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

[Venko]

Folks...

I will check back in a day or two, but please know this:

The EM resident was too broad in their speech in my opinion.

As a generality, I believe airways are the focus of study of anesthesiology.

I continue to believe (despite how arrogant it may be) that there are some select ED docs who can under select circumstances perform better than select anesthesiologists.

I am not the airway king of emergency medicine and am fortunate to work with great team of surgeons and anesthesiologists who back me up in those times of need.

You all are great at what you do. Don't let the misguided ED resident make you feel less than valued. Please don't undervalue others either in return.

I love that I'm not an anesthesiologist and that you all love that you are. The patients get the best of all of us this way.


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[deleted547339]

Where the hell are the mods???

 

[MoMoGesiologist]

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

Oh man that was the smoothest easiest AFOI I've ever seen. All he did was a transtracheal block and spray the VCs during the AFOI? No glycco, nebulized lidocaine plus multiple lidocaine swish and spits and lido sprays, no sedatives and infusions!? Is this really how people are doing these out there? So many ways of doing anesthesia I've never seen or experienced or can even think or dream of. What a world what a world...

 

[pgg]

Where the hell are the mods???

Use the report button if you feel strongly that a post or a thread needs action.

 

[B-Bone]

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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Relatively recent Mayo anesthesia grad here (actually we were interns together!). At least during my tenure, CA-2 carrying code pager went to every level one trauma activation in the ED. Rarely (but definitely not never) intervened, but always present.

 

[Venko]

Relatively recent Mayo anesthesia grad here (actually we were interns together!). At least during my tenure, CA-2 carrying code pager went to every level one trauma activation in the ED. Rarely (but definitely not never) intervened, but always present.

Yup. All level reds. (We got rid of level 1 and 2 designations a few years ago).

Of the percent of intubations in our ED, anesthesia attends...rarely.


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[pjl]

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 know exactly who that one anesthesiologist is.

Guys, give the ED guy a break, he just is arguing that in some situations he may be better suited. Just like when a patient needed a trach in my ED, the two ED boarded people backed up and let anesthesia handle it...Generally ED is all over that, but not every time, everywhere.


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[Arch Guillotti]

Where the hell are the mods???

Usually threads like this die out after everyone has beaten the subject to a pulp. Use the "REPORT POST" function if something bothers you terribly.

 

[anbuitachi]

I think he's just saying its not 100%. There may be a ED doctor somewhere who is better than an anesthesiologist somewhere. I dont disagree with that. Everyone has different backgrounds. Even in my department in one institution we have plenty of anesthesiology attendings whos done 2 residencys, or multiple fellowships, or switched over from another field (ortho, surgery, urology, medicine, etc). I can imagine our residents who were recently senior urology residents might put in foleys better than some urology attendings (who probably haven't put one in in a while). The same goes for ED, it depends on their environment/background/training.

 

[bashwell]

Obviously the best at airway management is either the CRNA or the ED doctor who is not an MD.

 

[AdmiralChz]

Obviously the best at airway management is either the CRNA or the ED doctor who is not an MD.

Hah (in a scared laugh sort of way), I'd probably also recommend this solid "doctor" as well, Dr. Love:

Florida Teen Arrested for Posing as a Licensed Doctor: Authorities

 

[Psai]

Obviously the best at airway management is either the CRNA or the ED doctor who is not an MD.

It's really sad how quickly the term "board certification" became meaningless with nurses giving them out like little league trophies while medical boards are adding more and more expensive nonsense every year.

 

[IlDestriero]

Obviously the best at airway management is either the CRNA or the ED doctor who is not an MD.

You know her DNP research project was good because it is going to be published in the Journal of Emergency Nursing!
I definitely want to read it.



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Il Destriero

 

[IlDestriero]

Oooh, I found it!
Cardiac or Anxiety: A Literature Review of the Young Adult Patient Who Presents to the Emergency Department With Chest Pain 108 Kathryn Lynn Miley, DNP
It took 3 years to make it to print even though it was "accepted" in 2013 and was a literature review that we would give an intern or 4th year med student to do, if they had the time.
I'm sure her patients sleep better knowing she's an expert in the very dangerous young adult chest pain!
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Il Destriero

 

[bashwell]

As far as learning some actual airway management, the more senior residents and attendings might already know all this stuff so apologies if it shouldn't be here, but I really like Keith Greenland's videos (he's an anesthesiologist/anaesthetist in Australia).

