Thoughts on this?

[Dwindlin]

This is a thread from the Anesthesia forum. Reaction to the FDA backing the ASA on propofol. A couple EM people responded in the thread but I was hoping to see some more EM opinions and I wasn't sure how many of the EM guys trolled around the Gas forum. Honestly not looking to stir up a fight, just wanted some more thoughts from EM attendings/residents.

Please if any mods think this will cause any problems delete it. Thanks!

http://forums.studentdoctor.net/showthread.php?t=758889

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[docB]

I read about half of it before it got really boring. This is all about $$$ just like everything else. The gas guys think there is this pot of gold out there that they can tap into by forcing themselves into every sedation that happens anywhere. There isn't. They are not going to accept being put on call to respond to all the uninsured shoulders and abscesses and the hospitals aren't going to pay them to do it. The hospitals aren't going to accept admitting all these patients who could previously get their procedures and go home.

So I predict that this battle will be between the hospitals and anesthesia. The hospitals can make anesthesia call with 30 response times to the ER for sedations a requirement of hospital credentials.Anesthesia can fight and fight but they'll get paid the same for these cases as we do, $0.

In the interim we'll keep doing what we do but with worse agents for a while.

Gotta go to a code. Too bad I'm not as much of an "artist with the airway" as those anesthesiologists.

 

[wook]

It cracks me up that anesthesia wants this. I call them regularly to the ED to do the procedural sedation, since I cannot use propofol (been using it for several years without a problem). They tell me they're too busy.

Wook

 

[southerndoc]

If they're on call and you request them, EMTALA requires that they respond.

 

[leorl]

I dunno, don't really see the problem I guess. Have never really ever had a problem with propofol or any of the other sedative agents. Full stomach or not, no one has ever vomitted on me or risked aspiration. No one has ever been knocked out for a prolonged amount of time. If the sedation is for intubation, we put in OG tubes and honestly, who cares whether there's a full stomach if there's an emergent airway situation. Stabilize and try to prevent secondary effects later.

The great thing about propofol for procedural sedation is that it's the only agent you need with great effect and short duration of action. No one really ever gives the full sedation dose (40) in one whack. It's usually titrated with 10 or 20 aliquots. Much better than having to give versed + 50 then 50 then 50 then 50 then 50 of fentanyl, or etomidate and an analgesic...and waiting...and waiting...and waiting...

 

[docB]

If they're on call and you request them, EMTALA requires that they respond.

At all of my hospitals they are NOT on the call list. If a surgeon needs one he calls his own. When it's a no pay case he has to go to the favor bank. If this propofol bs gets bad the hospitals will have to force anesthesia onto the call list so they will be obligated to respond to the ED.

I dunno, don't really see the problem I guess. Have never really ever had a problem with propofol or any of the other sedative agents. Full stomach or not, no one has ever vomitted on me or risked aspiration. No one has ever been knocked out for a prolonged amount of time. If the sedation is for intubation, we put in OG tubes and honestly, who cares whether there's a full stomach if there's an emergent airway situation. Stabilize and try to prevent secondary effects later.

The great thing about propofol for procedural sedation is that it's the only agent you need with great effect and short duration of action. No one really ever gives the full sedation dose (40) in one whack. It's usually titrated with 10 or 20 aliquots. Much better than having to give versed + 50 then 50 then 50 then 50 then 50 of fentanyl, or etomidate and an analgesic...and waiting...and waiting...and waiting...

But what anesthesia is saying is that even if you and I don't see bad outcomes there are rare bad outcomes out there that could (they argue) be averted if anesthesiologists were doing all the sedations. They just don't realize what they're really biting off with all this.

And Southerndoc's point about EMTALA reminds me of another aspect of this (I say reminds because we've been discussing this at meetings lately). One reason anesthesia will never respond to the ED for a no pay if they're not formally on call is that we don't have a favor bank to go to. We don't give them all our paying gallbladders and kiddie ears. But if there's a shoulder out and I can't sedate the patient I'm calling the ortho. The ortho will have to call in gas to do the sedation and if the case is a no pay then they're going to be pretty unhappy. No matter how you slice it they will wind up doing a lot of stuff for free that we used to just take care of and send home.

