Fire during intubation

[Nephro critical care]

So I have this patient with respiratory failure who I am preoxygenating with nasal cannula prior to RSI. I took the cannula off and intubated the patient and he developed ventricular fibrillation immediately afterwards. Code was called and the nurse shocked him. Patient came back to sinus rhythm with the shock but bang at the same time the patient's bedsheets caught fire. Nurses frantically tried to extinguish the fire and then I who was at the head of the bed picked up the sheets and shook them until the fire was extinguished. Turns out the nasal cannula were still on the bed blowing oxygen on the patient and the defibrillator paddles sparked a fire . No harm was done but I was thinking both the patient and me at the head of the bed would have easily been turned into blackened Jamaican Jerk chicken.

Beware of nasal cannulas during defibrillation .

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[deleted171991]

Interesting. Worth a case report.

 

[BigRedBeta]

As my wife said "well that's...shocking"
Sorry that's terrible. Have heard of issues like this in the OR, but never with NC flow. What was the flow rate?

 

[Nephro critical care]

It was 15 liters i.e maxed out . When the person was defibrillated a spark shot out from the paddles towards the cannula but the cannula being not flammable did not catch fire . But the bed sheets had some nylon mixed in so they did.

 

[drmwvr]

Beware of nasal cannulas during defibrillation .

Unrelated comment here, but why take them off for intubation? Might give some advantage in prolonging apneic oxygenation.

Back on topic, we've switched to adhesive pads for just such issues.

 

[Nephro critical care]

I tend to take the cannulas off when I start bagging . The cannulas prevent a good seal . Some of this is probably dogma ground into me from training. My standard intubation RSI procedure in ICU is preoxygenate with cannulas ( which doesn't necessarily bring up sats in ARDS unless using bipap ) . Then give 2 mg of versed and then etomidate (0.4 mg / kg ) . After etomidate usually pt will tolerate oral airway . Then bag up rapidly to sats 95% or greater ad make sure they can be bagged. Bag for 2 -3 minutes but if you bag too long then pt's stomach will fill up with air and there is risk for vomiting. Then succinylcholine ( or roc if hyperkalemia or contraindications to sux ) and then tube 1 minute later. Works like a charm .

Follow with propofol gtt and keep Levophed ready. If vent dysynchrony in 1st hour give rocuronium 1 dose after additional Versed, fentanyl , propofol . Invest in A -line at 1st sign of hypotension. 1st hour after intubation and rocuronium is golden time for procedures like central line , Aline and bronchoscopy.

 

[tartesos]

I tend to take the cannulas off when I start bagging . The cannulas prevent a good seal . Some of this is probably dogma ground into me from training. My standard intubation RSI procedure in ICU is preoxygenate with cannulas ( which doesn't necessarily bring up sats in ARDS unless using bipap ) . Then give 2 mg of versed and then etomidate (0.4 mg / kg ) . After etomidate usually pt will tolerate oral airway . Then bag up rapidly to sats 95% or greater ad make sure they can be bagged. Bag for 2 -3 minutes but if you bag too long then pt's stomach will fill up with air and there is risk for vomiting. Then succinylcholine ( or roc if hyperkalemia or contraindications to sux ) and then tube 1 minute later. Works like a charm .

Follow with propofol gtt and keep Levophed ready. If vent dysynchrony in 1st hour give rocuronium 1 dose after additional Versed, fentanyl , propofol . Invest in A -line at 1st sign of hypotension. 1st hour after intubation and rocuronium is golden time for procedures like central line , Aline and bronchoscopy.

Neat layout.
Doesn't sound too rapid to me.

And you forgot the #notmedicaladvice.



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[tartesos]

Interesting. Worth a case report.

At least a poster!


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[Nephro critical care]

It's not that rapid but I feel 5 minutes of preparation/ preoxygenation / or bagging to sats > 95 % is worth it if you can get an extra 3 minutes while you are getting the tube in on the 1st attempt. Invariably happens that if pts sats are 89 - 90% at the time of intubation attempt I will fumble with the glidoscope stylet in the back of the oropharynx and then nurse will inform me sats are 80% and I will have to pull out and restart bagging. And once you have given NMB it becomes harder to get sats up with bagging. By then I am getting Prinzematal's angina and it's not a nice feeling.

