# Freestanding ED physicians sued after suspected loss of airway

#### FFP

##### Spending my time
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What are your thoughts about how they went about this intubation? With impending airway comprise stated with AMS and progressive swelling, no time for an awake fiber optic. I wonder if they had a fiber optic in hand at these facilities. Induction of etomidate/sux/midaz seems reasonable. I’m kinda surprised paramedic got it after 4th try with glidescope over the EM doc but who knows. I wonder what they tried to sedate the patient with as it doesn’t state in the article. Do they even have stuff like propofol drips, fentanyl drips etc? Should they even have privy to that type of sedation? This is not in their usual scope of care I believe? This doesn’t look good for freestanding EDs for true emergencies like this.
Worst induction ever with a possible neck hematoma. World class stupid. This was the classic case of a ketamine or ketadex induction, to buy time while navigating an unknown anatomy. This is the patient one does not paralyze until the last minute, when one sees the glottis and is ready to intubate. They were very lucky they got the tube in.

Also, they should have opened up the stitches first.

The value of a CXR is as a third-party record of an ETT-in-place at a given time.

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#### Groove

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15+ Year Member
EM doc here...interesting case, tragic. So, the first thing I find odd is that there are 2 docs that seem to be described as equally involved in this pt's care. Most FSEDs, that I've seen at least, have one clinical doc on shift so this must be either a really busy FSED, right around shift change? or perhaps the "EM trained" doc was the owner and just happened to be there? I can't tell. Anyway, if the primary physician was the FM doc and he didn't have all the additional requisite training and experience dealing with these types of situations, then that might explain things. I find it very odd that the "EM trained" (ABEM?..doesn't say) failed to intubate (Or was it the FM doc?), yet the paramedic successfully intubated. That really just..never happens in my experience. Not to slight medics, some of which can be skilled with endotracheal intubation in the field, but I've never seen a medic take over an airway in real world practice because an EP failed to intubate. Most of them here use Kings or combitubes. In fact, most ABEM docs are going to be trained to cric as the ultimate back up and if they haven't done one in a live pt, they should have done several on cadavers and simulations as part of their training. An EM trained doc is going to be much more aggressive about performing a cric, barring that there weren't anatomical/post surgical issues that prevented it from being done. Usually they have already thought about it in advance and mentally made the decision that it's a viable surgical option.

Also, what kind of airway equipment was readily available at the FSED? Theoretically, it should mimic most ED's, in which case: LMAs, bougies, bronch, OPAs, NPAs, blades, fiberoptic laryngoscopes, cric kit, etc..

As far as the case... Yikes. I would imagine zooming in on her neck and the hairs standing up on the back of my neck. Danger Will Robinson! Danger! The first question I have...was she truly decompensating where intubation was absolutely indicated prior to transport? Anyone with common sense would have to know this has a very high probability of turning South very quickly. Therefore, a reasonable EP would want all of their backup devices available. This one screams awake FOI. I can't rationalize why someone would paralyze this patient and use standard RSI. It also would be a good idea to ask the medic for a combitube or King Laryngeal tube to have on hand for a worst case scenario. Better to do awake FOI, take a peek and paralyze at the cords. However, if she's breathing on her own and not in extremis and there wasn't a sudden clinical change, I'd have been very tempted to fly her to the closest tertiary care center where her surgeon has hospital privileges without touching that neck. Really weird that someone like this chose to present to an FSED of all places?

Anyway, I'm surmising that they might have been short a few backup airway devices.

The CXR as standard of care? Eh..I guess. Yes, we probably order a ton more of these in the ED than you guys do in the OR after intubation. It is rather routine to get a confirmatory CXR in the ED. Do we really need it to know we're in the right place? Not really, but it's just how most of us were trained. The majority of the time, I'm looking to see if I need to pull the tube back and I want to examine the chest and lungs for any other valuable/relevant information that would influence my care of the pt. It's not simply to measure ETT to carina. Personally, I intubate just a tad deep because they whip the pt off to CT or elsewhere and I'm paranoid of the tube getting dislodged. I wouldn't think to transfer a pt without getting one after intubation, but that's me. I think he was giving roc to prolong the paralysis. ED RNs are not the best at sedating patients quickly and correctly titrating for an accurate RASS, etc.. so many times we'll give a longer acting paralytic to keep them still while we're running the other tests for fear they'll wake up and grab the tube. Roc just happens to be the 2nd most readily available paralytic in most EDs.

It sounds like the pt wasn't sedated well enough post intubation (common in real world) and they forgot to push more paralytics to keep them still (important for transport). No confirmation CXR...I know this is debated on this thread but I'd have to argue from EM perspective, this is very common and probably standard of care. I'd honestly have to fault them for not performing one. Failure to identify tube dislodgment and to correct it in a timely manner proved fatal.

Easy to nit pick these types of cases, but it's always important to keep in mind that it could happen to anyone. Thanks for sharing!

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#### Arch Guillotti

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EM doc here...interesting case, tragic. So, the first thing I find odd is that there are 2 docs that seem to be described as equally involved in this pt's care. Most FSEDs, that I've seen at least, have one clinical doc on shift so this must be either a really busy FSED, right around shift change? or perhaps the "EM trained" doc was the owner and just happened to be there? I can't tell. Anyway, if the primary physician was the FM doc and he didn't have all the additional requisite training and experience dealing with these types of situations, then that might explain things. I find it very odd that the "EM trained" (ABEM?..doesn't say) failed to intubate (Or was it the FM doc?), yet the paramedic successfully intubated. That really just..never happens in my experience. Not to slight medics, some of which can be skilled with endotracheal intubation in the field, but I've never seen a medic take over an airway in real world practice because an EP failed to intubate. Most of them here use Kings or combitubes. In fact, most ABEM docs are going to be trained to cric as the ultimate back up and if they haven't done one in a live pt, they should have done several on cadavers and simulations as part of their training. An EM trained doc is going to be much more aggressive about performing a cric, barring that there weren't anatomical/post surgical issues that prevented it from being done. Usually they have already thought about it in advance and mentally made the decision that it's a viable surgical option.

