Hospitals replacing anesthesia docs with EM?

[Groove]

---

Members do not see this ad.

It’s a good thing I sit my own cases and don’t supervise CRNAs.

You're a new attending I believe, so give it time. It also explains much of the attitude. You'll relax much more after a few years and hopefully realize we're all playing on the same team and doing the best we can. The point is that you are probably never consulted in the ED. I think all of us that have been doing this long enough can attest to that. I've literally never seen anesthesia in the ED since residency so somewhere in the ball park of 16 years. That being said, I've certainly been called emergently to the ICU once in a blue moon at 3am for an airway issue where the APC can't tube and I didn't throw a temper tantrum because the gas or ICU attending wasn't in house because the APCs are generally good that staff the units at night and I know if I'm getting called...it's probably for a good reason and I'm more than willing to help someone out if they need me. Something like that doesn't happen with enough regularity for me to stand on a soap box about it though and I suspect ED consults are much the same for you.

 

[Dantrolene FC]

You're a new attending I believe, so give it time. It also explains much of the attitude. You'll relax much more after a few years and hopefully realize we're all playing on the same team and doing the best we can. The point is that you are probably never consulted in the ED. I think all of us that have been doing this long enough can attest to that. I've literally never seen anesthesia in the ED since residency so somewhere in the ball park of 16 years. That being said, I've certainly been called emergently to the ICU once in a blue moon at 3am for an airway issue where the APC can't tube and I didn't throw a temper tantrum because the gas or ICU attending wasn't in house because the APCs are generally good that staff the units at night and I know if I'm getting called...it's probably for a good reason and I'm more than willing to help someone out if they need me. Something like that doesn't happen with enough regularity for me to stand on a soap box about it though and I suspect ED consults are much the same for you.

I think you misunderstand me. I’m not saying I’m not willing to help out if someone needs help. I absolutely am willing to help and do help. I just don’t want to be asked to stand outside the room just in case someone needs help.

Let’s say you had to cric a patient. Are you going to ask the ENT surgeon to stand outside the room just in case you need help. Of course not, you’re either going to cric the patient or call the ENT surgeon to do it.

 

[JacobMcCandles]

I am trained to do chest tubes. But the only time I’d do it is if a surgeon, intensivist, or EM doctor isn’t available. For example, I could cause a pneumothorax doing a supraclavicular block. If that’s the case, it’s up to me or the ortho surgeon to do the chest tube unless I’m at a facility with one of the above people around.

Eh, not every pneumothorax needs a chest tube but that’s neither here nor there.

 

[Arch Guillotti]

I think you missed the point. I take backup as calling them to watch me intubate just in case I miss. But yeah, if its difficult, I would call them to help just as any doc in the hospital should come to help another doc.

lol I have never called an ER doc in my life for anything. I wish ai could say the reverse was true.

 

[hoot504]

lol I have never called an ER doc in my life for anything. I wish ai could say the reverse was true.

He's just pissed about all those emmy wins the pitt racked up.

Don't worry bud I'm sure HBO is about to greenlight the anesthesia version. Any day now...

 

[Arch Guillotti]

He's just pissed about all those emmy wins the pitt racked up.

Don't worry bud I'm sure HBO is about to greenlight the anesthesia version. Any day now...

I have no idea what that means.

 

[hoot504]

I have no idea what that means.

You're not the intended audience so I wouldn't lose sleep over it.

 

[Porfirio]

The only time I ever saw Anes in the ER was during COVID when the surgery volume went to basically 0 and they were begging to help intubate COVID patients for RVUs.

Ah, how times change.

 

[Groove]

lol I have never called an ER doc in my life for anything. I wish ai could say the reverse was true.

Yet, you'll be ending up on our tracking board one of these days won't you big guy? If there's one thing this specialty has taught me is that all you Monday quarterbacking specialists end up in our department eventually. Either calling us frantically headed to our ED with your loved one or showing up as a patient. It won't be your best day....but we'll help you get through it all the same.

 

[southerndoc]

I have no idea what that means.

I actually didn't finish it. Reminded me too much of work. Was pretty realistic with exception of the administrator hounding staff mid-shift about Press Ganey numbers. We usually do that via email. LOL

 

[southerndoc]

Yet, you'll be ending up on our tracking board one of these days won't you big guy? If there's one thing this specialty has taught me is that all you Monday quarterbacking specialists end up in our department eventually. Either calling us frantically headed to our ED with your loved one or showing up as a patient. It won't be your best day....but we'll help you get through it all the same.

