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

[migm]

I'm failing to see the compelling evidence, aside from anecdote and dogmatic declarations. Anyway, it doesn't matter and ultimately this is off topic - I completely agree that it comes down to the risks vs reward as pointed out. It is very different where I work - and that difference also comes to you when it's time to do emergent cases, NPO doesn't matter as its small fish compared to the life threat.

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[BLADEMDA]

I'm failing to see the compelling evidence, aside from anecdote and dogmatic declarations. Anyway, it doesn't matter and ultimately this is off topic - I completely agree that it comes down to the risks vs reward as pointed out. It is very different where I work - and that difference also comes to you when it's time to do emergent cases, NPO doesn't matter as its small fish compared to the life threat.

I'm sorry you "fail to see the evidence" because I've seen it from ER and the O.R.; it's a devastating complication that's considered "Gross Malpractice" in my specialty if I sedated a patient with a full stomach for a "short procedure." Since Anesthesiologists are the experts in the field of sedation and Airway (yes, we are the experts) I firmly believe heavy sedation of a full stomach patient in the E.R. is a bad idea. This isn't "dogma" because I live it on a daily basis; I've seen the harm that comes from an aspiration pneumonia.

Don't you think we would have abandoned this "dogma" years ago if it had no basis in reality? I certainly would have done so as I have with other dogmas in my field.
All I really care from this discussion is that ER physicians recognize that sedation carries significant risks in the E.R. and one should proceed with caution.

 

[migm]

No **** sherlock re risks! it is shocking to me your clear picture of this is simply not supported with the literature and the subsequent ACEP guidelines. The question is not whether aspiration pneumonia can be devastating, I just don't think NPO status makes any difference in my setting. You may be the expert in the OR but you are not in the ED. And the argument that "if it were dogma it would be abandoned" is laughable

 

[BLADEMDA]

No **** sherlock re risks! it is shocking to me your clear picture of this is simply not supported with the literature and the subsequent ACEP guidelines. The question is not whether aspiration pneumonia can be devastating, I just don't think NPO status makes any difference in my setting. You may be the expert in the OR but you are not in the ED. And the argument that "if it were dogma it would be abandoned" is laughable

ED has a lower standard of care; it's that simple. That was my argument from the beginning of this discussion. This "lower standard" probably exists in other areas of care by ER Physicians.

 

[Man o War]

I'm failing to see the compelling evidence, aside from anecdote and dogmatic declarations. Anyway, it doesn't matter and ultimately this is off topic - I completely agree that it comes down to the risks vs reward as pointed out. It is very different where I work - and that difference also comes to you when it's time to do emergent cases, NPO doesn't matter as its small fish compared to the life threat.

This is the same argument nurses use to claim parity with both you and I. The proper study hasn't been done, so therefore you have to prove I'm not fit to (fill in the blank).
That's like me saying I could run an ER safely because nobody has done a study proving otherwise, which we all know would not be in the patient's best interest.

 

[BLADEMDA]

This is the same argument nurses use to claim parity with both you and I. The proper study hasn't been done, so therefore you have to prove I'm not fit to (fill in the blank).
That's like me saying I could run an ER safely because nobody has done a study proving otherwise, which we all know would not be in the patient's best interest.

Let it go. Lower standard of care.

 

[migm]

edit: nevermind. this discussion is not worth it if there is not mutual respect

 

[Robotic Wis-Hipple]

I think we all understand that you guys sedate for time sensitive orthopedic realignment etc and there's always a risk/benefit analysis that I'm sure goes with this as it pertains to a full stomach. I'm not really sure what we expect you to do in these situations, RSI intubations?..... maybe you should be doing nerve blocks and no sedation. Oh wait.....

 

[BLADEMDA]

Goodbye Standard of Care, Hello Reasonable Practice

Goodbye Standard of Care, Hello Reasonable Practice - Emergency Physicians Monthly

In the E.R. it is "reasonable practice" to sedate patients with full stomachs. In the O.R. such a practice is not considered reasonable.

 

[migm]

.

 

[nimbus]

I don't know the data but I do believe sedation for a brief procedure without airway instrumentation carries a different and lower aspiration risk than the average general anesthetic in the OR. Even our own NPO guidelines have evolved, especially with recent ERAS protocols. It's fair to have different NPO guidelines. I don't think ER docs would continue a practice that causes problems for them just like anesthesiologists wouldn't.

