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

[epidural man]

I think it is unbelievable hilarious that others are worried about loosing practice to other physicians who learn a few skills we have.

GI docs aren't teaching colonoscopies to other physicians, because other physicians probably don't want to do them. If they did, they would have become a GI Doc. If other docs wanted to do anesthesia, and practice anesthesia - they would have become anesthesiologists.

It astounds me the fear people have about protecting knowledge. It is sad. Knowledge and skill should be easily passed around and shared. It makes the world better. It makes us all better. To say otherwise is strange, lacks compassion, foresight, and smacks at greed.

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[FollowTheMoney]

I think it is unbelievable hilarious that others are worried about loosing practice to other physicians who learn a few skills we have.

GI docs aren't teaching colonoscopies to other physicians, because other physicians probably don't want to do them. If they did, they would have become a GI Doc. If other docs wanted to do anesthesia, and practice anesthesia - they would have become anesthesiologists.

It astounds me the fear people have about protecting knowledge. It is sad. Knowledge and skill should be easily passed around and shared. It makes the world better. It makes us all better. To say otherwise is strange, lacks compassion, foresight, and smacks at greed.

Knowledge is literally your only asset. You have zero value without it. The more others know or learn your skills, the more expendable you become. Nurse anesthetists have gotten as far as they have from all the knowledge they have learned from us. No one would have thought nurses would be threatening our livelihood, yet here we are. I'm not saying they can handle advanced complex cases, but they can handle the majority of the routine cases and that's where the problem lies. We've gone from MD only to ACT and before you know it mid level independence. Why? Because idealistic people that think similarly to you have put us in this position and it's only going to get worse now that AMCs are in charge. At least before, they worked for you so it was never a problem and you could bill for their work.

 

[Carbocation1]

I think it is unbelievable hilarious that others are worried about loosing practice to other physicians who learn a few skills we have.

GI docs aren't teaching colonoscopies to other physicians, because other physicians probably don't want to do them. If they did, they would have become a GI Doc. If other docs wanted to do anesthesia, and practice anesthesia - they would have become anesthesiologists.

It astounds me the fear people have about protecting knowledge. It is sad. Knowledge and skill should be easily passed around and shared. It makes the world better. It makes us all better. To say otherwise is strange, lacks compassion, foresight, and smacks at greed.

LOL do you think we should be friends with ISIS too? Sounds like you're excited to dig your own grave.

 

[nimbus]

If an EM doctor wants to learn a block, it's probably because they see it as a solution to a problem they are encountering in the ER, not because they want to steal work from anesthesiologists. I have no desire to do emergency medicine and I'm pretty sure the ER docs have their hands full and don't want to add an anesthesia gig to the 40 hats they are already wearing. Like I said, I wished they would learn to do their own blood patches.

 

[IM2GI]

It's a slippery slope. EM docs will learn anesthesia, then GI docs will be next. Next thing you know, the anesthetic will be ordered by the surgeon to be carried out by the CRNA/McSleepy.

When will the ASA sack up and take control of the specialty?

I already do way more sedation than I want to be doing.

 

[Urzuz]

Yeah - I'd teach them.

It doesn't hurt our field - it never would. (in fact, it helps it...because no one wants to go to the ER and do a nerve block ...and this isn't taking patients from the OR in any stretch of the imagination).

See above. I work in a private practice and we do go to the ER and do nerve blocks.

If an EM doctor wants to learn a block, it's probably because they see as a a solution to a problem they are encountering in the ER, not because they want to steal work from anesthesiologists. I have no desire to do emergency medicine and I'm pretty sure the ER docs have their hands full and don't want to add an anesthesia gig to the 40 hats they are already wearing. Like I said, I wished they would learn to do their own blood patches.

It isn't about "stealing work," it is granting proficiency to others in something that distinguishes you from everyone else (and in a practical sense, they will take that proficiency and bill for it). Yes, you can also do a million other things that distinguish you from ED physicians, but this is one of those things in your domain.

Let me give you guys a small anecdote. Around a year or two back our general surgeons began doing ultrasound-guided TAP blocks in their hand-assisted colectomy patients. This is while the patient was UNDER ANESTHESIA, with a BOARD-CERTIFIED ANESTHESIOLOGIST sitting there watching them do it. Not a CRNA. Not a resident. We are an MD-only group. Now, let me ask you guys, why do you think they began doing that? Is it because they genuinely thought they could do a block better than me or anyone in our group (despite literally not knowing the names of the muscles that he was injecting between -- he had the audacity to ask me for the names of the muscle layers when another surgeon came by to watch him do it)? Or could it be because they wanted to squeeze some extra dollars out of the patient while they were already there? I'll let you decide. Another anecdote -- one of the neurosurgeons I work with wanted me to give a lecture to their NPs regarding pain management perioperatively. We usually get consulted for chronic or challenging pain management, and there was a noticeable improvement in outcomes when an anesthesiologist was involved, so he asked me to lecture them. My response? Um, no. You want my knowledge, you can consult me. I'm not going to give a one hour lecture to midlevel providers and have them prescribe potent medications like ketamine and methadone not knowing what the hell they're doing. To be clear, we bill for pain consultations and all blocks we do.

Anesthesiology is at a cross-roads now. I don't know what practice setting you guys work in, but with bundled payments and all the healthcare reform that is coming down the pipeline, including the buying and selling of anesthesia practices, showing one's value in a private practice system is as important as ever. Look no further than this whole perioperative surgical home nonsense. Despite how idiotic it is, increasing one's footprint in the hospital shows your relevance. If we have our trauma orthopods telling the administration that the anesthesiologists are providing a valuable service by putting fascia iliaca catheters in, or all the surgical specialties saying that we provide excellent chronic pain care, we are less likely to be replaced by a group of CRNAs or an AMC if they came in trying to undercut us. If you go and teach everyone the things that make you unique, you have just lost an opportunity to show your relevance in the hospital system (and, in turn, your income).

I know this may be radical thinking for some private practice groups, but in the climate we're in now, we felt like you can either evolve or get left in the 1990s, praying that administrators will view your intubation skills as a strong enough differentiation from the CRNAs across town chomping at the bit.

 

[FollowTheMoney]

See above. I work in a private practice and we do go to the ER and do nerve blocks.



