine that needs to go to the OR, I think it is just fine to have it done fiberoptically by anesthesia. My colleagues in anesthesia love not having to respond to the ED night and day for disasters because we safetly manage 99% of the emergency airways at our hospitals. I also think the performance of anesthesiologists in the chaos of an ED is not at the same level as their performance in their own environment. So we have a duty to train both specialties as well as we can with the available resources.

Different anesthesia departments are willing to provide different experiences and some will offer pure airway rotations. However, it is also important to remember that residency is not medical school. The very big difference is that residents are paid and expected to provide some work in exchange for their experience. Sometimes compromise and work with low educational yield can be required to get the access and high yield experience. Just as no one thinks twice about assessing the 1,235th alcoholic found down during an ED rotation, it's not too radical to be asked to manage an anesthetized patient in exchange for the intubation. LMAs are also a useful skill for EM physicians as a rescue device. Furthermore, there is value is pain management, and experience in the use of anesthetic drugs (propofol, barbituates, ketamine, muscle relaxants, etc...). With boarding of unit players and the changing nature of the specialty, an EM physician may be required to keep a patient under general anesthesia in the ED for prolonged periods. Guess where the best place to learn this is? Finally playing catcher is a useful skill for a pitcher. Knowing how to package a patient for the OR, and understanding what happens to the surgical emergency once launched from the ED is very valuable.

The RRC monitors the number of intubations/resident and all programs must hit the target number that will give you the right skill set. Finally, as on every rotation, if you do the scut with a smile, people will bend over backwards to give you extra helpings of the stuff you crave.

bulgethetwine · Mar 22, 2007

militarymd said:
To anyone who is interested...read my post.

I offered an observation....about the type of rotations that exist.

I explained why what some would want out of a rotation is not something that anesthesia departments offer.

I made an observation that junior trainees (pgy 1's) can be overconfident.....I don't need to know the trainee...the simple fact is that is true 99% of the time regardless of what that trainee thinks of himself....overconfidence...knowing what they need to do ...etc.

This is followed by insults.....

As pointed out by the stone thrower...this is a PUBLIC forum......points of view are offered.....I would submit that my point of view is wider than a PGY'1's.....

which is then followed by insults from the PGY1....

hmmmm

Mil MD:

No insults offered here -- seriously. The intent of my OP in this thread was to suggest a way how an EM - Anesthesia collaboration might be done better by both sides.

I think the shared olive branch is admitting that EMers shouldn't be seeking an intubation camp, and that anesthesia needs to take a softer approach, and avoid trying to, at least in some cases, strong hand off-service residents (EM or otherwise) into learning the finer points of anesthesia-specific knowledge. It's not high yield for our practice, and it doesn't help patient care.

Learning how to intubate under controlled OR conditions with anesthesia attending supervision DOES benefit patients --- the person who you might otherwise be asked to come and help with in the ED in the middle of the night for instance. And doing a-lines and dealing with medicines and interventions in the PACU, too.

So your point of view is welcome -- it reinforces the need for us, as EMers, to look beyond the intubation aspects of an anesthesia rotation. But to simply state that what some would want is "not offered by anesthesia departments" is not only a blanket statement which does not apply to all departments, but is a nose-thumbing rejection of any meaningful dialogue.

I've taken your point of view, and tried to understand and integrate it in a framework that might work for both sides. If I was a residency director, it would be what I would try to create for a rotation tomorrow -- a reflection of what Corps and many others have found when they are let down by their rotation, and a reflection of anesthesia feedback as regards the airway-centric view and approach of many EM residents.

So I challenge you to contribute and help refine such a view, or maybe point out obstacles to implementation. There are no flames in this post, I hope you agree, and I've no agenda -- as you said, this is an anonymous and public forum. Neither one of us have anything but virtual turf to protect, so help me understand how I could design a better mousetrap.

bulgethetwine · Mar 22, 2007

Haemr Head said:
What we have here, is a failure to communicate....