 

[EM2BE]

Has anyone here had to do a procedural sedation class/exam to get credentialed? I know where I am they started forcing them to do this no matter how long they've been doing it.

 

[deleted6669]

Has anyone here had to do a procedural sedation class/exam to get credentialed? I know where I am they started forcing them to do this no matter how long they've been doing it.

yup, everywhere I work. and I have to log 10/yr or have to retake the test.

 

[wook]

Has anyone here had to do a procedural sedation class/exam to get credentialed? I know where I am they started forcing them to do this no matter how long they've been doing it.

Yes. That's why I find it interesting that I cannot use etomidate or propofol or ketamine (we don't do pediatrics). I'm credentialed for procedural sedation, yet cannot use the drugs, except for versed and fentanyl.

 

[docB]

Has anyone here had to do a procedural sedation class/exam to get credentialed? I know where I am they started forcing them to do this no matter how long they've been doing it.

yup, everywhere I work. and I have to log 10/yr or have to retake the test.

We have one hospital where the anesthesia guys tried to set something like this up. They did it because they saw the writing on the wall, i.e. them having to take call and sedate the uninsured so the were trying to avoid that.

That's a possible bandaid that could be put on this problem, everyone gets some "credential" and then the whole problem goes away.

 

[jbar]

If I'm reading the other thread right, they are saying that anyone who hasn't been fasting should get RSI and tubed for the procedure. I'm just a med student but I'm pretty sure that the risks of intubating every patient who needs a fracture reduced or a shoulder put back are much higher than the risks of procedural sedation. That's crazy talk, right?

 

[EMRAGE]

Anesthesia may do more intubation but ER docs due more difficult intubation in worse situations. If airway control during procedural sedation is the main concern, I would have no problem making an argument that we too are masters of the airway.

RAGE

 

[cyclohexanol]

If I'm reading the other thread right, they are saying that anyone who hasn't been fasting should get RSI and tubed for the procedure. I'm just a med student but I'm pretty sure that the risks of intubating every patient who needs a fracture reduced or a shoulder put back are much higher than the risks of procedural sedation. That's crazy talk, right?

That's exactly what I got out of reading that other thread, and I agree that it seems that DL and endotracheal intubation pose risks greater than just inducing short GA for a reduction. -shrug-

 

[Arch Guillotti]

Anesthesia may do more intubation but ER docs due more difficult intubation in worse situations. If airway control during procedural sedation is the main concern, I would have no problem making an argument that we too are masters of the airway.

RAGE

Visiting from the anesthesiology forum and can't resist the bait so flame away at me if you like since I am stepping out of my usual forum.

Unless you are an attending anesthesiologist and well as an ER doc I disagree vehemently with your assertion that you do more difficult intubations in worse situations. We have enough patients that come to us in the OR that are expected and unexpected difficult airways to keep sharp. At the risk of flaming you, I believe that we are not involved in as many bad situations because we avoid them in the first place😀. I know that our situations and locations are very different and while I like to take a poke at the ED docs sometimes we only have to go help them out of a jam every once in a while.

It isn't so much an issue now that I am finished, but most anesthesiology residents at academic medical centers get plenty of experience with not only difficult airways but bad situations outside of the OR - ICU's or elsewhere. many times we were not called until a sick/difficult patient was crumping or until the nitwit😎 general surgery resident induced and couldn't manage the airway.

I am not trying to start a flame war by any means and you may be the cats meow at intubating but us anesthesiologists are pretty damn good at what we do.

I don't want to be called to the ED any more than the next anesthesiologist for the record.

 

[EMRAGE]

Visiting from the anesthesiology forum and can't resist the bait so flame away at me if you like since I am stepping out of my usual forum.

Unless you are an attending anesthesiologist and well as an ER doc I disagree vehemently with your assertion that you do more difficult intubations in worse situations. We have enough patients that come to us in the OR that are expected and unexpected difficult airways to keep sharp. At the risk of flaming you, I believe that we are not involved in as many bad situations because we avoid them in the first place😀. I know that our situations and locations are very different and while I like to take a poke at the ED docs sometimes we only have to go help them out of a jam every once in a while.

