Shoulder Reduction Advice

[TheComebacKid]

Is there an official process for us to get "credentialed" to do blocks? I'm all for watching stuff on YouTube but if god forbid you have a complication, "I watched it on YouTube" is really not a great defense.

I feel like this is something that needs to be incorporated into EM training and perhaps give folks some required numbers. Outside of digital nerve blocks, I never blocked anything in training.

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[BoardingDoc]

Is there an official process for us to get "credentialed" to do blocks? I'm all for watching stuff on YouTube but if god forbid you have a complication, "I watched it on YouTube" is really not a great defense.

I feel like this is something that needs to be incorporated into EM training and perhaps give folks some required numbers. Outside of digital nerve blocks, I never blocked anything in training.

Credentialing is a hospital driven thing, not a training thing per se. In general though, nerve blocks are within the wheelhouse and scope of practice of an EM trained physician.

 

[Southpaw]

Is there an official process for us to get "credentialed" to do blocks? I'm all for watching stuff on YouTube but if god forbid you have a complication, "I watched it on YouTube" is really not a great defense.

I feel like this is something that needs to be incorporated into EM training and perhaps give folks some required numbers. Outside of digital nerve blocks, I never blocked anything in training.

Anesthesiologist here. You'd need to get credentialed through your hospital. I imagine your credentials committee will ask for some sort of evidence, outside of youtube videos, that you know how to do the block.

FWIW, I do interscalenes for post-op pain routinely and it's not a risk free endeavor. You're going to get the phrenic. People will get SOB, some will drop their sats. When this happens they'll be sitting in your ED waiting for the effect to wear off. You may get some very prolonged blocks and it will be concerning for you. Some patients, very rarely, can have permanent nerve damage. I'm not trying to scare you, it's just reality. We see it in our closed claims data, though to be honest I haven't looked at that data in a while.

If I were you, I'd get comfortable with propofol. I'd personally push propofol 100 times out of 100 for shoulder reduction if I had to choose between propofol and an interscalene block.

 

[thegenius]

Welcome to North Dakota. We were not allowed to perform procedural sedation for "routine" procedures because the ED nurses were not capable/whatever of "monitoring patients under sedation" as determined by the ND Board of Nursing. So yes, physicians could order and give the medications but the RNs can't "monitor" the patient, enter CRNA job protection.

Although we were allowed to give the same medications for RSI...and we were allowed to for an "emergent" procedure like surgical chest tube placement, emergent fracture/dislocation reduction (pulseless limb or tenting), lateral canthotomy, etc.

Cue wonderful times like CRNAs refusing to sedate a child with an angulated forearm fracture because they ate one piece of candy 2.5 hours ago, so we had to transfer then 2 hours away to for sedation and reduction. Or giving IV ketamine then walking away to go get a coffee after the procedure was done (so the patient was unattended), causing my ED charge to tell them to get their #$$ back in the room to monitor the patient (that's what they're getting paid to do) who was still dissociated.

We live in such a pathetic country. I'm sometimes embarrassed to live within the borders of the US.

 

[thegenius]

You don't even need the sterile gloves or probe cover. You can use chloroprep at the site you are going to inject and also use it as your us medium. No need to drape the probe or get out sterile gel. Start to finish it can be done in under 5 minutes.

I reduce a shoulder about once/2-3 months. It's not that common. That being said, I would love to learn how to do an interscalene block. There are lots of blocks I would love to learn how to do.

The problem is they are rare enough that I need to commit to doing it once I actually get a shoulder to reduce...and even then I would like to see it done one in real life before trying it myself. I watch these youtube videos and everybody is gowned up like they are walking into Chernobyl, it's hard to see exactly how the probe is placed...this and that.

There is so much sheit I would like to being 7 years out now as an attending but I'm in this mode of just decompressing the ER, handing out narcotics, enjoying the few interactions where people who really want to be helped listen to my advice, and going home to relax.


