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Thu Aug 24 12:41:12 BST 2006

Many anesthesiologists here in the States don't seem to have your same
commitment. 

E

Errington C. Thompson, MD, FACS, FCCM

Trauma/Surgical Critical Care

Mission Hospital

Asheville, NC

Author - A Letter to America

www.whereistheoutrage.net <http://www.erringtonthompsonmd.com/> 

Everyone deserves to make an informed decision

                                - Errington Thompson, MD

  _____  

From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of John Holmes
Sent: Thursday, August 24, 2006 3:10 AM
To: trauma-list at trauma.org
Subject: Re: Anesthesia in the ED

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.   

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.

John

Dr John L Holmes 
Director Emergency Medicine 
Mater Adult Hospital 
Brisbane, Australia

  _____  

From:  "artlam" <artlam at u.washington.edu>
Reply-To:  "Trauma &amp; Critical Care mailing list"
<trauma-list at trauma.org>
To:  "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Subject:  Re: Anesthesia in the ED
Date:  Wed, 23 Aug 2006 23:13:48 -0700
>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 &amp; 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 &amp; 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 &amp; 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
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>>>>>trauma-list : TRAUMA.ORG
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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
>>>>
>>>>
>>>>
>>>>--
>>>>trauma-list : TRAUMA.ORG
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>>>>http://www.trauma.org/traumalist.html
>>>>
>>>
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>>
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>
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>trauma-list : TRAUMA.ORG
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