Propofol use by EM physicians

[deleted171991]

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But isn’t the Halodol we use ‘For IM use only.’ ?

And we'll be promptly sued the moment the patient goes into arrest after giving it, even if ASA 1000. Why assume the risk for other providers? Let them give propofol solo if they want to, just not on your watch.

We're mostly dealing with patients and families who don't understand science and who need scapegoats.

 

[Twiggidy]

To be the devil's advocate here and side a bit with the ER doc in the thread, I can understand why they would want to graduate to propofol at somepoint. Not every patient can get proper sedation with versed and fentanyl, especially if they're a "2am see you at EDC Las Vegas type". I personally don't care what any MD uses to get his/her job done with the caveat that you know the dose, reaction, and potential negative consequences of the drugs and are ready to deal with them. I don't want to be "airway rescuer" because someone sees me push a stick of propofol and think they can do the same. People really underrate that as anesthesiologist we evaluate situations very quickly and know what to do with almost every dose of medicine we give, so while it may look "willy nilly" it really isn't.

 

[nimbus]

People really underrate that as anesthesiologist we evaluate situations very quickly and know what to do with almost every dose of medicine we give, so while it may look "willy nilly" it really isn't.

Experienced EM docs who use propofol all the time are probably the same. I worry about the ones who are just beginning or only use it a handful of times per year. That said, propofol is the best drug for the job in many instances and facilitates efficient throughout in a busy ER.

 

[B-Bone]

Another thing to consider, if you're going to limit their ability to use propofol locally, is whether you plan to make your department/staff available to sedate all their fracture reductions and shoulder relocations and whatever else they're doing that currently does not impact your schedule. These procedures need to get done. Some need sedation. BCEP's should be capable of managing this (though I do believe a second provider should be present), and if you say they're not, somebody else (i.e. anesthesia) has to sedate them.

 

[DrGasPasser]

But for those non-anesthesiologists (EM, dentists, OMFS'ers, etc) who are posting and reading, there's something you have to understand:

When you ask a bunch of anesthesiologists their opinions on things like sedation and anesthesia, the only answer you can expect, and the only answer you're going to get, is one grounded in our own standard of care. What else are we going to say?

Safe sedation requires a qualified person, dedicated to the task of sedation and monitoring, not also doing the procedure, with appropriate monitors (to include etCO2), with appropriate equipment and supplies for resuscitation immediately at hand, with appropriate time space and personnel for recovery prior to discharge.

If you're not doing that to my standards in your corner of the hospital, don't expect me to smile and nod when the hospital credentialing or P&T committee asks my opinion.

Is there someone in this thread who is suggesting that this is not happening in EDs? Is there anyone saying that it shouldn’t be?

The documents that I provided from ACEP about the safe use of procedural sedation clearly described those measures and the few exceptions where a single physician provider is acceptable (i.e. remote single coverage hospitals, procedures that can be performed by a nurse such as delivering cardioversion, etc.). Unless you have first hand experience witnessing your hospital’s EPs performing reckless sedations, it’s probably more accurate to start from the assumption that they are following industry standards.

 

[MoMoGesiologist]

You don’t need to do a three year anesthesia residency to give propofol. I’m pretty sure ED docs are smart enough to figure it out. Let’s let ED docs run the ED by ACEP standards and not enforce ASA guidelines to a place where it was never meant to be applied.

Another example, ACEP finds it safe and standard of care not to wait for ASA NPO guidelines to sedate and fix fractures and lacs or whatever else it is ED docs do. Are we gonna tell ED docs “no you need to wait 8 hours“ before they fix some poor kids dislocated shoulder?

 

[DrGasPasser]

Experienced EM docs who use propofol all the time are probably the same. I worry about the ones who are just beginning or only use it a handful of times per year. That said, propofol is the best drug for the job in many instances and facilitates efficient throughout in a busy ER.

It would be relatively uncommon for a EP to come out of residency within the past decade having less than 20 sedations with just Propofol. They will have a similar number sedations with Etomidate. Ketamine is given like candy in the EDs and most grads will have given it more than 50 times for sedation. Keep in mind those numbers are just sedations and exclude RSIs.

Interestingly, the cocktail least familiar to most new grads is Versed/opiate. While we use Versed and opiates individually all the time, we rarely use that combination anymore for procedural sedation.

One last point that is probably significant is that most of our procedures involve single doses of anesthetic for brief procedures. We don’t do colonoscopies or endoscopes in the ED without intubating the patients. Things like cardioversion, fracture reduction, chest tubes, etc. rarely require a second dose, and I can’t say that I’ve ever seen a propofol infusion started on non-intubated patients in the ED. In fact, I specifically tell my residents that stacking several doses of propofol over 10-15 min for your orthopedist who is getting a leg day trying to get that hip prosthesis back in is asking for a trip to the M&M stage.

 

[deleted126335]

For malpractice to be malpractice, a deviation from the local standard of care is required. At places where non-anesthesiologists/non-CRNAs/non-AAs are routinely using propofol for sedation, that standard of care is pretty clear.