It isn't so much an issue now that I am finished, but most anesthesiology residents at academic medical centers get plenty of experience with not only difficult airways but bad situations outside of the OR - ICU's or elsewhere. many times we were not called until a sick/difficult patient was crumping or until the nitwit😎 general surgery resident induced and couldn't manage the airway.

I am not trying to start a flame war by any means and you may be the cats meow at intubating but us anesthesiologists are pretty damn good at what we do.

I don't want to be called to the ED any more than the next anesthesiologist for the record.

I don't think anyone, especially me, is disregarding any anesthesiolgists abilities or skills. I also have no intent to flame you.

I've jumped from life flight plenty of times to find patients with bloody and mangled, dark airways. I'm not sure how you plan and prepare for that. I promise my comfort level with intubation far exceeds the realm of a controlled surgical suite or ICU bed.

If I call for your "help" it's simply for documentation that I did so, not because I feel you are going to get the tube and I'm not. Strictly CYA. Now, if you decide that you are going to do the intubation, I let you. It's professional courtesy and is protective for me if things go bad.

The times that we've called anesthesia to the ER for airway help, were also calling the trauma attending for help with an emergent cric. Rarely did management change once anesthesia arrived.

Everything is easier in a controlled environment... no argument there. Planning and being prepared is best. That is a luxury we don't have in EM

My anesthesia rotation was awesome, I tubed many, many pts that month. Things only got worse from an airway standpoint after that. The skill I learned, were invaluable. Props to your specialty for that.

EMRAGE

 

[kungfufishing]

Anesthesiologists are airway and sedation experts. Acknowledging their expertise, to me, is simply stating the obvious. It is what they do for a living every day all the time. I think this thread would be better if we redirected back to the more important point, which is that with respect to sedation, Emergency Physicians should not be lumped into a category with other groups who simply do not possess the airway management and resuscitation skills that we do. There is plenty of evidence suggesting that propofol is a safe and effective drug for procedural sedation in the ED.

 

[deleted109597]

The anesthesia group at my moonlighting gig made us take a test to prove we were "competent" to perform DAI and procedural sedation. Part of me didn't want to take it and instead just call them every time. The side issue though, is that politically this is a sensitive subject because of Michael Jackson, as well as the reams of people who are put in bad situations because the GI/Cards/whatever procedure going on in some suite turns bad and there isn't someone nearby who knows what end of the ETT goes in what hole. Unfortunately EPs are getting lumped in with them. And in some places (rural, etc), their non EM training may not have included much in the way of procedural sedation or airway management. And I would rather take the easy test and know that the non-BCEM guys that I take checkout from also have had a little refresher on the drugs and how they work.
I still think making gas come down for all sedations, or worse, forcing the hospital to admit all the procedures will make this go away for us.

 

[Arch Guillotti]

If I call for your "help" it's simply for documentation that I did so, not because I feel you are going to get the tube and I'm not. Strictly CYA.

Everybody needs to call for help every now and then. If you don't you are a blame fool.

I could care less if I am ever called to the vile cesspool😀 that you work in. Fortunately, where I work the ED docs manage their business pretty well.

Rock on cowboy

 

[The White Coat Investor]

In my experience the difference between most airways anesthesiologists do and most airways that emergency docs do is that the anesthesiologists patients can be woken up and sent home if you can't get the airway. That simply isn't an option in the ED. If it was elective, I wouldn't be doing it.

We get called for all the emergent airways in the hospital because anesthesia isn't there. I was once even called to the OR to intubate (by a CRNA whose "supervisor" was at home.) The surgeon had criched the patient by the time I got there, so I showed the CRNA where his glidescope and difficult airway cart were and how to use them and we debated replacing the crich with what would have been a pretty easy glidescope intubation before deciding just to leave it for now.

 

[pgg]

I chased that other crossposted airway thread over here and saw this one ...

It cracks me up that anesthesia wants this.

For the record (already set straight by Arch 🙂), we don't want them.

Read my posts in the OP's referenced thread if you're interested in the long version of my opinion on the matter.

The short version is that most of us are not interested in dictating another specialty's practice of medicine or standard of care. I think it's stupid and largely inappropriate to tell EM guys that they can't use propofol. I understand why such prohibitions irritate you.

