Emergency Med Providing General Anesthesia

Discussion in 'Anesthesiology' started by jj337, 01.13.14.

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  1. jj337

    jj337 5+ Year Member

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  3. norwood

    norwood ASA Member 7+ Year Member

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    Just some thoughts:

    1. Who is actually providing the GA? If the ER doc is providing it hands-on, he can't leave the bedside. If it's a nurse doing something more than just assisting a hands-on doc, what anesthesia training has she had? If the doc steps out, how does she know when to call for help? Can she give meds without the doc there if he gets tied up? I'm assuming the ER does not employ a CRNA. But if it's the doc hands-on, how does this affect ER staffing?
    2. What monitoring do they do, i.e., with respect to capnography?
    3. How are they recovering patients afterwards? Is their RN-to-pt staffing suitable for this?
    4. What does the hospital stand to gain by diverting pts who need GA from the OR? It seems to me like it's taking on an awful lot of liability just to please the ER docs.
     
  4. jj337

    jj337 5+ Year Member

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  5. FFP

    FFP Offline Gold Donor 7+ Year Member

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    I think this is highly irregular and a recipe for disaster. The ED docs should not provide general anesthesia, except for minutes (e.g. for reducing shoulder dislocations). If this a habit in you hospital, maybe you should create a dedicated non-OR anesthesia location, staffed by anesthesia when needed.
     
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  6. pgg

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

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    Wow, the usual MO for the ER is to call their GA TIVAs "sedation" wink-wink and sidestep the issue entirely. At least this guy's admitting that it's GA. First step in solving a problem is admitting you have one.

    I wouldn't vote to credential an EM physician to administer general anesthesia any more than I'd vote to credential a neurologist to read pap smears. When we as anesthesiologists sit on these committees, the only answer we can give when asked questions about anesthesia and sedation is one grounded in our own standard of care. We're on these committees BECAUSE of our expertise, not in spite of it. It'd be wrong to waive our standards if they can't be met by another department. We shouldn't endorse this activity.

    The ER's option is to post the case to the OR, or hire someone with appropriate training and provide equipment and space for recovery. If the committee overrules you and goes ahead anyway, at least you have your documented 'nay' vote to wave around when things eventually go badly.
     
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  7. Mman

    Mman Senior Member 10+ Year Member

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    The ASA has guidelines for "delineation of clinical privileges in anesthesiology", search their website under the Standards, Guidelines, and Statements section.

    I think it's a bad idea to try to credential somebody for administering anesthesia that isn't trained in it (didn't complete a residency in it). What they need to stick with is "procedural sedation" and if they need to rescue their sedation with an airway (intubation), then so be it. But that would be a QA event and flagged for review IMHO.

    Also pretty sure ED societies have guidelines suggesting that the person doing the procedure can't be the one doing the sedation.
     
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  8. jj337

    jj337 5+ Year Member

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  9. jj337

    jj337 5+ Year Member

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  10. e30ftw

    e30ftw peace 2+ Year Member

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    so what is this guy actually doing?

    is he inducing, paralyzing, intubating patients for procedures >30 min then extubating in the ED and discharging them home?

    I've never heard of this and it would be completely outside EM scope of practice, not to mention virtually impossible because of the volume of patients that would accumulate during the EP's absence.

    if he's giving an 80mg slug of propofol with the patient on a NC/face mask while titrating "procedural sedation" that is within EM scope of practice.
     
  11. jj337

    jj337 5+ Year Member

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    This is exactly what he is doing. Scary.
     
  12. nimbus

    nimbus Member 10+ Year Member

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    Wow......no s***?!

    Is this a rural hospital with limited medical staff?
     
  13. BobBarker

    BobBarker Member 10+ Year Member

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    Good for him. We let nurses do anesthesia every day so why not let another physician.
     
  14. jj337

    jj337 5+ Year Member

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  15. IlDestriero

    IlDestriero Ether Man 7+ Year Member

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    Wow.
    No words.
    Don't allow this malpractice to continue. If you have an exclusive contract, the hospital is violating it by allowing this. That's obviously anesthesia, not procedural sedation. That's another possible angle of attack for you. If you're at a place that would want this to happen, you might need to rethink why you're there.
    Make your General Anesthesia credentials conditional on being board certified or board eligible in anesthesia, or the CRNA board. Problem solved. Every place I worked required this for credentialing and it is checked with each renewal.
     