 

[Man o War]

edit: nevermind. this discussion is not worth it if there is not mutual respect

I respect the hell out of you guys, I just think there's a lot of overconfidence with sedation. My last hospital actually had to implement/spell out a strict sedation policy because there was quite a bit of cowboy stuff going on. Not just in the ER either.

 

[migm]

Can you give some examples? I don't want to be in the cowboy camp when it comes to this but I'm not sure what you would consider to qualify. Apparently my sedation of a selected pt with an emergent condition is downright dangerous and unacceptable to some. I'm also not an expert when it comes to managing de novo hypotension, apnea/respiratory failure or aspiration - all conditions that come to my ED and that I am trained for and do manage on a routine basis

edit: fwiw i sit on my hospital procedural sedation committee, so especially relevant to know what others are doing

 

[nimbus]

Goodbye Standard of Care, Hello Reasonable Practice

Goodbye Standard of Care, Hello Reasonable Practice - Emergency Physicians Monthly

In the E.R. it is "reasonable practice" to sedate patients with full stomachs. In the O.R. such a practice is not considered reasonable.

How can you argue with reasonable? Reasonable is reasonable by definition.

 

[Man o War]

Can you give some examples? I don't want to be in the cowboy camp when it comes to this but I'm not sure what you would consider to qualify. Apparently my sedation of a selected pt with an emergent condition is downright dangerous and unacceptable to some. I'm also not an expert when it comes to managing de novo hypotension, apnea/respiratory failure or aspiration - all conditions that come to my ED and that I am trained for and do manage on a routine basis

edit: fwiw i sit on my hospital procedural sedation committee, so especially relevant to know what others are doing

The large majority of emergent calls to GI, Cath lab, ER, etc were for obese patients with sleep apnea being given too many narcotics. Some of the doses were truly unbelievable and demonstrated a clear lack of knowledge on the part of the physician performing the sedation....non anesthesia docs not knowing the difference between mild/moderate and deep sedation.
The policy said nobody except anesthesia could use propofol; the anesthesia dpt had to grant conscious sedation privileges, and could also revoke privileges if a doctor had too many near misses (data was collected on this and a threshold set, which I can't recall since it was so long ago). There was mandatory training/inservice for docs wanting privileges on the sedation levels. I'm probably forgetting some pieces of it but those were the big ones. Weeding out the bad apples via denying sedation privileges cut down on the emergent calls a ton.

 

[migm]

well okay - but precisely the patients I try hard to not even sedate unless it's truly emergent, and even then, with ketamine, with minimal if any narcotics, and airway stuff ready to go. I'd much rather send these to the OR. but maybe this is just part of how emergency medicine grows up (or so I hope)

 

[Man o War]

well okay - but precisely the patients I try hard to not even sedate unless it's truly emergent, and even then, with ketamine, with minimal if any narcotics, and airway stuff ready to go. I'd much rather send these to the OR. but maybe this is just part of how emergency medicine grows up (or so I hope)

It sounds like you get it then. Seems like common sense, but you'd be surprised. I remember thinking wow it's stupid we have to even spell this stuff out, but things were getting out of hand.

 

[anbuitachi]

well okay - but precisely the patients I try hard to not even sedate unless it's truly emergent, and even then, with ketamine, with minimal if any narcotics, and airway stuff ready to go. I'd much rather send these to the OR. but maybe this is just part of how emergency medicine grows up (or so I hope)

Not every EM doc sits on the hospital sedation committee

 

[IlDestriero]

It sounds like you get it then. Seems like common sense, but you'd be surprised. I remember thinking wow it's stupid we have to even spell this stuff out, but things were getting out of hand.

Our hospital has a sedation service and the problems we get called for time and again are for inability to sedate (they give the standard meds in the usual doses and the kid is not sedated enough and will likely not be sedated without dangerously large doses therefore needing conversion to GA or wake up and reschedule) and lost airways 2/2 obstruction and/or laryngospasm. Those can be pretty scary and we're trying to work with them on that. They are very reluctant to give Succs, even though it's the obvious answer.
Fortunately we have a good relationship with the ED guys and we help them with the L1 traumas and known or difficult appearing airways. We manage the sedation service's credentialing but the ED has their own standards. That's fine with me. We definitely can't support all the sedation they do for CTs, Appy MRs, lacs, splinting, etc. We'd care more I imagine if they had to call for help often, but they don't.
At one of my old jobs the ED guys had vastly different comfort and experience with sedation for procedures and that was painful. One guy is essentially doing GA with an unsecured airway and the next one won't even attempt glyco and a litttle ketamine for a stable older kid to put on a cast. If it needed more than that, they got a GA when my schedule allowed. That ER sedation was a pain in the ass, trust me, you don't want those calls. One dude didn't even want to do normal semi urgent airways, he'd call me. I was so happy to be in the OR. The experience, confidence, and level of laziness are very wide out in the more rural places.


