Propofol use by EM physicians

[Twiggidy]

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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 don't think anyone in this entire thread is trying to take away propofol sedation from ER docs. I'm not sure where you're getting that. I've read just about every response in this thread and it's mostly, "Let the ER docs do whatever they want to do". Can we criticize how you do it? Yeah man, this is America. Everyone is allowed to be Monday morning quarterback. Hell, we criticize the way each other does anesthesia all the time.

 

[emergentmd]

I don't think anyone in this entire thread is trying to take away propofol sedation from ER docs. I'm not sure where you're getting that. I've read just about every response in this thread and it's mostly, "Let the ER docs do whatever they want to do". Can we criticize how you do it? Yeah man, this is America. Everyone is allowed to be Monday morning quarterback. Hell, we criticize the way each other does anesthesia all the time.

Most Anes docs don't give a second thought on what we do in the ER. All specialists are happy if we never call them and leave them alone. But the anesthesiology dept definitely care. There is a reason we had to jump through a bunch of hoops 10 yrs ago and looks like the OP has to jump through the same hoops.

We used Propofol without any issues for decades. No different than using paralytics which has a greater chance of death. But 10 yrs ago, our EM docs had to jump through a bunch of hoops including taking some stupid Sedation test( Which never changed so we just all copied the answers) and have the Chair of Anes sign off on our privileges.

It doesn't affect me anymore as I am out of the hospital for the most part. No more hoops to jump through. I can push Propofol if I want, make whatever protocols we want, and haven's taken any silly moderate sedation test generated by Anesthesiology.

 

[chudat]

I am all for physicians first approach. But how many times they call us for airway emergencies after botched intubation attempts. Just because they can doesn’t mean they should.

Had a discussion with an IR physician regarding they also want to use prop in their procedures for tough cases. I preceded on asking how does she feel about pain docs ordering films at outside facility and billing for reading CT. Shut her up pretty fast.

The standard is always be able to rescue airways. Sure slap on some oxygen 95% of the time would be fine. I had a TEE the other day after 50 of prop, I stayed in the procedure room for another 45 min because the sat would dip down to low 80s even with mask. Patient did not wake up fully even with good stimulation.

Sure most of the cases in ED would probably be “okay” but, not a big fan to rescue someone else’s messes especially when I am stuck somewhere else.

I disagree. If the IR attending wants to use prop and agrees to take on all management then by all means go head. If the pain docs wants to bill for the CT then he or she better be able to interpret the CT and take on all responsibilities for the CT read.

 

[IlDestriero]

I guarantee you that if anesthesia suddenly took over sedation credentialing is was either after a bad outcome somewhere in the system or driven by the executive suite. So, they make a test, make sure you’re board certified, in good standing in the hospital, and rubber stamp the papers. Then when it all goes balls up they can say that you were properly vetted and credentialed to provide deep sedation, practicing within your accepted guidelines, etc. and any issues arising from that sedation are yours.

 

[IlDestriero]

I disagree. If the IR attending wants to use prop and agrees to take on all management then by all means go head. If the pain docs wants to bill for the CT then he or she better be able to interpret the CT and take on all responsibilities for the CT read.

If the IR attending, with essentially zero airway experience, wants to start pushing propofol for procedures the answer is NFW! Because they will be calling codes and airway emergencies that the ED/PICU/Anesthesia/etc. will be responding to.

 

[Planktonmd]

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.

My friend, no one wants to "micromanage you" .
We are just saying that if you want to use a certain medication or a certain technique, your fight is not with us, it is with the hospital administration and pharmacy who decide what you can and cannot do.
If the hospital administration asks us to be the ones who determines what your privileges should be, then we have to apply our standards not EM standards.
Your grievances are valid but you should address them with the hospital credentialing not with us.
And you still don't understand that when we do an anesthetic we have to follow all the guidelines of our specialty not yours.
I hope this helps.

 

[pgg]

our EM docs had to jump through a bunch of hoops including taking some stupid Sedation test( Which never changed so we just all copied the answers)

If you had to copy the answers to the "sedation test" in order to pass it, maybe you shouldn't be providing sedation. 🙂

 

[migm]

..then we have to apply our standards not EM standards...

Perhaps if you have been deemed to be in charge, for whatever reason, you may recognize that the emergency department is not the same as the OR and apply our own, evidence based (https://www.acep.org/globalassets/s...duled-procedural-sedation-sept-28-2018-cp.pdf), guidelines. These guidelines, by the way, were crafted with an anesthesiologist invited (but per the guidelines "Eight other organizations representing general medicine, anesthesiology, dentistry, and gastroenterology were invited to participate, but either declined or did not respond.")