Sometimes it helps to remember what we are all trying to accomplish: providing the best possible patient care now and in the future through the most optimal training for all residents from all disciplines. It's not about who is better but who needs the training and where it can be best provided. Training and patient safety need to be balanced. But if we start focusing only on service and risk, then the only providers who will intubate will be the most experienced attendings. Since I am counting on today's EM residents to save my life when I need it in the future, I selfishly will ensure that they get lots of practice on my watch. So to my anesthesiology colleague, I will simply argue that you aren't obliged to do anything you don't want to, but thanks for the help and teaching you can provide to the EM residents because it will make all of out patients safer in the long run.

Airway skills in the ED are different than in the OR, more than in better patient preparation. I say this from the perspective of someone who has lived both roles as an attending in both specialties although my anesthesiology days are far in the past. An anesthesiologist must know how to intubate fiberoptically but this skill is optional and potentially unnecessary for an EM specialist. On the other hand, an EM specialist must be comfortable in performing a cric in under 2 minutes. A rare anesthesiologist will feel comfortable performing a surgical cric. A few anesthesiologists I know would rely on the (shudder) percutaneous device if they ever were forced to a surgical airway. The remainder would yell for a surgeon or even call for back-up from the ED (I personally know of a good number of cases where this has happened).

EM physicians will probably not reach the same level of technical skills with a laryngoscope as someone who intubates 3 times a day, but they are the ones on duty at night when no one else is around to secure an airway. Finally EM physicians routinely have to do something anesthesiologists rarely do, namely decide to intubate someone they have had little time to assess and who has not yet fully shown that the tube is needed. Airway management is not an area for competition between EM and anesthesia but one where we need to recognize the different skill set and accept that each specialty complements the other. If I have a stable patient with an unstable cervical spine that needs to go to the OR, I think it is just fine to have it done fiberoptically by anesthesia. My colleagues in anesthesia love not having to respond to the ED night and day for disasters because we safetly manage 99% of the emergency airways at our hospitals. I also think the performance of anesthesiologists in the chaos of an ED is not at the same level as their performance in their own environment. So we have a duty to train both specialties as well as we can with the available resources.

Different anesthesia departments are willing to provide different experiences and some will offer pure airway rotations. However, it is also important to remember that residency is not medical school. The very big difference is that residents are paid and expected to provide some work in exchange for their experience. Sometimes compromise and work with low educational yield can be required to get the access and high yield experience. Just as no one thinks twice about assessing the 1,235th alcoholic found down during an ED rotation, it's not too radical to be asked to manage an anesthetized patient in exchange for the intubation. LMAs are also a useful skill for EM physicians as a rescue device. Furthermore, there is value is pain management, and experience in the use of anesthetic drugs (propofol, barbituates, ketamine, muscle relaxants, etc...). With boarding of unit players and the changing nature of the specialty, an EM physician may be required to keep a patient under general anesthesia in the ED for prolonged periods. Guess where the best place to learn this is? Finally playing catcher is a useful skill for a pitcher. Knowing how to package a patient for the OR, and understanding what happens to the surgical emergency once launched from the ED is very valuable.

The RRC monitors the number of intubations/resident and all programs must hit the target number that will give you the right skill set. Finally, as on every rotation, if you do the scut with a smile, people will bend over backwards to give you extra helpings of the stuff you crave.

Fantastic post.

This, in my opinion, is the value of a public forum.

You wrote:

"Sometimes compromise and work with low educational yield can be required to get the access and high yield experience. Just as no one thinks twice about assessing the 1,235th alcoholic found down during an ED rotation, it's not too radical to be asked to manage an anesthetized patient in exchange for the intubation."

I agree -- but the "managing" can be of variable utility, too. I think the managing aspects particularly during PACU, transfer to SICU, etc. are the salient features. For instance -- an ideal experience might be to cover 3 rooms, do all three tubes, but then be assigned one room to return to for the rest of the case? Better ratio of airway to routine use of the anesthesia machine, and following one patient to conclusion provides maximum exposure to the use of the pharmacologic interventions that might be required in immediate post-op care which are the area of expertise of both the EM and anesthesia physician.