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Il Destriero

 

[BLADEMDA]

Our hospital has a sedation service and the problems we get called for time and again are for inability to sedate (they give the standard meds in the usual doses and the kid is not sedated enough and will likely not be sedated without dangerously large doses therefore needing conversion to GA or wake up and reschedule) and lost airways 2/2 obstruction and/or laryngospasm. Those can be pretty scary and we're trying to work with them on that. They are very reluctant to give Succs, even though it's the obvious answer.
Fortunately we have a good relationship with the ED guys and we help them with the L1 traumas and known or difficult appearing airways. We manage the sedation service's credentialing but the ED has their own standards. That's fine with me. We definitely can't support all the sedation they do for CTs, Appy MRs, lacs, splinting, etc. We'd care more I imagine if they had to call for help often, but they don't.
At one of my old jobs the ED guys had vastly different comfort and experience with sedation for procedures and that was painful. One guy is essentially doing GA with an unsecured airway and the next one won't even attempt glyco and a litttle ketamine for a stable older kid to put on a cast. If it needed more than that, they got a GA when my schedule allowed. That ER sedation was a pain in the ass, trust me, you don't want those calls. One dude didn't even want to do normal semi urgent airways, he'd call me. I was so happy to be in the OR. The experience, confidence, and level of laziness are very wide out in the more rural places.


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Il Destriero

How would you handle a case where the kid is being "sedated" for a procedure in radiology by the ER team. You are called to help manage the case because the kid needs "more sedation" but radiology doesn't want to stop the procedure. FYI, the kid had a FULL MEAL 2 hours ago per the mother (as relayed by the ER team). Naturally, the ER team decided sedation was just fine because it met their standard of care.

The moment you assume care of that kid is the ER standard of care for sedating patients who are NOT NPO now your standard of care? What will you tell the Radiologist who doesn't want to stop the procedure for an intubation? If the kid aspirates at the end of the procedure was your decision to "go along with the ER" going to hold any water in court?

 

[IlDestriero]

When I'm called, I'm called by the sedation service. They follow our guidelines. The ED manages their own stuff fine. If they call me, the stool has already hit the fan and they're down the rabbit hole. In that case I'm there for the airway and then they can decide how to salvage their disaster. Nobody's suing me for that, and I'm not going to suddenly take over as the physician of record. They can manage a tubed patient, or the PICU can if they're that unstable. Unless it's some life threatening emergency, I don't think the radiologist gets a vote from his or her windowless cubicle. I've had a couple run ins with them over the years, they usually recognize the error of their ways with a reality check and come up with an agreeable plan, IR even more so as they're actually in the trenches and take some responsibility for the patient.
There's a difference between rescuing a patient and assuming care. I can't be responsible for what some other physician jacked up before I got there. I'm happy to own what I do.
The lawyers can try to argue anything they want. But it's like an urgent care sending an MI patient home with some Zantac and then trying to sue the ED physician that appropriately treated you for your MI when the ambulance drops you off an hour or so later.


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Il Destriero

 

[IlDestriero]

The cases that do make me a little nervous are ones where the patient has been injured by complications from some botched surgery elsewhere and transferred here for damage control and salvage. I'm always concerned, probably not so wrongly, that I'll get drawn into some litigation nightmare that the original surgeon and his attorney will be trying to dilute with more deep pockets. Even if I'm dropped, it's still stress and hassle that I don't want. I document the hell out of those cases.


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Il Destriero

 

[migm]

How would you handle a case where the kid is being "sedated" for a procedure in radiology by the ER team. You are called to help manage the case because the kid needs "more sedation" but radiology doesn't want to stop the procedure. FYI, the kid had a FULL MEAL 2 hours ago per the mother (as relayed by the ER team). Naturally, the ER team decided sedation was just fine because it met their standard of care.

