U/S guided regional anestheisa in the ED by ED docs

[turnupthevapor]

Wondering if I could have your input.

I have been asked to speak to our ER dept about regional anesthesia. The dept uses a lot of ultrasound and are interested in nerve blocks. My plan is to teach them as I feel it is in their scope of practice but I will do so with a word of caution as they should not be taken lightly.

Also they need to check with their malpractice, hosptial privledges, and dept befor starting the blocks

What do you guys think? I did find a few artlces suggesting it can be done

.Blaivas.. M, Lyon M. Ultrasound-guided ..interscalene.. block for shoulder dislocation reduction in the ED. Am J ..Emerg.. Med. 2006;24:293–6. [..PubMed..].​

. .​

.
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.Liebmann.. O, Price D, Mills C, Gardner R, Wang R, Wilson S, et al. Feasibility of forearm ..ultrasonography..-guided nerve blocks of the radial, ..ulnar.., and median nerves for hand procedures in the emergency department. Ann ..Emerg.. Med. 2006;48:558–62. [..PubMed..].​

. .​

.
.
.Ultrasound-guided nerve blocks in the emergency department. J ..Emerg.. Trauma Shock. 2010 Jan–Mar; 3(1): 82–88. .​

. .​

.
Stone MB, Wang R, Price DD. Ultrasound-guided ..supraclavicular.. brachial plexus nerve block ..vs.. procedural sedation for the treatment of upper extremity emergencies. Am J ..Emerg.. Med. 2008;26:706–10. [..PubMed.

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[IlDestriero]

I would never be a part of that.
Why don't you teach their sedation nurses to use propofol and fentanyl as well and maybe you can fire a couple of your partners.
Enough people want to do our job already, and think that they can, why help make things worse?
It's all about patient care, right? The fact that they can bill for it is just a bonus...
I would tell them that regional anesthesia is something that you are happy to do for them, and that you would be happy to come down and give them a lecture showcasing all the services that your group can provide.

 

[Planktonmd]

Why is it that anesthesiologists are always willing to teach others how to do anesthesia for free?
Why do we feel that we should teach everyone our trade but then we get upset when they replace us?
Regional anesthesia is not within the scope of practice of ER docs or anyone else.
It is the practice of anesthesia and if they want to learn it they can go do a residency in anesthesia.

Wondering if I could have your input.

I have been asked to speak to our ER dept about regional anesthesia. The dept uses a lot of ultrasound and are interested in nerve blocks. My plan is to teach them as I feel it is in their scope of practice but I will do so with a word of caution as they should not be taken lightly.

Also they need to check with their malpractice, hosptial privledges, and dept befor starting the blocks

What do you guys think? I did find a few artlces suggesting it can be done

.Blaivas.. M, Lyon M. Ultrasound-guided ..interscalene.. block for shoulder dislocation reduction in the ED. Am J ..Emerg.. Med. 2006;24:293–6. [..PubMed..].​

.
.
.Liebmann.. O, Price D, Mills C, Gardner R, Wang R, Wilson S, et al. Feasibility of forearm ..ultrasonography..-guided nerve blocks of the radial, ..ulnar.., and median nerves for hand procedures in the emergency department. Ann ..Emerg.. Med. 2006;48:558–62. [..PubMed..].​

.
.
.Ultrasound-guided nerve blocks in the emergency department. J ..Emerg.. Trauma Shock. 2010 Jan–Mar; 3(1): 82–88. .​

.
Stone MB, Wang R, Price DD. Ultrasound-guided ..supraclavicular.. brachial plexus nerve block ..vs.. procedural sedation for the treatment of upper extremity emergencies. Am J ..Emerg.. Med. 2008;26:706–10. [..PubMed.

 

[proman]

I agree. The EM forum has a thread about US guided regional. For some reason they think just because they have an ultrasound machine they can stick a needle anywhere they choose. I'm not against EM doing anatomical blocks (like alveolar, median, or hematoma) but doing a block that would otherwise require nerve stimulation is a stretch. Plus, how do they assess nerve function after reductions for the several hours it takes to recover? Regional anesthesia has enough complications when performed by people formally trained in the anatomy and techinque, let alone by an EP who went to a weekend course.

 

[leaverus]

I gotta agree with everyone else so far. Why do you want to teach non-anesthesiologists what should be strictly your domain. Frankly i'm surprised your group doesn't want the extra business. Isn't it in your best interests to offer to do blocks whenever the ER guy calls? Don't be a sell-out, man; we already got enough of em in this field.