The flip side is that EM physicians should understand that when you ask an anesthesiologist about the safe way to render a full stomach patient unconscious for a painful procedure, you're going to get an answer grounded in our society's guidelines and our standard of care.

Where the conflict typically arises is that individual hospital policies are set by hospital committees. If such questions are raised to us during these staff meetings, the only thing we can do is answer in the context of our own standard of care ... and this is how policies get made. This doesn't mean there's a conspiracy to defraud you of 2 AM uninsured I&D opportunities.

If I call for your "help" it's simply for documentation that I did so, not because I feel you are going to get the tube and I'm not. Strictly CYA.

Wow.

 

[Dwindlin]

Saw this article this morning, http://www.acep.org/Content.aspx?id=75563.

Think this will make a difference in places getting significant push back from gas about ED sedation?

 

[wook]

Saw this article this morning, http://www.acep.org/Content.aspx?id=75563.

Think this will make a difference in places getting significant push back from gas about ED sedation?

We're trying to use it at one of the hospitals I work at. I think it provides us with more leverage to do what's right for our patients.

I wish we had more folk like pgg and Arch working with us on this. I think all our patients would benefit.


Thanks.


Wook

 

[wook]

Everybody needs to call for help every now and then. If you don't you are a blame fool.

Agreed!


Wook

 

[Birdstrike]

It is such a struggle to get consultants at my (community) hospital to do anything, this whole sedation/propofol battle will never be an issue where I'm at. Anesthesia coming in for every sedation? Hilarious. They could care less what we do, as long as we don't call them. We're the only "anesthesiologists" in the hospital at night doing airways at all. They're happy to be the airway experts during working hours, and give us the "airway expert badge" to wear at night. Its 100% political. It has more to do with Anesthesia losing turf to CRNAs than anything.

I can play "whack-a-mole": ban propofol, I'll use etomidate; ban etomidate, I'll use fentanyl/versed, ban fentanyl/versed, I'll use ketamine, ban ketamine and I'll go back to brevital.

 

[Hamhock]

This thread,

http://forums.studentdoctor.net/forumdisplay.php?f=45

in the anesthesiology forum results in the usual discussion between ED docs and anesthesiologists regarding this topic. If you have read most of these threads, there is not that much new.

However, I think post#68 is noteworthy. The author (an anesthesiologist who is a frequent poster in their forum and an occasional poster here) has been saying parts of this post in many different threads, but I think it is all summarized in this one thread. And although I am pure EM and behind our specialty all the way, I think we really need to carefully read then:

1. Tone done the rhetoric.

2. Dramatically increase our understanding/education of moderate sedation vs. deep sedation vs. general anesthesia and stop foolishly calling it concious sedation...and even admit to ourselves where in that spectrum we are when we are using procedural sedation. When I ask junior residents where in the spectrum they are or where they want to be, I often get blank looks or uncertain responses.

3. Increase our education of residents regarding agents and their effects (or lack thereof) on amenesia/hypnosis/analgesia/etc.

4. Further develop our own guidlelines and scope regarding procedural sedation, admitting that we often use deep sedation/general anesthesia...and stop asking other specialties to define our scope for us.

5. Then really consider the more interesting clinical questions regarding our modern EM use of procedural sedation. For example: Despite our literature and guidelines, there are cases that I think if we are really honest with ourselves, we should probably be using RSI before procedural sedation. And if we do, it brings up all kinds of interesting questions:
a. How, where, and when to extubate?
b. Should extubation be part of EM education for residents?
c. If a case needs RSI and procedural sedation, should we be doing it at all? ...or maybe, these should go to the OR (even if the injury or procedure is relatively minor)/be performed by an anethesiologist? [[please no flames - I'm pure EM; just asking a few questions]]
d. and more...

HH

 

[Birdstrike]

I think we can safely say, "game over".

From the American Society of Anesthesiologists own website:

"Q4: Why is there a particular mention in the IG on the emergency department’s (ED’s) sedation policies?

