Anesthesia in the ED

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nice way of team work
ante


2006/8/29, Bryan Boling <bryanboling at gmail.com>:
>
> In the Level I center I used to work at, there were 3 tiers of trauma
> alert,
> the lowest was handled strictly by ED with Trauma Surg notified by page
> but
> not coming to the Trauma Bay, the middle (most frequent) was handled by ED
> and Trauma Surg on alternate weeks and the highest was always trauma surg.
> Anesthesia also came to those.  The reasoning for anesthesia showing up at
> the highest level was not that ED/Trauma Surg couldn't manage the airways
> (because of the parameters for that tier, the victim was almost always
> tubed
> in the field prior to arrival anyway) but it was to start a work up for
> the
> OR.
>
> They usually stood back and started their pr-op assessment and started
> formulating an anesthesia plan in case they went emergently to the OR.
> Often times, they would leave the trauma bay to go set up the OR once it
> appeared that emergency surgery was likely.  I always thought that was the
> nice thing about having them around so that when we rolled out the door to
> the OR, Anesthesia was waiting and ready.
>
> I only can remember two instances where Anesthesia moved in to handle the
> airway.  Once when ED and Surgery were arguing about it while the patient
> rapidly decompensated ("A is for airway!" I remember the Anes attending
> shouting as he pushed the two bickering residents aside) and once when an
> anesthesia resident HAPPENED to be in the ED (because they were the ICU
> resident on call) and ED and Surg neither could get the airway.
>
> bryan
>
> On 8/28/06, Jago Miloguz <japrak at gmail.com> wrote:
>
> > there is no doubt that anesthesiologists are experts on airway
> managment,
> > but in places where emergency system works just fine l think that there
> is
> > no need for standard present of anesthesiologist, not saying that ED
> > residents or attending would not ever need them, perhaps in some rare
> > cases,
> > such as severe RA or spondilitis ankylosa where deflexion could cause
> > c-spine injury. and yet again anesthesia and intensive care usualy goes
> > together so pts can benefit from both. on the other hand, ED physicians
> > are
> > usualy well educated to provide sufficient care on both fields, taking
> > care
> > of airway and providing all neccessery invasive and non-invasive
> > therapeutical procedures that could be done in ED. and if in someones
> > system
> > ED doc is not educated to perform those then properly skilled doc from
> > anesthesia or surgery should pay a visit to a emergency department. so
> use
> > the best possible choice to give the patient all right treatment,
> because
> > we
> > must not ever forget that in bottom line goal is to give the patient
> best
> > care that we can provide them with.
> > ante
> >
> >
> > 2006/8/27, statman2500 at aol.com <statman2500 at aol.com>:
> > >
> > > 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 <http://trauma.org/>
> > > >>>> To change your settings or unsubscribe visit:
> > > >>>> http://www.trauma.org/traumalist.html
> > > >>>> --
> > > >>>> trauma-list : TRAUMA.ORG <http://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 <http://trauma.org/>
> > > >>> To change your settings or unsubscribe visit:
> > > >>> http://www.trauma.org/traumalist.html
> > > >>>
> > > >>
> > > >> --
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> > > >> To change your settings or unsubscribe visit:
> > > >> http://www.trauma.org/traumalist.html
> > > >
> > > > --
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> > > > To change your settings or unsubscribe visit:
> > > > http://www.trauma.org/traumalist.html
> > > >
> > > --
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> > > To change your settings or unsubscribe visit:
> > > http://www.trauma.org/traumalist.html
> > >
> ________________________________________________________________________
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> >
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