Propofol on ER

[Planktonmd]

CUMM'ON, PLANK.

GIMME A *****NG BREAK, DUDE.

Ya think any anesthesia department on the planet has the desire/ability to run down to the ER every time an ER physician or a consultant in the ER needs sedation?

In my bum-fuk-egypt gig, every once in a while we'd go to the ER and squirt some propofol into a dislocated hip patient's IV for an orthopedist that was one of our premium playas.

That was preferential treatment for a dude that made us, literally, millions of dollars.

But thats not sustainable....we couldnt always go...

At my current gig theres no way we could provide that type of service.

How do you staff for something like that? The ER, where anything could happen at anytime?

You can't.

Far better to get the ER docs comfortable with sedation.

They're doctors.

Actually they're, behind us, the best at airway management.

So wheres your beef with this?

This is not "sedation" this is general anesthesia because their end point is being able to pull on a broken bone without the patient screaming, any patient who doesn't scream when you manipulate their broken bones is under GA.
I understand the staffing issues and believe me I don't like getting called to the ER for this kind of stuff, but that doesn't mean I will endorse ER physicians administering GA without training even if they call it "procedural sedation".
We make the administration of anesthetics look so easy in our hands that people think that anyone can do it.
This type of anesthetic (GA with unprotected airway) is as you know dangerous and requires vigilance and continuous interaction with the patient, the airway and the monitors, no one is trained to simultaneously do these tasks other than us and the other anesthesia providers.
The others can do it and get away with it most of the time, but it is substandard patient care and we should not endorse it.

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[canjosh]

Sedation in the ER (or anywhere) is a touchy subject, because it's easy to go too far and wind up with a general anesthetic - typically with an unsecured airway in a trauma patient with a full stomach. Most would agree that this is not a good thing.

The ER docs at your institution are licensed physicians, and sedation is within their scope of practice. If another department (anesthesiology) is dictating what drugs stocked are in their realm, they need to put on their big boy pants and fight that pharmacy political battle. Not just cue the Bon Jovi cowboy music, and charge ahead with off-label use of an inferior drug.

What will they do when the all-powerful anesthesiologists realize that they're using etomidate for "sedation" in the ER, and get that drug banned too? Uncork the whiskey bottle?

I know you're just reporting what you've observed, and that the sedation techniques at your hospital aren't yours to choose. Not really trying to pounce on you personally.

Thank you...I don't take any of that personally. I assume the dept of anesthesia already knows the EDPs are using etomidate for procedures...I am fairly certain that an anesthesia representative had to sign off on the sedation policy for the ED. I will double check on that before I commit to saying that our anesthesia dept is aware of the drugs our guys use. I fully agree that ED sedation is a touchy subject (and rightfully so), but I believe EM and anesthesia should really commit to working together to find a happy, safe medium for non-anesthesia provider sedation.

 

[jwk]

Thank you...I don't take any of that personally. I assume the dept of anesthesia already knows the EDPs are using etomidate for procedures...I am fairly certain that an anesthesia representative had to sign off on the sedation policy for the ED. I will double check on that before I commit to saying that our anesthesia dept is aware of the drugs our guys use. I fully agree that ED sedation is a touchy subject (and rightfully so), but I believe EM and anesthesia should really commit to working together to find a happy, safe medium for non-anesthesia provider sedation.

By policy, propofol, pentothal, brevital, ketamine, and etomidate are anesthesia-only drugs in our hospital.

 

[huktonfonix]

thats a really fine line. It sounds like the hospital policy is to make induction drugs "anesthesia only", but we can induce with benzos and narcotics too. I wonder where they draw that line. Like one of my attendings told me once, "You can kill someone with almost any medication in this drawer".

 

[jwk]

thats a really fine line. It sounds like the hospital policy is to make induction drugs "anesthesia only", but we can induce with benzos and narcotics too. I wonder where they draw that line. Like one of my attendings told me once, "You can kill someone with almost any medication in this drawer".

The idea has been that the Anesthesia Department is responsible for anesthesia-related services throughout the hospital. (Isn't there some JCAHO phraseology related to that?)

 

[core0]

By policy, propofol, pentothal, brevital, ketamine, and etomidate are anesthesia-only drugs in our hospital.

Where I was previously Propofol was limited to BC EM, anesthesia and critical care physicians in those departments. So the pulmonologists could use if for bronchs but GI couldn't. Other hospital in the same system is using it for Colonoscopies by GI. Go figure.

David Carpenter, PA-C

 

[deleted6669]

Where I was previously Propofol was limited to BC EM, anesthesia and critical care physicians in those departments. So the pulmonologists could use if for bronchs but GI couldn't. Other hospital in the same system is using it for Colonoscopies by GI. Go figure.

David Carpenter, PA-C

we use propofol for adult reductions, ketamine for peds procedures and etomidate only for rsi.
I've been using more propofol recently(last 6 mo or so), especially for shoulder dislocations. we have to have r.t. in the room by protocol but it's worth the hassle.

 

[canjosh]

By policy, propofol, pentothal, brevital, ketamine, and etomidate are anesthesia-only drugs in our hospital.

This is why the EM guys are thrown for a loop whey they come on sdn and are told they are dumb for using etomidate. At their respective hospital, they're being told (presumably by anesthesia) that etomidate is 'ok' for use in the ED. Then they come here, and are told the exact opposite. It's as if someone was to tell you that you should have been operating that laryngoscope with your right hand all these years. Anyways, before I start to beat a dead horse, I'll fade into the background and reassume my role as sponge--soaking up what knowledge I can...thanks for your responses.

 

[roja]

This is not "sedation" this is general anesthesia because their end point is being able to pull on a broken bone without the patient screaming, any patient who doesn't scream when you manipulate their broken bones is under GA.
I understand the staffing issues and believe me I don't like getting called to the ER for this kind of stuff, but that doesn't mean I will endorse ER physicians administering GA without training even if they call it "procedural sedation".
We make the administration of anesthetics look so easy in our hands that people think that anyone can do it.
This type of anesthetic (GA with unprotected airway) is as you know dangerous and requires vigilance and continuous interaction with the patient, the airway and the monitors, no one is trained to simultaneously do these tasks other than us and the other anesthesia providers.
The others can do it and get away with it most of the time, but it is substandard patient care and we should not endorse it.

Do you really think that EMP's are so foolish as to administor drugs that have this type of potentially dangerous side effect in a cavalier fashion, pushing propofol through an IV, in a hallway and then, in Macgyver fashion, relocating a shoulder/ankle/fracture and splint it, then maybe checking the airway?

Regardless of what you want to call it, 'concious sedation' requires TWO physicians, one who is at the head of the bed, monitoring the airway, vitals, etc. The SECOND physician is the one doing the procedure.