The concept of "local standard of care" has pretty much gone away. The general legal rule is that there is one standard of care. Standards of care are established by expert opinion testimony. But jury instructions on "local or rural standards are different" just don't fly much anymore.

On the plus side, this prevents the argument that solo CRNAs should be held to a lower standard than anesthesiologists because they just don't have the training.

 

[emergentmd]

I was the ED chair for our city's referral hospital, discussed this ad nauseam 10 yrs ago for over a year. Took a year to get all of the ducks in a row, put verbiage to make Gas happy, put verbiage in to make ER docs happy, put verbiage to make the Nursing society happy, put verbiage in to make the C-Suite happy. And NO, we have no requirements to have 2 docs to push propofol. I push propofol in Free standing ERs all the time, Level 1 trauma, and All levels in between. In 20 yrs doing EM, I know of zero cases where there was a bad outcome when an ABEM doc managed it.

How can anyone tell an ER doc that they can't use propofol when our OWN society clearly states that we are proficient?

Is Gas going to come down to our ER every time I need to do any procedural sedation?

My ER is too busy to wait 2-3 hrs for Gas to come down, and when they do come down I may be busy taking care of a code, doing a procedure, dealing with a crashing pt, getting lunch, scratching my A$$. Are they going to wait around until I am done?

Is Gas going to come down and make the pt wait 6-8 hrs to be NPO before pushing propofol? If they do that, I am admitting the pt b/c there is no way I am locking up a bed waiting 8hrs.

Is Gas going to come down and tell my guy with a shoulder dislocation or kid with a fracture/dislocation that they need to suffer in pain for another 8 hrs b/c they ate before going to the soccer game.

After 8 hrs, Is Gas going to call the orthopod to reduce a shoulder at 2am b/c I am likely home and in no way am I going to pass a procedure for the oncoming doc.

Why can an ER doc give paralytics and guarantee that I will need to secure an airway but can't give propofol with the slight chance that I will need to intubate?

Truthfully, I would be happy if Gas would come down and do all of my sedation. Would make my life easier. I rather walk in, do a 1 min procedure, and walk out to let Gas wake the pt up.

 

[nimbus]

I was the ED chair for our city's referral hospital, discussed this ad nauseam 10 yrs ago for over a year. Took a year to get all of the ducks in a row, put verbiage to make Gas happy, put verbiage in to make ER docs happy, put verbiage to make the Nursing society happy, put verbiage in to make the C-Suite happy. And NO, we have no requirements to have 2 docs to push propofol. I push propofol in Free standing ERs all the time, Level 1 trauma, and All levels in between. In 20 yrs doing EM, I know of zero cases where there was a bad outcome when an ABEM doc managed it.

How can anyone tell an ER doc that they can't use propofol when our OWN society clearly states that we are proficient?

Is Gas going to come down to our ER every time I need to do any procedural sedation?

My ER is too busy to wait 2-3 hrs for Gas to come down, and when they do come down I may be busy taking care of a code, doing a procedure, dealing with a crashing pt, getting lunch, scratching my A$$. Are they going to wait around until I am done?

Is Gas going to come down and make the pt wait 6-8 hrs to be NPO before pushing propofol? If they do that, I am admitting the pt b/c there is no way I am locking up a bed waiting 8hrs.

Is Gas going to come down and tell my guy with a shoulder dislocation or kid with a fracture/dislocation that they need to suffer in pain for another 8 hrs b/c they ate before going to the soccer game.

After 8 hrs, Is Gas going to call the orthopod to reduce a shoulder at 2am b/c I am likely home and in no way am I going to pass a procedure for the oncoming doc.

Why can an ER doc give paralytics and guarantee that I will need to secure an airway but can't give propofol with the slight chance that I will need to intubate?

Truthfully, I would be happy if Gas would come down and do all of my sedation. Would make my life easier. I rather walk in, do a 1 min procedure, and walk out to let Gas wake the pt up.

All great points. Can’t argue with any of them. Just as it disrupts your workflow to wait for anesthesia, it disrupts our workflow to go down there.

 

[Consigliere]

Anyone saying ED docs shouldn't be giving Propofol is a god damn retar_d (yes I know that's not "PC" - don't care). If you really want to go down to the ED for every shoulder and hip reduction than you gets what you gets for taking that extra chromosomal stance.

 

[WholeLottaGame7]

I was the ED chair for our city's referral hospital, discussed this ad nauseam 10 yrs ago for over a year. Took a year to get all of the ducks in a row, put verbiage to make Gas happy, put verbiage in to make ER docs happy, put verbiage to make the Nursing society happy, put verbiage in to make the C-Suite happy. And NO, we have no requirements to have 2 docs to push propofol. I push propofol in Free standing ERs all the time, Level 1 trauma, and All levels in between. In 20 yrs doing EM, I know of zero cases where there was a bad outcome when an ABEM doc managed it.

How can anyone tell an ER doc that they can't use propofol when our OWN society clearly states that we are proficient?

Is Gas going to come down to our ER every time I need to do any procedural sedation?

My ER is too busy to wait 2-3 hrs for Gas to come down, and when they do come down I may be busy taking care of a code, doing a procedure, dealing with a crashing pt, getting lunch, scratching my A$$. Are they going to wait around until I am done?