 

[cfdavid]

I would never be a part of that.
Why don't you teach their sedation nurses to use propofol and fentanyl as well and maybe you can fire a couple of your partners.
Enough people want to do our job already, and think that they can, why help make things worse?
It's all about patient care, right? The fact that they can bill for it is just a bonus...
I would tell them that regional anesthesia is something that you are happy to do for them, and that you would be happy to come down and give them a lecture showcasing all the services that your group can provide.

Amen. It always "sounds" benign in the beginning.

 

[IlDestriero]

This is actually a great example of why it is worth the effort and lost income to try to get members of your group on various hospital committees. This is especially true if you are PP "outsiders". If you are integrated into the system, your opposition to this invasion into what can be shown to be clearly part of your scope of practice may be better received. Someone could be in a position to stop this before it gets off the ground, or at least limit it's scope. Depending on how your contract is worded, you could also argue that the practice of regional anesthesia (major conductive nerve blocks as opposed to "local") violates your existing contract to exclusively provide all anesthesia services for the hospital.
This can only hurt you, and everyone else, in the long run.

 

[lakerjock]

Heck no. It is not within their scope of practice. Just because I can use a scalpel and suture, doesn't mean I should perform a whipple. Just because the ED can use an U/S for a couple things, doesn't mean they should be doing peripheral nerve blocks.

They haven't been trained, and shouldn't practice on patients. Residency with numerous blocks (either trained with Nerve Stimulator or U/S) allows for the knowledge and skillset to perform a block. One could progress from a nerve stimulator technique to U/S with some guided training. Now if you and your partners are willing to supervise all U/S guided blocks in the ER for the next few years (in order for there to be appropriate volume, depending on the size of your ED), then your group is nuts.

Bottom line is if there is need for a peripheral nerve block in the ED, your group should be CONSULTED as you are the EXPERTS, and you should appropriately get PAID.

 

[gasaddict54]

This is a perfect example of EXACTLY the kind of situations where we lose control of our profession.

 

[dhb]

I don't see this a way for ER docs to become anesthesiologist through the back door. What do you want them to do? versed and fentanyl? propofol? they are already doing this and nerve blocks in the ER... Would you rather take care of every dislocated joint that comes through the door?

Are cardiologist against anesthesiologist using TEE?
Are radiologist against anesthesiologist using ultrasound?
Should we call the pulm guy for a bronchoscopy?

ER docs don't want to become anesthesiologist just as much as we don't want to be any other specialty but we share certain tools to treat patients.
Let them do their job and deal with the consequences.

 

[leaverus]

Are cardiologist against anesthesiologist using TEE?
Are radiologist against anesthesiologist using ultrasound?
Should we call the pulm guy for a bronchoscopy?

Those are not valid comparisons.
Am i asking the cardiologist to come teach me TEE? No.
Am i asking the radiologist to come to teach how to the use the ultrasound? No.
Am i calling the pulm guy to come teach me how to do a bronchoscopy? No.

Those guys can be against it all they want, but i learned from other anesthesiologists.

Are turnup's ER colleagues asking him to come teach them how to do what should strictly be an anesthesiologist's skillset? Yes.

 

[ProRealDoc]

Wondering if I could have your input.

I have been asked to speak to our ER dept about regional anesthesia. The dept uses a lot of ultrasound and are interested in nerve blocks. My plan is to teach them as I feel it is in their scope of practice but I will do so with a word of caution as they should not be taken lightly.

Also they need to check with their malpractice, hosptial privledges, and dept befor starting the blocks

What do you guys think? I did find a few artlces suggesting it can be done

.Blaivas.. M, Lyon M. Ultrasound-guided ..interscalene.. block for shoulder dislocation reduction in the ED. Am J ..Emerg.. Med. 2006;24:293–6. [..PubMed..].​

.Liebmann.. O, Price D, Mills C, Gardner R, Wang R, Wilson S, et al. Feasibility of forearm ..ultrasonography..-guided nerve blocks of the radial, ..ulnar.., and median nerves for hand procedures in the emergency department. Ann ..Emerg.. Med. 2006;48:558–62. [..PubMed..].​

.Ultrasound-guided nerve blocks in the emergency department. J ..Emerg.. Trauma Shock. 2010 Jan–Mar; 3(1): 82–88. .​

.Stone MB, Wang R, Price DD. Ultrasound-guided ..supraclavicular.. brachial plexus nerve block ..vs.. procedural sedation for the treatment of upper extremity emergencies. Am J ..Emerg.. Med. 2008;26:706–10. [..PubMed.

