Anesthesiologist vs ER Physician for Intubation

Discussion in 'Anesthesiology' started by s204367, Nov 15, 2005.

  1. s204367

    s204367 Member
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    OK, this is NOT what it sounds like. A few nights ago on call I was called to the ED because one of the ER docs pushed etomidate on a frail old lady for the orthopod to perform a reduction of a dislocated hip...i.e- General anesthesia in the ED. I was a bit appalled by the lack of monitoring and airway equiptment present..and what really happenned was some myoclonus, that we all know can be seen in up to 30% of pt's given etomidate....anyway, it turns out some of the orthopods have been ordering nurses to push propofol with a RT present, reducing a fracture and leaving...relying on the RELATIVE safety profile of propofol. Again, GA in the ED, just wait until that little old lady with an unknown AV mean gradient of 55 comes in and gets 75 mg of propofol...boxed.

    Anyway, we had a joint meeting today with the vp of the hospital, nursing and chair of the ED department. The ER physicians are relly pushing to be allowed to use these agents( propofol and etomidate), with no repsect to NPO status whatsoever( i am aware of the lack of evidence based medicine behind this in the first place, but again another topic).

    Well, the ER doc got all flustered, and started ranting that he would argue that ED physicians are better at crash intubations than anesthesiologists in the first place.....we all refrained from disputing him, and I have certainly seen lots of literature quite to the contrary....I could not find them earlier, and do not want to start a debate here, but does anyone have the citations off hand???

    ALso, what are teh ER physicians allowed to use at you hospitals??
     
  2. militarymd

    militarymd SDN Angel
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  3. driverabu

    driverabu www.riograndband.com
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    Answer the ? first and see how this person responds...then we'll see if it's true trolling. Give the brotha/sista a chance first! ;)
     
  4. Noyac

    Noyac ASA Member
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  5. toughlife

    toughlife Resident
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    i have a question... as an anesthesiologist... are you not allowed to question what these docs are doing? I think it is BS that these idiots put the patient under GA and then, when they get into trouble, call you to save their ass. I personally would be offended if I was called to bail someone out after they tried to do my job. I would just stand there and watch them go down in flames.
     
  6. OldManDave

    OldManDave Fossil Bouncer Emeritus
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    At Dartmouth, there is a policy that no one administers propofol unless they also place a definitive airway, i.e. intubate the patient or they already have a trach, except an anesthesiologist. No one has the authority except anesthesiologists to administer etomidate. So, essentially, the ER docs use propofol for inductions for intubation. Most nearly all of the time, if an ER doc plans to intubate, they notify anesthesia - if they suspect in any way there may be difficulties, they are required to have one of us in attendance. We have the authority to either allow them to proceed or to usurp them & do it ourselves - our decision.

    Essentially, in the ICUs, propofol is restricted to use in placing airway, or to sedate a pt who already has a definitive airway in place. Same story for etomidate...and over half our ICU attendings are anesthesiologists and there is always at least 1 anesthesiology resident amongst the two ICU resident teams and no uncommonly two.

    I personally feel that our ER docs very much respect our position & the inherent dangers of these two agents. There seems to be solid communication. And, they know their limits. As a resident, they defer to me for all trauma a/w management and frequently call one of us down to standby for virtually all intubations.

    We sure as hell do not let orthopods use them! They do their closed reductions either with lighter doses of benzos & maybe an opiate. However, if they want to induce GA, we are involved w/o question.

    Anesthesia is definitely one of the, if not the most powerful political player at Hitchcock. The only group that parallels our influence is cardiology.
     
  7. toughlife

    toughlife Resident
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    :thumbup: Great to know some places know where to draw the line.
     
  8. jetproppilot

    jetproppilot Turboprop Driver
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    Let them think they are better at crash intubations in the hospital. ( :laugh:)

    Actually, I'd prefer they think that.
     
