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When I was shadowing I observed general surgeon perform a endotracheal intubation (believe that's what it's called) is this common in a rural hospital?
I have never heard the term MDA from any ED doc, from any doc in person. Maybe he is married to a CRNA.It's so weird that an alleged "EM attending" spends so much time trolling the anesthesia forum. Not buying it for a second.
When I was shadowing I observed general surgeon perform a endotracheal intubation (believe that's what it's called) is this common in a rural hospital?
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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.
It's so weird that an alleged "EM attending" spends so much time trolling the anesthesia forum. Not buying it for a second.
You think someone has been on the EM boards for over a decade just in the off chance he can troll the anesthesia boards one day?
Not very doctor like if you ask me, not at all.I'm at a loss for why an "EM attending" would behave the way he has here, it makes no sense though. He acts like the nurses who come here.
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.
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A hospital so remote video laryngoscopes can't even be recruited to live there.
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.
A hospital so remote video laryngoscopes can't even be recruited to live there.
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.
true story.What is scary is one day he'll have a real difficult trauma airway, and then he don't know what to do, and he will be to arrogant to call anesthesia fast enough, and the patient will die.
my guess is that is what is in their kits
I have to get them from the OR, which takes 30-60 minutes. Half the time it takes longer. Our kits come with cutting needles. Hence the reason most of us just use what's in the kit when trying to do an LP between sick patients.
Can't you (or someone) just have the ED order LP kits with pencil point needles? At some point "it's just what's in the kit" doesn't cut it (no pun intended).
I'm pretty sure I did OR moonlighting at that hospital. There was a lot of sketchy stuff going on down there.Rural Georgia. Yet they call themselves a "regional" medical center. The care those poor patients receive in the ICU is so far below what I would consider standard of care. A lot of my notes end with: "Recommend transfer to a facility with the capability of 24/7 critical care services."
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When I was at my .mil little hospital, I got so tired of doing blood patches because those asshats wouldn't use a non cutting needle because "they forgot" or "don't know where to get one" etc., so I went down there and taped one of ours to every LP kit they had on the shelf.
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Il Destriero
Of course they can. It's probably not even a custom option. They know and don't care.
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Il Destriero
You don't understand the bureaucracy behind the behemoth of a non-profit health system where I work. We have 11 hospitals. Because of central ordering, a change must be agreed upon by all hospitals, approved by administration for cost differences, etc. before being implemented. I feel like it's trying to get Medicare to change something when you're trying to get all to agree. Then there is an education issue. Don't get me started there. We have to go through training every year just to do stool guaiacs.
If you had to do your own blood patches I bet it would change in a hurry. I have no problem giving up the title of BLOOD PATCH MASTER. Just steal a whole box of pencil point needles from the OR and keep them next to your LP trays. I'm sure any anesthesiologist would be happy to show you where they are kept.
Can get pressures and as much csf as you care to drink from a 25g pencan.Our spinal needles are tiny though
Can get pressures and as much csf as you care to drink from a 25g pencan.
Hah, IlD is ex-military ...You don't understand the bureaucracy behind the behemoth of a non-profit health system where I work. We have 11 hospitals. Because of central ordering, a change must be agreed upon by all hospitals, approved by administration for cost differences, etc. before being implemented. I feel like it's trying to get Medicare to change something when you're trying to get all to agree. Then there is an education issue. Don't get me started there. We have to go through training every year just to do stool guaiacs.
Everything's stat in the ED!!might take a year... i highly doubt ED docs want to wait for a year
As someone who watches a lot of other people intubate patients...there's no question. Anesthesia by a mile.
Like others said I have a very hard time with the ED residents who seem like adrenaline junkies when it comes to emergent procedures. My goal as a trauma chief is to try and have everyone proceeding in a calm and orderly fashion; not to have cowboys running around
I rotated at 5 different hospitals as a resident, and had a lot of trauma experience in one of those hospitals, and three ER months as an intern, and also rotated with ER residents in the ICU as an intern.