Personally, I would love love love to never have to do 'conscious sedation' again. If I could get an anaesthesiologist to come down and do all this for me, I would be blissfully happy. I work in an ED that sees 160K patients/year. Its a level 1 trauma center. Each of my nurses is often carrying 8-10 (sometimes up to 12-15) patients a piece, often with 1-2 critical care patients boarding in the ED. My residents see on average 3-4 patients an hour (on average 1-2 more patients per hour than is recommended by an ATTENDING physician). So, taking *two* doctors and one nurse out of the circuit for almost an hour, grinds the ED to a hault. Not to mention what happens if a trauma or medical resuscitation comes in.

Although my own institution is waaaaaaaaaaay behind in terms of consious sedation, (we are only 'allowed' to use fentanyl/versed or ketamine/versed) I actively avoid any thing that remotely resembles 'sedation' (if at all possible) because it would kill my nursing supply. I have gotten incredibly creative with nerve blocks and analgesia. Not perfect, but I am left with little options. The truth of the matter is, fentanyl/versed seems MUCH more dangerous in terms of respiratory distress. Because getting anaesthesia to administer propofol (one of my only options in sever cases) is near impossible, I am faced with two options: 1- push horse doses of medications (had a chronic shoulder dislocation/fracture in a methadonian that DEPLETED the pyxis of fentanyl. Ortho kept calling for more and I kept trying to force them to the OR to give propofol- which is the only place we can get propofol given).

I have deep respect for propofol. I would *love* to have a combined educational and policy that bridges these issues. Education and communication are the only way these issues are going to be solved. I would love to feel comfortable coming into another forum and discussing cases/ideas/issues, but often anaesthesia mandates without discussion, at least in our hospital.


Despite the cliched picture of ED docs wanting to intubate anyone with a trache, I think this is grossly overstated. The last thing I want to do is to cause one of my patients who is here for a relatively simple procedure to end up tubed. I would love for all my patients to be adequately prepared, from an anaesthesia standpoint: empty stomach, etc etc. Unfortunately, they aren't.

 

[Planktonmd]

Do you really think that EMP's are so foolish as to administor drugs that have this type of potentially dangerous side effect in a cavalier fashion, pushing propofol through an IV, in a hallway and then, in Macgyver fashion, relocating a shoulder/ankle/fracture and splint it, then maybe checking the airway?

Regardless of what you want to call it, 'concious sedation' requires TWO physicians, one who is at the head of the bed, monitoring the airway, vitals, etc. The SECOND physician is the one doing the procedure.


Personally, I would love love love to never have to do 'conscious sedation' again. If I could get an anaesthesiologist to come down and do all this for me, I would be blissfully happy. I work in an ED that sees 160K patients/year. Its a level 1 trauma center. Each of my nurses is often carrying 8-10 (sometimes up to 12-15) patients a piece, often with 1-2 critical care patients boarding in the ED. My residents see on average 3-4 patients an hour (on average 1-2 more patients per hour than is recommended by an ATTENDING physician). So, taking *two* doctors and one nurse out of the circuit for almost an hour, grinds the ED to a hault. Not to mention what happens if a trauma or medical resuscitation comes in.

Although my own institution is waaaaaaaaaaay behind in terms of consious sedation, (we are only 'allowed' to use fentanyl/versed or ketamine/versed) I actively avoid any thing that remotely resembles 'sedation' (if at all possible) because it would kill my nursing supply. I have gotten incredibly creative with nerve blocks and analgesia. Not perfect, but I am left with little options. The truth of the matter is, fentanyl/versed seems MUCH more dangerous in terms of respiratory distress. Because getting anaesthesia to administer propofol (one of my only options in sever cases) is near impossible, I am faced with two options: 1- push horse doses of medications (had a chronic shoulder dislocation/fracture in a methadonian that DEPLETED the pyxis of fentanyl. Ortho kept calling for more and I kept trying to force them to the OR to give propofol- which is the only place we can get propofol given).

I have deep respect for propofol. I would *love* to have a combined educational and policy that bridges these issues. Education and communication are the only way these issues are going to be solved. I would love to feel comfortable coming into another forum and discussing cases/ideas/issues, but often anaesthesia mandates without discussion, at least in our hospital.


Despite the cliched picture of ED docs wanting to intubate anyone with a trache, I think this is grossly overstated. The last thing I want to do is to cause one of my patients who is here for a relatively simple procedure to end up tubed. I would love for all my patients to be adequately prepared, from an anaesthesia standpoint: empty stomach, etc etc. Unfortunately, they aren't.

No one is disputing that ER physicians are valuable clinicians and very busy in general.
What you are referring to as "conscious sedation" is simply general anesthesia.
Conscious sedation means the patient responds to verbal commands and otherwise maintains all his reflexes, this is not what you guys are doing when you administer anesthesia for an Orthopod to reduce a fracture, you are rendering the patient unconscious, you are doing GA with unprotected airway.
As I mentioned earlier, when an outsider looks at an anesthesia provider administering an anesthetic it might look simple but it really isn't.
We are constantly watching the patient, controlling the airway, listening to the SPO2, and always aware of the hemodynamic and respiratory status of the patient, there is more to it than you might think, and this is why there is a specialty called anesthesiology.
As an ER physician you are definitely qualified to understand the pharmacology of these hypnotic drugs and memorize the dosages but you were not trained on how to safely administer anesthesia for another physician to do a surgical procedure, you might elect to do it and most of the time get away with it, but that doesn't make it right regardless of the staffing or political reasons that pushed you to do it.

 

[Dinkyconductor]

Interesting thread...have to say I've never been called to the ER to give sedation, guess I've been lucky.

So obviously everyone else is giving decent doses of propofol in patients with full stomachs in the ER. I'm actually surprised this doesn't seem to be causing too many problems. For example, when a patient comes in with a full stomach for an emergency OR procedure that could be done under heavy sedation, I've always opted for RSI and GA, then suctioned out the stomach before waking them up. If I could do it under regional + minimal sedation (say, 1mg midaz), then I do it, but anything heavier, and I put them to sleep.

So I guess you guys just sit them up (to let gravity work for you), have suction ready, and hope for the best? Or are you placing NG tubes first before the procedure?

 

[roja]

No one is disputing that ER physicians are valuable clinicians and very busy in general.
What you are referring to as "conscious sedation" is simply general anesthesia.
Conscious sedation means the patient responds to verbal commands and otherwise maintains all his reflexes, this is not what you guys are doing when you administer anesthesia for an Orthopod to reduce a fracture, you are rendering the patient unconscious, you are doing GA with unprotected airway.
As I mentioned earlier, when an outsider looks at an anesthesia provider administering an anesthetic it might look simple but it really isn't.
We are constantly watching the patient, controlling the airway, listening to the SPO2, and always aware of the hemodynamic and respiratory status of the patient, there is more to it than you might think, and this is why there is a specialty called anesthesiology.
As an ER physician you are definitely qualified to understand the pharmacology of these hypnotic drugs and memorize the dosages but you were not trained on how to safely administer anesthesia for another physician to do a surgical procedure, you might elect to do it and most of the time get away with it, but that doesn't make it right regardless of the staffing or political reasons that pushed you to do it.