It isn't about "stealing work," it is granting proficiency to others in something that distinguishes you from everyone else (and in a practical sense, they will take that proficiency and bill for it). Yes, you can also do a million other things that distinguish you from ED physicians, but this is one of those things in your domain.

Let me give you guys a small anecdote. Around a year or two back our general surgeons began doing ultrasound-guided TAP blocks in their hand-assisted colectomy patients. This is while the patient was UNDER ANESTHESIA, with a BOARD-CERTIFIED ANESTHESIOLOGIST sitting there watching them do it. Not a CRNA. Not a resident. We are an MD-only group. Now, let me ask you guys, why do you think they began doing that? Is it because they genuinely thought they could do a block better than me or anyone in our group (despite literally not knowing the names of the muscles that he was injecting between -- he had the audacity to ask me for the names of the muscle layers when another surgeon came by to watch him do it)? Or could it be because they wanted to squeeze some extra dollars out of the patient while they were already there? I'll let you decide. Another anecdote -- one of the neurosurgeons I work with wanted me to give a lecture to their NPs regarding pain management perioperatively. We usually get consulted for chronic or challenging pain management, and there was a noticeable improvement in outcomes when an anesthesiologist was involved, so he asked me to lecture them. My response? Um, no. You want my knowledge, you can consult me. I'm not going to give a one hour lecture to midlevel providers and have them prescribe potent medications like ketamine and methadone not knowing what the hell they're doing. To be clear, we bill for pain consultations and all blocks we do.

Anesthesiology is at a cross-roads now. I don't know what practice setting you guys work in, but with bundled payments and all the healthcare reform that is coming down the pipeline, including the buying and selling of anesthesia practices, showing one's value in a private practice system is as important as ever. Look no further than this whole perioperative surgical home nonsense. Despite how idiotic it is, increasing one's footprint in the hospital shows your relevance. If we have our trauma orthopods telling the administration that the anesthesiologists are providing a valuable service by putting fascia iliaca catheters in, or all the surgical specialties saying that we provide excellent chronic pain care, we are less likely to be replaced by a group of CRNAs or an AMC if they came in trying to undercut us. If you go and teach everyone the things that make you unique, you have just lost an opportunity to show your relevance in the hospital system (and, in turn, your income).

I know this may be radical thinking for some private practice groups, but in the climate we're in now, we felt like you can either evolve or get left in the 1990s, praying that administrators will view your intubation skills as a strong enough differentiation from the CRNAs across town chomping at the bit.

^^^ Now this is someone with a brain in their head AND common sense.

 

[deleted547339]

Most of the posts here are fantastical thinking about the boogie man. We (ER docs) aren't stealing your jobs, CRNAs are. You are highly trained professionals, start acting like it and being more confident in your self. Stop getting into silly arguments like this.

We don't want to take away your money/consults. If we're doing nerve blocks, it's not a question of "should I call anesthesia for a block, or should I do it myself?" It's a question of "is it better for the patient to use a ton of local and not get good anesthesia, or try a block?" I learned to be very adept at MSK US in residency and feel very comfortable doing an US guided median and posterior tibial nerve blocks (in addition to a few anatomic blocks). Our faculty who taught these skills had done an US fellowship and were very skillful in the technique.

I don't want to do epidurals, axillary or interscalene blocks, etc. I don't want to come up to the OR or the floor and do a nerve block. I don't want to take money out of anyone else's pockets. I want to simply provide good analgesia for someone who would otherwise have a very painful procedure then go home. If I had an anesthesia group that was happy to come down at 2AM to block all of my lacs, I'd be happy to consult them and put some money in their pocket. I'd happily never do a block again. But I've never known of a pain service that wants to get called at 2 in the morning for a lac repair on a drunk guy who got hit in the head with a beer bottle.

We're all doctors. We're all on the same team. There's plenty of midlevels, administrators, politicians and financial advisors trying to separate us from our money - the ER docs are not your competition. We're not trying to infringe on your specialty. We're talking about doing a relatively benign procedure that can help the patient in a patient that would otherwise not result in a consult for you.

 

[epidural man]

Most of the posts here are fantastical thinking about the boogie man. We (ER docs) aren't stealing your jobs, CRNAs are. You are highly trained professionals, start acting like it and being more confident in your self. Stop getting into silly arguments like this.

We don't want to take away your money/consults. If we're doing nerve blocks, it's not a question of "should I call anesthesia for a block, or should I do it myself?" It's a question of "is it better for the patient to use a ton of local and not get good anesthesia, or try a block?" I learned to be very adept at MSK US in residency and feel very comfortable doing an US guided median and posterior tibial nerve blocks (in addition to a few anatomic blocks). Our faculty who taught these skills had done an US fellowship and were very skillful in the technique.

I don't want to do epidurals, axillary or interscalene blocks, etc. I don't want to come up to the OR or the floor and do a nerve block. I don't want to take money out of anyone else's pockets. I want to simply provide good analgesia for someone who would otherwise have a very painful procedure then go home. If I had an anesthesia group that was happy to come down at 2AM to block all of my lacs, I'd be happy to consult them and put some money in their pocket. I'd happily never do a block again. But I've never known of a pain service that wants to get called at 2 in the morning for a lac repair on a drunk guy who got hit in the head with a beer bottle.

We're all doctors. We're all on the same team. There's plenty of midlevels, administrators, politicians and financial advisors trying to separate us from our money - the ER docs are not your competition. We're not trying to infringe on your specialty. We're talking about doing a relatively benign procedure that can help the patient in a patient that would otherwise not result in a consult for you.

How do I like this post twice?

 

[epidural man]

Knowledge is literally your only asset. You have zero value without it. The more others know or learn your skills, the more expendable you become. Nurse anesthetists have gotten as far as they have from all the knowledge they have learned from us. No one would have thought nurses would be threatening our livelihood, yet here we are. I'm not saying they can handle advanced complex cases, but they can handle the majority of the routine cases and that's where the problem lies. We've gone from MD only to ACT and before you know it mid level independence. Why? Because idealistic people that think similarly to you have put us in this position and it's only going to get worse now that AMCs are in charge. At least before, they worked for you so it was never a problem and you could bill for their work.

I was wondering if you could do something for me.

