Everybody wants to be a hater...

[Groove]

Anesthesia having a good ol time bashing the ED and how much we suck at intubations.

EM residents claiming they are better at trauma/difficult airway management than anesthesiologists??

Have fun.

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[Dr Mantis Toboggan]

Anesthesia having a good ol time bashing the ED and how much we suck at intubations.

EM residents claiming they are better at trauma/difficult airway management than anesthesiologists??

Have fun.

Anesthesia is better at intubating than me. I've done hundreds while they've done many thousands. I'm competent and can intubate most people with my various tricks. I don't mind calling them in if I think the airway is tough: they are paid to be on call and always seem happy enough to help me.

 

[Mad Jack]

Anesthesia having a good ol time bashing the ED and how much we suck at intubations.

EM residents claiming they are better at trauma/difficult airway management than anesthesiologists??

Have fun.

They're specifically making fun of a guy that never calls anesthesia because he thinks he can intubate as well as someone whose specialty is airway management. I mean, there's a few jabs at specific bad providers they know or have seen, but EM docs in general are competent at intubations. Anesthesiologists just happen to be exceedingly awesome at intubations.

 

[Vandalia]

I don't see anything particularly outrageous. Radiologists are better at reading imaging than we are, cardiologists are better at interpreting the crazy EKG, orthopedic surgeons are better at dealing with many fractures/dislocations. That is the nature of a specialty that is something of a generalist.

But we are also better than a orthopedic surgeon at interpreting EKG, better than a cardiologist at reading non-cardiac imaging, and better than a radiologist at handling fractures.

 

[TheComebacKid]

To preface this, I will say that overall with the all of the different nuances of airway management, anesthesia has the airway thing down better than EM.

But I'll take the bait for a second and let my knee jerk defensive EM attitude kick in. I have observed "chaotic" situations on the floor where anesthesia is managing airway versus the chaotic intubation in the ED. While overall the technical skill of anesthesia is likely better than ours, the comfort with chaos and performing under highly stressful situations is an asset that emergency physicians have. Anesthesia (and all other services) can claim superiority at a variety of different procedures and interventions if they want, but they cannot argue that the pressure of working in the ED with a truly unstable patient is something that we excel at and are trained for better than other specialties (*Awaits some anesthesiologist to tell anecdotal story for how some EM attending called them on the phone freaking out and asking for help*). I don't buy the notion that we are "second best" at everything. I think we are experts (and the best) at resuscitation and operating under highly stressful circumstances. All the fine motor skills and whatever you have in your bag of airway tricks goes out the window when your HR is 180 and your catecholamines are surging.

I am indebted to my anesthesia colleagues for allowing me to come into the OR and to learn how to intubate on their patients. But I also did notice on multiple occasions that the laryngoscope was literally snatched away from me as soon as the patient's O2 sat was 95% and the anesthesia attending started freaking out. That doesn't happen in the ED. Maybe the anesthesiologist thought I was so incompetent with intubating that they weren't willing to take a chance. Maybe they were doing the right thing for the patient. But the level of stress and anxiety in the room felt like it was unnecessarily through the roof for what was told to me was a routine airway.

We have anesthesia backup in our ED. They come to all the bad traumas. I have never personally witnessed them have to intervene and intubate because the ED resident or ED attending couldn't secure the airway. But I am sure it has happened in the past and I am grateful that they are there for back up.

 

[Robotic Wis-Hipple]

To preface this, I will say that overall with the all of the different nuances of airway management, anesthesia has the airway thing down better than EM.

But I'll take the bait for a second and let my knee jerk defensive EM attitude kick in. I have observed "chaotic" situations on the floor where anesthesia is managing airway versus the chaotic intubation in the ED. While overall the technical skill of anesthesia is likely better than ours, the comfort with chaos and performing under highly stressful situations is an asset that emergency physicians have. Anesthesia (and all other services) can claim superiority at a variety of different procedures and interventions if they want, but they cannot argue that the pressure of working in the ED with a truly unstable patient is something that we excel at and are trained for better than other specialties (*Awaits some anesthesiologist to tell anecdotal story for how some EM attending called them on the phone freaking out and asking for help*). I don't buy the notion that we are "second best" at everything. I think we are experts (and the best) at resuscitation and operating under highly stressful circumstances. All the fine motor skills and whatever you have in your bag of airway tricks goes out the window when your HR is 180 and your catecholamines are surging.

I am indebted to my anesthesia colleagues for allowing me to come into the OR and to learn how to intubate on their patients. But I also did notice on multiple occasions that the laryngoscope was literally snatched away from me as soon as the patient's O2 sat was 95% and the anesthesia attending started freaking out. That doesn't happen in the ED. Maybe the anesthesiologist thought I was so incompetent with intubating that they weren't willing to take a chance. Maybe they were doing the right thing for the patient. But the level of stress and anxiety in the room felt like it was unnecessarily through the roof for what was told to me was a routine airway.

We have anesthesia backup in our ED. They come to all the bad traumas. I have never personally witnessed them have to intervene and intubate because the ED resident or ED attending couldn't secure the airway. But I am sure it has happened in the past and I am grateful that they are there for back up.

Eh, both "sides" will have anecdotes. You may work at a place where anesthesia is weak, I may work at a place where EM consults everything etc.

I'll say that obviously you guys are horribly under appreciated, I initially wanted to do EM but it fell out of favor for me once I realized how much non-emergency there was and I felt like a triaging IM doc. I'm glad you guys all love it, and your field is full of excited docs advancing many areas of your practice. You guys all have far more broad knowledge than I do and that's the fact that gets underappreciated imo.

The only point you made that is a tad nails on chalkboard to me is your discussion of chaotic situations and the Anesthesia attendings that snatched your laryngoscope at an SpO2 of 95%. Again, I'm sure those anecdotes occurred/exist. But our M.O. is having a plan A, B, C, and D for everything. We're planners. We worry about the plane getting hit by a flock of geese while on autopilot and the proximity to the Hudson for every case. That's just our nature. And my anecdote is the many handfuls of Attendings that walked around and calmly gave direction or made management decisions like there was ice water in their veins when the case was going to **** and the surgeon was losing their wig. That's what drew me to anesthesia (well, and the fact I hated the idea of having to know so much about 10 different medical fields). So I take some offense to this idea that we only deal with ideal conditions, I mean, we go take those pt's many of your colleagues think propofol is gonna kill and give them much more vasodilating/cardio-depressant drugs and get them through a surgery being run by surgeons that think the only thing the heart is for is moving ancef around. But overall, you guys are well read, advance your field aggressively, and do an important job during hours of the day/night many of my colleagues don't want to be bothered.

And I agree with whoever said we should be uniting to fight these big corporations taking money off the backs of the talent and their midlevel Trojan horses.

