Question for the Attendings - ER Sedation

[Sevo]

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Question to all of the private practice attendings that read this group ---

Do your groups have any sort of policies or standards in place regarding providing sedation down in the ER for quick procedures like close reduction of joints?

I'm out of residency and new to private practice, having recently joined a group that covers a private, level one trauma center. There's been some argument here before my arrival for the last few months as to whether or not we, as a group, should be providing sedation for these procedures in the trauma bays. During residency, I and a few other group members occasionally did this in less than ideal monitoring and NPO situations, usually with straight 1 to 1.5mg/kg propofol boluses. Some of the more conservative members of the group tend to lean towards the either the "trauma bay sux and tube" or "the trauma surgeons be damned, I'm not doing this anywhere but the OR." With this said, I wouldn't be surprised if there's some sort of clause in my malpractice insurance contract that probably makes me fully at fault for anything I do outside of the OR area beyond airways.

Curious if you guys have any opinions one way or another on the issue. Feel free to answer here or through private mail.

Thanks.

 

[jetproppilot]

Question to all of the private practice attendings that read this group ---

Do your groups have any sort of policies or standards in place regarding providing sedation down in the ER for quick procedures like close reduction of joints?

I'm out of residency and new to private practice, having recently joined a group that covers a private, level one trauma center. There's been some argument here before my arrival for the last few months as to whether or not we, as a group, should be providing sedation for these procedures in the trauma bays. During residency, I and a few other group members occasionally did this in less than ideal monitoring and NPO situations, usually with straight 1 to 1.5mg/kg propofol boluses. Some of the more conservative members of the group tend to lean towards the either the "trauma bay sux and tube" or "the trauma surgeons be damned, I'm not doing this anywhere but the OR." With this said, I wouldn't be surprised if there's some sort of clause in my malpractice insurance contract that probably makes me fully at fault for anything I do outside of the OR area beyond airways.

Curious if you guys have any opinions one way or another on the issue. Feel free to answer here or through private mail.

Thanks.

Nice post concerning a relevant facet of our practice, Sevo.

Litiginously speaking, I dont know the answer.

Practically speaking, I do.

As anesthesiologists, we are well reimbursed, for the most part.

And if a certain situation doesnt impede on us in a chronic fashion, I'd say its best to respond to the ER.

And I say that from experience.

It is only periodic that I get a request for some kind of sedation from the ER. Usually commensurate to what you posted.

Is the request from orthopedists periodic/rare?

Tell them you are on your way. Cater to them. This is a business, dude. This is your Hardware Store and you are trying to sell pliers.

Providing sedation for major customers of yours for their periodic ER needs, if its only periodic, is a way to sell yourself. And your business. Only happens every once in a while. Take the hit.

Is it happening all the time?

Thats another story.

But I'll bet it happens minimally enough that you just need to suck it up. Thats where my practice is now. Minimal ER calls.....yeah, they're there....but not enough to make an issue of.....

...again, you said in your post occasional.....

I'll respond occasionally to the ER, even if its at 3am.

And you should too.

But again, key word, like in your post, is occasional.

Responding with open arms to a major orthopedic player in your practice with an ER problem at 3am is better than a full-page add in the Wall Street Journal touting your practice. Cuz remember, said orthopedist is your customer. And if you come into the ER with a smile at 3am, youre on your way to the anesthesia creed:

ability, amicability, and availability leads to very large bank accounts.

And BTW, I'm sure this issue in your group is not based on whether malpractice covers-you-or-not in the ER. The argument in the group is based on the potential of the inconvenient 3am call. Been there.

Your malpractice covers you in the ER. Youre a residency trained MD. You can keep yourself out of trouble. Get it done (at 3am). You know how to do it safely. And secure the orthopedist player by your 3am work.

 

[militarymd]

I go...makes for happy colleagues...

You never know when you may need something from the ER folks.

 

[jwk]

Question to all of the private practice attendings that read this group ---

Do your groups have any sort of policies or standards in place regarding providing sedation down in the ER for quick procedures like close reduction of joints?