 

[Arch Guillotti]

Oooh, I found it!
Cardiac or Anxiety: A Literature Review of the Young Adult Patient Who Presents to the Emergency Department With Chest Pain 108 Kathryn Lynn Miley, DNP
It took 3 years to make it to print even though it was "accepted" in 2013 and was a literature review that we would give an intern or 4th year med student to do, if they had the time.
I'm sure her patients sleep better knowing she's an expert in the very dangerous young adult chest pain!
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Il Destriero

They don't do a dissertation or anything really academic. Every one I have ever seen has been a literature review or some other nonsense.

 

[Arch Guillotti]

Obviously the best at airway management is either the CRNA or the ED doctor who is not an MD.

I admit I should have probably gone to medical school

This pretty much says it all. Just a wannabe.

 

[Psai]

They don't do a dissertation or anything really academic. Every one I have ever seen has been a literature review or some other nonsense.

Excuse you, she's a board certified emergency medicine doctor and as such is better than trauma difficult airway management than everyone posting here except venko and groove. Do you deny that at least one np is better than some anesthesiol hahaha I can't finish it.

 

[deleted697535]

Recently ran across an interesting conversation on reddit, started off by this quote from a third year EM resident:

"Almost any trauma that requires intubation by definition should be considered a difficult airway and require anticipation of a difficult airway. Similarly with medical resuscitations in the ED. These are precisely the patients that should be intubated by an emergency physician or intensivist, as they are the most competent airway team member in the room in those situations, not the anesthesiologist who intubates under ideal conditions."

ba ha ha ha ha, that is beyond funny....

 

[deleted697535]

OB has crash intubations just as gnarly as trauma.

Right on mate. Would this emerg resident take on a 300 pound category 1 c-section at 3am? Solo?

 

[Groove]

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.

LOL. I love these anecdotal posts that somehow imply this vast evidence of "crashing airway" or "trauma airway" superiority in anesthesia vs EM. Like everyone else is aware of just how much we suck....except us and just don't want to tell us so that they won't hurt our feelings. Like we're the fat kid on the playground with our parachute pants split open exposing our soiled briefs but nobody has the heart to come tell us. (Ok, I'm showing my age here..) I'm just saying give some of us an effing break. If your mad skills are so superior then where is your data supporting this intubation superiority in the ED? Studies like this one just don't show ANY STATISTICAL DIFFERENCE between an emergency medicine attending and an anesthesiology attending with intubation success rates. Given...there is a dearth of studies out there, but the two that I managed to find show....nothing, nada, zilch.

So, if you want to run around yapping about how superior you are at intubating my patients "and everybody knows it", then generate some studies so that you can do more than dog paddle in this evidence based swimming pool we live in these days. Generate some lit on anesthesia attending intubation success vs CRNA success while you're at it. (Why aren't there more of these?) I can't imagine the hell storm that would generate but still...

I mean, do you have anything other than anecdotal "I was there on a murky night at 12am when a roided up ED attending with a cowboy hat on chewing on a toothpick single handedly perforated this guys esophagus and transected his spinal column with one DL attempt!" Horrors!

CONCLUSIONS

In a single, urban ED, we found that emergency physicians and EM residents under their supervision can safely manage the airways of trauma victims withsuccess and failure rates similar to those of anesthesiologists. It may be safe for trauma centers to utilize emergency physicians as the primary managers of the airway, with anesthesiologists available for difficult cases. Resistance to trauma airway management by EM is not supported by current data.



Oh, and thanks to whomever posted the Keith Greenland link...very educational. I like those...

Ok, I'll stop.

 

[nimbus]

with anesthesiologists available for difficult cases. .

I don't understand the point of this. The original Reddit post says EM docs are superior. What could an anesthesiologist offer since we only intubate under ideal conditions? Wouldn't the EM doc be better for difficult cases? But you can call us for the ideal ones.

 

[Southpaw]

Ok, I'll stop.

Please do. I was sympathetic to your desire for MD only care and supported your feelings. I was sympathetic to your initial posting, and stated as such saying we should all be on the same team.

Now, you've gone entirely overboard, and appear to be shaming us with your desire for inferiority studies (CRNAs do the same, maybe PAs and NPs in the ED will pick up that baton before long). Please, take your ball and go home. You win, or whatever. Argument over. The only people who continue to care I imagine, are medical students, young residents, and bitter attendings. I'm surprised and disappointed this is the direction you've decided upon. I've always respected your posting in the ED forum (which I read often but rarely post in as I'm certainly a fish outta water there).

