Propofol on ER

[dhb]

You can't put an anesthesiologist behind every stick of propofol. ER docs are second to anesthesiologist in managing airway issues so i don't have a problem with it.
If you go to your local ER with a dislocated shoulder would you rather have the ER doc push 100mg of the white stuff and pop it back in or wait a few hours just to have an anesthesiologist do the sedation/GA?
I think propofol is much safer than versed/fentanyl.

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[Planktonmd]

You can't put an anesthesiologist behind every stick of propofol. ER docs are second to anesthesiologist in managing airway issues so i don't have a problem with it.
If you go to your local ER with a dislocated shoulder would you rather have the ER doc push 100mg of the white stuff and pop it back in or wait a few hours just to have an anesthesiologist do the sedation/GA?
I think propofol is much safer than versed/fentanyl.

So if in the future they say that an ER Physician can give anesthesia (Short Procedural Sedation) for a surgeon to do an appendectomy, would that be ok as well?

 

[roja]

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.

Believe it or not, my last point wasn't about you at all. I was speaking to a pervasive trend I see in medicine in general.

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.

I can define it. I have been educated. I have simply chosen to discontinue the discussion with you because you do not seem interested in having a discussion- you are only interested in stating your same view, ad nauseum with out considering any other opinions. You have not offered up any *facts*. You have offered up your opinion, which you are fully entitled to.

Several of us have given you various definitions, etc.

(and I doubt that you have spent much time in the ED, you seem to be under the misconception that we deliver sedation so that surgeons can come and do procedures. In fact, we do our procedures. When we do CS, it takes two EM docs.)


dhb

I agree with your regarding the combination of versed/fentanyl. I think this is a much more dangerous combination. It is terrible in terms of potential respiratory status and lasts much longer than necessary. As most procedures in the ED last less than 5 minutes, this combination is ridiculous.

As we have incredibly limited options where I am, for shoulders, I often use a combination of intraarticular injection (with lidocaine and morphine [gets the mu receptors], iv valium and toradol. I have also used nitrous as well, which has worked many times.

jetproppilot, pgg

Given as much as you use propofol, I would think that your combined antecedent experience is pretty worthwhile. Has anyone explored why it seems to be more painful? ways to counter it?

 

[Planktonmd]

(and I doubt that you have spent much time in the ED,

You are wrong.

you seem to be under the misconception that we deliver sedation so that surgeons can come and do procedures. In fact, we do our procedures. When we do CS, it takes two EM docs.)

No, I know what you do, and If you have tried to read my posts you would have noticed that I was specifically addressing this new phenomenon of ER physicians anesthetizing patients for surgeons, it's being done in many places and if you are not aware of it you might want to ask around.
We were actually approached by the ER group where I am because they want to figure out a protocol to administer anesthesia for surgeons in the ER.
And my input is not only opinions it is facts because I am not aware of any literature showing that ER Physicians are capable of administering GA safely.
Do you have such evidence?

 

[jetproppilot]

You are wrong.


No, I know what you do, and If you have tried to read my posts you would have noticed that I was specifically addressing this new phenomenon of ER physicians anesthetizing patients for surgeons, it's being done in many places and if you are not aware of it you might want to ask around.
We were actually approached by the ER group where I am because they want to figure out a protocol to administer anesthesia for surgeons in the ER.
And my input is not only opinions it is facts because I am not aware of any literature showing that ER Physicians are capable of administering GA safely.
Do you have such evidence?

UHHHHH, Plank, you're not absorbing the posts made by many people here. And you keep saying the same thing over and over. Doesnt make for a great exchange of information. Could be wrong, but it sounds to me like nobody wants to use GENERAL ANESTHESIA like you keep posting. And theres more of a chance of HELL FREEZING OVER than an anesthesia group running to the ER every time some sedation is needed. Its impractical. Its undoeable. Its unnecessary. The ER dudes can handle it.

I respect your passion about your opinion.

I don't understand, though, how (it seems) a lotta info has been exchanged here, and its kinda like you have an ignore button on...like you havent read the other posts.

BTW, why does ER docs giving sedation bother you so?

 

[SoCuteMD]

You are wrong.