 

[TheComebacKid]

The only point you made that is a tad nails on chalkboard to me is your discussion of chaotic situations and the Anesthesia attendings that snatched your laryngoscope at an SpO2 of 95%. Again, I'm sure those anecdotes occurred/exist. But our M.O. is having a plan A, B, C, and D for everything. We're planners. We worry about the plane getting hit by a flock of geese while on autopilot and the proximity to the Hudson for every case. That's just our nature. And my anecdote is the many handfuls of Attendings that walked around and calmly gave direction or made management decisions like there was ice water in their veins when the case was going to **** and the surgeon was losing their wig. That's what drew me to anesthesia (well, and the fact I hated the idea of having to know so much about 10 different medical fields). So I take some offense to this idea that we only deal with ideal conditions, I mean, we go take those pt's many of your colleagues think propofol is gonna kill and give them much more vasodilating/cardio-depressant drugs and get them through a surgery being run by surgeons that think the only thing the heart is for is moving ancef around. But overall, you guys are well read, advance your field aggressively, and do an important job during hours of the day/night many of my colleagues don't want to be bothered.

I very much appreciate your input. Thank you for responding.

I think your analogy of the miracle on the Hudson may be appropriate. But while anesthesia may be Sully with years of experience, multiple pre-flight checklists that have already been done, location of the nearest airport (or body of water for that matter) to land, EM I think has a role here too.

Our training is more about damage control. We are the passenger who is grabbed from the back and suddenly thrown into the cockpit and asked to land the plane when the pilot is intoxicated. We don't have the luxury of preparation. Just two days ago we had a drop off GSW in the waiting room that got emergently intubated. I didn't have the opportunity to check to make sure suction was working, that the bougie was there, that the cuff on the ET tube was inflating etc. We just grabbed the guy off the floor and intubated him. I'm sure if an anesthesiologist saw my technique they could have found something wrong with it. But I would ask my fellow anesthesiologists to be mindful when finger pointing at the EM doc who was unprepared for the intubation, who had a peri-intubation arrest or some other catastrophic complication. These are difficult circumstances that don't always end well. And I know that you folks do intubate patients who are crashing and need an airway, this however is in essence the only time we intubate people.

Could an anesthesiologist have handled that airway? Most definitely. Maybe your training prepares you to keep calm under these difficult circumstances as well. But I can tell you that while we are very easily dismissed as doing everything in the hospital second best, our training is focused on staying calm under pressure and stabilizing a patient in extremis. Our patient populations and the circumstances of stabilizing a patient are extremely different. Every single intubation we do in the ED is because the patient desperately needs it, not because it is an elective case. It's true, the ENT case where the patient has had tons of neck radiation is a difficult airway that you guys manage with ease. But in the ED I'm called upon to intubate that same patient with a stomach full of food after he has been bagged by EMS and has vomitus all over the airway and is altered. If someone has a fat neck or OSA, I don't look back in the chart and see what their prior Mallampati was and whether or not they were a difficult intubation. We just go, and sometimes it ends poorly and we get very Monday morning quarterbacked by our anesthesia colleagues based on how we handled the airway. I would be lying if I said I wasn't resentful of that.

I don't deny there are anesthesiologists who are excellent at stabilizing patients in crisis. But I feel like the medical community at large needs to concede that EM as a specialty was created for that purpose. While you aren't simply there to babysit patient's in the GI suite who get routine colonoscopies, we are not just here to solely tend to the drug seekers and those that need primary care.

 

[ranvier]

The only point you made that is a tad nails on chalkboard to me is your discussion of chaotic situations and the Anesthesia attendings that snatched your laryngoscope at an SpO2 of 95%. Again, I'm sure those anecdotes occurred/exist. But our M.O. is having a plan A, B, C, and D for everything. We're planners.
And I agree with whoever said we should be uniting to fight these big corporations taking money off the backs of the talent and their midlevel Trojan horses.

Sorry this was your student experience. Since the pt is NPO, and the airway in the OR under controlled conditions as has been pointed out, I want my student to hear the desaturations, know how to bag appropriately, even discuss use of a rescue device/LMA. That is the whole point and why you are there....as long as you aren't a midlevel, I am happy to share what I know and do with a future physician colleague.

 

[Robotic Wis-Hipple]

I very much appreciate your input. Thank you for responding.

I think your analogy of the miracle on the Hudson may be appropriate. But while anesthesia may be Sully with years of experience, multiple pre-flight checklists that have already been done, location of the nearest airport (or body of water for that matter) to land, EM I think has a role here too.

Our training is more about damage control. We are the passenger who is grabbed from the back and suddenly thrown into the cockpit and asked to land the plane when the pilot is intoxicated. We don't have the luxury of preparation. Just two days ago we had a drop off GSW in the waiting room that got emergently intubated. I didn't have the opportunity to check to make sure suction was working, that the bougie was there, that the cuff on the ET tube was inflating etc. We just grabbed the guy off the floor and intubated him. I'm sure if an anesthesiologist saw my technique they could have found something wrong with it. But I would ask my fellow anesthesiologists to be mindful when finger pointing at the EM doc who was unprepared for the intubation, who had a peri-intubation arrest or some other catastrophic complication. These are difficult circumstances that don't always end well. And I know that you folks do intubate patients who are crashing and need an airway, this however is in essence the only time we intubate people.

Could an anesthesiologist have handled that airway? Most definitely. Maybe your training prepares you to keep calm under these difficult circumstances as well. But I can tell you that while we are very easily dismissed as doing everything in the hospital second best, our training is focused on staying calm under pressure and stabilizing a patient in extremis. Our patient populations and the circumstances of stabilizing a patient are extremely different. Every single intubation we do in the ED is because the patient desperately needs it, not because it is an elective case. It's true, the ENT case where the patient has had tons of neck radiation is a difficult airway that you guys manage with ease. But in the ED I'm called upon to intubate that same patient with a stomach full of food after he has been bagged by EMS and has vomitus all over the airway and is altered. If someone has a fat neck or OSA, I don't look back in the chart and see what their prior Mallampati was and whether or not they were a difficult intubation. We just go, and sometimes it ends poorly and we get very Monday morning quarterbacked by our anesthesia colleagues based on how we handled the airway. I would be lying if I said I wasn't resentful of that.

I don't deny there are anesthesiologists who are excellent at stabilizing patients in crisis. But I feel like the medical community at large needs to concede that EM as a specialty was created for that purpose. While you aren't simply there to babysit patient's in the GI suite who get routine colonoscopies, we are not just here to solely tend to the drug seekers and those that need primary care.

I 100%, unequivocally agree with everything you wrote here sans a few minor things (so I guess 98%). If you are the passenger pulled to pilot the aircraft, and that happened to you daily, you'd start planning ahead pretty quickly and Monday morning quarterback yourself. Planning is all mental and systems/logistics based. If when I was a resident a surgical emergency rolled in with no warning and my trauma room had no bougie, or my laryngoscope handle's battery was dead, or the ETT cuff was broken my attendings would've eaten me alive, TPS reports would flow, those are never events. Now I'm not saying that's your job to check cuffs etc, you have 10+ patients you're simultaneously caring for while I may have 4 (maybe consider 8 if you count various stages of recovery, preop, intraop), but these are Swiss cheese holes that need closed systematically.