  9. zippy2u

    zippy2u Senior Member
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    In the anesthesiology world there is no such phrase as "crash intubation" for "crash" implies being out of control and the anesthesiologist should never be "out of control" of an intubation.... -----Zip
     
  10. adleyinga

    adleyinga Einstein
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    So tough guy- you would watch a patient die when you could hav easily saved them- since we are much much better at intubation then tey are?

    At my place this has ben a problem for years- the ER guys want to intubate traumas- they need to know how to for situation when they are only physicain in small ERs.

    The trauma guys call us the bail out ER often but the ER guys still won't admit that we are better.

    Alot of political capital can be wasted on this fight. The only thing that will change it is more deaths as described here
     
  11. jetproppilot

    jetproppilot Turboprop Driver
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    Ole Zipster comes through with another "Zipperphrase".

    I agree. An intubation is an intubation. Some are just harder than others.
     
  12. jetproppilot

    jetproppilot Turboprop Driver
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    But save the CSI melodrama, adle.

    Just about every ASA three I put to sleep I could write some melodramatic crap like that.

    Just part of the job.

    Lets not make Saving Private Ryan out of it.
     
  13. VolatileAgent

    VolatileAgent Livin' the dream
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    my troll-dar is going off a bit, but i'll take the bait.

    most ER docs i know would much rather have an anesthesiologist manage an airway. period. we just, quite simply, do it more often and therefore have more ability to learn how to get out of trouble. as far as pushing propofol in the ED, i don't know about your institution but it's verboten at mine. etomidate, on the other hand, is not. still, 'bailing out' colleagues is something we do all the time. it's just usually called a "consult".
     
  14. jetproppilot

    jetproppilot Turboprop Driver
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    Well put, Volatile. And lets keep it an, uhhh,....consult.
     
  15. nitecap

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    Well Put
     
  16. adleyinga

    adleyinga Einstein
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    I think you misunderstand- Tough said he would watch the ER guy go down with the patient, Have felt tha way mayself- especially when they are jerks.

    Not being melodramatic- just that fulfill my wish of watching them crash and burn because a pt is invovled.
    Wha I find even more satisfying is watching the ER attending struggle for 10 mintues and then have a CA-1 intubate in 15 sec flat
     
  17. jetproppilot

    jetproppilot Turboprop Driver
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    Theres no drama there. We intubate people for a living.

    IMHO, a seasoned CA-1 is better at airway management than any ER attending. No pretentiousness intended. But think about it.

    Analagous to a factory line.

    The more you do/see, the better you are.

    And any "senior" CA-1 (close to being a CA-2) has seen more airways than any ten-year-plus ER attending.
     
  18. toughlife

    toughlife Resident
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    i would not let the patient die. What I would to do is, roll up the latest edition of Anesthesiology and while smacking the ER resident doc on the head with it, I would say "Don't (smack) do (smack) that (smack) s*** (smack) again (again)". :laugh:
     
  19. driverabu

    driverabu www.riograndband.com
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    :laugh: :laugh: :laugh: :laugh: :laugh:

    Well put!!
     
  20. davvid2700

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    What do you care what the ER doc does down in the ER? Is it Your ER? If he feels comfortable pushing propofol without any monitors or supplemental oxygen.. thats his business. I feel it is not the correct way to practice , but he didnt ask me. IF he asks you.. tell him but until then mind your own business. Getting into other peoples business can get you into trouble..
     
  21. Noyac

    Noyac ASA Member
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    :(
    I see where your coming from and have some of the same feelings. But in most hospitals (at least all those that I have been affiliated with) the anesthesiology dept. is asked to write the conscious-deep sedation policies. We are then placed/thrown in the position of credentialing the other services. So now we are intimately involved whether we want to be or not. :(
     
  22. militarymd

    militarymd SDN Angel
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    Same here, I've been supporting the Intensivists and ER docs in their use of iv hypnotics, but the nursing department is the road block.
     
  23. davvid2700

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    why is the nursing department a road block
     
  24. jwk

    jwk CAA, ASA-PAC Contributor
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    And keeping your mouth shut because you don't want to get involved gets patients killed.