 

[SurfingDoctor]

One could always pre-oxygenate and intubate with high flow nasal cannula instead.

https://www.ncbi.nlm.nih.gov/m/pubmed/25479117/

 

[Nephro critical care]

That's indeed true . I have had a good experience intubating ARDS / high oxygen requirements with 100% high flow at 60 L / min. Sats remained 90% despite not being an easy airway. Only problem is the cost as our hospital RT department would get upset if we used an Optiflow device just for intubation because it would be wasted afterwards.

Also the fire that would have occurred with high flow oxygen from defibrillator paddles would be interesting . Probably the fire department would have to come to put it out.

 

[OTCAwesome]

It's not that rapid but I feel 5 minutes of preparation/ preoxygenation / or bagging to sats > 95 % is worth it if you can get an extra 3 minutes while you are getting the tube in on the 1st attempt. Invariably happens that if pts sats are 89 - 90% at the time of intubation attempt I will fumble with the glidoscope stylet in the back of the oropharynx and then nurse will inform me sats are 80% and I will have to pull out and restart bagging. And once you have given NMB it becomes harder to get sats up with bagging. By then I am getting Prinzematal's angina and it's not a nice feeling.

In a true RSI you shouldn't be bagging the patient. Also after giving a paralytic, it should be easier to bag the patient, not harder

 

[Nephro critical care]

In a true RSI you shouldn't be bagging the patient. Also after giving a paralytic, it should be easier to bag the patient, not harder

I guess my technique would be defined as a ' modified ' RSI intubation. ICU intubations are different from ED intubations in that usually the patient has been sick for some time so less likely to have a full stomach. That is unless they were getting tube feeds. They are also going to be more hypoxic so you will have less time to get the tube in so better have sats 99 % prior to 1st attempt.

To me at least the big fat dudes become harder to bag once I give the sux. Their oropharynx just collapses .

 

[chocomorsel]

I guess my technique would be defined as a ' modified ' RSI intubation. ICU intubations are different from ED intubations in that usually the patient has been sick for some time so less likely to have a full stomach. That is unless they were getting tube feeds. They are also going to be more hypoxic so you will have less time to get the tube in so better have sats 99 % prior to 1st attempt.

To me at least the big fat dudes become harder to bag once I give the sux. Their oropharynx just collapses .

Maybe you are spending all your energy bagging a non paralyzed patient that by the time you are bagging them and they are relaxed, you muscles are fatigued. With proper technique, relaxant almost always helps with mask/bag ventilation.

Also, with patients who are septic, sick ice, etc, they may not have per se a "full stomach" worth of food, but what about delayed gastric emptying and higher content of stomach acids, illeus than healthy patients? If you make a decision to RSI a patient, especially a septic patent (GI induced especially) put that pressure on the cricoid and go for the tube as soon as he/she defasciculates. Been there, done that, a whole bunch of green **** spewed out into the airway.

 

[tartesos]

Maybe you are spending all your energy bagging a non paralyzed patient that by the time you are bagging them and they are relaxed, you muscles are fatigued. With proper technique, relaxant almost always helps with mask/bag ventilation.

Also, with patients who are septic, sick ice, etc, they may not have per se a "full stomach" worth of food, but what about delayed gastric emptying and higher content of stomach acids, illeus than healthy patients? If you make a decision to RSI a patient, especially a septic patent (GI induced especially) put that pressure on the cricoid and go for the tube as soon as he/she defasciculates. Been there, done that, a whole bunch of green **** spewed out into the airway.

True that with the back up. If it catches you by surprise( vomit or blood), you can always intubate the esophagus with an ETT and put it to the side of the mouth towards the staff you dislike the most( ), and have them hold the suction to it, it looks cool. and lets you keep the area clean and see better( Do not attempt this with a glidescope), no need to inflate the balloon but if you do remember to deflate on once you pass the cords....

 

[tartesos]

One could always pre-oxygenate and intubate with high flow nasal cannula instead.

Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hyp... - PubMed - NCBI

This works great. As a rule, if someone is on HFNC, do not ever take them off to intubate as I`ve seen some people do, max the flow and go straight to tubing, no need to bag, and you can bag on top of it if need be( not the best seal but....)
#notmedicaladvice

 

[turkeyjerky]

I guess my technique would be defined as a ' modified ' RSI intubation. ICU intubations are different from ED intubations in that usually the patient has been sick for some time so less likely to have a full stomach. That is unless they were getting tube feeds. They are also going to be more hypoxic so you will have less time to get the tube in so better have sats 99 % prior to 1st attempt.

To me at least the big fat dudes become harder to bag once I give the sux. Their oropharynx just collapses .

I really hate to derail the thread and apologize, but your technique is not even close to being RSI, modified or not, and you'll confuse yourself and others if you refer to it as such. Please just call it an intubation (using a suboptimal method for proxy gentian, sedation and paralysis...sorry)

 

[Nephro critical care]

HFNC helps especially as a pre-oxygenator on steroids . Our hospitals issue with HFNC is that the Airflow / Optiflow cannula is not cheap so our hospital gives us crap if we are using it for a short time just to preoxygenate prior to intubation. But it works great as a preoxygenator I have had a recent IPF with really s''''' sats who I preoxygenated and then they didn't desat while I took time to look during intubation. It won't help though if you fail on your intubation attempt and then desat only good bagging will bail you out at that point.

What's wrong about bagging ? it's what will save you if you fail to intubate . I have done 500 ICU intubations with maybe 5 fails where I needed to call anesthesia . I never learnt how to LMA . And yet I have never had trouble with desating because I could always bag them with a jaw thrust .

 

[psychbender]

There's nothing wrong with manually ventilating they patient. The problem is doing so and calling it "rapid sequence." RSI is push induction drugs, sux or high - dose roc, tube seconds later. Slowly working in induction drugs, using lower doses of relaxants, ventilating the patient while giving everything time to work is not rapid, but may be the best thing for the patient, depending on the clinical situation. My only gripe with your technique is that you use a lot of etomidate when it may not be necessary to use any at all, or only a tiny bit is needed (if I use it, I'll typically only give 0.1mg/kg in the critically ill). But, if it works, it works.

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[Hamhock]

I never learnt how to LMA . And yet I have never had trouble with desating because I could always bag them with a jaw thrust .

Wow.
Who taught you airway management? (which is very different than "intubation")

It's a matter of time, my friend...

HH

 

[Nephro critical care]

Wow.
Who taught you airway management? (which is very different than "intubation")

It's a matter of time, my friend...

HH

I guess the LMA is a good skill to learn. Unfortunately though for CC sometimes it's a hard skill to learn if you don't do it as ICU pts unlike OR pts get tubed every time never LMA . Sometimes in a pinch it's hard to get an LMA in so I just focused on good bag / mask skills . Maybe that's also fellowship training which has carried on. We would call anesthesia if expected difficult airway and sometimes they used an intubating LMA . If we were responsible and anesthesia weren't available and SHTF we would slash / cric. All fellows got a couple of crics that way . Maybe that's not right but that's the way we did it.

I haven't had that happen as an attending though. I have learnt to assess airway well prior to intubation and call anesthesia if I anticipate it's difficult which is probably 5 -10 % of the time . I ask anesthesia to let me try with them around and sometimes they comply but mostly they have a CRNA who wants 1st dibs and they let their CRNA do it. I have seen CRNAs mess up the intubation very badly too CRNAs should not do ICU intubation. They shove the tubes in with so much force and cause airway trauma and make it tough for the anesthesia attending as well.

 

[DrSnips]

Interesting. Worth a case report.

Case report? This is worth a RCT. You need one arm getting shocked with the nasal cannula, one arm shocked without it and then a control arm that starts off on fire.

 

[Nephro critical care]

Case report? This is worth a RCT. You need one arm getting shocked with the nasal cannula, one arm shocked without it and then a control arm that starts off on fire.

Nothing to snicker about . Everyone has an personal adverse event they learn from and maybe report / blog so that others don't make the same mistake. It's easy to forget nasal cannulas when you have an unexpected cardiac arrest during an intubation.

 

[shoal007]

this is a modified delayed sequence intubation. but none the less i wouldnt recommend it. Youre going to get aspiration at some point and a horrible airway. bipap them if theyre awake to get their sats up then rsi.

just imho. good luck

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[Nephro critical care]

Yeah I have changed my practice a little bit and am now doing more a straight RSI. Some of this modified delayed SI was fellowship learned dogma. Many attendings have a different way of doing things and pass it on to their fellows. When you get on into the real world you learn new ways of how the rest of the world does things .