NinerNiner999 · Mar 22, 2007

I've scrubbed in on cases that last longer than my shifts do now...

corpsmanUP · Mar 22, 2007

Dr. Haemr,
Thank you for one of the best posts I have ever had the priveledge of reading on SDN. I am humbled by your wisdom and appreciate greatly your willingness to speak to the issue.

UPDATE:
I spoke with the rotation coordinator, also the assistant department head, just today. He asked me how much airway exposure I had received as of today. He was actually almost apologetic and offered me multiple ways to let me get more rotations before the end of the month. I offered to let the call team take my pager number and I told him I would get on my moto and be there in 7 minutes. We also talked about doing some stuff like this even after my rotation when I am on a day off in the ETC. These were all ideas I offered and he did not seem aversed to such.

He told me it was challenging to schedule residents from other services and put them in situations to get a lot of tubes. He said he could schedule me for long cases that would likely result in intubations, but that would likely mean only 1-2 a day. He said if he put me in a high traffic room that it likely would result in more LMA usage. He also mentioned how it is entirely staff dependent as to what they like to use and that he can't always predict that.

The bottom line is that he was more than helpful and I should have approached him a week earlier. Good outcome overall!!

militarymd · Mar 23, 2007

corpsmanUP said:
1. 99% of 1st year residents are overconfident (any data here or just anecdotal based on your experience?)

2. Do anesthesia departments not offer high numbers of intubation attempts to offservice residents...everywhere? This has already been disputed by posters in the closed thread multiple times. Perhaps this is just another one of your anecdotal viewpoints that you are applying to the whole world. And you say I have bitemporal hemianopsia?

3. And thanks for again showing your obvious bias towards EM, towards residents in general, and towards those who would disagree with you. It seems no stone throwing is necessary when you place yourself at the bottom of a landslide of boulders.

militarymd said:
The "Anesthesia Rotation".....is an ANESTHESIA rotation....It is NOT an AIRWAY rotation...unless that is what your EM program has arranged specifically with the Anesthesia program.

From what I'm hearing....your rotation is NOT a AIRWAY Rotation....

As for arranging an AIRWAY specific rotation where you run around tubing people and leaving....I will have to say "Good luck"......

For the other EM folks...I understand your points...and I agree...

For the cocky pgy 1.....not only do you have blinders on....you CAN't read.

I commented on the rotation that you're on (what it is versus what you want) .....and I offered my opinion on the "tube and run" rotation....AND wished you good luck in getting that rotation....and what do you do? Act like a 4 year old.

You are so self-centered that you only read the parts about you....because my assessment of you....cocky, overconfident, and junior....obviously hit home.

Dr. Will · Mar 23, 2007

"Bigger person...paging the bigger person." How 'bout we all just relax a little bit and try to make nice.

SolidGold · Mar 23, 2007

I'd love to know where you're an attending MilitaryMD...

deleted109597 · Mar 23, 2007

Can't we all just get along?

BKN · Mar 23, 2007

I notice that Quinn implied a question to me in the other thread. The answer to any RRc question is to go read the material for RRC-EM on the website. The guidelines are 35 intubations and 3 crics.

To add my two cents. I tell my residents to get 30 intubations and 8 LMAs while on Anesthesia. I want them to see some normal airways under ideal conditions and have a rescue airway for when they can't intubate. I'd like them to know the RSI drugs and their complications. I want them to know how to properly BVM. Beyond that I don't think they get much benefit from more prepared intubations. The rest of your life all you will do is "crash" intubations and you'll learn those in the ED.

And yes, those that cooperate with the Anesthesiologists and do some "scut" end up with more intubations than those who fight it.

corpsmanUP · Mar 23, 2007

To MilitaryMD

I will no longer be replying or commenting to you. Feel free to take the last word.