    In our hospital, except for propofol infusions on vent patients in the ICU, anesthesia providers are the ONLY people in the house that are allowed to administer propofol, pentothal or brevital, etomidate, and ketamine. No ER docs, no GI docs, no intensivists, no exceptions. They want to use those drugs? They call us and we give them.

    Look at the original post for this thread - it summarizes exactly why these drugs should only be used by anesthesia providers.

    And as far as ER docs intubating better than anesthesia? Bite me. Not even in their wildest fantasy. :)
     
  25. jwk

    jwk CAA, ASA-PAC Contributor
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    Because in some states it is actually ILLEGAL for RN's to administer propofol except for ventilated patients in the ICU.
     
  26. beezar

    beezar Senior Member
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    A lot of ER docs really don't understand what we do in the OR. I had one ER attending question why a 4th yr ER resident was not allowed to do a code blue intubation over a CA-2, stating that the ER resident has a lot more experience with intubations. Imagine his surprise when we told him that the CA-2 has done 500+ intubations in his 1st yr of residency.
     
  27. davvid2700

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    DUDE

    Take it easy. I think you are suffering from little man syndrome..

    Im a physician. ALl Im saying is that Im not going to follow every other doctor around to monitor how they are practicing and to correct every move they make.. Im not going to tell them what dose of versed to give and what not to give.. They are physicians. They know about drugs and such. Im not arrogant enough to say that I am the only one who can give propofol safely. Im not the only one that can administer conscous sedation. To say that ER docs, who are atls trained and know about airway management who spent 4 years in a residency cannot administer conscious sedation safely is laughable.. And it is especially laughable coming from a AA.
     
  28. EMApplicant

    EMApplicant Senior Member
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    As an er intern that has rotated through anesthesia at my institution, all i can say is that it has left a bad taste in my mouth. The CRNAs for the most part have been pretty cool and willing to help teach me to intubate. The residents just ignore us and the attendings are basically d*cks. Not a single anesthesiologist has actually TAUGHT us anything thus far (yes, we've been polite, considerate, etc., etc.). Unfortunatley, I imagine these same people will be bad-mouthing our airway skills later down the line. Maybe this is just the sh*tty situation at my program, but hopefully everyone trash talking ER on this board has actually tried to help TEACH the er residents and interns how to improve. :idea:
     
  29. Noyac

    Noyac ASA Member
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    Sorry that your experience is so BAD. It definately was not that way where I trained. I have alot of respect for all physicians until they violate that respect. I don't agree that only anesth can give these drugs and I have stated that before on this board. But I do like to point out that propofol is a little different and one can really get into trouble fast with it. At my hosp. we are actively helping those that wish to use propofol, learn the ins and outs of it and effective airway management skills. If that offends you then you need to your sensitivity level. Also, don't make the mistake in believing that everyone on this board agrees with everything said here. This is a small group of people with many different view points. If you want a suggestion, read Jet's posts and I'm sure you won't be offended. He seems to have a great grasp on things.
     
  30. The White Coat Investor

    The White Coat Investor Practicing Doc and Blogger
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    Man...lots of people with panties in a wad. Keep in mind that emergency medicine is a specialty of breadth, we know a little about a lot rather than a lot about a little. We don't claim to be the experts in intubating, in delivering babies, in running traumas, or even managing critical patients. What we do claim to be is available. In the ivory towers it is easy to get a trauma surgeon, an anesthesiologist or an OB in the ED in a matter of minutes. However, where MOST physicians practice, this simply isn't practical. So the EPs gotta do it. We do the best we can, and for the most part, take excellent care of our patients, and know when we're getting into a situation beyond our abilities. At that point, yes we consult. We don't do 500 airways as a first year resident. In fact, many EM residents graduate with only 100-150 intubations. A high percentage of those are "trauma airways" and most programs give excellent training with alternative airway management techniques. I've used a light wand, intubating LMA, fiberoptic, Glidescope, mac blade, miller blade, bougie, crich, needle crich (cadaver) etc. Are we better at managing "crash airways?" Don't know. The only data I've seen seems to indicate that senior anesthesia residents and senior EM residents are equivalent at securing the airway of trauma patients and that both get nearly all of the intubations presented to them. I've had anesthesia called to the ED for exactly 1 intubation during my residency. It was a pediatric multiple trauma where the trauma surgeons had some concern the tube wasn't in due to the patient's sats not improving despite bilateral chest tubes, ETCO2 confirmation, and direct visualization of the tube passing the cords. Turned out the trachea had a large laceration in it and one of the bronchi was detached from the trachea. The patient certainly didn't improve after the anesthesiologist replaced the tube. (Later declared unsalvageable in the OR)