Also, what kind of airway equipment was readily available at the FSED? Theoretically, it should mimic most ED's, in which case: LMAs, bougies, bronch, OPAs, NPAs, blades, fiberoptic laryngoscopes, cric kit, etc..

As far as the case... Yikes. I would imagine zooming in on her neck and the hairs standing up on the back of my neck. Danger Will Robinson! Danger! The first question I have...was she truly decompensating where intubation was absolutely indicated prior to transport? Anyone with common sense would have to know this has a very high probability of turning South very quickly. Therefore, a reasonable EP would want all of their backup devices available. This one screams awake FOI. I can't rationalize why someone would paralyze this patient and use standard RSI. It also would be a good idea to ask the medic for a combitube or King Laryngeal tube to have on hand for a worst case scenario. Better to do awake FOI, take a peek and paralyze at the cords. However, if she's breathing on her own and not in extremis and there wasn't a sudden clinical change, I'd have been very tempted to fly her to the closest tertiary care center where her surgeon has hospital privileges without touching that neck. Really weird that someone like this chose to present to an FSED of all places?

Anyway, I'm surmising that they might have been short a few backup airway devices.

The CXR as standard of care? Eh..I guess. Yes, we probably order a ton more of these in the ED than you guys do in the OR after intubation. It is rather routine to get a confirmatory CXR in the ED. Do we really need it to know we're in the right place? Not really, but it's just how most of us were trained. The majority of the time, I'm looking to see if I need to pull the tube back and I want to examine the chest and lungs for any other valuable/relevant information that would influence my care of the pt. It's not simply to measure ETT to carina. Personally, I intubate just a tad deep because they whip the pt off to CT or elsewhere and I'm paranoid of the tube getting dislodged. I wouldn't think to transfer a pt without getting one after intubation, but that's me. I think he was giving roc to prolong the paralysis. ED RNs are not the best at sedating patients quickly and correctly titrating for an accurate RASS, etc.. so many times we'll give a longer acting paralytic to keep them still while we're running the other tests for fear they'll wake up and grab the tube. Roc just happens to be the 2nd most readily available paralytic in most EDs.

It sounds like the pt wasn't sedated well enough post intubation (common in real world) and they forgot to push more paralytics to keep them still (important for transport). No confirmation CXR...I know this is debated on this thread but I'd have to argue from EM perspective, this is very common and probably standard of care. I'd honestly have to fault them for not performing one. Failure to identify tube dislodgment and to correct it in a timely manner proved fatal.

Easy to nit pick these types of cases, but it's always important to keep in mind that it could happen to anyone. Thanks for sharing!

My experience is that every transport team wants a tenuous airway secured beforehand.

#### Groove

##### Member
15+ Year Member
My experience is that every transport team wants a tenuous airway secured beforehand.

It's def a clinical call. In this case, if the pt is breathing, protecting their airway and there's no sudden change in exam or clinical state, you could make an argument that the risk for complication leading to death is too high to perform intubation at the FSED with limited resources and based on the physicians clinical determination, the pt's airway is stable for transfer. The accepting doc can't overrule that, all he can do is make recommendations prior to transport. The original doc could reason that it would be far better to intubate in a controlled environment with anesthesia, ENT and most importantly...her surgeon if available. That's just a high risk airway for an FSED of all places. I know lots of FSED owners love to tout how they have all the resources of a hospital ED but that's just it...you're not a hospital. You have no specialists, no backup to call on and no OR to go to should there be a sudden surgical emergency. I have mixed feelings about them. On one hand I'm glad we can open our own FSEDs and bill the facility fee and its certainly much better business for us. Is it better for the pt? Probably not.

Now, if the pt is worsening then sure...go for it, but I'd think long and hard before committing to that route working in one of those places.

I had the opportunity to go work full time at one years back but I was worried about skill atrophy. Most of the time it's like working at an urgent care. I don't think any of those guys intubate or perform procedures anywhere near the frequency of someone working in a moderate to high acuity hospital ED. If they're still around when I'm on the hind end of my career, I may consider it. It is very low stress from what I understand...above case as an exception of course.

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#### Mman

##### Senior Member
It's def a clinical call. In this case, if the pt is breathing, protecting their airway and there's no sudden change in exam or clinical state, you could make an argument that the risk for complication leading to death is too high to perform intubation at the FSED with limited resources and based on the physicians clinical determination, the pt's airway is stable for transfer. The accepting doc can't overrule that, all he can do is make recommendations prior to transport. The original doc could reason that it would be far better to intubate in a controlled environment with anesthesia, ENT and most importantly...her surgeon if available. That's just a high risk airway for an FSED of all places. I know lots of FSED owners love to tout how they have all the resources of a hospital ED but that's just it...you're not a hospital. You have no specialists, no backup to call on and no OR to go to should there be a sudden surgical emergency. I have mixed feelings about them. On one hand I'm glad we can open our own FSEDs and bill the facility fee and its certainly much better business for us. Is it better for the pt? Probably not.

Now, if the pt is worsening then sure...go for it, but I'd think long and hard before committing to that route working in one of those places.

I had the opportunity to go work full time at one years back but I was worried about skill atrophy. Most of the time it's like working at an urgent care. I don't think any of those guys intubate or perform procedures anywhere near the frequency of someone working in a moderate to high acuity hospital ED. If they're still around when I'm on the hind end of my career, I may consider it. It is very low stress from what I understand...above case as an exception of course.

a free standing ED should be considered an urgent care. If you have a medical emergency you should definitely not go to such a thing.

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#### Groove

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a free standing ED should be considered an urgent care. If you have a medical emergency you should definitely not go to such a thing.