No, I know what you do, and If you have tried to read my posts you would have noticed that I was specifically addressing this new phenomenon of ER physicians anesthetizing patients for surgeons, it's being done in many places and if you are not aware of it you might want to ask around.
We were actually approached by the ER group where I am because they want to figure out a protocol to administer anesthesia for surgeons in the ER.
And my input is not only opinions it is facts because I am not aware of any literature showing that ER Physicians are capable of administering GA safely.
Do you have such evidence?

I've never heard of an EP administering GA in the ED. For what purpose would they want to do this?

I have seen an EP do conscious sedation to allow a surgeon to attempt a procedure in the ED, but this is really no different than an EP administering conscious sedation so that another EP can perform the procedure.

 

[Planktonmd]

UHHHHH, Plank, you're not absorbing the posts made by many people here. And you keep saying the same thing over and over. Doesnt make for a great exchange of information. Could be wrong, but it sounds to me like nobody wants to use GENERAL ANESTHESIA like you keep posting. And theres more of a chance of HELL FREEZING OVER than an anesthesia group running to the ER every time some sedation is needed. Its impractical. Its undoeable. Its unnecessary. The ER dudes can handle it.

I respect your passion about your opinion.

I don't understand, though, how (it seems) a lotta info has been exchanged here, and its kinda like you have an ignore button on...like you havent read the other posts.

BTW, why does ER docs giving sedation bother you so?

Based on my personal observation, when surgeons ask these guys to give "sedation" for a procedure, what is usually done is GA if they are using an induction agent.
I mean they are reaching levels where the patient is unconscious and apneic and this in my opinion is not "sedation".
If they are going to give GA they need to adhere to the same rules and be held to the same standards we have.
The history of our specialty is full of examples of nice guys who said: So what, let the others do this part of my job, there is plenty for all of us.
The result of these guys good intentions are well known: We lost critical care, we lost pain management.....
I say if they want to do my job they need to be as good!
That might sound too militant but I don't feel like being nice tonight.

 

[pgg]

I agree with your regarding the combination of versed/fentanyl. I think this is a much more dangerous combination. It is terrible in terms of potential respiratory status and lasts much longer than necessary.

I'll just throw out one more thought in the fentanyl/Versed vs propofol sedation debate, that I haven't seen mentioned yet in this thread.

Fentanyl and Versed both have effective, fast-onset reversal agents. Propofol doesn't - once you've pushed it, it's there until it's not. In any discussion about the safety of these two techniques, the existence of naloxone and flumazenil add ... something. Maybe not a lot, but something.

The nurse who couldn't ventilate or intubate a patient if her own life depended on it can still inject Narcan and flumazenil if things go bad.

Given as much as you use propofol, I would think that your combined antecedent experience is pretty worthwhile. Has anyone explored why it seems to be more painful? ways to counter it?

I usually give some IV lidocaine first, sometimes with a pseudo-Bier-block technique where I grab the arm with one hand and squeeze a bit so the lidocaine has more time to numb the vein. I've convinced myself that this sort of helps. Injecting the first bit slowly also seems to reduce the pain.

A big slug of pre-induction fentanyl does the trick, too.

For sedation (vs induction) injecting slowly and warning the patient that it might sting are all I do.

 

[pd4emergence]

Interesting thread. I hate to say it since everybody seems to disagree with what plank is saying but I can see where he is coming from. I don't spend much time in the ED. I don't know how often fractures and dislocations get reduced there. We seem to do quite a few in the OR. When we do them in the OR they get a general anesthetic. If they are not NPO and it is an emergency they get a tube. What happens in the ED with similiar cases? Can you really reduce a fracture or dislocation and still maintain airway reflexes? Honestly I haven't tried. Where does sedation end and GA begin? I don't know because it doesn't really matter to me in the OR. I think this is the main difference to my approach as an anesthesiologist compared to an EM physician. I don't care if the pt becomes apneic, I will take care of it. To me, once the patient becomes apneic and loses their airway reflexes then they have met my criteria for a general anesthetic. I don't believe general anesthetics should be done in the ED. I don't go to the ED to provide any services other than lines/intubations and preoperative assesments and occasionally code response. I do not do cases in the ED. I am happy to get those patients that need to come to the OR for procedures there as quickly as possible. But I also approach every case as a possible general anesthetic and I ensure NPO guidelines are met if the case is not an emergency. As for the propofol issue, if ED physicians want to use propofol, I wish them luck. They can handle the airway if they need to. One thing about propofol that ED folks should know is that if things go badly, medicolegally your a$$ is in a sling. It says in the insert that only people trained in general anesthesia should use it. I agree wholeheartedly it is better than giving 8 of versed and 200 of demerol to a crackhead. But the insert says what it says. As for giving the green light for everyone to get to use propofol it just isn't a good idea. Especially in the GI lab where the doc may or may not be able to handle the airway.