CS_22 · Mar 23, 2007

corpsmanUP said:
To MilitaryMD

I will no longer be replying or commenting to you. Feel free to take the last word.

Finally, the high road...

corpsmanUP · Mar 23, 2007

CS_22 said:
Finally, the high road...

Now I didn't say I wouldn't comment to someone else!!

Haemr Head · Mar 23, 2007

BKN said:
I notice that Quinn implied a question to me in the other thread. The answer to any RRc question is to go read the material for RRC-EM on the website. The guidelines are 35 intubations and 3 crics.

Ever wonder who comes up with these numbers? Thirty five intubations is less than one/month and most anesthesia rotations will cover the full residency quota. The real number should probably break down practice tubes (simulators, resus manniquins), elective tubes, and crash intubation. Hard to study in terms of skill level but wouldn't you think that at least 30 elective and 20+ crash tubes would be a minimum.

Three crics is also interesting. With RSI everywhere, not criking (1) every facial fracture anymore, and much better airway skills in the ED, most departments are luck to see 3 crics/year let alone 3/res. It's a good thing the RRC accepts simulators, cadaver labs, and animal labs. Cric training is a fundemental skill but probably would be better mandated by defining the training process than the number needed. With 3 per res, no sheep is safe at our hospital.

(1) This is how one goes about inventing new verbs and applies creative spelling.

CS_22 · Mar 23, 2007

corpsmanUP said:
Now I didn't say I wouldn't comment to someone else!!

My apologies corps. Didn't mean to stir up the pot more.

docB · Mar 23, 2007

BKN said:
I notice that Quinn implied a question to me in the other thread. The answer to any RRc question is to go read the material for RRC-EM on the website. The guidelines are 35 intubations and 3 crics.

Is that on the "(insert airway or anesthesia)" rotation or throughtout residency. I had about that many tubes on my rotation and probably 4 or 5 times that in my residency but no crics. I did 2 crics on on cadavers in residency and have done 1 as an attending (went well) and 1 needle cric with retrograde tube. I don't think anyone in my class got 3 crics in residency.

Haemr Head · Mar 23, 2007

35 is the number of tubes needed during the entire course of residency inclduing the anesthesia rotation, not just on a specific rotation.
The one that gives the most headaches to the PD is the requirement for 6 cardiac pacing events. It's not clear if this means intravenous pacing only or the highly complex maneuver of slapping on the Zoll's pads.
The 10 pediatric trauma resuscitations can also be a bit tricky depending on how you define resuscitation and the specific role you need to have to score the point.

corpsmanUP · Mar 23, 2007

Haemr Head said:
35 is the number of tubes needed during the entire course of residency inclduing the anesthesia rotation, not just on a specific rotation.
The one that gives the most headaches to the PD is the requirement for 6 cardiac pacing events. It's not clear if this means intravenous pacing only or the highly complex maneuver of slapping on the Zoll's pads.
The 10 pediatric trauma resuscitations can also be a bit tricky depending on how you define resuscitation and the specific role you need to have to score the point.

Great point. I counted 2 that I paced when they were dead and asystolic, so perhaps a good way to get credit for it would be to pace all codes at the end!!! If we had to get 6 intravenous pacer insertions, we would be waiting about a decade at my institution.

militarymd · Mar 24, 2007

corpsmanUP said:
If we had to get 6 intravenous pacer insertions, we would be waiting about a decade at my institution.

Here's something to think about.

You have no problems with a "tube and run" rotation with us gas guys.....why don't you call up the cards guys and ask to set up a "insert pacemaker and run" rotation and see what they say...

during my fellowship, I inserted my pacemakers in an old fashioned rotation....scut, patient workup, etc....

No sarcasm here....Serious suggestion......What do you think?

