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

[nimbus]

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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.

Maybe the EM docs can block with exparel😉

 

[Twiggidy]

Maybe the EM docs can block with exparel😉

I think i see what you did there....

 

[Mman]

Maybe the EM docs can block with exparel😉

here's what I worry about. Say the ED does some sort of block for ED comfort and to get the patient to surgery, but it's not an appropriate block (via location or duration) for postop pain control. Am I supposed to do another block? That adds potential risk of local anesthetic toxicity as well as potential nerve injury risk from another physical ding to the nerve. So if I'm being conservative I just let it go and do nothing and then the patient has worse postop pain and increased complications from narcotics all because I was prevented from providing optimal anesthetic care by what the ED doc did. It gets to be a little bit complicated and a slippery slope if the patients start receiving regional anesthetics in the ED and then later need to come for surgery.

 

[deleted162650]

here's what I worry about. Say the ED does some sort of block for ED comfort and to get the patient to surgery, but it's not an appropriate block (via location or duration) for postop pain control. Am I supposed to do another block? That adds potential risk of local anesthetic toxicity as well as potential nerve injury risk from another physical ding to the nerve. So if I'm being conservative I just let it go and do nothing and then the patient has worse postop pain and increased complications from narcotics all because I was prevented from providing optimal anesthetic care by what the ED doc did. It gets to be a little bit complicated and a slippery slope if the patients start receiving regional anesthetics in the ED and then later need to come for surgery.

Agree 100%. That's why if a surgical pt in the ED needs a block WE should be the ones to do it.

 

[GravelRider]

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

Hey, I have enough to do when I am on-call between traumas, "emergent" cases, and OB that I do not need to be running up to the ICU for every COPD exacerbation that fails bipap or down to the ED for every dislocated shoulder that needs a block. I don't have enough incentive to want to add responsibility to my workload so someone else can make a few more bucks off of me. Anesthesiology dug it's grave long ago and doing a few blocks in the ED is not going to save it.

 

[Twiggidy]

Well, when I was a surgery intern in the ICU and for the airways and the hospital airways I noticed they would send a CRNA for the intubations,, that's when I should've seen the writing on the wall.

 

[deleted162650]

Hey, I have enough to do when I am on-call between traumas, "emergent" cases, and OB that I do not need to be running up to the ICU for every COPD exacerbation that fails bipap or down to the ED for every dislocated shoulder that needs a block. I don't have enough incentive to want to add responsibility to my workload so someone else can make a few more bucks off of me. Anesthesiology dug it's grave long ago and doing a few blocks in the ED is not going to save it.

I understand where you're coming from. With the push towards employment, I think I unionizing will our best defense.

 

[ballinsncbirth]

as an ER doc I think this thread is hilarious. Why are you teaching an ER doc to do regional anesthesia?. Not only is this not in my scope of practice it is completely useless in an ER practice. In my five years of practice I haven I ever thought "man I wish I could do a scalene block or give an epidural " . I don't have the time, interest or need to learn these skills. If I need to sedate or "procedurally sedate " someone I do it with propofol , ketamine, etomidate, etc.

This must be an academic center ER asking for this. The only regional anesthesia that would be somewhat useful would be a femoral nerve block in my old hip fractures. But I have never needed one as morphine /fentanyl works just fine even in my 90 year old. I learned medial nerve, hematoma, tibial nerve blocks in residence just for fun , but never have had the need to use them , and have no interested in trying to half ass a procedure which I am not skilled.

Now could I learn these skills? maybe ........ER docs are very good at ultrasound (most new ones anyway ) But just because I could doesn't mean I should. Even if learned the skill there is no way I would use it enough to become proficient , safe and reliable.


ED docs have enough stuff to do than to be spending 45 minutes trying to poach anesthesia skills just to "look cool"

Let ER docs be ER docs and anesthesia be aesthesia .

 

[DrDrummer]

Not only is this not in my scope of practice it is completely useless in an ER practice. [...] Even if learned the skill there is no way I would use it enough to become proficient , safe and reliable.

EM Resident here. I get what you're saying, and mostly agree -- in the community especially, there aren't a lot of really compelling reasons to use regional blocks given the time it takes to do, the lack of an ability to bill for it (in most settings), and the concerns raised in this thread by our anesthesia colleagues / other services that might have concerns with the "loss of the neuro exam" in a fracture case, or whatever. However, I disagree that regional anesthesia is outside the scope of our practice, and think there's tons of examples of how it is certainly useful in EM daily practice.