Well, that's the whole point. By tricking out an "urgent care" with the resources of a real ED, they can classify themselves as an ED and everything gets up charged. They can bill the hospital facility fee. (Big $$) If you're out in the middle of nowhere then sure, it might be a good idea to present to one. After all, for most cases they can probably stabilize you, treat you and then transport you or even direct admit to a hospital nearby. However, nobody builds these in the middle of nowhere. Your goal is to cherry pick insured patients and lure them in under the guise of convenience which is why these things get built near shopping malls. Personally, I wouldn't be surprised to see legislative crack downs on these types of operations in the future. Then we'll start seeing proliferation of these micro hospitals which we're already starting to see in certain states. Chasing that dolla!$$$#### vector2 ##### It's not what you know, it's what you can prove. Lifetime Donor 10+ Year Member Well, that's the whole point. By tricking out an "urgent care" with the resources of a real ED, they can classify themselves as an ED and everything gets up charged. They can bill the hospital facility fee. (Big $$) If you're out in the middle of nowhere then sure, it might be a good idea to present to one. After all, for most cases they can probably stabilize you, treat you and then transport you or even direct admit to a hospital nearby. However, nobody builds these in the middle of nowhere. Your goal is to cherry pick insured patients and lure them in under the guise of convenience which is why these things get built near shopping malls. Personally, I wouldn't be surprised to see legislative crack downs on these types of operations in the future. Then we'll start seeing proliferation of these micro hospitals which we're already starting to see in certain states. Chasing that dolla!$$$

That's ridiculous that FSEDs are collecting facility fees well above urgent care reimbursement rates, esp if that's also the case for lower acuity CPTs. Not to veer too far off topic, but absolutely egregious **** like that solely in the furtherance of fleecing the pt or the pt's insurance is why the idea of single payer or flawed surprise billing legislation gets so much traction.

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#### Mman

##### Senior Member
Well, that's the whole point. By tricking out an "urgent care" with the resources of a real ED, they can classify themselves as an ED and everything gets up charged. They can bill the hospital facility fee. (Big $$) If you're out in the middle of nowhere then sure, it might be a good idea to present to one. After all, for most cases they can probably stabilize you, treat you and then transport you or even direct admit to a hospital nearby. However, nobody builds these in the middle of nowhere. Your goal is to cherry pick insured patients and lure them in under the guise of convenience which is why these things get built near shopping malls. Personally, I wouldn't be surprised to see legislative crack downs on these types of operations in the future. Then we'll start seeing proliferation of these micro hospitals which we're already starting to see in certain states. Chasing that dolla!$$\$

I understand the point (), but it is still unethical and wrong.

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#### nimbus

##### Member
15+ Year Member
I understand the point (), but it is still unethical and wrong.

And gullible patients like the unfortunate lady in this thread don’t know the difference. Same for stroke and stemi patients who get suboptimal outcomes by going to these places.

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#### chocomorsel

##### Senior Member
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I understand the point (), but it is still unethical and wrong.
Capitalism at its best! Isn’t that why this country is so darn great!
Show me the money!!!!!

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#### ShockIndex

##### Toxically Masculine
It beats socialism.

Show me someone else’s money!!!

...and the starvation

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#### chocomorsel

##### Senior Member
10+ Year Member
It beats socialism.

Show me someone else’s money!!!

...and the starvation
Because they are starving all over Western Europe and Australia and NZ and Canada.
I must have missed that news clip on Fox News.

#### Groove

##### Member
15+ Year Member
I understand the point (), but it is still unethical and wrong.

Is it though? It's the same reason a general surgeon builds and operates in a small surgicenter owned by the surgery group. They bilk the facility fee and don't have to pay the hospital for any OR time, etc.. If there's any complication or decompensation, there's no ICU or additional resources. The pt has to get transferred out. I've had to deal with multiple patients emergently sent to the ED from these places. What's so different about an EP building and equipping a standalone modern ED and promising to provide a higher quality of "emergency care" compared to an urgent care center, etc.. ? There's still a tremendous amount of pathology that they could see, treat and discharge on their own that an urgent care would be ill equipped to deal with... In a perfect scenario, I still think it's always best when an ED is attached to a hospital for the reasons I listed above but I also feel the same way about an OR. I might not personally think they are a great idea, but I can't fault the owners for wanting to build them.

The care provided would be higher than it would be in a small volume ED out in the middle of nowhere with no specialists in house. I've worked at those types of EDs...where you're dusting off cobwebs in a closet looking for a CVL kit or ETTs.

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#### Mman

##### Senior Member
Is it though? It's the same reason a general surgeon builds and operates in a small surgicenter owned by the surgery group. They bilk the facility fee and don't have to pay the hospital for any OR time, etc.. If there's any complication or decompensation, there's no ICU or additional resources. The pt has to get transferred out. I've had to deal with multiple patients emergently sent to the ED from these places. What's so different about an EP building and equipping a standalone modern ED and promising to provide a higher quality of "emergency care" compared to an urgent care center, etc.. ? There's still a tremendous amount of pathology that they could see, treat and discharge on their own that an urgent care would be ill equipped to deal with... In a perfect scenario, I still think it's always best when an ED is attached to a hospital for the reasons I listed above but I also feel the same way about an OR. I might not personally think they are a great idea, but I can't fault the owners for wanting to build them.

The care provided would be higher than it would be in a small volume ED out in the middle of nowhere with no specialists in house. I've worked at those types of EDs...where you're dusting off cobwebs in a closet looking for a CVL kit or ETTs.

I think if you are calling something an ED, I have an expectation that it can provide emergency care. I am assuming these places are not in podunk land competing with ED's attached to tiny rural hospitals but that they are in major markets trying to siphon patients () from other large hospitals that can provide the same level of care.