A4: The ED is a unique environment where patients present on an unscheduled basis with often very complex problems that may require several emergent or urgent interventions to proceed simultaneously to prevent further morbidity or mortality. In addition, emergency medicine- trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general)."

http://www.asahq.org/Home-Page/ASA-News-and-Alerts/Whats-New/~/media/For%20Members/Advocacy/ASA%20in%20Washington/2011%20FAQ%20for%20CMS%20Revised%20Hospital%20Inte rpretive%20Guidelines.ashx

Also, very nicely described here:

http://www.epmonthly.com/features/cu...-a-win-for-em/

 

[deleted109597]

You can say that, but unless your actual hospital committee buys that logic, you still have to jump through the hoops.

 

[Birdstrike]

You can say that, but unless your actual hospital committee buys that logic, you still have to jump through the hoops.

You're 100% right. It's unfortunate when hospital politics forces us to do things that we think are not necessarily best for patients, because the "Turf Gods" have been angered. It's an unfortunate reality. Those two links I posted two posts above are fairly recent, and probably have not had time to be presented before many committees.

As EM physicians we tend to be isolated from hospital politics (mistake) and therefore we are always being reactive instead of proactive.

 

[The White Coat Investor]

I'm surprised they included general anesthesia in that statement. I think a better description of my skill set would be that I know how to rescue a patient who inadvertently slips into general anesthesia while I'm trying to keep them in deep sedation. I certainly don't plan to take patients to general anesthesia in the ED. In general, brief, deep sedation is what we need for reductions, nasty I&Ds, some unique suturing situations, etc.

 

[lushmd]

I'm surprised they included general anesthesia in that statement. I think a better description of my skill set would be that I know how to rescue a patient who inadvertently slips into general anesthesia while I'm trying to keep them in deep sedation. I certainly don't plan to take patients to general anesthesia in the ED. In general, brief, deep sedation is what we need for reductions, nasty I&Ds, some unique suturing situations, etc.

If by "they" you're referring to the ASA, "they" haven't. Please note that Birdstrike's link isn't to some sort of ASA official position statement. Its to a link on the ASA website that shows a section of text from CMS. This is why you seem the same text in both of BS' links.

 

[Birdstrike]

I'm surprised they included general anesthesia in that statement. I think a better description of my skill set would be that I know how to rescue a patient who inadvertently slips into general anesthesia while I'm trying to keep them in deep sedation. I certainly don't plan to take patients to general anesthesia in the ED. In general, brief, deep sedation is what we need for reductions, nasty I&Ds, some unique suturing situations, etc.

As a fellow EP, I have a question: Have you ever intubated someone in the ED, put in an NG or OG tube and given them some IV pain medicine, benzodiazepines (or propofol drip) and a long acting paralytic, rendering them completely unconscious, paralyzed and devoid of any pain response and reflexes (airway, gag or otherwise)?

If so, what is that? Please, help me learn.

 

[The White Coat Investor]

As a fellow EP, I have a question: Have you ever intubated someone in the ED, put in an NG or OG tube and given them some IV pain medicine, benzodiazepines (or propofol drip) and a long acting paralytic, rendering them completely unconscious, paralyzed and devoid of any pain response and reflexes (airway, gag or otherwise)?

If so, what is that? Please, help me learn.

Not a bad point, despite the sarcasm. 🙂 But no one is talking about that. They're talking about the patients we put down AND wake up, not the ones we ship off to the ICU.

 

[NEATOMD]

I have an attending at my institute that is boarded in EM and anesthesiology.
His main gripe with EM docs is that most really don't know what defines each level of sedation. He thinks this is what gets us into trouble most of the time (when we do).
That said, he believes ED docs do a great job with anesthesia in general when trained to use it and points out that even anesthesiology's research points out that aspiration isn't common for sedations even with people who practically put down the burger within seconds of getting the meds.

What is probably most dangerous in my opinion than the issue with propofol is that my institute lets us use paralytics in the ER but not on the floors. ...Nothing like jamming a tube into closed chords or teeth for that matter.

 

[Hamhock]

I have an attending at my institute that is boarded in EM and anesthesiology.
His main gripe with EM docs is that most really don't know what defines each level of sedation. He thinks this is what gets us into trouble most of the time (when we do).

Exactly!

(see my post above and many posts in the anesthesiology forum thread)

HH

 

[13770]

yes, the new CMS policy embracing the ACEP guidelines should take care of this perspective.