Anesthesia doesn't want PM&R doing procedures

[wonthurtabit1]

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In the hospital system where I work (not academic), Anesthesia/Pain is lobbying to be the only service which does Spine intervention procedures. 👎 Instead of remaking the wheel, I am hoping that the folks in this forum might be able to help me compile a list of resources (society position papers, etc) to counter. I would like to put together a list of talking points a la "white paper" style. Is there a consensus on who should do the procedures? How much training/what training they should have? How should we assist our colleagues who want to learn procedures many years after finishing residency? Yeah... and BTW, can't we all get along? 😍

 

[Tenesma]

dude it is all about politics... there are quite a few centers where PM&R is lobbying to be the sole spine proceduralists... there are also some centers where anesthesia/pain does all the CT-guided blocks!!!!
there are also some centers where IR does all the procedures....

 

[drusso]

The message to communicate is that specialty of origin is not as important as competency. There are a variety of ways to achieved competency in pain procedures: Formal fellowship, preceptorship, on the job training, etc. The PM&R ACGME-competencies and PASSOR provide clear documentation of what is within the scope of practice of a musculoskeletal physiatrist. I'm sure that something similar exists in the anesthesia world.

PASSOR Scope of Practice

 

[wonthurtabit1]

drusso & tenesmus -thanks!!

A follow-up question. What do you think of the ISIS guidelines for competancies? Any others which would be helpful?

Anesthesia is making their view the "holy grail." In their opinion the standard should be an Anesthesia/Pain Medicine fellowship which is ACGME-accredited plus Board Certification in Pain Medicine from the ABA. I will concede that as one way, however, other equally competant physicians have a background in either ACGME or non-ACGME PMR Interventional Fellowship training plus/minus ABA boards. Next w/i PMR I believe that the Fellowships which offer a balance of spine, sports medicine, EMG and interventional spine are also excellent. Some PMR interventionalists become indistinguishable from anesthesiologists. The area that is most contentious in my opinion is that for PMR docs who must achieve competancy thru preceptorship, on-the-job training and courses.

In the real world of spine care, I believe PMR docs and anesthesia docs could learn a lot from each other, but that is usually wishful thinking given the protectionist attitudes often exhibited by both specialities.

 

[stim4u]

I was performing a case recently in the OR. Cervical SCS trial in a young healthy male with a brachial plexopathy/neuropathic pain syndrome. Pt was place in prone position, sedated with moderate-deep MAC. We entered the T2-3 epidural space, threaded the SCS electrode to C3 without difficulty. While trying to test coverage of the patients neck and arm symptoms, he was not responsive. The CNRA felt the patient was "too sedated" from the propofol, versed, fentanyl etc. We waited a good 15minutes to have him "wakeup". He was hemodynamically stable, sats normal, rr 10-14, just unresponsive. What do you do? Abort, wait? Assuming the procedure was straight forward and there is was no significant cervical stenosis (on MRI) or procedural errors, what would your next step be? I am interested in peoples responses, whether it be an anesthesiologist, physiatrist, or a psychiatry for that matter. Ultimately these situations come up, and addressing these issues acutely is critical. I know this senario does not predict the best "spine doctors" but at least it reinforced my belief that I am appropriately trained for pain medicine.

 

[Aether2000]

Narcan plus Romazicon IV then continue on with the procedure with the patient awake.

 

[lobelsteve]

I agree with the Narcan, but would skip the Flumazenil.
HR?, BP?, Sats?
Ankle Jerk?
Clonus?

I'd give Narcan per protocol as long as vitals were stable, if no response after 3 doses, abort, flip patient, assess.

My thoughts on skipping the BZD reversal is because if for any reason there is a seizure, there is no rapid way to stop it.

 

[HTD]

The ugly word that they don't want you to use is "Econminc Credentaling". They are claiming that they provide superior care so you shouldn't do it for the sake of the patient. I assure you if that proceedure had low pay, they would not block you. People like this are often very aggressive in local medical staff politics. Your college or society can help you by giving you facts about your competency to take to the credentialing committee.

My first day in practice, someone tried to stop me from diong a "Lap Appy", they would have no objection, however, to me doing a whipple on a 2 year old. That proceedure did not make them money. 🙁

Okay, back to being positive. Keep up your training and feel comfortable fighting for the privliges you deserve.

 

[Aether2000]

Actually, more propofol (not reversed by romazicon) will abort any seizure as will thiopental in high enough doses. Nevertheless, sequential administration of narcan then romazicon may make sense, then investigate other causes including blood sugars, etc. Of course having a CRNA with a little more common sense than to load up patients with multiple sedative drugs for a procedure that will require patient cooperation and discourse may be an option also.