 

[Southpaw]

I don't understand the point of this. The original Reddit post says EM docs are superior. What could an anesthesiologist offer since we only intubate under ideal conditions? Wouldn't the EM doc be better for difficult cases? But you can call us for the ideal ones.

It's a pointless study, and the conclusion was made before the study even began. Consider why one would even decide to undertake such a study.


Edit - just read the conclusions that @Groove posted as I can't access the study. I'm so glad that ED docs concluded they're just fine w airway management provided there are anesthesiologists around to help when needed. Real ground breaking, shocking info there.

 

[Groove]

It's a pointless study, and the conclusion was made before the study even began. Consider why one would even decide to undertake such a study.


Edit - just read the conclusions that @Groove posted as I can't access the study. I'm so glad that ED docs concluded they're just fine w airway management provided there are anesthesiologists around to help when needed. Real ground breaking, shocking info there.

Relax, most of my posts are half serious. I have nothing but respect for you guys.

I just chuckle at some of these anecdotal posts where the ED doc sounds like a character out of South Park.

 

[AdmiralChz]

Seriously, @Groove this thread was 4 days old and on the way to the depths of the forums when you revived it. We get it, we hurt your feelings. When you go on the attack on us with the CRNA stuff multiple times in a thread you aren't going to win many friends around here.

This was a thread about a ridiculous, almost funny reddit post. People respond to such things with anecdotal stories, because they are also ridiculous and funny and give something to talk about - people do this in person all the time but unli

Have I witnessed an instance of an anesthesiology attending in residency have a total meltdown and be unable to handle a huge emergency come crashing through the OR doors? Of course, residency is 3 years long.
Have I seen some trauma surgeons lose their cool in similarly bad situations out of their control? You bet.
Have I witnessed some really inappropriate airway management by ER residents and attendings during training? Of course. Have I seen some melt down and be unable to handle a critical stroke patient just before going to the IR suite? Yep.

Unlike you, we aren't extrapolating these (often humorous, but sometimes scary) anecdotal stories to an entire specialty. On the whole, anesthesiologists are excellent at OR emergencies, trauma surgeons are great at dealing with life-threatening penetrating injuries and ER physicians are solid at resuscitation and triage.

So, my point is, calm down and relax. Coming back after several days ready for another fight and backing yourself up with the non-inferiority studies (with a conclusion that having consultant specialists around is a good thing!) - it reeks of the behavior more expected of a militant physician extender in your ER or ICU. Also, quit complaining about other specialties - a quick visit to your own subspecialty forum finds threads in the top half of the first page lamenting about treatment from surgeons and how they suck, how internal medicine sucks, how anesthesiologists suck and how even your own scribes suck! Enough with the MD on MD violence, just go away.

 

[booohooo]

Personal anecdote time!

Last weekend I was on call at a large academic hospital in a major US city as a lowly CA2.

Airway pager goes off, location: Emergency Room. I barely leave the call room when airway pager goes off again, this time it's calling for the surgical airway team. I'm like F******

I get down there, it doesn't look good. bloody LMAs, ETTs, DLs, glidescope. ED attending is up top bagging the patient. I identify myself and other ED attending near top of bed tells me it's impossible, LMA doesn't fit well, can't get a view with DL or glidescope, we must get a a surgical airway. Surgery wasn't down there yet so I insisted I take a look and intubated the guy on 1st attempt. Grade II view with some external manipulation.

feltgoodman.jpg

 

[IlDestriero]

Boom! Good job. Hopefully he wasn't down long.


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Il Destriero

 

[Urzuz]

Personal anecdote time!

Last weekend I was on call at a large academic hospital in a major US city as a lowly CA2.

Airway pager goes off, location: Emergency Room. I barely leave the call room when airway pager goes off again, this time it's calling for the surgical airway team. I'm like F******

I get down there, it doesn't look good. bloody LMAs, ETTs, DLs, glidescope. ED attending is up top bagging the patient. I identify myself and other ED attending near top of bed tells me it's impossible, LMA doesn't fit well, can't get a view with DL or glidescope, we must get a a surgical airway. Surgery wasn't down there yet so I insisted I take a look and intubated the guy on 1st attempt. Grade II view with some external manipulation.

feltgoodman.jpg

I'm calling BS on this one. Evidence has proven that ED docs are not inferior to anesthesiologists when it comes to airway management.

 

[Psai]

Personal anecdote time!

Last weekend I was on call at a large academic hospital in a major US city as a lowly CA2.