The reason I put concious sedation in quotes was because the relevance of this issue is less about semantics and more about patient care, the realities of medical practice and skill.

Believe it or not, EM physicians who are giving medications for reduction are also AWARE of the patients hemodynamic and respiratory status, watching the patient, and controlling the airway- for the very short time that the procedure needs to be done. I am not quite sure why you assume that because the procedure and anesthesia tha tis being given is happening in the ED, that no one is aware or cares about the complexity of the situation. Your arguement seems to stem from the belief that EM doctors are not capable or trained at giving BRIEF, procedural anesthesia/sedation. We are skilled at doing this and we take it VERY seriously. No one is advocating pushing propofol in a hallway, without adequate monitoring while performing a procedure.

I think you would be hard pressed to find an EM physician who thinks that being trained to do BRIEF, procedurally related anesthesia/sedation equates to BEING an aneesthesiologist. If I/we wanted to do this, we would do that particular residency. I personally could not and don't want to managed prolonged anesthesia/sedations.

And as I said, I would be more than happy (in fact) esctatic to have a board certified anesthesiologist, or even a resident, coming down to do all of my SHORT procedural anesthesia/sedations. Then *I* could do the procedures (which I would much rather do). However, as one of your colleagues mentioned, I have yet to meet an anesthesiologist who was happy and/or willing to pop into the ED every couple of hours (sometimes more) to do this type of work. What exactly are you proposing as the solution?

In my mind, the solution is education and collaboration. Believe it or not, I am capable and willing to learn not just dosages, but the risks/benefits/techniques/etc that are required for procedural sedation/anesthesia. I do this for *lots* of other drugs. (anesthesia is not the only field that has drugs that require complex thinking skills, weighing in risks/benefits/side effects/monitoring/etc)

My colleagues and I are not grunting monkeys who think anyone can do your job and just try and mimic what we see on ER. We recognize the complexities of what we are doing and would like to work WITH anesthesia to find solutions to a difficult solution.

 

[roja]

Interesting thread...have to say I've never been called to the ER to give sedation, guess I've been lucky.

So obviously everyone else is giving decent doses of propofol in patients with full stomachs in the ER. I'm actually surprised this doesn't seem to be causing too many problems. For example, when a patient comes in with a full stomach for an emergency OR procedure that could be done under heavy sedation, I've always opted for RSI and GA, then suctioned out the stomach before waking them up. If I could do it under regional + minimal sedation (say, 1mg midaz), then I do it, but anything heavier, and I put them to sleep.

So I guess you guys just sit them up (to let gravity work for you), have suction ready, and hope for the best? Or are you placing NG tubes first before the procedure?

Much like anesthesia having important semantics for levels of sedation, we have the same in the ED for emergent status. Emergent to me, means life/limb threatening. For these patients, although I would love to take the time to assess their stomach status, etc, I don't have time. (meaning, life threatening= RSI, limb threatening= probably not RSI but the treatment is probably going to be pain management only, maybe a touch of versed --->something like a bad ankle dislocation with tenting or no pulse. these are usually procedures that take a few seconds)

For other procedures that are maybe urgent (not life/limb threatening but needs to be done soon), I will often assess their gastric content status and if they have eaten recently, will try and hold off on the procedure an adequate amount of time (and usually this isn't to much of a problem as it takes forever to get these things set up....)

 

[Planktonmd]

The reason I put concious sedation in quotes was because the relevance of this issue is less about semantics and more about patient care, the realities of medical practice and skill.

Believe it or not, EM physicians who are giving medications for reduction are also AWARE of the patients hemodynamic and respiratory status, watching the patient, and controlling the airway- for the very short time that the procedure needs to be done. I am not quite sure why you assume that because the procedure and anesthesia tha tis being given is happening in the ED, that no one is aware or cares about the complexity of the situation. Your arguement seems to stem from the belief that EM doctors are not capable or trained at giving BRIEF, procedural anesthesia/sedation. We are skilled at doing this and we take it VERY seriously. No one is advocating pushing propofol in a hallway, without adequate monitoring while performing a procedure.

I think you would be hard pressed to find an EM physician who thinks that being trained to do BRIEF, procedurally related anesthesia/sedation equates to BEING an aneesthesiologist. If I/we wanted to do this, we would do that particular residency. I personally could not and don't want to managed prolonged anesthesia/sedations.

And as I said, I would be more than happy (in fact) esctatic to have a board certified anesthesiologist, or even a resident, coming down to do all of my SHORT procedural anesthesia/sedations. Then *I* could do the procedures (which I would much rather do). However, as one of your colleagues mentioned, I have yet to meet an anesthesiologist who was happy and/or willing to pop into the ED every couple of hours (sometimes more) to do this type of work. What exactly are you proposing as the solution?

In my mind, the solution is education and collaboration. Believe it or not, I am capable and willing to learn not just dosages, but the risks/benefits/techniques/etc that are required for procedural sedation/anesthesia. I do this for *lots* of other drugs. (anesthesia is not the only field that has drugs that require complex thinking skills, weighing in risks/benefits/side effects/monitoring/etc)

My colleagues and I are not grunting monkeys who think anyone can do your job and just try and mimic what we see on ER. We recognize the complexities of what we are doing and would like to work WITH anesthesia to find solutions to a difficult solution.

Again you are beside the point:
Giving an anesthetic to facilitate a surgical procedure done by another physician is not something you are trained to do, it is a combination of art and science called the practice of Anesthesiology.
Agreeing to be pushed into a situation where you are the anesthesia provider is your decision, no one else's, and by that agreement you are saying to the patient that you are capable of providing a safe effective anesthetic within the same standards that apply to trained anesthesia providers including for example NPO rules and the correct choice of anesthetic technique.

 

[roja]

Again you are beside the point:
Giving an anesthetic to facilitate a surgical procedure done by another physician is not something you are trained to do, it is a combination of art and science called the practice of Anesthesiology.
Agreeing to be pushed into a situation where you are the anesthesia provider is your decision, no one else's, and by that agreement you are saying to the patient that you are capable of providing a safe effective anesthetic within the same standards that apply to trained anesthesia providers including for example NPO rules and the correct choice of anesthetic technique.

Actually, I think I am right on point. I am looking at the realistic aspect of both our fields.