 

[drusso]

Politics can be ugly, but usually level heads will prevail. Ask for data and keep the conversation focused on "the high ground." They don't have a legal leg to stand on.

BTW, why was this topic moved to the "VIP Lounge?" 🙂

I wasn't a big fan of the the whole idea, but I understand that other users wanted it. However, this is the kind of topic that I think a lot of non-registered med students, residents, etc would benefit from reading...

Just for my own edification, what are the criteria for a regular forum topic versus a VIP Lounge topic??

 

[stim4u]

From my experience after about 15 minutes (the context sensitive half life of of propofol) the infusions/boluses should have been eliminated. This would leave either excessive sedation from benzos or fentanyl (or other badness). I opted to use flumazenil 0.2mg IV push, since such a minimal dose would unlikely cause significant reversal or seizures (0.2mg q5-10min upto 1mg typically). The patient fortunately woke-up within 30 seconds and was able to verbalize and move all extremities. The unfortunate part of this case was that the CRNA/anesth was heavy handed, and wanted to know what "color" the flumazenil bottle was.... 🙄

IF the pt had not restored consciousness, I agree, a survey exam and flip/abort as soon as possible.

stim4u

 

[Tenesma]

stim4u... while you bring up an interesting point, you have to leave your prior training at the door. When there is a case going on it is really the anesthesia providers responsibility to manage the situation... we should only be stepping in if a) we are supervising the CRNA b) the anesthesia provider is grossly incompetent...

 

[seaofred]

I was performing a case recently in the OR. Cervical SCS trial in a young healthy male with a brachial plexopathy/neuropathic pain syndrome. Pt was place in prone position, sedated with moderate-deep MAC. We entered the T2-3 epidural space, threaded the SCS electrode to C3 without difficulty. While trying to test coverage of the patients neck and arm symptoms, he was not responsive. The CNRA felt the patient was "too sedated" from the propofol, versed, fentanyl etc. We waited a good 15minutes to have him "wakeup". He was hemodynamically stable, sats normal, rr 10-14, just unresponsive. What do you do? Abort, wait? Assuming the procedure was straight forward and there is was no significant cervical stenosis (on MRI) or procedural errors, what would your next step be? I am interested in peoples responses, whether it be an anesthesiologist, physiatrist, or a psychiatry for that matter. Ultimately these situations come up, and addressing these issues acutely is critical. I know this senario does not predict the best "spine doctors" but at least it reinforced my belief that I am appropriately trained for pain medicine.

I would argue that with a RR of 14 it is unlikely to be the opioids and go with flumaz first.

 

[ParaVert]

I disagree with the idea of leaving prior training at the door, letting the anesthesia "provider" handle the situation. It is in the patient's best interest that both the interventionalist (pain doc) and anesthesia "provider" work together to manage a potentially catastrophic situation. Without belaboring the somewhat passe notion of "Captain of the Ship," I can't remember a cardiac surgeon ever just hangin' loose during a code in the heart room during my residency.

As an anesthesiologist, I am acutely aware of the range of sensitivities pain patients have to opiates and sedatives. It is not uncommon for a pain patient to be overdosed on the table during painful procedures. A heavy handed CRNA/doc is a dangerous thing, especially if he/she doesn't do a lot of pain patients. A fat, apneic/hypoxic, unresponsive patient in the prone position with a needle in the back is not "amateur hour." Both sides of the drape must work together without fear of stepping on toes for the safety of our patients.

stim4u... while you bring up an interesting point, you have to leave your prior training at the door. When there is a case going on it is really the anesthesia providers responsibility to manage the situation... we should only be stepping in if a) we are supervising the CRNA b) the anesthesia provider is grossly incompetent...

 

[PGY2]

Regarding the case: I agree, RR of 14, normal sats, stable hemodynamics... I guess you could check for pinpoint pupils too. But agree with flumazenil. Iwould have skipped the narcan altogether in the absence of pinpoint pupils and a normal RR. Dont really see how threading of a stim lead can cause unresponsiveness (pain yes, motor or sensory deficits yes, but unresponsiveness?? probably not).

 

[Tenesma]

paravert... where i trained in anesthesia it was the anesthesia provider who ran the ship.... the surgeons often stood their dumbfounded and usually offered their help. It is funny how when we were anesthesia residents we got pissed off because the surgeons felt like throwing in their 2 cents (which was useless most of the time), and now all of a sudden as the interventionalist you want to throw in your 2 cents. While we (anesthesia background pain guys) are acutely aware of intra-operative issues, most of us havent' spent that much time on the anesthesia side of things...

So my original point still stands (please re-read it)... but it doesn't mean that their can't be communication between both sides on how to optimize things. I know at Dartmouth (via Fanciullo) they have a prepped gurney specifically for this (so they can flip the patient onto their back on a moment's notice) - which i think is a bit excessive.