Don't take it personal. He's not talking about that. How many anesthesiologists need to call an ER doc to bail them out? I am clueless what gas does what and how to operate most of their equipment.

I also wouldn't expect an interventional cardiologist, trauma surgeon, or neurosurgeon to call an ER doc to bail them out. "Dr. southerndoc, Dr. Neuro needs help with a burr hole. Can you come to OR 3?"

 

[Mount Asclepius]

Most other specialities don’t call us for help because we have already taken care of 70-80% of all comers in the ED and discharged them. We know a little bit of everything even if we are just experts at resuscitation and working up undifferentiated patients. If we put other specialists in the ED they would consult all the other specialities way more than we do. We aren’t the master of each subspeciality of medicine.

It’s not very respectful, especially as an administrator, to come into another specialities’ forum and make an implied derogatory and glib statement without acknowledging an obvious difference between roles of specialities in the healthcare system.

As a brand new attending I once requested anesthesia come be backup for a patient post-operative from an ACDF with an expanding neck hematoma and stridor. It was a disaster because anesthesia wanted to intubate not be back up (I acquiesced), they wanted to do with Precedex (not immediately available), couldn’t get the tube on first pass, and I had to assist them with intubating over a bougie. Looking back I wouldn’t have called them at all. I acknowledge it was awkward to ask for them to be backup. If anything, I would have paged ENT instead and asked them to come in to be backup for a difficult emergent cric instead while I attempted intubation. Sure, I could have attempted intubation and had cric as my own backup plan, but I wanted to do what was best for the patient as a new grad with not a ton of experience (despite having phenomenal airway experience in residency). Since then, I’ve never involved anesthesia in the ED for airway management. Other than procedural sedations and RSI/DSI/awake intubations for emergent airways, I don’t perform general anesthesia. That’s not my field or area of expertise. We all have a role to play.

 

[Dantrolene FC]

Most other specialities don’t call us for help because we have already taken care of 70-80% of all comers in the ED and discharged them. We know a little bit of everything even if we are just experts at resuscitation and working up undifferentiated patients. If we put other specialists in the ED they would consult all the other specialities way more than we do. We aren’t the master of each subspeciality of medicine.

It’s not very respectful, especially as an administrator, to come into another specialities’ forum and make an implied derogatory and glib statement without acknowledging an obvious difference between roles of specialities in the healthcare system.

As a brand new attending I once requested anesthesia come be backup for a patient post-operative from an ACDF with an expanding neck hematoma and stridor. It was a disaster because anesthesia wanted to intubate not be back up (I acquiesced), they wanted to do with Precedex (not immediately available), couldn’t get the tube on first pass, and I had to assist them with intubating over a bougie. Looking back I wouldn’t have called them at all. I acknowledge it was awkward to ask for them to be backup. If anything, I would have paged ENT instead and asked them to come in to be backup for a difficult emergent cric instead while I attempted intubation. Sure, I could have attempted intubation and had cric as my own backup plan, but I wanted to do what was best for the patient as a new grad with not a ton of experience (despite having phenomenal airway experience in residency). Since then, I’ve never involved anesthesia in the ED for airway management. Other than procedural sedations and RSI/DSI/awake intubations for emergent airways, I don’t perform general anesthesia. That’s not my field or area of expertise. We all have a role to play.

That’s a weird experience. Was it an anesthesiologist that came? I would never use Precedex as an induction agent. I’m sorry you had such a horrible experience.

It sounds like they sent an intern to you.

 

[TooMuchResearch]

The only time I ever saw Anes in the ER was during COVID when the surgery volume went to basically 0 and they were begging to help intubate COVID patients for RVUs.

Ah, how times change.

Ours asked too and we decided against it. Plastics wanted to get called for simple lac repairs. Ortho for reductions. We decided against all of it.

 

[emergentmd]

lol I have never called an ER doc in my life for anything. I wish ai could say the reverse was true.