 

[MoMoGesiologist]

Perhaps if you have been deemed to be in charge, for whatever reason, you may recognize that the emergency department is not the same as the OR and apply our guidelines. Or let us determine our own destiny as board certified physicians.

Bend the knee to House Anesthesia!

 

[WholeLottaGame7]

But the anesthesiology dept definitely care. There is a reason we had to jump through a bunch of hoops 10 yrs ago and looks like the OP has to jump through the same hoops.

Maybe. But more likely some sort of asinine hospital/JCAHO/clipboard carrying administrator requirement. Hell, last year everyone in our anesthesia department had to take an online module and fill out a form to get "credentialed" to place central lines. Completely asinine.

 

[deleted547339]

CRNAs are destroying your field and ya’ll want talk about something that we’ve been doing safely for the past decade?

 

[IlDestriero]

What is currently the biggest threat to our field is management companies, that’s probably the biggest threat to EM physicians as well. Stay focused. If the executive suite wants Anesthesia to take over the management of sedation, it’s not because the “gas guys” went on a power trip. You can change your local politics.

 

[DrGasPasser]

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.

You write that as if there are no major complications associated with central line placement. This question has been looked at - a lot. There is no evidence that patients in the PROCESS or ARISE trials had better outcomes when lines were placed early or pressors were given peripherally for the first 24 hours. That is a combined 3000 patients in those 2 trials. This randomized trial of central vs. peripheral pressors saw no serious complications from extrav in the peripheral arm.https://www.ncbi.nlm.nih.gov/m/pubmed/23782969/

Rather than put a line in every patient, I try to anticipate the patient’s course over the first 12 hours of my care and escalate my therapeutics accordingly. It is this mentality of, “Every patient with X needs Y” that causes a bunch of people to be subjected to a whole lot of risk with variable reward.

 

[DrGasPasser]

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.

Earlier in this thread, someone mention the concept of a universal standard of care. I’m not sure where that forum member practices, but that is not the case in TN or NC - 2 states where I routinely serve as an expert witness. In these 2 states, the standard of care is very much determined by what a prudent doctor of similar training would do under a similar set of circumstances. It is important enough in my field that physician experts are probed in their familiarity with hospital size, acuity, and demographics under deposition to insure their experience and resources with the situation at hand.

With that being said, it is easy to see why EM physicians are going to say that EM training and the ED patient population is sufficiently different than anesthesia to constitute a separate standard of care. As I previously mentioned, EPs often sedate patients with lower ASA classes and for shorter durations than their anesthesia colleagues. This might explain why EPs enjoy surprisingly low complication rates despite violating many of the cardinal tenants of anesthesiology.

Finally, EPs have been using Propofol and Etomidate for deep sedation for about 20 years. That should be more than enough time for someone to show harm if there was a systemic safety issue.

 

[nimbus]

CRNAs are destroying your field and ya’ll want talk about something that we’ve been doing safely for the past decade?

No. CRNAs are not destroying anesthesiology. They have been around since the 1930s. Private equity and vulture capitalists are. Just like EM.

 

[nimbus]

Earlier in this thread, someone mention the concept of a universal standard of care. I’m not sure where that forum member practices, but that is not the case in TN or NC - 2 states where I routinely serve as an expert witness. In these 2 states, the standard of care is very much determined by what a prudent doctor of similar training would do under a similar set of circumstances. It is important enough in my field that physician experts are probed in their familiarity with hospital size, acuity, and demographics under deposition to insure their experience and resources with the situation at hand.

With that being said, it is easy to see why EM physicians are going to say that EM training and the ED patient population is sufficiently different than anesthesia to constitute a separate standard of care. As I previously mentioned, EPs often sedate patients with lower ASA classes and for shorter durations than their anesthesia colleagues. This might explain why EPs enjoy surprisingly low complication rates despite violating many of the cardinal tenants of anesthesiology.

Finally, EPs have been using Propofol and Etomidate for deep sedation for about 20 years. That should be more than enough time for someone to show harm if there was a systemic safety issue.

I agree that brief sedation with no airway instrumentation greatly reduces the risk of vomiting and aspiration.