The blocks I use the most are digital blocks, nerve blocks for complex lacerations on the forearm, and as an adjunct for pain control in hip fractures. I also use blocks for dental pain and for facial lacerations when I don't want to disrupt the anatomy before a repair. All of these can be done using a landmark-based approach, but (at least for the extremities), your precision is improved with ultrasound. We also tend to use lidocaine instead of bupiv which reduces the likelihood of many of the serious complications that occur with regional anesthesia.

All that said, there are a lot of useful applications for ultrasound-guided regional blocks, and the knowledge is becoming more and more widespread and adopted -- but as you said, I think it's generally at academic shops where residents are curious and have the time/interest to do this and aren't thinking as much about their RVUs or moving patients. A leader in the field from EM is Andrew Herring at Highland, who runs this website: Welcome and promotes this as a way to improve patient care.

While it may be in the future that people try to start billing for these procedures, and who knows, maybe someone will decide (Herring has published on this) that we can/should be placing catheters, for the time being I think plenty of people are already doing this safely without any instruction from anesthesiologists every day as part of their practice. I doubt this trend will reverse itself.

 

[nimbus]

EM Resident here. I get what you're saying, and mostly agree -- in the community especially, there aren't a lot of really compelling reasons to use regional blocks given the time it takes to do, the lack of an ability to bill for it (in most settings), and the concerns raised in this thread by our anesthesia colleagues / other services that might have concerns with the "loss of the neuro exam" in a fracture case, or whatever. However, I disagree that regional anesthesia is outside the scope of our practice, and think there's tons of examples of how it is certainly useful in EM daily practice.

The blocks I use the most are digital blocks, nerve blocks for complex lacerations on the forearm, and as an adjunct for pain control in hip fractures. I also use blocks for dental pain and for facial lacerations when I don't want to disrupt the anatomy before a repair. All of these can be done using a landmark-based approach, but (at least for the extremities), your precision is improved with ultrasound. We also tend to use lidocaine instead of bupiv which reduces the likelihood of many of the serious complications that occur with regional anesthesia.

All that said, there are a lot of useful applications for ultrasound-guided regional blocks, and the knowledge is becoming more and more widespread and adopted -- but as you said, I think it's generally at academic shops where residents are curious and have the time/interest to do this and aren't thinking as much about their RVUs or moving patients. A leader in the field from EM is Andrew Herring at Highland, who runs this website: Welcome and promotes this as a way to improve patient care.

While it may be in the future that people try to start billing for these procedures, and who knows, maybe someone will decide (Herring has published on this) that we can/should be placing catheters, for the time being I think plenty of people are already doing this safely without any instruction from anesthesiologists every day as part of their practice. I doubt this trend will reverse itself.

From the couple of blocks I looked at, Herring's site looks like high quality instruction. Anesthesiologists definitely will NOT have a monopoly on regional anesthesia going forward. People make a big deal of it when in reality it's just putting a needle tip next to a nerve. Monkey skills.

Much like anesthesiologists do intraoperative echo because cardiologists don't hang out in OR's, EM docs will perform regional anesthesia in the ER when their patients need it. Are cardiologists crying about intraop TEE exams they "lost" to anesthesiologists?

 

[psychbender]

Much like anesthesiologists do intraoperative echo because cardiologists don't hang out in OR's, EM docs will perform regional anesthesia in the ER when their patients need it. Are cardiologists crying about intraop TEE exams they "lost" to anesthesiologists?

Actually, I have met a few cardiologists that complain about anesthesiologists doing TEE in the OR.

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[Robotic Wis-Hipple]

Actually, I have met a few cardiologists that complain about anesthesiologists doing TEE in the OR.

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As have I.

 

[nimbus]

Actually, I have met a few cardiologists that complain about anesthesiologists doing TEE in the OR.

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Ours couldn't be bothered. They must be slow.

Are their complaints going to influence your behavior in ANY way? Are you going to call them or not learn TEE or stop doing TEE?

 

[psychbender]

Ours couldn't be bothered. They must be slow.

Are their complaints going to influence your behavior in ANY way? Are you going to call them or not learn TEE or stop doing TEE?

Nope.

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[pgg]

Actually, I have met a few cardiologists that complain about anesthesiologists doing TEE in the OR.

Which is funny because they're not as good at it as we are.

 

[psychbender]

Which is funny because they're not as good at it as we are.

Shhhh, don't tell them that, it'll hurt their feelings. It's funny, the last time I saw a cardiologist come to the OR (I was asking if his functioned looked as poor the day before when he read the TTE, as I don't have access to his images), he had no idea how to work the machine (same one they had in clinic), as he has a tech for that.

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[Twiggidy]

From the couple of blocks I looked at, Herring's site looks like high quality instruction. Anesthesiologists definitely will NOT have a monopoly on regional anesthesia going forward. People make a big deal of it when in reality it's just putting a needle tip next to a nerve. Monkey skills.

