Hospitals replacing anesthesia docs with EM?

[Brigade4Radiant]

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Seems like for endoscopy stuff some hospitals are using EM and ICU docs

 

[Tiger26]

There are days when the idea of anesthesia looks far more appealing than the ED and I feel totally comfortable sedating emergencies. I couldn't imagine defending myself if something happened just doing elective cases day after day.

On the other hand, the midlevels jump fields all the time, seemingly without any repercussions (GI-->Derm-->Cardiology ....)

 

[DrDrummer]

Someone asked me to go to the GI lab once and push Propofol for some GI doc who couldn’t adequately sedate a food impaction early in my post-residency job. I said no way, not my circus/monkeys/etc and also having sat on sedation committees in residency I was aware of GI labs as being dangerous places in terms of bad outcomes (especially food boluses done as MAC with a non-secured airway).

I was surprised and dismayed when one of the other ER docs happily ran down the hall to do it. 5-6 years later I think my answer would definitely still be the same. Very bad idea.

 

[emergentmd]

I am paid as an ER doc to take care of everything in the ER and have accepted that this extends to hospital Codes.

I am not paid to deliver babies, put in floor central lines, pretend to be an anesthesiologist, default floor EKG reader, or Trauma team back up.

As a favor to my hospitalist friends, I have put in a few central lines on the floor but rare.

 

[Jabbed]

Off-topic, but I really wish that our anesthesia credentialing extended to RSI’ing patients for prosthetic hip reductions. These can be the absolute worst with over-sedating to the point of apnea followed by everyone in the department taking a turn riding mee-maa’s leg.

Wouldn’t it be nice if we could just push etomidate/roc, put in an LMA, and manipulate that hip without any muscle tone? Is there any strong argument to why we shouldn’t be allowed to do this? The alternative is often admitting/transferring the patient to have this exact process done 12-24 hrs later.

 

[TooMuchResearch]

Off-topic, but I really wish that our anesthesia credentialing extended to RSI’ing patients for prosthetic hip reductions. These can be the absolute worst with over-sedating to the point of apnea followed by everyone in the department taking a turn riding mee-maa’s leg.

Wouldn’t it be nice if we could just push etomidate/roc, put in an LMA, and manipulate that hip without any muscle tone? Is there any strong argument to why we shouldn’t be allowed to do this? The alternative is often admitting/transferring the patient to have this exact process done 12-24 hrs later.

I had a retired anesthesiologist with an acetabular reinforcement ring ask me to do just this so he didn't have to go to the OR. My thought was that somewhere between propofol to apnea and a few minutes of BVM and propofol, paralytic, and secured airway with ventilator, I cross the line into anesthesiologist territory. Can I probably do it safely much of the time? Definitely. Do I think I should? Probably not.

 

[Jabbed]

I had a retired anesthesiologist with an acetabular reinforcement ring ask me to do just this so he didn't have to go to the OR. My thought was that somewhere between propofol to apnea and a few minutes of BVM and propofol, paralytic, and secured airway with ventilator, I cross the line into anesthesiologist territory. Can I probably do it safely much of the time? Definitely. Do I think I should? Probably not.

I don’t even think you need the vent. Etomidate/sux and 5 minutes of RT bagging. I would even use a defasciculating dose of rocuronium for style points.

For hip sedations there’s already a high chance inducing apnea and needing to ventilate the patient anyway. Might as well secure the airway.

 

[AlmostAnMD]

I have done etomidate for hips

this was after fentanyl/versed/propofol combo or sequence wasn't working well.

Notes said previous hip reductions had to be done in OR which in my more cavalier early attendinghood struck me as a challenge

Knocked it out with low dose etomidate (I did sedation only, ortho did reduction but said they couldn't get it done in ED previously on this patient).

Great drug for reductions. Used it for elbows too

and cardioversions, it's literally the best drug for cardioversions and if you have a different opinion, you're wrong. I did an EP rotation as a resident (great decision!) and we had a cardioversion clinic where we just went room-to-room and etomidate/cardioverted and woke them up and walked them out. Like a treadmill. Once I saw this I never went back.

 

[southerndoc]

I had a retired anesthesiologist with an acetabular reinforcement ring ask me to do just this so he didn't have to go to the OR. My thought was that somewhere between propofol to apnea and a few minutes of BVM and propofol, paralytic, and secured airway with ventilator, I cross the line into anesthesiologist territory. Can I probably do it safely much of the time? Definitely. Do I think I should? Probably not.

