EM residents claiming they are better at trauma/difficult airway management than anesthesiologists??

Discussion in 'Anesthesiology' started by operavore, Aug 7, 2017.

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  1. periopdoc

    periopdoc Cardiac Anesthesiologist
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    My ER colleagues must be pretty good at airway management. They never call me for backup, or to bail them out.

    Pulm intensivists too. They only call for the really gnarly airways, and never ask for me to back them up (even though I sometimes can tell that is what they kind of want). If they call me for an airway that I find only has a moderate pucker factor, I will usually offer to back them up.

    Thanks guys.


    But don't get me started on the paramedic students. They are banned from my OR now.
     
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  3. bashwell

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    Anesthesiology has got to be one of the most underappreciated specialties. Almost everyone seems to think they're better than anesthesiologists at x, y, z . . . until they get rekt and have to call anesthesiology for help! But I appreciate the schadenfreude. :rofl:
     
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  4. mmag

    mmag Member

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    We work hard to make it look easy.
     
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  5. IlDestriero

    IlDestriero Ether Man
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    "Wow, this guy must have a TE fistula."


    --
    Il Destriero
     
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  6. powermd

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    I practice pain medicine full time now, but this reminds me of my first night of team captain call at my training institution. First 15 minutes on duty and I get 3 pages for stat airway assistance. The first was in IR. I had to intubate him awkwardly ducking under the c-arm. Done with that, I headed over the CCU. Just as I'm assessing the situation, the pager goes off for the children's hospital. The CCU guys were cool and said, yeah... go take care of THAT instead, we got this old guy.

    I book it on over to the new baby-momma unit and wade through a crowd of people in the room. Apparently a new mom had smothered her 1-day old under her breast and the baby went apneic. The PICU people apparently couldn't intubate and were bagging the very cyanotic kid. Calmly I pulled out my miller 1 and got the airway in about 10 seconds. I think that may have been my easiest tube ever. The baby pinked up soon after. On to my next job. To this day I still wonder what became of that kid.

    So I think I got to be "that guy" a few times. I'm glad my present job is much less exciting!
     
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  7. acidbase1

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    Holy shhhhjjjt
     
  8. FFP

    FFP Grunt, body, pompous ass, pissant, buzzkill, jaded
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    The EM doc's EEG?

    </sarcasm>
     
    #57 FFP, Aug 9, 2017
    Last edited: Aug 9, 2017
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  9. Hoya11

    Hoya11 Senior Member

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    He made it to the unit intubated/sedated no pressors after intubation. The EEG was maybe a day after he came in. It was a surprise to me and an indication of just how long the ER doc struggled before calling directly for the surgical airway.

    CT of the neck while he was in the unit showed a big hematoma starting from the carotid, no evidence of allergic reaction. He had had a CABG ~1 yr ago and was on plavix and asa.
     
  10. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay

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    Kids, don't drink and post.
     
  11. Noyac

    Noyac ASA Member
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    Wow I should reread my posts before I hit send. It was late I guess. Hope the gist was conveyed.
     
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  12. Noyac

    Noyac ASA Member
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    Ha ha. Yep. Didn't see this post until after I sent the previous one.
     
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  13. Groove

    Groove Member
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    Deleted. I hate being the one to make inflammatory posts. This thread just rubbed me the wrong way.
     
    #62 Groove, Aug 9, 2017
    Last edited: Aug 9, 2017
  14. southerndoc

    southerndoc life is good
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    Don't recall seeing this post, but not all emergency physicians are pompous. I didn't train in anesthesiology, so I'm not an expert. In fact, when a severe angioedema, 400 pound patient came in the other day, I paged anesthesia immediately. It took 4 anethesiologists to intubate the patient. I recognized my limitations and didn't try. Some of my colleagues would call that weak, but I call it being smart.

    I don't pretend to be a cardiologist because I see a ton of EKG's, I don't pretend to be a trauma surgeon because I do the initial assessment of trauma patients, I don't call myself a neurosurgeon because I see many patients with subdurals and subarachnoids, and I certainly don't call myself an anesthesiologist because I intubate frequently. Frequently for me is way more than most emergency physicians -- at least once every other shift in one of the nation's busiest ER's -- but that number is a laughable number compared to what an anesthesiologist does on a daily basis.

    I drive on the interstate frequently and don't consider myself a NASCAR driver.

    Consider your source here. A PGY-3 who either is full of himself or works in a department where faculty are full of themselves.
     