 

[nimbus]

You write that as if there are no major complications associated with central line placement. This question has been looked at - a lot. There is no evidence that patients in the PROCESS or ARISE trials had better outcomes when lines were placed early or pressors were given peripherally for the first 24 hours. That is a combined 3000 patients in those 2 trials. This randomized trial of central vs. peripheral pressors saw no serious complications from extrav in the peripheral arm.https://www.ncbi.nlm.nih.gov/m/pubmed/23782969/

Rather than put a line in every patient, I try to anticipate the patient’s course over the first 12 hours of my care and escalate my therapeutics accordingly. It is this mentality of, “Every patient with X needs Y” that causes a bunch of people to be subjected to a whole lot of risk with variable reward.

That could very well be true. Maybe we get an skewed perspective because we tend to see the ones who are rushed to the OR in extremis, usually underresuscitated, with high dose pressors running through a shady peripheral IV. There may be a large percentage of others that do very well that we as anesthesiologists never see. And central line complications are extremely low in experienced hands as long as they are removed when no longer indicated.

 

[Druggernaut]

An argument had started in our hospital system regarding our insistence that the ED use moderate sedation using ketamine/versed/fentanyl/? etomidate? for joint manipulation/setting fractures/etc.

They want to use propofol for "deep sedation". Which, in discussion, is obviously general anesthesia. As most know, EM's NPO standards are much more lax than ours.

I know ultimately it's more important what the depth of sedation is, but I also feel like propofol gives them a slippery slope.

I'd like to hear how others have dealt with this in the past. And what other policies say. Our EM docs state we are the only system in our state that doesn't allow the use of propofol in the ED, which we doubt.

I'm emergency medicine, but just figured I'd inject our perspective as well as some data.

I work in a system where I end up doing a lot of procedural sedation, it's almost exclusively deep sedation, and the majority is with propofol. The biggest intervention I've done in two years here has been placing a nasal airway in a 400 lb lady with multiple long bone fractures requiring reduction and splinting. She had received ketamine, no propofol, and it was placed because her sats had dipped to the low 90's and I was working with a little bit of a nervous resident.

I'd also be much more concerned about NPO status in etomidate than propofol.

Your system would be in the minority as far as restricting propofol. The only place that I've worked with such a restriction was a rural ED as a moonlighting resident, where ortho and anesthesia would be called in and typically go to the OR for reductions since they limited the ED to Versed/fentanyl. I did take a transfer from a very small hospital a few months ago who told me the patient was really difficult to sedate and kept desaturating while still somehow being in too much pain to relax and cooperate with shoulder reduction. He must've either been limited to opiates and benzos as well or just uncomfortable doing more as a probably non-EM boarded physician, and the patient was an incredibly easy reduction after a small push of propofol and one maneuver. No airway compromise, no hemodynamic instability, and woke up fast. It seems like limiting the ED like that compromises patient safety rather than improving it. You're probably also reducing the quality of the EM physicians your system retains, because most of us who are well trained and aren't just looking for a really easy job to ride out until retirement would choose to work in a system that respected their EM staff more.

I am sorry, but it's not. The exceptions should be truly minor and very short cases (e.g. minutes of suturing in kids), if any.

...

Also, these cases are waaaaay more prone to emesis on a full stomach than your usual RSI., where the patient is muscle-relaxed. So you need an airway expert at the head, because seconds can matter. I am speaking as somebody who's had an NPO patient throw up A LITER of intestinal contents in the middle of a propofol sedation case (he had undiagnosed autonomic dysfunction). Had I not been at the head, it would have been a massive aspiration; there was none.

ED procedural sedation is almost exclusively short things. 10-15 minutes is probably the upper limit of most aside from working with ortho residents who need to have an absolutely anatomical reduction to avoid being destroyed in morning report. The anesthesia dogma is that there's a high risk of aspiration if not NPO, but I'm curious if there's much data to support that. As another poster linked here, the American College of Emergency Physicians has taken the position that NPO status is not important for ED sedations. There have also been multiple studies demonstrating no increase in adverse events between having one physician dedicated to the sedation as well as one doing the procedure versus one physician doing both with nursing or respiratory therapy assistance.

 

[woopedazz]

There have also been multiple studies demonstrating no increase in adverse events between having one physician dedicated to the sedation as well as one doing the procedure versus one physician doing both with nursing or respiratory therapy assistance.

Really? Like what ones? In Aus whenever anyone gets sedation in ED it's a big deal and at absolute bare minimum there is a senior ED reg doing drugs/airway - normally they have a junior reg to do drugs and learn. There is always another doc doing the reduction/procedure. Can't imagine a nurse doing either the airway or drugs.