    Like with any procedure, there is a learning curve. It is steep at first, but certainly continues to climb no matter how many one does. I think the only point I'd dispute is that a CA-1 is a better intubater than a residency trained EM attending who has been practicing in a high acuity facility for 10+ years. But who knows, I could be wrong. Someone want to do a study? I suspect it would have to be huge to actually show a difference.


    Ann Emerg Med. 2004 Jan;43(1):48-53. Related Articles, Links


    Alternating day emergency medicine and anesthesia resident responsibility for management of the trauma airway: a study of laryngoscopy performance and intubation success.

    Levitan RM, Rosenblatt B, Meiner EM, Reilly PM, Hollander JE.

    Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. [email protected]

    STUDY OBJECTIVE: We compare laryngoscopy performance and overall intubation success in trauma airways when primary airway management alternated between emergency medicine and anesthesia residents on an every-other-day basis. METHODS: Data on all trauma intubations during approximately 3 years were prospectively collected. Primary airway management was assigned to emergency department (ED) residents on even days and anesthesia residents on odd days. Emergency medicine residents intubated patients who arrived without notification or who needed immediate intubation before anesthesia arrived. The study was conducted in an inner-city, Level I trauma center with approximately 50,000 ED patients and 1,800 major trauma cases a year. Main outcomes were success or failure at laryngoscopy and the number of laryngoscopy attempts needed for intubation. RESULTS: Six hundred fifty-eight trauma patients were intubated during the study period. Laryngoscopy was successful in 654 of 656 cases. Two (0.3%) patients underwent cricothyrotomy after failed laryngoscopy, and 2 (0.3%) patients had awake nasal intubation without laryngoscopy. The specific number of laryngoscopy attempts was unknown in 6 cases (3 from each service), resulting in 650 cases for laryngoscopy performance analysis. Overall, 87% of patients were intubated on first attempt, and 3 or more attempts occurred in 2.9% of patients. Laryngoscopy performance by service (broken down by 1, 2, and >or=3 attempts) was as follows: emergency medicine 86.4%, 11%, and 2.6% versus anesthesia 89.7%, 6.7%, and 3.6%. Analysis by service was done by using Wilcoxon Mann-Whitney testing (P=.225). CONCLUSION: There were no differences in laryngoscopy performance and intubation success in trauma airways managed on an every-other-day basis by emergency medicine versus anesthesia residents.

    J Trauma. 2001 Dec;51(6):1065-8. Related Articles, Links


    Role of the emergency medicine physician in airway management of the trauma patient.

    Omert L, Yeaney W, Mizikowski S, Protetch J.

    Department of Surgery, Allegheny General Hospital, South Tower, Pittsburgh, Pennsylvania 15212, USA.

