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<P>As someone trained in both anaesthesia and emergency medicine I feel that not too many generalisations should be made. It comes down to an individual's aptitude, experience, initial and ongoing training etc etc. </P>
<P>As an emergency physician I have been confronted with far more difficult airway scenarios than in the controlled environment of the operating suite. I disagree that doing 4-6 per day gives you any inate advantage if you are fundamentally properly trained and experienced. Other peoples' experiences may vary.</P>
<P>John</P>
<P>Dr John L Holmes <BR>Director Emergency Medicine <BR>Mater Adult Hospital <BR>Brisbane, Australia</P></DIV>
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<DIV></DIV>From: <I>"artlam" <artlam@u.washington.edu></I><BR>Reply-To: <I>"Trauma &amp; Critical Care mailing list" <trauma-list@trauma.org></I><BR>To: <I>"Trauma &amp; Critical Care mailing list" <trauma-list@trauma.org></I><BR>Subject: <I>Re: Anesthesia in the ED</I><BR>Date: <I>Wed, 23 Aug 2006 23:13:48 -0700</I><BR>>As I said, there is a lot of regional variation, and you are <BR>>certainly entitled to your opinion.The unfortunate thing with ER <BR>>physician is, depends on what program they went to, some of them had <BR>>never received adequate training in the first place. I have been <BR>>training residents for more than 27 years, and have trained many who <BR>>used to be ER physicians. Some of them in fact are most difficult <BR>>to train, because
they think they know how to intubate. I also used <BR>>to moonlight as an ER physician. As well, 4-6 intubations a day <BR>>indeed does not equate to a bloody Lefort 3 in a month, it is a lot <BR>>more training and experience. Once a month will not cut it, no <BR>>matter how challenging it appears to be. I am pleased that you <BR>>support the ER physicians as the best to manage the difficult <BR>>airway; they need it.<BR>><BR>><BR>><BR>>Arthur Lam M.D., F.R.C.P.C.<BR>>Anesthesiologist-in-Chief<BR>>Director, Cerebrovascular Laboratory<BR>>Harborview Medical Center<BR>>Professor of Anesthesiology and Neurological Surgery<BR>>University of Washington<BR>>Seattle, WA<BR>>----- Original Message ----- From: "Mike" <mmackinnon@cox.net><BR>>To: "Trauma &amp; Critical Care mailing list"
<BR>><trauma-list@trauma.org><BR>>Sent: Wednesday, August 23, 2006 10:59 PM<BR>>Subject: Re: Anesthesia in the ED<BR>><BR>><BR>>>Well<BR>>><BR>>>I have to say this isnt typically the case.<BR>>><BR>>>4-6 intubations a day does not equal one bloody lefort 3 intubation <BR>>>a month with teeth in the airway.<BR>>><BR>>>That is like saying that the RN who puts an IV in the big juicy AC <BR>>>4-6 times a days is better than the one who does the hardest IV in <BR>>>the ER ONCE a day. Its simply not on the same level of difficulty. <BR>>>Your comparing oranges to apples.<BR>>><BR>>>As for the trauma anesthesiologists, well, lets be honest, 99% of <BR>>>pts who need a tube come with one to the trauma room and its rare <BR>>>they have to do a difficult intubation there either. I support