 

[dhb]

Those guys can be against it all they want, but i learned from other anesthesiologists.

How do you think the first anesthesiologist learned these skills?

 

[IlDestriero]

They are not going to take our jobs, but these blocks will take cases out of our ORs and $ out of our pockets. I wouldn't help anyone do that.

 

[leaverus]

How do you think the first anesthesiologist learned these skills?

I knew you'd ask me that. I'm pretty sure the first anesthesiologist learned from a CRNA because everyone knows that CRNAs were practicing anesthesia long before docs...

 

[2win]

I knew you'd ask me that. I'm pretty sure the first anesthesiologist learned from a CRNA because everyone knows that CRNAs were practicing anesthesia long before docs...

What about us practicing emergency medicine as a supplemental way to increase our income?
Are the ER docs ready to let us do it?
They push really hard for a critical care felllowship and they are already accepted.
They have already FP in ER taking shifts...
What about the radiology docs practicing pain medicine?
Is getting blurry out there...
Overall I am not ready to give away any knowledge or privileges only they can give us something back.

 

[monchi]

Even if you taught these ED physicians, are they prepared to deal with LA toxicity? Do they have a local anesthetic crash cart? If not, I would say they don't know even the very basics of regional.

What happens if the block doesn't work? Do they have anesthesia back-up 24/7 to trouble-shoot or place the difficult blocks? Even with anesthesia back-up, placing a block when one has already been attempted can be close to impossible.

 

[dhb]

I knew you'd ask me that. I'm pretty sure the first anesthesiologist learned from a CRNA because everyone knows that CRNAs were practicing anesthesia long before docs...

I knew you would answer that

 

[turnupthevapor]

I am going to use the lecture more of a showcase to show what we do.

Just so everyone knows the ER now does digital blocks (anyone complaining about this? How bout field blocks, or writs blocks...how bout ankle blocks?) these are similar no?

My hospitals ER also uses propofol to set shoulders...Although we feel we can do it better I am sure everyone agrees it is with in their scope of practice)

Remeber ER docs are DOCS! they went to the same schools you all went to and are not idiots! I agree they must respect the blocks but if you came from a program in anesthesia and weren't taught regional you can still learn on your own, right?

don't think this takes money our of our pockets. It is for management of acute pain not to do surgery in the ED!

 

[lane]

I am going to use the lecture more of a showcase to show what we do.

Just so everyone knows the ER now does digital blocks (anyone complaining about this? How bout field blocks, or writs blocks...how bout ankle blocks?) these are similar no?

My hospitals ER also uses propofol to set shoulders...Although we feel we can do it better I am sure everyone agrees it is with in their scope of practice)

Remeber ER docs are DOCS! they went to the same schools you all went to and are not idiots! I agree they must respect the blocks but if you came from a program in anesthesia and weren't taught regional you can still learn on your own, right?

don't think this takes money our of our pockets. It is for management of acute pain not to do surgery in the ED!

 

[2win]

I am going to use the lecture more of a showcase to show what we do.

Just so everyone knows the ER now does digital blocks (anyone complaining about this? How bout field blocks, or writs blocks...how bout ankle blocks?) these are similar no?

My hospitals ER also uses propofol to set shoulders...Although we feel we can do it better I am sure everyone agrees it is with in their scope of practice)

Remeber ER docs are DOCS! they went to the same schools you all went to and are not idiots! I agree they must respect the blocks but if you came from a program in anesthesia and weren't taught regional you can still learn on your own, right?

don't think this takes money our of our pockets. It is for management of acute pain not to do surgery in the ED!

So if they do all this stuff - why do they need a lecture from you?
Looks like the CRNA-s that "are equal with physicians" but they still need to be trained by us. Nobody said that ER docs are "idiots". Where did you get it from???
"but if you came from a program in anesthesia and weren't taught regional you can still learn on your own, right?" - it is almost - if you come from a program who didn't do intubations you can still learn on your own - isn't it?
"don't think this takes money our of our pockets. It is for management of acute pain not to do surgery in the ED" - any procedure/treatment that can be done by somebody else take money from your pocket.
So - do they let you at your hospital to take call in ER? Why not?

 

[usnavdoc]

I am going to use the lecture more of a showcase to show what we do.

Just so everyone knows the ER now does digital blocks (anyone complaining about this? How bout field blocks, or writs blocks...how bout ankle blocks?) these are similar no?