You appear to be locked into the idea that anesthesiologist are the only ones capable of learning how to administer short, safe effective anesthetics. (the same standards could be argued not to apply because the patient scenario, treatments etc are NOT the same as what is in the OR. and ankle reduction is NOT a surgical procedure. Neither is shoulder reduction. Or a fracture reduction. )

I'm sorry that you seem to be locked into such a dogmatic view. Because the truth of the matter is, I have patients that need concious sedation/anesthesia for treatments. I have no one to provide those procedures. So, for my patients safety and well being, I have *LEARNED* the appropriate medications, side effects, monitoring, etc to offer it to them. (Thankfully, not everyone in your field is that rigid, or that threatend by others learning a particular, limited aspect of your field.)
And as medicine is a field that is constantly changing and being updated, I continue to educate myself on the procedures and information I need.

By your standards, if a person in mexico is in need of treatment and a particular specialist isn't available, then that patient should just be denied care because a physician who complete a particular residency is not there.

Thankfully, most physicians are intelligent, capable individuals, able to learn. I just attending an event with a cardiac anesthesiologist who is now a 'bush doctor' in africa. He is not trained in pediatrics or infectious disease and yet is providing these services because if he doesn't, they simply won't be provided. In essence, he is being PUSHED into providing care he didn't do a residency in. But thankfully, he is able to LEARN the things he needs to provide the care that is not being provided to his patients.

This seems to be a very dogmatic and circular point for you, so I think I will just leave it as one of these:

 

[Planktonmd]

Actually, I think I am right on point. I am looking at the realistic aspect of both our fields.

You appear to be locked into the idea that anesthesiologist are the only ones capable of learning how to administer short, safe effective anesthetics. (the same standards could be argued not to apply because the patient scenario, treatments etc are NOT the same as what is in the OR. and ankle reduction is NOT a surgical procedure. Neither is shoulder reduction. Or a fracture reduction. )

I'm sorry that you seem to be locked into such a dogmatic view. Because the truth of the matter is, I have patients that need concious sedation/anesthesia for treatments. I have no one to provide those procedures. So, for my patients safety and well being, I have *LEARNED* the appropriate medications, side effects, monitoring, etc to offer it to them. (Thankfully, not everyone in your field is that rigid, or that threatend by others learning a particular, limited aspect of your field.)
And as medicine is a field that is constantly changing and being updated, I continue to educate myself on the procedures and information I need.

By your standards, if a person in mexico is in need of treatment and a particular specialist isn't available, then that patient should just be denied care because a physician who complete a particular residency is not there.

Thankfully, most physicians are intelligent, capable individuals, able to learn. I just attending an event with a cardiac anesthesiologist who is now a 'bush doctor' in africa. He is not trained in pediatrics or infectious disease and yet is providing these services because if he doesn't, they simply won't be provided. In essence, he is being PUSHED into providing care he didn't do a residency in. But thankfully, he is able to LEARN the things he needs to provide the care that is not being provided to his patients.

This seems to be a very dogmatic and circular point for you, so I think I will just leave it as one of these:

I am not sure why you are getting so defensive, and why you are comparing what you are doing to practicing medicine in the jungle or third world countries!
You are practicing in the U.S. aren't you?
In the U.S. providing anesthesia requires training.
Now, about me being threatened by you, that's your idea not mine, I actually can't stand having to go to the ER to give anesthesia but that doesn't mean I will endorse people with substandard training becoming anesthesia providers.
I am in no way underestimating your training in ER medicine, I am just stating my opinion that: You are not trained to administer anesthesia and that you actually don't even realize what you don't know.
You can disagree with my opinion but that doesn't make it:

 

[roja]

I am not sure why you are getting so defensive, and why you are comparing what you are doing to practicing medicine in the jungle or third world countries!
You are practicing in the U.S. aren't you?
In the U.S. providing anesthesia requires training.
Now, about me being threatened by you, that's your idea not mine, I actually can't stand having to go to the ER to give anesthesia but that doesn't mean I will endorse people with substandard training becoming anesthesia providers.
I am in no way underestimating your training in ER medicine, I am just stating my opinion that: You are not trained to administer anesthesia and that you actually don't even realize what you don't know.
You can disagree with my opinion but that doesn't make it:

There are several points:

1. the third world example is an analogy. It is used to illustrate, in a more direct and obvious way, that sometimes we don't get to practice in ideal settings. With escalating patient to doctor ratios, nursing shortages, and a decided ABSCENCE of anesthesiologist in the ED, the reality of practice is that while I may not have been INITIALLY trained to administer SHORT, PROCEDURAL sedation (and most ED sedations last <5minutes), myself and MANY of my colleagues have taken upon ourselves to get training in this area.

2. I am trained. As an Emergency physician. And that includes training in many areas, including short, procedural sedation. That in no way makes me an anesthesiologist. or even a pretend one. It makes me trained to do that.

3. You have in fact, proved my point. Most anesthesiologist I know, would not only balk at coming to the ED to give procedural sedation, but would wonder why the EP's can't do it themselves. It is almost *beneath* them (several friends- gas attendings/residents- paraphrased). They would much rather be in the OR handling the long, complicated cases that they do.


Medicine isn't a perfect world. Radiologists got defensive and threatened with emergency ultrasound. Until they realized that they would no longer have to come into the ED to do gallbladder u/s at 2am in the morning, and be available 24/7 to the ED. The u/s we do in the ED doesn't make us radiologist. It makes us skilled in a small, ED specific aspect. It requires training and education.


Just like procedural sedation.

Just out of curiosity, when as a resident, are you allowed to do procedural sedation. I have seen PGY2's doing this, on those rare rare occasions.

Poll your colleagues. How many of them are going to be willing to be on call 24/7 to come to the ED to do a 5 minute procedure like a shoulder or fracture? Your own field is struggling under high case loads. Do you really want to add all these people to it? Do you truly believe that another physician isn't capable of being trained to do this? That it takes 5 years to do procedural sedation training? That this is *all* your residency trains you to do? (I am exaggerating to make a point, RESIDENCY is to teach all the multitude of things that you do in your field, not just procedural sedation)

 

[fakin' the funk]

You can give my seventy-four-year old mom fifty milligrams of 2-3-diisopropyl phenol right now.

2,6-diisopropylphenol

 

[jetproppilot]

2,6-diisopropylphenol

Woops!

Thanks.

 

[Planktonmd]

There are several points:

1. the third world example is an analogy. It is used to illustrate, in a more direct and obvious way, that sometimes we don't get to practice in ideal settings. With escalating patient to doctor ratios, nursing shortages, and a decided ABSCENCE of anesthesiologist in the ED, the reality of practice is that while I may not have been INITIALLY trained to administer SHORT, PROCEDURAL sedation (and most ED sedations last <5minutes), myself and MANY of my colleagues have taken upon ourselves to get training in this area.