Post some articles by well respected sources that demonstrate, or make a good argument for hoarding knowledge (in any field) rather than share it. After you do that, I'll post some research on the opposite idea.

 

[GravelRider]

I wonder if the people worried about EM docs "stealing" blocks did a regional fellowship?

Of all the difficulties facing anesthesia, this one is way low down on the list...if even on that list at all. We have practices literally training our cheaper and more easily controlled replacements and we're worried about an EM doc treating his or her patient?

 

[IlDestriero]

Why is it that anesthesiologists have the least common sense of any medical profession? Teaching nurses and other doctors how to do your job is idiotic, but I guess that never occurred to anyone. Why would you give away the only value you have? If we didn't have people trying to take our jobs or business, we would have a much better job market and much more job security. I don't see any other specialty going out of their way to train people outside of their profession to do their job.

We teach the sedation team because we don't have the time or resources to do all the sedation cases, and many are done in the evening when nobody wants to work. And they pay us a lot of money. Not my decision, but that's why. And the hospital wants the sedation service. So we either play nice or cause big problems for ourselves and they'd probably carry on without us anyway.


--
Il Destriero

 

[Urzuz]

Most of the posts here are fantastical thinking about the boogie man. We (ER docs) aren't stealing your jobs, CRNAs are. You are highly trained professionals, start acting like it and being more confident in your self. Stop getting into silly arguments like this.

We don't want to take away your money/consults. If we're doing nerve blocks, it's not a question of "should I call anesthesia for a block, or should I do it myself?" It's a question of "is it better for the patient to use a ton of local and not get good anesthesia, or try a block?" I learned to be very adept at MSK US in residency and feel very comfortable doing an US guided median and posterior tibial nerve blocks (in addition to a few anatomic blocks). Our faculty who taught these skills had done an US fellowship and were very skillful in the technique.

I don't want to do epidurals, axillary or interscalene blocks, etc. I don't want to come up to the OR or the floor and do a nerve block. I don't want to take money out of anyone else's pockets. I want to simply provide good analgesia for someone who would otherwise have a very painful procedure then go home. If I had an anesthesia group that was happy to come down at 2AM to block all of my lacs, I'd be happy to consult them and put some money in their pocket. I'd happily never do a block again. But I've never known of a pain service that wants to get called at 2 in the morning for a lac repair on a drunk guy who got hit in the head with a beer bottle.

We're all doctors. We're all on the same team. There's plenty of midlevels, administrators, politicians and financial advisors trying to separate us from our money - the ER docs are not your competition. We're not trying to infringe on your specialty. We're talking about doing a relatively benign procedure that can help the patient in a patient that would otherwise not result in a consult for you.

I wonder if the people worried about EM docs "stealing" blocks did a regional fellowship?

Of all the difficulties facing anesthesia, this one is way low down on the list...if even on that list at all. We have practices literally training our cheaper and more easily controlled replacements and we're worried about an EM doc treating his or her patient?

I think you guys are both completely missing the point and focusing on the wrong part of the argument against teaching others our skills. I don't think anyone here is saying that EM physicians pose a bigger "threat" to our practice than CRNAs do, or that EM physicians are even on the "threat list". That being said, going out of our way to train people in a unique skillset that we offer is idiotic, plain and simple.

As it is everyone thinks they can do anesthesia and everyone thinks they understand the nuances of it (surgeons recommending LMA vs intubation for patients, GI physicians administering propofol, [cardiologist administering propofol in a residential home?!], CRNAs practicing solo in BFE without an anesthesiologist in sight, etc.). In this case, people think that they can take a weekend course in ultrasound-guided regional anesthesia and suddenly they are capable of sticking needles into any part of the body. Why would any self-respecting anesthesiologist want to be a part of that? Ethically, would you want someone who has learned how to do a block in a weekend course to be sticking needles in your grandmother?

And I go back to, why in God's name would anyone willingly take the time and effort to go educate someone properly on how to do the things that make us unique? While we're at it, why don't we give the GI guys pointers on running propofol sedation as well? Per your guys' argument, they are also physicians, and I don't know a single anesthesia group that wants to do a colonoscopy at 6pm on a Friday. They are giving midazolam and fentanyl anyway, so let us go and educate them on how to safely and properly administer a better anesthetic. Have some pride in your work and recognize that enough of our practice has been eroded by people thinking anesthesiology is so straightforward and easy that they can do it as well. It is a slippery slope. Teaching ER physicians blocks may not be a big deal in the grand scheme of things, but over time teaching people more and more about what makes you unique can add up.

In fact, with CRNAs -- do you think that the first anesthesiologist who taught a CRNA how to perform a safe anesthetic, intubate properly, basic physiology, etc ever would have dreamed the problem would have ballooned into what it is today? "They just want to learn how to do a direct laryngoscopy. It is just an arterial line. I'm sure showing them how to do a fiberoptic bronchoscope can't be that big of a deal". It is absolutely insane to me that despite how much people effort people spend in bemoaning the CRNA situation, they will turn around and advocate for giving away more of our practice knowledge to others. Maybe it is because I'm relatively young and want to preserve the future of my specialty selfishly for myself, or for the anesthesiology residents in training, and you guys are older and don't care as much. I'm not quite sure.

TimesNewRoman, I have no idea what practice setting you work in, but if you don't think that your fellow EM colleagues around the country want to bill for ultrasound-guided blocks that they perform to reduce a shoulder, you are completely naive to the business of medicine.

As others have said, I could care less if you are doing blocks in the ED. Be my guest, I don't care. Just don't think I am going to take time to put together a course on how to properly do blocks for you.

 

[pgg]

Next time I see a CT surgeon and cardiologist doing a TAVR side by side, I'll ask them WTF they think they're doing, sharing knowledge with their competition.

 

[GravelRider]

I think you guys are both completely missing the point and focusing on the wrong part of the argument against teaching others our skills. I don't think anyone here is saying that EM physicians pose a bigger "threat" to our practice than CRNAs do, or that EM physicians are even on the "threat list". That being said, going out of our way to train people in a unique skillset that we offer is idiotic, plain and simple.