Is Gas going to come down and make the pt wait 6-8 hrs to be NPO before pushing propofol? If they do that, I am admitting the pt b/c there is no way I am locking up a bed waiting 8hrs.

Is Gas going to come down and tell my guy with a shoulder dislocation or kid with a fracture/dislocation that they need to suffer in pain for another 8 hrs b/c they ate before going to the soccer game.

After 8 hrs, Is Gas going to call the orthopod to reduce a shoulder at 2am b/c I am likely home and in no way am I going to pass a procedure for the oncoming doc.

Why can an ER doc give paralytics and guarantee that I will need to secure an airway but can't give propofol with the slight chance that I will need to intubate?

Truthfully, I would be happy if Gas would come down and do all of my sedation. Would make my life easier. I rather walk in, do a 1 min procedure, and walk out to let Gas wake the pt up.

I also know CRNAs who have "practiced" for 30 years and claim they have never had a serious complication. There's a difference between not having any complications and not being aware of having any complications. There's a lot of willful ignorance out in the world. Sometimes it's necessary to help yourself sleep at night.

But if you've done 5,000 propofol sedations in the ED on full stomachs, something bad has happened, whether you are aware of it acutely or not. Whether the math works out on a societal level or not, I have no idea. If I'm one of the 4999 people that will do fine not waiting 8 hours to have their shoulder reduced, I'm totally fine with not waiting. If I'm the 1 out of 5000 people that aspirates and dies or has a prolonged ICU stay on the vent, I'm going to be pretty upset that we didn't wait a few hours.

 

[emergentmd]

I also know CRNAs who have "practiced" for 30 years and claim they have never had a serious complication. There's a difference between not having any complications and not being aware of having any complications. There's a lot of willful ignorance out in the world. Sometimes it's necessary to help yourself sleep at night.

But if you've done 5,000 propofol sedations in the ED on full stomachs, something bad has happened, whether you are aware of it acutely or not. Whether the math works out on a societal level or not, I have no idea. If I'm one of the 4999 people that will do fine not waiting 8 hours to have their shoulder reduced, I'm totally fine with not waiting. If I'm the 1 out of 5000 people that aspirates and dies or has a prolonged ICU stay on the vent, I'm going to be pretty upset that we didn't wait a few hours.

What an asinine statement.

Comparing a midlevel that you are supervising to another Doc that you have no association with is just plain stupid.

I work in the ED that comes with inherent risks and nothing is ever controlled. If 1 out of 5000 aspirates then that is the risk I take as a boarded EM doc vs keeping 5000 people in pain waiting for the mythical 8th hour. Give me this risk vs having to pump dilaudid ever 30 minutes while waiting 8 hrs. No different than the risk that I don't admit every Freaking Chest pain patient just in case one may have an MI.

Gas needs to stay in their Lane. I would never tell any other doc that they shouldn't do something especially if their Board is clear.

I don't know why anyone would want to take on more work. When I run to a code, I pray that some doc beat me to it.

Don't you see the irony that you don't want me to use propofol but when a code happens, Gas are always too busy or late to the code only to show up after I intubate. Funny how you guys don't fight to run all codes in the hospital b/c all EM docs would gladly give up this right.

 

[nimbus]

Funny how you guys don't fight to run all codes in the hospital b/c all EM docs would gladly give up this right.

We would if there was a sizable stipend to sit around in-house waiting for codes. But there never is. Even those of us who take in-house call are often taking care of patients in the OR. It’s just not practical. Covering codes is just a really crappy, inefficient, poorly compensated task. Nobody wants it.

 

[emergentmd]

We would if there was a sizable stipend to sit around in-house waiting for codes. But there never is. Even those of us who take in-house call are often taking care of patients in the OR. It’s just not practical. Covering codes is just a really crappy, inefficient, poorly compensated task. Nobody wants it.

And you think the EM doc is just sitting somewhere in the call room waiting for a code to happen? You think we get a stipend for covering codes? You think we aren't as busy running around taking care of crashing patients, doing procedure, running codes in the ER? You think this is very practical for me to drop everything for 30-60 minutes when I have 10+ patients I am managing?

You think I want to take on this extra work and risks b/c covering codes is just as crappy, inefficient, and poorly compensated for me. You think EM docs really want it?

When gas fights to run codes b/c its best care for the patients, then they can run the procedural sedation in my ER.

 

[nimbus]

And you think the EM doc is just sitting somewhere in the call room waiting for a code to happen? You think we get a stipend for covering codes? You think we aren't as busy running around taking care of crashing patients, doing procedure, running codes in the ER? You think this is very practical for me to drop everything for 30-60 minutes when I have 10+ patients I am managing?

You think I want to take on this extra work and risks b/c covering codes is just as crappy, inefficient, and poorly compensated for me. You think EM docs really want it?

When gas fights to run codes b/c its best care for the patients, then they can run the procedural sedation in my ER.

Not at all. I am agreeing with you. I know your days are a lot more hectic than mine. I don’t want to go to the ER to sedate patients and I don’t want to cover codes. I like to sit on a stool in the OR and take care of one patient at a time in a very controlled and focused environment. I’m just saying that if code coverage was adequately compensated, then people would fight for it. More power to you.