    #63 southerndoc, Aug 9, 2017
    Last edited: Aug 9, 2017
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  15. Ezekiel2517

    Ezekiel2517 Anesthesiologist
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  17. Apollyon

    Apollyon Screw the GST
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    I don't Reddit. Honest question - is there any vetting? Or can anyone claim to be X, Y, or Z? My point is that, could this be from someone just wanting to fan the flames? If so, it seems effective.

    Where I am, way the hell out in the boonies, when I get a code coming in (during business hours), the CRNAs both turn out, and tube the pt. I'm fine with that. Between 3pm and 7am, it's me.
     
  18. Man o War

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    Go away murse.
    Your use of MDA is a dead give away.
     
  19. throckmortonDO

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    EM attending here

    Anesthesia intubates multiple times a day. I don't. when you do something repeatedly like that, you develop the skills to be the best.
    I've had some humbling airway experiences over the past 5 years, I do have a tool that anesthesia might not have which is cric or surgical trach.
    Thats about it.

    You guys are the airway kings. the guy who posted about tubing better sounds like a moron.

    And whoever said Groove is a 'murse' got it wrong. He's an experienced EM attending.

    instead of trashing each other, shouldn't we be focused on the fact that corporate groups are pillaging our specialties and making us responsible for overseeing midlevels we don't get to vet or train?

    Think about it.
     
  20. Man o War

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    I'm happily proven wrong. What's his name?
    He's been trolling this forum hard since the whole "I just had surgery and I've always asked for an MD but now I'll take the CRNA". Stinks to me.
     
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  21. Man o War

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    And I agree, this is a dumb argument. There's about 1000 things you guys are better at than me. That's why we specialize in medicine.
     
  22. Consigliere

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    Whatever. I can say I pitch just as well as Jake Arrieta but that doesn't make it so.
     
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  23. AdmiralChz

    AdmiralChz ASA Member

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    @Groove did you really go and post in the EM subforum about how hurt your feelings are? Trying to get backup?

    Everybody wants to be a hater...

    I'm sorry that you didn't get anyone to back you up in your crusade against us, your responders so far have agreed with us! We are just saying to respect the airway and critiquing how cocky a random reddit user was. Coming here and insulting us won't really prove anything... C'mon man!
     
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  24. dchz

    dchz Avoiding the Dunning-Kruger
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    I might have to disagree here, why is this tool more available to you than us?
     
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  25. Mr. Hat

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    Doc on doc crap like this is why we'll soon be arguing who the real master of the airway is: The ER DNP or the CRNA
     
  26. southerndoc

    southerndoc life is good
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    I think a lot of people think the anesthesiologists aren't allowed to use a scalpel. Just because you choose not to use it doesn't mean you aren't trained in it or aren't credentialed for it.
     
  27. Robotic Wis-Hipple

    Robotic Wis-Hipple ASA Member

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    My credentials say I can place chest tubes lol. I sure as hell am not letting a pt die without a scalpel, finger, bougie cric attempt.
     
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  28. AdmiralChz

    AdmiralChz ASA Member

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    Surgical trach equipment definitely not, but a cricothyrotomy kit (typically Melker, but there are others) are on almost all difficult airway carts that I've seen. At my residency program hospital (typical large, tertiary care center), such a kit was used exactly once over the past 10 years outside of the emergency room when we went looking for statistics (at least, that's all that we could find evidence of).

    To be completely honest I've seen some really horrendous airway disasters, but with all the modern and solid equipment we have now (mostly LMAs to get SOME ventilation through in a pinch) I hope to never have to reach for the cric kit.
     
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  29. dchz

    dchz Avoiding the Dunning-Kruger
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    but if you do reach for it, it's not gonna be there because it's not available to you :(
     
  30. Groove

    Groove Member
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    I posted a long response in our own thread in the EM forum and I stand by what I said. I think what ultimately pissed me off about this thread were the derogatory and insulting comments (by a few of you, not all) criticizing ER docs and EM residents who improperly manage the airway (in your opinion) in areas of the hospital where anesthesia traditionally is just never available. The whole thread started because of an EM residents' post on reddit about finding an attending with the most experience when intubating messy, crashing trauma patients. You think that's you? You think you intubate more of that patient population than anybody else in the hospital? I don't. I just found this thread and some of the comments incredibly counterproductive and unprofessional and it reminds me why we're losing the battle to MLPs who by and large work together and respect each other to a much greater degree and hence why they are lobbying state legislatures much more effectively. Yes, my original post was not helpful either, which is why I deleted it.
     