My hospitals ER also uses propofol to set shoulders...Although we feel we can do it better I am sure everyone agrees it is with in their scope of practice)

Remeber ER docs are DOCS! they went to the same schools you all went to and are not idiots! I agree they must respect the blocks but if you came from a program in anesthesia and weren't taught regional you can still learn on your own, right?

don't think this takes money our of our pockets. It is for management of acute pain not to do surgery in the ED!

I wouldnt teach them. There is enough encroachment into our specialty without helping it along in any capacity.

As an aside, what happens when they have their first cast of toxicity or a high block and a pt dies. Do you hold any responsibility legal or otherwise to their incompetance. Im sure they are going to say you taught them all they know. Im also sure that another anesthesiologist is willing to say this is not the standard of care. I dont know the answer to this but its something to think about.

 

[IlDestriero]

I don't understand why you would want to give this work away. If you have too much work to do, just hire someone. We do lots of closed reductions in the OR, if they can't be done with minimal sedation they go upstairs now or in the AM. I used to do some ketamine, etc in the ED as well at my old place. That was/is EASY money in my pocket.
It starts with shoulders and fingers, next you have pinnings in the procedure room. More lost loot for your group. The ortho guy will be pushing for that when the ED crew can give them blocks, don't doubt that for a second. They may even hire them to moonlight in their clinic to do blocks that you used to do. Don't think so? Why not? We used to do blocks for extremity procedures in our pain clinic. Block in, set up, checked and they went down to the ortho clinic for their surgery with a conscious sedation nurse. You're on a slippery slope, and I don't think you guys even see what could happen a couple years from now. Once they're cleared to do blocks, you've lost control and it will be too late to go back.
Why would any anesthesiologist want anything to do with this. Are you guys short sighted or just too lazy to help them out? You have to pick your battles, and I would fight this to the death, no question.

 

[Jay K]

Agree that it's not a good idea, out of their scope of practice and compromises patient safety. Re: dhb's comments about wanting to deal with every dislocation that comes into the ER; I understand this sentiment while in residency because your production and how hard you work does not directly affect your compensation, but it's a different story when you're in private. If a dislocation requires a consult by me for regional anesthesia then I would welcome all comers while I'm on service. I believe I would provide superior anesthetic services over an ER trained physician and a positive experience by the patient would also be great PR for the field.

TurnUp, would you mind telling us if you are in academia or on salary in your current position, where "less work" would not affect your compensation or group's position/politics/standing with the hospital?

 

[SleepIsGood]

I think TURNUP THE VAPOR is either getting paid to do this or is just having hallucinations.

either way, dont sell out the profession.

Man you've worked way too hard to get there. Once they learn the trade, you'll be the first person they'll try to circumvent.

 

[Planktonmd]

No one is saying ER Docs are inferior or are not doctors!
It's not the point, the point is that you have a trade, a set of skills and a special education that allows you to make a good living.
Why on earth do you want to teach others to do your job?
You had to go to a four years residency and suffer to learn how to become an anesthesiologist, why would you offer that knowledge and experience to others for free?
When are we going to understand the simple fact that in medicine IT IS about protecting your turf, every one does it, why shouldn't we?
Anyone who tells you that it's not about turf protection is either an idealistic dreamer or an idiot.

I am going to use the lecture more of a showcase to show what we do.

Just so everyone knows the ER now does digital blocks (anyone complaining about this? How bout field blocks, or writs blocks...how bout ankle blocks?) these are similar no?

My hospitals ER also uses propofol to set shoulders...Although we feel we can do it better I am sure everyone agrees it is with in their scope of practice)

Remeber ER docs are DOCS! they went to the same schools you all went to and are not idiots! I agree they must respect the blocks but if you came from a program in anesthesia and weren't taught regional you can still learn on your own, right?

don't think this takes money our of our pockets. It is for management of acute pain not to do surgery in the ED!

 

[Apollyon]

As an EM doc, if I called anesthesia for a ring block, I would be called in the office. I don't want to do regional. From my last place, I was there once when anesthesia was called for backup - for a difficult tube. My colleague did not have a secondary plan - he couldn't get it in with the laryngoscope, so called for backup. We got a CRNA - who used a bougie and followed the bubbles.

When I was a resident, anesthesia was called for an emergent airway once when I was working - the tube was in by the time the team (attending and resident) got there (between 2 and 3 minutes).