 

[emergentmd]

Not at all. I am agreeing with you. I know your days are a lot more hectic than mine. I don’t want to go to the ER to sedate patients and I don’t want to cover codes. I like to sit on a stool in the OR and take care of one patient at a time in a very controlled and focused environment. More power to you.

If Gas could guarantee me propofol sedation within 1 hr of being called, I would gladly never order propofol again. I get no joy taking the risk of sedation. My life would be much better if the hospital took everything off my plate that other specialist are better at than I would do. Pulm=codes, Gas=procedural sedation, ortho=reduce fractures, ENT=peritonsillar abscess aspiration, Gas=central line. I have done enough and would sleep much better if I did not do another in my life..

 

[pgg]

Unless you have first hand experience witnessing your hospital’s EPs performing reckless sedations,

Well yeah, that's kind of the point! Just about all of us have witnessed sedations in the ER that are "reckless" by our standards - NPO violations, not having a dedicated person to do the sedation and monitoring. Moreover, this worldview is absolutely pervasive in emergency rooms:

I work in the ED that comes with inherent risks and nothing is ever controlled.

and the consequence of everything being an "emergency" in an ER, with a bit of an adrenaline junkie culture, is that often they don't take the time to control the things they can control. Because emergency! If I had a nickel for every time I've gone to the ER for an anticipated difficult airway (good on 'em for calling us!) and done a basic equipment check to find that their RN is ready to push drugs for me, but there isn't a Yankauer within 30 feet of the bed, or a ventilator isn't present and RT is nowhere to be found, or that the patient isn't even on 100% oxygen to denitrogenate them ...

The ER is a dramatic place, but they sure manufacture a lot of self-inflicted drama.

ALL THAT SAID - it's clear that they aren't killing people left and right with their methods, so I'm not advocating that they not be allowed to do what they do. They're doctors, they have degrees, they have licenses, they're credentialed.

it’s probably more accurate to start from the assumption that they are following industry standards.

They are following their standards, and that's fine. Again, my argument is that we shouldn't be making rules about how other doctors practice. But when they or a hospital committee ask us how it should be done, the only answer we can give is grounded in our standard of care. That's all.

 

[Hork Bajir]

@emergentmd your points are all well taken... But please stop calling anesthesiologists “gas”. It’s disrespectful, and frankly it makes you sound like an idiot med student who is posting a thread about “can’t decide between EM or gas!!??!1?”

You’ve gotta give respect in order to get respect.

 

[Consigliere]

And you think the EM doc is just sitting somewhere in the call room waiting for a code to happen? You think we get a stipend for covering codes? You think we aren't as busy running around taking care of crashing patients, doing procedure, running codes in the ER? You think this is very practical for me to drop everything for 30-60 minutes when I have 10+ patients I am managing?

You think I want to take on this extra work and risks b/c covering codes is just as crappy, inefficient, and poorly compensated for me. You think EM docs really want it?

Are the answers to these questions "no?"

 

[Ronin786]

I've given up trying to argue with ED physicians about the way they practice. I thought some anesthesiologists were short-sighted in their approach to an anesthetic by talking about how "they just have to get them through the case" then I started talking to most EM docs.

The primary objective in the emergency department is getting the patient out of the emergency department in as short time as possible. I don't know when that superceded doing what's best for the patient, but once viewed in that light, any argument becomes moot.

"Why did you intubate this patient, when you could have just put them on BiPAP?"
"I couldn't risk them getting worse and I have to get them out of the ED"

"Why is this patient coming to the ICU with three pressers going through a 22g and no arterial line?"
"I had to get them out of the ED. Can't keep them there long enough to put a central line/a-line"

"Why are you calling a surgical consult for a patient with no labs or imaging?"
"Can't sit around waiting for the results, other patients might come in"

"Why did you sedate this kid who just had pizza before they dislocated their shoulder playing football"
"Have to get them out of the ED. Can't sit around for 8 hours in pain."

There are countless other examples, but when everything is viewed from an optic of getting people out of the ED then there is no argument to be made. And I realize this comes off as ED bashing, but I really believe we see things from such different viewpoints that a consistent discussion is impossible. Just like I don't expect an IM doc to be able to talk to me about proper protocol for medication administration in the OR.

That said, I frankly don't care what the ED board says about your privileges. They're notorious for setting their own standards that differ from most other practices. Just take a look at their position when it comes to ACLS, ATLS or PALS.

 

[Twiggidy]

First of all, @emergentmd the whole "Gas" thing......so ten years ago. In the words of the GOAT Lebron James, "Do better." Now having said that, I 100% agree that you should be able to give whatever drugs you want whenever you want because you have two letters after you name that says "M.D." Quitely frankly, you won't get an argument out of 99% of anesthesiologist over it unless they're itching for some billing to pay for their divorces and private jets. As Nimbus implied, I slow trot or stay on the crapper during codes because I'm not here for a p*ssing match. I could care less who runs the code. Honestly I put that more in ER realm than anesthesia realm anyway.