And I promise you, for every day of lap choles in ASA 2-3's I have there are >3 days of sick hearts or ECMO pt's we haven't completed the last billable procedure on and 0.5-1 emergent bring back heart they extubated who is now crashing in tamponade.

But otherwise awesome post.

 

[Groove]

Interesting... Some of the responses or lack thereof have surprised me. Apparently we have a lot of different philosophical views on airway management in the hospital and the overall nature/skillset/purpose of EM. Well, call me a minority but I'm sorry guys and girls... I don't nor have I ever bought into the old derogatory descriptor "jack of all trades and master of none" applied by some to describe our specialty. I'm not a generalist. I'm a specialist. I'm also valued in the hospital because of my unique skillset as an EM doc.

Where I was trained, I was taught that we are indeed specialists in emergency medicine. I was taught that we are masters of the emergent airway, masters at resuscitation, masters at recognizing, diagnosing and managing the emergent and life threatening pathologies that span all subspecialties. We are masters at integration. I was trained that I should be just as good at managing these disease processes as other specialist in those early critical hours that take place in the ED. This was the purpose in creation of our "specialty". As for airway... I was trained to intubate messy, crashing, unstable patients. I'm trained to use a variety of tools including but not limited to laryngoscopes, cmacs, glidescopes, bougies, froyas, LMAs, intubating LMAs, fiberoptic bronchoscopes, blind intubations, retrograde intubations (at least in theory and on a cadaver, lol) , lighted stylet assisted intubations, awake intubation, rapid sequence intubations, and if need be... surgical cric and percutaneous trach. If there's one thing I've learned to respect, it's the airway. There is just so much that can go wrong, but if I can't ventilate a patient, then chances are another "specialist" would have a very hard time ventilating them also. I'm in no way the best, nor do I claim to be, but I was trained well and I'm confident in my abilities without being overconfident.

Does anesthesia intubate more than we do on the daily basis? Sure they do. I respect their sheer depth of expertise. They are better at fiberoptics than I am along with a ton of other stuff but I don't think that makes them a master at emergent airways. I don't think they intubate the traumatic, bleeding, crashing, rapidly decompensating pts as frequently as I do. That's just being realistic. They don't live in the ER. Unless you guys are working and training in a much different hospital environment, I have gone most of my career for the most part...never seeing anesthesia. We never consulted them in the ED in residency more than one one occasion that I can recall for airway assistance. I have consulted them a total of one time in my professional career and they never showed up until the airway was established (angioedema/cric). Actually, their CRNA showed up 30 mins later and looked incredibly grateful that he hadn't been around when the s*** hit the fan. I guess what I'm saying is... if you are so readily willing to hand the airway management mantle to anesthesia then where are they when it matters? I think they are great at what they do, in the environment where they do it but where is anesthesia at most floor or ICU codes? Who responds to most of those? The ER doc or the ICU doc. Have you ever known an anesthesiologist to be available or around at 2 or 3am in the ER when things get hairy? I haven't. I'll tell you who I call in those situations when I need a second set of hands or some assistance with a fiberoptic approach.... I call the pulmonary/cc guys. I'd personally rather have them on standby than anyone else. If I can't get them I'd rather have an EM trained colleague. That's just me. Everyone has their own skill set in the hospital and truth be told, nobody should be trying to be a cowboy thinking they are the best at something. Egos aside, it should always be what's best for the pt. If that's call anesthesia for backup in your facility then so be it but that hasn't been my experience. They are just never available.

So there, I said it. I don't think anesthesia is the intubation king. I think pulmonary/cc (or anesthesia/cc) working in the ICU and EM intubate more messy, crashing patients in suboptimal conditions than anesthesia does. That being said, I think they obviously intubate more frequently and are more facile at sophisticated and alternate approaches to airway management but I don't think that necessarily always helps them very much with intubation scenarios in the ER.

 

[Robotic Wis-Hipple]

I'm gonna have to disagree with that post though lol. Pulm? Really?

Where I trained we responded to all level 1 traumas in the ED at night or on call to be airway. Difficult airway team is anesthesia where I trained and where I currently work.

Now, I can totally buy the anesthesia Dept getting soft and not doing either of those in the average community hospital in this country. Atrophy occurs for sure.

But Pulm? Really?

 

[Fox800]

Where I trained we responded to all level 1 traumas in the ED at night or on call to be airway. Difficult airway team is anesthesia where I trained and where I currently work.

That's cool and all, but I can tell you that this is not the norm across the country.

But then again, I'm training at a program where we would never, ever call anesthesiology to handle an airway in the resus bay. It helps that we have every airway toy known to man.

 

[AdmiralChz]

Well, Groove, it's fine that you have no respect for Anesthesiology. I don't really care. But this...

I'll tell you who I call in those situations when I need a second set of hands and I plan on taking a look DL and if things get bad transitioning quickly to something like fiberoptic NT intubation... I call the pulmonary/cc guys. I'd personally rather have them on standby than anyone else.

When things get bad during a DL you transition to fiberoptic nasal, which takes the most time of all airway management and likely a horrendous choice with a bloodied airway, and you'd ask pulmonary for assistance? They'd laugh you right off the phone. Please review your society's difficult airway algorithm. And of course asking a consultant for backup isn't always an option - you have at best minutes if not seconds in a bad situation and sometimes the ER is on the opposite end of the hospital from the OR, anesthesiology can't be expect to get there in time for a true emergency.

I'm training at a program where we would never, ever call anesthesiology to handle an airway in the resus bay. It helps that we have every airway toy known to man.

"He who knows best knows how little he knows" - Thomas Jefferson. Respect the airway is all I will say - toys only get you so far.

 

[Robotic Wis-Hipple]

That's cool and all, but I can tell you that this is not the norm across the country.

But then again, I'm training at a program where we would never, ever call anesthesiology to handle an airway in the resus bay. It helps that we have every airway toy known to man.

Pretty sure I said that's not the norm nationwide in the very post you quoted, but I wanted a program where I'd put a few tubes thru the bubbles in patients who shotgunned their own jaw off.

But I'm also sure your Dept and their "we would never call anesthesia cuz we have all the toys" attitude/policy is silly and sort of what started this whole thing. Believing there isn't anything another specialist could teach you is the epitome of conscious ignorance.

 

[Groove]

Well, Groove, it's fine that you have no respect for Anesthesiology. I don't really care. But this...