At my last shop, there was the university hospital, where general surgery would tube the traumas, and, if there was a problem, they would call anesthesia (I was there, but they never called me in the room). There were also two community hospitals and a stand-alone ED. At one of the community hospitals, ortho one day told me to do an intra-articular block for a reduction (as I'd never done it in training), but that was after he'd reduced it (that is, for future encounters)). At the other, I did the propofol sedation for ortho to do another reduction (which was it's own headache, as my FM-trained coworker doing the "fast track" side wasn't CS-credentialed, but I thought she was credentialed for reductions, but she was not "comfortable" with this straightforward anterior shoulder dislocation), and ortho was not only allowing, but happy for me to do the CS.

In one final case, I had a kid that was now a young adult that had something neuro going on and had needed sedation for MRI in the past, and still needed it (whatever). The anesthesiologist on duty, when I spoke with him, well, can I say he sounded flustered? He told me he was running 3 rooms, and couldn't do it (in his defense, he may have just been spazzy).

I don't want your job. If I did, I would have trained in it. Where I've been, anesthesia hasn't been busting down the doors to do these things for us, so I can see why some might want to do it - then, when there's a complication, they'll feel the heat. However, the same thing was said of endotracheal intubation, including the unrecognized hazards of esophageal intubation. That is something that anesthesiologists experienced in the OR, and ended up with brain damaged patients. I don't think anyone here is old enough to recall when oxygenation was gauged by the color of the blood, visually.

People either see anesthesia and EM as similar or dissimilar; I see them as similar. Critically ill patients, and procedure heavy, and, mostly, a straightforward and uninvolving caseload, with the occasional sphincter tightening moment. Whereas I have a bunch of patients at once, yours have their ability to protect themselves intentionally (in most cases) reduced, and, as such, you guys have a much lower provider-to-patient ratio.

There's enough work to go around without me adding to my workload.

 

[jwk]

I am going to use the lecture more of a showcase to show what we do.

Just so everyone knows the ER now does digital blocks (anyone complaining about this? How bout field blocks, or writs blocks...how bout ankle blocks?) these are similar no?

My hospitals ER also uses propofol to set shoulders...Although we feel we can do it better I am sure everyone agrees it is with in their scope of practice)

Remeber ER docs are DOCS! they went to the same schools you all went to and are not idiots! I agree they must respect the blocks but if you came from a program in anesthesia and weren't taught regional you can still learn on your own, right?

don't think this takes money our of our pockets. It is for management of acute pain not to do surgery in the ED!

Using your logic, they should be doing spinals and epidurals as well to reduce lower extremity fractures.

And you don't think it takes money out of your pocket? Are you serious?

 

[jwk]

I don't think anyone here is old enough to recall when oxygenation was gauged by the color of the blood, visually.

And you would be wrong. Routine SaO2 monitoring started in the early to mid 1980's. I started anesthesia school in 1979.

 

[Apollyon]

And you would be wrong. Routine SaO2 monitoring started in the early to mid 1980's. I started anesthesia school in 1979.

God's honest truth, I didn't think of you when I "ran the list" in my head while writing.

 

[SleepIsGood]

And you would be wrong. Routine SaO2 monitoring started in the early to mid 1980's. I started anesthesia school in 1979.

You man anesthesia assistant school.

Not a bad thing. Just making sure people aren't confused when reading your post.

 

[Planktonmd]

So we actually agree, You are not planning to become an anesthesiologist, so you don't need to learn ultrasound guided nerve blocks.

People either see anesthesia and EM as similar or dissimilar; I see them as similar. Critically ill patients, and procedure heavy, and, mostly, a straightforward and uninvolving caseload, with the occasional sphincter tightening moment. Whereas I have a bunch of patients at once, yours have their ability to protect themselves intentionally (in most cases) reduced, and, as such, you guys have a much lower provider-to-patient ratio.

There's enough work to go around without me adding to my workload.

 

[Apollyon]

So we actually agree, You are not planning to become an anesthesiologist, so you don't need to learn ultrasound guided nerve blocks.

Correct. If I can do it by landmarks, I'm going to keep doing it. If it's anything technical beyond that, no thanks - it's something that I shouldn't be doing (or need to do) in the ED.

 

[yasawa]

I am going to use the lecture more of a showcase to show what we do.

Just so everyone knows the ER now does digital blocks (anyone complaining about this? How bout field blocks, or writs blocks...how bout ankle blocks?) these are similar no?