 

[Random Anesthesiologist]

You're either doing an RSI, or you're not. This modified rsi business is not rsi. If your patient can tolerate a nasal cannula, they can tolerate true preoxygenation with a bag-mask and a seal and allowing them to spontaneously breathe with assistance. If my resident ever tried to intubate in the unit or in the OR the way you did, there would be a very long discussion at the very least and probably having them present at M&M. Find an anesthesiologist and follow them. Make them teach you the correct way to manage an airway, including an LMA. If you are going to be intubating anyone in your career, you'd better know the difficult airway algorithm and how to implement the steps. You don't usually have time in a can't-ventilate can't-intubate situation to wait for backup.


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[Random Anesthesiologist]

Also, I forgot to add, obtaining a high alveolar O2 concentration is important, but so is denitrogenation, which is very inefficient with a nasal cannula (ie open circuit).

 

[chessknt]

Also, I forgot to add, obtaining a high alveolar O2 concentration is important, but so is denitrogenation, which is very inefficient with a nasal cannula (ie open circuit).

Not if the NC is set to a flush rate:
http://www.annemergmed.com/article/S0196-0644(16)30296-7/pdf

it is loud and annoying but in the typical declining confused ICU patient the loud noise is usually more tolerable than having somebody standing over them smashing something on to their face.

 

[Nephro critical care]

Recently I was interviewing at a university program which doesn't even permit anesthesia to do ICU intubations. Anesthesia are considered airway experts for OR / ambulatory settings but not for critical care. Either the Pulm / CC guy gets the tube or if he can't then trauma surgery is back up for surgical airway.

 

[turkeyjerky]

Not if the NC is set to a flush rate:
http://www.annemergmed.com/article/S0196-0644(16)30296-7/pdf

it is loud and annoying but in the typical declining confused ICU patient the loud noise is usually more tolerable than having somebody standing over them smashing something on to their face.

That study compares flush rate 02 (ie turning the 02 all the way up--past 15 lpm) via a NRB to 15 lpm via a BVM. Doesn't have anything to do with a NC

 

[Angry Birds]

You're either doing an RSI, or you're not. This modified rsi business is not rsi. If your patient can tolerate a nasal cannula, they can tolerate true preoxygenation with a bag-mask and a seal and allowing them to spontaneously breathe with assistance. If my resident ever tried to intubate in the unit or in the OR the way you did, there would be a very long discussion at the very least and probably having them present at M&M. Find an anesthesiologist and follow them. Make them teach you the correct way to manage an airway, including an LMA. If you are going to be intubating anyone in your career, you'd better know the difficult airway algorithm and how to implement the steps. You don't usually have time in a can't-ventilate can't-intubate situation to wait for backup.


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I agree with all that you have said, but I have one issue with it, which may or may not be correct. However, I remember reading/learning that the bag-mask is not good for passive breathing... But, I guess you are side-stepping that issue with the 15 liters nasal cannula, and of course assisted ventilation as needed.

The reason I ask is that I often see medics and RT's just placing the bag-mask on the patient's mouth... But, the flow rate through a high-flo oxygen mask is much better. Correct?

Your thoughts?

 

[psychbender]

I agree with all that you have said, but I have one issue with it, which may or may not be correct. However, I remember reading/learning that the bag-mask is not good for passive breathing... But, I guess you are side-stepping that issue with the 15 liters nasal cannula, and of course assisted ventilation as needed.

The reason I ask is that I often see medics and RT's just placing the bag-mask on the patient's mouth... But, the flow rate through a high-flo oxygen mask is much better. Correct?

Your thoughts?

The key is "assist with ventilation." While holding the mask, one can tell when the patient is initiating a breath, and you simultaneously squeeze the bag to deliver your "assisted" tidal volume. An even better way to do this is with a Jackson-Reese circuit. A bonus with the Jackson-Reese is that if your mask seal is ****ty, you'll immediately know, as the bag doesn't inflate. Too often, I see interns, nurses, or RTs hammering away with the BVM, not realizing that they don't have **** for a seal, and all that oxygen is blowing across the patient's face.

