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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. grapp

    grapp Premed 1 2+ Year Member

    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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  3. ranvier

    ranvier I can't anesthetize a rumor. 10+ Year Member

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    I have never heard the term MDA from any ED doc, from any doc in person. Maybe he is married to a CRNA.
     
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  4. nimbus

    nimbus Member 10+ Year Member

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    The first intubation I ever saw as a medical student was an awake blind nasal by a medicine chief resident at Bellevue Hospital. He was slick AF. Bellevue is not a rural hospital.
     
    Last edited: Aug 11, 2017
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  5. TimesNewRoman

    TimesNewRoman 2+ Year Member

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    So that's fair, but there was a whole lot of F the ED earlier in the thread.
     
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  6. TimesNewRoman

    TimesNewRoman 2+ Year Member

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    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?
     
  7. Man o War

    Man o War 2+ Year Member

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    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.
     
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  8. grapp

    grapp Premed 1 2+ Year Member

    Not very doctor like if you ask me, not at all.
     
  9. SnapperRocks

    SnapperRocks ASA Member 2+ Year Member

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    A hospital so remote video laryngoscopes can't even be recruited to live there.

     
  10. nimbus

    nimbus Member 10+ Year Member

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    VLs need amenities too
     
  11. tkim

    tkim 10 cc's cordrazine 10+ Year Member

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    I use Whitacre needles for my LPs, and usually use the same puncture I made with the lido needle, or use the Quincke to make a shallow puncture and finish with the Whitacre. I never measure opening pressures, since a lot of my patients are super fat and lying recumbent obscures any landmarks, if there were any to begin with, so all of them sit upright, making opening pressures meaningless. I like anesthesiologists. Have called for them twice in seven years, and one time they pulled my ass from the fire, and another time I wish I hadn't called. But everyone lived, so, bonus.
     
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  12. G-Man82

    G-Man82 10+ Year Member

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    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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  13. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    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.
     
  14. kjamess

    kjamess 7+ Year Member

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    true story.
     
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  15. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    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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  16. twoliter

    twoliter ASA Member 2+ Year Member

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    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).
     
  17. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    Of course they can. It's probably not even a custom option. They know and don't care.


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  18. psychbender

    psychbender Cynical Member 10+ Year Member

    I'm pretty sure I did OR moonlighting at that hospital. There was a lot of sketchy stuff going on down there.

    Sent from my SM-G930V using Tapatalk
     
  19. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    wow what a nice guy. which one did you give them?
     
  20. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    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.
     
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  21. nimbus

    nimbus Member 10+ Year Member

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    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.
     
    Last edited: Aug 11, 2017
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  22. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    Our spinal needles are tiny though
     
  23. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    Whoa guys, this thread has gone waaaay off track. Can we please get back to making fun of EM docs' inferior airway skills.

    :D:poke::D
     
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  24. ranvier

    ranvier I can't anesthetize a rumor. 10+ Year Member

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    Can get pressures and as much csf as you care to drink from a 25g pencan.
     
  25. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    might take a year... i highly doubt ED docs want to wait for a year
     
  26. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    Hah, IlD is ex-military ... :)
     
  27. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    Everything's stat in the ED!! ;)
     
  28. SouthernSurgeon

    SouthernSurgeon Lifetime Donor Classifieds Approved 7+ Year Member

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    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
     
  29. Timeoutofmind

    Timeoutofmind 2+ Year Member

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    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.
     
  30. Venko

    Venko True to self Lifetime Donor Classifieds Approved 10+ Year Member

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    It not likely that either side can claim to own every scenario.

    I know that I have not intubated under the conditions that many of my flight nurses have and I would look foolish claiming expertise over them in a case of needing to intubated on my belly in the rain in the dark with few tools and meds.

    I have very little experience managing OR airways and would be a fish out of water there.

    I can say though there are many anesthesiologist who have not managed airways like I have. I would still take a teammate in my ED any day.

    I am fortunate to work with amazing anesthesia group and I hope they believe they are fortunate to have an amazing EM group to partner with too.

    It's more dependent upon the specific person, their experience, etc rather than a specialty.

    The resident who wrote the blanket statement was too bold, and I would caution this collection of upstanding anonymous posters from making the same mistake in reverse.

    In my opinion of course.


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  31. filhodeinferno

    filhodeinferno 7+ Year Member

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    Anecdotes are fun. The most violent intubation I've ever seen was by an anesthesia attending during residency. Code on the floor. Came flying in all flustered and acting like dick to everyone. Smashed a few of the teeth right down the oropharynx and then spent a helluva long time fishing them out. Made me cringe because I'd never seen such abuse of an airway, even by EM interns. You know what though, my anecdotes prove nothing, and neither do yours.

    In the end, it's ridiculous to suggest that EM is better than anesthesia at intubating. It's all about the numbers. Anesthesia do more, so they're going to be better. It's as simple as that. EM docs as a whole do a decent job at intubating and saving a lot of people, though, so stop using your anecdotes to suggest that we're all just a bunch of ignorant butchers who are doing more harm to people than good for people by showing up to work.
     
  32. G-Man82

    G-Man82 10+ Year Member

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    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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  33. Venko

    Venko True to self Lifetime Donor Classifieds Approved 10+ Year Member

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    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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  34. Ezekiel2517

    Ezekiel2517 Anesthesiologist 10+ Year Member

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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.
     
  35. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    I think this one has run its course.


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  36. Venko

    Venko True to self Lifetime Donor Classifieds Approved 10+ Year Member

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    Okay.

    You've worked everywhere.

    You believe 100% of anesthesiologists are better than 100% emergency docs at intubation.

    I am humbled by your experience.