When things get bad during a DL you transition to fiberoptic nasal, which takes the most time of all airway management and likely a horrendous choice with a bloodied airway, and you'd ask pulmonary for assistance? They'd laugh you right off the phone. Please review your society's difficult airway algorithm. And of course asking a consultant for backup isn't always an option - you have at best minutes if not seconds in a bad situation and sometimes the ER is on the opposite end of the hospital from the OR, anesthesiology can't be expect to get there in time for a true emergency.

Where did I say I didn't respect you guys? Of course I do. I just don't think you intubate our patient population with as much frequency as we do. That makes sense doesn't it? Second, you're trying to read mismanagement into a thought process I was typing rapidly. I'm not referring to a specific case or a specific approach to airway management so it makes for a piss poor opportunity to lecture on a hypothetical case you are creating in your head. That being said, I've most def called our pulm/cc doc for backup on similar cases and they are always very helpful and available. Does that surprise you?

 

[AdmiralChz]

Where did I say I didn't respect you guys? Of course I do. I just don't think you intubate our patient population with as much frequency as we do. That makes sense doesn't it? Second, you're trying to read mismanagement into a thought process I was typing rapidly. I'm not referring to a specific case or a specific approach to airway management so it makes for a piss poor opportunity to lecture on a hypothetical case you are creating in your head. That being said, I've most def called our pulm/cc doc for backup on similar cases and they are always very helpful and available. Does that surprise you?

The fact you call a specialist likely less comfortable with airway management than yourself rather than calling a consultant expert is where I inferred a lack of respect. So yes, I'm very surprised. And disappointed in your view of us, but hey life will go on.

You say you have training in just about all airway management methods available which is great, and I am sure you are proficient in all of them. You shouldn't need us then, or pulm.

 

[dchz]

toys only get you so far.

My ex girlfriend disagrees...

In all seriousness, the dunning-kruger effect is in full force here...

I believe there should be more respect between the two specialties, but where i come from, respect is earned by good patient care, not by typing on a forum board saying how others are unprepared for certain situations. (specially when one's scope and world view is narrow)

I'm going to purely speak as a patient advocate here, without the distinction of specialty or even the MD title. If you decide to go to fiber optic AFTER you've induced the patient, you're doing it wrong.

I guess what I'm saying is... if you are so readily willing to hand the airway management mantle to anesthesia then (1)where are they when it matters? I think they are great at what they do, in the environment where they do it but where is anesthesia at most floor or ICU codes? Who responds to most of those? The ER doc or the ICU doc. Have you ever known an anesthesiologist to be available or around at 2 or 3am in the ER when things get hairy? I haven't. I'll tell you who I call in those situations when I need a second set of hands and I plan on taking a look DL and if things get bad transitioning quickly to something like fiberoptic NT intubation... I call the pulmonary/cc guys. I'd personally rather have them on standby than anyone else. If I can't get them I'd rather have an EM trained colleague. That's just me. Everyone has their own skill set in the hospital and truth be told, (2)nobody should be trying to be a cowboy thinking they are the best at something. (3)Egos aside, it should always be what's best for the pt. If that's call anesthesia for backup in your facility then so be it but that hasn't been my experience.

In response to your questions:

1) Anes responds to EVERY code blue in my training institution, a tertiary care center in a city of more than 1.4 million, an anesthesia resident (pgy-3 or pgy-4) is at EVERY code blue, period. (we often given the airway away, but if there is anything uncertain, the patient comes first). Every ICU intubation calls for anesthesia back up (again we give away the airway a lot, but the patient comes first). We are there at 2 or 3am in the ER so things DO NOT get hairy.

As a pgy-1 and pgy-2, i've intubated many trauma and ICU patients. I have news for you: your "crashing" icu patient isn't crashing as fast as a patient that had a full dose of propofol or a patient that just had he leg hacked off by a car or a patient that's just been shot 5 times in the abdomen. The physiology of shock behaves the same in the OR as it does in the ER. And the "messy and crashing" patient does not have their trachea magically shifted behind the esophagus. I don't know one pulm/cc fellow or attending that has ever thought they should have the airway when anesthesiologists are there.

2) which brings me to the point of cowboying:
Cowboying: I'm best at placing airways in the ER because i'm more experienced at traumatic airways than you.

3)I don't think anyone really believes you're putting your ego aside. it is because of ego that you created this thread in the first place. It is ego that led you to believe that pulm/cc will be better at bailing you out with a bronchoscope. It certainly will be ego that will hurt patients when the airway is not secured.

 

[nimbus]

Interesting... Some of the responses or lack thereof have surprised me. Apparently we have a lot of different philosophical views on airway management in the hospital and the overall nature/skillset/purpose of EM. Well, call me a minority but I'm sorry guys and girls... I don't nor have I ever bought into the old derogatory descriptor "jack of all trades and master of none" applied by some to describe our specialty. I'm not a generalist. I'm a specialist. I'm also valued in the hospital because of my unique skillset as an EM doc.

Where I was trained, I was taught that we are indeed specialists in emergency medicine. I was taught that we are masters of the emergent airway, masters at resuscitation, masters at recognizing, diagnosing and managing the emergent and life threatening pathologies that span all subspecialties. We are masters at integration. I was trained that I should be just as good at managing these disease processes as other specialist in those early critical hours that take place in the ED. This was the purpose in creation of our "specialty". As for airway... I was trained to intubate messy, crashing, unstable patients. I'm trained to use a variety of tools including but not limited to laryngoscopes, cmacs, glidescopes, bougies, froyas, LMAs, intubating LMAs, fiberoptic bronchoscopes, blind intubations, retrograde intubations (at least in theory and on a cadaver, lol) , lighted stylet assisted intubations, awake intubation, rapid sequence intubations, and if need be... surgical cric and percutaneous trach. If there's one thing I've learned to respect, it's the airway. There is just so much that can go wrong, but if I can't ventilate a patient, then chances are another "specialist" would have a very hard time ventilating them also. I'm in no way the best, nor do I claim to be, but I was trained well and I'm confident in my abilities without being overconfident.

Does anesthesia intubate more than we do on the daily basis? Sure they do. I respect their sheer depth of expertise. They are better at fiberoptics than I am along with a ton of other stuff but I don't think that makes them a master at emergent airways. I don't think they intubate the traumatic, bleeding, crashing, rapidly decompensating pts as frequently as I do. That's just being realistic. They don't live in the ER. Unless you guys are working and training in a much different hospital environment, I have gone most of my career for the most part...never seeing anesthesia. We never consulted them in the ED in residency more than one one occasion that I can recall for airway assistance. I have consulted them a total of one time in my professional career and they never showed up until the airway was established (angioedema/cric). Actually, their CRNA showed up 30 mins later and looked incredibly grateful that he hadn't been around when the s*** hit the fan. I guess what I'm saying is... if you are so readily willing to hand the airway management mantle to anesthesia then where are they when it matters? I think they are great at what they do, in the environment where they do it but where is anesthesia at most floor or ICU codes? Who responds to most of those? The ER doc or the ICU doc. Have you ever known an anesthesiologist to be available or around at 2 or 3am in the ER when things get hairy? I haven't. I'll tell you who I call in those situations when I need a second set of hands or some assistance with a fiberoptic approach.... I call the pulmonary/cc guys. I'd personally rather have them on standby than anyone else. If I can't get them I'd rather have an EM trained colleague. That's just me. Everyone has their own skill set in the hospital and truth be told, nobody should be trying to be a cowboy thinking they are the best at something. Egos aside, it should always be what's best for the pt. If that's call anesthesia for backup in your facility then so be it but that hasn't been my experience. They are just never available.