As it is everyone thinks they can do anesthesia and everyone thinks they understand the nuances of it (surgeons recommending LMA vs intubation for patients, GI physicians administering propofol, [cardiologist administering propofol in a residential home?!], CRNAs practicing solo in BFE without an anesthesiologist in sight, etc.). In this case, people think that they can take a weekend course in ultrasound-guided regional anesthesia and suddenly they are capable of sticking needles into any part of the body. Why would any self-respecting anesthesiologist want to be a part of that? Ethically, would you want someone who has learned how to do a block in a weekend course to be sticking needles in your grandmother?

And I go back to, why in God's name would anyone willingly take the time and effort to go educate someone properly on how to do the things that make us unique? While we're at it, why don't we give the GI guys pointers on running propofol sedation as well? Per your guys' argument, they are also physicians, and I don't know a single anesthesia group that wants to do a colonoscopy at 6pm on a Friday. They are giving midazolam and fentanyl anyway, so let us go and educate them on how to safely and properly administer a better anesthetic. Have some pride in your work and recognize that enough of our practice has been eroded by people thinking anesthesiology is so straightforward and easy that they can do it as well. It is a slippery slope. Teaching ER physicians blocks may not be a big deal in the grand scheme of things, but over time teaching people more and more about what makes you unique can add up.

In fact, with CRNAs -- do you think that the first anesthesiologist who taught a CRNA how to perform a safe anesthetic, intubate properly, basic physiology, etc ever would have dreamed the problem would have ballooned into what it is today? "They just want to learn how to do a direct laryngoscopy. It is just an arterial line. I'm sure showing them how to do a fiberoptic bronchoscope can't be that big of a deal". It is absolutely insane to me that despite how much people effort people spend in bemoaning the CRNA situation, they will turn around and advocate for giving away more of our practice knowledge to others. Maybe it is because I'm relatively young and want to preserve the future of my specialty selfishly for myself, or for the anesthesiology residents in training, and you guys are older and don't care as much. I'm not quite sure.

TimesNewRoman, I have no idea what practice setting you work in, but if you don't think that your fellow EM colleagues around the country want to bill for ultrasound-guided blocks that they perform to reduce a shoulder, you are completely naive to the business of medicine.

As others have said, I could care less if you are doing blocks in the ED. Be my guest, I don't care. Just don't think I am going to take time to put together a course on how to properly do blocks for you.

How do you know it was an anesthesiologist teaching the EM doc how to do regional blocks? Maybe it was a textbook and few YouTube videos. That's how a lot of anesthesiologists learn them.

Should the cardiologists be complaining about anesthesiologists using TEE in the OR? Maybe the next time you throw a bronchoscope down to check the placement of a double lumen tube, you should consult a pulmonologist. How about if you give insulin during a case...shouldn't you be consulting endocrine? Heck, why don't we have infectious disease administer all the pre-op cefazolin?

 

[IM2GI]

I like how this thread presumes that a 1 hour lecture is enough to teach someone how to do a specialized procedure that people spend an entire fellowship learning how to do properly and safely.

 

[deleted547339]

I think you guys are both completely missing the point and focusing on the wrong part of the argument against teaching others our skills. I don't think anyone here is saying that EM physicians pose a bigger "threat" to our practice than CRNAs do, or that EM physicians are even on the "threat list". That being said, going out of our way to train people in a unique skillset that we offer is idiotic, plain and simple.

As it is everyone thinks they can do anesthesia and everyone thinks they understand the nuances of it (surgeons recommending LMA vs intubation for patients, GI physicians administering propofol, [cardiologist administering propofol in a residential home?!], CRNAs practicing solo in BFE without an anesthesiologist in sight, etc.). In this case, people think that they can take a weekend course in ultrasound-guided regional anesthesia and suddenly they are capable of sticking needles into any part of the body. Why would any self-respecting anesthesiologist want to be a part of that? Ethically, would you want someone who has learned how to do a block in a weekend course to be sticking needles in your grandmother?

And I go back to, why in God's name would anyone willingly take the time and effort to go educate someone properly on how to do the things that make us unique? While we're at it, why don't we give the GI guys pointers on running propofol sedation as well? Per your guys' argument, they are also physicians, and I don't know a single anesthesia group that wants to do a colonoscopy at 6pm on a Friday. They are giving midazolam and fentanyl anyway, so let us go and educate them on how to safely and properly administer a better anesthetic. Have some pride in your work and recognize that enough of our practice has been eroded by people thinking anesthesiology is so straightforward and easy that they can do it as well. It is a slippery slope. Teaching ER physicians blocks may not be a big deal in the grand scheme of things, but over time teaching people more and more about what makes you unique can add up.

In fact, with CRNAs -- do you think that the first anesthesiologist who taught a CRNA how to perform a safe anesthetic, intubate properly, basic physiology, etc ever would have dreamed the problem would have ballooned into what it is today? "They just want to learn how to do a direct laryngoscopy. It is just an arterial line. I'm sure showing them how to do a fiberoptic bronchoscope can't be that big of a deal". It is absolutely insane to me that despite how much people effort people spend in bemoaning the CRNA situation, they will turn around and advocate for giving away more of our practice knowledge to others. Maybe it is because I'm relatively young and want to preserve the future of my specialty selfishly for myself, or for the anesthesiology residents in training, and you guys are older and don't care as much. I'm not quite sure.

TimesNewRoman, I have no idea what practice setting you work in, but if you don't think that your fellow EM colleagues around the country want to bill for ultrasound-guided blocks that they perform to reduce a shoulder, you are completely naive to the business of medicine.

As others have said, I could care less if you are doing blocks in the ED. Be my guest, I don't care. Just don't think I am going to take time to put together a course on how to properly do blocks for you.

This type of attitude is what makes me hate medicine sometimes.

 

[Mman]

I like how this thread presumes that a 1 hour lecture is enough to teach someone how to do a specialized procedure that people spend an entire fellowship learning how to do properly and safely.

To be fair, if you need a fellowship to learn how to do a peripheral nerve block properly and safely you probably should have chosen a different residency program.

 

[IM2GI]

To be fair, if you need a fellowship to learn how to do a peripheral nerve block properly and safely you probably should have chosen a different residency program.

I guess my point is, if you can really learn how to do it from a powerpoint, it probably is not that big of a "secret sauce."

 

[Southpaw]

I guess my point is, if you can really learn how to do it from a powerpoint, it probably is not that big of a "secret sauce."