Frankly, I think most ER docs I have seen have rudimentary airway skills and also don't know what they don't know. I have very little regard for their airway skills, and think a lot of bad things happen that shouldn't and they don't even see or understand this when these situations occur because of their lack of knowledge in monitoring during critical situations, nuances of capnography, no knowledge of any techniques beyond slash trach/VL/DL, poor to no preoxygination, no consideration of patient positioning in terms of helping out ventilation/oxygenation/shunting/etc or in terms of aligning the oropgaryngeal and laryngeal axes. And forget about recognition and treatment of laryngospasm, or any knowledge of pharmacology of induction and paralytic agents beyond the most rudimentary and cookie cutter approach.
I mean just in terms of patient positioning alone, half the time I would walk in and be like ???????? as some fatty was sprawled semi diagonally across the bed with one leg hanging off and with no pilllows under the head and is s/p fourteen DL attempts and bloody airway without appropriate monitoring of VS the whole time going on, and no LMA anywhere in sight even though the pt is blue
I saw someone die in the ER as an intern that was basically an iatrogenic butchering of this lady's airway by the ED staff and it was very sobering and horrific. She came in 85% on a nonrebreather and maintaining her own airway with a tablet lodged in her throat, and they etomidate/sux'd her. Didn't call Anes/surg till she was dead basically...
Just being honest here
And I like ER medicine and respect ER docs and what they do and their skills and knowledge generally speaking and I do pain full time so I have zero skin in the game. They are good people, but the culture of Emergency medicine as regards airway managment is pretty low brow/EMT style.
And while I am at it, similar situation when someone is bleeding out or septic. Max speed ER resuscitation is about 1/4 the speed of anes resuscitation and has waaaay to much nursing involvement. I will say they can code someone according according to the algorithm at least, which is more than the surgeons or medicine people
ER docs reading this...what I am saying is please just call overhead for help more regularly and earlier. I know u want to "keep your skills" but honestly you will learn a lot more than in just trying to cram tubes in these people's gullets with the same few tricks over and over...even from the most mediocre of anesthesiologists.
And you just might save a life.
I've practiced in every setting and type of facility imaginable. From what I've seen, I'll take the "small community outpatient" anesthesiologist every time. That dude manages more airways in a week or two than that em doc does in a year. And unexpected difficult airways show up at these outpatient facilities all the time. No matter how easy or difficult the airway, it still comes down to basic fundamental airway management. Technique, skills, knowledge, precision, and composure that comes from experience and practice.I'm highly skeptical of a small community anesthesiologist who has been doing almost exclusively outpatient surgery practice over a seasoned EM doc in my major quaternary center with an airway of a older morbidly obese man who had radiation to his airway for OP cancer and decided to take his own life by shooting himself under the jaw. These cases come to my hospital.
It's about the case and the persons experience. Some of that is specialty, but it's not a global thing.
Just as a community shop ED doc who just finished from residency and didn't have much experience is not going to do okay with the above example either.
It's the generalizations that are offensive to both sides.
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I've practiced in every setting and type of facility imaginable. From what I've seen, I'll take the "small community outpatient" anesthesiologist every time. That dude manages more airways in a week or two than that em doc does in a year. And unexpected difficult airways show up at these outpatient facilities all the time. No matter how easy or difficult the airway, it still comes down to basic fundamental airway management. Technique, skills, knowledge, precision, and composure that comes from experience and practice.
I'm highly skeptical of a small community anesthesiologist who has been doing almost exclusively outpatient surgery practice over a seasoned EM doc in my major quaternary center with an airway of a older morbidly obese man who had radiation to his airway for OP cancer and decided to take his own life by shooting himself under the jaw. These cases come to my hospital.
They sure can show everywhere. I didn't mean to say they couldn't. The frequency isn't the same in my experience though.