So there, I said it. I don't think anesthesia is the intubation king. I think pulmonary/cc (or anesthesia/cc) working in the ICU and EM intubate more messy, crashing patients in suboptimal conditions than anesthesia does. That being said, I think they obviously intubate more frequently and are more facile at sophisticated and alternate approaches to airway management but I don't think that necessarily always helps them very much with intubation scenarios in the ER.

That's funny. Tell that to our pulmonary/CC docs who call us when they think they have a difficult intubation. In the past 2 years I've also been called by the ED for an angioedema, an epiglottitis and 2 Ludwig's angina. Maybe it's just my hospital....but they call us. We never call them. We are inhouse 24/7. Sometimes they have to wait if we are doing a case.

 

[dchz]

I just don't think you intubate our patient population with as much frequency as we do. That makes sense doesn't it?

nope, it does not make sense to me: the arytenoid cartilages are still posterior to the glottis and anterior to the esophagus, as i said before. The tube still goes into the trachea, which does not all of a sudden open at the umbilicus once the patient steps into the ER. The blood that pools in the oropharynx still obey the laws of physics and get suctioned at the same specific gravity/weight.

The patient still lives once we oxygenate them.

 

[Groove]

The fact you call a specialist likely less comfortable with airway management than yourself rather than calling a consultant expert is where I inferred a lack of respect. So yes, I'm very surprised. And disappointed in your view of us, but hey life will go on.

You say you have training in just about all airway management methods available which is great, and I am sure you are proficient in all of them. You shouldn't need us then, or pulm.

Our pulm/cc docs fiber optically intubate all the time. They do perc trachs also. I think you guys who are in the ivory towers of academia or not too far removed will find that your hospital environment/policies/specialist skill sets will change dramatically as you work in different hospitals. Again, I don't know any other way to say it. I work in a shop where anesthesia is not available with regularity. On the most part, I have never worked in a hospital where they are routinely found in the ER. Period.

 

[IlDestriero]

Anesthesia having a good ol time bashing the ED and how much we suck at intubations.

EM residents claiming they are better at trauma/difficult airway management than anesthesiologists??

Have fun.

That's not what that thread was about at all.
It was about some ***** who thinks we aren't airway experts even though we do intubations on all comers, ICU, NICU, emergent surgeries, codes, airway emergency pages, etc. all day every day.
And as an aside, I honestly think a lot of "difficult airways" are difficult because people don't take the few seconds needed to properly position the patient and themselves. When I hear some kid is a difficult airway from the PICU or outside hospital but looks grossly normal, I almost always do a regular DL or maybe a VL, but intubate without the monitor, and probably 4 times out of 5 they're not that difficult, maybe a little anterior or small mouth opening that makes a MAC blade a problem.



--
Il Destriero

 

[Groove]

nope, it does not make sense to me: the arytenoid cartilages are still posterior to the glottis and anterior to the esophagus, as i said before. The tube still goes into the trachea, which does not all of a sudden open at the umbilicus once the patient steps into the ER. The blood that pools in the oropharynx still obey the laws of physics and get suctioned at the same specific gravity/weight.

The patient still lives once we oxygenate them.

You're a first or second year anesthesia resident, right?

 

[dchz]

Our pulm/cc docs fiber optically intubate all the time. They do perc trachs also. I think you guys who are in the ivory towers of academia or not too far removed will find that your hospital environment/policies/specialist skill sets will change dramatically as you work in different hospitals. Again, I don't know any other way to say it. I work in a shop where anesthesia is not available with regularity. On the most part, I have never worked in a hospital where they are routinely found in the ER. Period.

There are hospitals where the general surgeon has to step in and be the trauma surgeon when a healthy patient walks in after a firework accident. But that general surgeon that works there will never say I'm so much better at trauma surgery than my counterpart trauma surgeon at an ivory tower academia hospital because that trauma surgeon is never available where i work.

In rural communities, a lot of family practice docs deliver a lot of babies. But i have never met one who claims that fam doc are better at delivering babies than OB/Gyn because the family doc is more available or the OBs are bad at delivering babies in the family doc's "patient population"

A lot of ER attendings had to sew up cuts and etc during ED visits, but I have never met an ED doc saying they are better at sewing cuts than a plastic surgeon because the plastic surgeon only sews cuts in the OR.

I hope the analogy here is clear.

If not let me drive it home:

There are pulm/cc docs that intubate all the time, but i have never met one that says i'm better than anesthesiologists at intubating my patient population because my patient in the ICU is crashing and anesthesiologists only know how to intubate in the OR with controlled conditions.

 

[IlDestriero]

"The wise know their weakness too well to assume infallibility; and he who knows most, knows best how little he knows." - Thomas Jefferson, The Proceedings of the Government of the United States, in maintaining The Public Right to the Beach of the Missisipi, Adjacent to New-Orleans, Against the Intrustion of Edward Livingston (1812)[1]


--
Il Destriero

 

[Apollyon]

not by typing on a forum board saying how others are unprepared for certain situations. (specially when one's scope and world view is narrow)

But isn't that what the anesthesiology guys are doing in that other thread that was posted in the anesthesia forum, about EM docs?

And, it is telling, somewhat, when a whole bunch of anesthesiologists comes to a different forum to make their point. It has been said on SDN that going to another forum and telling that specialty that they suck is not appropriate. That hasn't come to pass whole hog, but hewing close to it.

And, as I've said many, many times on SDN, no thread is complete without MFing EM.

 

[dchz]

But isn't that what the anesthesiology guys are doing in that other thread that was posted in the anesthesia forum, about EM docs?

And, it is telling, somewhat, when a whole bunch of anesthesiologists comes to a different forum to make their point. It has been said on SDN that going to another forum and telling that specialty that they suck is not appropriate. That hasn't come to pass whole hog, but hewing close to it.

And, as I've said many, many times on SDN, no thread is complete without MFing EM.

For those of you that are missing the whole picture, @Groove posted the following in the thread he linked, then created this thread, then deleted the following post in the other thread after many of us have already read it. That's why it looks like there are a lot of backlash coming out of nowhere.