Hahaha, your such a piece of work. You’re not even a real doc. You push drugs, watch over some nurses that does a similar job, and do some blood patch. I doubt you know much about actually taking care of a patient. 🙂

Funny that one of my my gas friends called me for advice and sent me a mailbox full of files asking what it all meant.

No worries, when your family is sick, I hope you take him straight to day surg and bypass the ER all together.

 

[emergentmd]

Yet, you'll be ending up on our tracking board one of these days won't you big guy? If there's one thing this specialty has taught me is that all you Monday quarterbacking specialists end up in our department eventually. Either calling us frantically headed to our ED with your loved one or showing up as a patient. It won't be your best day....but we'll help you get through it all the same.

He is one of the mods that attacks posters he disagrees with. best to ignore

 

[Mount Asclepius]

That’s a weird experience. Was it an anesthesiologist that came? I would never use Precedex as an induction agent. I’m sorry you had such a horrible experience.

It sounds like they sent an intern to you.

Yes, attending anesthesiologist. There are good and bad physicians in every field. You shouldn’t judge a physician, and especially not an an entire specialty, based upon one encounter. Being out of your element (ED rather than the OR), while not an excuse does impact you. All that being said, I learned a valuable real world lesson about who is the best physician to emergently manage airways in the ED.

 

[AlmostAnMD]

Ours asked too and we decided against it. Plastics wanted to get called for simple lac repairs. Ortho for reductions. We decided against all of it.

Rofl

Dude we were happy to let plastics come do repairs and ortho do reductions

That **** was hilarious

 

[Porfirio]

That’s a weird experience. Was it an anesthesiologist that came? I would never use Precedex as an induction agent. I’m sorry you had such a horrible experience.

It sounds like they sent an intern to you.

Yeah man. It was wild times. So many hungry unicorns in the ER.

 

[Groove]

Don't take it personal. He's not talking about that. How many anesthesiologists need to call an ER doc to bail them out? I am clueless what gas does what and how to operate most of their equipment.

I also wouldn't expect an interventional cardiologist, trauma surgeon, or neurosurgeon to call an ER doc to bail them out. "Dr. southerndoc, Dr. Neuro needs help with a burr hole. Can you come to OR 3?"

The point is man.....it's just absolutely absurd to me that these guys are even taking the time to finger wag in here about calling them down to the ED. As if it EVER happens.

It would be like me going to an airline flight steward/stewardess conference and lecturing them against identifying doctors on the plane who don't want to be called to help out an emergency because it happened once 20 years ago.

 

[southerndoc]

Hahaha, your such a piece of work. You’re not even a real doc. You push drugs, watch over some nurses that does a similar job, and do some blood patch. I doubt you know much about actually taking care of a patient. 🙂

Funny that one of my my gas friends called me for advice and sent me a mailbox full of files asking what it all meant.

No worries, when your family is sick, I hope you take him straight to day surg and bypass the ER all together.

Let's try to keep it nice and civil.

I don't think he meant it like some people are taking it. I think he's simply saying he's never called an ER doc for anything related to his career. Quite frankly, why would he? He's not saying he will never ask an ER doc for anything. Talking about sick family members, etc. is taking it way out of context.

At any rate, let's move on.

 

[southerndoc]

The point is man.....it's just absolutely absurd to me that these guys are even taking the time to finger wag in here about calling them down to the ED. As if it EVER happens.

It would be like me going to an airline flight steward/stewardess conference and lecturing them against identifying doctors on the plane who don't want to be called to help out an emergency because it happened once 20 years ago.

Many Level I trauma centers have anesthesia routinely respond to all Level I activations. We do, and I feel sorry for them because they waste their time 90% of the time. The other 10% they are just going back to the OR quickly. I can count on one hand the number of times that anesthesiology has intubated a trauma patient in the ER.

 

[CopaceticOne]

Many Level I trauma centers have anesthesia routinely respond to all Level I activations. We do, and I feel sorry for them because they waste their time 90% of the time. The other 10% they are just going back to the OR quickly. I can count on one hand the number of times that anesthesiology has intubated a trauma patient in the ER.

At the Level 1 trauma center I work at, anesthesia has to show up for every serious* trauma. I tell our anesthesia residents their sole job in being there is to listen to EMS report, patients LOC on arrival, understand what injuries are identified, what lines the patient has, what has already happened in the trauma bay, etc. If the trauma surgeons say OR stat, the resident then communicates what they know to the OR anesthesia team and assigns who is going to do what as soon as the patient enters the OR.