My hospitals ER also uses propofol to set shoulders...Although we feel we can do it better I am sure everyone agrees it is with in their scope of practice)

Remeber ER docs are DOCS! they went to the same schools you all went to and are not idiots! I agree they must respect the blocks but if you came from a program in anesthesia and weren't taught regional you can still learn on your own, right?

don't think this takes money our of our pockets. It is for management of acute pain not to do surgery in the ED!

if they want management of acute pain, then consult the pain team. that's what my hosp does. Acute pain will come down with the fellow and resident and they will place the block. done and done.

Some anesthesiologists are brilliant physicians but extremely dumb business people. We are physician consultants. If they want our expert advice, then they will have to PAY us for it and WATCH as we place the blocks. dont willingly go and teach them. Its funny cause ER docs are all about doing procedures but the moment they have to medically manage pts they consult another service. Procedures are billable but spending 30mins working up a r/o stroke pt is not so they page the neurology service so they can waste their time talking to the pt (sorry, just bitter. I hated my month in the ER. the anesthesiology interns dont get to do a damn thing but be primary care docs while we watch the ER res struggle through intubations and line placements).

 

[Apollyon]

Some anesthesiologists are brilliant physicians but extremely dumb business people. We are physician consultants. If they want our expert advice, then they will have to PAY us for it and WATCH as we place the blocks. dont willingly go and teach them. Its funny cause ER docs are all about doing procedures but the moment they have to medically manage pts they consult another service. Procedures are billable but spending 30mins working up a r/o stroke pt is not so they page the neurology service so they can waste their time talking to the pt (sorry, just bitter. I hated my month in the ER. the anesthesiology interns dont get to do a damn thing but be primary care docs while we watch the ER res struggle through intubations and line placements).

You show your lack of knowledge about how things work. Why do docs in the ED call neurology for CVAs? Because time is brain, for one, and, secondly, in many systems, for TPA for CVA, the doc in the ED CAN'T give it (the question of not WANTING to give it is a separate one).

And you, as the anesthesiology intern, are better than everyone else at "primary care management"? When I was a resident at BNTH (Big Name Teaching Hospital), we were told to leave something for the medicine residents to do; patients were coming up completely worked up and just short of having a bow put on them. And you are better - as an intern - at intubating and starting central lines? Hubris, maybe?

 

[jwk]

God's honest truth, I didn't think of you when I "ran the list" in my head while writing.

What, you forget all about us old farts?

 

[yasawa]

You show your lack of knowledge about how things work. Why do docs in the ED call neurology for CVAs? Because time is brain, for one, and, secondly, in many systems, for TPA for CVA, the doc in the ED CAN'T give it (the question of not WANTING to give it is a separate one).

And you, as the anesthesiology intern, are better than everyone else at "primary care management"? When I was a resident at BNTH (Big Name Teaching Hospital), we were told to leave something for the medicine residents to do; patients were coming up completely worked up and just short of having a bow put on them. And you are better - as an intern - at intubating and starting central lines? Hubris, maybe?

First off, by "primary care" I mean all non admit pts who come in c/o of headaches or need BP meds refilled since they dont have insurance. Secondly, I said "r/o". all r/o CVAs, MIs etc get passed long. All MIs and CVAs go straight to the interventional teams anyways. The ED physicians dont even see them. Everything else is categorized I-III for rule outs. IIIs and sometimes IIs get passed along to the medical students in the ED to workup. These then get passed along to the medical teams who send down med students to workup. Trust me, I def dont have hubris but am pretty sure all the anesthesiology interns in my class are better at intubating than most ED interns and even residents. We spend 1 month on gen surg placing chest tubes and central lines and 2months of ICU placing more lines and intubating in addition to our month of anesthesia. So clearly at this point in the year based simply on numbers we have done more intubations and line placements than the avg ED resident. In addition to 2months of ICU as an M4 where we had a min of 20 central line placements/month on our check off list I do believe that I am probably a little bit better than the avg ED res.

 

[Arch Guillotti]

if they want management of acute pain, then consult the pain team. that's what my hosp does. Acute pain will come down with the fellow and resident and they will place the block. done and done.

Outside of academics, I am not sure there are too many pain teams out there.

 

[Lurch]

Geez, I wish I had gone to your medical school.