Awww, did you guys get tired of getting beat down by all the CRNA >= MDA bitch-slappery or screamed at by the surgeon in the OR and need to create a thread where you could all circle round and hate on the EM doc together to get your egos re-inflated? Did the little PGY1-4 EM resident hurt your feelings?

What a ridiculous thread. Do we need to consult you guys more in the ED to make you feel important? Cuz God knows you'll be soooo responsive at 3am for the variceal bleeder projectile vomiting blood or the 650lb beached whale with a COPD exacerbation barfing and aspirating partially digested big macs who's cyanotic who needs intubation. Want to take over airway in the ED? Want us to consult you to the bedside STAT for every "intubation assessment"? What about the floor codes, do you want to have to respond to all of those instead of the ER doc or the intensivist? (Because you're sooooo good at intubation)? Yeah, I thought not. I feel absolutely no need to brag on my airway skills in this thread or drop my pants and take part in this pissing contest nor do I need to defend ED docs everywhere. You've got docs who are airway masters and docs who are airway disasters and everywhere in between. If you think you guys are the only docs in the hospital with facile at airway management then you need to get out more.

One would hope we're reasonably good at disaster airway management in the ED because if it's you or your family member arriving in extremis with an indication for a definitive airway, it's going to be me or one of my colleagues standing over your bed intubating you and your loved one. Your anesthesia colleague is going to be nowhere to be found and can't remember the last time he/she was consulted in the ED and likely will have a hard time finding their way down here. C'mon, let's be honest though.... you'd send the CRNA.

Aww, I love you guys and girls! DON'T BE A HATER!

FRIENDLY EM DOC

With that said, i'm going to refrain from posting more in this thread, i have made all the points that are constructive.

 

[Groove]

It's always the PGY 1's and 2's that are convinced they know so much, lol.

For those of you that are missing the whole picture, @Groove posted the following in the thread he linked, then created this thread, then deleted the following post in the other thread after many of us have already read it. That's why it looks like there are a lot of backlash coming out of nowhere.

" Groove said: ↑
Awww, did you guys get tired of getting beat down by all the CRNA >= MDA bitch-slappery or screamed at by the surgeon in the OR and need to create a thread where you could all circle round and hate on the EM doc together to get your egos re-inflated? Did the little PGY1-4 EM resident hurt your feelings?

What a ridiculous thread. Do we need to consult you guys more in the ED to make you feel important? Cuz God knows you'll be soooo responsive at 3am for the variceal bleeder projectile vomiting blood or the 650lb beached whale with a COPD exacerbation barfing and aspirating partially digested big macs who's cyanotic who needs intubation. Want to take over airway in the ED? Want us to consult you to the bedside STAT for every "intubation assessment"? What about the floor codes, do you want to have to respond to all of those instead of the ER doc or the intensivist? (Because you're sooooo good at intubation)? Yeah, I thought not. I feel absolutely no need to brag on my airway skills in this thread or drop my pants and take part in this pissing contest nor do I need to defend ED docs everywhere. You've got docs who are airway masters and docs who are airway disasters and everywhere in between. If you think you guys are the only docs in the hospital with facile at airway management then you need to get out more.

One would hope we're reasonably good at disaster airway management in the ED because if it's you or your family member arriving in extremis with an indication for a definitive airway, it's going to be me or one of my colleagues standing over your bed intubating you and your loved one. Your anesthesia colleague is going to be nowhere to be found and can't remember the last time he/she was consulted in the ED and likely will have a hard time finding their way down here. C'mon, let's be honest though.... you'd send the CRNA.

Aww, I love you guys and girls! DON'T BE A HATER!

FRIENDLY EM DOC"

With that said i'm going to refrain from posting more in this thread, i have made all the points that are constructive.

LOL, dude it was a derogatory and insulting thread with a lot of EM bashing going on. It pissed me off. I vented, then I felt bad about posting it. So what?

Shouldn't a brand new PGY2 resident be studying instead of trolling the EM forum?

 

[Angry Birds]

Where the hell are these mythical places where the anesthesiologist comes to all code blues? Hot damn I wish that were the case where I work and have worked.

 

[Vandalia]

Interesting... Some of the responses or lack thereof have surprised me. Apparently we have a lot of different philosophical views on airway management in the hospital and the overall nature/skillset/purpose of EM. Well, call me a minority but I'm sorry guys and girls... I don't nor have I ever bought into the old derogatory descriptor "jack of all trades and master of none" applied by some to describe our specialty. I'm not a generalist. I'm a specialist. I'm also valued in the hospital because of my unique skillset as an EM doc.g patients in suboptimal conditions than anesthesia does. That being said, I think they obviously intubate more frequently and are more facile at sophisticated and alternate approaches to airway management but I don't think that necessarily always helps them very much with intubation scenarios in the ER.

I think you are making a distinction without a difference. There are specialties that have a generalist aspect since they end up seeing everything that walks through the door no matter the age, gender, organ system, or pathology. Or at least something pretty close to seeing everyone. This is in contrast to those specialties that focus on incredibly tiny aspects of incredibly tiny parts of the population, e.g., a pediatric neuro-ophthalmologist. EM provides very unique and specific skills that make it a specialty but it also sees everyone that walks through the door that gives it a generalist aspect. General surgery is a specialty. There are specialties that have their turf pretty much to themselves, then there are specialties that have overlaps with other specialties. If you draw one of those old Venn-diagrams, the specialty of EM shares space with just about every other specialty. Those specialties are generally better at the fundamental skills that are proper to their specialty, but that does not make them better at Emergency Medicine. Being able to intubate, or read an EKG, or splint a fracture does not make you an EM physician.

 

[Angry Birds]

I think you are making a distinction without a difference. There are specialties that have a generalist aspect since they end up seeing everything that walks through the door no matter the age, gender, organ system, or pathology. Or at least something pretty close to seeing everyone. This is in contrast to those specialties that focus on incredibly tiny aspects of incredibly tiny parts of the population, e.g., a pediatric neuro-ophthalmologist. EM provides very unique and specific skills that make it a specialty but it also sees everyone that walks through the door that gives it a generalist aspect. General surgery is a specialty. There are specialties that have their turf pretty much to themselves, then there are specialties that have overlaps with other specialties. If you draw one of those old Venn-diagrams, the specialty of EM shares space with just about every other specialty. Those specialties are generally better at the fundamental skills that are proper to their specialty, but that does not make them better at Emergency Medicine. Being able to intubate, or read an EKG, or splint a fracture does not make you an EM physician.

We are the best.

 

[TheComebacKid]

There are hospitals where the general surgeon has to step in and be the trauma surgeon when a healthy patient walks in after a firework accident. But that general surgeon that works there will never say I'm so much better at trauma surgery than my counterpart trauma surgeon at an ivory tower academia hospital because that trauma surgeon is never available where i work.