I mean what is the point of a free standing ED if a patient comes in with acute appendicitis and you have to send them somewhere else? Or an open fracture? Or any other number of actual emergencies that require surgery or admission? If you want to be an urgent care and sew up lacerations and treat asthma flares that would seem more appropriate.

When a surgeon is operating in a surgery center, those should (and nearly always are) patients have small outpatient procedures that are expected to go home. It would not advertise itself as a hospital, nor would it draw patients to it that needed hospitalization and those same surgeons likely have credentials and operate at a nearby hospital for bigger cases and sicker patients.

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#### TimesNewRoman

##### EM/CCM
7+ Year Member
I think if you are calling something an ED, I have an expectation that it can provide emergency care. I am assuming these places are not in podunk land competing with ED's attached to tiny rural hospitals but that they are in major markets trying to siphon patients () from other large hospitals that can provide the same level of care.

I mean what is the point of a free standing ED if a patient comes in with acute appendicitis and you have to send them somewhere else? Or an open fracture? Or any other number of actual emergencies that require surgery or admission? If you want to be an urgent care and sew up lacerations and treat asthma flares that would seem more appropriate.

When a surgeon is operating in a surgery center, those should (and nearly always are) patients have small outpatient procedures that are expected to go home. It would not advertise itself as a hospital, nor would it draw patients to it that needed hospitalization and those same surgeons likely have credentials and operate at a nearby hospital for bigger cases and sicker patients.

I live in a certificate of need state. Our hospital opened a FSED in a well-insured (mostly blue collar, but high employment) area to improve our payer mix because we can’t add more beds in other areas. It’s staffed by the same board certified MDs.

We have a C-MAC, disposable bronch, blood, CT, etc. We get everything you get at the main site except shocked trauma. Acuity is slightly lower, but not a ton. Honestly, it’s not that different from being at the main site except everything is done by phone when appropriate. You don’t get the same BS of some service wanting to send their resident down just because they’re there. We’re maybe 15-20m from the main site and have rapidly available EMS crews. STEMIs go directly to the lab from our site - honestly, due to the fact that we’re closer to where a lot of folks live, I bet 911 call to balloon time isn’t significantly higher.

I’m kind of surprised how strongly you are opposed to this model. Do you think we should only have tertiary care hospitals? There are plenty of community hospitals where you don’t have a full call roster. I’ve worked at plenty of places that didn’t have neurosurgery or vascular or whatever, you ship when appropriate. This really isn’t any different, except patients (should) get better care by having a competent physician with appropriate support closer to home. Also, it’s a bit easier to transfer since we’re all still in the same system - we have auto-accept policies for stemis, strokes, trauma, etc.

The case presented above is a lost airway - has essentially nothing to do with the fact that the patient was at a FSED. If they didn’t have VL or other difficult airway stuff (or a competent MD), that’s a different issue. I know plenty of crappy hospitals with poor resources and crappy docs. It’s tough to say if this was just crap luck and a (potentially) inevitable outcome or an incompetent doc without going through the details of the case. I think this highlights the importance of robust residency training with sick patients - not just having a burned out ophthalmologist working in an ED or a marginal student matching at a new sketchy HCA residency program that farms out their trauma and ICU rotations to real hospitals.

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#### NITRAS

2+ Year Member
I‘m an internist, but my hospital during residency didn’t have continuous EtCO2. The EMS had it, but we didn’t in the ED nor in the ICU. This freestanding Ed might not have had it, either.

I still see no reason not go get a pCXR post intubation. . . .but I don’t practice much ICU care anymore.

#### Mman

##### Senior Member
I live in a certificate of need state. Our hospital opened a FSED in a well-insured (mostly blue collar, but high employment) area to improve our payer mix because we can’t add more beds in other areas. It’s staffed by the same board certified MDs.

So is there no other hospital in this well insured area? Because that would seem odd.

#### vector2

##### It's not what you know, it's what you can prove.
10+ Year Member
I live in a certificate of need state. Our hospital opened a FSED in a well-insured (mostly blue collar, but high employment) area to improve our payer mix because we can’t add more beds in other areas. It’s staffed by the same board certified MDs.

We have a C-MAC, disposable bronch, blood, CT, etc. We get everything you get at the main site except shocked trauma. Acuity is slightly lower, but not a ton. Honestly, it’s not that different from being at the main site except everything is done by phone when appropriate. You don’t get the same BS of some service wanting to send their resident down just because they’re there. We’re maybe 15-20m from the main site and have rapidly available EMS crews. STEMIs go directly to the lab from our site - honestly, due to the fact that we’re closer to where a lot of folks live, I bet 911 call to balloon time isn’t significantly higher.

I’m kind of surprised how strongly you are opposed to this model. Do you think we should only have tertiary care hospitals? There are plenty of community hospitals where you don’t have a full call roster. I’ve worked at plenty of places that didn’t have neurosurgery or vascular or whatever, you ship when appropriate. This really isn’t any different, except patients (should) get better care by having a competent physician with appropriate support closer to home. Also, it’s a bit easier to transfer since we’re all still in the same system - we have auto-accept policies for stemis, strokes, trauma, etc.

The case presented above is a lost airway - has essentially nothing to do with the fact that the patient was at a FSED. If they didn’t have VL or other difficult airway stuff (or a competent MD), that’s a different issue. I know plenty of crappy hospitals with poor resources and crappy docs. It’s tough to say if this was just crap luck and a (potentially) inevitable outcome or an incompetent doc without going through the details of the case. I think this highlights the importance of robust residency training with sick patients - not just having a burned out ophthalmologist working in an ED or a marginal student matching at a new sketchy HCA residency program that farms out their trauma and ICU rotations to real hospitals.

What's your overall admission rate compared to the hospital based EDs in the area? And I take it pts are being billed for a bus ride too everytime they do require admission from the FSED?

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#### TimesNewRoman

##### EM/CCM
7+ Year Member
What's your overall admission rate compared to the hospital based EDs in the area? And I take it pts are being billed for a bus ride too everytime they do require admission from the FSED?