2. I am trained. As an Emergency physician. And that includes training in many areas, including short, procedural sedation. That in no way makes me an anesthesiologist. or even a pretend one. It makes me trained to do that.

3. You have in fact, proved my point. Most anesthesiologist I know, would not only balk at coming to the ED to give procedural sedation, but would wonder why the EP's can't do it themselves. It is almost *beneath* them (several friends- gas attendings/residents- paraphrased). They would much rather be in the OR handling the long, complicated cases that they do.


Medicine isn't a perfect world. Radiologists got defensive and threatened with emergency ultrasound. Until they realized that they would no longer have to come into the ED to do gallbladder u/s at 2am in the morning, and be available 24/7 to the ED. The u/s we do in the ED doesn't make us radiologist. It makes us skilled in a small, ED specific aspect. It requires training and education.


Just like procedural sedation.

Just out of curiosity, when as a resident, are you allowed to do procedural sedation. I have seen PGY2's doing this, on those rare rare occasions.

Poll your colleagues. How many of them are going to be willing to be on call 24/7 to come to the ED to do a 5 minute procedure like a shoulder or fracture? Your own field is struggling under high case loads. Do you really want to add all these people to it? Do you truly believe that another physician isn't capable of being trained to do this? That it takes 5 years to do procedural sedation training? That this is *all* your residency trains you to do? (I am exaggerating to make a point, RESIDENCY is to teach all the multitude of things that you do in your field, not just procedural sedation)

I am not sure what "Short Procedural Sedation" is!
Can you define that for me?
If you give an anesthetic to a patient then you cause pain and the patient does not react or reacts minimally to that pain, this is General Anesthesia.
If you want to give GA you have to be trained to do it and adhere to the same standards that professionals who give anesthesia adhere to.
I didn't say you can't be trained but you are NOT trained.
My objection is mainly to the ER physician giving an anesthetic for another specialist to do a procedure, the duration is irrelevant, it can be 1 minute or 2 hours, you are there acting as an anesthesia provider and the patient assumes that you are a qualified anesthesia provider because you assumed that role.
Let me repeat this one more time:
When you watch an anesthesia provider giving an anesthetic it does appear simple, and many people assume that there is nothing to it, it is simply not the case, it's a continuous process of interaction with the patient, the airway, the different monitors, drugs, fluids....
It looks deceivingly easy but it is not.

 

[roja]

How do you get from our posts that we just watched a little anesthesia, thought it looked easy, and thought about doing it ourselves?

How do you know what standards are being met? My hospital, along with our anesthesia department, has not only assumed, but trained and examined my knowledge and skills to determine that I am qualified to administer this.

You seem to be repeating the same thing over and over- (without appearing to be listening to anything else that is being said, as well as ignoring any of the other issues being raised.) that EP's just decided that your job looked easy, grabbed a couple of syringes and just started giving meds, willy nilly, without any education, skill training or thought.

Anyway, your point is taken. You seem to have no interest in actually discussing anything or even adressing any of the myriad of other points raised.

 

[Planktonmd]

How do you get from our posts that we just watched a little anesthesia, thought it looked easy, and thought about doing it ourselves?

How do you know what standards are being met? My hospital, along with our anesthesia department, has not only assumed, but trained and examined my knowledge and skills to determine that I am qualified to administer this.

You seem to be repeating the same thing over and over- (without appearing to be listening to anything else that is being said, as well as ignoring any of the other issues being raised.) that EP's just decided that your job looked easy, grabbed a couple of syringes and just started giving meds, willy nilly, without any education, skill training or thought.

Anyway, your point is taken. You seem to have no interest in actually discussing anything or even adressing any of the myriad of other points raised.

You still did not answer my question: What is "Short Procedural Sedation"?
And if there is such thing who is the entity that defines it?
And could you walk us through the process through which your "anesthesia department" determined that you can administer general anesthesia safely?
You seem to always return to this accusatory pattern every time you have nothing to say.

 

[militarymd]

How do you get from our posts that we just watched a little anesthesia, thought it looked easy, and thought about doing it ourselves?

How do you know what standards are being met? My hospital, along with our anesthesia department, has not only assumed, but trained and examined my knowledge and skills to determine that I am qualified to administer this.

You seem to be repeating the same thing over and over- (without appearing to be listening to anything else that is being said, as well as ignoring any of the other issues being raised.) that EP's just decided that your job looked easy, grabbed a couple of syringes and just started giving meds, willy nilly, without any education, skill training or thought.

Anyway, your point is taken. You seem to have no interest in actually discussing anything or even adressing any of the myriad of other points raised.

 

[Planktonmd]

something funny?

 

[southerndoc]

Personally, I would love love love to never have to do 'conscious sedation' again.

Which is why I use a lot of blocks. It's amazing the manipulation you can do with a hematoma block, regional block, etc without the patient experiencing discomfort. I can reduce 90% of shoulder dislocations with an intraarticular injection of lidocaine. It's supported by evidence, and it works great. No risk of sedation, no waiting around for a person to wake up prior to discharge.

Yes, this opens up another can of worms for the anesthesiologists, but it's safer than snowing someone under with a bunch of propofol, etomidate, or whatever your drug of choice.

I'm fortunate to have the ability to use propofol where I will be attending next year. I've used it plenty of times with great success. Although I'm no anesthesiologist by any means, sedation is part of my training, and I feel comfortable enough to use it, but scared enough to recognize the consequences. (I'm always open to suggestions though for better alternatives or better use of it.)

Sorry, I'm jumping boards here, but I'm only participating because a medical student pointed this thread out to me.

Jet, thanks for the tips on propofol!

On another note, while we're discussing propofol, what is your opinion of generic propofol? We don't use it at my institution, but I've heard that it requires higher dosing and the sulfites in it can trigger bronchospasm easily. (I thought the FDA made pharmaceutical companies stop manufacturing drugs that contained sulfites, so how did this get approved?)

 

[southerndoc]

So I guess you guys just sit them up (to let gravity work for you), have suction ready, and hope for the best? Or are you placing NG tubes first before the procedure?

If it's something that can wait (a laceration repair in a kid), I'll wait 4-6 hours after they ate.

 

[Planktonmd]

Yes, this opens up another can of worms for the anesthesiologists.

No it doesn't!
Why do you think it should?
A hematoma block (whatever that might be) or an intra articular injection are not procedures that any anesthesiologist I know would even consider doing.

I'm fortunate to have the ability to use propofol where I will be attending next year. I've used it plenty of times with great success. Although I'm no anesthesiologist by any means, sedation is part of my training, and I feel comfortable enough to use it, but scared enough to recognize the consequences.

Well, maybe you can give us the definition of: "Short Procedural Sedation"
and tell us how it is different from general anesthesia.