  16. Guy Caballero

    Guy Caballero 2+ Year Member

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    Are you all not aware that Emergency Medicine docs have no limitations in what they are experts in? If you doubt this statement, just ask them.
     
  17. jj337

    jj337 5+ Year Member

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  18. Mman

    Mman Senior Member 10+ Year Member

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    Does he also do appendectomies in the ED while he's got them asleep? I mean if he can do the anesthesia, why not do the surgery as well.
     
  19. Hamhock

    Hamhock 7+ Year Member

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    I have never heard of an EM doc intentionally inducing a patient, placing an endotracheal tube, keeping the patient under general anesthesia during a procedure performed by the ED doc or another doc, and then extubating the patient and waiting for recovery before discharge. Please share more if you are able.

    This is far outside the standard of care.

    Actually, I can't imagine -- even in the most academic of EDs (that is, EDs that can have an ED doc waste at least an hour) -- of any ED that could "afford" to do this. And I can't imagine any Chair allowing such action.

    However, I will say:
    -EM docs induce GA (while calling it wink-wink moderate sedation) all of the time; and I think transient GA is perfectly fine...and I bet most honest posters here agree
    -cases that call for GA or regional anesthesia occur in the ED all of the time; some of us usually get away with regional anesthesia (single shots) for ortho, others use prolonged "moderate/deep" sedation; more than a few of us have requested help from anesthesiology for these cases, but the "consultants" are not interested
    -be very careful what you ask for. Be careful how much you want to prevent ED docs from practicing general anesthesia, as you may quickly find out first-hand how often deep sedation and transient general anesthesia is required in the ED
    -I was originally trained in EM and I openly use the wink-wink method; but I know there is a better way, but anesthesia won't do it and I know they will object if I do it (hel!, review some of the angry posts on this forum about EM docs doing single shot regional anesthesia!) -- sometimes the risks of inferior anesthesia outweigh the risks of delaying procedures (dislocated hips come to mind -- try getting an anesthesiologist to come in a 2:30am for that!)

    HH

    {{Emergency Medicine docs have no limitations in what they are experts in? If you doubt this statement, just ask them}} -- these attacks are clearly nonsense (yes, maybe there are some crazy EM docs, just like in every specialty) and certainly discourage honest and informative discussion...childish humor at best.

    HH
     
  20. e30ftw

    e30ftw peace 2+ Year Member

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    yawn..

    Sorry OP works in this environment. I have never heard of such a thing and it is far outside the norm in Emergency Medicine. OP should have no problem stopping this practice at your hospital.

    Hopefully you will have positive interactions with EM residency trained physicians in the future and foster an atmosphere of mutual respect for our respective specialties.

    We have great working relationship with anesthesia at my institution and I use what I learned on anesthesia every day in the department.
     
  21. Southpaw

    Southpaw ASA Member 10+ Year Member

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    HH,

    Most anesthesiologists aren't interested in performing anesthesia in the ED when 'consulted' because we feel it safer to do the case in an operating room. You may say I'm 'unavailable', but were I available to come down to your ED and do the case, I'd be just as available to do the case in the OR. I was rarely called by the ED while in residency, and haven't been called at all in my first year of private practice, but if I am called I'd be more than happy to help out.

    Also, when I'm on call I'm in-house for >24 hrs straight. Same for my partners. That means my hospital has anesthesiology (we are an MD-only group) coverage 24/7/365. You got a dislocated hip at 2:30am that needs fixin'? Call me up, I'm in the hospital already and ready to do it. While you may believe my situation to be abnormal, I think 24/7/365 anesthesiology coverage is pretty standard for any hospital of reasonable size. You'll hear BLADEMDA gripe about it from time to time, claiming it's why we're not a 'lifestyle' specialty.