I'm out of residency and new to private practice, having recently joined a group that covers a private, level one trauma center. There's been some argument here before my arrival for the last few months as to whether or not we, as a group, should be providing sedation for these procedures in the trauma bays. During residency, I and a few other group members occasionally did this in less than ideal monitoring and NPO situations, usually with straight 1 to 1.5mg/kg propofol boluses. Some of the more conservative members of the group tend to lean towards the either the "trauma bay sux and tube" or "the trauma surgeons be damned, I'm not doing this anywhere but the OR." With this said, I wouldn't be surprised if there's some sort of clause in my malpractice insurance contract that probably makes me fully at fault for anything I do outside of the OR area beyond airways.

Curious if you guys have any opinions one way or another on the issue. Feel free to answer here or through private mail.

Thanks.

We've got a different take on it than Jet.

Our primary responsibility is the OR, L&D and GI Lab. We also have an agreement to cover elective cardioversions and some of the more invasive radiology procedures. All of these are SCHEDULED or done as add-on's later in the day. Our primary responsibility (besides the patient) is to provide those services that we have agreed to provide. We don't have extra people standing around to run to the ER.

As a matter of department policy, we do not and will not give an anesthetic (and that includes propofol "sedation" which we all know is really a general anesthetic in most cases) in the ER. If closed reductions require anesthesia, those patients are done in the OR in our environment. Patients get full monitoring (as they should), and since virtually none of them will meet NPO guidelines, they all get a tube as well. No short cuts for surgeon or patient convenience.

Our hospital also has specific policy, written by our department, that propofol, pentothal, brevital, amidate, and ketamine may ONLY be given by an anesthesia provider. ER docs cannot do an end-around and push their own propofol (and neither can the GI docs 😉 )

 

[nimbus]

We've got a different take on it than Jet.


Our hospital also has specific policy, written by our department, that propofol, pentothal, brevital, amidate, and ketamine may ONLY be given by an anesthesia provider. ER docs cannot do an end-around and push their own propofol (and neither can the GI docs 😉 )

Instead, they will give Versed 5mg+fentanyl 200 mics to an 80 year old who won't remember his own name for the next week. Propofol 30-50mg or Amidate 10 mg would be alot better on MOST cases. This is suboptimal care for political reasons. Our ER docs manage some really bad airways on a regular basis. They do all the intubations in the trauma bay at our level 1 trauma center. I don't have a problem with them using whatever they want for procedural sedation in the ER. The GI docs are another story.

 

[jwk]

Instead, they will give Versed 5mg+fentanyl 200 mics to an 80 year old who won't remember his own name for the next week. Propofol 30-50mg or Amidate 10 mg would be alot better on MOST cases. This is suboptimal care for political reasons. Our ER docs manage some really bad airways on a regular basis. They do all the intubations in the trauma bay at our level 1 trauma center. I don't have a problem with them using whatever they want for procedural sedation in the ER. The GI docs are another story.

Sub-optimal care is having an anesthetic administered by a non-anesthesia provider - that's not politics - that's a basic patient safety issue. We (anesthesiologists, CRNA's and AA's), along with our professional organizations (ASA, AANA, AAAA) all have statements to this effect. Propofol is an anesthetic agent, and as such should be used only by anesthesia providers, except on ventilated patients in the ICU. The package inserts and the FDA statements haven't changed last time I checked.

 

[Noyac]

I find this to be a touchy topic for many reasons. First, I don't want to be called every time the ER docs or anyone else in the ER wants someone sedated for something. I currently go to the ER when asked, with a smile on my face. But if this got to be all the time I would not be happy. I find out why this pt is different and why I am needed. Secondly, I am on the fence with the propofol issue. I feel that if you can maintain an airway and intubate (this must be well documented) then you can use the propfol. Currently, I very little calls to the ER which is great and when they do call I come running b/c its usually a big deal. I have always been impressed with the skills of the ER folks at every place that I have worked.

 

[jetproppilot]

I find this to be a touchy topic for many reasons. First, I don't want to be called every time the ER docs or anyone else in the ER wants someone sedated for something. I currently go to the ER when asked, with a smile on my face. But if this got to be all the time I would not be happy. I find out why this pt is different and why I am needed. Secondly, I am on the fence with the propofol issue. I feel that if you can maintain an airway and intubate (this must be well documented) then you can use the propfol. Currently, I very little calls to the ER which is great and when they do call I come running b/c its usually a big deal. I have always been impressed with the skills of the ER folks at every place that I have worked.