 

[southerndoc]

By the way, if the anesthesiologists want to do my procedural sedations where I will be attending next year, I am all for it. The reality is they will probably laugh if I call them.

 

[Planktonmd]

By the way, if the anesthesiologists want to do my procedural sedations where I will be attending next year, I am all for it. The reality is they will probably laugh if I call them.

What is a hematoma block???

 

[Planktonmd]

What is a hematoma block???

Oh, never mind I found it: It's basically transforming a closed fracture into an open one by putting a needle into it to avoid doing a proper anesthetic.

 

[tkim]

What is a hematoma block???

Before reducing a fx, you inject lido over the periosteum.

At least that's what I know it as.

 

[southerndoc]

Oh, never mind I found it: It's basically transforming a closed fracture into an open one by putting a needle into it to avoid doing a proper anesthetic.

Correct. Supported by evidence and done safely for many years by practicing good sterile technique.

 

[Planktonmd]

Correct. Supported by evidence and done safely for many years by practicing good sterile technique.

You are still converting a closed fracture into an open one!
Anyway, do you know the definition of "Short Procedural sedation" and if it is different from General Anesthesia?

 

[jetproppilot]

Sorry, I'm jumping boards here, but I'm only participating because a medical student pointed this thread out to me.

Jet, thanks for the tips on propofol!

On another note, while we're discussing propofol, what is your opinion of generic propofol?

1) Wish you would visit more often.

2) No problem, Dude.

3) Definite difference in potency compared to Diprivan. Seems, albeit anecdotally, you need to give more to achieve the same effect. Also makes alotta people cough during administration. Uhhhhhh, IT SUCKS.

 

[jetproppilot]

So Plank,

REGISTERED NURSES give sedation every day. Every single day.

In GI suites across the nation.

They buzz people out to the point that a snake can be put into the patients stomach through their mouth...

and into their large intestine via the patient's butthole.

If the patient squirms, the RN gives more versed/fentanyl until they don't squirm.

Sorry, I disagree with your assessment.

I think board-certified ER doctors are fully within their realm giving sedation for procedures in their home.

The ER.

You haffta admit that the RNs in the GI suites are pretty good at what they do, huh?

And you're saying a doctor thats trained as the first line doc for any critical emergency that walks thru the door can't give sedation for a procedure?

ER doctors

1) Handle trauma

2) Handle any medical emergency that presents itself

3) Place chest tubes

4) Crack chests

5) Handle airways

And its beyond their realm to squirt a little propofol into an IV?

HAHAHAHAHAHAHAHAHAHAHAHAHA

just expressing my opinion and feelings, Plank. Don't take it personal. Its OK for people to disagree.

 

[southerndoc]

You are still converting a closed fracture into an open one!
Anyway, do you know the definition of "Short Procedural sedation" and if it is different from General Anesthesia?

I don't recall being the one who used the term "short procedural sedation."

What I do in the ED is classified by the Joint Commission (formerly JCAHO) as "procedural sedation." Some of the procedures I perform are not short by any means (e.g., complicated abscess drainage).

My goal is to facilitate procedures with analgesia and sedation. My goal is not to anesthetize a person. My goal is always to keep the patient awake enough to protect his or her own airway, to allow him or her a level of sedation that will facilitate performing a procedure, but still have a degree of responsiveness (ideally verbal, but often pain). Anesthesiology is not my specialty, so I could be wrong here, but I was under the impression that general anesthesia is a state of complete unawareness whereby a person cannot be awakened or will not respond to verbal or painful stimuli. If what I perform is general anesthesia, then you and the Joint Commission disagree on its terminology.

In an ideal world, an anesthesiologist would perform all procedural sedations, an orthopedic surgeon would perform all reductions, a general surgeon would drain all abscesses, and a cardiologist would perform all defibrillations.

I must ask you, if a patient coded in the operating room, would you consider it an injustice to defibrillate the patient without the presence of cardiology? Like you are in your field, cardiology is the expert in matters pertaining to the heart. They could argue that only they have the proper training to administer potentially lethal amounts of electrical current required to defibrillate a heart.

I am not a master of any specialty, with perhaps exception to emergent resuscitations. I am primarily a jack of all trades -- a little knowledge to cover the majority of cases seen. To keep from calling in specialists at 3 am, I am trained to provide definitive or temporizing care. Ideally that care would be delivered by a specialist, but in the majority of times this care can be provided by someone that is lesser trained. Is it ideal? No. Is it practical? Yes. I'm not going to be able to get a cardiologist to come in at 3 am to supervise my administration of adenosine for SVT, an orthopedic surgeon to reduce the uncomplicated Colles fracture, the endocrinologist to treat the patient in DKA, the OB/gyn to evaluate the 13-week pregnant patient with vaginal bleeding, or the anesthesiologist to intubate the trauma patient that just rolled in the door. Why? Because they recognize that the majority of times, these cases can be handled by an emergency physician.

When I am over my head or if I feel uncomfortable in the slightest bit, I do not hesitate to call. This is why I ask that you not ask me why I cannot handle the situation by myself when I phone you asking for help. If I'm uncomfortable with it, respect that and come in to see the patient. It's best for me, you, and the patient. Perhaps you can teach me a trick to make me more comfortable if that same scenario presents, or perhaps you realize that my uncomfortableness was a sign of something more seriously wrong with the patient, and I am reminded again the need to call you.

 

[jetproppilot]

I don't recall being the one who used the term "short procedural sedation."

What I do in the ED is classified by the Joint Commission (formerly JCAHO) as "procedural sedation." Some of the procedures I perform are not short by any means (e.g., complicated abscess drainage).

My goal is to facilitate procedures with analgesia and sedation. My goal is not to anesthetize a person. My goal is always to keep the patient awake enough to protect his or her own airway, to allow him or her a level of sedation that will facilitate performing a procedure, but still have a degree of responsiveness (ideally verbal, but often pain). Anesthesiology is not my specialty, so I could be wrong here, but I was under the impression that general anesthesia is a state of complete unawareness whereby a person cannot be awakened or will not respond to verbal or painful stimuli. If what I perform is general anesthesia, then you and the Joint Commission disagree on its terminology.

In an ideal world, an anesthesiologist would perform all procedural sedations, an orthopedic surgeon would perform all reductions, a general surgeon would drain all abscesses, and a cardiologist would perform all defibrillations.

I must ask you, if a patient coded in the operating room, would you consider it an injustice to defibrillate the patient without the presence of cardiology? Like you are in your field, cardiology is the expert in matters pertaining to the heart. They could argue that only they have the proper training to administer potentially lethal amounts of electrical current required to defibrillate a heart.