    I got the impression from your post that much of what you do and why you do it, with regards do performing GA in the ED, was due to lack of availability from an anesthesiologist. I can only say that I think that's a shame. But if you want to do some regional blocks and perform GA down in your ED, fine by me, just never let me see you complain about EDs that are staffed by non-boarded EM docs, or FM docs, or any other specialty. And never let me see you write that you think you're 'better trained' than they are, or do the job better than they do, as most EM docs believe. And don't say a word to me if mid-career I decide to come down to your ED and practice EM because I want to, without doing another residency. Better believe I'll call a spade a spade. Forgot who said it, but recently read a good quote basically saying that every doc thinks they can deliver a baby and do an anesthetic.

    As for the specific situation that jj337 posted about, I think what the ED doc is doing is absolutely stupid and blatant malpractice. He may get away with it most of the time, maybe even the very large majority of the time, but you better believe there will be some bad, avoidable events that occur due to what he's doing.
     
    Last edited: 01.14.14
  22. nimbus

    nimbus Member 10+ Year Member

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    Question for OP. Does the ED doc keep an anesthesia machine down there or is he running TIVAs?
     
  23. 2ndyear

    2ndyear Senior Member 10+ Year Member

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    I know what most administrators are thinking: "Why not just get anesthesia to do the cases in the ED then?". Perfectly reasonable right.... Seriously though, if the OR is that full then I'd start there. If it's a physical space issue that's harder to deal with. Staffing issues should be easier. I'd also direct Risk Management to have a frank discussion with the ED doc who wants to do this. Clearly it's outside of the standard of care. Perhaps his malpractice carrier should provide a statement that providing full GA with intubation is covered by his policy.
     
  24. BobBarker

    BobBarker Member 10+ Year Member

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    He probably feels this is acceptable because most anesthesiologists could quit work today and find a rural ED willing to pay them between $150 and $200 an hour to staff their ED solo.
     
  25. jwk

    jwk CAA, ASA-PAC Contributor 10+ Year Member

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    Nobody has mentioned The Joint Commission yet, but I can imagine that this practice runs afoul of numerous Joint Commission standards.
     
  26. jj337

    jj337 5+ Year Member

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  27. jj337

    jj337 5+ Year Member

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  28. jwk

    jwk CAA, ASA-PAC Contributor 10+ Year Member

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    This is wrong on so many different levels. Among other things...

    I can't imagine the insurance companies will pay for general anesthesia in these cases. If they're being coded as "sedation" then that's fraud, and insurance companies/CMS don't reimburse for GA unless provided by an MD, CRNA, or AA that is not otherwise involved in the procedure.

    Why would you need GA to "suture up a hand or similar procedures"? How often does this occur?

    This is pretty classic tail wagging the dog kind of stuff - and a disaster waiting to happen. Your medical staff bylaws should have strict prohibitions on this kind of thing happening. Sedation is one thing, but GA is and should be strictly the purview of the anesthesia department. Oral surgeons have a significant amount of exposure to GA during residency and do GA in their offices - far more training than an ER doc would have in anesthesia - but they can't come to the hospital and do it.
     
  29. dotcb

    dotcb --------- 10+ Year Member

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    I'm an emergency physician 7 years into my career. Providing procedural sedation that includes intubating a patient and extubating them - this is way outside the norm of Emergency Medicine practice. I've never seen this, and I don't think most of us would want to do it.

    I routinely provide procedural sedation with agents such as propofol, ketamine, barbiturates, etomidate, etc. safely with airway backup, monitoring, and capnography. I and my colleagues in my group do this safely and have data to support it. The key is to know when your skill set has been exceeded, and this comes with experience.

    Our field overlaps with many others, but we're not trying to take work from anesthesia. The anesthesiologists at my center have plenty to do, and we have a collegial relationship. We're able to provide safe, timely care to the emergency department patients who need what we're able to provide.
     
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  30. CodeBlu

    CodeBlu Van Wilder Lifetime Donor 5+ Year Member

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    Maybe I've been exposed to bad practice... But, usually when someone presents to the ED, GCS <8 or can't protect their airway the EM doc induces them, gives some roc or sux and then tubes them... right? I've definitely seen an induction/intubation and then a propofol TIVA running on someone in the ED for at least a few hours sometimes (bed issue, ICU backlogged etc etc). And, there most certainly isn't 1 on 1 nursing care. They're on a monitor of course.

