Pediatrician (not PEDS ANES) Anesthesia Story

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doctor712

doctor712

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True Story.

So, I take my youngest guy into the pediatrician two days ago, for an ear infection, and I'm making small talk with his PEDS doctor, a very nice woman who has been our doc for years. She's in new digs, in a pediatric "hospital", and I asked her how she liked the new setting - as opposed to the old office in a plain old office complex, she goes on about how it's been an adjustment, it's more clinic/hospital-feeling than before.

I ask, "How so..."

And she tells a story about part of her new responsibilities, (she's a pp sole practitioner) whereby, for example, that day, she was called quickly to cover a case in her new hospital setting because an anesthesiologist (presumably a Peds Anesthesiologist) wasn't present, they needed her (an MD) to "be there" in case the patient (kid) "coded during the procedure."

HUH?!?!?!?

I mean, all docs run codes in either M4 and/or residency I'm told, but why is a pediatrician (with no formal anesthesia training) present for an anesthesia case ("twilight anesthesia" was how she described it when I asked what kind of case it was)?

Isn't that for the person giving the anesthesia to be in charge of? And wait a second - where was the anesthesiologist?
Granted, I know CRNAs and GIs give meds, and sometimes you guys aren't in the room - but - why the call to a PP Pediatrician?!

She said they don't have anesthesia on call 24/7 (despite the fancy name associated with this Peds Hospital), she ran off the days and times anesthesia was in house, and that this was a "last minute add-on" of an "otherwise healthy kid", but they "needed me there, to cover in case he coded."

Am I the only one who thinks this is a little WONKY?????

So, another doc is giving anesthesia, (presumably), maybe GI, or Ortho, or ICU, and when Anesthesia is gone for the day, a PLAIN OLD PEDIATRICIAN (no offense to PEDS peeps, love em, thank you GOD for them!), covers Anesthesia-related cases?!?!? She says, normally it's Anesthesia, when they aren't there, it's usually, an "Intensivist", and she's next in line...

I'm glad PEDS now doubles as Anesthesia training. 👎 Remind my to go to IVY TOWER if I ever need Anesthesia.

Sour taste for this place. I guess Florida has its own set of rules...

Esplain is this is normal, if you would. THANKS!

D712
 
please PM me the name of this children's hospital. i'd like to see if they have a fellowship and if so, i will cancel their name from my eventual list when it's time for me to apply. thanks
 
For all, it's an off-shoot of a larger Children's Hospital, and does not have an Anesthesia Residency program. However, a PEDS ANESTHESIA fellowship is listed on the main Children's Hospital site. Whether or not Peds Anesthesia rotates at this one off-shoot hospital is anyone's guess...

D712
 
Inpatient facility? (with OR's that do more than ambulatory cases)? with an ICU?
 
Masseter Spasm said:
Inpatient facility? (with OR's that do more than ambulatory cases)? with an ICU?
Click to expand...

This is not a surgical center. It's definitely a hospital. ICU was just me guessing where this procedure was done. But the pediatrician did mention intensivists, if that helps.
This children's hospital is the same physical size as a normal hospital in my hometown growing up. again, not a surgi center.

I take it from the initial replier above, and a splash of common sense,
That this is a pretty crappy practice for them to be doing.

D712
 
The only way this would be acceptable is if she didn't describe the whole situation and she was called in to do a "conscious sedation" case-- many pediatricians/peds hospitalists are trained to provide sedation for short, uncomplicated procedures in which this type of sedation would be appropriate (I realize the term "conscious" is a misnomer), meaning some combination of ketamine and versed, generally. To work in our peds urgent care, you need be trained in sedation (think ortho fracture reductions, or small lac repairs). Many pediatricians don't want to be affiliated with the hospital because this may become part of their expected responsibilities.

If intensivists were involved there's no way a general pediatrician would be called in as back up for a code situation.

At our institution the only folks who can provide sedation for procedures in children are our peds ED docs, pediatric hospitalists trained in conscious sedation, sedation nurses in MRI/radiology, peds intensivists and anesthesia. No surgeons. The hospitalists provide sedation for things like burn dressing changes on the floor, LPs in onc kids, etc. Very limited repertoire of drugs, always with in house anesthesia backup.

I think we're missing part of the story here.
 
michigangirl said:
The only way this would be acceptable is if she didn't describe the whole situation and she was called in to do a "conscious sedation" case--
Click to expand...