the <BR>>>ER physician as one of the best at difficult airway intubation.<BR>>><BR>>>MM<BR>>>----- Original Message ----- From: "artlam" <BR>>><artlam@u.washington.edu><BR>>>To: "Trauma &amp; Critical Care mailing list" <BR>>><trauma-list@trauma.org><BR>>>Sent: Wednesday, August 23, 2006 1:56 PM<BR>>>Subject: Re: Anesthesia in the ED<BR>>><BR>>><BR>>>>I cannot agree with you more. It has been a struggle for me to <BR>>>>come up with a policy that would allow ED physicians to maintain <BR>>>>their airway skills without jeopardizing patient safety or <BR>>>>training of our residents. It has also been difficult to convince <BR>>>>ED physicians that anesthesiologist may still have an edge with <BR>>>>the real difficult airways. However,
there is clearly a regional <BR>>>>variation. We are a level 1 trauma center where Anesthesiology is <BR>>>>always responsible for all airway problems in the ER, but I also <BR>>>>know there are places where anesthesiologists never frequent the <BR>>>>ER.<BR>>>><BR>>>><BR>>>>Arthur Lam M.D., F.R.C.P.C.<BR>>>>Anesthesiologist-in-Chief<BR>>>>Director, Cerebrovascular Laboratory<BR>>>>Harborview Medical Center<BR>>>>Professor of Anesthesiology and Neurological Surgery<BR>>>>University of Washington<BR>>>>Seattle, WA<BR>>>>----- Original Message ----- From: "Avi Roy Shapira" <BR>>>><avir@bgumail.bgu.ac.il><BR>>>>To: "Trauma &amp; Critical Care mailing list" <BR>>>><trauma-list@trauma.org><BR>>>>Sent:
Monday, August 21, 2006 3:51 AM<BR>>>>Subject: RE: Anesthesia in the ED<BR>>>><BR>>>><BR>>>>><BR>>>>>Tim,<BR>>>>><BR>>>>>I disagree with the claims that ED docs or surgeons are just as <BR>>>>>good as<BR>>>>>anesthesiologists in airway management.<BR>>>>><BR>>>>>I think it should be obvious that someone who does 4-6 <BR>>>>>intubations each<BR>>>>>working day is better than anyone who does them only <BR>>>>>occasionally, however<BR>>>>>well trained.<BR>>>>><BR>>>>>For the majority of patients, it does not matter. But for the odd <BR>>>>>patient<BR>>>>>with a difficult airway, short neck, low chin, it does. The <BR>>>>>reason is that<BR>>>>>the
anesethesiologist had encountered many more of these than any <BR>>>>>ED doc.<BR>>>>><BR>>>>>Lets assume that 2% of individuals have difficult airway. If you <BR>>>>>do 5<BR>>>>>intubations a day, 5 days a week, you will see 50X25 or 1250 a <BR>>>>>year. That<BR>>>>>means 25 patients with difficult airway a year.<BR>>>>><BR>>>>>I doubt even the busiest ED doc does more than 50 intubations a <BR>>>>>year, if<BR>>>>>that many. That means that the ED doc, or trauma surgeon will<BR>>>>>have to tackle at most one such patient a year. So, however well <BR>>>>>trained,<BR>>>>>your ED doc may not know how to deal with one.<BR>>>>><BR>>>>>I would expect a higher rate of surgical airways, in places that
<BR>>>>>do not<BR>>>>>use anesthesiologists as part of the trauma team.<BR>>>>><BR>>>>>I suspect that the reason that you don't have an anesthesiologist <BR>>>>>on the<BR>>>>>team is that you don't have enough of them.<BR>>>>><BR>>>>>Our trauma team includes a surgeon, who is the team leader, a <BR>>>>>surgery<BR>>>>>resident, and an anesthesiologist (and a couple of nurses). The <BR>>>>>latter is<BR>>>>>either a certified one, or a senior resident. It works well, and <BR>>>>>we are<BR>>>>>very pleased with not having to worry about the airway <BR>>>>>management.<BR>>>>><BR>>>>>Avi<BR>>>>><BR>>>>><BR>>>>><BR>>>>><BR>>>>>, On
Mon, 21 Aug 2006, Hardcastle, Tim, Dr<BR>>>>><tch@sun.ac.za> wrote:<BR>>>>><BR>>>>>>Hi all<BR>>>>>><BR>>>>>>In South Africa we have front-room medical officers (GP level - <BR>>>>>>non-surgeons who choose to only work in Trauma Unit / ER) and <BR>>>>>>since 2004 emergency medicine trainees (new discipline in SA) <BR>>>>>>who do the ER airway, together with us (the Trauma Surgery <BR>>>>>>attendings and trainee people). Anaesthetists are available only <BR>>>>>>when not busy in the OR (very seldom).<BR>>>>>><BR>>>>>>We therefore have to be very skilled at airway options and <BR>>>>>>management. Additionally, with the excessive workload: often <BR>>>>>>three or four cases pending for
