Anesthesia in the ED

Sun Aug 27 03:46:53 BST 2006

The Level 1 that I worked at had a service driven unwrittten protocol.  If a significant trauma was expected the nurse (without physician request) would usually call anesthesia to come down prior to pt arriving.  This allowed the general surgery docs to concentrate on assessing the patient. 
 Medicine patients, if not already intubated, were usually tubed by the medicine residents/attending.  However, due to multiple disagreements between the nursing and medical staff regarding airway control/protection, the anesthesia chair decided that nursing could call for an airway assessment by anesthesia if their was a disagreement with the medicine resident/attending.  While it bruised some egos, both medical and nursing, airway sentinel events decreased significantly. 

-----Original Message-----
From: artlam at u.washington.edu
To: trauma-list at trauma.org
Sent: Thu, 24 Aug 2006 1:13 AM
Subject: Re: Anesthesia in the ED

As I said, there is a lot of regional variation, and you are certainly entitled to your opinion.The unfortunate thing with ER physician is, depends on what program they went to, some of them had never received adequate training in the first place. I have been training residents for more than 27 years, and have trained many who used to be ER physicians. Some of them in fact are most difficult to train, because they think they know how to intubate. I also used to moonlight as an ER physician. As well, 4-6 intubations a day indeed does not equate to a bloody Lefort 3 in a month, it is a lot more training and experience. Once a month will not cut it, no matter how challenging it appears to be. I am pleased that you support the ER physicians as the best to manage the difficult airway; they need it. 

Arthur Lam M.D., F.R.C.P.C. 
Anesthesiologist-in-Chief 
Director, Cerebrovascular Laboratory 
Harborview Medical Center 
Professor of Anesthesiology and Neurological Surgery 
University of Washington 
Seattle, WA 
----- Original Message ----- From: "Mike" <mmackinnon at cox.net> 
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org> 
Sent: Wednesday, August 23, 2006 10:59 PM 
Subject: Re: Anesthesia in the ED 