I see both sides of the argument here, but we should both agree that no one should be doing nerve blocks after watching a power point. While it may not appear overly complex, things can certainly go wrong. I'm sure that my attendings had some pretty severe hypertension teaching me how to do nerve blocks when I was a junior resident, unable to find the needle, and not terribly respectful of a hidden vascular structure here or there.

Lots of surgeries aren't terribly complex in nature but that doesn't mean they should be performed by untrained hands. All that being said, ED docs should free to do as they please with their patients in their department. I'm happy to help you guys out whenever I'm called, however rare that is.

 

[Urzuz]

Next time I see a CT surgeon and cardiologist doing a TAVR side by side, I'll ask them WTF they think they're doing, sharing knowledge with their competition.

You should ask the CT surgeons what they think about cardiologists doing TAVRs when there aren't any cardiologists around. Or ask a neurosurgeon what they think about ortho doing spine, or ask radiologists about neurosurgeons doing interventional radiology procedures. The answers may surprise you!

How do you know it was an anesthesiologist teaching the EM doc how to do regional blocks? Maybe it was a textbook and few YouTube videos. That's how a lot of anesthesiologists learn them.

Should the cardiologists be complaining about anesthesiologists using TEE in the OR? Maybe the next time you throw a bronchoscope down to check the placement of a double lumen tube, you should consult a pulmonologist. How about if you give insulin during a case...shouldn't you be consulting endocrine? Heck, why don't we have infectious disease administer all the pre-op cefazolin?

The original post in this thread was about an anesthesiologist who was asked to lecture the ED docs regarding blocks. That is what I was basing all my posts on.

And regarding your examples, how many other specialists have willingly taught you anything unique to their practice? I'm not talking about in residency. I'm talking about in the real word, where you are looking for proficiency in something that they make their livelihood from. How many cardiologists have you had taking time out of their day to teach you TEE, or pulmonary docs teaching you about fiberoptic bronchoscopes?

This type of attitude is what makes me hate medicine sometimes.

You know, I agree with you. I hate having this attitude as well, and it sucks that this is the way it is. But unfortunately circumstances beyond any of our control has created a really &$@" environment to practice medicine. Anesthesiology especially is at a crossroads where we have to do everything to preserve our practice environment. How many other specialties are needing to reinvent themselves through bull#*&$ like the Periop Surgical Home? That's right, NONE. Only our specialty. So sorry if some of us are a little sensitive to people encroaching on our territory. We have played this game once before and it's come back to **** us royally.

 

[IM2GI]

I see both sides of the argument here, but we should both agree that no one should be doing nerve blocks after watching a power point. While it may not appear overly complex, things can certainly go wrong. I'm sure that my attendings had some pretty severe hypertension teaching me how to do nerve blocks when I was a junior resident, unable to find the needle, and not terribly respectful of a hidden vascular structure here or there.

Lots of surgeries aren't terribly complex in nature but that doesn't mean they should be performed by untrained hands. All that being said, ED docs should free to do as they please with their patients in their department. I'm happy to help you guys out whenever I'm called, however rare that is.

Yea in general I think we should stick to our core competencies despite what our license gives us privileges to do. I definitely see both sides, but the initial vitriol that this guy got for saying he was going to give a talk was a bit extreme. Giving a talk on how to do something is far different than mentoring/teaching someone to be competent.

 

[anbuitachi]

it's idealistic vs realistic. ideally we should all be helping each other out and improving patient care as a whole. realistically, we all need a job, and someone else billing for a procedure that is in your specialty means less work for you, which will probably eventually put some anesthesiologist some where out of a job and they will have to watch their kids starve to death. this happens in every specialty.

 

[deleted547339]

it's idealistic vs realistic. ideally we should all be helping each other out and improving patient care as a whole. realistically, we all need a job, and someone else billing for a procedure that is in your specialty means less work for you, which will probably eventually put some anesthesiologist some where out of a job and they will have to watch their kids starve to death. this happens in every specialty.

No. You're just wrong. No one would ever consult anesthesia for a peripheral nerve block for a lac repair in the ED. You're comparing apples and oranges.

This isn't interventional cards taking away cabgs or valves from CT surgeons. This is expanding the pool of patients.

 

[anbuitachi]

No. You're just wrong. No one would ever consult anesthesia for a peripheral nerve block for a lac repair in the ED. You're comparing apples and oranges.

This isn't interventional cards taking away cabgs or valves from CT surgeons. This is expanding the pool of patients.

Sure, so what exactly are anesthesiologists teaching ED docs to do if ED docs already know how to do them?

 

[B-Bone]

This whole discussion is apropos for my group right now. Our orthopods have decided that they want all their hip fracture patients to have fascia iliaca blocks (done by us) in the ED when they show up, whether they're having surgery that day or not. It's gonna be a huge pain in the ass while covering the OR and OB on call, but we're sucking it up and making it work. Trying to "be good physician partners" and "demonstrate value". Sometimes it's these little things that can add up once contract time comes around with the hospitals.


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[nimbus]

This whole discussion is apropos for my group right now. Our orthopods have decided that they want all their hip fracture patients to have fascia iliaca blocks (done by us) in the ED when they show up, whether they're having surgery that day or not. It's gonna be a huge pain in the ass while covering the OR and OB on call, but we're sucking it up and making it work. Trying to "be good physician partners" and "demonstrate value". Sometimes it's these little things that can add up once contract time comes around with the hospitals.


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Teach the ER guys, or better still the orthopods how to do it so it can be their pain in the ass

At the least you guys can ask to have an ultrasound, block cart, consent ready to sign at the bedside before you are called. Just like a labor epidural. Then you can be in and out. Better still you can have the patients brought to you in preop holding or pacu.

 

[cleansocks]

A push to disseminate the basics to "the masses" is a sign that regional has become a lot more complex and warrants the designation "subspecialty." This happens with every single complicated, difficult profession. It is a good sign. And it can't be stopped. All we can do for job security is to continue advancing the profession. Regional is one of the coolest and fastest growing branches of anesthesia, and I think regional fellows of all anesthesiologists have the least to fear about others doing the basic blocks.

I also agree that people are selfish *ssholes that screw others over for petty, disgusting reasons so I see why there is a lot of worry.

 

[deleted547339]

Sure, so what exactly are anesthesiologists teaching ED docs to do if ED docs already know how to do them?

