Question from an incoming M1

[DevinBookerMD]

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question answered, thanks!

 

[abolt18]

So I was getting into a pretty heated argument with a friend of mine regarding being treated by a physician vs a mid level and the conversation spiraled downward. I said that I would want my family and myself to be treated by a physician always over a mid level. They (ER tech) said that if they ever had a serious incident and needed to be intubated or central lined and it was a difficult airway etc., they would want this one PA that works in their ED to treat him over any of the ER attendings. I said that if I were in that situation I would rather have an anesthesiologist, who is the expert on the air way not ER attendings, to treat me. He then said that in all of his time working in the ED he never saw anesthesia get paged down to the ED to help with an intubation or central line. He said that if they couldn't get it themselves they would go straight to cutting open their throat and intubating them that way. I thought that it was quite common to page the anesthesiologist for a difficult airway trauma. He basically started saying "I don't know what you've read in a textbook or anything, but this is what I see in real life" (one of his favorite lines btw). So my question to you all, is it common for anesthesia to be paged by trauma when there is a difficult airway?

Totally variable based on the hospital.

Our hospital, ED residents go to all codes in the hospital to "handle" the airway, but services call anesthesia for difficult airways. We definitely aren't typically going to the ER for intubations or lines, but this is a large academic medical center. The ER residents or trauma surgery residents are down there lining and tubing people. Let them have it, we get more than enough airways and I hope for them to be competent in airway management when they go out into the real world and end up taking care of my grandparents or parents.

They celebrate victory when they "didn't have to look at the screen" on the c-mac. Yay.

On a separate note. I won't go to urgent care anymore because I know I'll just see a know-little NP who has little ability to use nuance and clinical judgement in scenarios that are outside of picture perfect algorithms.

 

[JiPo]

It is institution dependent. At my shop, anesthesiologists are on standby in the trauma bay while EM attempts to secure the airway. Needless to say, it is very painful to watch them induce and intubate, and we often have to step in to rescue them.

 

[kidthor]

For our major traumas (level 1 trauma center peds/adults) the anesthesiologists manage all airways. This is the highest possible level of care, however it is not the standard of care. Many places alternatively have an EM doctor manage the airway, but likely there is always an anesthesiologist on call as backup. EM doctors are typically competent at airways but they don't do it several times a day like most of us do.

As a corollary - want an orthopedic surgeon to reduce your fracture vs an EM doctor? Both will probably work out, but the orthopedist is the highest possible level of care. What you really want either way is someone competent to do this - and that'll be most board certified doctors in whatever speciality. Also, midlevels should never be doing any of this just as they shouldn't be intubating or putting in lines.

By the way... everywhere I've been we've rarely been paged to the ED to help with an airway, but when we do it's bad - nonetheless we can usually get it done. What's important is to let the system do it's thing. Provided it's a good system.

 

[DevinBookerMD]

Totally variable based on the hospital.

Our hospital, ED residents go to all codes in the hospital to "handle" the airway, but services call anesthesia for difficult airways. We definitely aren't typically going to the ER for intubations or lines, but this is a large academic medical center. The ER residents or trauma surgery residents are down there lining and tubing people. Let them have it, we get more than enough airways and I hope for them to be competent in airway management when they go out into the real world and end up taking care of my grandparents or parents.

They celebrate victory when they "didn't have to look at the screen" on the c-mac. Yay.

On a separate note. I won't go to urgent care anymore because I know I'll just see a know-little NP who has little ability to use nuance and clinical judgement in scenarios that are outside of picture perfect algorithms.

It is institution dependent. At my shop, anesthesiologists are on standby in the trauma bay while EM attempts to secure the airway. Needless to say, it is very painful to watch them induce and intubate, and we often have to step in to rescue them.

For our major traumas (level 1 trauma center peds/adults) the anesthesiologists manage all airways. This is the highest possible level of care, however it is not the standard of care. Many places alternatively have an EM doctor manage the airway, but likely there is always an anesthesiologist on call as backup. EM doctors are typically competent at airways but they don't do it several times a day like most of us do.

As a corollary - want an orthopedic surgeon to reduce your fracture vs an EM doctor? Both will probably work out, but the orthopedist is the highest possible level of care. What you really want either way is someone competent to do this - and that'll be most board certified doctors in whatever speciality. Also, midlevels should never be doing any of this just as they shouldn't be intubating or putting in lines.

By the way... everywhere I've been we've rarely been paged to the ED to help with an airway, but when we do it's bad - nonetheless we can usually get it done. What's important is to let the system do it's thing. Provided it's a good system.

I suspected it would be a institution dependent. they work at a level 1 hospital so I assumed anesthesia would be available. He said that the PA has done it so many times and that the attendings defer to him because he is better at it than they are.

 

[JiPo]

I suspected it would be a institution dependent. they work at a level 1 hospital so I assumed anesthesia would be available. He said that the PA has done it so many times and that the attendings defer to him because he is better at it than they are.

That is the result of years of laziness turning a once competent (hopefully) physician into a a glorified midlevel and a charting monkey. I would never let my skills deteriorate that far.

 

[kidthor]

I suspected it would be a institution dependent. they work at a level 1 hospital so I assumed anesthesia would be available. He said that the PA has done it so many times and that the attendings defer to him because he is better at it than they are.

If true that is shameful. I doubt it’s true though.

 

[BLADEMDA]

So I was getting into a pretty heated argument with a friend of mine regarding being treated by a physician vs a mid level and the conversation spiraled downward. I said that I would want my family and myself to be treated by a physician always over a mid level. They (ER tech) said that if they ever had a serious incident and needed to be intubated or central lined and it was a difficult airway etc., they would want this one PA that works in their ED to treat him over any of the ER attendings. I said that if I were in that situation I would rather have an anesthesiologist, who is the expert on the air way not ER attendings, to treat me. He then said that in all of his time working in the ED he never saw anesthesia get paged down to the ED to help with an intubation or central line. He said that if they couldn't get it themselves they would go straight to cutting open their throat and intubating them that way. I thought that it was quite common to page the anesthesiologist for a difficult airway trauma. He basically started saying "I don't know what you've read in a textbook or anything, but this is what I see in real life" (one of his favorite lines btw). So my question to you all, is it common for anesthesia to be paged by trauma when there is a difficult airway?

Your friends and you are very Green to say the least:

1. ER Attendings are trained in airway management. They should have the skills necessary to intubate a patient. These days we have airway equipment that makes 98% of intubations fairly easy. In some hospitals Anesthesiologists go to every trauma alert and manage the airway. At other facilities Anesthesia is back-up to the ER Attending and shows up only when called/invited to the event.

2. Central lines- Again we have U/S equipment available which makes this fairly straightforward procedure with a high success rate. Even without Ultrasound central line is a procedural skill that a PA, CRNA or any midlevel can easily master.

Now, I have seen major F-ups by ER attendings on items 1 and 2. I have personally seen an ER attending kill a patient by failing to obtain an adequate airway and by the time I secured the Endotracheal tube the patient was dead.

"Real life" involves risks/complications and even death. This isn't TV or a reality show. If a Physician wants to delegate a procedure to his/her PA then that physician is assuming responsibility for all complications. During your training you will see many "providers" doing all sorts of procedures. Do not over-react to midlevel providers doing these sorts of things. Remember, the buck stops with the Physician Attending assuming full responsibility.