Admission rate is probably 10% vs. 20% at our main site (wild guess). We eat the cost of transfer.

#### TimesNewRoman

##### EM/CCM
7+ Year Member
So is there no other hospital in this well insured area? Because that would seem odd.

There is not.

#### Beeftenderloin

7+ Year Member
ED RNs are not the best at sedating patients quickly and correctly titrating for an accurate RASS, etc.. so many times we'll give a longer acting paralytic to keep them still while we're running the other tests for fear they'll wake up and grab the tube.

If you don’t know how to manage a patient in the peri-intubation period (which includes more than just putting the tube in, ie appropriate post intubation management/sedation) then call someone who does. The concept of “just paralyze them because the nurses don’t know how to sedate them correctly” is garbage critical care and certainly not what I would want for myself or a loved one.

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#### Mman

##### Senior Member
If you don’t know how to manage a patient in the peri-intubation period (which includes more than just putting the tube in, ie appropriate post intubation management/sedation) then call someone who does. The concept of “just paralyze them because the nurses don’t know how to sedate them correctly” is garbage critical care and certainly not what I would want for myself or a loved one.

No offense, but I'm not going down to the ER to manage sedation and paralysis on every patient they have to put a tube in.

They are not providing "critical care", they are providing emergency care. Standards of care in an ED are different than an ICU or an OR.

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#### Beeftenderloin

7+ Year Member
No offense, but I'm not going down to the ER to manage sedation and paralysis on every patient they have to put a tube in.

They are not providing "critical care", they are providing emergency care. Standards of care in an ED are different than an ICU or an OR.

I’m not suggesting they call for help with sedation after the tube is in. I’m suggesting that if they aren’t able to appropriately manage the full peri-intubation period then they shouldn’t initiate the process at all and should call for help from the start. The vast majority of intubations that occur in the ED are not truly “intubate in the next 5 seconds or the patient codes” scenarios. There is time for a nurse to grab a vial or propofol. Or at least give a push of Midazolam and fentanyl until they can.

I can’t relate to what you are saying on this issue. I’ve never heard that the standard of care anywhere is to paralyze intubated patients without sedation to facilitate work-up. Whether in the ICU, OR or ED.

#### MirrorTodd

##### It's a gas.
10+ Year Member
No offense, but I'm not going down to the ER to manage sedation and paralysis on every patient they have to put a tube in.

They are not providing "critical care", they are providing emergency care. Standards of care in an ED are different than an ICU or an OR.
While that's true, I'd say it's highly ER dependent. Why would the "standards" not basically be the same for sedation? The last pt I got called down for to bring up to the cath lab, the pt was on 1 mcg/kg/min of propofol AND the pump was set for a 70kg guy BUT he weighed 140kg. And people were wondering why he was sweating.

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#### Mman

##### Senior Member
I’m not suggesting they call for help with sedation after the tube is in. I’m suggesting that if they aren’t able to appropriately manage the full peri-intubation period then they shouldn’t initiate the process at all and should call for help from the start. The vast majority of intubations that occur in the ED are not truly “intubate in the next 5 seconds or the patient codes” scenarios. There is time for a nurse to grab a vial or propofol. Or at least give a push of Midazolam and fentanyl until they can.

I can’t relate to what you are saying on this issue. I’ve never heard that the standard of care anywhere is to paralyze intubated patients without sedation to facilitate work-up. Whether in the ICU, OR or ED.

I think you are misreading the post you replied to. Nowhere did it say they were going to paralyze the patient and provide no sedation. It said they couldn't trust the nurses to appropriately titrate the sedation they were giving well enough to prevent potential self extubation. It's like the surgeon complaining that the patient is awake because they moved. They aren't awake, they are deeply anesthetized, but they still moved. Patients in the ED can be deeply sedated and amnestic but still move if they are not adequately paralyzed.

Nobody is saying it's OK to push 100 mg of rocuronium and give no sedation.

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#### Mman

##### Senior Member
While that's true, I'd say it's highly ER dependent. Why would the "standards" not basically be the same for sedation? The last pt I got called down for to bring up to the cath lab, the pt was on 1 mcg/kg/min of propofol AND the pump was set for a 70kg guy BUT he weighed 140kg. And people were wondering why he was sweating.

I'm pretty sure if you gave me 1 mcg/kg/min of propofol I could still drive a car even if you calculated my weight correctly.

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#### MirrorTodd

##### It's a gas.
10+ Year Member
I'm pretty sure if you gave me 1 mcg/kg/min of propofol I could still drive a car even if you calculated my weight correctly.
Not after you'd been paralyzed with 100mg of Roc.

11 users

#### Beeftenderloin

7+ Year Member
I think you are misreading the post you replied to. Nowhere did it say they were going to paralyze the patient and provide no sedation. It said they couldn't trust the nurses to appropriately titrate the sedation they were giving well enough to prevent potential self extubation. It's like the surgeon complaining that the patient is awake because they moved. They aren't awake, they are deeply anesthetized, but they still moved. Patients in the ED can be deeply sedated and amnestic but still move if they are not adequately paralyzed.

Nobody is saying it's OK to push 100 mg of rocuronium and give no sedation.

Yea, that’s a fair point. I think I was more focused on the part where it said they weren’t good at getting the sedation going quickly. They’re typically pretty on the ball with that sort of thing in the ED I occasionally get called down to help out in.

#### Groove

##### Member
15+ Year Member
If you don’t know how to manage a patient in the peri-intubation period (which includes more than just putting the tube in, ie appropriate post intubation management/sedation) then call someone who does. The concept of “just paralyze them because the nurses don’t know how to sedate them correctly” is garbage critical care and certainly not what I would want for myself or a loved one.