OR at once and only two EOR at <BR>>>>>>night, any remotely stable cases (e.g. GSW with acute abdo but <BR>>>>>>not active bleeding) will wait their turn in the holding area in <BR>>>>>>the Unit, they do not go to OR holding/recovery area. We will <BR>>>>>>moniotr and prioritise as needed.<BR>>>>>><BR>>>>>>Overall the Trauma Service runs the unit, however.<BR>>>>>><BR>>>>>>The joys of the mixed first-third world!<BR>>>>>><BR>>>>>>Tim<BR>>>>>>Dr T C Hardcastle<BR>>>>>>M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)<BR>>>>>>Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)<BR>>>>>>ATLS instructor and DSTC Cape Town Course Director<BR>>>>>>Intern program
Coordinator: Surgery<BR>>>>>>Program Manager: Emergency Medicine (SU)<BR>>>>>>Clinical Head (Director): Diana Princess of Wales Trauma Unit<BR>>>>>>Department of Surgery Room 4064<BR>>>>>>Tygerberg Hospital / University of Stellenbosch<BR>>>>>>PO Box 19063<BR>>>>>>Tygerberg 7505<BR>>>>>>Western Cape<BR>>>>>>South Africa<BR>>>>>>e-mail: tch@sun.ac.za<BR>>>>>>Cell: +27824681615<BR>>>>>>Office: +27219389281 or 4911 pager 0302<BR>>>>>><BR>>>>>><BR>>>>>><BR>>>>>>-----Original Message-----<BR>>>>>>From: trauma-list-bounces@trauma.org<BR>>>>>>[mailto:trauma-list-bounces@trauma.org]On Behalf
Of<BR>>>>>>bensonblues@comcast.net<BR>>>>>>Sent: Monday, August 21, 2006 5:43 AM<BR>>>>>>To: trauma-list@trauma.org<BR>>>>>>Subject: Anesthesia in the ED<BR>>>>>><BR>>>>>><BR>>>>>>At SJH, emergency medicine does the trauma airways (kids and <BR>>>>>>adults) and anesthesia responds only if requested. The residents <BR>>>>>>receive strong training in airway management and anesthesia and <BR>>>>>>become quite good, putting them to sleep and paralyze 'em as <BR>>>>>>necessary. We rarely see anesthesia in the ED, and it has not <BR>>>>>>been a problem in the residency's tens year history. DB<BR>>>>>>--<BR>>>>>>trauma-list : TRAUMA.ORG<BR>>>>>>To change your settings or
unsubscribe visit:<BR>>>>>>http://www.trauma.org/traumalist.html<BR>>>>>>--<BR>>>>>>trauma-list : TRAUMA.ORG<BR>>>>>>To change your settings or unsubscribe visit:<BR>>>>>>http://www.trauma.org/traumalist.html<BR>>>>>><BR>>>>><BR>>>>>==========================================================================<BR>>>>>Aviel Roy-Shapira, M.D. Soroka University Hospital &<BR>>>>>Dept. of Surgery A. and Ben-Gurion University <BR>>>>>Medical School<BR>>>>>the Critical Care Unit POB 151,
Beer Sheva, Israel<BR>>>>><BR>>>>>email:avir@bgumail.bgu.ac.il Fax:972-7-6403260 <BR>>>>>voice:972-7-6403390<BR>>>>><BR>>>>><BR>>>>><BR>>>>>--<BR>>>>>trauma-list : TRAUMA.ORG<BR>>>>>To change your settings or unsubscribe visit:<BR>>>>>http://www.trauma.org/traumalist.html<BR>>>>><BR>>>><BR>>>>--<BR>>>>trauma-list : TRAUMA.ORG<BR>>>>To change your settings or unsubscribe visit:<BR>>>>http://www.trauma.org/traumalist.html<BR>>><BR>>>--<BR>>>trauma-list : TRAUMA.ORG<BR>>>To change your settings or unsubscribe visit:<BR>>>http://www.trauma.org/traumalist.html<BR>>><BR>><BR>>--<BR>>trauma-list : TRAUMA.ORG<BR>>To change your
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