This argument isn't even really and ER vs anesthesia argument to begin with, rather it's usually administration trying to dictate who can do what. So the beef is really with the suits and clipboard nurses. What most doctors who aren't anesthesiologists want to avoid is sedating someone and getting to the point of a breathing tube. Now, ER docs (see how I respect the field) know how to manage airways (at least most do) so they shouldn't have a problem or be afraid to administer Propofol. They should know what to do if they overdo it. It's the GIs, cardiologist, etc who DON'T know what to do and haven't managed an airway in years so they want nothing to do with propofol sedation.

Again, as Nimbus said, most of us want to sit the stool in our controlled environment and address our own problems and not be firefighters for the hospital. That's why I said I have no problem AT ALL with ER docs giving propofol so long as they know what to do when something goes wrong (which the do or they should)

Also, ER docs should be well accustomed to doing their own central lines. As a matter of fact, every doctor, especially in the age of ultrasound should be accustomed to doing their own central lines. Prep, drape, probe, lidocaine, vessel, needle, blood, wire, dilate (skin only!), catheter, flush, sew, dressing. Done.

 

[Twiggidy]

"Why is this patient coming to the ICU with three pressers going through a 22g and no arterial line?"
"I had to get them out of the ED. Can't keep them there long enough to put a central line/a-line"

Preach.

 

[dhb]

"Why did you sedate this kid who just had pizza before they dislocated their shoulder playing football"
"Have to get them out of the ED. Can't sit around for 8 hours in pain."

While I agree with most of the thread, the whole waiting for X hours for an emergency that will never be an empty stomach makes no sense to me. If the ER doc wants to do it in the ER that's fine with me. If the surgeon wants to bring the case to the OR i'm not waiting 8 GD hours for nothing.
Trauma=emergency=full stomach deal with it.

 

[IlDestriero]

I don’t care what the ED physicians do. If they want to sedate people and reduce fractures or whatever, great go for it. Prop, ketamine, hypnosis, whatever the hospital will credential you to do, it’s all yours. I’ll sleep through that closed reduction. Thanks! I don’t need the money, but I will take the sleep. Ortho isn’t bringing them to the OR after about 8 anyway unless it’s open or pulseless, and maybe not even then.
We don’t do anything in the ED. Well we try to go to the level one traumas and we will intubate known “critical airways”, but only if we are available.
The only reason we are involved in sedation is because our hospital system has put Anesthesia in charge of sedation services. We’d probably try to dump that, but it’s bad optics and they pay us a shocking amount of money to chair that committee and back up sedation. That usually entails placing an oral airway, bag mask ventilation for 5 minutes or less, and canceling the sedation.
Our ED folks don’t do propofol sedation, but there is a subset of sedation service physicians that do. Critical care does as well, though they’re far more likely to use Fent/Midaz/Vec than prop.

 

[narcotics999]

Preach.

Worse one: septic pt coming from ICU with pressors, 22g, and no A-line and CVC.

 

[narcotics999]

While I agree with most of the thread, the whole waiting for X hours for an emergency that will never be an empty stomach makes no sense to me. If the ER doc wants to do it in the ER that's fine with me. If the surgeon wants to bring the case to the OR i'm not waiting 8 GD hours for nothing.
Trauma=emergency=full stomach deal with it.

full stomach for emergency is not the problem; the problem is full stomach, deep sedation with no tube

 

[pgg]

While I agree with most of the thread, the whole waiting for X hours for an emergency that will never be an empty stomach makes no sense to me. If the ER doc wants to do it in the ER that's fine with me. If the surgeon wants to bring the case to the OR i'm not waiting 8 GD hours for nothing.
Trauma=emergency=full stomach deal with it.

No one waits 8 hours for an emergency.

If it's an emergency it goes, with proper aspiration precautions taken.

 

[dhb]

full stomach for emergency is not the problem; the problem is full stomach, deep sedation with no tube

It's not my problem i'm not doing it.

 

[dhb]

No one waits 8 hours for an emergency.

If it's an emergency it goes, with proper aspiration precautions taken.

Well there are a lot of posters ready to wait for that magical number at which point the stomach automatically voids itself of all content.

 

[Arch Guillotti]

Well there are a lot of posters ready to wait for that magical number at which point the stomach automatically voids itself of all content.

So what do you do?

 

[dhb]

So what do you do?

What's best

 

[WholeLottaGame7]

What an asinine statement.

Comparing a midlevel that you are supervising to another Doc that you have no association with is just plain stupid.

I work in the ED that comes with inherent risks and nothing is ever controlled. If 1 out of 5000 aspirates then that is the risk I take as a boarded EM doc vs keeping 5000 people in pain waiting for the mythical 8th hour. Give me this risk vs having to pump dilaudid ever 30 minutes while waiting 8 hrs. No different than the risk that I don't admit every Freaking Chest pain patient just in case one may have an MI.

Gas needs to stay in their Lane. I would never tell any other doc that they shouldn't do something especially if their Board is clear.

I don't know why anyone would want to take on more work. When I run to a code, I pray that some doc beat me to it.