 

[Planktonmd]

Perhaps if you have been deemed to be in charge, for whatever reason, you may recognize that the emergency department is not the same as the OR and apply our own, evidence based (https://www.acep.org/globalassets/s...duled-procedural-sedation-sept-28-2018-cp.pdf), guidelines. These guidelines, by the way, were crafted with an anesthesiologist invited (but per the guidelines "Eight other organizations representing general medicine, anesthesiology, dentistry, and gastroenterology were invited to participate, but either declined or did not respond.")

I agree! No anesthesiologist wants to dictate how another specialist practices, and we agree that the ER is different as you stated. But in our specialty it's not acceptable to change the guidelines or accept a lesser level of vigilance or safety based on location or based on anything else.
If we give anesthesia in the OR or in the parking lot we have to follow the same guidelines.
If the hospital asks us to determine how you can do your sedation, we have to hold you to the same standards based on how we practice.
Is it right or fair? probably not, but we cannot say that it's OK for non anesthesiologists to do things that are considered malpractice in our specialty.
Again, your fight is not with us, it is with hospital administration who dictates that we have to tell you how to do sedation.

 

[Mman]

The anesthesia dogma is that there's a high risk of aspiration if not NPO, but I'm curious if there's much data to support that.

The anesthesia dogma is definitely not that there is a high risk of aspiration in non NPO patients. We make people be NPO for elective procedures, but we induce people all the time for emergencies and they usually do not aspirate. It's simply a balance of risk/reward and determining how relatively elective or urgent something is.

 

[Mman]

Again, your fight is not with us, it is with hospital administration who dictates that we have to tell you how to do sedation.

CMS requires anesthesia to guide those policies for a hospital.

But I think the CMS requirement is that anesthesia determines how privileges are handed out for varying levels of sedation, not the actual practice of the sedation.

 

[Planktonmd]

CMS requires anesthesia to guide those policies for a hospital.

But I think the CMS requirement is that anesthesia determines how privileges are handed out for varying levels of sedation, not the actual practice of the sedation.

Local sedation policies vary widely, and in many places they dictate what medications are allowed to be used by non anesthesiologists in addition to the standards of monitoring and staffing.

 

[Southpaw]

I disagree. If the IR attending wants to use prop and agrees to take on all management then by all means go head. If the pain docs wants to bill for the CT then he or she better be able to interpret the CT and take on all responsibilities for the CT read.

By ‘agrees to take on all management’ why don’t you give me a bit more detail on what exactly that means.

 

[Twiggidy]

By ‘agrees to take on all management’ why don’t you give me a bit more detail on what exactly that means.

It means you know the dose you're going to give, the effect of said dose, and the potential side effects of said does. It means in the event of an allergy or overdose, you're prepared to handle that consequence of using the drug. There are many who want to use propofol who don't know what dose to use.

 

[Southpaw]

It means you know the dose you're going to give, the effect of said dose, and the potential side effects of said does. It means in the event of an allergy or overdose, you're prepared to handle that consequence of using the drug. There are many who want to use propofol who don't know what dose to use.

In my experience it means that [name of random service] wants to sedate however they want bc they believe anesthesia slows them down, but wants to call anesthesia when they’ve almost killed the patient.

 

[vector2]

It means you know the dose you're going to give, the effect of said dose, and the potential side effects of said does. It means in the event of an allergy or overdose, you're prepared to handle that consequence of using the drug. There are many who want to use propofol who don't know what dose to use.

I dose propofol in half inches but I believe my colleagues across the pond use centimeters

 

[Xerxes1729]

That could very well be true. Maybe we get an skewed perspective because we tend to see the ones who are rushed to the OR in extremis, usually underresuscitated, with high dose pressors running through a shady peripheral IV. There may be a large percentage of others that do very well that we as anesthesiologists never see. And central line complications are extremely low in experienced hands as long as they are removed when no longer indicated.

Whether or not the patient needs a CVL in the ED is highly variable. Does the patient have great veins and 18g and 16g AC lines? They can probably wait and get a CVL in the ICU or OR. But if the person has terrible peripheral access and is critically ill, even if they're not on vasopressors, I'll often place a line. I find a conversation with the admitting intensivist is usually helpful in borderline cases. It's usually pretty easy to come to an agreement based on the patient's situation and the logistics of the ED and ICU at the time.

 

[Ronin786]

I'm emergency medicine, but just figured I'd inject our perspective as well as some data.

