Pulmonologists pushing prop for Endo!

Started by Greenbayslacker
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Greenbayslacker

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A friend in medical billing is telling me about a scheme they are running at their hospital. With the lack of anesthesia and high costs, they have employed critical care pulmonologists instead to give propofol for elective outpatient EGD/colonoscopies. I tried explaining that this is probably malpractice but I’m not really sure what exact grounds to stand on. Anyone have solid evidence I can show?
 
Greenbayslacker said:
A friend in medical billing is telling me about a scheme they are running at their hospital. With the lack of anesthesia and high costs, they have employed critical care pulmonologists instead to give propofol for elective outpatient EGD/colonoscopies. I tried explaining that this is probably malpractice but I’m not really sure what exact grounds to stand on. Anyone have solid evidence I can show?
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I wonder how they bill for it too?

Also have you ever seen Pulm/CC intubate? It's painful.
 
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Greenbayslacker said:
A friend in medical billing is telling me about a scheme they are running at their hospital. With the lack of anesthesia and high costs, they have employed critical care pulmonologists instead to give propofol for elective outpatient EGD/colonoscopies. I tried explaining that this is probably malpractice but I’m not really sure what exact grounds to stand on. Anyone have solid evidence I can show?
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How is it malpractice? What makes it malpractice?
 
makemoney2024 said:
I can’t believe they are actually available. I thought there was also a shortage of ICU docs.
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That's what i was thinking. There's no way that an icu doc is more productive and useful pushing prop on one patient at a time than running a unit

it's funny to watch them pick induction doses. They always stand there like hmm pretending to think about it as they order 20 of etomidate every time
 
makemoney2024 said:
How is it malpractice? What makes it malpractice?
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If its not malpractice it's definitely pushing the boundaries...
Critical care vs elective outpatient work?
Come on...

Are they allowed sedate with prop for their own bronchs? Where I work, Noone is allowed give deep sedation for their own procedure and bill for both
 
PpfSuxTube said:
If its not malpractice it's definitely pushing the boundaries...
Critical care vs elective outpatient work?
Come on...

Are they allowed sedate with prop for their own bronchs? Where I work, Noone is allowed give deep sedation for their own procedure and bill for both
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Every place is so different. That is why we can’t argue it’s malpractice because some places let non anesthesia staff use propofol . And if they are ICU docs as well (most are) for sure have privileges to push the stuff.
So that’s why it would be difficult to prove malpractice. Since it’s standard for them to order and can push it in ICU (although they order nurses to do it). Someone can argue that if they can push it on the sickest patients they can push it on slightly less sick pulm cripples or CA rule outs.
So many grey areas.
 
If they are comfortable doing it. Why not?

EM docs direct nurses to sedate all the time in the ER for procedures. With propofol at times also.

Pulmonary sedate their own bronch many times.

This is where anesthesia leadership/management policy and guidelines is actual valuable (show your value to hospital administrators) by devising and educating non anesthesia providers their roles in their own sedation out of the OR

Administration loves their crap you feed them about saving them money and you are providing value added advice for them. Of course you are laughing all the way because it off loads workload on your own dept.
 
medicine2wallstreet said:
They're a physician. It's not malpractice. No evidence to show. We don't own the rights to propofol as anesthesiologists.
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Correct. But, If you are using it in a non-intubated patient you damn well better be trained in airway management and be equipped, ready, and attentive to manage the patient's airway and for hypotension/resuscitation, etc.

Failure to meet the above is malpractice.
 
Greenbayslacker said:
A friend in medical billing is telling me about a scheme they are running at their hospital. With the lack of anesthesia and high costs, they have employed critical care pulmonologists instead to give propofol for elective outpatient EGD/colonoscopies. I tried explaining that this is probably malpractice but I’m not really sure what exact grounds to stand on. Anyone have solid evidence I can show?
Click to expand...
From a billing standpoint-I don't know.