If you don't live in the vicinity of a center caring for those people, the frequency of it happening is less.
Also, if you primarily do outpatient surgery, you won't have those cases.
Just as an em doc who primarily does wound care center management isn't going to be as great at running a code as someone who is doing it more frequently regardless of the specialty.
I am confident that there are better persons out there at almost everything I do, but I am not the worst. I believe that I could appropriately setup, perform an intubation, and post intubation care better than at least one anesthesiologist in the world on at least one patient scenario.
I see the variety of EM docs and skills. I would never say that they are 100% better than anyone at anything...too much variability.
The idea that someone intubates daily therefore they are the unbeatable airway champion of the world is like saying that because I drive the same road everyday I am better at driving that road in every condition, in every car, and at every speed than everyone else.
I am staggered by the idea that certain people on here believe that 100% of their colleagues are better than 100% of another group at anything.
It's almost comical.
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I am staggered by the idea that certain people on here believe that 100% of their colleagues are better than 100% of another group at anything.
Everyone loses their skills given time if not consistently in practice. I'm in academics and we see some dangerous airways. They are always handled by us with a Resident, and it's not a rare thing when I actually take over the airway. Yet, there are anesthesia attendings who've clearly lost it. I had some of them when I was a resident. Imagine those attendings in the middle of the night with an angioedema patient. It was NOT pretty. I've seen some slick ED attendings, too. But as others have mentioned, the airway is one of our specialties because we just do MANY of them, and definitely NOT always under ideal conditions. E.g. VA codes that occur in the parking lot or their nursing home. Or the crashing, aspirating trauma patient who got rushed up from the trauma bay and is being prepped as we try and get the airway with blood constantly in the view with air bubbles being the only indicator of an airway.
It makes no sense to bash the other specialties. We function in different arenas, but it will be rare to find an ED Attending who can manage an airway as well as we can. Not with so many primary care type problems in the ED.
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Your lack of knowledge of what we do in the OR is very palpable my friend.
I'll leave it at that.
I have no idea of the skill set of a small community ED doc, it is not my specialty. You are generalizing and pretty arrogant. Please run this by a mayo trauma anesthesiologist since you have that group practice all over your sig lmao. Here, Ill help you, start with mike murray.I'm highly skeptical of a small community anesthesiologist who has been doing almost exclusively outpatient surgery practice over a seasoned EM doc in my major quaternary center with an airway of a older morbidly obese man who had radiation to his airway for OP cancer and decided to take his own life by shooting himself under the jaw. These cases come to my hospital.
It's about the case and the persons experience. Some of that is specialty, but it's not a global thing.
Just as a community shop ED doc who just finished from residency and didn't have much experience is not going to do okay with the above example either.
It's the generalizations that are offensive to both sides.
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I have no idea of the skill set of a small community ED doc, it is not my specialty. You are generalizing and pretty arrogant. Please run this by a mayo trauma anesthesiologist since you have that group practice all over your sig lmao. Here, Ill help you, start with mike murray.
Turth of the matter is that I never see an ED attending in the ORs.
We on the other hand... are in the ED all the time for multiple different reasons including AW management.
But to ea. his own.
I love the mayo anesthesiologists.
My point was that not ALL anesthesia docs are better than ALL ED docs.
I love the mayo anesthesiologists.
My mayo colleagues who do only anesthesia pain may find themselves uncomfortable walking into our ED resuscitation room just as I am likely to be quite uncomfortable in their setting.
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Couple things on this one.
1) They wouldln't come to the ED to do any AWs.
2) If they had to, they have 3 years of intubating experience in their training alone.
You're right. They wouldn't come. But they are anesthesiologists. My point was only that there are some whose airway comfort and skills may be less than some ED docs. It's conceivable to you I think. I know there are anesthesiologists who are better at echo than some cardiologists. There are some anesthesiologists that are better than some pulmonologists at bronchoscopy. There are some anesthesiologists who are better at finance than some financial planners