I'm not saying all, or even many, do. Most practicing EM docs aren't comfortable with US. I'm saying I feel comfortable doing a couple. If you go out to a community hospital where the newest grad is >5 years from residency, I'd be shocked if any knew how to do an US guided block.

Also, I'm not an US guru. I saw a lot of utility in US for lines and blocks, so I learned that. I know some of my residency colleagues loved US and can do full gallbladder US, can diagnose diastolic dysfunction, etc. I'm not about that. And some of those ARE taking money out of the radiologists pockets. That's a different conversation, though.

 

[anbuitachi]

A push to disseminate the basics to "the masses" is a sign that regional has become a lot more complex and warrants the designation "subspecialty." This happens with every single complicated, difficult profession. It is a good sign. And it can't be stopped. All we can do for job security is to continue advancing the profession. Regional is one of the coolest and fastest growing branches of anesthesia, and I think regional fellows of all anesthesiologists have the least to fear about others doing the basic blocks.

I also agree that people are selfish *ssholes that screw others over for petty, disgusting reasons so I see why there is a lot of worry.

Not when CRNAs get a hold of it. Then it becomes 'easy' and doesn't need a subspecialty

 

[anbuitachi]

To be fair, if you need a fellowship to learn how to do a peripheral nerve block properly and safely you probably should have chosen a different residency program.

I dont know dood. To get good #s in residency is not easy these days with growing # of residents, and stress w finances. Many programs have 20+ per year now of residents. You'd have to do a ton of cases to give every resident a lot of blocks. It's not like PP where they do 50 knees in one day. It's even harder when attendings are double covering and having to give other attendings breaks on top of it, or also covering 25 PACU patients.

I mean the majority of residents will graduate proficient in common blocks ... off the top of my head, interscallene, supraclav, infra, axillary, adductor, pop, femoral, tap are the ones everyone will have done many times. But depending on where you at, others can be much harder to come buy, including catheter insertions, QL, ES, paravert, pec blocks, serratus, etc . Especially also depends on type of surgeons you have. Even thoracic epidurals, many residents dont top 50, especially with so many regional fellowships where fellows will have first dibs in many blocks

Obviously many programs offer electives to do additional regional months so there is that option.

 

[deleted171991]

I like how this thread presumes that a 1 hour lecture is enough to teach someone how to do a specialized procedure that people spend an entire fellowship learning how to do properly and safely.

Some "specialized procedures" require one hour of teaching and 10-20 supervised procedures. It's not rocket science. Do you need a fellowship for most regional blocks? Nope.

 

[deleted171991]

I dont know dood. To get good #s in residency is not easy these days with growing # of residents, and stress w finances. Many programs have 20+ per year now of residents. You'd have to do a ton of cases to give every resident a lot of blocks. It's not like PP where they do 50 knees in one day. It's even harder when attendings are double covering and having to give other attendings breaks on top of it, or also covering 25 PACU patients.

I mean the majority of residents will graduate proficient in common blocks ... off the top of my head, interscallene, supraclav, infra, axillary, adductor, pop, femoral, tap are the ones everyone will have done many times. But depending on where you at, others can be much harder to come buy, including catheter insertions, QL, ES, paravert, pec blocks, serratus, etc . Especially also depends on type of surgeons you have. Even thoracic epidurals, many residents dont top 50, especially with so many regional fellowships where fellows will have first dibs in many blocks

Obviously many programs offer electives to do additional regional months so there is that option.

You don't get to do those blocks because nobody gives a crap about most of them in PP. And even if they do, how complicated is to learn most of them? Read up, watch three, do three under supervision. It will take a lot of repetition to get to do them fast (and to decrease failure rates), but speed is not such a big deal in most places if not done in the OR.

 

[deleted171991]

This whole discussion is apropos for my group right now. Our orthopods have decided that they want all their hip fracture patients to have fascia iliaca blocks (done by us) in the ED when they show up, whether they're having surgery that day or not. It's gonna be a huge pain in the ass while covering the OR and OB on call, but we're sucking it up and making it work. Trying to "be good physician partners" and "demonstrate value". Sometimes it's these little things that can add up once contract time comes around with the hospitals.


Sent from my iPhone using SDN mobile app

It's an upcoming Medicare quality measure. It's not just you. I have also heard about it.

 

[anbuitachi]

You don't get to do those blocks because nobody gives a crap about most of them in PP. And even if they do, how complicated is to learn most of them? Read up, watch three, do three under supervision. It will take a lot of repetition to get to do them fast (and to decrease failure rates), but speed is not such a big deal in most places if not done in the OR.

pretty complicated. takes a lot of experience to get used to the anatomy and doing them on diff types of patients. like above people said, would you like to have your blocks done by someone whos watched 3 and done 3?

And those blocks may become increasingly important as we are getting preliminary data on effects of volatiles/opioids on cancer recurrences etc, and moving to ERAs for everything. And how payment is going toward value based w metrics. We seem to be moving more toward regional and TIVA.

 

[deleted171991]

pretty complicated. takes a lot of experience to get used to the anatomy and doing them on diff types of patients. like above people said, would you like to have your blocks done by someone whos watched 3 and done 3?

The bean counters would disagree.

And yes, that's exactly how I learned some of the blocks I do in PP.

 

[Mman]

I dont know dood. To get good #s in residency is not easy these days with growing # of residents, and stress w finances. Many programs have 20+ per year now of residents. You'd have to do a ton of cases to give every resident a lot of blocks. It's not like PP where they do 50 knees in one day. It's even harder when attendings are double covering and having to give other attendings breaks on top of it, or also covering 25 PACU patients.

I mean the majority of residents will graduate proficient in common blocks ... off the top of my head, interscallene, supraclav, infra, axillary, adductor, pop, femoral, tap are the ones everyone will have done many times. But depending on where you at, others can be much harder to come buy, including catheter insertions, QL, ES, paravert, pec blocks, serratus, etc . Especially also depends on type of surgeons you have. Even thoracic epidurals, many residents dont top 50, especially with so many regional fellowships where fellows will have first dibs in many blocks

Obviously many programs offer electives to do additional regional months so there is that option.

That's why I said pick a different residency program. I realize not all residency programs are excellent. I was able to do several months of regional anesthesia and put in more crazy blocks and catheters than I can count and that was a very useful skill to have transitioning to private practice.