First off, by "primary care" I mean all non admit pts who come in c/o of headaches or need BP meds refilled since they dont have insurance. Secondly, I said "r/o". all r/o CVAs, MIs etc get passed long. All MIs and CVAs go straight to the interventional teams anyways. The ED physicians dont even see them. Everything else is categorized I-III for rule outs. IIIs and sometimes IIs get passed along to the medical students in the ED to workup. These then get passed along to the medical teams who send down med students to workup. Trust me, I def dont have hubris but am pretty sure all the anesthesiology interns in my class are better at intubating than most ED interns and even residents. We spend 1 month on gen surg placing chest tubes and central lines and 2months of ICU placing more lines and intubating in addition to our month of anesthesia. So clearly at this point in the year based simply on numbers we have done more intubations and line placements than the avg ED resident. In addition to 2months of ICU as an M4 where we had a min of 20 central line placements/month on our check off list I do believe that I am probably a little bit better than the avg ED res.

 

[Gimlet]

So clearly at this point in the year based simply on numbers we have done more intubations and line placements than the avg ED resident....I do believe that I am probably a little bit better than the avg ED res.

Which is exactly why the ED residents should be struggling through those intubations and line placements while you manage the other patients, right?

FTR, I'll be doing a couple of weeks of ICU in April with a medicine PGY3 as my senior resident who isn't "certified" in central lines yet, and therefore have been told that she gets priority on all lines that month. Not excited about that...but then again, I haven't gotten even a fraction of the experience with them that you have.

 

[leaverus]

Which is exactly why the ED residents should be struggling through those intubations and line placements while you manage the other patients.

Agree. Any monkey can be trained to do procedures - look at all the ****s doing it every day. Managing medical problems is what takes real skill & knowledge. Also, i too wish i had gone to yasawa's med school.

 

[cchoukal]

I'm a little perplexed why you'd need a nerve block for reducing a subluxed shoulder. Although it is painful before and during the reduction, after reduction, the pain goes down substantially. I'm not sure I could justify an hours-long block and the potential complications of the IS block for a minutes-long stimulation.

And I agree with what many others have said about teaching people to do the things that make your practice unique. There seems to be a fine line between playing nice and getting along with others to show that your group is a "team player" and an asset and giving away all your bargaining power, and I think this crosses that line.

 

[jd1572]

I would not show them how to do blocks. If your private practice group wants to present something like, "This is what our consult service can do for you", that might be OK. But please don't sell out the specialty.

Wondering if I could have your input.

I have been asked to speak to our ER dept about regional anesthesia. The dept uses a lot of ultrasound and are interested in nerve blocks. My plan is to teach them as I feel it is in their scope of practice but I will do so with a word of caution as they should not be taken lightly.

Also they need to check with their malpractice, hosptial privledges, and dept befor starting the blocks

What do you guys think? I did find a few artlces suggesting it can be done

.Blaivas.. M, Lyon M. Ultrasound-guided ..interscalene.. block for shoulder dislocation reduction in the ED. Am J ..Emerg.. Med. 2006;24:293–6. [..PubMed..].​

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.Liebmann.. O, Price D, Mills C, Gardner R, Wang R, Wilson S, et al. Feasibility of forearm ..ultrasonography..-guided nerve blocks of the radial, ..ulnar.., and median nerves for hand procedures in the emergency department. Ann ..Emerg.. Med. 2006;48:558–62. [..PubMed..].​

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.Ultrasound-guided nerve blocks in the emergency department. J ..Emerg.. Trauma Shock. 2010 Jan–Mar; 3(1): 82–88. .​

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Stone MB, Wang R, Price DD. Ultrasound-guided ..supraclavicular.. brachial plexus nerve block ..vs.. procedural sedation for the treatment of upper extremity emergencies. Am J ..Emerg.. Med. 2008;26:706–10. [..PubMed.

 

[sevo85288]

we don't own regional or any other type of anesthesia. if an ER doc wants to learn it, and a surgeon agrees to them doing it; and they consent the patient, then can go for it. no one owns anything in medicine. you can argue about the merits of it, but ER docs do all sorts of invasive things and regional nerve blocks are there for anyone to learn. they give GAs in the ER; so why are you guys against them giving regionals?

 

[keeping-it-real]

the anesthesia guys/gals need to take a breather and stop displacing your CRNA baggage onto the other physicians. i'm pretty sure that the ER and Anesthesia purviews aren't going to be crossing paths anytime soon, and i'm pretty sure that the ER guys/gals have a favorable opinion of most of the MDAs (irony mine) and aren't looking to take their gold and silver.

I agree with the previous post that there is likely little need for regional blocks for simple things like shoulder dislocations outside of some ASA IV nightmare that can't be positioned properly for some of the less painful reduction methods. That doesn't mean there is no role for learning some tips and tricks, though, to help in those more difficult situations.