    I mean I'm a med student and I've done more time in anesthesia than is probably healthy for someone applying to it... but I am still not comfortable inducing someone without the attending within 6 feet of me. It's not that I can't do it... it's that I'm scared out of my mind of what COULD go wrong.
     
  31. e30ftw

    e30ftw peace 2+ Year Member

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    that's just RSI and appropriate sedation ie: critical care. being on a vent in the ICU or ED for respiratory failure is not the same as TIVA.

    The OP is talking about an ED doc intubating an otherwise healthy patient for a procedure, giving propofol during the procedure, then extubating in the ED and dc'ing home.

    I have no idea why the hell anyone would want to do that in the first place other than billing for anesthesia (which seems quite foolish and unnecessary for an EP) but that seems to be the issue.

    personally I've never seen an anesthesiologist or CRNA in our ED for airway/sedation and I really don't think they have any interest in overseeing our intubations or babysitting septic shock patients while they sit on the vent. Only time I have ever seen anesthesia down there was for a blood patch consult.
     
  32. Hamhock

    Hamhock 7+ Year Member

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    Please read my post above about how I feel the practice of the OP's "friend" in the ED is well beyond the traditional scope of emergency medicine and certainly well beyond the scope of "typical" practice in emergency medicine before responding to this post.

    However, I am starting to wonder if what is being discussed is really "that far" out there.

    Do the anesthesiologists here feel CCM docs should not be intubating and then extubating for diagnostic TEE?

    And if you have no problem with that, please explain how that is different than an EM doc (who likely has more airway and sedation/analgesia experience) intubating and extubating for an urgent or emergent therapeutic procedure?

    HH
     
  33. jwk

    jwk CAA, ASA-PAC Contributor 10+ Year Member

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    If they're giving an anesthetic AND doing the TEE, then yes, that's a problem.
     
  34. Ronin2258

    Ronin2258 Prometheus Unbound 5+ Year Member

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    So basically turning the ED into an outpatient urgent surgery center.

    I'm glad I'm not the only one terrified about this.

    Does the MD stay with the patient at all times when under and until they recovered? Do they even know the discharge criteria from an outpatient center? One of my attendings described what we do very succinctly: we perform controlled poisoning of the patient, and are able to recover them from it.

    Part of my training is to teach ED first years (they are with me for an entire day of cases,) and I can honestly say I have spooked them more than once because of what we can do with the airway. I hammer into them that nothing we or they do is benign, and they have to take into consideration that things can go wrong quickly.

    This sounds like a recipe in disaster, with a side order of malpractice for being out of the scope of practice.

    There is a reason there is a credentialed provider at the head of the table while the other one is working: to keep bad things in check, and to stop them as they evolve.
     
  35. nimbus

    nimbus Member 10+ Year Member

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    We (anesthesiologists) do this all the time. What's the problem?

    Btw...when we provide anesthesia for cardiologists doing TEE, we generally don't intubate. TEE probe itself makes a nice oral airway.
     
    Last edited: 01.16.14
  36. Hamhock

    Hamhock 7+ Year Member

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    And if it is for the cardiologist to do the TEE?

    HH

    and then a response to nimbus' point would also be informative

    (by the way: I am not trying to be argumentative here. I am honestly interested in viewpoints. As an EM doc I was often asked to intubate and provide sedation/analgesia for procedures such as crashing UGIBleeeds requiring EGD. I didn't extubate these patient's, but there were plenty of ICU boarders who we extubated after prolonged ED stays and were able to admit to the floor. I have extubated a previous EtOHer and discharged from the ED. As CCM we often intubate and extubate for procedures such as TEE in the ICU. And occasionally we are called on to provide resuscitation and general anesthesia for traditional "OR cases"; a recent bedside laparotomy comes to mind.)

    HH
     
  37. FFP

    FFP Offline Gold Donor 7+ Year Member

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    I actually prefer to call general anesthesia controlled coma. That's exactly how I describe it to my more inquisitive patients.
     

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