 

[nimbus]

Not when CRNAs get a hold of it. Then it becomes 'easy' and doesn't need a subspecialty

Most blocks actually are "easy" and don't need a subspecialty. I see no reason why a CRNA or an ER doc or anybody else couldn't learn them. Review the pertinent anatomy and literature, watch a couple videos or live demos, do a couple with someone who knows what they are doing (for tips), then you're good to go.

 

[BLADEMDA]

Most blocks actually are "easy" and don't need a subspecialty. I see no reason why a CRNA or an ER doc or anybody else couldn't learn them. Review the pertinent anatomy and literature, watch a couple videos or live demos, do a couple with someone who knows what they are doing (for tips), then you're good to go.

Once you learn how to use the U/S properly and have performed several hundred blocks it should be relatively easy to transition to other U/S guided blocks. That's the whole point of medical school and residency: to prepare you for change/learn new things.

I've had no problem doing each and every "new block" that come along every few years.

 

[Robotic Wis-Hipple]

I can see both sides honestly, but I think the EM folks are quite a progressive bunch and they see a lot of writing on the wall regarding the way they are being treated as a commodity much like we are and choose to adapt and improve their service fairly aggressively. So while I can sort of see the slippery slope argument and the discomfort in actively teaching your ED how to do US blocks like an IS/SC, outside of that I think you have to respect their drive. These are the same guys that are essentially creating their own echo board (CCM as well) because the NBE (which isn't actually a board tbh) isn't really catering to their needs. Now should I be pissed because that's my turf? Or should I just gloat in the fact that I stole it from cardiology first?

I mean come on, how many Regional guys wanna be called after 4pm? I just don't see many Anesthesiologists being stoked to run down to the ED everytime a dislocated shoulder walks in. Now B-Bone's situation is more a service line issue and I 100% think anesthesia should be doing those blocks.

 

[nimbus]

I can see both sides honestly, but I think the EM folks are quite a progressive bunch and they see a lot of writing on the wall regarding the way they are being treated as a commodity much like we are and choose to adapt and improve their service fairly aggressively. So while I can sort of see the slippery slope argument and the discomfort in actively teaching your ED how to do US blocks like an IS/SC, outside of that I think you have to respect their drive. These are the same guys that are essentially creating their own echo board (CCM as well) because the NBE (which isn't actually a board tbh) isn't really catering to their needs. Now should I be pissed because that's my turf? Or should I just gloat in the fact that I stole it from cardiology first?

I mean come on, how many Regional guys wanna be called after 4pm? I just don't see many Anesthesiologists being stoked to run down to the ED everytime a dislocated shoulder walks in. Now B-Bone's situation is more a service line issue and I 100% think anesthesia should be doing those blocks.

They are progressive. And like they've had their own airway experts for years, I guarantee they will develop their own regional anesthesia experts and the useful blocks will be taught at their training programs and CME meetings. It doesn't matter if we teach them or not. They will learn it. It's good for the patients. I applaud them.

Regional Anesthesia an Alternative to Opioids in the Emergency Department - ACEP Now

 

[epidural man]

I think you guys are both completely missing the point ....

Uhh....

You've heard the saying "while pointing a finger, there are three pointing back at you" right?

No one is saying an ER physician is going to learn the vast knowledge, skill set, and nuances required to successfully place a needle under ultrasound guidance around a nerve bundle - in a weekend. That is a ludicrous idea for sure.

However, ER physicians already know a tremendous amount about ultrasound technology, knobology, and ultrasound diagnostics, and ultrasound guided procedures. They have led the way (with exception to radiologists of course) in bedside ultrasonography. They have that part down.

The have plenty of knowledge about local anesthetics, and have great procedural skills. This is not new to them.

They just want a little help connecting these dots - which is a very small leap for them.

I have placed the needled next to nerve bundles plenty of times for the first time - without ever having anyone explain it to me or having been taught. How was I able to confidently do that safely?

Because I already have the skill to place a needle, with direct visualization using ultrasound, around known structures. I can then read a book and learn some significant anatomy about another body part and place the needle near that structure using my already developed skills.

 

[Urzuz]

Uhh....

You've heard the saying "while pointing a finger, there are three pointing back at you" right?

No one is saying an ER physician is going to learn the vast knowledge, skill set, and nuances required to successfully place a needle under ultrasound guidance around a nerve bundle - in a weekend. That is a ludicrous idea for sure.

However, ER physicians already know a tremendous amount about ultrasound technology, knobology, and ultrasound diagnostics, and ultrasound guided procedures. They have led the way (with exception to radiologists of course) in bedside ultrasonography. They have that part down.

The have plenty of knowledge about local anesthetics, and have great procedural skills. This is not new to them.

They just want a little help connecting these dots - which is a very small leap for them.

I have placed the needled next to nerve bundles plenty of times for the first time - without ever having anyone explain it to me or having been taught. How was I able to confidently do that safely?

Because I already have the skill to place a needle, with direct visualization using ultrasound, around known structures. I can then read a book and learn some significant anatomy about another body part and place the needle near that structure using my already developed skills.

I think the discussion points that I was making are getting misinterpreted. I have nothing but respect for ED physicians. They are facile with the ultrasound and have the procedural skills necessary to do blocks, without a doubt. I just don't believe in training people in a skill that I make my livelihood from, no matter how insignificant of a territorial creep it may be, since I believe our specialty is at a crossroads and needs as big of a footprint as it can get in every hospital at this time. If doing blocks is medically necessary, you should be there doing them. Giving lectures can increase your footprint in a hospital temporarily, but you are essentially "teaching a man to fish so he can eat for a lifetime." For example, when deciding how to divide up bundled payments for a hip fracture, if there is a portion allocated for a fascia iliaca block to reduce opioid consumption, you can bet they will happily claim they can do them if you teach them proficiency in it. Or, if you have a program set up like my group or B-bone's, you can show value to the hospital when contract renewal rolls around.

Despite how benign it may seem on this board (e.g.: we don't want to do axillary blocks, we don't want to bill for interscalene blocks), you have to be more realistic and understand that others around the country won't be so altruistic when it comes to making extra money.

