Anesthesia Issue!!

[corpsmanUP]

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Wish I had never started this thread. I should have known this would happen!

 

[DrQuinn]

I'm not exactly sure, but the RRC # is surprisingly low, I think 25 or so (I'm sure BKN or someone else knows it). I think on my anesthesia rotation (we did two weeks), most of us averaged around 20-40. I think by end of PGY1 year we had well over 50 in the ED itself.

Talk to your PD.

I know here where I'm at (Georgetown/Washington Hospital Center) our interns get to just go room to room. They are even letting them attempt bronchs/fiberoptics and trauma airways as PGY1s. But that is the benefit of being at a new program. I think you're at an established program, and sometimes its a bit more difficult to "flex your muscles" and get the stuff that you want.

But. Talk to your PD.

Q

 

[kbrown]

Your experience is just about the same as everyone else in the place. Most places that have an EM residency also have Anesth residents. This means that their primary goal is to train their residents on airway and gas management. Usually, we get stuck in simple quick in and out cases because the gas residents are busy doing longer more complex cases, like hearts, transplants, trauma. So we get put in things like hernia repairs, wide excision biopsy of breast, in short something quick and easy so that a ton on anesthesia isn't given, i.e., LMA's. They turn rooms around faster that way.

Our dept sends us to a Same Day Surg clinic in the burbs where we do primarily LMA's all day. Despite this, our residents still get PLENTY of tubes in the dept. The average resident in our high acuity area will get 2-3 tubes each shift, as many as 6. They feel VERY comfortable with the airway about two months into their second year.

I know that your dept is a little smaller, and not inner city detroit, but it is The Trauma Center for your state, so you likely get a lot of sick pts. Ask your upperclassmen, I am sure that they feel very comfortable with the airway. They likely learned it from tubin' a crapped out COPD'er with 2 cups of green mucous in her throat, a neck the size of your thigh and just finished eating a tuna salad sandwich with a diet coke. That is our airway.

Most residents honestly use anesth and radiology as vacation months. Re-finish your deck this month.

This is just a reality that I have realized. If they don't wanna give you more ETT's then learn what you can, and go home early. Enjoy your month.

 

[NinerNiner999]

Also remember that requirements aside, there are "old school" anesthesia attendings who still consider EM to have taken their procedure. Obviously not all anesthesiologists feel this way, but some do. As a result, some may feel reluctant to let EM residents trump theirs.

I had 72 airways during my trauma anesthesia month, and that was around average. Don't worry about numbers - you will easily meet your RRC requirements...

 

[corpsmanUP]

Done with this thread

 

[12R34Y]

I've had about 50 intubations this year (intern) so far. Some in the department, quite a few (30ish) in anesthesia month, some in ICU, some floor codes etc...

We work almost exclusively with CRNA's. We room hop from room to room. BAG'em, TUBE'em, some want you to tape it in place etc.... then leave and find another room.

I don't think your problem is unique at all, but having said that....I don't think any resident graduating from EM residency feel inadequately trained in airway by the time they're done.

later

 

[ERMudPhud]

My program didn't even have an anesthesia month. I never felt like I missed anything. I did a 2 week elective at the childrens hospital for two reasons only. First, to tube lots of babies and little kids. Second to do LMA's on the bigger kids and teens since I felt my LMA experience was much more limited. They let me hop from room to room so I got plenty in two weeks and ever since then I'm grateful for the experience whenever I have to tube a baby.

 

[docB]

It's silly and counterproductive for them not to let you room hop. You're there for the airways. Not to learn how to do anesthesia. I'm not sure what a "well rounded view of anesthesia cases" would do for you. It's just professinal arrogance. Next time I'm tubing an exsanguinating GI Bleeder with no IV access down in the ED I'd like to call your gas attending and ask him to come down with his janitor and deal with it, and no I don't know when the last time he ate was.

 

[militarymd]

A few thoughts from a anesthesia/critical care guy in PP...former education committee chair for a Navy program...former ICU attending for many different types of residents...including EM.


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"......

Direct Laryngoscopy and intubation can cause potential major and minor injury leading to thousands of dollars of dental repair.....Why would ANY anesthesia attending allow a rotator to potentially cause dental and or other injury to one of his patients by performing the DL and then leaving and having no other responsiblity in the care of the patient?

My group just stroked a check for over 2,000 dollars for dental injury to crowns....and we have only senior and experienced CRNA and MDs....so why would any attending open themselves to additional liability?

As for your (over)confidence in handling all the Airways in the OR after your intern year....ask yourself why it is so easy in the OR.......Airways are Airways....why is it easy in the OR?