I asked if this was "conscious sedation" and she said, "twilight." so, yes, short procedure was described. explicit type of anesthesia was not. however, why does this "make it right?" my true feeling is this pediatrician has been doing private practice peds for 20 years, I'm not thinking she took a refresher in the last month. just the feeling i got.

michigangirl said:
If intensivists were involved there's no way a general pediatrician would be called in as back up for a code situation.
Click to expand...

well, this is exactly the case. she was brought it to do a case that frontline anesthesia and back up intensivists were not available for. wish i knew the case....

michigangirl said:
At our institution the only folks who can provide sedation for procedures in children are our peds ED docs, pediatric hospitalists trained in conscious sedation, sedation nurses in MRI/radiology, peds intensivists and anesthesia. No surgeons. The hospitalists provide sedation for things like burn dressing changes on the floor, LPs in onc kids, etc. Very limited repertoire of drugs, always with in house anesthesia backup.
I think we're missing part of the story here.
Click to expand...

i clearly don't have the whole picture, but i assure you, this isn't a peds hospitalist, peds fellowed ER doc, etc. old fashioned pediatrician in office setting for years.

Also, to the other peeps above, I just spoke to the local PD with affiliated program here, school's residents don't rotate at this kids hospital.

D712
 
She probably had some arrangement to cover the facility for emergencies. She's on "call" and there's no anesthesia team there for an urgent procedure (Picc line, MRI, whatever). Now she had to staff the conscious sedation nurse because they have to have MD back up.
Btw pediatric conscious sedation is really usually room air general with an unprotected airway, done by providers with limited emergency management skills. You don't want that for your child.

Cheers!
 
Probably she is just being immediately available in case of a pediatric code where the "conscious sedation" RN gets into trouble.

They probably want an MD who is PALS certified immediately available. We don't own ACLS, PALS, or NRP. Nor do we want to.
 
Bertelman said:
The fact that she is calling it "twilight" suggests she is not trained in sedation.
Click to expand...

Strangely, I thought it was odd that I mentioned "conscious sedation" and her reply was a hesitant, "It was twilight" anesthesia.

WTF is that?!

The point of this post is, when it comes to me or my children, call me crazy, but I want a highly trained Anesthesiologist to provide for my family. Not an otherwise caring pediatrician. They deserve nothing less than the best mind/hands/skill, and as an anesthesiologist once told me during a chat, (paraphrasing), "We require board certification not because of the plaque on the wall, but because the data show that while a CRNA, MD, DO or GI can actually give anesthesia, when the S HIT hits the fan, it's those with BC that have better outcomes for their patients in time of crises."

In fact, this reminds me, that should be the mandate! Last years' ASA keynote was Atul Guwande, who wants, what: <1% mortality in all ORs worldwide? What a wonderful goal. The picture I painted up above, of the pediatrician covering, to this layman, doesn't seem the path. I could be very wrong though.

D712
 
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dr doze said:
Probably she is just being immediately available in case of a pediatric code where the "conscious sedation" RN gets into trouble.

They probably want an MD who is PALS certified immediately available. We don't own ACLS, PALS, or NRP. Nor do we want to.
Click to expand...

Doze, I understand your point here on PALS, and far be it for me to argue this point, but as far as your first line up above, when the conscious sedation patient codes, is that patient in equally competent hands with YOU or the pediatrician? And if not in equal hands, (though I'm not going to advocate for an overhaul and dreamy new anesthesia reality in the US overnight), do the data show that the patient would do better in your hands than in my son's pediatrician? I mean, the point of protecting a code situation, is...protecting as best. If that's all this hospital can buy, so be it. I'll never take my kid there for even an ear tube. Or snack from the vending machine, even that was broken. Frigging M&Ms were dangling there by a single strand of DNA (like that seinfeld episode). 😀

D712
 
doctor712 said:
Doze, I understand your point here on PALS, and far be it for me to argue this point, but as far as your first line up above, when the conscious sedation patient codes, is that patient in equally competent hands with YOU or the pediatrician? And if not in equal hands, (though I'm not going to advocate for an overhaul and dreamy new anesthesia reality in the US overnight), do the data show that the patient would do better in your hands than in my son's pediatrician? I mean, the point of protecting a code situation, is...protecting as best. If that's all this hospital can buy, so be it. I'll never take my kid there for even an ear tube. Or snack from the vending machine, even that was broken. Frigging M&Ms were dangling there by a single strand of DNA (like that seinfeld episode). 😀

D712
Click to expand...