 

[southerndoc]

Interesting thread. I hate to say it since everybody seems to disagree with what plank is saying but I can see where he is coming from. I don't spend much time in the ED. I don't know how often fractures and dislocations get reduced there. We seem to do quite a few in the OR. When we do them in the OR they get a general anesthetic. If they are not NPO and it is an emergency they get a tube. What happens in the ED with similiar cases? Can you really reduce a fracture or dislocation and still maintain airway reflexes? Honestly I haven't tried. Where does sedation end and GA begin? I don't know because it doesn't really matter to me in the OR. I think this is the main difference to my approach as an anesthesiologist compared to an EM physician. I don't care if the pt becomes apneic, I will take care of it. To me, once the patient becomes apneic and loses their airway reflexes then they have met my criteria for a general anesthetic. I don't believe general anesthetics should be done in the ED. I don't go to the ED to provide any services other than lines/intubations and preoperative assesments and occasionally code response. I do not do cases in the ED. I am happy to get those patients that need to come to the OR for procedures there as quickly as possible. But I also approach every case as a possible general anesthetic and I ensure NPO guidelines are met if the case is not an emergency. As for the propofol issue, if ED physicians want to use propofol, I wish them luck. They can handle the airway if they need to. One thing about propofol that ED folks should know is that if things go badly, medicolegally your a$$ is in a sling. It says in the insert that only people trained in general anesthesia should use it. I agree wholeheartedly it is better than giving 8 of versed and 200 of demerol to a crackhead. But the insert says what it says. As for giving the green light for everyone to get to use propofol it just isn't a good idea. Especially in the GI lab where the doc may or may not be able to handle the airway.

Usually reductions in the OR have already failed in the ED or are too severe for the ED (i.e., we recognize that procedural sedation won't be adequate enough to reduce the fracture).

 

[usnavdoc]

Interesting thread. I hate to say it since everybody seems to disagree with what plank is saying but I can see where he is coming from. I don't spend much time in the ED. I don't know how often fractures and dislocations get reduced there. We seem to do quite a few in the OR. When we do them in the OR they get a general anesthetic. If they are not NPO and it is an emergency they get a tube. What happens in the ED with similiar cases? Can you really reduce a fracture or dislocation and still maintain airway reflexes? Honestly I haven't tried. Where does sedation end and GA begin? I don't know because it doesn't really matter to me in the OR. I think this is the main difference to my approach as an anesthesiologist compared to an EM physician. I don't care if the pt becomes apneic, I will take care of it. To me, once the patient becomes apneic and loses their airway reflexes then they have met my criteria for a general anesthetic. I don't believe general anesthetics should be done in the ED. I don't go to the ED to provide any services other than lines/intubations and preoperative assesments and occasionally code response. I do not do cases in the ED. I am happy to get those patients that need to come to the OR for procedures there as quickly as possible. But I also approach every case as a possible general anesthetic and I ensure NPO guidelines are met if the case is not an emergency. As for the propofol issue, if ED physicians want to use propofol, I wish them luck. They can handle the airway if they need to. One thing about propofol that ED folks should know is that if things go badly, medicolegally your a$$ is in a sling. It says in the insert that only people trained in general anesthesia should use it. I agree wholeheartedly it is better than giving 8 of versed and 200 of demerol to a crackhead. But the insert says what it says. As for giving the green light for everyone to get to use propofol it just isn't a good idea. Especially in the GI lab where the doc may or may not be able to handle the airway.

It is an interesting thread for a variety of reason. This is actually the subject of my grand rounds presentation so Ive been watching from afar.

With regards to what plank is saying(albeit from a more militant perspective than need be) the ASA supports his assertations. Although what I think is making this conversation difficult is the use of differing terminology.