should anesthesiologists be the ones running codes?

[ghostsnake]

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it seams that almost every ED MD I have encountered at some point comes across a difficult airway that has to call the anesthesiologist. I work the night shift and most of the time the anesthesiologist is busy with a csection or other procedure. I have seen more than enough patients pass away because the anesthesiologist was not able to come in time or was not called soon enough.

so why not just staff hospitals appropriately with enough aneshesiologists to handle the codes?

 

[BobBarker]

It would cost too much money to have two in house anesthesiologists at hospitals that have in house overnight anesthesia coverage.

 

[PMPMD]

it seams that almost every ED MD I have encountered at some point comes across a difficult airway that has to call the anesthesiologist. I work the night shift and most of the time the anesthesiologist is busy with a csection or other procedure. I have seen more than enough patients pass away because the anesthesiologist was not able to come in time or was not called soon enough.

so why not just staff hospitals appropriately with enough aneshesiologists to handle the codes?

A couple of my anesthesia-CCM co-fellows take "airway call" at a community hospital. I think it pays $40/hr. They have to be in-house, but rarely get called.

 

[joeDO2]

I have seen more than enough patients pass away because the anesthesiologist was not able to come in time or was not called soon enough.

This situation should really never happen. My background is prehospital and even with paramedics, good difficult airway training can prevent this. In the thousands of intubations performed in the system I worked in I am not aware of a single case that came to this so it certainly shouldn't be happening in the hospital setting with more equipment and more skilled providers. If it is a problem at your institution maybe anesthesia should review these cases and develop a simple protocol for dealing with a difficult airway using the tools you have available. As an example, the protocol I functioned under was:

1 attempt with direct laryngoscopy and bougie immediately available at bedside
If unsuccessful, use optical device (airtraq/glidescope)
If not immediately successful, place extraglottic device (gel LMA and KingLT available)
If unable to ventilate or establish airway, insert QuikTrach and ventilate

The protocol would obviously have to be adjusted to your facility and the skill set of your providers but the important thing is that is be practiced and timed using the devices so that the clinicians are performing the tasks quickly by muscle memory and don't have to stop and think in the middle of the already stressful situation.

 

[Bertelman]

This situation should really never happen.

I agree. I wonder if maybe these were patients that were heading to that outcome regardless of what happened, and incidentally an airway was not secured. I heard of a mortality from loss of airway in the ED occurring only once in my 3-yr residency, and it was a very big deal.

 

[Oggg]

If you can't intubate, go to tracheostomy

 

[Mman]

it seams that almost every ED MD I have encountered at some point comes across a difficult airway that has to call the anesthesiologist. I work the night shift and most of the time the anesthesiologist is busy with a csection or other procedure. I have seen more than enough patients pass away because the anesthesiologist was not able to come in time or was not called soon enough.

so why not just staff hospitals appropriately with enough aneshesiologists to handle the codes?

Running codes and securing airways are 2 different things. I've rarely seen people that couldn't at least be adequately ventilated in the ED before we arrive. Check that, I've never seen it at our current institution. But it's possible a coding patient could die before their airway was secured, however that's not necessarily related to their lack of an ETT.

 

[Skip2myLou]

not to mention the acls is going away from airway in that mask vent is fine and Dl should not stop compressions

 

[BADMD]

I have seen more than enough patients pass away because the anesthesiologist was not able to come in time or was not called soon enough.

More than enough? Really, how many could that possibly be.

I have run into exactly one patient in more than 7 years where I really could not in some way oxygenate due to an airway related issue. That was during residency and I can say that wouldn't happen now.

It is extremely unusual for a patient to die in the ED related to pure airway issue. While some patients are extremely difficult to intubate, there are lots of different adjuvents one can use to oxygenate. I am frankly amazed at how many people with difficult airways I can bag with good positioning and an oral or nasal airway. The biggest problem I've seen EPs have is adopting a "never say die" attitude where THE TUBE MUST GO IN, rather than backing off and re-evaluating.

 

[imfrankie]

More than enough? Really, how many could that possibly be.

I have run into exactly one patient in more than 7 years where I really could not in some way oxygenate due to an airway related issue. That was during residency and I can say that wouldn't happen now.

It is extremely unusual for a patient to die in the ED related to pure airway issue. While some patients are extremely difficult to intubate, there are lots of different adjuvents one can use to oxygenate. I am frankly amazed at how many people with difficult airways I can bag with good positioning and an oral or nasal airway. The biggest problem I've seen EPs have is adopting a "never say die" attitude where THE TUBE MUST GO IN, rather than backing off and re-evaluating.

No kidding. "Tube must go in" after which it is found to be in the esophagus once the patient lands in the ED.

 

[jwk]

not to mention the acls is going away from airway in that mask vent is fine and Dl should not stop compressions

Most anesthesia folks can intubate without stopping compressions.

 

[periopdoc]

While the anesthesiologist is probably the best individual to run codes we are not necessarily the most appropriate. To run a successful code the team needs a common understanding and approach. With our second nature understanding of and approach to cardiovascular pharma, we frequently depart from established protocols. This can be very frustrating for other team members.

Of course I am certain that my colleagues, like me, would be more than willing to take in house airway/ code call. I seriously doubt there are many hospitals who could afford the necessary stipend.

And $40 per hour??? Are you sure you can't do better than that? That's bare minimum for home call and I made significantly more than that for in-house call as a fellow. See if you can find a place that needs OB coverage.