> Well 
> 
> I have to say this isnt typically the case. 
> 
> 4-6 intubations a day does not equal one bloody lefort 3 intubation a > month with teeth in the airway. 
> 
> That is like saying that the RN who puts an IV in the big juicy AC 4-6 > times a days is better than the one who does the hardest IV in the ER ONCE > a day. Its simply not on the same level of difficulty. Your comparing > oranges to apples. 
> 
> As for the trauma anesthesiologists, well, lets be honest, 99% of pts who > need a tube come with one to the trauma room and its rare they have to do > a difficult intubation there either. I support the ER physician as one of > the best at difficult airway intubation. 
> 
> MM 
> ----- Original Message ----- > From: "artlam" <artlam at u.washington.edu> 
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org> 
> Sent: Wednesday, August 23, 2006 1:56 PM 
> Subject: Re: Anesthesia in the ED 
> 
> 
>>I cannot agree with you more. It has been a struggle for me to come up >>with a policy that would allow ED physicians to maintain their airway >>skills without jeopardizing patient safety or training of our residents. >>It has also been difficult to convince ED physicians that anesthesiologist >>may still have an edge with the real difficult airways. However, there is >>clearly a regional variation. We are a level 1 trauma center where >>Anesthesiology is always responsible for all airway problems in the ER, >>but I also know there are places where anesthesiologists never frequent >>the ER. 
>> 
>> 
>> Arthur Lam M.D., F.R.C.P.C. 
>> Anesthesiologist-in-Chief 
>> Director, Cerebrovascular Laboratory 
>> Harborview Medical Center 
>> Professor of Anesthesiology and Neurological Surgery 
>> University of Washington 
>> Seattle, WA 
>> ----- Original Message ----- >> From: "Avi Roy Shapira" <avir at bgumail.bgu.ac.il> 
>> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org> 
>> Sent: Monday, August 21, 2006 3:51 AM 
>> Subject: RE: Anesthesia in the ED 
>> 
>> 
>>> 
>>> Tim, 
>>> 
>>> I disagree with the claims that ED docs or surgeons are just as good as 
>>> anesthesiologists in airway management. 
>>> 
>>> I think it should be obvious that someone who does 4-6 intubations each 
>>> working day is better than anyone who does them only occasionally, >>> however 
>>> well trained. 
>>> 
>>> For the majority of patients, it does not matter. But for the odd >>> patient 
>>> with a difficult airway, short neck, low chin, it does. The reason is >>> that 
>>> the anesethesiologist had encountered many more of these than any ED >>> doc. 
>>> 
>>> Lets assume that 2% of individuals have difficult airway. If you do 5 
>>> intubations a day, 5 days a week, you will see 50X25 or 1250 a year. >>> That 
>>> means 25 patients with difficult airway a year. 
>>> 
>>> I doubt even the busiest ED doc does more than 50 intubations a year, if 
>>> that many. That means that the ED doc, or trauma surgeon will 
>>> have to tackle at most one such patient a year. So, however well >>> trained, 
>>> your ED doc may not know how to deal with one. 
>>> 
>>> I would expect a higher rate of surgical airways, in places that do not 
>>> use anesthesiologists as part of the trauma team. 
>>> 
>>> I suspect that the reason that you don't have an anesthesiologist on the 
>>> team is that you don't have enough of them. 
>>> 
>>> Our trauma team includes a surgeon, who is the team leader, a surgery 
>>> resident, and an anesthesiologist (and a couple of nurses). The latter >>> is 
>>> either a certified one, or a senior resident. It works well, and we are 
>>> very pleased with not having to worry about the airway management. 
>>> 
>>> Avi 
>>> 
>>> 
>>> 
>>> 
>>> , On Mon, 21 Aug 2006, Hardcastle, Tim, Dr 
>>> <tch at sun.ac.za> wrote: 
>>> 
>>>> Hi all 
>>>> 
>>>> In South Africa we have front-room medical officers (GP level - >>>> non-surgeons who choose to only work in Trauma Unit / ER) and since >>>> 2004 emergency medicine trainees (new discipline in SA) who do the ER >>>> airway, together with us (the Trauma Surgery attendings and trainee >>>> people). Anaesthetists are available only when not busy in the OR (very >>>> seldom). 
>>>> 
>>>> We therefore have to be very skilled at airway options and management. >>>> Additionally, with the excessive workload: often three or four cases >>>> pending for OR at once and only two EOR at night, any remotely stable >>>> cases (e.g. GSW with acute abdo but not active bleeding) will wait >>>> their turn in the holding area in the Unit, they do not go to OR >>>> holding/recovery area. We will moniotr and prioritise as needed. 
>>>> 
>>>> Overall the Trauma Service runs the unit, however. 
>>>> 
>>>> The joys of the mixed first-third world! 
>>>> 
>>>> Tim 
>>>> Dr T C Hardcastle 
>>>> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA) 
>>>> Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU) 
>>>> ATLS instructor and DSTC Cape Town Course Director 
>>>> Intern program Coordinator: Surgery 
>>>> Program Manager: Emergency Medicine (SU) 
>>>> Clinical Head (Director): Diana Princess of Wales Trauma Unit 
>>>> Department of Surgery Room 4064 
>>>> Tygerberg Hospital / University of Stellenbosch 
>>>> PO Box 19063 
>>>> Tygerberg 7505 
>>>> Western Cape 
>>>> South Africa 
>>>> e-mail: tch at sun.ac.za 
>>>> Cell: +27824681615 
>>>> Office: +27219389281 or 4911 pager 0302 
>>>> 
>>>> 
>>>> 
>>>> -----Original Message----- 
>>>> From: trauma-list-bounces at trauma.org 
>>>> [mailto:trauma-list-bounces at trauma.org]On Behalf Of 
>>>> bensonblues at comcast.net 
>>>> Sent: Monday, August 21, 2006 5:43 AM 
>>>> To: trauma-list at trauma.org 
>>>> Subject: Anesthesia in the ED 
>>>> 
>>>> 
>>>> At SJH, emergency medicine does the trauma airways (kids and adults) >>>> and anesthesia responds only if requested. The residents receive strong >>>> training in airway management and anesthesia and become quite good, >>>> putting them to sleep and paralyze 'em as necessary. We rarely see >>>> anesthesia in the ED, and it has not been a problem in the residency's >>>> tens year history. DB 
>>>> -- 
>>>> trauma-list : TRAUMA.ORG 
>>>> To change your settings or unsubscribe visit: 
>>>> http://www.trauma.org/traumalist.html 
>>>> -- 
>>>> trauma-list : TRAUMA.ORG 
>>>> To change your settings or unsubscribe visit: 
>>>> http://www.trauma.org/traumalist.html 
>>>> 
>>> 
>>> ========================================================================== 
>>> Aviel Roy-Shapira, M.D. Soroka University Hospital & 
>>> Dept. of Surgery A. and Ben-Gurion University Medical >>> School 
>>> the Critical Care Unit POB 151, Beer Sheva, Israel 
>>> 
>>> email:avir at bgumail.bgu.ac.il Fax:972-7-6403260 >>> voice:972-7-6403390 
>>> 
>>> 
>>> 
>>> -- 
>>> trauma-list : TRAUMA.ORG 
>>> To change your settings or unsubscribe visit: 
>>> http://www.trauma.org/traumalist.html 
>>> 
>> 
>> -- 
>> trauma-list : TRAUMA.ORG 
>> To change your settings or unsubscribe visit: 
>> http://www.trauma.org/traumalist.html 
> 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/traumalist.html 
>  
-- 
trauma-list : TRAUMA.ORG 
To change your settings or unsubscribe visit: 
http://www.trauma.org/traumalist.html 
________________________________________________________________________
Check out AOL.com today. Breaking news, video search, pictures, email and IM. All on demand. Always Free.