I greatly appreciate the trauma bay crew doing what they do best, managing the patient when they hit the doors in an unknown state. Having someone in the OR, besides the focused surgeon, who has the knowledge of what happened prior really helps in managing the patient intraop. Maybe my opinion is because a large number of traumas that roll in go straight to the OR from the trauma bay.

*they divide the traumas into two levels - Level 1s (what I’m referring to as serious) are GSWs, motorcycle accidents, some car accidents, vascular injuries, head injuries etc. Level 2s are everything else & we don’t go to those. The trauma EP will downgrade a Level 1 on occasion. In rare instances the Level 2 is upgraded.

 

[WilcoWorld]

I think what will obviously address this valid concern about hospitals over-working EPs in order to short change Anesthesiologists is othering
(and then crapping on) each other while private equity firms balance their spreadsheets.

----

To the thread's original question, is it appropriate for EP's do deep sedations? The answer is simple:
if it's for an emergent procedure - yes.
if it's for an elective procedure - no.

----

As for the SDN Culture Wars part of the thread:
-I've been working EM two decades and Anesthesia has never asked me to "bail them out" by asking me to come to the OR, that's preposterous.
But
-I have also gotten a LOT of patients sent to the ED from the pre-op clinic for abnormal vitals, and many family members of patients sent to the ED from the post-op waiting area for syncope, chest pain, seizure, etc.

I guess I'd argue that if you've ever told a patient to "go to the nearest ER", then Emergency Medicine was bailing you out.

 

[pkwraith]

I actually think it would be great to have more collaboration between EM and Anesthesia

One of my coresidents went to work at a rare shop where anesthesia would come down and intubate/paralyze for reductions and extubate
Where I trained, anesthesia came and did iliacus blocks for all hip fractures, which honestly better care for the hip fx demographic and really not sure why this isn't offered as standard of care.
At one of my tertiaries, we have an airway alert where anesthesia and surgery shows up to extremely difficult airways.

But then again at one of my hospitals the other day there was a shoulder dislocation on the floor after a seizure, and Anesthesia apparently don't do procedural sedations? So they were exploring options if we could go up to do a procedural sedation or have the patient come down to the ED? I'm not getting why Anesthesia is incapable of doing procedural sedation, and they ended up making the patient go to the OR.

 

[TooMuchResearch]

Rofl

Dude we were happy to let plastics come do repairs and ortho do reductions

That **** was hilarious

Those are billed procedures. Our contract gives us first right of refusal.

 

[CopaceticOne]

I'm not getting why Anesthesia is incapable of doing procedural sedation, and they ended up making the patient go to the OR.

I wonder if the barrier was expected standard of care and materials availability. Most inpatient units don’t have the capabilities for required monitoring for MAC; ICUs being the exception.

 

[JacobMcCandles]

I wonder if the barrier was expected standard of care and materials availability. Most inpatient units don’t have the capabilities for required monitoring for MAC; ICUs being the exception.

Just because a patient is in the OR doesn’t mean they have to have general sedation. They could find an open room wherever there’s capabilities and do moderate sedation.

 

[AlmostAnMD]

Those are billed procedures. Our contract gives us first right of refusal.

Story time

Our ultra-specialists were dinguses. They would complain anytime they were called about anything, especially when called on holidays/after hours

On a random PRE-COVID Saturday at 3a, a 7 year old girl was bit in the face by a pitbull ("breed of peace!"), taking off most of her upper and lower lip. No internal trauma (dentition, tongue, etc). But savagely destroyed her lower face.

Plastics was called at 3a to repair the face

What followed was a lot of cursing, yelling and screaming about how the ED doc should "do his best" and send it to his clinic on monday. Mind you, this is a 7 year old girl with her entire life ahead, do you want that in your hands? Of course not, and if you think you have the skills to repair face meat as an ED doc you're delusional and dangerous. I'm talking full thickness ripping through both. Not sure how the bleeding wasn't worse, honestly.

After a heated discussion that involved escalating to VPMA, the surgeon came in to repair the girl's face. Before he went to the room, though, he proceeded to very loudly and publicly berate the ED doc for waking him up over this. The guy then proceeds to spend an hour delicately reconstructing her face in a way that honestly looks like it never happened.