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[MSmentor018]

in the OR when using a bovie that happens, esp on ENT cases but never seen that when zapping a pt out of v fib. easy case report for sure. and if you're still in training, hopefully a paid conference somewhere nice!

 

[coffeebythelake]

Recently I was interviewing at a university program which doesn't even permit anesthesia to do ICU intubations. Anesthesia are considered airway experts for OR / ambulatory settings but not for critical care. Either the Pulm / CC guy gets the tube or if he can't then trauma surgery is back up for surgical airway.

i'm an anesthesiologist. we routinely get called to deal with airway issues in the ICU. many of the units are staffed by ICU trained anesthesiologists not Pulm/CCM. you are horribly misinformed if you think we don't manage patients that are critically ill in the OR's.

also how many intubations do you think an anesthesiologist has performed vs pulm/ccm?? sounds like that program you interviewed at 1. has some huge turf issues and 2. loves to use video laryngoscopes and/or have a high rate of surgical airways

also reading your posts, why would you even do 15L by NC? then switch to ambu-bag? HFNC? doesn't make sense.

 

[deleted547339]

i'm an anesthesiologist. we routinely get called to deal with airway issues in the ICU. many of the units are staffed by ICU trained anesthesiologists not Pulm/CCM. you are horribly misinformed if you think we don't manage patients that are critically ill in the OR's.

also how many intubations do you think an anesthesiologist has performed vs pulm/ccm?? sounds like that program you interviewed at loves to use video laryngoscopes or have a high rate of surgical airways

Nice necrobump.

 

[chocomorsel]

i'm an anesthesiologist. we routinely get called to deal with airway issues in the ICU. many of the units are staffed by ICU trained anesthesiologists not Pulm/CCM. you are horribly misinformed if you think we don't manage patients that are critically ill in the OR's.

also how many intubations do you think an anesthesiologist has performed vs pulm/ccm?? sounds like that program you interviewed at 1. has some huge turf issues and 2. loves to use video laryngoscopes and/or have a high rate of surgical airways

also reading your posts, why would you even do 15L by NC? then switch to ambu-bag? HFNC? doesn't make sense.

He or she didn't say that anesthesiologists are experts in the OR and ambulatory places only. My understanding is that the program he or she interviewed at thought that.

Yes, the 15l NC makes no sense.

 

[Nephro critical care]

i'm an anesthesiologist. we routinely get called to deal with airway issues in the ICU. many of the units are staffed by ICU trained anesthesiologists not Pulm/CCM. you are horribly misinformed if you think we don't manage patients that are critically ill in the OR's.

also how many intubations do you think an anesthesiologist has performed vs pulm/ccm?? sounds like that program you interviewed at 1. has some huge turf issues and 2. loves to use video laryngoscopes and/or have a high rate of surgical airways

also reading your posts, why would you even do 15L by NC? then switch to ambu-bag? HFNC? doesn't make sense.

I did not state that pulm/CC is better than anesthesia. I just stated that at my CC interviews (n=3) CC is expected to be better than anesthesia at airway manage to in the ICU. On a CC interview when asked what you do for difficult intubations , the wrong answer will be that I call anesthesia. Nope you the CC guy is expected to be the master of difficult intubations in the crashing patient. I lost out on a very coveted job by stating I will call anesthesia for difficult intubations. They stated that for a difficult intubation they will have 2 intensivists ; one holding the video laryngoscope and one holding the fiber optic.
As far as whether anesthesia , EM or CC are better at critical care management , I’ll say that in the first 60 minutes anesthesia/EM will be as good at CC mgmt as a pulm/IM/CC if not better. Anesthesia especially if the diagnosis was already made. But as minutes turn to hours and hours to days , days to weeks and the patient is not getting better and family is getting antsy then the benefit of having the long term perspective favors the IM intensivist.