Do the pulmonologists at the facility have privileges for deep sedation/General Anesthesia? Is the liability carrier for the facility and for the docs doing this aware? They might have an opinion on the matter.
 
medicine2wallstreet said:
They are board certified physicians in critical care. I'd say they are plenty trained in that.
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If that’s accurate and not just some old pulm doc who is credentialed for vent management calling themselves an ICU doc, They should be good to go.
 
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Not sure how people are defending this. They have as much business doing deep procedural sedation (i.e. room air general) as I do running an ICU (none). And I did 6 months of ICU training during residency. How much training do they get on procedural sedation of a NON-INTUBATED patient? Not much or really any from what I have seen. The idea that a MAC is some easy case is just insane. Just yesterday colleague had a patient spasm in endo. Had to give sux and intubate. You think a pulm crit doc can mask the patient, draw up drugs and intubate as quickly as we can? Not even close. Disaster waiting to happen if you ask me.
 
Greenbayslacker said:
A friend in medical billing is telling me about a scheme they are running at their hospital. With the lack of anesthesia and high costs, they have employed critical care pulmonologists instead to give propofol for elective outpatient EGD/colonoscopies. I tried explaining that this is probably malpractice but I’m not really sure what exact grounds to stand on. Anyone have solid evidence I can show?
Click to expand...
If they deviate from the SOC in regards to sedation (our standards most likely in a court of law as plaintiffs attorney will use an anesthesiologist expert) AND they harm a patient, then it would indeed be malpractice.
 
Guys it's all fine until someone aspirate and dies or something terrible for example.

Wouldn't an insurance company have an absolute field day on this...

So many things to go after a critical care doc on... fasting guidelines, glp1 meds, ..

Just because someone can do something, doesn't mean an insurance company or lawyer agrees

I could probably relocate a shoulder, I've seen enough... doesn't mean I'm down in emerg letting rip
 
rick roller pump said:
Not sure how people are defending this. They have as much business doing deep procedural sedation (i.e. room air general) as I do running an ICU (none). And I did 6 months of ICU training during residency. How much training do they get on procedural sedation of a NON-INTUBATED patient? Not much or really any from what I have seen. The idea that a MAC is some easy case is just insane. Just yesterday colleague had a patient spasm in endo. Had to give sux and intubate. You think a pulm crit doc can mask the patient, draw up drugs and intubate as quickly as we can? Not even close. Disaster waiting to happen if you ask me.
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Maybe they can’t move as fast as we can but they know how to intubate. Maybe brutally but they do. And if they are smart they get the suxx already drawn up or at least on top of cart w syringe ready to go as well. And can direct the nurses to draw up the drugs.
Honestly, they intubate all the time in the ICU. They have privileges for moderate sedation for the ICU.
Is it ideal, no. But hell it’s better than when the GIs do it. Now that **** is malpractice. But we all know how greedy GI docs are.
 
PpfSuxTube said:
Guys it's all fine until someone aspirate and dies or something terrible for example.

Wouldn't an insurance company have an absolute field day on this...

So many things to go after a critical care doc on... fasting guidelines, glp1 meds, ..

Just because someone can do something, doesn't mean an insurance company or lawyer agrees

I could probably relocate a shoulder, I've seen enough... doesn't mean I'm down in emerg letting rip
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NPO guidelines are easy to Google and ICU docs should also know this basic info as well.
 
Ronin786 said:
While I wouldn't want a Pulm-CC doc doing anybody I care about's endoscopy, there's theoretically nothing illegal about it. Lots more scope creep to worry about than the ICU guy pushing propofol.

www.tampabay.com

A Florida ob/gyn played anesthesiologist for fatal Brazilian butt lift, state says

The only disciplinary action on the ob/gyn’s license is from 2019, but it also involves the death of a patient.
www.tampabay.com www.tampabay.com
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I remember this. And I agree with you. At least they are trained in airway management and somewhat in induction drugs.
 