So, covid comes around and plastics wants to see cases

Every time he came down

every
single
time

this story was told to him


now he doesn't yell when we call at 3a

Thinking about billing today is short-sighted. Think about the long game and what you have to gain from taking the COVID hit.

(you could say the morale of the story is leverage anything, but the real moral is we are nobody and gtfo like I did)


EDIT: A-hole auto-corrects to Dingus? Man they really need to remove the profanity filter here, I'm allowed to be professional and curse, just like in real life

 

[southerndoc]

EDIT: A-hole auto-corrects to Dingus? Man they really need to remove the profanity filter here, I'm allowed to be professional and curse, just like in real life

That's hilarious. Promise it wasn't my doing! lol Anyone who knows me knows I curse like a sailor and go into F-tach a lot so I definitely wouldn't do that.

 

[VA Hopeful Dr]

That's hilarious. Promise it wasn't my doing! lol Anyone who knows me knows I curse like a sailor and go into F-tach a lot so I definitely wouldn't do that.

Yeah that's been a thing for many years at this point. Wouldn't surprise me if it was a very old April fool's joke that just stuck around.

 

[Pinner Doc]

Don't take it personal. He's not talking about that. How many anesthesiologists need to call an ER doc to bail them out? I am clueless what gas does what and how to operate most of their equipment.

I also wouldn't expect an interventional cardiologist, trauma surgeon, or neurosurgeon to call an ER doc to bail them out. "Dr. southerndoc, Dr. Neuro needs help with a burr hole. Can you come to OR 3?"

Interestingly. we have assisted on traumas and c sections in the OR.

 

[circleK]

Great thread. I agree with above who said we need more collaboration between anesthesia and ER.

You do not want to get involved in the elective endo suite…it is boooring AF. But if you’d like to take over the ECTs that would be great.

Also I guess I’m one of the few docs who actually enjoyed The Pitt (but I’m not ER).

 

[Arcan57]

I got called into the OR to run a code once on someone that died during surgery. Very weird experience. GYN just kinda stood there watching and the anesthesiologist (MD) spent the entire code futzing with placing a radial a-line. It didn't end well and was quite difficult to document in a neutral manner.

 

[Jabbed]

I got called into the OR to run a code once on someone that died during surgery. Very weird experience. GYN just kinda stood there watching and the anesthesiologist (MD) spent the entire code futzing with placing a radial a-line. It didn't end well and was quite difficult to document in a neutral manner.

I actually had the exact same experience, including the radial arterial line.

 

[Porfirio]

I always love the $initiative$ when dudes want art lines on someone without a pulse. Extra billables baby.

 

[BoardingDoc]

I got called into the OR to run a code once on someone that died during surgery. Very weird experience. GYN just kinda stood there watching and the anesthesiologist (MD) spent the entire code futzing with placing a radial a-line. It didn't end well and was quite difficult to document in a neutral manner.

WTF? In what world are we getting called to the OR to run a code?

Forgetting for the moment that the OR staff should theoretically be able to manage this (and the surgeon could presumably treat the underlying cause for the arrest).... leaving the ER to respond to a code in the OR seems like a great way to get sued for abandoning the ER if anything bad happens while you're away.

That is precisely why our ED had a long conversation with hospital admin about overnight intubations and the new policy became "anyone who needs to be emergently intubated overnight gets wheeled down to the ER. We don't go to them, they come to us."

 

[turkeyjerky]

I always love the $initiative$ when dudes want art lines on someone without a pulse. Extra billables baby.

Honestly, I kinda love having an a-line in for arrests. Takes all the guess work out of pulse checks, helps titrate epi dosing, differentiates psuedo-pea from pea, etc. But I tend to think that in many of these cases, people can easily lose situational awareness and become task-focused. Also, occasionally there's an element of subconscious desire to abdicate responsibility due to discomfort.

 

[Mount Asclepius]

Agree, an arterial line can be helpful as long as it’s not distracting you from trying to fix reversible causes of the arrest. Better to place a central femoral arterial line than a peripheral radial arterial line. I often do for cardiopulmonary arrest patients depending upon the circumstances of the arrest.