I got called STAT to the ER a couple of nights ago because of a failed intubation.....patient blue...volmit all over the place....blood all over the face.......2 EM attendings struggling...

I pulled the patient to the head of the bed....I locked the bed...I raised the bed...then I positioned the patient properly...then I perfomed DL x 1 and intubated....

I would suggest observing and learning what MAKES the OR intubations Easy rather than trying to get MORE DIFFICULT intubations.

 

[lattimer13]

kicks feet up and sits back ready to enjoy the forthcoming show.

 

[StudentDoc327]

I pulled the patient to the head of the bed....I locked the bed...I raised the bed...then I positioned the patient properly...then I perfomed DL x 1 and intubated....

I would suggest observing and learning what MAKES the OR intubations Easy rather than trying to get MORE DIFFICULT intubations.

No offense, but Im only a med student and even I know that one of the most if not the most important aspects of intubating is positioning the patient properly. I don't think most board certified EM docs are so clueless that they are going to go over to the table and stick the damn tube in any way it fits with the patient lying completely flat half-way down the table. But, after you learn the basics of positioning and what not, do you really think it is time efficient to have the EM resident sit through the whole surgery. What about ENT? They intubate. Do they have to stick around and watch you chart as well if they for some reason wanted to get a little airway practice?

I guess it would make more sense if the person who actualy broke the teeth or botched the attempted intubation was liable instead of the faculty on the case though.

 

[militarymd]

No offense, but Im only a med student and even I know that one of the most if not the most important aspects of intubating is positioning the patient properly. I don't think most board certified EM docs are so clueless that they are going to go over to the table and stick the damn tube in any way it fits with the patient lying completely flat half-way down the table. But, after you learn the basics of positioning and what not, do you really think it is time efficient to have the EM resident sit through the whole surgery. What about ENT? They intubate. Do they have to stick around and watch you chart as well?

I'm just telling you what I did to help out a couple of my colleagues at my hospital....

As for efficiency....of course not......but is the rotation an "airway" rotation or not.....I'm simply point out that it probably isn't....

And as for getting just an AIRWAY rotation with the department? Very unlikely....I would never support such a rotation at my former program simply because of the issues of liability.

Would an EM program support a program where the rotator comes and just does a "closed reduction" and leaves to go do another procedure? or suture's a wound , and just leaves and goes an sutures another wound?

these procedures aren't quite analogous, but you get my point.

 

[NinerNiner999]

I'm just telling you what I did to help out a couple of my colleagues at my hospital....

As for efficiency....of course not......but is the rotation an "airway" rotation or not.....I'm simply point out that it probably isn't....

And as for getting just an AIRWAY rotation with the department? Very unlikely....I would never support such a rotation at my former program simply because of the issues of liability.

Would an EM program support a program where the rotator comes and just does a "closed reduction" and leaves to go do another procedure? or suture's a wound , and just leaves and goes an sutures another wound?

these procedures aren't quite analogous, but you get my point.

Yes, an EM program would, and we expose ourselves to every consultant who performs a procedure in our department. This includes ENT residents who pack noses and refuse to admit them, surgeons who I&D large abcesses outside of the OR, and, yes, anesthesiologists such as yourself who serve as our airway backup, intubate our patients when needed, and sign their notes and leave the ED immediately after they completed their intubation. Oh but wait - that's exactly what you don't want us to do.

Are you saying that every Anesthesia resident who enters our ED for backup on the septic 800 lb patient, should stay while we give IV antibiotics, titrate pressors, and manage their care? If so, then we can accomodate you. I think that we both know that nobody - anesthesiologist or surgeon - wants an ED intern with no focus on managing OR sedation and intraoperative management caring for their patients. I think we can also all agree that the overall "yield" of such an experience would be very low for both sides.

"Liability" is unfortunately the name of the game when we train new physcians, and anyone who stands behind this shield in academics as a reason not to educate our medical future should get out of the academic world. Oh wait - you are in private practice. Thanks.

 

[Apollyon]

As for efficiency....of course not......but is the rotation an "airway" rotation or not.....I'm simply point out that it probably isn't....

When I was a resident, it had been changed my year when I did it so that you stayed with the room, instead of going room to room, as it was said, indeed, that it was NOT an "intubation rotation", but "anesthesia rotation" (including a written shelf-type exam at the end, VERY heavy on OB anesthesia, like epidurals - for EM residents (??)). Now, you say, sounds normal; however, when the anesthesiology resident is doing a crossword puzzle, and I don't even have a chair to sit on, please tell me the value of that. Watching someone titrate sevo and look at the BIS monitor was low-yield. Boy howdy, was it low-yield. Even at Big-Time Medical Center, where I trained, the anesthesiology trainees that were interested in looking over the drape as to what was occurring were the minority.