In rural communities, a lot of family practice docs deliver a lot of babies. But i have never met one who claims that fam doc are better at delivering babies than OB/Gyn because the family doc is more available or the OBs are bad at delivering babies in the family doc's "patient population"

A lot of ER attendings had to sew up cuts and etc during ED visits, but I have never met an ED doc saying they are better at sewing cuts than a plastic surgeon because the plastic surgeon only sews cuts in the OR.

I hope the analogy here is clear.

If not let me drive it home:

There are pulm/cc docs that intubate all the time, but i have never met one that says i'm better than anesthesiologists at intubating my patient population because my patient in the ICU is crashing and anesthesiologists only know how to intubate in the OR with controlled conditions.

I don't think the analogy is valid.

Emergency medicine, by definition, is the management of emergencies. Family medicine, while they deliver babies, that is not at the core of what their specialty is. So of course it doesn't make sense for them to say they are better than OBGYNs.

Crashing airways are by definition, emergencies, and at the crux of what we do in the ED. So just because anesthesia does a billion more airways, that does not equate to anesthesia being the expert of the crashing airway. I for one do believe however that anesthesia has the skill set to manage these airways if they need to. But while I don't agree with everything Groove said, I think there is some truth to the notion that we see more bad airways than anesthesia.

While this thread probably comes off to most as a genital size measuring contest between two specialties, I think there's more to this that I would want my anesthesia colleagues to understand. You need to get out of this mindset that the ED is not "the best" at things, and they are second best at everything because a specialist can do it better. Our specialty was created because when the specialists were staffing the EDs and were not EM trained, patients were dying because they did not have the training in delivering emergency care. Even to this day, if you look at outcomes of EDs that are not staffed by board certified EM trained physicians, there are some very noticeable issues. There is evidence based studies that show that trauma surgeons managing unstable patients on their own have worse outcomes when they do not have a team that includes an ED physician. This is not to say that trauma "cannot handle traumas" or anesthesia "cannot handle crash airways". But we are the best at delivering emergency care in the form of identifying life threatening problems and taking immediate measures to stabilize patients and perform damage control resuscitation. Period. It's true, I can't perform definitive management of these problems, but I can hold them over until they get to the OR or the ICU better than anyone else. Why other specialties refuse to give this benefit and expertise to the ED is beyond me. It gets very old when other specialties who do not work in the emergency department nor been trained in emergency medicine, always have to lecture us on how they can manage emergencies in the emergency department better than we can. If they could, our specialty would be phased out.

We bring something different to the table, just like your specialty does. While many people will probably say that it is not worth it to take part in all this petty bickering, I for one think that we have earned our seat at the table and we start earning some respect from our friends upstairs. There needs to be a mutual respect. I would never in a billion years say that I have a better understanding of cardiac physiology and TEE's than a cardiac anesthesiologist. I even conceded that when it comes to overall management of airways, anesthesia are the experts. But yet you guys on the other side refuse to return the favor and acknowledge that when it comes to unstable crashing airways that we do a damn good job?

 

[anbuitachi]

Where the hell are these mythical places where the anesthesiologist comes to all code blues? Hot damn I wish that were the case where I work and have worked.

Anesthesiologists here go to all code blues here except in the ED and ICU unless called. ED calling anesthesiology here is definitely the least common. ICU calls very frequently.

I don't think the analogy is valid.

Emergency medicine, by definition, is the management of emergencies. Family medicine, while they deliver babies, that is not at the core of what their specialty is. So of course it doesn't make sense for them to say they are better than OBGYNs.

Crashing airways are by definition, emergencies, and at the crux of what we do in the ED. So just because anesthesia does a billion more airways, that does not equate to anesthesia being the expert of the crashing airway. I for one do believe however that anesthesia has the skill set to manage these airways if they need to. But while I don't agree with everything Groove said, I think there is some truth to the notion that we see more bad airways than anesthesia.

While this thread probably comes off to most as a genital size measuring contest between two specialties, I think there's more to this that I would want my anesthesia colleagues to understand. You need to get out of this mindset that the ED is not "the best" at things, and they are second best at everything because a specialist can do it better. Our specialty was created because when the specialists were staffing the EDs and were not EM trained, patients were dying because they did not have the training in delivering emergency care. Even to this day, if you look at outcomes of EDs that are not staffed by board certified EM trained physicians, there are some very noticeable issues. There is evidence based studies that show that trauma surgeons managing unstable patients on their own have worse outcomes when they do not have a team that includes an ED physician. This is not to say that trauma "cannot handle traumas" or anesthesia "cannot handle crash airways". But we are the best at delivering emergency care in the form of identifying life threatening problems and taking immediate measures to stabilize patients and perform damage control resuscitation. Period. It's true, I can't perform definitive management of these problems, but I can hold them over until they get to the OR or the ICU better than anyone else. Why other specialties refuse to give this benefit and expertise to the ED is beyond me. It gets very old when other specialties who do not work in the emergency department nor been trained in emergency medicine, always have to lecture us on how they can manage emergencies in the emergency department better than we can. If they could, our specialty would be phased out.

We bring something different to the table, just like your specialty does. While many people will probably say that it is not worth it to take part in all this petty bickering, I for one think that we have earned our seat at the table and we start earning some respect from our friends upstairs. There needs to be a mutual respect. I would never in a billion years say that I have a better understanding of cardiac physiology and TEE's than a cardiac anesthesiologist. I even conceded that when it comes to overall management of airways, anesthesia are the experts. But yet you guys on the other side refuse to return the favor and acknowledge that when it comes to unstable crashing airways that we do a damn good job?

I'm pretty sure a crashing airway is still an airway by definition.... what is so special about a crashing airway anyway... i dont see it. it's just another airway

 

[DeadCactus]

I'm pretty sure a crashing airway is still an airway by definition.... what is so special about a crashing airway anyway... i dont see it. it's just another airway

The patient the airway is connected to.

 

[Iso4ane]

Just one/two things I want to mention. Luck is when preparation meets opportunity. Anesthesia intubates in a controlled environment because we make it controlled environment. Our most basic checklist (any day 1 ca-1 would know) can be applied in any intubating situation and at minimum will tell you what you do and do not have on hand.

 

[Robotic Wis-Hipple]

I think most, if not all Anesthesiologists would concede that EM docs are the best at managing emergencies on all comers. And concede is the wrong word, it should be expect, as that is literally what your field and training is built upon just as you guys should all concede/expect that we are the best at inducing pharmacologic comas and navigating the seas of surgical intervention safely. These shouldn't even be debates. Anyone that's worked at a VA and been in EDs without EM trained docs can tell you that, I sure can. But the fact we are bickering on this is a sad proof that the suits are getting what they want.