You don't get it and don't know what it's like in the ED, and that's perfectly fine. As I said, the nurses are unable to quickly and adequately get optimal sedation levels, even with perfect orders placed. It's a function of individual skill levels, nurse to pt ratio, staffing levels, availability of drugs and resources, what's coming in the door, etc.. 30% are seasoned nurses, 30% are decent but lazy, 40% are brand new and fresh from nursing school who are dangerous. Turnover is rampant so you're getting used to new nurses and training them how to do things. This is common in just about any ED. My job is to rapidly work the pt up for emergent pathology once I've stabilized them. That means blood needs to get drawn quickly, imaging needs to be done quickly, etc.. The pt is sedated following an intubation but it's not optimal for all the reasons listed above. There's only one thing worse than sending a critical pt to CT and then dealing with a GSW, stroke or another resp failure coming through the doors and that's getting a call overhead that the pt in CT woke up, grabbed their ETT and yanked it out and is now coding because the brand new nurse in charge of that pt didn't know how to titrate sedation levels or wasn't able to do it quickly enough before CT. It's better and safer for all involved to paralyze the pt long enough to get critical diagnostic studies completed safely and in the interim...optimize sedation levels.

If you think you can do better, then by all means come down to the ED and help us all out with sedation/ventilation on our intubated pt's. I'll be happy to page you overhead to run down during all hours of the day/night and maybe you can teach me a few things.

1 users

#### nimbus

##### Member
15+ Year Member
You don't get it and don't know what it's like in the ED, and that's perfectly fine. As I said, the nurses are unable to quickly and adequately get optimal sedation levels, even with perfect orders placed. It's a function of individual skill levels, nurse to pt ratio, staffing levels, availability of drugs and resources, what's coming in the door, etc.. 30% are seasoned nurses, 30% are decent but lazy, 40% are brand new and fresh from nursing school who are dangerous. Turnover is rampant so you're getting used to new nurses and training them how to do things. This is common in just about any ED. My job is to rapidly work the pt up for emergent pathology once I've stabilized them. That means blood needs to get drawn quickly, imaging needs to be done quickly, etc.. The pt is sedated following an intubation but it's not optimal for all the reasons listed above. There's only one thing worse than sending a critical pt to CT and then dealing with a GSW, stroke or another resp failure coming through the doors and that's getting a call overhead that the pt in CT woke up, grabbed their ETT and yanked it out and is now coding because the brand new nurse in charge of that pt didn't know how to titrate sedation levels or wasn't able to do it quickly enough before CT. It's better and safer for all involved to paralyze the pt long enough to get critical diagnostic studies completed safely and in the interim...optimize sedation levels.

If you think you can do better, then by all means come down to the ED and help us all out with sedation/ventilation on our intubated pt's. I'll be happy to page you overhead to run down during all hours of the day/night and maybe you can teach me a few things.

Agree it’s often safest and best to paralyze patients during their workup but they need sedation if we’re gonna do that.

The most efficient and consistent way to manage sedation is to start it yourself. Why not include a big 100ml vial of propofol and infusion pump tubing in your intubation kits? Then you can start the infusion yourself immediately after you intubate. It literally takes one minute and it doesn’t matter who the nurse is.

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4 users

#### vector2

##### It's not what you know, it's what you can prove.
10+ Year Member
You don't get it and don't know what it's like in the ED, and that's perfectly fine. As I said, the nurses are unable to quickly and adequately get optimal sedation levels, even with perfect orders placed. It's a function of individual skill levels, nurse to pt ratio, staffing levels, availability of drugs and resources, what's coming in the door, etc.. 30% are seasoned nurses, 30% are decent but lazy, 40% are brand new and fresh from nursing school who are dangerous. Turnover is rampant so you're getting used to new nurses and training them how to do things. This is common in just about any ED. My job is to rapidly work the pt up for emergent pathology once I've stabilized them. That means blood needs to get drawn quickly, imaging needs to be done quickly, etc.. The pt is sedated following an intubation but it's not optimal for all the reasons listed above. There's only one thing worse than sending a critical pt to CT and then dealing with a GSW, stroke or another resp failure coming through the doors and that's getting a call overhead that the pt in CT woke up, grabbed their ETT and yanked it out and is now coding because the brand new nurse in charge of that pt didn't know how to titrate sedation levels or wasn't able to do it quickly enough before CT. It's better and safer for all involved to paralyze the pt long enough to get critical diagnostic studies completed safely and in the interim...optimize sedation levels.

If you think you can do better, then by all means come down to the ED and help us all out with sedation/ventilation on our intubated pt's. I'll be happy to page you overhead to run down during all hours of the day/night and maybe you can teach me a few things.

Yea man, we get it, you're busy. If you can't effectively titrate some sedation before slamming 100 of roc or count on your nurses to do as such, at least draw up 5-10 mg of versed depending on the patient size and give it when you're giving paralytic. That will buy you around an hour if not more of anterograde amnesia to get your diagnostic studies and transport done.

1 users

#### Groove

##### Member
15+ Year Member
Agree it’s often safest and best to paralyze patients during their workup but they need sedation if we’re gonna do that.

The most efficient and consistent way to manage sedation is to start it yourself. Why not include a big 100ml vial of propofol and infusion pump tubing in your intubation kits? Then you can start the infusion yourself immediately after you intubate. It literally takes one minute and it doesn’t matter who the nurse is.

Good idea in theory, but not very practical I'm afraid. That would probably violate a number of hospital bylaws, joint commission requirements, etc.. There are a host of rules and regulations regarding storage of medications that are a function of the board of pharmacy for your state and director of pharmacy at your particular hospital. As above, there are also a host of federal/state regulations. I believe it has to be in a locked and secure pre-designated location and only accessible to key personnel. You can't keep proprofol in a code cart or anything I don't think, at least I've never seen it done.