    I'm too naive to see anything as all or none. I have been humbled too many times.


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  37. sevoflurane

    sevoflurane Ride 10+ Year Member

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    That's funny... because that was my exact same case about 3 years ago in BFE middle America in a small community hospital.
    Blew out the front of his entire face by pulling the trigger too hard and moving anteriorly--> obese, drunk, full stomach... etc.
    ED docs wanted nothing to do with it and I'm glad I was called up front before any heroics were attempted.

    We are all a team here... but don't dismiss for one nanosecond the fact that we handle all sorts of AWs, it is a major part of our training and our DAILY experience. What... you don't think histories of previous failed intubations don't show up at ASCs? C'mmon man... we deal with ALL comers ALL the time. How about epiglotittis and hereditary angioedema with a full blown out episode... yep.. those show up at the community hospital because I've been there done that. I am at a big center now and I can tell you that the frequency of difficult AWs is about the same.

    On the other hand, I seriously wonder how many ED docs have the skills to do GP, VG, SP, SLN, etc nerve blocks and REALLY manage a soon to be lost AW b4 real $hit hits the fan while at the same time avoiding the 5mg of versed and 300 mg of ketamine for sedation AND still making it look good. But that is part of the point: not only are we the AW experts... we are the sedation to full anesthesia experts. They are all symbiotic.

    We joke around on here about retrograde intubations... but the fact is that there a ton of us out there that know how to do them and have a nice series of them under our belts.

    Again, we are here to take care of patients together, but let's not get overboard on the egos when you are generalizing specialties.

    I love my ED colleagues... they are similar to anesthesia in a lot of ways. So mad props to them. :horns:
     
    Last edited: Aug 12, 2017
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  38. Venko

    Venko True to self Lifetime Donor Classifieds Approved 10+ Year Member

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    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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  39. sevoflurane

    sevoflurane Ride 10+ Year Member

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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.
     
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  40. sevoflurane

    sevoflurane Ride 10+ Year Member

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    Agree with you here... and your statement is true for just about any job in and out of health care.
     
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  41. Venko

    Venko True to self Lifetime Donor Classifieds Approved 10+ Year Member

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    I completely agree...it's rare.

    Thank you for allowing for the possibility though.

    It's common sense.


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  42. Venko

    Venko True to self Lifetime Donor Classifieds Approved 10+ Year Member

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    I agree. It's likely that I know about as much of the OR airways as you know of my EDs airways.

    How would we both do at an airway outside of the OR? Also, what if it's an anesthesiologist who has been working a pain clinic doing injections for 10 years?

    I'm sure there are are some anesthesiologists who can perform an echocardiogram better than some cardiologists right?

    Let's just be real. With so much variability, it's not entirely about specialty, but the individual and the case at hand in the context it is presented.


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    Last edited: Aug 12, 2017
  43. sevoflurane

    sevoflurane Ride 10+ Year Member

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    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.
     
  44. ranvier

    ranvier I can't anesthetize a rumor. 10+ Year Member

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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.
     
  45. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    Sorry, I've been gone for a few hours. Did we decide who can piss further yet??
     
  46. Venko

    Venko True to self Lifetime Donor Classifieds Approved 10+ Year Member

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    I love the mayo anesthesiologists.

    My point was that not ALL anesthesia docs are better than ALL ED docs. 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.

    What generalization did I say that was arrrogant though? Skepticism is not a guarantee...it's being guarded or uncertain. I don't believe my mayo colleagues would be upset about it.

    Arrogant? Maybe I'm arrogant to say that I am better than at least one anesthesiologist in one airway in one scenario. I have one example in mind where the anesthesiologist was fired Over the case that they worked with me (not Mayo but at a county hospital I have worked).

    Wow, I never thought of that as an arrogant statement, but I will ponder the criticism.

    After all, are all of you equally savvy with the airway? Every community outpatient surgery center anesthesiologist is as good at he airway as every other anesthesiologist at all airways?

    By the way, I put my signature on to show that I stand by what I am saying. It's not always perfect, but I don't hide behind the anonymity of the internet. I truly believe what I say and don't say it just to get a rise out of anyone, I say it because I believe it's the best for the patient. In this case, you know my name, where I work and can easily contact me if you have questions etc. Also, when I post things, people can know from where I am coming. The Mayo Clinic world is certainly not always universally applicable, so it's important to me that people know when I say as I have in other posts: we have a great relationship with the trauma surgeons or share a picture of my office space...people know I'm being truthful.

    I am unblinding myself.




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    Last edited: Aug 12, 2017
  47. Venko

    Venko True to self Lifetime Donor Classifieds Approved 10+ Year Member

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    Anesthesia is rare to come to our ED. They are wonderful and I do call them as I am not personally the most savvy ED doc with the airway. I have other expertise so I call my anesthesia colleagues for potentially difficult cases to stand with me. Though it's rare in general for anesthesia to come to our ED.


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    Last edited: Aug 12, 2017
  48. sevoflurane

    sevoflurane Ride 10+ Year Member

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    :thumbup:
     
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  49. sevoflurane

    sevoflurane Ride 10+ Year Member

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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.
     
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  50. Venko

    Venko True to self Lifetime Donor Classifieds Approved 10+ Year Member

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    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 ;)


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  51. sevoflurane

    sevoflurane Ride 10+ Year Member

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    So just so we are clear Venko... ED isn't a real AW specialty until I see one of you do this...




    Just kidding... of course.

    You are always welcome on here and I can tell you that I am VERY greatful that EM has become more proficient at AW management over the last 10 years. If you guys can safely intubate a patient in the ED I would MUCH prefer that as I really don't want to. Mad respect.

    It's all tongue and cheek here browski. Don't take anything personally.
     
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