Have never sedated a kid for just imaging. That's an admission and anesthesia's or the sedation team's job . I dont have time to screw around in MRI for sedation.

 

[pgg]

How would you handle a case where the kid is being "sedated" for a procedure in radiology by the ER team. You are called to help manage the case because the kid needs "more sedation" but radiology doesn't want to stop the procedure. FYI, the kid had a FULL MEAL 2 hours ago per the mother (as relayed by the ER team). Naturally, the ER team decided sedation was just fine because it met their standard of care.

The moment you assume care of that kid is the ER standard of care for sedating patients who are NOT NPO now your standard of care? What will you tell the Radiologist who doesn't want to stop the procedure for an intubation? If the kid aspirates at the end of the procedure was your decision to "go along with the ER" going to hold any water in court?

Why is stopping the procedure for an intubation a problem? They've already stopped it about 11 times because of the poor sedation, and then they stopped it again when you were called. They want my help "sedating" a full stomach kid they can stop it a 13th time and let me RSI and intubate him.

 

[deleted547339]

Let it go. Lower standard of care.

Shots fired.

 

[BLADEMDA]

Shots fired.

Politically correct addendum: "Different Standard of Care"

 

[Modanq]

To bring the conversation back I had my final ED shift this weekend as a visiting rotator and they had a flash education session in which I was an observer and they were going over Supraclav blocks. And I did go ahead and do a little teaching but I did get the feeling that most of them were reluctant to stick a needle next to the artery and lung. In the ED they have to manipulate the needle and do the injection without a nurse more often than not (i.e. no extra hands for aspiration). I do believe in my "teaching" there were subtle concepts that I think are hard to measure in terms of outcomes. Should you go with volume block versus concentration block, Intrafasical - epineural block. But, I think over time it will be the ED docs who basically just do the simple blocks. The question is how can we improve as Anesthesiologists -
Its akin to reducing fractures or casting. Many times ED docs do those tasks however there is an internal/departmental barometer or cliff where the complex issues are farmed out. Similar to sedation teams - simple sedations get the green light and the complex ones go to the sedation team. That to me seems like a middle approach. Anesthesiologists win by offering services to other colleagues like sedation teams and block teams. ED docs get to take care of the overwhelming number of patients and keep things moving.
Patients should come first, Education should be shared and all MDs should be respected in todays world both professionally and financially for their services.

We as anesthesiologist should make these committees and be at the decision making table for hospital policies and guidelines.....

 

[Twiggidy]

I'm not teaching anyone anything. If you need me to do something for the patient I'll do it (likely better and safer) and show my worth. Once "any MD can do X" occurs then you've devalued my field. If a practice is too busy to handle this, then hire more people. I bet there are plenty of graduates and people currently working who you can find to help even is it's part time or locums.

Someone mentioned "the boogey man", well, the boogey man is real, because these hospitals are going to do whatever they can to cut costs and the minute they find out that an ER doc can do the blocks, a nurse can do some lines and even epidurals, then suddenly the CEO will ask, "Why are we pay this group of guys 350k when I can pay a nurse 100k and throw few extra bucks at the ER doc?" The CEO and accounting will either hack away at your salary or your job completely. This is reality. The world is getting expensive and people are getting cheap. The more patients read about how much money we make (and I've had several patients upon meeting then for a preop mention how anesthesiologist are in the top 3 highest paid physicians) the more they think we really don't deserve that pay, so we have to prove our worth.

I'm (we) are worth more than anyone else because we trained to this this and we're better at this than anyone else. Yep, I'm a bit crazy, but that's my 2c

 

[nimbus]

I'm not teaching anyone anything. If you need me to do something for the patient I'll do it (likely better and safer) and show my worth. Once "any MD can do X" occurs then you've devalued my field. If a practice is too busy to handle this, then hire more people. I bet there are plenty of graduates and people currently working who you can find to help even is it's part time or locums.

Someone mentioned "the boogey man", well, the boogey man is real, because these hospitals are going to do whatever they can to cut costs and the minute they find out that an ER doc can do the blocks, a nurse can do some lines and even epidurals, then suddenly the CEO will ask, "Why are we pay this group of guys 350k when I can pay a nurse 100k and throw few extra bucks at the ER doc?" The CEO and accounting will either hack away at your salary or your job completely. This is reality. The world is getting expensive and people are getting cheap. The more patients read about how much money we make (and I've had several patients upon meeting then for a preop mention how anesthesiologist are in the top 3 highest paid physicians) the more they think we really don't deserve that pay, so we have to prove our worth.