- pod

 

[PMPMD]

And $40 per hour??? Are you sure you can't do better than that? That's bare minimum for home call and I made significantly more than that for in-house call as a fellow. See if you can find a place that needs OB coverage.

- pod

Yeah that's the best that those guys found - I had a better gig at my old institution.

 

[MTGas2B]

Yeah that's the best that those guys found - I had a better gig at my old institution.

Hopefully for $40 an hour they are sleeping 95% of the time.

 

[Hamhock]

I have seen more than enough patients pass away because the anesthesiologist was not able to come in time or was not called soon enough.

so why not just staff hospitals appropriately with enough aneshesiologists to handle the codes?

Is your hospital staffed with EM-trained docs? If so, I would be shocked if there was more than one patient who "pass away because the anesthesiologist was not able to come in time".

In seven years in the ED I have not seen this or heard about this even once.

Regarding anesthesiologists "running codes": I would argue they are probably better than most other docs in the hospital, but not the best choice (in general)...although rare, "reversible" codes that require a chest tube or circ (as examples) are more common than codes that fail because an ETT could not be placed.

HH

 

[periopdoc]

and I personally believe that all anesthesiologists should be reasonably comfortable with placing chest tubes and performing crics, but that is just MHO.

- pod

 

[BobBarker]

Is your hospital staffed with EM-trained docs? If so, I would be shocked if there was more than one patient who "pass away because the anesthesiologist was not able to come in time".

In seven years in the ED I have not seen this or heard about this even once.

Regarding anesthesiologists "running codes": I would argue they are probably better than most other docs in the hospital, but not the best choice (in general)...although rare, "reversible" codes that require a chest tube or circ (as examples) are more common than codes that fail because an ETT could not be placed.

HH

Nothing like an emergent circ to really get the endorphins popping. They should add "tallywacker" to the list of H's and T's the next time they refresh ACLS.

 

[Idiopathic]

i just assumed "more than enough" meant "one"

 

[MTGas2B]

and I personally believe that all anesthesiologists should be reasonably comfortable with placing chest tubes and performing crics, but that is just MHO.

- pod

Comfortable with chest tube, I agree, I think they are easier than central lines

Building comfort with crics, bit more of challenge. In my practice I haven't been able to build my comfort with crics 🙂


I did perc trachs in fellowship, unfortunately I really don't have much opportunity to do them in practice.

 

[periopdoc]

Perhaps I should modify the statement. Instead of comfort with crics, you should have some comfort with the surgical airway of your choice.

Scrub in with the ENT on some thyroid cases. Get to know the anatomy and get a feel for it.

- pod

 

[proman]

Comfortable with chest tube, I agree, I think they are easier than central lines

Building comfort with crics, bit more of challenge. In my practice I haven't been able to build my comfort with crics 🙂


I did perc trachs in fellowship, unfortunately I really don't have much opportunity to do them in practice.

Do transtracheal lido every chance you get for awake intubations. It's justifiable, helps the intubation and gives great practice.

 

[sevoflurane]

I'm too busy to run a code in the middle of the day. I leave that up to the ED and hospitalists. If they need help with intubation then that's another story. They can call me at that point.

I did 1000000x as many code AW's in residency as I do in private practice.... and I like it that way.

 

[ghostsnake]

maybe some or all that I've observed had fates predetermined regardless of being successfully placed with an ET tube. The fact I have witnessed more than one pt go more than 20 minutes with an ED MD/MD's trying to jam a tube down their trachea (getting esophogus) is a little ridiculous right? I know they have lma's which they never use. I've seen a fiber optic in their bags (one admitted he has no idea how to use it)

one code 2 ED MD's tried relentlessly and unsuccessfully until they gave up and said, "ever do a cricothyrotomy?"
the other responded "not on a live person"

just this week though they started using cmac devices. maybe the winds of change are upon us. if not I will try to talk to anesthesia and have them light a fire under their feet

 

[Hamhock]

maybe some or all that I've observed had fates predetermined regardless of being successfully placed with an ET tube. The fact I have witnessed more than one pt go more than 20 minutes with an ED MD/MD's trying to jam a tube down their trachea (getting esophogus) is a little ridiculous right? I know they have lma's which they never use. I've seen a fiber optic in their bags (one admitted he has no idea how to use it)

one code 2 ED MD's tried relentlessly and unsuccessfully until they gave up and said, "ever do a cricothyrotomy?"
the other responded "not on a live person"

just this week though they started using cmac devices. maybe the winds of change are upon us. if not I will try to talk to anesthesia and have them light a fire under their feet

troll?

HH

 

[yappy]

For codes ran by non-anesthesia what do you guys think of the use of a duel lumen device like the Combitube as a solution for difficult airways?

http://vam.anest.ufl.edu/airwaydevice/combitube/index.html

 

[toomuch]

The hospitals can go further and have surgeons be at every code to do a cric or trach in case the anesthesiologist can't get an airway.

 

[Mman]

For codes ran by non-anesthesia what do you guys think of the use of a duel lumen device like the Combitube as a solution for difficult airways?

http://vam.anest.ufl.edu/airwaydevice/combitube/index.html

The ASA difficult airway algorithm supports the use of supraglottic devices such as Combi-tubes or LMAs.

 

[PMPMD]

Hopefully for $40 an hour they are sleeping 95% of the time.

Yeah at least.

 

[periopdoc]

For $40 an hour I would be happy to sleep at home and come in if they need me.

- pod

 

[pgg]

For $40 an hour I would be happy to sleep at home and come in if they need me.

- pod

$6720/week for continuous coverage for an event that'll never happen, sign me up! 😀