The bit about it being unsafe was a small, theoretical part of a larger point I was making, which may not be applicable to ED physicians who trained on ultrasound.

Anyway, I think I have contributed more than my fair share of unsolicited opinions to this discussion so I'll stop responding unless someone has a specific question for me. I'll reiterate that this has nothing to do with animosity that I have towards ED physicians, or my thinking that they are incapable of the procedural skill. It just has to do with the preservation of a specialty that I love, that I have dedicated my life to, which has been completely bastardized and corrupted from every which angle -- from CRNAs, to other anesthesiologists, to other MDs, all the way to your newly minted graduate from the online CRNA DNAP ABCD XYZ program.

 

[BLADEMDA]

This is a non-issue. ER Physicians have no interest or privileges to work in the O.R. That isn't going to happen. It's outside their specialty because patients may need a GA to go with that block. I mean it's like selling a hamburger without the fries and drink. Who would want to go to that restaurant over a full service one?

I've got no issues with the ER Docs doing whatever they like in their domain. Please and I mean PLEASE keep doing that job so I don't have to. I do take issue with sedating non NPO patients and having them aspirate in the ER. That's my main beef with the ER residency programs. Their airway management skills and sedation skills are not up to par with ours. Hence, I want the ER MD/DO to call me before getting into trouble and not after.

The modern ER Physician is pretty good compared to the ones from 20 years ago; but, there is still a lot of room for improvement.

 

[BLADEMDA]

Error #1: Delaying deep sedation until fasting times are met

• The American Society of Anesthesiologists (ASA) states that the current fasting guidelines are based on insufficient evidence but still “strongly recommend” the following (2):
  • 2 hours for clear liquids, 6 hours for a solid light meal and 8 hours for a fatty or fried meal
  • ASA guidelines are often extrapolated to procedural sedation in the ED
• However, literature for procedural sedation in the ED states that fasting makes no difference on the risk of emesis or aspiration (3).
  • Harms of delaying the procedure include increased pain, progression of lesion, and a more difficult procedure
  • The American College of Emergency Physicians (ACEP) Clinical Policy 2013 guidelines state that procedural sedation should not be delayed in the ED based on fasting time (4)
  • Always ensure, however, that your decisions on nil per os (NPO) status in sedation reflect your hospital’s applicable policies

http://www.emdocs.net/top-10-errors-of-procedural-sedation-in-the-emergency-department/

 

[migm]

Error #1: Delaying deep sedation until fasting times are met

• The American Society of Anesthesiologists (ASA) states that the current fasting guidelines are based on insufficient evidence but still “strongly recommend” the following (2):
  • 2 hours for clear liquids, 6 hours for a solid light meal and 8 hours for a fatty or fried meal
  • ASA guidelines are often extrapolated to procedural sedation in the ED
• However, literature for procedural sedation in the ED states that fasting makes no difference on the risk of emesis or aspiration (3).
  • Harms of delaying the procedure include increased pain, progression of lesion, and a more difficult procedure
  • The American College of Emergency Physicians (ACEP) Clinical Policy 2013 guidelines state that procedural sedation should not be delayed in the ED based on fasting time (4)
  • Always ensure, however, that your decisions on nil per os (NPO) status in sedation reflect your hospital’s applicable policies

http://www.emdocs.net/top-10-errors-of-procedural-sedation-in-the-emergency-department/

So show me the data that NPO in the ED for the type of emergent temporary sedation we perform makes a difference and exceeds the risks/pain of delay to meet that arbitrary threshold? I've got no qualms getting sedated by my colleague if the need arose.

 

[dhb]

So show me the data that NPO in the ED for the type of emergent temporary sedation we perform makes a difference and exceeds the risks/pain of delay to meet that arbitrary threshold? I've got no qualms getting sedated by my colleague if the need arose.

Hard to show data that's not reported.

 

[BLADEMDA]

So show me the data that NPO in the ED for type of emergent procedural sedation we perform makes a difference and that the risks of aspiration do not exceed the risks of delaying a procedure for that risk?

I'm not going to argue over the data. But, I have seen more than a few patients in my ER aspirate gastric contents after "moderate sedation" by an ER Physician. Since the MD/DO administering this sedation isn't as skilled at maintaining airway reflexes as an Anesthesiologist (admittedly it is a hard skill to acquire) the patient can easily "cross-over" into deep sedation rather quickly.

There is a reason we have stuck with the 6 hour rule in anesthesia: Patients can and do aspirate with deep sedation. Anyone who has practiced anesthesia for more than 20 years knows "we can get away with a lot most of the time" when we ignore our rules. But, some of the time it bites us in the arse. Aspiration is just such a thing where the odds of any one patient actually aspirating is remote but if it does occur the complication is devastating to the patient. So, it comes down to risk/reward in the ER with an acceptable incidence of complications vs the O.R. where the expectation is on safety first.

Pre-Procedural Fasting in Emergency Sedation

 

[BLADEMDA]

So show me the data that NPO in the ED for the type of emergent temporary sedation we perform makes a difference and exceeds the risks/pain of delay to meet that arbitrary threshold? I've got no qualms getting sedated by my colleague if the need arose.

If you have risk factors for aspiration besides just eating a full meal at your local burger joint then you are rolling the dice here. It's one based on ignorance and lack of case experience. ER physicians "get away" with a lot and I'm glad it works out most of the time. But, it's still dangerous at a level higher than not wearing your seat belt or not wearing a helmet when riding a motorcycle.

 

[Man o War]

This is a non-issue. ER Physicians have no interest or privileges to work in the O.R. That isn't going to happen. It's outside their specialty because patients may need a GA to go with that block. I mean it's like selling a hamburger without the fries and drink. Who would want to go to that restaurant over a full service one?

I've got no issues with the ER Docs doing whatever they like in their domain. Please and I mean PLEASE keep doing that job so I don't have to. I do take issue with sedating non NPO patients and having them aspirate in the ER. That's my main beef with the ER residency programs. Their airway management skills and sedation skills are not up to par with ours. Hence, I want the ER MD/DO to call me before getting into trouble and not after.

The modern ER Physician is pretty good compared to the ones from 20 years ago; but, there is still a lot of room for improvement.

Totally agree. I had an ER doc get pissy with me when I declined her plan to sedate my 2 year old in the ER and asked for an anesthesiologist.