Don't you see the irony that you don't want me to use propofol but when a code happens, Gas are always too busy or late to the code only to show up after I intubate. Funny how you guys don't fight to run all codes in the hospital b/c all EM docs would gladly give up this right.

Chill, bro or bro-ette. I never said I didn't want you using propofol, I just said you need to be honest with yourself about the risks you're taking on and be cool with it. Which it sounds like you are, so good on ya.

If it makes you feel better, I can amend my statement to say "I know anesthesiologists who've been practicing for 30 years who claim they've never had any complications," but to be honest, that's not nearly as true as it is for CRNAs. There's an element of Dunning-Krueger at play.

 

[Twiggidy]

Worse one: septic pt coming from ICU with pressors, 22g, and no A-line and CVC.

You really wonder where they did their fellowships and how they managed to graduate.

 

[migm]

We all graduated with roughly the same amount of skill and knowledge. What changes in EM (and may not be obvious unless you're in the field) is your local environment and hospitals. There is real pressure to see and dispo patients within a certain timeframe or else someone sends you a nastygram or docks your pay or you lose your job. When the business of emergency medicine is more important than doing the right thing patients suffer. Same thing as with CRNAs.

 

[MoMoGesiologist]

Worse one: septic pt coming from ICU with pressors, 22g, and no A-line and CVC.

Playing devils advocate: is there any trial out there showing alines or CVCs save lives? Get people better faster?

10-20 years ago, someone would have been saying “Omg the ICU let the Hgb sit at 8? Why aren’t those dummies transfusing!?” Or ”OMG the ICU doc must be stupid he didn’t put a PA catheter in this sick pt, doesn’t he know how to resuscitate?” Even today I hear surgeons getting all out of sorts at the base excess and giving fluids to correct it.

Maybe docs will look back in 10-20 years and say, “look at how many pts they put at risk lining up these pts and causing all those infections and complications“. We always think we r such geniuses, but look at how many things we used to do have been proven to be useless or even harmful.

 

[nimbus]

Playing devils advocate: is there any trial out there showing alines or CVCs save lives? Get people better faster?

10-20 years ago, someone would have been saying “Omg the ICU let the Hgb sit at 8? Why aren’t those dummies transfusing!?” Or ”OMG the ICU doc must be stupid he didn’t put a PA catheter in this sick pt, doesn’t he know how to resuscitate?” Even today I hear surgeons getting all out of sorts at the base excess and giving fluids to correct it.

Maybe docs will look back in 10-20 years and say, “look at how many pts they put at risk lining up these pts and causing all those infections and complications“. We always think we r such geniuses, but look at how many things we used to do have been proven to be useless or even harmful.

Sometimes we do things because it makes our job easier, not because it improves outcomes. For example it’s easier to check serial blood gases if the patient has an Aline.

 

[Beeftenderloin]

Playing devils advocate: is there any trial out there showing alines or CVCs save lives? Get people better faster?

10-20 years ago, someone would have been saying “Omg the ICU let the Hgb sit at 8? Why aren’t those dummies transfusing!?” Or ”OMG the ICU doc must be stupid he didn’t put a PA catheter in this sick pt, doesn’t he know how to resuscitate?” Even today I hear surgeons getting all out of sorts at the base excess and giving fluids to correct it.

Maybe docs will look back in 10-20 years and say, “look at how many pts they put at risk lining up these pts and causing all those infections and complications“. We always think we r such geniuses, but look at how many things we used to do have been proven to be useless or even harmful.

Your point is well taken, but it’s much easier to titrate vasoactives in critically ill patients with an art line and the risk of placement is pretty low. And although there is some reasonable safety data for low dose norepinephrine and phenylephrine peripherally, anyone getting high dose or multiple pressers needs the CVC, no questions asked, until we get data that proves otherwise.

 

[Mman]

10-20 years ago, someone would have been saying “Omg the ICU let the Hgb sit at 8? Why aren’t those dummies transfusing!?” Or ”OMG the ICU doc must be stupid he didn’t put a PA catheter in this sick pt, doesn’t he know how to resuscitate?” Even today I hear surgeons getting all out of sorts at the base excess and giving fluids to correct it.

I think you mean more like 20-30+ years agos

 

[Planktonmd]

If ER physicians want to use Propofol or whatever else they should be allowed to do so as long as the anesthesiology department is not approving their privileges for moderate/deep sedation.
If we are signing off on their privileges, as is the case in many places, and if we are maintaining the sedation policy of the hospital, then we have the right to say that Propofol is used in the ER unintentionally or intentionally as a general anesthetic, and that general anesthesia should be done by anesthesia professionals.

 

[Lexdiamondz]

If ER physicians want to use Propofol or whatever else they should be allowed to do so as long as the anesthesiology department is not approving their privileges for moderate/deep sedation.
If we are signing off on their privileges, as is the case in many places, and if we are maintaining the sedation policy of the hospital, then we have the right to say that Propofol is used in the ER unintentionally or intentionally as a general anesthetic, and that general anesthesia should be done by anesthesia professionals.

That's not totally unreasonable, just understand the consequences of such action. As someone mentioned before if you guys are going to take that stance, you need to make either a provider available to come down to the ER to perform these sedations effectively 24/7 or these patients need to be admitted.