Much like anesthesiologists do intraoperative echo because cardiologists don't hang out in OR's, EM docs will perform regional anesthesia in the ER when their patients need it. Are cardiologists crying about intraop TEE exams they "lost" to anesthesiologists?

Some places...yes. Especially a busy cardiac center. Those TEEs are easy icing on the cake for those cardiologists.

 

[Twiggidy]

Ours couldn't be bothered. They must be slow.

Are their complaints going to influence your behavior in ANY way? Are you going to call them or not learn TEE or stop doing TEE?

In most cases (not all but most) we're being taught TEE by other anesthesiologists, people in our field, not the cardiologist.

 

[pgg]

Shhhh, don't tell them that, it'll hurt their feelings. It's funny, the last time I saw a cardiologist come to the OR (I was asking if his functioned looked as poor the day before when he read the TTE, as I don't have access to his images), he had no idea how to work the machine (same one they had in clinic), as he has a tech for that.

They've got sort of an odd arrangement where I'm a fellow. Apparently all of the OR-dedicated machines, probes, and the network infrastructure behind them are owned/maintained by cardiology, and their dept gets the facility fee. They pay the salary of the tech who cleans our probes. The anesthesiologists who do TEEs in the OR and ICU bill for the professional fee. And thus is everyone satisfied.

We spent a week in the outpatient echo lab with them. One of their fellows spent a couple weeks in the OR with us. Different worlds. The clinic and echo lab wasn't my element, and the OR isn't theirs.

 

[nimbus]

In most cases (not all but most) we're being taught TEE by other anesthesiologists, people in our field, not the cardiologist.

Who taught the first set of anesthesiologists? Or were they self taught? Serious question.

In the end, if there is utility, it will happen whether we like it or not.

 

[nimbus]

We spent a week in the outpatient echo lab with them. One of their fellows spent a couple weeks in the OR with us. Different worlds. The clinic and echo lab wasn't my element, and the OR isn't theirs.

So they are sharing trade secrets with anesthesiologists? Idiots!

 

[pgg]

Who taught the first set of anesthesiologists?

Whatever came before YouTube, of course.

Probably a page on MySpace with a bunch of animated gifs and flashing text back in the days when Netscape was king of browsers, before the <blink> tag was deprecated, when modems and Al Gore ruled the internet.

Maybe uuencoded clips on Usenet, before the AOLers showed up and ruined it.

 

[deleted171991]

Which is funny because they're not as good at it as we are.

Some are. They are just too lazy to perform them. But have them read or guide a TEE, and it can be eye opening.

 

[Man o War]

Which is funny because they're not as good at it as we are.

Our cardiologists are cool, there is no turf war, and we do the echos for their procedures. They tell me our newer partners get as good or better images as they get themselves when they do TEE.

 

[nimbus]

In researching this further it appears that TEE was a joint effort and anesthesiologists were integral to its development and clinical application (Oka, Cahalan, Roizen, Cucchiarella, er al). I wonder how far we would have gotten without collaboration and cooperation from cardiologists.

 

[pgg]

Some are. They are just too lazy to perform them. But have them read or guide a TEE, and it can be eye opening.

I don't disagree and I don't really mean to disparage them. 🙂

I've worked with cardiologists in cardiac ORs as a resident, and in the peds cardiac OR as a fellow.

Compared to anesthesiologists doing TEEs, they very very clearly don't have the same sense of situational awareness WRT what's going on with the surgery or anesthetic, and in that regard they don't add what we do in that setting. They know the things that matter to the surgeon but not to us. Our task in the OR is just different than what they do with TEE most of the time.

They do have a breadth of knowledge we don't. There's a reason the PTEeXAM exists (beyond a cash grab by the NBE, you cynic!) and has the narrow focus it does.

 

[Twiggidy]

I don't disagree and I don't really mean to disparage them. 🙂

I've worked with cardiologists in cardiac ORs as a resident, and in the peds cardiac OR as a fellow.

Compared to anesthesiologists doing TEEs, they very very clearly don't have the same sense of situational awareness WRT what's going on with the surgery or anesthetic, and in that regard they don't add what we do in that setting. They know the things that matter to the surgeon but not to us. Our task in the OR is just different than what they do with TEE most of the time.

They do have a breadth of knowledge we don't. There's a reason the PTEeXAM exists (beyond a cash grab by the NBE, you cynic!) and has the narrow focus it does.

You want to talk cash grab....let's talk Basic PTE certficiation.....I'd love to see where the thread goes on that one

 

[deleted171991]

You want to talk cash grab....let's talk Basic PTE certficiation.....I'd love to see where the thread goes on that one

That is one royally useless exam, especially for its fee.