I'm (we) are worth more than anyone else because we trained to this this and we're better at this than anyone else. Yep, I'm a bit crazy, but that's my 2c

The reality is that if people can do these procedures proficiently for 100k then that's how much the procedures are worth.

 

[dmk5n]

Apollo, great company.

 

[deleted171991]

Patients should come first, Education should be shared and all MDs should be respected in todays world both professionally and financially for their services.

We as anesthesiologist should make these committees and be at the decision making table for hospital policies and guidelines.....

This is such a BS. I see you are making a nice career out of it, the rest of us be damned.

Nobody should teach anybody else a skill they make their living from. @Urzuz is perfectly right. This is ridiculous. You may believe that ED docs are no threat, since they won't do blocks on periop patients, but you guys are wrong. You don't know what the future brings. You don't know what value anesthesiologists will bring to the hospital in a CRNA world. Keep giving pieces of our turf away, and soon we will be just the *****s who taught everybody else how to steal their job.

First we taught them how to manage airways, now we are teaching them blocks. What's next? OR anesthesia?

 

[Arch Guillotti]

First we taught them how to manage airways

You are mad because the ED docs are doing airways that we "taught" them?

 

[nimbus]

This is such a BS. I see you are making a nice career out of it, the rest of us be damned.

Nobody should teach anybody else a skill they make their living from. @Urzuz is perfectly right. This is ridiculous. You may believe that ED docs are no threat, since they won't do blocks on periop patients, but you guys are wrong. You don't know what the future brings. You don't know what value anesthesiologists will bring to the hospital in a CRNA world. Keep giving pieces of our turf away, and soon we will be just the *****s who taught everybody else how to steal their job.

First we taught them how to manage airways, now we are teaching them blocks. What's next? OR anesthesia?

I think EM docs will end up doing periop blocks. The elderly hip fractures will get fascia iliaca blocks early in their ED stay minimizing opioids. They will come up to the OR pre-blocked. It's actually better patient care. It's what I would want for my elderly family members. Unless you're willing to go down to the ED quickly with a smile on your face, it makes sense for the EM docs to do it themselves.

 

[deleted162650]

I think EM docs will end up doing periop blocks. The elderly hip fractures will get fascia iliaca blocks early in their ED stay minimizing opioids. They will come to the OR pre-blocked. It's actually better patient care. It's what I would want for my elderly family members.

Exactly this. And no reason for it to stop there. How 'bout the dude with the tri-mal ankle Fx that ortho just added on for once their clinic is over - why let him sit in pain for 4hrs? Just some bup/dex in popliteal and he's comfy while sitting around the ED all afternoon. Same thing goes for the distal radius Fx in the next bed over.

If you don't like the sound of that, then maybe a walk down to the ED or having the pt sent over to PACU to do it yourself is a better alternative. The patients will remember that and love you for it, they will tell the surgeons how great it was, the ED will love you 'cuz now they don't have to keep feeding Dilaudid to them while they hang out.

 

[Twiggidy]

If you don't like the sound of that, then maybe a walk down to the ED or having the pt sent over to PACU to do it yourself is a better alternative. The patients will remember that and love you for it, they will tell the surgeons how great it was, the ED will love you 'cuz now they don't have to keep feeding Dilaudid to them while they hang out.

But that's exactly the point that many of the "against" are making. Just go the ER, pop in the block, and bill. I've actually had to bite my tongue a bit when the hospital has been calling me to do things because in the back off head I say, "well, if they all start learning to do it, what use is there for me?" Like I said, if it's an issue of being to busy then hire more people but you have to show the hospital that "X can't be done without an anesthesiologists". I know in my hospital in particular that are a handful of things that "can't" and "won't" get done unless my partners and I aren't there and we've made that very clear to the hospital. If we start teaching ER docs, or nurses, or ICU docs to do these things, then now they don't need us.

I think what's getting lost in the discussion is: "Whatever procedure you do you have to be ready for the consequences of the procedure going wrong?"

We know what to do if we accidentally give toxic doses of meds or accidently inject Bupiv into the blood stream and the ER docs probably do too, but we're ready to take immediate action. The reason most cardiologist or GI docs don't give propofol isn't because they don't know how to do it, it's that they're not equipped to handle a situation in which the wrong dose (ie too much leading to prolonged apnea) is given. That's literally the only reason. Otherwise, everyone would give propofol.