 

[IlDestriero]

Playing devils advocate: is there any trial out there showing alines or CVCs save lives? Get people better faster?

10-20 years ago, someone would have been saying “Omg the ICU let the Hgb sit at 8? Why aren’t those dummies transfusing!?” Or ”OMG the ICU doc must be stupid he didn’t put a PA catheter in this sick pt, doesn’t he know how to resuscitate?” Even today I hear surgeons getting all out of sorts at the base excess and giving fluids to correct it.

Maybe docs will look back in 10-20 years and say, “look at how many pts they put at risk lining up these pts and causing all those infections and complications“. We always think we r such geniuses, but look at how many things we used to do have been proven to be useless or even harmful.

When the pressors extravasate due to a failed IV and the patient needs skin grafts, that’s a problem. When the PIV fails on the unstable pressor patient and you have to put in an IO line emergently, that’s a problem. There are plenty of reasons for picc lines or central lines in ICU patients.

 

[Planktonmd]

That's not totally unreasonable, just understand the consequences of such action. As someone mentioned before if you guys are going to take that stance, you need to make either a provider available to come down to the ER to perform these sedations effectively 24/7 or these patients need to be admitted.

Sure, it is an issue we need to consider, but if the ER physician is unable to do a procedure with whatever medications are available per hospital policy, then maybe he/she should consult a surgeon.
Also when an ER physician calls anesthesia, a different standard applies, which means unless it's a life threatening emergency the patient has to be NPO per ASA guidelines, and if it's an emergency and the patient is full stomach, then the patient will have to have general anesthesia with ETT, which means it's probably better to take the patient to the OR.

 

[GaseousClay]

If Gas could guarantee me propofol sedation within 1 hr of being called, I would gladly never order propofol again. I get no joy taking the risk of sedation. My life would be much better if the hospital took everything off my plate that other specialist are better at than I would do. Pulm=codes, Gas=procedural sedation, ortho=reduce fractures, ENT=peritonsillar abscess aspiration, Gas=central line. I have done enough and would sleep much better if I did not do another in my life..

ok TRIAGE. if triage wants to use propofol then triage should use propofol. who cares?

 

[jw3600]

I've given up trying to argue with ED physicians about the way they practice. I thought some anesthesiologists were short-sighted in their approach to an anesthetic by talking about how "they just have to get them through the case" then I started talking to most EM docs.

The primary objective in the emergency department is getting the patient out of the emergency department in as short time as possible. I don't know when that superceded doing what's best for the patient, but once viewed in that light, any argument becomes moot.

"Why did you intubate this patient, when you could have just put them on BiPAP?"
"I couldn't risk them getting worse and I have to get them out of the ED"

"Why is this patient coming to the ICU with three pressers going through a 22g and no arterial line?"
"I had to get them out of the ED. Can't keep them there long enough to put a central line/a-line"

"Why are you calling a surgical consult for a patient with no labs or imaging?"
"Can't sit around waiting for the results, other patients might come in"

"Why did you sedate this kid who just had pizza before they dislocated their shoulder playing football"
"Have to get them out of the ED. Can't sit around for 8 hours in pain."

There are countless other examples, but when everything is viewed from an optic of getting people out of the ED then there is no argument to be made. And I realize this comes off as ED bashing, but I really believe we see things from such different viewpoints that a consistent discussion is impossible. Just like I don't expect an IM doc to be able to talk to me about proper protocol for medication administration in the OR.

That said, I frankly don't care what the ED board says about your privileges. They're notorious for setting their own standards that differ from most other practices. Just take a look at their position when it comes to ACLS, ATLS or PALS.

The **** is an aline gonna change? CVC- I agree.

 

[deleted697127]

When the pressors extravasate due to a failed IV and the patient needs skin grafts, that’s a problem. When the PIV fails on the unstable pressor patient and you have to put in an IO line emergently, that’s a problem. There are plenty of reasons for picc lines or central lines in ICU patients.

Exactly. I have seen extravasation on pressors a hand full of times. I think the numbers needed to harm of not placing a central line is vastly under appreciated by specialists who do not place their own IVs. Patients on pressors tend to have zillions of holes in their vessels from frequent blood draws. Those holes leak. There is a reason you start distally and work your way up the arm. If a central line is indicated, place the central line. I see a lot of what i suspect is justification of laziness.

 

[emergentmd]

ok TRIAGE. if triage wants to use propofol then triage should use propofol. who cares?

I never meant Gas to be derogatory and apologize to all. Alittle from being lazy to type out Anesthesiologist and alittle from some posters user name having Gas in their name.

 

[emergentmd]

All specialities get enough micromanagement from Admin, I don't ever understand why another specialty would like to micromanage another.

I am not sure why these threads always devolve into how poor EM outcomes are, complain about our care, or complain how we don't meet your standards. The ER is a different beast than a scheduled OR case, you can't apply your standards to the ER. I hear many complaints about Anes from other specialties so no reason to throw stones in a glass house.