SolidGold · Mar 24, 2007

Military, you do realize that the majority of EM programs have a "tube and run" anesthesia rotation don't you? Our training hospital in Tampa, as well as many others in the country, also lets Special Forces come into the OR and ED to do "tubes and run." Want to tell them they can't train either because they have no good reason to be there? Why are you so worried about people doing what you guys call easy tubes anyways?

Haemr Head · Mar 24, 2007

Thanks for showing up Military, but I think we've got it covered.

militarymd · Mar 24, 2007

Haemr Head said:
Thanks for showing up Military, but I think we've got it covered.

A procedure is a procedure....

what's the difference between putting polyvinyl chloride between vocal cords and putting a copper wire through some blood vessels?

Both are potentially life saving....both can cause significant harm if done incorrectly....

FoughtFyr · Mar 24, 2007

militarymd said:
A procedure is a procedure....

what's the difference between putting polyvinyl chloride between vocal cords and putting a copper wire through some blood vessels?

Both are potentially life saving....both can cause significant harm if done incorrectly....

Because you (meaning anesthesiologists in general not you personally) are not the only physicians in the hospital who intubate on a regular basis. Despite common belief, intubation is a primary skill for EPs.

Additionally, a local study demonstrated that when an anesthiologist was called to the ED to "back up" the EPs and actually attempted to intubate, they were only successful 50% of the time. The other 50% required a second EP to bail out both the first and the anesthesiologist. Needless to say we don't call them down anymore...

- H

bulgethetwine · Mar 24, 2007

militarymd said:
A procedure is a procedure....

what's the difference between putting polyvinyl chloride between vocal cords and putting a copper wire through some blood vessels?

Both are potentially life saving....both can cause significant harm if done incorrectly....

If it smells like a troll, looks like a troll, and sounds like a troll...
then he probably lives under a bridge.

Clearly this poster has nothing constructive to add.

Haemr Head · Mar 24, 2007

militarymd said:
A procedure is a procedure....

what's the difference between putting polyvinyl chloride between vocal cords and putting a copper wire through some blood vessels?

Both are potentially life saving....both can cause significant harm if done incorrectly....

My point about pacer wires was to suggest that the RRC mandate of a minimum number of procedures creates problems, is unrealistic, not based on evidence, and possibly detrimental to training. I also believe that requiring specific numbers of procedures forces programs to use procedural rotations that diminish the educational value. I do think that the number of intubations is a better measure of a program's ability to train the residents in the essential skills than most of the others procedures listed, but I still dislike the number game.

That said training an EM specialist in emergency airway management is a very different problem than teaching transvenous pacer placement. The frequency, complexity of indications, contraindications, pharmaceuticals, equipment, team training, rescue techniques, time constraints, risk, and liability are infinitely greater with emergency airway management than transvenous pacemaker placement. There is no way to provide as much airway experience as is optimally needed as it is. A lab or two in residency would cover transvenous pacer placement nicely.

To be accredited, a program must demonstrate that each resident is hitting a target. With the limited time allotted to training, this may force programs to create "procedural rotations" to meet these targets at the expense of the full experience. Personally, I don't like procedural rotations from an educational viewpoint. We use full experience rotations on cards and anesthesia rather than procedure scavenging only. I would rather achieve additional technical excellence with simulators and labs. As I said earlier, I do believe that it is of better value to integrate with the anesthesia team rather than cherry pick procedures. However, I know that I am often wrong and respect the right of each program and hospital to set up the system that they feel bests meets their goals. Vive la difference!

With transcutaneous pacing and readily available cath labs with fluoro, the frequency of placing pacer wires in the ED has dropped dramatically. Requiring 6 is an anachronism from the days when every 3 degree block would have a placer floated blindly in the ED. I'd rather have my residents spend a week in the pain clinic than hang around to float a wire.

Im sure you dont mean it, but your posts do come across as a bit provocative. Personally, I find it more entertaining to destroy people online in a first person shooter and use these forums to try and generate collaborative light rather than heat, but again, to each his own.

Dr. Will · Mar 24, 2007

militarymd said:
Here's something to think about.