 

[12R34Y]

A few thoughts from a anesthesia/critical care guy in PP...former education committee chair for a Navy program...former ICU attending for many different types of residents...including EM.


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"......

Direct Laryngoscopy and intubation can cause potential major and minor injury leading to thousands of dollars of dental repair.....Why would ANY anesthesia attending allow a rotator to potentially cause dental and or other injury to one of his patients by performing the DL and then leaving and having no other responsiblity in the care of the patient?

My group just stroked a check for over 2,000 dollars for dental injury to crowns....and we have only senior and experienced CRNA and MDs....so why would any attending open themselves to additional liability?

As for your (over)confidence in handling all the Airways in the OR after your intern year....ask yourself why it is so easy in the OR.......Airways are Airways....why is it easy in the OR?

I got called STAT to the ER a couple of nights ago because of a failed intubation.....patient blue...volmit all over the place....blood all over the face.......2 EM attendings struggling...

I pulled the patient to the head of the bed....I locked the bed...I raised the bed...then I positioned the patient properly...then I perfomed DL x 1 and intubated....

I would suggest observing and learning what MAKES the OR intubations Easy rather than trying to get MORE DIFFICULT intubations.

My anesthesia month is entirely an INTUBATION/AIRWAY month. Nothing else. We do this at 2 different hospitals and it is assumed that the EM resident does the pre-oxygenation, Bags the patient, waits for the vec/roc/succs to take effect and tubes the patient, comfirms placement and promptly walks out the door.

None of the anesthesia residents/staff WANTS us to stay in there. It's a waste of our time and there is no room for the resident and staff half of the time let alone some other EM resident. You just get in the way.

We room hop. I've tubed up to 4 people within about 30 minutes just by going room to room.

Some of the cases we intubate and then prep the neck and put an introducer in and float a swan and then leave. Again........nobody wants or expects us to stay.

How can you tell me as an EM resident that I'm supposed to get ANYTHING that is useful to me in the practice of EM by standing around for a lap chole.

We never extubate patients (99.9% of times), we don't ever use inhaled anesthesia, we never use ephedrine, or phenylephrine the way you guys do, we generally don't use BIS monitors acutely etc.....

It's just not practical or useful info for us. We need to learn how to get an airway and see lots of different glottis's, tongues, heads, noses, blades, BVM styles etc....

that's all we need.

we do ICU rotations and cardiology rotations and pulm rotations where we get the pressor, vent management, etc.....stuff.

later

 

[corpsmanUP]

Done

 

[QuikClot]

In a perfect world with an infinite amount of time for training, of course it would be advantageous to see surgeries from beginning to end, and to immerse oneself in all things anesthesia. Unfortunately, every hour spent doing that is an hour taken away from something else.

The things that an EM physician must understand and be able to do in medicine are endless, as you all know. Toxicology. Airway. Cardiac. Pulmonary. Peds, geriatrics, and everything in between, etc. The point being, one of the few areas of medical knowledge which is unlikely to ever be needed is a detailed knowledge of inhaled anesthetics and long-term sedation. Its a highly specialized field.

With all respect for the help of the anesthesia department in managing difficult airways, what makes them good is practice. No one else gets a fraction of the practice they do. No one has seen as many airways. The OR is a painstakingly controlled enviroment, one that cannot be replicated in the ED. Watching the anesthesiologists work does not enable the EM physician either to be as practiced as they are or to control their surroundings the way the anesthesiologist can. For that reason -- whether or not some programs intend this -- it isn't an effective use of time.

But that is a universal feature of the allopathic education. Though wonderful in many ways, we are taught by specialists, and specialists always think that what you need to know to be a doctor is what they need to know to be a specialist. Very few people have the discipline to recognize that a non-specialist needs a different kind of skill set from their own.

 

[militarymd]

11 years AD...Year in GITMO....time in Iraq....sell out...hmmmm....

You bring up an issue....I'm giving it to you straight from our side of the curtain....and you're calling me names.....hmmmm...

The difference between Anesthesia coming to the ER...and ER coming to the OR is this...

In my limited experience of doing anesthesia since 1993 in multiple hospitals...including Level 1 trauma centers....

Anesthesia is ASKED to come to various places around the hospital.....

Anesthesia DOES NOT aske anyone to come to the OR....

That is the difference.

The way I see things....when you ASK someone to come to your space...you are thankful that they come to help out....

When you ASK someone to ENTER THEIR space...you respect the rules of their space....

Simple courtesy.

 

[NinerNiner999]

Also remember that requirements aside, there are "old school" anesthesia attendings who still consider EM to have taken their procedure. Obviously not all anesthesiologists feel this way, but some do. As a result, some may feel reluctant to let EM residents trump theirs.