If Anesthesia really wants to put your standards into the ER, then don't just throw out mandates without fixing the problem. You can't just say you will not approve of EM docs using Propofol and then walk away to let us solve the problem. You guys would be up in arms if we made your job 10x more difficult and walked away. Imagine if the EM docs refused to take care of Codes, left that at your doorstep, and walked away.

If Anes really believe we are providing poor care with Propofol in the ER and you can provide better, then in the name of patient safety, STEP UP to the plate.

1. Guarantee all ER Propofol/moderate sedation cases will be staffed in 1 hr
2. Guarantee that you and Ortho will take over patient care if you need the magical 8 hrs. Good luck convincing ortho that they have to come in at 2am while waiting for 6 hrs NPO to reduce a shoulder.
3. You can talk to the patient why their child needs to wait 6 hrs in pain for something I could do in 1 hr
4. You can talk to the patient why they will be getting a 20K OR bill that would be a fraction if I took care of it in an hr.

Instead of just talking, back it up and hire another Anesthesiologist just to cover ER sedation. Step up and take over management of the patient.

Remember, EM docs never wanted your help with this or would ever consult you. Ill wait while hell freezes over. I forgot, there is no money in this but if there were a nice payday you guys would be jumping all over this.

 

[GaseousClay]

All specialities get enough micromanagement from Admin, I don't ever understand why another specialty would like to micromanage another.

I am not sure why these threads always devolve into how poor EM outcomes are, complain about our care, or complain how we don't meet your standards. The ER is a different beast than a scheduled OR case, you can't apply your standards to the ER. I hear many complaints about Anes from other specialties so no reason to throw stones in a glass house.

If Anesthesia really wants to put your standards into the ER, then don't just throw out mandates without fixing the problem. You can't just say you will not approve of EM docs using Propofol and then walk away to let us solve the problem. You guys would be up in arms if we made your job 10x more difficult and walked away. Imagine if the EM docs refused to take care of Codes, left that at your doorstep, and walked away.

If Anes really believe we are providing poor care with Propofol in the ER and you can provide better, then in the name of patient safety, STEP UP to the plate.

1. Guarantee all ER Propofol/moderate sedation cases will be staffed in 1 hr
2. Guarantee that you and Ortho will take over patient care if you need the magical 8 hrs. Good luck convincing ortho that they have to come in at 2am while waiting for 6 hrs NPO to reduce a shoulder.
3. You can talk to the patient why their child needs to wait 6 hrs in pain for something I could do in 1 hr
4. You can talk to the patient why they will be getting a 20K OR bill that would be a fraction if I took care of it in an hr.

Instead of just talking, back it up and hire another Anesthesiologist just to cover ER sedation. Step up and take over management of the patient.

Remember, EM docs never wanted your help with this or would ever consult you. Ill wait while hell freezes over. I forgot, there is no money in this but if there were a nice payday you guys would be jumping all over this.

yeah I was just being stupid about the gas/triage thing. I agree with you and not sure why people in my specialty would argue against you doing what is clearly in your scope of practice. GI nurses and docs use propofol without us all the time around the country, EM docs are far more equipped to deal with sedation related complications so again who cares if they want to use it.

 

[nimbus]

All specialities get enough micromanagement from Admin, I don't ever understand why another specialty would like to micromanage another.

I am not sure why these threads always devolve into how poor EM outcomes are, complain about our care, or complain how we don't meet your standards. The ER is a different beast than a scheduled OR case, you can't apply your standards to the ER. I hear many complaints about Anes from other specialties so no reason to throw stones in a glass house.

If Anesthesia really wants to put your standards into the ER, then don't just throw out mandates without fixing the problem. You can't just say you will not approve of EM docs using Propofol and then walk away to let us solve the problem. You guys would be up in arms if we made your job 10x more difficult and walked away. Imagine if the EM docs refused to take care of Codes, left that at your doorstep, and walked away.

If Anes really believe we are providing poor care with Propofol in the ER and you can provide better, then in the name of patient safety, STEP UP to the plate.

1. Guarantee all ER Propofol/moderate sedation cases will be staffed in 1 hr
2. Guarantee that you and Ortho will take over patient care if you need the magical 8 hrs. Good luck convincing ortho that they have to come in at 2am while waiting for 6 hrs NPO to reduce a shoulder.
3. You can talk to the patient why their child needs to wait 6 hrs in pain for something I could do in 1 hr
4. You can talk to the patient why they will be getting a 20K OR bill that would be a fraction if I took care of it in an hr.

Instead of just talking, back it up and hire another Anesthesiologist just to cover ER sedation. Step up and take over management of the patient.

Remember, EM docs never wanted your help with this or would ever consult you. Ill wait while hell freezes over. I forgot, there is no money in this but if there were a nice payday you guys would be jumping all over this.

I think most anesthesiologists prefer to mind our own business and not be involved in setting policy for other specialties. Unfortunately anesthesia departments are often charged with setting sedation policies throughout the hospital. When asked for our opinion, we can only give one based on our own training, experience and standards. That’s all we can do. It is drilled into every anesthesiologist from day one of residency that patients need to be fasted before sedation if at all possible. That may change in the future but for now it is the current standard. Since EM has their own training in procedural sedation, perhaps hospitals should allow them to set their own policies.