NP's and procedures

[ledo99]

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I'm leaving my current group in a couple of months, they asked me if I can "train" one of our nurse practitioners to do Botox injections and occipital nerve blocks; non of the other physicians in the group do these procedures. my response was that I don't think it's a good idea to have a mid-level perform these procedures indeprendantly if there are no physicians in the group who can actually supervise or manage these patients in case there are any complications. I know these are relatively simple procedures compared to spinal injections, etc. but at the end of the day these are invasive procedures and there is also a decision-making process here to determine the type of patients who need them and how to manage them afterwards, assess the response, modify the treatment plan, etc. and I'm not sure they would have the proper model to do that if they want to get this done with an NP under the "supervision" of an MD who's never done any of these procedures before!

what do you guys think? I wanted to share this with you to get some feedback and ideas. I know they'll talk about this again before I leave! lol

 

[facets]

Absolutely not, there have been cases of patients going into full code after occipital nerve blocks. The theory is that the medication can go up the nerve to the brain stem. For that reason, occipital nerve blocks stay in recovery for 15 minutes. Who will handle or even recognize this complication?

 

[jsaul]

Absolutely not, there have been cases of patients going into full code after occipital nerve blocks. The theory is that the medication can go up the nerve to the brain stem. For that reason, occipital nerve blocks stay in recovery for 15 minutes. Who will handle or even recognize this complication?

arterial uptake possible as well. I would not train NPs due to these procedures.

 

[lobelsteve]

http://www.nexuspaincare.com/pdf/22.pdf

This arose because after a fellow performed an occipital block, the patient died.

 

[PMR 4 MSK]

tell them you will train one of their docs to do it, and then they can train the NP if they see fit.

If a problem arises, the NP and the group can still point the finger at you, as the trainer, as vicariously liable for any problem she has.

 

[DOctorJay]

come on guys, as someone excited to start fellowship next year...

JUST SAY NO

 

[ledo99]

Thanks guys. I will stick to my initial response... "No means No!" lol..

the more I think about this the more I believe it doesn't make any sense from a safety or quality of care stadpoint.. it seems that they are mainly interested in keeping those patients and not losing them to the "competetion" rather than providing good quality care with the proper tools.

 

[ledo99]

http://www.nexuspaincare.com/pdf/22.pdf

This arose because after a fellow performed an occipital block, the patient died.

do you have another link to this? I couldn't open this article. Thanks.

 

[geauxg8rs]

I heard Racz talk a few years ago about a GON where they put the needle through the skull and injected with a less than desirable outcome.

 

[facets]

i heard racz talk a few years ago about a gon where they put the needle through the skull and injected with a less than desirable outcome.

coool!!

 

[lobelsteve]

http://www.practicalpainmanagement....tions/emergency-protocols-spinal-injectionist


Working link.

 

[lobelsteve]

I heard Racz talk a few years ago about a GON where they put the needle through the skull and injected with a less than desirable outcome.

Sudden unconsciousness during a lesser occipital nerve block in a patient with the occipital bone defect.

Okuda Y, Matsumoto T, Shinohara M, Kitajima T, Kim P.Occipital nerve block is usually considered to be a very simple and safe regional anaesthetic technique. We describe a case of sudden unconsciousness during a lesser occipital nerve block in a patient with an occipital bone defect. A 63-year-old man complained of headache, which was localized to the right occipital region. A right lesser occipital nerve block with a local anaesthetic was performed for treatment. During the lesser occipital nerve block, the patient suddenly became disturbed and lost consciousness. Two hours after the incident, the patient was fully awake without neurological sequelae. He had previously undergone a microvascular decompression for right trigeminal neuralgia. The patient had a bone defect following craniotomy. We believed that the loss of consciousness during lesser nerve block may be due to a subarachnoid injection. Occipital nerve block is relatively contraindicated in the presence of a bone defect.

 

[ghost dog]

I'm leaving my current group in a couple of months, they asked me if I can "train" one of our nurse practitioners to do Botox injections and occipital nerve blocks; non of the other physicians in the group do these procedures. my response was that I don't think it's a good idea to have a mid-level perform these procedures indeprendantly if there are no physicians in the group who can actually supervise or manage these patients in case there are any complications. I know these are relatively simple procedures compared to spinal injections, etc. but at the end of the day these are invasive procedures and there is also a decision-making process here to determine the type of patients who need them and how to manage them afterwards, assess the response, modify the treatment plan, etc. and I'm not sure they would have the proper model to do that if they want to get this done with an NP under the "supervision" of an MD who's never done any of these procedures before!

what do you guys think? I wanted to share this with you to get some feedback and ideas. I know they'll talk about this again before I leave! lol

I think an equally relevant issue is : can a NP take a proper history and physical elucidating that an occipital nerve block or Botox is indicated for a chronic pain patient? Without supervision ?

This is a quite a detailed and complex endeavour.

I completely agree with the above; is a NP qualified to run an ACLS code complete with intralipid protocol? Without supervision?

Please.

The med mal lawyers rub their hands with glee.

 

[doctorlarry]

Absolutely not, there have been cases of patients going into full code after occipital nerve blocks. The theory is that the medication can go up the nerve to the brain stem. For that reason, occipital nerve blocks stay in recovery for 15 minutes. Who will handle or even recognize this complication?

Really? That's quite a distance from occipital nerve down to C2/C3 then back up to spinal trigeminal tract to brainstem. Then again, this pathway is implicated in trigeminocervical complex of migraine and possible mech behind ON stim for migraine.

And whats up with the skull defect, one ought to be able to know the history and palpate before placing the needle. Physician or not.

 

[ghost dog]

Really? That's quite a distance from occipital nerve down to C2/C3 then back up to spinal trigeminal tract to brainstem. Then again, this pathway is implicated in trigeminocervical complex of migraine and possible mech behind ON stim for migraine.

And whats up with the skull defect, one ought to be able to know the history and palpate before placing the needle. Physician or not.

You can get a cardiac arrest from LAST.

It ain't pretty.

Again, a med mal practice lawyer's dream (if a NP was doing this in isolation).