I believe it takes 5 minutes to do an interscalene block, and you've probably done 10, or even more. It would probably take me 20 minutes. I don't know.

 

[thegenius]

Anesthesiologist here. You'd need to get credentialed through your hospital. I imagine your credentials committee will ask for some sort of evidence, outside of youtube videos, that you know how to do the block.

FWIW, I do interscalenes for post-op pain routinely and it's not a risk free endeavor. You're going to get the phrenic. People will get SOB, some will drop their sats. When this happens they'll be sitting in your ED waiting for the effect to wear off. You may get some very prolonged blocks and it will be concerning for you. Some patients, very rarely, can have permanent nerve damage. I'm not trying to scare you, it's just reality. We see it in our closed claims data, though to be honest I haven't looked at that data in a while.

If I were you, I'd get comfortable with propofol. I'd personally push propofol 100 times out of 100 for shoulder reduction if I had to choose between propofol and an interscalene block.

Thank you for your insight. And thank goodness there are several ways to skin a cat. getting the phrenic nerve doesn't sound fun

 

[Apollyon]

We live in such a pathetic country. I'm sometimes embarrassed to live within the borders of the US.

Dude, really? Literal millions are trying to get here illegally, there are many who legally get here that are the best and the brightest from their own countries, and we don't make anyone stay here that wants to voluntarily leave. If you are embarrassed, nobody is holding you back from going to another country.

 

[thegenius]

Dude, really? Literal millions are trying to get here illegally, there are many who legally get here that are the best and the brightest from their own countries, and we don't make anyone stay here that wants to voluntarily leave. If you are embarrassed, nobody is holding you back from going to another country.

I didn't say I want to leave. I can not like aspects of our society and still want to live here.

When I hear that crap above...yes. it's embarrassing.

We can be so much better in this country on so many levels. We have seemingly infinite wealth, talent, education, resolve, etc.



Can't I be critical of something and still embrace that same thing?
I mean....that guy above is transferring an arm fracture 2.5 hours because his hospital wont let him use a medicine he is board certified in using. It's daft.

EDIT: Maybe I shouldn't have said we live in a pathetic country. Maybe that hospital system is pathetic. But sometimes I do think there are aspects of our country that are pathetic.

 

[Rendar5]

Are you working somewhere which doesn't allow the ed to use prop? Are you writing this post from 2004?

Yes, not for sedation at least. Doesn’t bother me too much cause anaesthesia is in house and comes down to do sedations for us whenever we need. Our group never felt the need to fight for propofol privilege for sedation since it doesn’t affect our day to day patient care. If anaesthesia wasn’t so easily accessible we would have had it a long time ago.

The only downside is residents I work with don’t get to train on it at our site or the other site that they train at, both of which are completely separate hospital corporations and ED groups in South Florida. I kind of understand our site but don’t get it honestly for the other site but I’ve heard their culture is very weird in some aspects

 

[lucid_leprechaun]

Would recommend the modified Cunningham technique for reasonable patients, works well and takes 10 minutes from door to dispo. But if they are in the “knock me out doc” mindset I usually oblige. I do a ketamine dissociation plus small aliquots of propofol for muscle relaxation, at base they’re out so it doesn’t take much to relax them. A little versed works well too. Hasn’t failed me yet

 

[emergentmd]

20 yrs in EM.

1st 10 yrs it was Etomidate and whatever pain meds you want to add on. No issues, pts woke up slower. Nothing to be scared about, I use it to intubate so if crap happens, I intubate

An older doc showed me the slow relaxing shoulder reduction sans any meds. Said he reduces all the shoulders without difficulties and almost never misses any. Just do it slowly, and never fails. I almost NEVER change my practice if it is working well, but he why not. Did his technique on 3 pts and never worked. So thought, maybe I was just rushing it. 4th Try and older doc working, again failed, so asked him to show me. Doc tried, didn't work after torturing the pt and 30 min of "slow" reduction. Screw it, etomidate and done in 2 min.