You have no problems with a "tube and run" rotation with us gas guys.....why don't you call up the cards guys and ask to set up a "insert pacemaker and run" rotation and see what they say...

during my fellowship, I inserted my pacemakers in an old fashioned rotation....scut, patient workup, etc....

No sarcasm here....Serious suggestion......What do you think?

I think it's cute that you're still holding on when the rest of us have decided to move on. To quote Robin Williams from "Good Will Hunting"

..."It's not your fault."

militarymd · Mar 24, 2007

Haemr Head said:
Im sure you dont mean it, but your posts do come across as a bit provocative. Personally, I find it more entertaining to destroy people online in a first person shooter and use these forums to try and generate collaborative light rather than heat, but again, to each his own.

Some of my posts ARE provocative, but most of the time....people find them provocative because I approach things from a different point of view....

I personally think that all physicians (pulm/ccm/anes/em/surgery) who deal with critically ill/injured patients should have more experience with transvenous pacemakers ......no one does enough of them...and when you need to do one....there is no gear around to do it...especially at 3 am

Perhaps I feel that way because I tube people all the time, but place transvenous pacemakers very rarely...

And gaining my experience with the pacemakers during my training from cards guys was by far worse than any experience any EM trainee had to go through from anesthesia guys.

deleted109597 · Mar 24, 2007

I find........ that your ........ incessant use of incorrect........ellipses annoying......

Mman · Mar 24, 2007

Haemr Head said:
Finally EM physicians routinely have to do something anesthesiologists rarely do, namely decide to intubate someone they have had little time to assess and who has not yet fully shown that the tube is needed.

I strongly agree that EM residents need to learn how to competently manage an airway. However, as an anesthesia resident I often have to make a decision on an intubation with little time. It's called the difficult airway pager. It goes off a lot and I have to go assess a patient that is crashing to some degree that the primary team and RT are incapable of managing. Usually they need a tube that may be difficult to place, sometimes they don't.

blotto geltaco · Mar 24, 2007

I wouldn't get too rankled up w/MMD. He's well known over on the anesthesia forums for stirring things up and then whining about being called names. later, bgt

Haemr Head · Mar 25, 2007

Mman said:
I strongly agree that EM residents need to learn how to competently manage an airway. However, as an anesthesia resident I often have to make a decision on an intubation with little time. It's called the difficult airway pager. It goes off a lot and I have to go assess a patient that is crashing to some degree that the primary team and RT are incapable of managing. Usually they need a tube that may be difficult to place, sometimes they don't.

I don't doubt it. But it's not quite the same sport as the decision making for the indications for intubation in the ED. In the ED, there is no primary team or inpatient course to guide you. You are the primary team, RT, and airway expert.

Do you intubate the asthmatic rolling into room 3 with a sat of 85% on 100% NRB? How about the patient with focal findings but an intact airway that might be a stroke or a bleed? How about the patient who swallowed a bottle of amitriptyline and is only a little tachycardic with a bit of slurred speech? One of the hardest parts of ED airway management is making the decision before the patient needs it. It is something you can't get on an anesthesia rotation.

There is plenty of decision making in anesthesia not limited to finding alternatives to endotracheal intubation or choice of technique. Its a wonderful specialty that requires years of training to be competent. My point was simply that one uses different skills than those needed in the ED. However, if you include the ED rotator on a difficult airway response team, that would be great education!

Mman · Mar 25, 2007

Do you intubate the asthmatic rolling into room 3 with a sat of 85% on 100% NRB? How about the patient with focal findings but an intact airway that might be a stroke or a bleed?

Yes, those things happen on the floor and ICU as well which is my point. I have no power myself to make it happen, but it would be reasonable if the EM resident rotating with us during the month also got paged when the difficult airway situations arose so they could go run over and see those situations.

NinerNiner999 · Mar 25, 2007

Mman said:
it would be reasonable if the EM resident rotating with us during the month also got paged when the difficult airway situations arose so they could go run over and see those situations.