 

[CCM-MD]

I did not state that pulm/CC is better than anesthesia. I just stated that at my CC interviews (n=3) CC is expected to be better than anesthesia at airway manage to in the ICU. On a CC interview when asked what you do for difficult intubations , the wrong answer will be that I call anesthesia. Nope you the CC guy is expected to be the master of difficult intubations in the crashing patient. I lost out on a very coveted job by stating I will call anesthesia for difficult intubations. They stated that for a difficult intubation they will have 2 intensivists ; one holding the video laryngoscope and one holding the fiber optic.
As far as whether anesthesia , EM or CC are better at critical care management , I’ll say that in the first 60 minutes anesthesia/EM will be as good at CC mgmt as a pulm/IM/CC if not better. Anesthesia especially if the diagnosis was already made. But as minutes turn to hours and hours to days , days to weeks and the patient is not getting better and family is getting antsy then the benefit of having the long term perspective favors the IM intensivist.

You also recently called ER doctors monkeys.

 

[chocomorsel]

I did not state that pulm/CC is better than anesthesia. I just stated that at my CC interviews (n=3) CC is expected to be better than anesthesia at airway manage to in the ICU. On a CC interview when asked what you do for difficult intubations , the wrong answer will be that I call anesthesia. Nope you the CC guy is expected to be the master of difficult intubations in the crashing patient. I lost out on a very coveted job by stating I will call anesthesia for difficult intubations. They stated that for a difficult intubation they will have 2 intensivists ; one holding the video laryngoscope and one holding the fiber optic.
As far as whether anesthesia , EM or CC are better at critical care management , I’ll say that in the first 60 minutes anesthesia/EM will be as good at CC mgmt as a pulm/IM/CC if not better. Anesthesia especially if the diagnosis was already made. But as minutes turn to hours and hours to days , days to weeks and the patient is not getting better and family is getting antsy then the benefit of having the long term perspective favors the IM intensivist.

Well of course you are biased for IM as the best docs in the CCU. Makes sense. Honestly, I agree with you and am looking for a CCM program that has lots of medicine in it. Anesthesia CCM programs mostly focus on surgical ICU and Cardiac. I learned alot in my MICU rotation compared to my SICU rotations while a resident. And the patients were more complicated with weird, esoteric diseases that medicine residents spend time learning more than we do. But a sharp CCM anesthesiologist and ER person who reads a lot would likely catch up with the IM guys over time IMO.

Secondly, I think you and I know that you were surprised at the attitudes at these places you interviewed at because you know that the anesthesiologists are the airway masters simply by the sheer volume of intubations they do in comparison to all other specialities. That just seems to be a territorial thing and not necessarily what's best for the patients. People's ego getting in the way of good patient care. Not surprising.

You may want to thank your lucky stars that you weren't offered that job. Could be badness waiting to happen. You may end up with a bad outcome and or in court by being coerced to place an airway that you are incapable of.

 

[Nephro critical care]

That’s indeed true. That place that I was angling for had quite a few pulm/CC docs with a few malpractice suits to their name. While it’s good to be a master of a critical skill like an airway; there are a few people whose airway I will like to defer to anesthesia.

 

[deleted547339]

Well of course you are biased for IM as the best docs in the CCU. Makes sense. Honestly, I agree with you and am looking for a CCM program that has lots of medicine in it. Anesthesia CCM programs mostly focus on surgical ICU and Cardiac. I learned alot in my MICU rotation compared to my SICU rotations while a resident. And the patients were more complicated with weird, esoteric diseases that medicine residents spend time learning more than we do. But a sharp CCM anesthesiologist and ER person who reads a lot would likely catch up with the IM guys over time IMO.

Secondly, I think you and I know that you were surprised at the attitudes at these places you interviewed at because you know that the anesthesiologists are the airway masters simply by the sheer volume of intubations they do in comparison to all other specialities. That just seems to be a territorial thing and not necessarily what's best for the patients. People's ego getting in the way of good patient care. Not surprising.

You may want to thank your lucky stars that you weren't offered that job. Could be badness waiting to happen. You may end up with a bad outcome and or in court by being coerced to place an airway that you are incapable of.

Simple numbers isn’t what makes mastery; it’s focused, intentional practice. Although, obviously, more exposure makes focused practice easier. I would say that someone who does a skill 1,000 times with little cognitive exertion may not be as well served as someone who does it 100 with intentionality.