You guys make pretty good money and it's obvious to everyone that you have an ongoing battle with the mid-levels. Trying to protect the few $$ that may be lost to the ER, though, is like worrying about physicians fees driving the exorbitant cost of healthcare. This battle is not where the war is being lost. Also, unlike the mid-levels, we're actually doctors too, and I would wager that many anesthesia and ER docs are pretty similarly minded and likely could've chosen and been capable of doing either field. We have nothing to prove to each other and certainly aren't looking to stake a claim in each other's turf.

Just as our use of ultrasound isn't meant to replace the radiologist, our use of regional anesthesia isn't meant as a stepping stone to taking over the OR. These are just tools. You guys need to calm down and redirect your efforts.

 

[IlDestriero]

the anesthesia guys/gals need to take a breather and stop displacing your CRNA baggage onto the other physicians.
...
You guys make pretty good money and it's obvious to everyone that you have an ongoing battle with the mid-levels. Trying to protect the few $$ that may be lost to the ER, though, is like worrying about physicians fees driving the exorbitant cost of healthcare. This battle is not where the war is being lost. Also, unlike the mid-levels, we're actually doctors too, and I would wager that many anesthesia and ER docs are pretty similarly minded and likely could've chosen and been capable of doing either field. We have nothing to prove to each other and certainly aren't looking to stake a claim in each other's turf.

Just as our use of ultrasound isn't meant to replace the radiologist, our use of regional anesthesia isn't meant as a stepping stone to taking over the OR. These are just tools. You guys need to calm down and redirect your efforts.

Sorry Chief,
I'm not going to help you learn to do something that I currently get paid to do. I don't care if you're a physician or not. If others want to give this work away they're short sighted. Once the Genie is out of the bottle, you never know where things will go, especially in smaller hospitals or rural areas. That is where things start, and than they spread. Just call us when you need a block. If we can't do it in your ED, send them to the OR. That's what happens at every place that I have worked/trained. It seems to work fine for everyone, including the patients. I don't know why you would want to be doing US guided blocks anyway, and I don't really care.
That's not displaced midlevel paranoia, that's keeping-it-real. I get paid to provide these services to the hospital, I think that I'll try to keep that exclusive arrangement. Thanks though.
I'll tell you something that I find interesting. I worked for a short time at a small community hospital. (not my kind of gig) The ED was usually really slow. Most of the ED docs there didn't want to do ANYTHING that we could do for them, regardless of what they were doing. IVCS, intubations, help with "monitoring/stabilizing" of critically ill asthma/COPD patients, etc. Our ICU was me in the PACU +/- the general surgeon while we waited for the helo/ambulance. It didn't matter what else was going on with us, they called anyway and complained if we were busy in the OR, etc. Even when they knew we were home in bed, they called. Of course, I didn't always come in...
I wonder how much of this relates to fee for service vs salary/per diem? Or just wanting more procedures, because you think that if you can, you should?
I got a call one day when I was 30 minutes out asking to come in to confirm an intubation that they were having problems with in a severe asthmatic patient, that was probably already dead. I said that if he had missed (about 10 minutes ago) he better get his act together and figure it out himself, and right now. It would be way too late by the time I arrived. I did call the (in-house) tech and had her take down the portable fiberoptic scope. She knew how to set it up and our RT was on the way in. They called about 15 minutes later and said "not to worry about it". I went in anyway to make sure that my name was NOT on the chart.

 

[Planktonmd]

All these cries for being nice to other doctors are great but that's not what happens in reality!
In reality medicine has become a cut throat business and if you flinch some one will take your money.
Only anesthesiologists have been a little slow to understand that turf battle. We gave away intensive care and pain medicine and now we are expected to give away regional anesthesia.

 

[igottaquestion]

Just as our use of ultrasound isn't meant to replace the radiologist,

ob/gyns read their own u/s for dating, etc. i don't know whether they had bad intentions toward radiologists, but it happened.

 

[leaverus]

That doesn't mean there is no role for learning some tips and tricks, though, to help in those more difficult situations.

The thread isn't about "tips and tricks." It's about an anesthesiologist considering teaching ER guys how to do full-blown U/S-guided peripheral nerve blocks. I'd say go for it if it was a mutually beneficial arrangement; but bottom-line is - what's the anesthesia dude getting out of it??

 

[turnupthevapor]

not sure I agree with any of you. But I do appreciate your input


I have never been called to manage acute pain in the ED and these blocks are not for cases that will be coming to the OR so it will not decrease the volume of blocks I do

thanks though