    BACKGROUND: A Level I trauma center recently underwent a policy change wherein airway management of the trauma patient is under the auspices of Emergency Medicine (EM) rather than Anesthesiology. METHODS: We prospectively collected data on 11 months of EM intubations (EMI) since this policy change and compared them to the last year of Anesthesia-managed intubations (ANI) to answer the following questions: (1) Is intubation of trauma patients being accomplished effectively by EM? (2) Has there been a change in complication rates since the policy change? (3) How does the complication rate at our trauma center compare with other institutions? RESULTS: EM residents successfully intubated trauma patients on their first attempt 73.7% of the time compared with 77.2% ANI. The overall success rates, i.e., securing the airway within three attempts, were 97.0% (EMI) and 98.0% (ANI). The airway was successfully secured by EMI 100% of the time while a surgical airway was performed in two ANIs. CONCLUSION: EM residents and staff can safely manage the airway of trauma patients. There is no statistically significant difference in peri-intubation complications. The complication rate for EDI (33%) and ANI (38%) is higher than reported in the literature, although the populations are not entirely comparable.

    Acad Emerg Med. 2004 Jan;11(1):66-70. Related Articles, Links


    A comparison of trauma intubations managed by anesthesiologists and emergency physicians.

    Bushra JS, McNeil B, Wald DA, Schwell A, Karras DJ.

    Department of Emergency Medicine, Temple University Hospital and School of Medicine, Philadelphia, PA 19140, USA. [email protected]

    Although airway management by emergency physicians has become standard for general emergency department (ED) patients, many believe that anesthesiologists should manage the airways of trauma victims. OBJECTIVES: To compare the success and failure rates of trauma intubations performed under the supervision of anesthesiologists and emergency physicians. METHODS: This was a prospective, observational study of consecutive endotracheal intubations (ETIs) of adult trauma patients in a single ED over a 46-month period. All ETIs before November 26, 2000, were supervised by anesthesiologists (34 months), and all ETIs from November 26, 2000, onward were supervised by emergency physicians (12 months). Data regarding clinical presentation, personnel involved, medications used, number of attempts required, and need for cricothyrotomy were collected. Study outcomes were: 1) successful intubation within two attempts, and 2) failure of intubation. Failure was defined as inability to intubate, resulting in successful intubation by another specialist, or cricothyrotomy. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were used to compare results between groups. RESULTS: There were 673 intubations during the study period. Intubation within two attempts was accomplished in 442 of 467 patients (94.6%) managed by anesthesiologists, and in 196 of 206 of patients (95.2%) managed by emergency physicians (OR = 1.109, 95% CI = 0.498 to 2.522). Failure of intubation occurred in 16 of 467 (3.4%) patients managed by anesthesiologists, and in four of 206 (1.9%) patients managed by emergency physicians (OR = 0.558, 95% CI = 0.156 to 1.806). CONCLUSIONS: Emergency physicians can safely manage the airways of trauma patients. Success and failure rates are similar to those of anesthesiologists.
     
  31. The White Coat Investor

    The White Coat Investor Practicing Doc and Blogger
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    I actually had a somewhat similar experience on my rotation. There were 2 or 3 residents who did some good teaching, but I think only 1 attending talked to me all month. Most of the intubations I've done, and all of them that were even remotely difficult, were done in the ED.
     
  32. jwk

    jwk CAA, ASA-PAC Contributor
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    Let's leave the intubation thing aside for a moment.

    The propofol debate that is currently raging is not about arrogance on the part of anesthesia - it's about patient safety. Again - look at the original post. It's a textbook example of a disaster waiting to happen in the ER because anesthesia wasn't involved.

    Just because they're physicians they know how to administer conscious sedation? C'mon. If that was truly the case, none of this would be debatable. As I've stated many times, I can't tell you how many patients I've resuscitated in the endoscopy suite when physicians overdosed a patient on Versed when it first came out. And by and large, ER and GI docs don't want conscious sedation. That's easy, without propofol, and without anesthesia. What they really want is deep sedation bordering on (or actually) general anesthesia. They just don't want to deal with all that pesky monitoring or ridiculous NPO stuff. Then when there is a problem, it's like OMG, what the hell happened?

    Someone correct me if I'm wrong - aren't there some JCAHO requirements that the anesthesia department be involved with policy-making and monitoring of conscious or deep sedation issues outside the OR?
     