Totally agree with everything you said, Noy.

 

[nimbus]

Sub-optimal care is having an anesthetic administered by a non-anesthesia provider - that's not politics - that's a basic patient safety issue. We (anesthesiologists, CRNA's and AA's), along with our professional organizations (ASA, AANA, AAAA) all have statements to this effect. Propofol is an anesthetic agent, and as such should be used only by anesthesia providers, except on ventilated patients in the ICU. The package inserts and the FDA statements haven't changed last time I checked.

what do your ER docs use for intubation?

 

[Sevo]

>what do your ER docs use for intubation?

Most ER docs tend to use combinations of versed, etomidate, and sux.

Thanks for all the opinions pro and con. To answer Jet, the requests for sedation have been more frequent as of recently, hence the controversy. The big fear is that eventually an aspiration will occur if we do enough of these favors for the trauma orthopods/surgeons down in the ER.

 

[Apollyon]

what do your ER docs use for intubation?

I prefer roc over sux, and I go with etomidate. Strangely, at Duke, in the ED, we don't (err...didn't - I'm not there anymore) have propofol for intubation, but we do for maintenance of sedation - but we do have ketamine, Brevital, etomidate, Versed, and fentanyl available. The strange part is that the MICU and Cardiology/CCU have propofol for bolus for intubation, but they don't have etomidate. I dated a cards fellow a few times, and she was amazed that we had etomidate.

I have a buddy that just finished anesthesia at Yale, and he was telling me that (2 or 3 years ago) they were rescuing 1 airway in the ED per week. I can tell you that I, myself, NEVER had the advanced airway team in the ED for an intubation. Once, when I was an intern, we called - but got the tube in before anesthesia got there. Likewise, I never had to cric a patient because I couldn't get the tube in.

One thing I found interesting was that someone above said that only anesthesia providers should be using anesthetics, and included AA's - anesthesia assistants. Now, an AA vs an EM MD/DO for intubation - you do not think that they are absolutely at minimum equivalent?

 

[nimbus]

Our hospital also has specific policy, written by our department, that propofol, pentothal, brevital, amidate, and ketamine may ONLY be given by an anesthesia provider. ER docs cannot do an end-around and push their own propofol (and neither can the GI docs 😉 )

I was wondering what the ER docs at this hospital use. They pretty much have their hands tied.

 

[Noyac]

I'll say this again. I believe that if you are trained and skilled (documented) in airway management then you may use whatever you wish. Mostly, I am talking about the doc's out there.

I know what I am comfortable with and what I am not comfortable with. I would not presume to tell any other Doctor out there what they can and cannot do. Why has it become our problem? It is b/c the drug company chose to put it on the label.

 

[nimbus]

Funny that the ER docs are qualified to push sux and rocuronium but not propofol.😱 again, this is politics.

 

[jetproppilot]

One thing I found interesting was that someone above said that only anesthesia providers should be using anesthetics, and included AA's - anesthesia assistants. Now, an AA vs an EM MD/DO for intubation - you do not think that they are absolutely at minimum equivalent?

Heres a turf war I'm not sure you wanna get into....

You mentioned AA vs EM MD/DO equivalent....

dude, I've been in private practice for ten years.

And when it comes to getting the tube in, your crudentials are secondary, and your experience is primary.

Lets just say that JWK (an AA by profession) TRUMPS EVERY allopathic med school/allopathic ER-residency-trained doctor out there, when you're talking about getting the tube in..

Without a doubt.

Uhhhhhh, no doubt.

I'll pick an AA like JWK to intubate me over an ER MD with 20 years experience any day of the week.

But hey, just my opinion, Slim.

 

[militarymd]

gotta go with jet on this one.

 

[Apollyon]

gotta go with jet on this one.

I have to tell you - before I came to SDN, I had never even heard of an "anesthesia assistant" - didn't even know they existed. Right now, I don't even know what their skills entail. I am NOT looking for a turf war.

And I'm not talking about the physical put-blade-in-mouth-elevate-visualize-place-tube - as has been made abundantly clear in all fields that tube, any monkey can place the tube, if you do it enough.