  31. urge

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  32. Quixotic2501

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    "Want us to consult you to the bedside STAT for every "intubation assessment"? What about the floor codes, do you want to have to respond to all of those instead of the ER doc or the intensivist? (Because you're sooooo good at intubation)? Yeah, I thought not."

    I know that the post was deleted, but for the record, at my institution, anesthesia are at all the floor codes to intubate and help manage care as well as respond on the floor for anyone who needs to be emergently intubated. We are called not uncommonly into ICUs where non-anesthesia intensivists feel uneasy about the airway. We carry the difficult airway pager in the children's hospital. We place the tube in less than 5 seconds after induction in a stat C-section. And I know you said it sarcastically, but, yeah, we, as a rule, tend to be soooooo good at intubation.
     
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  33. dchz

    dchz Avoiding the Dunning-Kruger
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    This is the exact situation at my training program as well. But @Groove works at a hospital where anesthesiologists are not available. I could understand from his world view why he would think that way, but it really speaks more to how little he has seen rather than who has the mastery of airways.
     
  34. CardioDad

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    mic drop.gif
     
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  35. TimesNewRoman

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    It's amazing how much people have this wrong. There are some people that are excellent at taking care of sick people and some that aren't. Anesthesia intubated much more often than EM (assuming you don't just follow around 4 CRNAs all day), so, by the very nature of the job, you should be better. That being said, it's not always true.

    Intubating in these conditions are about two things, and no one on this board seems to have the insight to explicitly identify the more important factor. There is obviously the mechanical and mental ability to think through an intubation and perform the task. This skill is obviously better cultivated in anesthesia.

    The second, and certainly more important, factor in this setting is stress management. Being able to keep your cool is a bad situation is arguably more important. Yes, technical ability is important, but when you use a CMAC to intubate a variceal bleed that vomits on the camera, it's more important to not let your pulse increase, suction aggressively and switch to DL. As several people have said, safe delivery of anesthetics should be boring, and some of my anesthesia colleagues have the superior technical proficiency to me but loose their cool in a crisis. It's the same thing as when you hear about a patient dying an airway death without an attempt at a surgical airway. Everyone knows that a surgical airway is the last step in the airway algorithm and will get that right on boards, but having the mental toughness to not get task oriented and loose the big picture is what allows this process to work correctly in real life. This follows for all specialties dealing with sick patients. A brilliant intensivist who looses his cool around actively decompensating patients is useless.

    At the end of the day, I don't care if an ER doc, anesthesiologist, or intensivist intubates me. I care they are facile at intubation AND keep their cool in a crisis. Yes, an anesthesiologist should be more technically adept at the procedure, but I don't want the guy who becomes all thumbs when a patient crumps.
     
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  36. IkeBoy18

    IkeBoy18 ASA Member

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    Whats this talk abt crisis management? Maybe its my residency location, volume of trauma, out of OR intubations and extremely sick patients, but I thought crisis management, emergent cric and resuscitation was well within the purview and skillset of the typical anesthesiologist. Maybe Im wrong.
     
  37. G-Man82

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    Same at all the places where I physically work. On the anesthesia side, I'll occasionally be assigned the attending airway pager and will go staff the airways (and occasionally just do them myself) all over the hospital. In my ICU when I'm on service the only time I called my colleagues in the OR was for a reintubation in a known difficult airway, which is a situation where I want as much assistance as possible. My colleagues are more than happy to assist.

    I do teleICU as well and cover a community hospital 200 miles away. That place is the sticks. No intensivists on staff. So at night, lines are placed by the on-call Surgeon who sometimes puts up a fight about coming back in. Airways are managed by the ED physician, who happens to be the only MD in house. I won't comment on his skill, but I have seen him just ram a tube down some morbidly obese woman's throat while RNs held her arms down. She was hypercapnic but not completely unresponsive. No video laryngoscopes exist there and I think he was afraid to over-sedate, so I don't blame him. The patient had a secured airway.

    Different arenas exist all over. In major healthcare organizations and academic facilities, we often exist 24/7. But in the community or the VA? Nope. At the VA the RT or hapless medical intern at night will tube the few times it's necessary. Talk about disaster.

    My point being that hospitals make do with the resources they have. Unfortunately that isn't always good. That community hospital at least has a physician who can intubate at night, unlike some of the others I've seen.