  33. canjosh

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    Let me pose this question...First of all, I'm a paramedic in a fairly small suburban ED. At night, the ED physician is the only doc in the house. Anesthesia is at home, and I've never seen them come in for an ED sedation, only for OR cases. We do give IV propofol to intubated patients in our dept. We also do some conscious sedation (i.e. Versed for reductions, etc), and the nursing policy is well structured and is faithfully followed. Now to the case in point...2 year old with a full thickness laceration to the middle of the tongue--the kind that has to be repaired. Ketamine is the drug of choice for us in this situation, and it is permitted per the policy for IM administration. Of course, I'm thinking some atropine would be nice, but the policy reads (roughly) that any medication associated with the sedation cannot be given IV. The pt did have a patent NS lock, btw. So, to follow our dept's Ketamine protocol, atropine was given but had to be given IM! The child was very compliant for the 4 Vicryl sutures, but of course his mouth was rather moist! I personally saw this situation as a problem with the policy as it currently reads--any thoughts? Does atropine have some dangerous concomitance with ketamine for which I am unfamiliar?
     
  34. DRTHOR

    DRTHOR New Member

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    I am a senior anesthesia resident at a Level One Trauma center in Florida. I have a very good friend who did ER at HCMC which is probably top five when it comes to ER programs in the country. He even admits that anesthesia are the airway experts. At the end of a CA-1 year the typical resident will probably have intubated more people that ER physicians their whole career. When trauma comes to the hopital that there is an airway issue, Anesthesia is the service that usually bails out ER. Now our ER colleauges are very good, but noone can compare to our experience, they just can't. This guy that said he could probably doesn't even know what a bullard laryngoscope is, or a MAC flip tip.
     
  35. jetproppilot

    jetproppilot Turboprop Driver
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    If I ever have to be intubated, and the choice is between an ER doc with 25 years experience and and SRNA about to graduate, I'll take the SRNA. Hands down.

    And that goes for my wife/kids/friends too.
     
  36. rn29306

    rn29306 Drugs are bad, m'kay?
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    Damn jet, thanks for the comment. Sitting on close to 570 airway maneuvers in a little over a year, hope to double that by grad time. Anyway, thanks again.
     
  37. jetproppilot

    jetproppilot Turboprop Driver
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    No need to thank me.

    If you do something a thousand times before you get to me, I'm the one who should thank you.
     
  38. canjosh

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    Anyone want to tackle my question^^? Poorly written policy or good reason that I'm not aware of?
     
  39. Noyac

    Noyac ASA Member
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    Sounds like a poor protocol to me. So what if the Dr. has an airway issue from the swollen tongue, ketamine sedation, or some other issue. Does he have to give the meds for intubation by the IM route also? This could make for an interesting induction when the pt. is desat'ing.

    However, I don't disagree with the sedation in the ER. I along with most anesthesiologists don't want to be called to the ER for every sedation case they do. However, a 2 yr with a tongue lac. I'd like to see that one. And don't forget that the ketamine will make him salivate ALOT. You can use atropine or Robinol but all bets are off in the IM route.
     
  40. canjosh

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    Thanks for the response. He may have been a little older--maybe 3, no older than 4, I'm second guessing now. I guess when it comes down to intubating in a 'decompensating' situation, you've moved out of the elective sedation stage to emergent airway control, so the conscious/moderate sedation protocol (as it is titled at our facility) goes out the window. Precisely why we had the PIV in place, btw. The procedure went as well as could be expected, I had the Frazier suction in one hand and was pulling traction with the other while the doc sutured. But, I believe it would have been an easier job, and a little safer had we had a drier mouth to work with s/p IV atropine. Thanks again for your reply!
    p.s. I always enjoy perusing the posts in the anesthesia forum...always lots of great info, and often very relevant to work in paramedicine and in-hospital emergency medicine. Keep it up!!
     
  41. jetproppilot

    jetproppilot Turboprop Driver
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  42. jetproppilot

    jetproppilot Turboprop Driver
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    Yeah, I gotta agree with Noy here.