Well - ultimately this, like all things in medicine, is a question of 'good enough' ...

Your average PALS-trained pediatrician might have been a reasonably qualified person for whatever it was they were doing.

Maybe an anesthesiologist would've been better.

Of course it'd be nice to have a pediatric fellowship trained anesthesiologist on standby too. Better yet if you limited that to pediatric fellowship trained anesthesiologists who scored >2 standard deviations above the mean on their written boards and have >10 years experience.

I'm being sort of facetious, but at some point, qualified means qualified enough.


There aren't enough of us to baby-sit every sedation case conducted in a hospital. Is a pediatrician with PALS a better backup than just the distracted procedure-doer and an RN with the minimum 5 supervised sedations on the credential card? Absolutely.

JCAHO requires that the anesthesia department monitor sedation practices within the hospital. If someone other than a physician is sedating a patient, presumably at some point the anesthesia department was aware and had input on the arrangement.


Not sure what to make of the 'twilight anesthesia' comment. Is it possible this pediatrician didn't know that you were more informed than the average parent? I dumb down my doctorspeak all the time if I think the person I'm talking to doesn't know anything about anesthesia. There's just no point in using precise terms.


The whole thing does strike me as odd, but ... she IS a doctor. If she and the hospital credentialing office are cool with it, she can do whatever she wants.
 
Arch Guillotti said:
I use the term "twilight anesthesia" sometimes since it seems to convey the gist of the matter fairly well to a number of folk.
Click to expand...

I thought twilight anesthesia was common verbage for the common folk. however, when the OP states "conscious sedation" it shows he knows something about it and the pediatrician still used the common word. goes to show she may not fully understand what's going on. i wouldnt want her in there personally.
 
As a pure peds anesthesia person, you can imagine that I have strong feelings about who should sedate and anesthetize kids, and what their skill level should be for each situation. pgg brought up many excellent points that I completely agree with. Bottom line with this story ...is that we don't have the story. We can talk about it till we're blue in the face, but we have no clue what kind of procedure she was asked to be a part of, what medications were being given, what the setting was (ED? inpt?).

If your kid is getting tubes, I hope that it's in an OR with a peds anesthesiologist. This case wasn't tubes. And I am utterly confused by how a pediatric hospital (is this an actual children's hospital?) isn't full of PALS certified folks. Every peds resident must be PALS certified, and every children's hospital has at least one Peds Attending in house at all hours (usually the Peds ED attending).

Again, details are sparse. So I can't judge. What I do know is that there aren't enough pedi anesthesiologists to go around and give a dose of versed for a facial lac repair or pus drainage in a healthy kid. My pediatrician colleagues in a children's hospital who are trained in BLS and PALS can do a safe job with this and know when to call for help.

Now when this gets dicey is when procedures are done on kids in offices, at the dentist, or at an adult hospital without pediatric resources or an appreciation for pediatric physiology or the importance of their medical histories is overlooked. Sad cases abound in the literature.
 
doctor712 said:
Doze, I understand your point here on PALS, and far be it for me to argue this point, but as far as your first line up above, when the conscious sedation patient codes, is that patient in equally competent hands with YOU or the pediatrician? And if not in equal hands, (though I'm not going to advocate for an overhaul and dreamy new anesthesia reality in the US overnight), do the data show that the patient would do better in your hands than in my son's pediatrician? I mean, the point of protecting a code situation, is...protecting as best. If that's all this hospital can buy, so be it. I'll never take my kid there for even an ear tube. Or snack from the vending machine, even that was broken. Frigging M&Ms were dangling there by a single strand of DNA (like that seinfeld episode). 😀

D712
Click to expand...

Agree with pgg and michigan girl. If you google "conscious sedation protocols RN" you will find lots of info on what goes on. In pediatrics too.
 
michigangirl said:
As a pure peds anesthesia person, you can imagine that I have strong feelings about who should sedate and anesthetize kids, and what their skill level should be for each situation. pgg brought up many excellent points that I completely agree with. Bottom line with this story ...is that we don't have the story. We can talk about it till we're blue in the face, but we have no clue what kind of procedure she was asked to be a part of, what medications were being given, what the setting was (ED? inpt?).

If your kid is getting tubes, I hope that it's in an OR with a peds anesthesiologist. This case wasn't tubes. And I am utterly confused by how a pediatric hospital (is this an actual children's hospital?) isn't full of PALS certified folks. Every peds resident must be PALS certified, and every children's hospital has at least one Peds Attending in house at all hours (usually the Peds ED attending).