We electively intubate all trauma patients going to IR for intrathoracic/intraabdominal injury (long story). We were told by med staff that even elective intubations are within our scope. Haven't pushed the limit for that difficult reduction, but maybe next time I will. Smidge of SCH, tube, reduce, extubate, home.

 

[southerndoc]

and cardioversions, it's literally the best drug for cardioversions and if you have a different opinion, you're wrong. I did an EP rotation as a resident (great decision!) and we had a cardioversion clinic where we just went room-to-room and etomidate/cardioverted and woke them up and walked them out. Like a treadmill. Once I saw this I never went back.

I do this with propofol. What's the advantage of etomidate over propofol for cardioversions? I average about 1-2 DCCVs per month and send 90% of them home.

 

[Dantrolene FC]

Someone asked me to go to the GI lab once and push Propofol for some GI doc who couldn’t adequately sedate a food impaction early in my post-residency job. I said no way, not my circus/monkeys/etc and also having sat on sedation committees in residency I was aware of GI labs as being dangerous places in terms of bad outcomes (especially food boluses done as MAC with a non-secured airway).

I was surprised and dismayed when one of the other ER docs happily ran down the hall to do it. 5-6 years later I think my answer would definitely still be the same. Very bad idea.

Anesthesiologist here. That’s 100% general anesthesia with an endotracheal tube. That is high risk for aspiration.

 

[Dantrolene FC]

I don’t even think you need the vent. Etomidate/sux and 5 minutes of RT bagging. I would even use a defasciculating dose of rocuronium for style points.

For hip sedations there’s already a high chance inducing apnea and needing to ventilate the patient anyway. Might as well secure the airway.

Would you reverse the defasiculating dose of rocuronium?

 

[Dantrolene FC]

I have done etomidate for hips

this was after fentanyl/versed/propofol combo or sequence wasn't working well.

Notes said previous hip reductions had to be done in OR which in my more cavalier early attendinghood struck me as a challenge

Knocked it out with low dose etomidate (I did sedation only, ortho did reduction but said they couldn't get it done in ED previously on this patient).

Great drug for reductions. Used it for elbows too

and cardioversions, it's literally the best drug for cardioversions and if you have a different opinion, you're wrong. I did an EP rotation as a resident (great decision!) and we had a cardioversion clinic where we just went room-to-room and etomidate/cardioverted and woke them up and walked them out. Like a treadmill. Once I saw this I never went back.

Methohexital is even better than etomidate.

 

[Dantrolene FC]

I do this with propofol. What's the advantage of etomidate over propofol for cardioversions? I average about 1-2 DCCVs per month and send 90% of them home.

I use propofol too for my stable cardioversions. The advantage of etomidate to propofol is hemodynamic stability (obviously) it is more forgiving than propofol.

But the real advantage of etomidate is it is shorteracting. Believe it or not, the 5 minute faster wake up really helps in a busy anesthesia practice.

 

[Jabbed]

I have done etomidate for hips

this was after fentanyl/versed/propofol combo or sequence wasn't working well.

Notes said previous hip reductions had to be done in OR which in my more cavalier early attendinghood struck me as a challenge

Knocked it out with low dose etomidate (I did sedation only, ortho did reduction but said they couldn't get it done in ED previously on this patient).

Great drug for reductions. Used it for elbows too

and cardioversions, it's literally the best drug for cardioversions and if you have a different opinion, you're wrong. I did an EP rotation as a resident (great decision!) and we had a cardioversion clinic where we just went room-to-room and etomidate/cardioverted and woke them up and walked them out. Like a treadmill. Once I saw this I never went back.

I will try this. I always use it for cardioversions and agree that it is both incredibly potent and quick to recover from.

 

[Jabbed]

Would you reverse the defasiculating dose of rocuronium?

We have sugammadex in our pyxis now. I’ve only used it for RSI dose reversal so I would admittedly check with pharmacy for dosing of 1/10th the normal RSI dose. I assume that was a tongue-in-cheek question, though.

 

[TooMuchResearch]

Methohexital is even better than etomidate.

I remember rotating through EP in residency and they used methohexital. I've never seen it on the ED though.