This would be ideal, and having done so on my airway rotation, it presents many more difficult airways outside of the controlled OR.

docB · Mar 25, 2007

Mman said:
Do you intubate the asthmatic rolling into room 3 with a sat of 85% on 100% NRB? How about the patient with focal findings but an intact airway that might be a stroke or a bleed?

Yes, those things happen on the floor and ICU as well which is my point. I have no power myself to make it happen, but it would be reasonable if the EM resident rotating with us during the month also got paged when the difficult airway situations arose so they could go run over and see those situations.

That's a good idea but sharing the airway pager call would limit the crash airway experience of the anesthesia residents. The way that I have seen it done (N=1 EM residency) was that Gas did the majority of tubes in the OR, never went to the ER and took all the in house crash tubes. EM got a few dozen tuben in the OR to get their feet wet then did all the ED tubes to learn crash tubes.

corpsmanUP · Mar 25, 2007

Check this out:
At our VA hospital which is where we do our internal medicine month, after midnight, there is literally NO ONE in house who is capable of managing an airway adequately. Anesthesia somehow struck some good deal so that they go home at midnight, and the ICU fellow goes home after close of normal business hours. And this being a place where each inpatient team follows its' own patient in the ICU (open ICU concept), you can imagine how this impacts patients between midnight and say 8 AM. I came in one morning to find one of my patients to have expired and the call team had run the code without as much as ANY advanced airway attempt. And it was a really long code too. It was shown that sats were in the 60's at the start when the patient still had a pulse.

And since there are only 6 EM resident in my class, there are only 6 months in the year that have an EM resident to assist with this after hours problem. And since there are only 4 inpatient teams, that means the EM resident in on only 1 of those teams and thus it is the rare night when there is an EM resident during the year. The IM residents in our system admit they are not trained to manage an airway effectively.

And the worst of it is that it takes some yelling to get the ICU or floor staff to get you the necessary stuff if you as the EM resident decide to do the tube on a sick patient. You are comfronted with "You should really call the fellow", and "The fellow is only 15 minutes away". Can you imagine that madness? I remember asking RT who would manage these patients when there was no EM resident and they told me that they would. But the night my patient died being bagged the whole code, no RT steped up. And I expect that is the norm. So I was so bothered by my fellow vets getting this type of care that I emailed my chairman and he told me he supported me taking it to the highest levels (he's an Army Vet). I emailed the assistant chief of staff at the VA 3 weeks ago and got no response.

What the hell would you guys do?

ERMudPhud · Mar 25, 2007

Sounds like the Bronx VA where I spent part of my internship year(mid 1990's). The RT's used to do brutane tubes if necessary. The first month of my internship year I watched the RT tube the goose over and over again. Each time he would pull the tube out, throw it away, and get a new one. Eventually he ran out of tubes and had to send someone to the store room for more. I got so fed up that by the end of the year I was talking to the New York Times. Nothing ever came of it.

DropkickMurphy · Mar 25, 2007

....tube the goose over and over again. Each time he would pull the tube out, throw it away, and get a new one. Eventually he ran out of tubes and had to send someone to the store room for more.

*shakes head* What a ****ing idiot.......

Jeff698 · Mar 26, 2007

Haemr Head said:
With 3 per res, no sheep is safe at our hospital.

The piggies at our place are the ones with their 'necks on the line'. Of course, being affiliated with Texas A&M, the sheep are nervous for other reasons.

Take care,
Jeff

DropkickMurphy · Mar 26, 2007

Jeff698 said:
Of course, being affiliated with Texas A&M, the sheep are nervous for other reasons.

"Ewe's not fat....ewe's just fluffy" :laugh:

DeLaughterDO · Mar 26, 2007

Jeff698 said:
The piggies at our place are the ones with their 'necks on the line'. Of course, being affiliated with Texas A&M, the sheep are nervous for other reasons.

Take care,
Jeff

d'oh!

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