And that's the real issue here. We each have made our respective fields appear far easier than they should look to the suits, MBAs, bean counters, and layman. Part of this is the advancement in safety we've authored. Part of this is the advancement in equipment i.e. the toys. Securing an airway now has never been easier with FOBs and glidescopes everywhere. The glide/cmac have made intubating so easy it can be done by any 14yo who ever played a video game. I'm not naive enough to think I'll ever in my career secure more difficult DL airways with a bougie etc than those that came before me etc. Sugammedex is already making me have to have real discussions with my residents or midlevels in the unit because they are incorrectly thinking they can not worry about inducing apnea any more, this is a simple thing but just another example of how advancements make things easier but don't necessarily mean the knowledge is there.

But our procedural skills are not what make us the respective specialists we are (well, maybe my TEE makes me the cardiac focused guy). It's not that you or I can intubate, as many of you have noted our CRNAs do that skillfully as well as you guys, intensivists etc. Its the when, why, and how that makes us airway or emergency experts. The real problem is many people are in fact showing they can do the algorithm or procedural aspects of our jobs, this is why hospitals are moving more and more to higher ratio care models, I'll be running 4 rooms while you guys staff a unit with 10-20 beds never having seen half the patients that flow thru it. So in that regard I think we each are dealing with the disrespect or the being taken for granted by those in power but not in the know.

 

[Groove]

I think you are making a distinction without a difference.

I'm no generalist...fortune cookies be damned!

 

[Groove]

Where the hell are these mythical places where the anesthesiologist comes to all code blues? Hot damn I wish that were the case where I work and have worked.

No kidding. I love these baby residents quoting all these "Well in my academic training institution anesthesia responds to all codes and is always available!" As if that's how things work out in the real world. It's going to be quite a shocker when they leave the nest.

 

[Dr Mantis Toboggan]

No kidding. I love these baby residents quoting all these "Well in my academic training institution anesthesia responds to all codes and is always available!" As if that's how things work out in the real world. It's going to be quite a shocker when they leave the nest.

I spent 12 years in academics and though I worked with many awesome off-service residents and faculty in that span there was frequently an "us-them" mentality between the ED and the various other specialists. The community hospital I work at now has a small group of great private anesthesiologists with a few CNRAs. We in the ED will respond to codes and run up and do emergent unit intubations at night: we have their back and they have ours.

Last time I needed them was for a head and neck CA patient who was hemorrhaging big time from his eroding neck mass. Rather than put him down solo we did a double set up where I had the neck prepared for a cric with blade in hand while he induced and stuck the tube after several looks and suction but no hypoxia. It was awesome, and I thanked him profusely for his help. Could I have done that all by myself? Maybe, but why take the chance?

Break down barriers, man. Respect and get to know your colleagues upstairs or downstairs. And if your shop is toxic, GTFO.

 

[ranvier]

We have their back and they have ours....kind of the opposite of deleting your post groove. Just because you don't have this relationship doesn't mean it isn't possible and even common.

 

[Groove]

We have their back and they have ours....kind of the opposite of deleting your post groove. Just because you don't have this relationship doesn't mean it isn't possible and even common.

Didn't you just call me annoying in the anesthesia forum and ask me to leave? LOL... Quit following me man. Let the thread die.

 

[nimbus]

I don't think the analogy is valid.


Crashing airways are by definition, emergencies, and at the crux of what we do in the ED. So just because anesthesia does a billion more airways, that does not equate to anesthesia being the expert of the crashing airway. I for one do believe however that anesthesia has the skill set to manage these airways if they need to. But while I don't agree with everything Groove said, I think there is some truth to the notion that we see more bad airways than anesthesia.

But yet you guys on the other side refuse to return the favor and acknowledge that when it comes to unstable crashing airways that we do a damn good job?

How is an "unstable crashing airway" different? It's a matter of putting a tube in a hole.

 

[Birdstrike]

Ignore the inter-specialty bashing. It's just, "My **** is bigger than your ****" nonsense.

 

[doctalaughs]

Ignore the inter-specialty bashing. It's just, "My **** is bigger than your ****" nonsense.

You guys are hilarious. But seriously, I'm a dermatologist and you have to admit I'm the TRUE king of the airway. I only set foot in the hospital a few times a year but I always make sure to intubate a few crashing patients on my way to see that drug rash.

On that note, once when I was a resident I was called in to see a "super weird" mole that turned out to be a chocolate chip melted onto the pannus of a morbidly obese woman. I guess we all have our strengths and weaknesses.


Sent from my iPhone using SDN mobile

 

[DarioArgento]

I learned to intubate from anesthesiologists and I've been very happy to have them come help for the handful of disaster airways I've come across so far in residency. We are all on the same team, trying to take care of patients.

 

[Janders]

I don't get all the black-and-white generalizations.

If by "anesthesia" you mean an anesthesia doc who does critical care that works in a busy level 1 center where they act as first responders to codes and run airways at all traumas--- well crap I bet that guy is better at airway than me! any airway!

If by "anesthesia" you mean the doc who's been out of residency 12 years and mostly does day surgery in an outpatient surgicenter with occasional days at a low-acuity community hospital with no code / trauma responsibility? I'd prefer to handle the difficult crash airway myself, thank you.

I imagine our specialties' skill sets, especially with the very specific topic of "crash bloody airway", have something of overlapping bell curves.

Anecdotes from 5years of data from a small-medium community hospital--
Anesthesia has been called to the ED 2x, once for an overnight dual-setup angioedema (ended up getting the tube with a dual-provider 3-handed moderate-sedation glidescope, and smiled and shook hands afterwards), and once for an angioedema they easily got with nasal fiberoptic.
EM has been called to the PACU 1x, for a failed airway after-hours (crash re-intubation after surgery), where EM placed an intubating LMA, resuc'd the patient, and then got the tube.

No one gloats. We are happy to help each other out. Often it doesn't depend the specialty, but the skill of the provider, or in a small place late at night-- just that another component physician is around to do anything to help.

 

[Old_Mil]

. There is evidence based studies that show that trauma surgeons managing unstable patients on their own have worse outcomes when they do not have a team that includes an ED physician.

Think about that for a second... When was the last time you saw a Trauma Surgeon take advice about anything from anyone?

In all seriousness, I heard the propaganda in residency as well. Post residency, working with colleagues who for the most part were FM trained with a year of EM fellowship, they are every bit as competent at what we do as we are.

 

[WilcoWorld]

Think about that for a second... When was the last time you saw a Trauma Surgeon take advice about anything from anyone?

About two weeks ago when I recommended obtaining and then interpreted the ECG on our 59 yo male single-vehicle MVC patient - it showed an acute MI.

 

[Angry Birds]

Let's both agree: ER docs and anesthesiologists are great and our shared enemy is the surgeon.

 

[IlDestriero]

Let's both agree: ER docs and anesthesiologists are great and our shared enemy is the surgeon.

Our shared enemy is the hospital administration. Though one surgeon might have made the list yesterday.


--
Il Destriero

 

[Apollyon]

Our shared enemy is the hospital administration. Though one surgeon might have made the list yesterday.


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Il Destriero