Last 10 yrs has been Propofol + pain meds, Traction and counter traction +/- shoulder manipulation for big boys. NEVER fails. Stopped with all the other techniques and always go straight to this. You need a strong helper, and you need to literally put all your weight and push off the bed with your legs sometimes but always goes back in. Sometimes it looks like I am literally turning their body into a pretzel but that is how ortho does it too.

The only time it fails is someone with multiple dislocations and joint just pops back out.

Learn this, don't be scared to put max force, sedate them well. Let me repeat, SEDATE them well. If they are moaning and you can't get it in, SEDATE them more. Propofol wears off in like 1 min, so bag them if you need although I have never needed this. Ortho guy told me if you give them to much, do a sternal rub and they will wake. Point is, don't be scared b.c you can manage the airway.

 

[Angry Birds]

Anesthesiologist here. You'd need to get credentialed through your hospital. I imagine your credentials committee will ask for some sort of evidence, outside of youtube videos, that you know how to do the block.

FWIW, I do interscalenes for post-op pain routinely and it's not a risk free endeavor. You're going to get the phrenic. People will get SOB, some will drop their sats. When this happens they'll be sitting in your ED waiting for the effect to wear off. You may get some very prolonged blocks and it will be concerning for you. Some patients, very rarely, can have permanent nerve damage. I'm not trying to scare you, it's just reality. We see it in our closed claims data, though to be honest I haven't looked at that data in a while.

If I were you, I'd get comfortable with propofol. I'd personally push propofol 100 times out of 100 for shoulder reduction if I had to choose between propofol and an interscalene block.

You've justified my lazy decision never to learn this block and just use Propofol.

 

[deleted875186]

Anesthesiologist here. You'd need to get credentialed through your hospital. I imagine your credentials committee will ask for some sort of evidence, outside of youtube videos, that you know how to do the block.

FWIW, I do interscalenes for post-op pain routinely and it's not a risk free endeavor. You're going to get the phrenic. People will get SOB, some will drop their sats. When this happens they'll be sitting in your ED waiting for the effect to wear off. You may get some very prolonged blocks and it will be concerning for you. Some patients, very rarely, can have permanent nerve damage. I'm not trying to scare you, it's just reality. We see it in our closed claims data, though to be honest I haven't looked at that data in a while.

If I were you, I'd get comfortable with propofol. I'd personally push propofol 100 times out of 100 for shoulder reduction if I had to choose between propofol and an interscalene block.

As another anesthesiology opinion ….

I would never do an interscalene block for this, far more risk than it’s worth, unless the patient was too sick, too obese, etc.

Propofol is the ideal agent. Etomidate burns on injection, causes nausea, people don’t feel as good waking up, but is relatively fast on and off. I would not use ketamine if I were planning to discharge the person, unless it’s a small 20-30 mg dose.

 

[RustedFox]

As another anesthesiology opinion ….

I would never do an interscalene block for this, far more risk than it’s worth, unless the patient was too sick, too obese, etc.

Propofol is the ideal agent. Etomidate burns on injection, causes nausea, people don’t feel as good waking up, but is relatively fast on and off. I would not use ketamine if I were planning to discharge the person, unless it’s a small 20-30 mg dose.

What's your propofol "recipe"?
I'm interested to see if Anes has any different thoughts/approaches.

 

[thegenius]

I'm always a wuss with propofol and always start with 0.5 or less. I do so so I don't have to BVM. I see anes go the full bore and give 1 or more, and just bag for a few minutes.

 

[Zebra Hunter]

I'm always a wuss with propofol and always start with 0.5 or less. I do so so I don't have to BVM. I see anes go the full bore and give 1 or more, and just bag for a few minutes.

I always give the full 1 mg/kg initially because I’ve found that if I don’t, about 80% of the time I’m having to re-dose and would typically get inadequate muscle relaxation. I’ve only had to bag someone twice after giving prop, and only had to do it for about a minute at most. Definitely need 1 extra set of hands in the room that are ready to assist if needed rather than just a single nurse, however.