Again, details are sparse. So I can't judge. What I do know is that there aren't enough pedi anesthesiologists to go around and give a dose of versed for a facial lac repair or pus drainage in a healthy kid. My pediatrician colleagues in a children's hospital who are trained in BLS and PALS can do a safe job with this and know when to call for help.

Now when this gets dicey is when procedures are done on kids in offices, at the dentist, or at an adult hospital without pediatric resources or an appreciation for pediatric physiology or the importance of their medical histories is overlooked. Sad cases abound in the literature.
Click to expand...

I understand and agree with you here, MichiganGirl, thank you very much for your thoughts! To answer your question, this place is a large Outpatient Center affiliated with a Children's Hospital. At least that's what the name says.

"XCITY CHILDREN'S HOSPITAL X FAMOUS PERSON'S NAME OUTPATIENT CENTER"

D712
 
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Ah, it all makes sense now.

The only subspecialties that see patients in this outpatient center are:
Allergy & Immunology
Orthopaedics (Spine & Scoliosis)
Clinical Genetics
Psychology
Endocrinology
Sports Medicine

So other than general pediatrics, this outpatient center very much deals with children with developmental needs, neuro kids, etc.-- it is associated with the children's hospital but is a free standing outpatient center. No inpatient docs-- only the allergy/immunology, endocrinology and genetics docs are peds board certified and even possibly have PALS-- and likely aren't up to date. My guess is she was called in for some sort of ortho thing on a kid who couldn't cooperate (cast removal, replacement) who needed some sedation to get it done.

There's no cardiology, pulmonary docs here, so they are not even doing sedated echos on little ones, very limited diagnostic services. They list MRI as one of their three diagnostic services with EEG, so they must have a peds anesthesiologist who staffs MRI when there are scheduled scans on little kids, but given that it's an outpatient center, there are no "emergency" MRIs, so if the anesthesiologist isn't scheduled to be there for outpatient MRIs on kids, they're just not there.

Just my theory based on the practice models I know.
 
I'm not sure why you even X'ed out the name. You put enough verbatim text in that paragraph that googling a couple lines gives it away.
 
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Vector2

If you saw I went through the trouble of taking out names, why create a post bringing attention to how to circumvent that?

At a loss.
D712
 
My peds rotation at Miami Childrens has MRI sedation cases routinely staffed by pediatricians in the early 2000s.
 
doctor712 said:
Vector2

If you saw I went through the trouble of taking out names, why create a post bringing attention to how to circumvent that?

At a loss.
D712
Click to expand...

I dunno, so maybe you could edit your post to take out the identifying information?
 
Hard to do after you quoted it yourself, wouldn't you think.

But thanks for reading my reply and removing your quoted text. I do appreciate that.

Kind suggestion (especially when we are dealing with people's locales etc: PM the thought?)

Thanks,
D712
 
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where I trained peds intensivists provided some sedation for minor procedures in ICU ( changing dressings). I did one month of PICU during my internship year ( total waste, BTW - plain rounding until you die)))
I also remember how they were freaking out when eventually as anesthesia resident I came for a longer dressing change and gave propofol - WHAT, you give kids THAT? (kid was a toddler with a central line, after MVA)
 
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hoyden said:
where I trained peds intensivists provided some sedation for minor procedures in ICU ( changing dressings). I did one month of PICU during my internship year ( total waste, BTW - plain rounding until you die)))
I also remember how they were freaking out when eventually as anesthesia resident I came for a longer dressing change and gave propofol - WHAT, you give kids THAT? (kid was a toddler with a central line, after MVA)
Click to expand...

don't know where you trained, but all PICUs ar enot the same. I'm surprised that any PICU has rounds that are longer than in an adult ICU, MICU, SICU or otherwise. Anyway, in our PICU all sedations are done by the intensivists-- bronchs, dressing changes, any procedure that requires sedation or intubation is taken care of by the intensivists unless the surgeon needs to do it in the OR. Also, our peds intensivists all use propofol (and know how to use it) regularly for intubations and sedations. The PICU and OR are the only places in the children's hospital propofol is used or available.

If you are an anesthesia resident please don't generalize and not do a PICU month-- our residents work their as#es off when they are in the PICU but its some of the best teaching available and some really nice folks in an acute care environment. Find out how the PICU at your institution rolls.
 
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