Airway pager goes off, location: Emergency Room. I barely leave the call room when airway pager goes off again, this time it's calling for the surgical airway team. I'm like F******

I get down there, it doesn't look good. bloody LMAs, ETTs, DLs, glidescope. ED attending is up top bagging the patient. I identify myself and other ED attending near top of bed tells me it's impossible, LMA doesn't fit well, can't get a view with DL or glidescope, we must get a a surgical airway. Surgery wasn't down there yet so I insisted I take a look and intubated the guy on 1st attempt. Grade II view with some external manipulation.

feltgoodman.jpg

Where is your double blinded randomized inferiority trial? How can you be sure that you're statistically significant to the ed attending?

 

[plick]

"He who knows best knows how little he knows." - Thomas Jefferson

Overreach by a PGY-3, but it's not uncommon to see some arrogance/over confidence in new CA-2s and even some CA-3s - I know many of us can think of a time when we were totally humbled with an unexpectedly terrible situation. Maybe this ER resident hasn't had that angioedema case yet, or even the bloody mess after a bad wreck with a poorly-sealing King tube in place. He will get humbled eventually.

I'm in EM and boy was I glad when anesthesia helped get the tube when I couldn't during my PGY2 ICU rotation; patient was SVC syndrome marshmallow man who pulled out his tube. The attending intensivist also couldn't get the tube. Granted, the anesthesiologist attending told me afterwards that was the hardest tube ever in his life.

Point is just be glad when there's other specialists that can be your backup. There's no need to minimize others and stroke your own ego.

Interestingly, hardest tube of my PGY3 was an anaphylaxis with airway edema that I had no choice but to cric after multiple failed tube attempts. Coincidentally I didn't have any anesthesiology backup at that time.


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[Laryngophed]

The most important thing I've taken away from this ****show is that we are all physicians and should be much more collegial and less "those damn x specialists." Another doc calls me for help and I think it is stupid? Guess what, I'll show up and do it even if I curse under my breath as I roll out of the call room bed. Because someone else who bears the same letters after their name said "I'm not the best person to handle this, could you please come help me and my patient." Because that's what is right.

All the while we are fighting with one another and watching our profession and scopes of practice get eroded away by our laziness, greed, or infighting.

But what do I know? I'm just a stupid resident who hasn't been out in the "real" world before.

 

[booohooo]

Where is your double blinded randomized inferiority trial? How can you be sure that you're statistically significant to the ed attending?

I don't have a a randomized control trial to document this lol. I was sharing a single recent personal anecdote.

 

[HooliganSnail]

I'm more likely to believe more reputable sources that say the earth is flat.

If ER residents were so great they would have left me alone instead of forcing the anesthesia team to attend trauma codes. We always stood back and let them try the airway, though occasionally they didn't even want to and left it to us. I trained at an institution with a top rated EM program and they didn't take us for granted. More often they were battling trauma surgery residents for turf and management decisions.

Let me know when EM residents cover codes and manage airways solo throughout the hospital. Lots of f'ed up situations with patients who nobody knows nothing about, nurses running around aimlessly like the apocalypse was coming, medicine residents pulling up EMR/labs, and patients dying while in weird locations and lying in weird positions with literal diarrhea spewing out the mouth and chest compressions going on.

I am an ER resident, and I cover codes and airways solo throughout the hospital. Our residents take rotating ICU call, and we are the crash team for the hospital when we are on.

We are also a small community hospital, and I haven't seen an anesthesiologist outside the OR in 3 years.

 

[AdmiralChz]

I am an ER resident, and I cover codes and airways solo throughout the hospital. Our residents take rotating ICU call, and we are the crash team for the hospital when we are on.

We are also a small community hospital, and I haven't seen an anesthesiologist outside the OR in 3 years.

Dude, this thread was just about dead and you brought it back. Why, so you could provide a weak personal anecdote?

 

[Psai]

We should go to the pulm forums and tell them that we are better than them at bronchs. "But we do it in emergent situations you only do it in controlled situations whaa"

 

[HooliganSnail]

Dude, this thread was just about dead and you brought it back. Why, so you could provide a weak personal anecdote?

You have posted several times nagging others about "reviving this dead thread". A bit odd. It was created less than a month ago. Also, if it's so dead, why are you still reading it?

The person I responded to was like "Let me know when ER docs can run codes on the floor, because I totally bail them out....blah blah blah." And I'm like.....ok, I'm letting you know. This is a fairly common practice.