 

[southerndoc]

I get a ballpark figure what they're 1 mg/kg push would be, but I generally just start with 0.5 and keep pushing until they're out. I rarely, if ever, require someone to be bagged. The only time I routinely require bagging is with hip reductions. I don't feel like throwing out my back, so I tell the RT to get ready to bag. Had another case of profound apnea/hypoxemia after a cardioversion for wide complex tachycardia.

 

[deleted875186]

What's your propofol "recipe"?
I'm interested to see if Anes has any different thoughts/approaches.

Push propofol until desired level of consciousness is desired. Healthy 30-40 year old, I give 40-50mg bolus, wait, repeat in 20-30 mg boluses or more depending on response. Healthy young people can take a lot of propofol, so a 1 mg/kg bolus may not even produce unconsciousness. Sick or frail patients, I will give 20mg, wait a solid one minute if concerned, and titrate from there.

It’s difficult because it’s all over the place depending on patient and their medical sotuatikn. I did an upper EGD for a 40 year old guy, healthy, came in with anemia ajd upper GI bleed from NSAIF, Hemoglobin 7. I gave this guy 50 mg propofol and within one minute his gag reflex was blunted and he was asleep but maintaining airway, and I thought, that was a much smaller propofol requirement than I would have thought.

 

[Jabbed]

Push propofol until desired level of consciousness is desired. Healthy 30-40 year old, I give 40-50mg bolus, wait, repeat in 20-30 mg boluses or more depending on response. Healthy young people can take a lot of propofol, so a 1 mg/kg bolus may not even produce unconsciousness. Sick or frail patients, I will give 20mg, wait a solid one minute if concerned, and titrate from there.

It’s difficult because it’s all over the place depending on patient and their medical sotuatikn. I did an upper EGD for a 40 year old guy, healthy, came in with anemia ajd upper GI bleed from NSAIF, Hemoglobin 7. I gave this guy 50 mg propofol and within one minute his gag reflex was blunted and he was asleep but maintaining airway, and I thought, that was a much smaller propofol requirement than I would have thought.

DipriMAN? Diprivan? Conflict of interest?
🤔

 

[Apollyon]

DipriMAN? Diprivan? Conflict of interest?
🤔

There used to be a mod who used the name Depakote, and a user who used the name quetiapine, as that was a med they took!

 

[turkeyjerky]

Shout out to the IA local anesthetic + Kocher method mentioned above. I've used this twice in the past week successfully. My go to as always been procedural sedation with external rotation (hennepin? milch?), although I've used FARES a few times on people who just want it back in asap.

 

[Jabbed]

Shout out to the IA local anesthetic + Kocher method mentioned above. I've used this twice in the past week successfully. My go to as always been procedural sedation with external rotation (hennepin? milch?), although I've used FARES a few times on people who just want it back in asap.

Works great for little old ladies, but I'll frequently add valium as well if they have muscle mass. IA lido does very little for muscle spasms.

 

[nimbus]

I always give the full 1 mg/kg initially because I’ve found that if I don’t, about 80% of the time I’m having to re-dose and would typically get inadequate muscle relaxation. I’ve only had to bag someone twice after giving prop, and only had to do it for about a minute at most. Definitely need 1 extra set of hands in the room that are ready to assist if needed rather than just a single nurse, however.

When our orthopedists can’t reduce a shoulder or hip in the operating room, they ask for sux and that usually helps. I give a healthy dose of propofol and always bag or stick in an lma.

 

[BoardingDoc]

When our orthopedists can’t reduce a shoulder or hip in the operating room, they ask for sux and that usually helps. I give a healthy dose of propofol and always bag or stick in an lma.

While I agree that ortho paralyzes people when they need to reduce in the OR, I would argue that if you're routinely needing to bag or LMA someone for a conscious sedation you're doing it wrong.

 

[nimbus]

While I agree that ortho paralyzes people when they need to reduce in the OR, I would argue that if you're routinely needing to bag or LMA someone for a conscious sedation you're doing it wrong.

