ER docs and ventriculostomy lines?

[nev]

Will ER physicians be able to place ventriculostomy lines in the future? Isnt there a possibility of having a massive hemorrhage with no neurosurgeon available?

Sorry if my question sounds stupid...

Nev

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[Chronic Student]

At Hermann Hospital in Houston the PA's place ventrics in the unit as a routine procedure and even as a rotating PA student I got to place 2 of them.

I don't see any reason why a doc couldn't do it. I don't mean to sound condescending, in fact just the opposite. Once you learn the procedure it is pretty straightforward.

Just my .02

-Mike

 

[docB]

Will ER physicians be able to place ventriculostomy lines in the future? Isnt there a possibility of having a massive hemorrhage with no neurosurgeon available?

Sorry if my question sounds stupid...

Nev

I don't know of any push to get EPs to do this. I don't know of any requirements to be trained in it nor do I know any EPs who have done them in residency. That doesn't mean it doesn't happen but I don't see this as something we're moving toward. We used to do burr holes for subdurals and epidurals but even that has proven to be of little benefit in the ED setting.

 

[BADMD]

nor do I know any EPs who have done them in residency.

I did some as part of my neurosurgery rotation as an intern. They aren't that hard, however I haven't done one in more than 3.5 years and have no desire to do any ever again. I'd much rather spend my time honing my ultrasound skills. They weren't a formal part of the training program, more of a "while I'm on neurosurgery, I'll do what a neurosurgery intern does..."

I guess in a pinch, where the neurosurgeon says "If you do not do this the patient will die" and I'm 6 hours by air from civilization, then I might give one a shot.

 

[Seaglass]

Trauma surgery is moving towards more of an "Emergent Surgery" model and in some places they are trying to get into doing crani's/bolts.

 

[davbrucas]

I have done 6 of them on a Neuro ICU rotation...about as difficult as a CVL.

 

[Midwest Medic]

I never have placed one, and have no intention of placing one. As long as a trauma center is somewhere near, then I will never have to place one. Also, I do not plan on monitoring ICP in the ED. If I am concerned about it, I look for the other signs of it and I assume that it is high and treat accordingly.

 

[BKN]

Will ER physicians be able to place ventriculostomy lines in the future? Isnt there a possibility of having a massive hemorrhage with no neurosurgeon available?

Sorry if my question sounds stupid...

Nev

I think it's not a question of can we do this as much as should we. The evidence for the benefit of this monitoring and therapeutic maneuver is weak to nonexistent. And the more things we do to make it easier for our consultants, the less they'll come to help us when we need it.

We've always been too ready to add more and more things to our practice because it's easier than motivating others to do their job.

There, rant done, I feel better.

 

[nev]

Thanks for the replies, guys...I did notice that the PAs in neurosurgical facilities could place ventricular lines. I bet an EM physician should because the faster the line is placed, the higher are the chances of survival or preservance of function.

 

[Seaglass]

Thanks for the replies, guys...I did notice that the PAs in neurosurgical facilities could place ventricular lines. I bet an EM physician should because the faster the line is placed, the higher are the chances of survival or preservance of function.

Hmm. I'd like to see the evidence your statement is based on.

 

[nev]

Hmm. I'd like to see the evidence your statement is based on.

Well, thats what my ACLS instructor told us...I thought it sounded right..

 

[Jeff698]

Well, thats what my ACLS instructor told us...I thought it sounded right..

Sigh...

We need an emoticon looking down and shaking his head in resignation.

Take care,
Jeff

 

[nev]

Sigh...

We need an emoticon looking down and shaking his head in resignation.

Take care,
Jeff

Lol..I didnt know he was wrong. Can you educate me on why placing the line ASAP doesnt matter?

 

[BKN]

Lol..I didnt know he was wrong. Can you educate me on why placing the line ASAP doesnt matter?

I was a resident 30+ years ago when all this started. I don't believe there ever has been any controlled study of ICP monitoring and control. I suspect there never will be. The neurosurgeons have bought it, and their reasons are at least fair. But the evidence for it wasn't there the last time I looked..

Cushing's response (hypertension, bradycardia followed by respiratory arrest) occurs with much higher ICPs than 20, which is where the Rx is usually begun. It's not clear at what pressure cell death would occur. Further there is the question of the direction of causality. Does increased ICP cause cell death or does cell death lead to ICP? (probably both).

So Jeff, given Nevs location, were you the ACLS instructor in question?

 

[Jeff698]

Sorry, Nev. My comment was more about the information coming from the ACLS instructor than anything else. I probably wouldn't put much into advice from them on, say, breech deliveries either.

So Jeff, given Nevs location, were you the ACLS instructor in question?

Nope. While I haven't quite let my ACLS instructor lapse, I haven't taught one in a year or so either. For some reason, moonlighting in an ED seems more appealing to me now. I'm not sure why.

BTW, Tyler isn't all that close to us. Oh wait, relative to El Paso I guess everything is close to us.

Take care,
Jeff