And that's what I was getting at - experience. You really think a fresh-out-of-school average AA (I'm not talking about JWK here - don't know him, and would think he's above average, several SD's to the right) can tube a crash patient better than an EM-trained doc with 20 years' experience?

Just like most things in medicine, 95% of whatever happens - in any field - is rote, and can be managed by a protocol or a monkey. The reason we're all here - specially-trained providers at any level - is to recognize when that 5% is there (and it isn't conveniently grouped together), and action that is beyond protocol (or needs to be done more expediently and efficiently) is needed.

I had the highest compliment I could get when I was a resident and had a busy airway weekend, and one of the RT's in our ED (I think he's the #2 senior guy at Duke) told me that, if he needed to be intubated, he would let me do it.

And, finally, to get back on track - anesthesia comes down and does the procedural sedation in the ED's where y'all are at? I know I'm a little late coming to that, but, if we couldn't do it (because of timing), it waited until the "stars aligned".

As always, anesthesia are my colleagues, and I would rather group than divide.

 

[jetproppilot]

I have to tell you - before I came to SDN, I had never even heard of an "anesthesia assistant" - didn't even know they existed. Right now, I don't even know what their skills entail. I am NOT looking for a turf war.

And I'm not talking about the physical put-blade-in-mouth-elevate-visualize-place-tube - as has been made abundantly clear in all fields that tube, any monkey can place the tube, if you do it enough.

And that's what I was getting at - experience. You really think a fresh-out-of-school average AA (I'm not talking about JWK here - don't know him, and would think he's above average, several SD's to the right) can tube a crash patient better than an EM-trained doc with 20 years' experience?

Just like most things in medicine, 95% of whatever happens - in any field - is rote, and can be managed by a protocol or a monkey. The reason we're all here - specially-trained providers at any level - is to recognize when that 5% is there (and it isn't conveniently grouped together), and action that is beyond protocol (or needs to be done more expediently and efficiently) is needed.

I had the highest compliment I could get when I was a resident and had a busy airway weekend, and one of the RT's in our ED (I think he's the #2 senior guy at Duke) told me that, if he needed to be intubated, he would let me do it.

And, finally, to get back on track - anesthesia comes down and does the procedural sedation in the ED's where y'all are at? I know I'm a little late coming to that, but, if we couldn't do it (because of timing), it waited until the "stars aligned".

As always, anesthesia are my colleagues, and I would rather group than divide.

Anyone who trains in anesthesia....MD, CRNA, AA, will probably put more tubes in during their training period than an ER doc will do in his career.

 

[Apollyon]

Anyone who trains in anesthesia....MD, CRNA, AA, will put more tubes in during their training period than an ER doc will do in his career.

I don't know the relevance of this - I mean, it's garbage in, garbage out. If your process is poor, and you're macerating the airway, and that's all you know, it doesn't matter how many times you do it. If it's good technique, then it's good every time. As I said before, any monkey can tube someone - it's the tough stuff that needs a specialist.

And I don't see it as a "zero-sum" game - I'm not good because someone else isn't. All I know is, is that I can get virtually all of the crash tubes in on the patients that need them.

Anyways, if an anesthesia provider could NOT get the tube in on an NPO, sedated, paralyzed, premedicated with glycopyrrolate or atropine, in the sniffing position on an OR table, they shouldn't be there. The easiest tube I've ever had - bar none - was as a paramedic, for the 'morning DOA'. This guy was dead, but warm and dead, so we had to work him. Thin guy, warm/borderline HOT house, hadn't had anything in ~9 hours. Airway was dry as a bone, no gag (as I said, dead), easy to manipulate - tube right in.

I am not looking to start an argument - as I said, I'm a grouper, not a divider. I work WITH my colleagues, not AGAINST them. It doesn't matter who the best is - it matters that the job gets done, with minimal or no side effects.

 

[militarymd]

When Jet says "put tube in"...he is referring to....as I would also...the entire sequence of events surrounding the physical act of placing the tube in....

It is part of the training.

 

[jetproppilot]

I am not looking to start an argument - as I said, I'm a grouper, not a divider. .

No argument here either.

Just an opinion.