Going back to my previous point [YOU] as an attending with "limited experience" may not [WANT] us there, but as residents with a scheduled rotation, it is implied that we are [ASKED] to be there. You make it painfully obvious that this is not the case, and I am sorry that this mentality still pervades into the world of medicine.

The other difference between visiting the ED and the OR is this - most of the consulted residents who come to the ED do not want to be there, but most of the ED residents who enter the OR for anesthesia do - even if you don't want us there.

 

[edinOH]

While we may disagree with our anesthesia colleague, can't we at least be respectful in our tone?

The guy is an attending with greater than 10 years experience. Some of us are residents. I'm a first year attending. Can't we find it within us to show some respect and professionalism in our responses?

 

[pushinepi2]

11 years AD...Year in GITMO....time in Iraq....sell out...hmmmm....

You bring up an issue....I'm giving it to you straight from our side of the curtain....and you're calling me names.....hmmmm...

The difference between Anesthesia coming to the ER...and ER coming to the OR is this...

In my limited experience of doing anesthesia since 1993 in multiple hospitals...including Level 1 trauma centers....

Anesthesia is ASKED to come to various places around the hospital.....

Anesthesia DOES NOT aske anyone to come to the OR....

That is the difference.

The way I see things....when you ASK someone to come to your space...you are thankful that they come to help out....

When you ASK someone to ENTER THEIR space...you respect the rules of their space....

Simple courtesy.

That was great. In any hospital, there will always be inter-departmental rivalries. Some friendly, some not so much. No different at my institution, and I can certainly appreciate militaryMD's standpoint. I'd venture to say that when anesthesia is "asked" to come to the emergency department, the situation is more of a cry for help. The data would support me in stipulating that EM residents (PGY-3's specifically) have little trouble salvaging most difficult airways. Anyway, our door is always open to you gas guys 🙂

Here's some perspective from my "side of the curtain." There is intrinsic value to rotating in ORs for an anesthesia / airway rotation. Most anesthesia docs and CRNAs realize that ED physicians intubate in less than controlled scenarios. I've found most of them eager to share advice and pointers. It is true, for example, that any technician can intubate. To prepare yourself to handle difficult airways with competence is a DIFFERENT MATTER entirely. This is where lessons from the OR are well engrained. As NinerNiner may corroborate, our trauma anesthesia month is a fantastic (and repetetive) lesson in PREPARATION. Every intubation, no matter how critical, is done with the same attention to detail, patient positioning, and planning for catastrophe. Though most of the 60-70 intubations go well, you're always vigilant for that stubborn floppy epiglottis or immobile neck. Numbers are important, to be sure, but take the time to smell the gas so to speak. There's lots of little tips on patient position, blade angle, laryngeal manipulation, and other strategies that can be gleaned from our anesthesia colleagues. Clearly, there's much more to airway management than 'sticking the tube in the right hole.' Meeting the RRC requirement is far less important than knowing how to assess and prepare for that inevitable difficult airway. There's usually more than a few CRNAs or anesthesiologists who love to share their expertise and trade secrets with people on the other side of the curtain. For example, one gas man advised me that having a large gut is definitely an asset in the failed airway scenario. You can utilize a protuberant abdomen to elevate a patient's head while simultaneously performing external laryngeal manipulation with your newly freed hand! Who would have thought? Priceless.

 

[docB]

For EM residents it should be an "airway" rotation. That rotation is usually done by midlevel residents (ie. seconds years) so they can get a handle on the basics of technique and anatomy. Once they've gotten their number of airways in a controlled setting it's time to start doing the first look in the ED with the vomit, blood, C-spine and plenty of backup.

I see no educational value in having EM residents sit through cases. We don't need to know about gas or running an hours long case and so on. I haven't even seen a non rigid bag since my airway rotation.

There's liability in having students and residents. It's present in all procedural medical education. I bear liability when I teach the IM and FM residents to suture, place central lines, intubate and so on. That's just how it is.

I'm glad you were able to help out the docs in the ED but I'm not sure what you wish up to take from that event.

 

[militarymd]

As I noted....that "airway" rotation would be great...

However...also as I noted....I doubt many residencies would offer that "airway" rotation....

and as long as it is an "anesthesia" rotation...

then the rotator should oblige the rotation requirement....as the "visitor"

 

[corpsmanUP]

Asking mods to scrap thread. If this conversation needs to continue, let it happen on someone else's watch.

 

[FoughtFyr]

Asking mods to scrap thread. If this conversation needs to continue, let it happen on someone else's watch.

Done

- H