Ronin786 said:
While I wouldn't want a Pulm-CC doc doing anybody I care about's endoscopy, there's theoretically nothing illegal about it. Lots more scope creep to worry about than the ICU guy pushing propofol.

www.tampabay.com

A Florida ob/gyn played anesthesiologist for fatal Brazilian butt lift, state says

The only disciplinary action on the ob/gyn’s license is from 2019, but it also involves the death of a patient.
www.tampabay.com www.tampabay.com
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Yeah, I’m not a fan of the idea of it but agree that there are far worse things going on. There was a place somewhere that a pulmonologist was remotely “supervising” CRNAs at a hospital from over a hundred miles away.
 
rick roller pump said:
Not sure how people are defending this. They have as much business doing deep procedural sedation (i.e. room air general) as I do running an ICU (none). And I did 6 months of ICU training during residency. How much training do they get on procedural sedation of a NON-INTUBATED patient? Not much or really any from what I have seen. The idea that a MAC is some easy case is just insane. Just yesterday colleague had a patient spasm in endo. Had to give sux and intubate. You think a pulm crit doc can mask the patient, draw up drugs and intubate as quickly as we can? Not even close. Disaster waiting to happen if you ask me.
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Anesthesia people without cc training were running icus during covid. There is apparently a shortage and now ccm is doing sedation. Whatever the billing isn't worth it to you guys and I wouldn't do it but if someone out there does something stupid/crazy who am I to care. People do wild **** all the time--there is literally a guy putting in PPMs where I work with a ****ing weekend training course on septic patients.

Fwiw I did hundreds of moderate sedation bronchs in training because anesthesia refused to support more than 5 bronchs a week.
 
My EM-trained take here. There is a big chasm between something that you CAN do and something that you SHOULD do. I feel well trained in airway management and procedural sedation with propofol. With that said, it would be insane to take a job doing elective sedations at an endo center.

I recognize that I am not the BEST person to do those tasks in the house of medicine. I do them when I need to do them and stand by it as good for the patient regardless of consequence or outcome. To do those same things ELECTIVELY is substandard care at best and malpractice at worst.

I stand by my paramedics intubating in the field, but if they wanted to intubate in the OR unsupervised I would slap them across the face.
 
skougess said:
I stand by my paramedics intubating in the field, but if they wanted to intubate in the OR unsupervised I would slap them across the face.
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The last sentence made me think of this.
1719764328697.gif
 
caligas said:
If they deviate from the SOC in regards to sedation (our standards most likely in a court of law as plaintiffs attorney will use an anesthesiologist expert) AND they harm a patient, then it would indeed be malpractice.
Click to expand...
Yes. What’s the standard of care for a pulmonologist? I’m pretty sure it’s not that, and I don’t think it would be hard to find accomplished experts to agree.
 
I wonder if it’s a billing issue though. Can they charge using anesthesia billing codes as a non-anesthesiologist?
 
IlDestriero said:
Yes. What’s the standard of care for a pulmonologist? I’m pretty sure it’s not that, and I don’t think it would be hard to find accomplished experts to agree.
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Not sure, it always seems like the standards of care are looser for non-anesthesiologist in regards to sedation. For example, emergency docs giving sedation on full stomachs. But I would think that if something went to trial, they would argue that this is a situation where anesthesia is typically performing the sedation, and we are the experts, and therefore our standards would apply.
 
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Had a cardiologist tell me recently that they opted to just use the pulmonologist for a TEE in the ICU recently, and the patient was coughing a bunch after the probe went down and so the cardiologist asked if the pulmonologist could help improve the coughing and he said “No, the patient has had enough, no more sedation.”

They had to abort the procedure and rebook it with an anesthesiologist. 🤣
 
Radar26 said:
Had a cardiologist tell me recently that they opted to just use the pulmonologist for a TEE in the ICU recently, and the patient was coughing a bunch after the probe went down and so the cardiologist asked if the pulmonologist could help improve the coughing and he said “No, the patient has had enough, no more sedation.”

They had to abort the procedure and rebook it with an anesthesiologist. 🤣
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No different than the GI folks who can do “most patients” with rn administered sedation usually Demerol/versed or the opthos than can do “most cataract patients” with a similar cocktail. Trying to save on resources where ever they can. Just like our supervision ratios have gone up and our excess staffing capacity has gone down.
 
