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Mon Aug 21 14:44:32 BST 2006

I second dr Hardcastle, we are not fortuned enough to always have a
anesthesiologist present and they work call and is not always available to
do intubations, in the level 1 trauma unit we work the trauma dr does it all
. also we have a system in place where we get phoned with all resus cases
and we make the needed call, if the trauma dr gives the order that we need a
macdreamy. We also have a cca in the unit who makes part of the nursing team
and he or she also does intubations, depends on how many redcodes we have at
the same time.

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Hardcastle, Tim, Dr <tch at sun.ac.za>
Sent: 21 August 2006 02:41 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Anesthesia in the ED

Avi

I did not say they are equal - just more available as you surmised. As far
as surgical airways are concerned, we have done 7 surgical crics since 1995
(around 1400 intubated trauma cases per annum). All other cases were safely
intubated. Only needed crics in patients with faces that were blown away /
crushed(4), gunshot neck that could not even be tubed by the anaesthesia
professor with a fibrescope (1) and big haematoma under tongue (2).

If we had the anaesthesia residents we would use them!

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 Avi Roy Shapira
Sent: Monday, August 21, 2006 12:52 PM
To: Trauma &amp; Critical Care mailing list
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
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==========================================================================
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

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