 

[deleted171991]

I am perfectly fine with having the patients sent to the PACU, or having a cart in the ED to do blocks. As I said, ED docs have been slowly stealing all kinds of business from anesthesia, just because a lot of us were/are lazy, just as they were when they let CRNAs do our jobs in the OR. If we want to have a future as a physician specialty, we should stop letting others do our job.

Anesthesia comes from the Greek anaisthesia, meaning lack of sensation, which is literally what a nerve block does. Whose job is that???

We should stop being so short-sighted and prepare for a future when much fewer of us will be needed in the OR. What will happen to the rest?

 

[Southpaw]

This issue any different than ED docs getting upset that family docs work in rural EDs or surgery residents moonlighting in an ED? Why don't EM programs allow FM or IM docs to come through their residency programs for a year, then go out and work in an ED? They're protecting their turf, no different than any other field. Anesthesiology has done a horrendous job of protecting their field. Others should take note.

@nimbus and @SaltyDog are right. It makes sense for the ED docs to do the blocks on patients coming through the ED. I have no issue with it. However, if your group is motivated you can certainly prove your worth by going to the ED for a block when you're called, no matter day or night.

Still, ED docs shouldn't get upset about turf protection. Every field of medicine is playing this game.

 

[Modanq]

So whats the solution beyond not teaching them??? Its hard to go up against a tide. I agree we should be doing the blocks but it's starting to sound a lot like when CRNAs started the creep.

 

[deleted547339]

WE DONT WANT TO TAKE YOUR BUSINESS.

 

[deleted162650]

So whats the solution beyond not teaching them??? Its hard to go up against a tide. I agree we should be doing the blocks but it's starting to sound a lot like when CRNAs started the creep.

Have the ED docs and Orthopods call you when there's a pt requiring a block. Send the pt to PACU and block them, then go about your business. Make yourself look good and make a little $ in the process.

 

[deleted162650]

WE DONT WANT TO TAKE YOUR BUSINESS.

I understand that's not your intention. But, given the current political climate our specialty is facing right now, it's better for us to just sack up and do the block ourselves rather than teach anyone else how to do it. Wish it wasn't this way, but that's where we're at. We're not trying to be dicks about it.

 

[Southpaw]

WE DONT WANT TO TAKE YOUR BUSINESS.

Doesn't really matter what you want. Matters what the surgeons, and more importantly, the hospital, wants. If your hospital wants people in the ED getting blocks to avoid narcotics, and the Anesthesia group shows little to no interest (lots of lazy anesthesiologists out there, and lots of groups who 'just don't get it') then guess what, you'll be doing them. Or your next hire will be a block guru fresh outta residency/fellowship.

 

[nimbus]

WE DONT WANT TO TAKE YOUR BUSINESS.

Aren't most ER docs paid hourly anyway? Do they even get any productivity incentives? If they do 6 blocks in a shift, do they make more money than if they did zero?

 

[deleted171991]

WE DONT WANT TO TAKE YOUR BUSINESS.

You may not want to, but you will. Normally it wouldn't be a problem (I hate turf wars, and I think both specialties have stuff to learn from the other) but, long-term, anesthesiology is fighting for its survival, and every little bit will count.

I am CCM-trained, and a lot of my best continuous education comes from EM FOAM blogs. So I have tremendous respect for the specialty and for the free flow of knowledge. We just can't afford it in anesthesiology right now.

 

[Robotic Wis-Hipple]

If bundled payments and ortho service lines are leading to blocks in the ED and the anesthesia group/service isn't fighting to not only lead the organization/flow of said service line but also to perform those blocks that group deserves to lose their contract as well as have bad karma forever for being a bunch of lazy sellout fools.

If you work at a hospital with an ED you're expected to cover emergencies, that's how this works, and if you can't see that blocking these patients is not only good patient care but group equity in this political climate, from both the hospital admin standpoint and the opioid crisis standpoint, again, you're a fool.

With all that said, I still think, as I said before and I'm shocked nobody came back at me for, we are arguing out of both sides of our mouths..... telling the ED guys they're committing violations of our standard of care sedating full stomachs for reductions etc but also telling them there should be no blocks in the ED. Seems to me blocking these cases solves both problems.