I work in a system where I end up doing a lot of procedural sedation, it's almost exclusively deep sedation, and the majority is with propofol. The biggest intervention I've done in two years here has been placing a nasal airway in a 400 lb lady with multiple long bone fractures requiring reduction and splinting. She had received ketamine, no propofol, and it was placed because her sats had dipped to the low 90's and I was working with a little bit of a nervous resident.

By definition you're not doing deep sedation if the one time you've ever had to manipulate the airway is once in a 400lber. Or the rest of your patients weigh 40lbs.

 

[IMGASMD]

I was just thinking we haven’t moved on to deep sedation vs GA discussion yet.....😉

 

[Twiggidy]

In my experience it means that [name of random service] wants to sedate however they want bc they believe anesthesia slows them down, but wants to call anesthesia when they’ve almost killed the patient.

That’s the real world definition....mine is admittedly more fantasyland

 

[woopedazz]

Perhaps if you have been deemed to be in charge, for whatever reason, you may recognize that the emergency department is not the same as the OR and apply our own, evidence based (https://www.acep.org/globalassets/s...duled-procedural-sedation-sept-28-2018-cp.pdf), guidelines. These guidelines, by the way, were crafted with an anesthesiologist invited (but per the guidelines "Eight other organizations representing general medicine, anesthesiology, dentistry, and gastroenterology were invited to participate, but either declined or did not respond.")

I had a quick look to see what their monitoring/staffing requirements were.

Was a bit surprised to see this as a recommendation:

Supplemental oxygen is commonly avoided when capnography is not used, thus permitting pulse oximetry to provide warning should interactive monitoring fail to detect ventilatory compromise.

Paraphrased: If you don't want to use capnography/clinical acumen, then a good way of telling when someone is obstructed is when they start desaturating. Patients desaturate faster when not pre-oxygenated/given supplemental oxygen. Therefore, it's advisable not to give supplemental oxygen so that patients desaturate earlier.

Personally I think that's the dumbest thing ever. "Provide warning" for what? That they're about to desaturate? The warning sign for impending desaturation is make them desaturate earlier? I don't get it.

 

[nimbus]

I had a quick look to see what their monitoring/staffing requirements were.

Was a bit surprised to see this as a recommendation:



Paraphrased: If you don't want to use capnography/clinical acumen, then a good way of telling when someone is obstructed is when they start desaturating. Patients desaturate faster when not pre-oxygenated/given supplemental oxygen. Therefore, it's advisable not to give supplemental oxygen so that patients desaturate earlier.

Personally I think that's the dumbest thing ever. "Provide warning" for what? That they're about to desaturate? The warning sign for impending desaturation is make them desaturate earlier? I don't get it.

Maybe there’s a reason no anesthesiologist wanted to have anything to do with that document.

 

[IMGASMD]

I had a quick look to see what their monitoring/staffing requirements were.

Was a bit surprised to see this as a recommendation:



Paraphrased: If you don't want to use capnography/clinical acumen, then a good way of telling when someone is obstructed is when they start desaturating. Patients desaturate faster when not pre-oxygenated/given supplemental oxygen. Therefore, it's advisable not to give supplemental oxygen so that patients desaturate earlier.

Personally I think that's the dumbest thing ever. "Provide warning" for what? That they're about to desaturate? The warning sign for impending desaturation is make them desaturate earlier? I don't get it.

Maybe they’re better at achieve moderate sedation and not pushing general anesthesia than you gas doctors.

 

[nimbus]

Maybe they’re better at achieve moderate sedation and not pushing general anesthesia than you gas doctors.

How? By giving 30mg of propofol instead of 40mg?

 

[IMGASMD]

How? By giving 30mg of propofol instead of 40mg?

 

[pgg]

I had a quick look to see what their monitoring/staffing requirements were.

Was a bit surprised to see this as a recommendation:

Supplemental oxygen is commonly avoided when capnography is not used, thus permitting pulse oximetry to provide warning should interactive monitoring fail to detect ventilatory compromise.

Paraphrased: If you don't want to use capnography/clinical acumen, then a good way of telling when someone is obstructed is when they start desaturating. Patients desaturate faster when not pre-oxygenated/given supplemental oxygen. Therefore, it's advisable not to give supplemental oxygen so that patients desaturate earlier.

Personally I think that's the dumbest thing ever. "Provide warning" for what? That they're about to desaturate? The warning sign for impending desaturation is make them desaturate earlier? I don't get it.

It's a tacit admission that they're not watching the patients when they sedate them. They don't feel a person dedicated to monitoring is necessary.

They don't expect to be able to notice ventilatory compromise unless the machine beeps at them, and calls their attention away from the procedure they're doing. Simple as that.