I am not a master of any specialty, with perhaps exception to emergent resuscitations. I am primarily a jack of all trades -- a little knowledge to cover the majority of cases seen. To keep from calling in specialists at 3 am, I am trained to provide definitive or temporizing care. Ideally that care would be delivered by a specialist, but in the majority of times this care can be provided by someone that is lesser trained. Is it ideal? No. Is it practical? Yes. I'm not going to be able to get a cardiologist to come in at 3 am to supervise my administration of adenosine for SVT, an orthopedic surgeon to reduce the uncomplicated Colles fracture, the endocrinologist to treat the patient in DKA, the OB/gyn to evaluate the 13-week pregnant patient with vaginal bleeding, or the anesthesiologist to intubate the trauma patient that just rolled in the door. Why? Because they recognize that the majority of times, these cases can be handled by an emergency physician.

When I am over my head or if I feel uncomfortable in the slightest bit, I do not hesitate to call. This is why I ask that you not ask me why I cannot handle the situation by myself when I phone you asking for help. If I'm uncomfortable with it, respect that and come in to see the patient. It's best for me, you, and the patient. Perhaps you can teach me a trick to make me more comfortable if that same scenario presents, or perhaps you realize that my uncomfortableness was a sign of something more seriously wrong with the patient, and I am reminded again the need to call you.

I still don't understand why Southern et al is being required on this board to justify something that they need to know how to do, and probably already know how to do, and if they don't know how to do it, are willing to learn!

THEY'RE DOCTORS, PLANK. THEY'RE US.

They're handling/wanna handle stuff they need to know how to handle.

please refer to post where I said I could give MY MOM 50mg propofol IV, during her shift in the high school cafeteria, and walk away. Yeah, she's gonna drop some pizza slices, but she'd be OK. Hard for me to buy into the suggestion that a board-certified emergency physician can't learn how to sedate patients for shoulder relocations et al.

 

[southerndoc]

I still don't understand why Southern et al is being required on this board to justify something that they need to know how to do, and probably already know how to do, and if they don't know how to do it, are willing to learn!

THEY'RE DOCTORS, PLANK. THEY'RE US.

They're handling/wanna handle stuff they need to know how to handle.

please refer to post where I said I could give MY MOM 50mg propofol IV, during her shift in the high school cafeteria, and walk away. Yeah, she's gonna drop some pizza slices, but she'd be OK. Hard for me to buy into the suggestion that a board-certified emergency physician can't learn how to sedate patients for shoulder relocations et al.

I guess the other option is to put a CRNA in the ED 24/7 to handle all the sedations.

 

[jetproppilot]

I guess the other option is to put a CRNA in the ED 24/7 to handle all the sedations.

Lets do it!

But you pay for their seventy bucks an hour plus bennies, OK?

 

[southerndoc]

Lets do it!

But you pay for their seventy bucks an hour plus bennies, OK?

No deal! I have to pay the student loans, the mortgage, and spend the rest on the significant other!

 

[Planktonmd]

So Plank,

REGISTERED NURSES give sedation every day. Every single day.

In GI suites across the nation.

They buzz people out to the point that a snake can be put into the patients stomach through their mouth...

and into their large intestine via the patient's butthole.

If the patient squirms, the RN gives more versed/fentanyl until they don't squirm.

Sorry, I disagree with your assessment.

I think board-certified ER doctors are fully within their realm giving sedation for procedures in their home.

The ER.

You haffta admit that the RNs in the GI suites are pretty good at what they do, huh?

And you're saying a doctor thats trained as the first line doc for any critical emergency that walks thru the door can't give sedation for a procedure?

ER doctors

1) Handle trauma

2) Handle any medical emergency that presents itself

3) Place chest tubes

4) Crack chests

5) Handle airways

And its beyond their realm to squirt a little propofol into an IV?

HAHAHAHAHAHAHAHAHAHAHAHAHA

just expressing my opinion and feelings, Plank. Don't take it personal. Its OK for people to disagree.

So, Jet let me ask you this:
Would you say that it's OK for RN's or whoever else to give general anesthetics as long as the patient doesn't die?
Is the only criteria for being a good anesthesia provider being able to avoid killing the patient?
And since this is how you see things do you think that the ASA should recognize nurses and ER physicians and everyone else who gives versed + Demerol as trained anesthesia providers?

 

[jetproppilot]

So, Jet let me ask you this:
Would you say that it's OK for RN's or whoever else to give general anesthetics as long as the patient doesn't die?
Is the only criteria for being a good anesthesia provider being able to avoid killing the patient?
And since this is how you see things do you think that the ASA should recognize nurses and ER physicians and everyone else who gives versed + Demerol as trained anesthesia providers?

Of course not.

But I do think there exists situations that require sedation but don't require the anesthesia department.

Read post #86 again. I liked it.

 

[Planktonmd]

So, Jet let me ask you this:
Would you say that it's OK for RN's or whoever else to give general anesthetics as long as the patient doesn't die?
Is the only criteria for being a good anesthesia provider being able to avoid killing the patient?
And since this is how you see things do you think that the ASA should recognize nurses and ER physicians and everyone else who gives versed + Demerol as trained anesthesia providers?

And one more question while we are at it:
If we are going to recognize them as anesthesia providers, should they follow the same rules we follow and be held to the same standards? or should they be exempt?
And is it OK for an ER physician to give GA (under a different name) for another physician to perform a procedure in the ER?

 

[Planktonmd]

I don't recall being the one who used the term "short procedural sedation."

What I do in the ED is classified by the Joint Commission (formerly JCAHO) as "procedural sedation." Some of the procedures I perform are not short by any means (e.g., complicated abscess drainage).

My goal is to facilitate procedures with analgesia and sedation. My goal is not to anesthetize a person. My goal is always to keep the patient awake enough to protect his or her own airway, to allow him or her a level of sedation that will facilitate performing a procedure, but still have a degree of responsiveness (ideally verbal, but often pain). Anesthesiology is not my specialty, so I could be wrong here, but I was under the impression that general anesthesia is a state of complete unawareness whereby a person cannot be awakened or will not respond to verbal or painful stimuli. If what I perform is general anesthesia, then you and the Joint Commission disagree on its terminology.

In an ideal world, an anesthesiologist would perform all procedural sedations, an orthopedic surgeon would perform all reductions, a general surgeon would drain all abscesses, and a cardiologist would perform all defibrillations.

I must ask you, if a patient coded in the operating room, would you consider it an injustice to defibrillate the patient without the presence of cardiology? Like you are in your field, cardiology is the expert in matters pertaining to the heart. They could argue that only they have the proper training to administer potentially lethal amounts of electrical current required to defibrillate a heart.