Keep in mind, that although accessing controlled drugs and carrying them around in your anesthesia cart or on your person might be pretty commonplace for you guys, it's very unusual and difficult for the rest of us. Hell, I don't even have access to a Pyxis. I also can't carry around controlled drugs very easily. Often, they are being handed to me by the nurse if I were carrying out procedural sedation, etc.. and I'm handing back what I have left over for them to document and waste. As for starting the infusion myself...sure that might be more efficient in particular cases, but why should I have to worry about propofol infusions? That's a nursing responsibility and it just wastes my time that could be better spent seeing another patient. I barely know how to operate an infusion pump as it is...

#### Groove

##### Member
15+ Year Member
Yea man, we get it, you're busy. If you can't effectively titrate some sedation before slamming 100 of roc or count on your nurses to do as such, at least draw up 5-10 mg of versed depending on the patient size and give it when you're giving paralytic. That will buy you around an hour if not more of anterograde amnesia to get your diagnostic studies and transport done.

No ones talking about RSI without sedation. All have etomidate/propofol/versed, etc.. on board prior to paralytics. As an example, propofol infusion might be started but not optimally titrated before they are whisked off to CT.

1 user

#### vector2

##### It's not what you know, it's what you can prove.
10+ Year Member
No ones talking about RSI without sedation. All have etomidate/propofol/versed, etc.. on board prior to paralytics. As an example, propofol infusion might be started but not optimally titrated before they are whisked off to CT.

I'm not talking about your induction meds either, although I'm surprised to hear that you sometimes give versed as part of an induction cocktail since I've never seen an ED give anything other than some combo of etom/prop/sux/roc to induce. You said "ED RNs are not the best at sedating patients quickly and correctly titrating for an accurate RASS, etc.. so many times we'll give a longer acting paralytic to keep them still while we're running the other tests for fear they'll wake up and grab the tube. " which I interpreted as you are giving additional paralytic (without additional sedation) some time after intubation but before a pt goes for a scan, but perhaps you mean you just do your intubation from the getgo with longer acting paralytic?

In any case, use more benzos throughout the peri-intubation period (i.e. 2mg with induction, 3mg right before nurse wheels to scanner) if you’re going to rely more on a paralytic first "sedation" strategy.

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#### nimbus

##### Member
15+ Year Member
Good idea in theory, but not very practical I'm afraid. That would probably violate a number of hospital bylaws, joint commission requirements, etc.. There are a host of rules and regulations regarding storage of medications that are a function of the board of pharmacy for your state and director of pharmacy at your particular hospital. As above, there are also a host of federal/state regulations. I believe it has to be in a locked and secure pre-designated location and only accessible to key personnel. You can't keep proprofol in a code cart or anything I don't think, at least I've never seen it done.

Keep in mind, that although accessing controlled drugs and carrying them around in your anesthesia cart or on your person might be pretty commonplace for you guys, it's very unusual and difficult for the rest of us. Hell, I don't even have access to a Pyxis. I also can't carry around controlled drugs very easily. Often, they are being handed to me by the nurse if I were carrying out procedural sedation, etc.. and I'm handing back what I have left over for them to document and waste. As for starting the infusion myself...sure that might be more efficient in particular cases, but why should I have to worry about propofol infusions? That's a nursing responsibility and it just wastes my time that could be better spent seeing another patient. I barely know how to operate an infusion pump as it is...

Don’t you already have propofol for intubation? You can make a care pathway so it’s there every time. The pump you can learn in 5min.

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1 user

#### nimbus

##### Member
15+ Year Member
Good idea in theory, but not very practical I'm afraid. That would probably violate a number of hospital bylaws, joint commission requirements, etc.. There are a host of rules and regulations regarding storage of medications that are a function of the board of pharmacy for your state and director of pharmacy at your particular hospital. As above, there are also a host of federal/state regulations. I believe it has to be in a locked and secure pre-designated location and only accessible to key personnel. You can't keep proprofol in a code cart or anything I don't think, at least I've never seen it done.

Keep in mind, that although accessing controlled drugs and carrying them around in your anesthesia cart or on your person might be pretty commonplace for you guys, it's very unusual and difficult for the rest of us. Hell, I don't even have access to a Pyxis. I also can't carry around controlled drugs very easily. Often, they are being handed to me by the nurse if I were carrying out procedural sedation, etc.. and I'm handing back what I have left over for them to document and waste. As for starting the infusion myself...sure that might be more efficient in particular cases, but why should I have to worry about propofol infusions? That's a nursing responsibility and it just wastes my time that could be better spent seeing another patient. I barely know how to operate an infusion pump as it is...
No ones talking about RSI without sedation. All have etomidate/propofol/versed, etc.. on board prior to paralytics. As an example, propofol infusion might be started but not optimally titrated before they are whisked off to CT.

????

So you already have propofol in your intubation box? You blame your nurses for being unskilled at sedation but what’s your role in this? It takes 5min to learn to use a pump.

1 users

#### Ronin786

7+ Year Member
If you don’t know how to manage a patient in the peri-intubation period (which includes more than just putting the tube in, ie appropriate post intubation management/sedation) then call someone who does. The concept of “just paralyze them because the nurses don’t know how to sedate them correctly” is garbage critical care and certainly not what I would want for myself or a loved one.
You don't get it and don't know what it's like in the ED, and that's perfectly fine. As I said, the nurses are unable to quickly and adequately get optimal sedation levels, even with perfect orders placed. It's a function of individual skill levels, nurse to pt ratio, staffing levels, availability of drugs and resources, what's coming in the door, etc.. 30% are seasoned nurses, 30% are decent but lazy, 40% are brand new and fresh from nursing school who are dangerous. Turnover is rampant so you're getting used to new nurses and training them how to do things. This is common in just about any ED. My job is to rapidly work the pt up for emergent pathology once I've stabilized them. That means blood needs to get drawn quickly, imaging needs to be done quickly, etc.. The pt is sedated following an intubation but it's not optimal for all the reasons listed above. There's only one thing worse than sending a critical pt to CT and then dealing with a GSW, stroke or another resp failure coming through the doors and that's getting a call overhead that the pt in CT woke up, grabbed their ETT and yanked it out and is now coding because the brand new nurse in charge of that pt didn't know how to titrate sedation levels or wasn't able to do it quickly enough before CT. It's better and safer for all involved to paralyze the pt long enough to get critical diagnostic studies completed safely and in the interim...optimize sedation levels.