 

[anbuitachi]

so what happens if patient aspirates and has prolonged hospitalization due to it and decides to sue? legally would lawyers apply the npo standards to ED?

 

[Mman]

I think EM docs will end up doing periop blocks. The elderly hip fractures will get fascia iliaca blocks early in their ED stay minimizing opioids. They will come up to the OR pre-blocked. It's actually better patient care. It's what I would want for my elderly family members. Unless you're willing to go down to the ED quickly with a smile on your face, it makes sense for the EM docs to do it themselves.

I can assure you our hip fracture patients are not making it to the OR several hours after being seen in the ED. It's usually at least the next day before they are in the OR, sometimes a few days depending on medical issues.

 

[GravelRider]

You guys are wise to want to protect your turf. Problem is, many (most?) of your colleagues don't give a rip, same as many (most?) of mine don't care about having an NP do their job as long as they can make an extra $30 an hour. I'd love to never do regional anesthesia or waste my time with conscious sedation again as long as I live. I'd much rather be seeing other patients in the department while you set up for and administer the sedation (which you're danged good at), and then be able to just walk in and reduce the hip real quick, walk back out, and get back to the other stuff I have to do. Problem is, in my experience, your colleagues have no interest in doing that. The last two calls I made for anesthesia assistance got me a CRNA, and God forbid I ask for someone to come in and do a blood patch (I'd be better off insulting their mother).

You guys get it. Being part of this community means you're more likely to be people who are engaged and who get it. But out in the real world, your associates are sending me CRNA's to do their work and getting angry if I ask for someone to come do a billable procedure. So why should I even bother? I'm better off just taking care of it myself.

We unfortunately live in a day and age where a lot of people would rather have the easy life and $$$$ now, in exchange for our job security and respect for our fields later.

Here's the problem. I am employed. The vast majority of the physicians I know are employed. I recently read an article that the number of employed physicians outnumber the physicians working for themselves nationally. If now all of a sudden another responsibility were given to me, I would not make any extra money. I have no incentive to protect my turf or expand my service line. I get all the stuff about midlevel encroachment, but to be perfectly honest, that thought is not crossing my mind when it's 2am and I'm in the middle of a 24 hour in-house call. I'm perfectly content letting respiratory therapists and PAs intubate in the ICU and ED physicians do blocks because I sure as heck have enough responsibility.

Now this is coming from someone who thinks anesthesiologists should be expanding responsibility outside of the OR. It's the employment of physicians has led to this complacency.

 

[Robotic Wis-Hipple]

Here's the problem. I am employed. The vast majority of the physicians I know are employed. I recently read an article that the number of employed physicians outnumber the physicians working for themselves nationally. If now all of a sudden another responsibility were given to me, I would not make any extra money. I have no incentive to protect my turf or expand my service line. I get all the stuff about midlevel encroachment, but to be perfectly honest, that thought is not crossing my mind when it's 2am and I'm in the middle of a 24 hour in-house call. I'm perfectly content letting respiratory therapists and PAs intubate in the ICU and ED physicians do blocks because I sure as heck have enough responsibility.

Now this is coming from someone who thinks anesthesiologists should be expanding responsibility outside of the OR. It's the employment of physicians has led to this complacency.

You're probably right.

 

[Twiggidy]

so what happens if patient aspirates and has prolonged hospitalization due to it and decides to sue? legally would lawyers apply the npo standards to ED?

Not sure

ER patients, especially trauma patients are loaded up on all sorts of drugs, even the ones that don't come to the OR. Again, I thinkn "propofol" is the magic word

Here's the problem. I am employed. The vast majority of the physicians I know are employed. I recently read an article that the number of employed physicians outnumber the physicians working for themselves nationally. If now all of a sudden another responsibility were given to me, I would not make any extra money. I have no incentive to protect my turf or expand my service line. I get all the stuff about midlevel encroachment, but to be perfectly honest, that thought is not crossing my mind when it's 2am and I'm in the middle of a 24 hour in-house call. I'm perfectly content letting respiratory therapists and PAs intubate in the ICU and ED physicians do blocks because I sure as heck have enough responsibility.

Now this is coming from someone who thinks anesthesiologists should be expanding responsibility outside of the OR. It's the employment of physicians has led to this complacency.

Someone hold my place in the unemployment line........RIP Anesthesiology