I am not a master of any specialty, with perhaps exception to emergent resuscitations. I am primarily a jack of all trades -- a little knowledge to cover the majority of cases seen. To keep from calling in specialists at 3 am, I am trained to provide definitive or temporizing care. Ideally that care would be delivered by a specialist, but in the majority of times this care can be provided by someone that is lesser trained. Is it ideal? No. Is it practical? Yes. I'm not going to be able to get a cardiologist to come in at 3 am to supervise my administration of adenosine for SVT, an orthopedic surgeon to reduce the uncomplicated Colles fracture, the endocrinologist to treat the patient in DKA, the OB/gyn to evaluate the 13-week pregnant patient with vaginal bleeding, or the anesthesiologist to intubate the trauma patient that just rolled in the door. Why? Because they recognize that the majority of times, these cases can be handled by an emergency physician.

When I am over my head or if I feel uncomfortable in the slightest bit, I do not hesitate to call. This is why I ask that you not ask me why I cannot handle the situation by myself when I phone you asking for help. If I'm uncomfortable with it, respect that and come in to see the patient. It's best for me, you, and the patient. Perhaps you can teach me a trick to make me more comfortable if that same scenario presents, or perhaps you realize that my uncomfortableness was a sign of something more seriously wrong with the patient, and I am reminded again the need to call you.

Nice post.

 

[toughlife]

let's stop bickering and try to be respectful of each other's fields. We are all physicians and should support each other. The only ones we should be bickering about are the paraprofessionals trying to play doctor.

 

[roja]

I still don't understand why Southern et al is being required on this board to justify something that they need to know how to do, and probably already know how to do, and if they don't know how to do it, are willing to learn!

THEY'RE DOCTORS, PLANK. THEY'RE US.

They're handling/wanna handle stuff they need to know how to handle.

please refer to post where I said I could give MY MOM 50mg propofol IV, during her shift in the high school cafeteria, and walk away. Yeah, she's gonna drop some pizza slices, but she'd be OK. Hard for me to buy into the suggestion that a board-certified emergency physician can't learn how to sedate patients for shoulder relocations et al.

Great perspective. One thing I have noticed on a number of these boards, and I hear my residents do some time, is carry big sticks trying to prove how their specialty is the best and everyone else is less. It drives me nuts and I simply like to point out what their life would be like without X specialty.

Hate surgeons? show me how you are going to take out the appendix when you have NO TRAINING to do it.

Hate FP? show me how you are going to manage HbA1C's, htn, etc on a regular basis.

Hate IM? you go manage the patients you admitted.

this can go on and on from any and all specialties. Its ridiculous. The 'marking of territories (aka pissing on trees) is part of what makes physicians so easy to dismantle in complex political issues.

We simply refuse to band together, recognize that we are all physicians, and work together to create better worlds for ourselves and our patients.



anyway, I digress off the thread.

Blocks are great, they help me avoid having to do sedation.

 

[Planktonmd]

Great perspective. One thing I have noticed on a number of these boards, and I hear my residents do some time, is carry big sticks trying to prove how their specialty is the best and everyone else is less. It drives me nuts and I simply like to point out what their life would be like without X specialty.

Hate surgeons? show me how you are going to take out the appendix when you have NO TRAINING to do it.

Hate FP? show me how you are going to manage HbA1C's, htn, etc on a regular basis.

Hate IM? you go manage the patients you admitted.

this can go on and on from any and all specialties. Its ridiculous. The 'marking of territories (aka pissing on trees) is part of what makes physicians so easy to dismantle in complex political issues.

We simply refuse to band together, recognize that we are all physicians, and work together to create better worlds for ourselves and our patients.



anyway, I digress off the thread.

Blocks are great, they help me avoid having to do sedation.

You still did not define "Short Procedural Sedation" for us!
My arguments from the very beginning were very clear and precise:
You are an ER physician, You are not trained nor qualified to administer anesthesia for a surgeon to do a procedure in the ER.
You wanted to turn it into a philosophical issue and tell me how the current health care system requires you to practice things beyond your specialty and gave me examples of third world countries and jungle medicine, and when I tried to bring the discussion to the original subject you accused me of being Territorial and pissing on trees.
The issue remains that you are trying to do things that you are not trained to do and that are beyond your expertise.
It's very simple.
You can't even define the sedation you are trying to claim that you know, and you can't even explain what process if any allowed you to claim that you are trained by your Anesthesia department.
I can keep going if you want to but I think my point is very clear.
Go ahead accuse me of being Territorial or whatever else, It will not change the facts.

 

[pgg]

Definite difference in [generic propofol's] potency compared to Diprivan. Seems, albeit anecdotally, you need to give more to achieve the same effect. Also makes alotta people cough during administration. Uhhhhhh, IT SUCKS.

Seems to sting a lot more too. We just switched over to the cheap stuff. More anecdotal evidence, but I've noticed (or think I've noticed) more people complain of pain during induction.

Worst I've seen was when I pushed about 10 mL of it during an induction before I realized the BP cuff was up on that side. Basically got a generic propofol Bier block. Man, did that poor woman yell. I felt like a *****.

 

[southerndoc]

You still did not define "Short Procedural Sedation" for us!
My arguments from the very beginning were very clear and precise:
You are an ER physician, You are not trained nor qualified to administer anesthesia for a surgeon to do a procedure in the ER.
You wanted to turn it into a philosophical issue and tell me how the current health care system requires you to practice things beyond your specialty and gave me examples of third world countries and jungle medicine, and when I tried to bring the discussion to the original subject you accused me of being Territorial and pissing on trees.
The issue remains that you are trying to do things that you are not trained to do and that are beyond your expertise.
It's very simple.
You can't even define the sedation you are trying to claim that you know, and you can't even explain what process if any allowed you to claim that you are trained by your Anesthesia department.
I can keep going if you want to but I think my point is very clear.
Go ahead accuse me of being Territorial or whatever else, It will not change the facts.

Boys and girls, arguing on the internet is like running in the special olympics. Only ******s will do it. Can't we all just get along without creating this territorial issue?

Plankton I would love for you to come do all my procedural sedations. I hope that you are on staff at the hospital where I will be practicing so I can call you into the ED for every sedation. Judging from your response here, I believe I won't have any resistance when I call you!

 

[Planktonmd]

Boys and girls, arguing on the internet is like running in the special olympics.

Can't we all just get along without creating this territorial issue?

Plankton I would love for you to come do all my procedural sedations. I hope that you are on staff at the hospital where I will be practicing so I can call you into the ED for every sedation. Judging from your response here, I believe I won't have any resistance when I call you!

Well, I would love to help you If I could, but even if I couldn't that doesn't mean it's OK for you to administer GA while a surgeon is doing a procedure.
The procedure can wait until an anesthesia provider is available and if one is not available this means your hospital should figure out a solution other than requiring you to do things that are beyond your expertise.
My Issue is precisely with an ER physician standing at the head of the table administering anesthesia electively for another specialty.
I have seen it done and it is not good patient care.