If you think you can do better, then by all means come down to the ED and help us all out with sedation/ventilation on our intubated pt's. I'll be happy to page you overhead to run down during all hours of the day/night and maybe you can teach me a few things.
Any discussion about ED "standards" always devolves into a "our job is to take care of emergencies so it's OK". You being busy shouldn't excuse you from providing the necessary care, but that's what the ABEM and corporate overlords have accepted.

1 users

#### Arch Guillotti

##### Senior Member
Staff member
Moderator
15+ Year Member
I like how in one thread everyone is pissed because some guy pushes the stretcher, then we expect this ED guy to set up the pump (which is a clearly defined duty of the ER nurse).

11 users

#### MoMoGesiologist

##### What is dead may never die
2+ Year Member
Any discussion about ED "standards" always devolves into a "our job is to take care of emergencies so it's OK". You being busy shouldn't excuse you from providing the necessary care, but that's what the ABEM and corporate overlords have accepted.
This is definitely NOT what the ED guy is saying. The ED can manage their own airways and sedation. Let’s not try to make it anesthesia land (where we are one to one with our patients, have meds/equipment within reach, and not moving patients anywhere). ED is a different ballgame. They have every right to set their standards how they see fit to best take care of patients.

1 users

#### Southpaw

15+ Year Member
I like how in one thread everyone is pissed because some guy pushes the stretcher, then we expect this ED guy to set up the pump (which is a clearly defined duty of the ER nurse).

It was @nimbus who always appears to love life literally doing any sort of duty in an OR. He’s also MD only far as I can tell which is basically a whole different field of medicine than supervision.

But what anesthesiologist hasn’t setup a pump? Even the laziest of bums presumably did it in residency?

Seems worthwhile to at least explore when the alternative in the discussion is paralysis with no sedation.

1 user

#### Hoya11

##### Senior Member
15+ Year Member
This is definitely NOT what the ED guy is saying. The ED can manage their own airways and sedation. Let’s not try to make it anesthesia land (where we are one to one with our patients, have meds/equipment within reach, and not moving patients anywhere). ED is a different ballgame. They have every right to set their standards how they see fit to best take care of patients.

The guy is blaming the improper sedation on a nurse, he should realize its HIS responsibility,

Imagine telling a patient, yeah the CRNA didn't give enough sevo so you woke up for a while during surgery, NBD shes new..

Its because sedation is seen as ancillary, anyone can do it, its all the same, just get the pump and the drug and do it, i mean right?

With the whole COVID thing, I hear a lot of "Well anesthesia is different" about sedation in the ICU when people are on fentanyl drips alone and god knows what... pulling out tubes while prone... and here it is again in the ER," well its different in anesthesia".... no... you just suck at it and don't realize it...

I wish there WAS in fact a way for us to help with these situations, but the ego games would never let me go down to the ER/ICU and come up with a sedation protocol (even after dealing with clip board nurses for months). In order for there to be a change there first needs to be acceptance that something is wrong, and we are not there yet , in the ICU or the ER...

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3 users

#### nimbus

##### Member
15+ Year Member
It was @nimbus who always appears to love life literally doing any sort of duty in an OR. He’s also MD only far as I can tell which is basically a whole different field of medicine than supervision.

Yup that’s me. Some nonanesthesia stuff I particularly enjoy:

Emptying foleys into the suction canister.

Securing NG tubes with the nasal bridle.

Removing stubborn rings that haven’t been taken off for 30 years.

Sitting on my stool.

Don’t enjoy pushing gurneys but I push it to the PACU. Some days it’s the only exercise I get.

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2 users

#### Mman

##### Senior Member
I wish there WAS in fact a way for us to help with these situations, but the ego games would never let me go down to the ER/ICU and come up with a sedation protocol (even after dealing with clip board nurses for months). In order for there to be a change there first needs to be acceptance that something is wrong, and we are not there yet , in the ICU or the ER...

Even a perfect protocol is going to fail more than you want it to when the nurses using it are inexperienced. Humans fail. Inexperienced ones fail even more.

#### migm

10+ Year Member
ABEM boarded

1. I don't think there is any excuse for under-sedating your patient. It as much your responsibility as it is doing a safe, effective intubation.

2. failing at post-intubation sedation is a big issue with our ADD brains, especially with roc\vec use.

3. I am not allowed to carry meds around the ED. I have no access to the Pyxis. This issue is solved with having airway boxes with appropriate medications in them as well as well as handy BC pharmacists in the room with you.

1 users

#### dchz

##### Avoiding the Dunning-Kruger
7+ Year Member
My job is to rapidly work the pt up for emergent pathology once I've stabilized them. That means blood needs to get drawn quickly, imaging needs to be done quickly, etc..

I am saying the following with the utmost respect.

Sedating them for the tube and the paralysis IS part of stabilizing them. They are just as unstable if their paralysis wears off and there is no sedation.

Let's be honest. You're not the one drawing blood. You're not the one taking them to imaging. The sedation part takes a few more clicks of the finger or a few more lines written on your written orders. There is no excuse not doing it. You're the leader of the ED team. If you know there are inadequacies in your staff, gather with their nursing leadership and come up with a solution to get a paralyzed pt some sedation. It's the humane thing to do. It brings me concern you don't see it this way. I'm not saying your job is easy and I can do better. I am saying this should be on the top of the priority list to prevent iatrogenic morbidity and mortality (as in the case of the OP).

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