Some of our cardiologists never request anesthesia for TEEs. They likely do a good job of numbing up the throat and coach the patient through the procedure. Others always ask for anesthesia.
 
One our EP cardiologist has some certification that allows him to push propofol/etomidate. He told me he stopped once he realized he was being reimbursed under $20 for it (on PPO patients!).

The pulmonary/ICU MDs providing procedural sedation for pulms and GIs is becoming more prevalent in academic settings. The children’s hospital in Little Rock definitely does it.
 
nimbus said:
Some of our cardiologists never request anesthesia for TEEs. They likely do a good job of numbing up the throat and coach the patient through the procedure. Others always ask for anesthesia.
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And at one place they ask for us even for an external cardioversion. It's mind-boggling. I don't know why the anesthesia chief allows this absolute nonsense and waste of resources.
 
nycitygas said:
One our EP cardiologist has some certification that allows him to push propofol/etomidate. He told me he stopped once he realized he was being reimbursed under $20 for it (on PPO patients!).

The pulmonary/ICU MDs providing procedural sedation for pulms and GIs is becoming more prevalent in academic settings. The children’s hospital in Little Rock definitely does it.
Click to expand...
Children? Are these pediatric pulmonologists? Wait.....is there such a thing?
 
Radar26 said:
Had a cardiologist tell me recently that they opted to just use the pulmonologist for a TEE in the ICU recently, and the patient was coughing a bunch after the probe went down and so the cardiologist asked if the pulmonologist could help improve the coughing and he said “No, the patient has had enough, no more sedation.”

They had to abort the procedure and rebook it with an anesthesiologist. 🤣
Click to expand...
This is hilarious. Can't fault a guy for knowing his limits and not setting himself up for failure with too much sedation.!!! The cardiologist could have used more local anesthestic. I wonder if patient was intubated though🤣🤣. Hopefully not.
 
makemoney2024 said:
Children? Are these pediatric pulmonologists? Wait.....is there such a thing?
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I’ve heard of other children’s hospitals that have sedation services run by pediatric intensivists. I imagine at least some of them have a background in anesthesia.
 
nimbus said:
I’ve heard of other children’s hospitals that have sedation services run by pediatric intensivists. I imagine at least some of them have a background in anesthesia.
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Where I trained, PICU doc did majority of peds sedation. We did peds Endo, and a bunch of LPs with intrathecal methotrexate under MAC. Most other stuff went to him. He also did a lot of sedation for peds MRIs. We obviously did all the GAs. He was never pushing propofol.

Current gig, old PICU doc does peds sedation for things like MRI. We're only involved if GA required.
 
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makemoney2024 said:
It’s not about the money when everyone wants a piece of anesthesia. We are spread too thin and these are 2 versed type of cases.
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Wut? Single slug of propofol. 70-100mg -> apnea -> shock -> breathe -> done.

Whole thing takes 5-10 minutes depending on how fast the nurses put the monitors, pads, and O2 on.

And really, our cardiologists do most of them without us, just with a little methohexital, but if their BMI gets up there or they are a little more complex, they ask for our help.
 
abolt18 said:
Wut? Single slug of propofol. 70-100mg -> apnea -> shock -> breathe -> done.

Whole thing takes 5-10 minutes depending on how fast the nurses put the monitors, pads, and O2 on.

And really, our cardiologists do most of them without us, just with a little methohexital, but if their BMI gets up there or they are a little more complex, they ask for our help.
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Except you still need the staff!!! How is this difficult to comprehend? And personally for me, short cases on the computer are painful.
I know they are easy, but spreading us into places that we aren’t needed doesn’t help this shortage.
 
makemoney2024 said:
Except you still need the staff!!! How is this difficult to comprehend? And personally for me, short cases on the computer are painful.
I know they are easy, but spreading us into places that we aren’t needed doesn’t help this shortage.
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We just add them in between pacemakers. We use the existing staff. It’s a 10-15 commitment.
 
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