    Big tongue lac on a kiddy probably needs to come to the OR.

    I'd rather come in at 2 am and put the kid to sleep so the surgeon can tie it up than risk some catastrophe that may cost the little s hithead his life.

    I've got a 2 year old.

    And if he gets a big tongue lac, Doctor ENT and I (and my best CRNA) are going to the OR.
     
  43. lattimer13

    lattimer13 good boy!
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    #1. no problem

    #2. i'm so sad.

    #3. up yours. no need to be a prick, DUDE. :laugh:
     
  44. lattimer13

    lattimer13 good boy!
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    for the rest of ya...here's the PDF files of the two articles i was orginally trying to post about EP vs Gas Trauma intubation. They are the full text articles that someone posted the abstracts to above.
     

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  45. jetproppilot

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    #3. Well taken.
    Nice dog.
     
  46. canjosh

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    But we're in a little catch-22. No pedi inpatient beds, so surgeons generally will not take kids to the OR (although this depends on the patient's insurance sometimes) :thumbdown: So if you're well insured the ENT may be more inclined to come in. I have seen a general surgeon refuse to come in for a 16-year old appy that weighed 90kg...excuse given--we don't do peds. Same surgeon came in for a 14 y/o 55kg appy at a later date. We had a 6 y/o T+A on the OR schedule the other day, so I know that our anesthesia doesn't have a problem with doing kiddos.
    On the other hand, if we called our local pediatric tertiary center, they'd tell us to repair in our ED--they'd repair it in theirs. I've worked in 2 pediatric tertiary centers and we always repaired tongues in the ED, not the OR. Although, as a parent certainly you'd have the right to request the OR...not many parents have the medical background that you do. I know I'd be nervous with my kid being sedated in a non-peds/non-trauma center ED. But, the peds facility does not have an obligation to accept the pt, and so we have our dilemma. :confused:
     
  47. Noyac

    Noyac ASA Member
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    Great. The better they are at it, the less I get called/awakened to come in and sedate or intubate someone. Hey, the ER is their domain. I don't want them in my domain telling me how to do **** and I ain't going to tell them how to do it in their domain. That is until they start calling me in. Then it is our domain and I will get involved. Personally, I'm better in my domain and they are better in their domain.










    Yeah Right!
     
  48. lattimer13

    lattimer13 good boy!
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    thanks. :thumbup:
     
  49. Tenesma

    Tenesma Senior Member
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    lattimer13.... find better data...

    study #1 is a well known study that is poorly done... but let's discuss the finer point: ER intubations led to 2 crics with Anesthesia intubations led to ZERO (0) crics.... i think while not statistically significant in that poorly powered study, if i were the patient i would much rather be in the NO cric group

    study #2... did YOU read that study? it is sooo poorly written that in the results and discussion section it discusses the results of other studies (not even its own results), and then to top it off they ADMIT that they were unable to compare anesthesia to EM... come on...

    bottom line... when there is an airway emergency in the OR, do you ever hear anesthesiologists scream for an EM consult STAT???? while EM residents are definitely taught techniques for managing difficult airways it don't mean diggity-shyte if they only used that technique on a real person ONCE or TWICE... during residency I performed over 100 emergency intubations on the floors and in the ER to bail out the ER attendings who tried 4 times after 3 of the ER residents butchered the airway... and that doesn't include the 2500-2800 intubations i did in the OR.

    In FACT - the ATLS guidelines clearly state that the "most experienced" laryngoscopist is to assume the airway, which means the CA-2s I supervise clearly outrank anybody else in the ER.... However at my old institution we usually let ER try to do their thing before we bailed them out in a nice courteous way... And then after we take over the airway and successfully intubate, I always hear them whispering between each other "oh, I could have gotten it too if he had let me try one more time".... right

    propofol in the ER? sure, as long as there is somebody available to provide immediate control of the airway, and the patient consents to GENERAL ANESTHESIA which is what it is....
     

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