It’s general anesthesia, not conscious sedation. Ortho doesn’t like patients to move or resist at all during joint reductions and we don’t paralyze conscious people.

 

[BoardingDoc]

It’s general anesthesia, not conscious sedation. Ortho doesn’t like patients to move or resist at all during joint reductions and we don’t paralyze conscious people.

I was wondering from your context what you meant. Doing this in the OR is obviously going to be MAC or general anesthesia, so that would make sense.

 

[thegenius]

Tiny bump.

How would you feel if a midlevel in triage saw a pt with a dislocated shoulder, reduced it him/herself (pre-xray +dislocation), and then discharged the patient?
Let's say there was no bad outcome, and let's also set aside the issue of lost money which is obvious.

Would you be incensed the way I am?
1) there is a credentialing issue
2) there is a liability issue
3) there is a cockiness issue
4) WTF are we good for if joint dislocations are managed in triage by a midlevel

Sometimes I think we are a victim of our own success.

 

[Fox800]

Tiny bump.

How would you feel if a midlevel in triage saw a pt with a dislocated shoulder, reduced it him/herself (pre-xray +dislocation), and then discharged the patient?
Let's say there was no bad outcome, and let's also set aside the issue of lost money which is obvious.

Would you be incensed the way I am?
1) there is a credentialing issue
2) there is a liability issue
3) there is a cockiness issue
4) WTF are we good for if joint dislocations are managed in triage by a midlevel

Sometimes I think we are a victim of our own success.

Uh, yeah. Would not be OK with that. At all. Would forward that to your medical director for review.

 

[Jabbed]

Tiny bump.

How would you feel if a midlevel in triage saw a pt with a dislocated shoulder, reduced it him/herself (pre-xray +dislocation), and then discharged the patient?
Let's say there was no bad outcome, and let's also set aside the issue of lost money which is obvious.

Would you be incensed the way I am?
1) there is a credentialing issue
2) there is a liability issue
3) there is a cockiness issue
4) WTF are we good for if joint dislocations are managed in triage by a midlevel

Sometimes I think we are a victim of our own success.

Neutral, as long as it’s without sedation and as long as I can bill for the reduction. I’m imagining that this was a patient with recurrent dislocation who just wanted to get out quickly.

 

[CoolDoc1729]

Tiny bump.

How would you feel if a midlevel in triage saw a pt with a dislocated shoulder, reduced it him/herself (pre-xray +dislocation), and then discharged the patient?
Let's say there was no bad outcome, and let's also set aside the issue of lost money which is obvious.

Would you be incensed the way I am?
1) there is a credentialing issue
2) there is a liability issue
3) there is a cockiness issue
4) WTF are we good for if joint dislocations are managed in triage by a midlevel

Sometimes I think we are a victim of our own success.

Whether the person wants to get out quickly or not, I’m not clear why the PA wouldn’t run it by you… except #3. My company had an extraordinarily arrogant locums pa working at my site for a few months .. I’m so thankful he’s off to save the world somewhere else now. Scary when they’re playing darts with your license …

 

[Arch Guillotti]

I was wondering from your context what you meant. Doing this in the OR is obviously going to be MAC or general anesthesia, so that would make sense.

No MAC for something like this in the OR. General anesthesia in one form or another basically 100% of the time.

 

[turkeyjerky]

Tiny bump.

How would you feel if a midlevel in triage saw a pt with a dislocated shoulder, reduced it him/herself (pre-xray +dislocation), and then discharged the patient?
Let's say there was no bad outcome, and let's also set aside the issue of lost money which is obvious.

Would you be incensed the way I am?
1) there is a credentialing issue
2) there is a liability issue
3) there is a cockiness issue
4) WTF are we good for if joint dislocations are managed in triage by a midlevel

Sometimes I think we are a victim of our own success.

Yeah, I'd be pissed. Midlevels Gone Wild.