 

[deleted547339]

I did not state that pulm/CC is better than anesthesia. I just stated that at my CC interviews (n=3) CC is expected to be better than anesthesia at airway manage to in the ICU. On a CC interview when asked what you do for difficult intubations , the wrong answer will be that I call anesthesia. Nope you the CC guy is expected to be the master of difficult intubations in the crashing patient. I lost out on a very coveted job by stating I will call anesthesia for difficult intubations. They stated that for a difficult intubation they will have 2 intensivists ; one holding the video laryngoscope and one holding the fiber optic.
As far as whether anesthesia , EM or CC are better at critical care management , I’ll say that in the first 60 minutes anesthesia/EM will be as good at CC mgmt as a pulm/IM/CC if not better. Anesthesia especially if the diagnosis was already made. But as minutes turn to hours and hours to days , days to weeks and the patient is not getting better and family is getting antsy then the benefit of having the long term perspective favors the IM intensivist.

We all get it, you think internists should rule the ICU and no one else can equal you special snowflakes. You’ve said your peace, now leave it alone.

 

[Siggy]

We all get it, you think internists should rule the ICU and no one else can equal you special snowflakes. You’ve said your peace, now leave it alone.

Wait, because you say a conversation is over, it's magically over? I think the snowflake tag is being thrown in the wrong direction on this one if that comment triggered you.

 

[deleted547339]

Wait, because you say a conversation is over, it's magically over? I think the snowflake tag is being thrown in the wrong direction on this one if that comment triggered you.

No, it’s just he has beat this dead horse many times and hopefully we can leave it alone rather than continuing along the same path.

 

[Nephro critical care]

Well I have tried to leave this discussion alone but every other day an ED physician does something while billing CC time that gets my goat.
Latest was last week when a poor 83 year old soul with metastatic cancer on hospice, DNR/I finally coded and a panicky aide at the nursing home called 911. EMS arrive and for some reason no one communicated that he is a DNR. EMS starts CPR and gets him to the ED where a testosterone packed ED doc got him back from the dead after 30 minutes of CPR in the meantime breaking each and every rib he had. Then the family arrived waving a white flag and affirms the DNR/I/CMO status. The ED doc then honored the DNR but insisted the patient has to come to the ICU for extubation. I gruffly accepted this palliative admission.
After patient arrived to ICU the ED physician got a call from the radiologist saying he saw a pneumothorax on the post code CXR from all the CPR. The ED doc proceeded to page me stat insisting he wanted to come to the ICU and put in a chest tube before the patient got palliatively extubated. I told him to have mercy and leave this poor soul alone.
I billed a discharge < 30 minutes while the ED billed 75 minutes of CC time.

 

[deleted547339]

Well I have tried to leave this discussion alone but every other day an ED physician does something while billing CC time that gets my goat.
Latest was last week when a poor 83 year old soul with metastatic cancer on hospice, DNR/I finally coded and a panicky aide at the nursing home called 911. EMS arrive and for some reason no one communicated that he is a DNR. EMS starts CPR and gets him to the ED where a testosterone packed ED doc got him back from the dead after 30 minutes of CPR in the meantime breaking each and every rib he had. Then the family arrived waving a white flag and affirms the DNR/I/CMO status. The ED doc then honored the DNR but insisted the patient has to come to the ICU for extubation. I gruffly accepted this palliative admission.
After patient arrived to ICU the ED physician got a call from the radiologist saying he saw a pneumothorax on the post code CXR from all the CPR. The ED doc proceeded to page me stat insisting he wanted to come to the ICU and put in a chest tube before the patient got palliatively extubated. I told him to have mercy and leave this poor soul alone.
I billed a discharge < 30 minutes while the ED billed 75 minutes of CC time.

Yes, an ER doc aggressively and successfully resuscitating a patient who he has no idea the code status of, billing for his time, and then finding out said patient is DNR, then asked me the ICU doc to do his job by providing end of life services in an appropriate setting while allowing him to get back to taking care of a busy ER that has since gotten backed up while he has been entirely focused on caring for this patient in cardiac arrest seems entirely inappropriate. What a jerk.

 

[CCM-MD]

Yes, an ER doc aggressively and successfully resuscitating a patient who he has no idea the code status of, billing for his time, and then finding out said patient is DNR, then asked me the ICU doc to do his job by providing end of life services in an appropriate setting while allowing him to get back to taking care of a busy ER that has since gotten backed up while he or she has been entirely focused on caring for this patient in cardiac arrest seems entirely inappropriate. What a jerk.

According to him: he was "born nice".