 

[Mount Asclepius]

That is precisely why our ED had a long conversation with hospital admin about overnight intubations and the new policy became "anyone who needs to be emergently intubated overnight gets wheeled down to the ER. We don't go to them, they come to us."

We used to do this, but were forced to stop. There are significant regulatory concerns with bringing an inpatient back to an area that is defined as outpatient and a lower level of care.

 

[WhatJobDoIPick]

We used to do this, but were forced to stop. There are significant regulatory concerns with bringing an inpatient back to an area that is defined as outpatient and a lower level of care.

Where are the regulations protecting us from liability when the grey infant wheels in while we are upstairs intubating meemaw?

This field is seriously a joke.

 

[TooMuchResearch]

Honestly, I kinda love having an a-line in for arrests. Takes all the guess work out of pulse checks, helps titrate epi dosing, differentiates psuedo-pea from pea, etc. But I tend to think that in many of these cases, people can easily lose situational awareness and become task-focused. Also, occasionally there's an element of subconscious desire to abdicate responsibility due to discomfort.

Check femoral with ultrasound.
Epi dosing is 1 mg every once in awhile until it's not.
Patient will likely be pronounced dead by the time my nurses remember how to get the setup...set up.

 

[TooMuchResearch]

Where are the regulations protecting us from liability when the grey infant wheels in while we are upstairs intubating meemaw?

This field is seriously a joke.

I leave my ED to get coffee or a snack but I guess the difference is I can always run back.

We still cover rapid response/codes in the small hospitals though. We're generally the only people qualified to run them...or at least the best qualified.

 

[Janders]

We used to do this, but were forced to stop. There are significant regulatory concerns with bringing an inpatient back to an area that is defined as outpatient and a lower level of care.

Disagree. Inpatients are constantly boarded in the ED. The ED is defined in our hospital policy as a disaster/critical care overflow area. There is no regulatory concern with bringing a patient to the ED. We are the highest level of care.

 

[Mount Asclepius]

Disagree. Inpatients are constantly boarded in the ED. The ED is defined in our hospital policy as a disaster/critical care overflow area. There is no regulatory concern with bringing a patient to the ED. We are the highest level of care.

The regulatory and legal team of a large organization disagrees with you.

 

[Pinner Doc]

WTF? In what world are we getting called to the OR to run a code?

Forgetting for the moment that the OR staff should theoretically be able to manage this (and the surgeon could presumably treat the underlying cause for the arrest).... leaving the ER to respond to a code in the OR seems like a great way to get sued for abandoning the ER if anything bad happens while you're away.

That is precisely why our ED had a long conversation with hospital admin about overnight intubations and the new policy became "anyone who needs to be emergently intubated overnight gets wheeled down to the ER. We don't go to them, they come to us."

When I practiced EM, I had to run codes allll over the hospital. Even when solo coverage in the ED.

 

[RustedFox]

When I practiced EM, I had to run codes allll over the hospital. Even when solo coverage in the ED.

I did until they squashed that.

 

[BoardingDoc]

We used to do this, but were forced to stop. There are significant regulatory concerns with bringing an inpatient back to an area that is defined as outpatient and a lower level of care.

I can understand that an administration might argue that. It doesn't make it correct. Not even taking into account that they're simply shifting the liability onto the ED doc, it is easy enough to define a hospital protocol which allows for this situation. The fact that they choose not to doesn't mean it's not an option.

 

[southerndoc]

Disagree. Inpatients are constantly boarded in the ED. The ED is defined in our hospital policy as a disaster/critical care overflow area. There is no regulatory concern with bringing a patient to the ED. We are the highest level of care.

There are regulatory issues at play as well as insurance/reimbursement issues. Moving the patient from inpatient to ED is often viewed by most insurers as discharging the patient, and bringing them back into the inpatient side would be viewed as a readmission.

However, it sounds like you aren't changing the status of the admission but instead are merely moving the physical location of the patient to the ER. That probably would be hard to say is a regulatory violation.

We cannot do this in my ER because the ER nurses document via Epic ASAP (along with physicians) whereas the inpatient side documents with another variant of Epic.

 

[JacobMcCandles]

it is easy enough to define a hospital protocol which allows for this situation.

A hospital protocol is not the end all be all in the medical world. Just ask your big brother (government). Like everything else, it’s never an issue until it becomes an issue.