    Sent from my iPhone using SDN mobile
     
    #85 G-Man82, Aug 9, 2017
    Last edited: Aug 10, 2017
  38. PageDrT

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    This is so obviously subjective thinking. I'm not even a Resident but critical thinking says check your source
     
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  39. TimesNewRoman

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    It should be, but every so often you read a headline about an airway death in an OR without an attempt at a backup/surgical airway. That was my point.
     
  40. Southpaw

    Southpaw ASA Member

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    What a dumb thread. Docs need to work the same sideline, not opposite sides. Long written responses by residents and young attendings are totally missing the point. I don't care who's schlong hangs lowest. I'll help take care of the patient if called. If you don't need me, then great. I hope that line of communication goes both ways, for all specialties. I know it doesn't, but it should.
     
  41. vector2

    vector2 ASA Member

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    You may very well be right that EM intubates more traumas in a particular institution than anesthesia, but the point you're missing is not that anesthesia may be able to successfully DL some difficult airway that you couldn't (although I'd guess that our pre test probability is somewhat higher). What we really get paid for is having a deft enough hand to not turn the airway into hamburger when a DL is difficult, and for having the sound judgement and skill to move to more advanced airway techniques before the **** has hit the fan.
     
  42. Groove

    Groove Member
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    Listen to you... "At my training institution..." again. Dude, you are a baby resident who knows jack s*** about 90% of what you're talking about with nothing better to do than troll these threads trying to convince everyone you have a relevant opinion on topics you have some of the least experience with when compared to most posters here. You haven't even left your nest yet, nor are you even ready or capable of passing your boards. When you get out in the real world, become a real attending and start realizing how little most hospitals reflect the environment you were trained in as a resident, some of these scenarios will start to make more sense. A PGY 2 lecturing me about what I have or haven't seen. LOL.
     
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  43. Groove

    Groove Member
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    Because I lack sound judgement in those scenarios and will turn their throat into a laryngeal and hypopharyngeal slushie with my frenetic DL attempts? Advanced airway? Is that like a King Airway? Haha, I get your point man but still... try implementing your pre test algorithms when the 600lb whale with a short neck, small mouth in a c-collar, aspirating her own vomit and cyanotic with a sat of 60% rolls through the ambulance bay doors and plops down on your trauma stretcher. It's not like all these pt's arrive with normal VS and wrist bands that say "I will catastrophically decompensated in 7.4 minutes, plan accordingly!". It sure would make my life easier though.
     
  44. ranvier

    ranvier I can't anesthetize a rumor.

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    When I visited the EM forum on this topic, the group seemed alot more collegial than you. You are becoming annoying. Sounds like you are amazing and never need help. We actually instantly implement those algorithms even in the example you list here. It's what many of us do. Why don't you go away since you aren't here for a real discussion?
     
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  45. Man o War

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    It's so weird that an alleged "EM attending" spends so much time trolling the anesthesia forum. Not buying it for a second.
     
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  46. pgg

    pgg Laugh at me, will they?
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    My brother is an EM doc.

    I give him **** all the time about doing LPs with barbaric 22g cutting needles and being the #2 cause of headaches in the hospital (behind nurses). Or about his noble task of saving the world from seeing their PCMs.

    And he gives me **** about being a stool-sitting monkey who stares at a monitor all day listening to beeps, a task that would be done by actual monkeys if not for a different group of monkeys (JHACO) making rules about poo-flinging.

    Obviously we respect each other's fields.

    This thread ... some doofus EM resident wrote something ridiculous about airway management, we made a little fun of it, and all of a sudden feelings got hurt. FFS guys, lighten up.
     
  47. ranvier

    ranvier I can't anesthetize a rumor.

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    Retrograde wire for the win.
     
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  48. nimbus

    nimbus Member

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    So why DO they use 22g cutting needles?;)
     
  49. anbuitachi

    anbuitachi ASA Member

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    my guess is that is what is in their kits
     
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  50. nimbus

    nimbus Member

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    Don't they care about the literature regarding PDPHAs?
     
  51. grapp

    grapp Premed 1

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    Don't get me started on the audacity of paramedic students, I'm only an EMT and I know how stupid they can be. Lol!
     
  52. pgg

    pgg Laugh at me, will they?
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    The 22 cutter is in the kit ... and since they're draining off CSF and measuring opening pressure, they need a larger needle. The procedure is technically easier with a bigger/stiffer needle too.

    But it seems to me they could at least use pencil-point 22 g needles. Maybe one of our EM visitors could tell us. :)
     
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