RSI Roc before etomidate?

[WilcoWorld]

I really respect @Arch Guillotti so please don't take this the wrong way:

Anesthesiologists are clearly the experts on OR intubation, but when it comes to the management of undifferentiated, crashing patients Emergency Physicians are the experts. Of course, that doesn't mean we can't be wrong or get better. But let's remember that the ER =/= the OR

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[southerndoc]

I really respect @Arch Guillotti so please don't take this the wrong way:

Anesthesiologists are clearly the experts on OR intubation, but when it comes to the management of undifferentiated, crashing patients Emergency Physicians are the experts. Of course, that doesn't mean we can't be wrong or get better. But let's remember that the ER =/= the OR

Keep in mind that this isn't true at all facilities. Some facilities have anesthesia intubate in their ER's (especially trauma patients).

 

[WilcoWorld]

Keep in mind that this isn't true at all facilities. Some facilities have anesthesia intubate in their ER's (especially trauma patients).

I'm aware of practice variation. I'm speaking more broadly about the specialties rather than individual physicians. Of course there are some EP's who suck (I assume this is true of some Anesthesiologists as well, but I'll stop short of saying it since I (fortunately) do not have personal knowledge of any).

Management of the undifferentiated crashing patient is the purview of Emergency Medicine. That's the claim I want to make.

 

[Arch Guillotti]

Management of the undifferentiated crashing patient is the purview of Emergency Medicine. That's the claim I want to make.

Of course it is however many anesthesiologists get a "healthy" dose of crashing patients in the ICU although most are least somewhat differentiated at that point. We can't always just drop whatever we are doing and run up there either so every now and then so unfortunately sometimes patients are at the Hindenburg phase when we get up there.

 

[Radetzky]

At the end of the day none of these little practice variations we debate make any difference to patients. Paralytic first vs second, sux vs roc, blah blah. As long as the tube goes through the cords and the bp doesn’t crash too much. That’s mostly dependent on the skill of the physician, however they choose to skin the cat

 

[GassYous]

I really respect @Arch Guillotti so please don't take this the wrong way:

Anesthesiologists are clearly the experts on OR intubation, but when it comes to the management of undifferentiated, crashing patients Emergency Physicians are the experts. Of course, that doesn't mean we can't be wrong or get better. But let's remember that the ER =/= the OR

Yeah anesthesiologists never get crashing patients ever. They always come with perfect histories, everything is normal, we have weeks to optimize the patient, airways are always easy. And being in the ED makes the airway 10x harder even with the same patient.

 

[Apollyon]

Just ask the other mod in the anesthesia forum. He said the myalgias were much worse than postop pain from an operation.

I was just thinking of that. IIRC (because I'm not going searching for the post), it was an ORIF of one of his forearms after a bike accident. He said that he felt like "I was hit by a truck" after the sux.

 

[thegenius]

I really respect @Arch Guillotti so please don't take this the wrong way:

Anesthesiologists are clearly the experts on OR intubation, but when it comes to the management of undifferentiated, crashing patients Emergency Physicians are the experts. Of course, that doesn't mean we can't be wrong or get better. But let's remember that the ER =/= the OR

All I will say...and this is out of due respect...is if I were a patient and crashing in the ER, I would rather have an anesthesiologist intubate me than an ER doc. Experience with 5,000 tubes beats 300 tubes

 

[WilcoWorld]

Yeah anesthesiologists never get crashing patients ever. They always come with perfect histories, everything is normal, we have weeks to optimize the patient, airways are always easy. And being in the ED makes the airway 10x harder even with the same patient.

I'm curious, did you read my post and conclude that I was making any such claims? Certainly wasn't my intention.

 

[ProwlerturnGas]

Some things I have noticed in this thread

Push your own meds on induction. Saves the questions from those that aren’t familiar with what you’re doing. Paralytic before sedation or vice versa I really don’t think matters too much. I’ve done it both ways.

If you want fast phenylephrine, when you start your shift get a 100ml bag if fluid and inject 10 mg of phenylephrine into it. That will give you 0.1 mg/ml of phenylephrine given in 1-2 ml aliquots for hypertension. You only need to find an empty syringe. Keep bag with you. Easy

 

[Rekt]

All I will say...and this is out of due respect...is if I were a patient and crashing in the ER, I would rather have an anesthesiologist intubate me than an ER doc. Experience with 5,000 tubes beats 300 tubes

Lets be real, the anesthesiologist would bring his CRNA down to do it for him.

 

[clibby]

Some things I have noticed in this thread

Push your own meds on induction. Saves the questions from those that aren’t familiar with what you’re doing. Paralytic before sedation or vice versa I really don’t think matters too much. I’ve done it both ways.

If you want fast phenylephrine, when you start your shift get a 100ml bag if fluid and inject 10 mg of phenylephrine into it. That will give you 0.1 mg/ml of phenylephrine given in 1-2 ml aliquots for hypertension. You only need to find an empty syringe. Keep bag with you. Easy

In the ED, just getting to the head of the bed in most rooms is a challenge. To leave the head of the bed to push meds and then get back in position is not safe. If you have time to set the tubing up to do it at the head of the bed, then maybe, but that is a cognitive load for you, your nurses will be thrown for a loop which is not good in a resus, and there may be protocols in some departments. It also means I can't be bagging the patient and sometimes it is just me and a nurse +/- an RT depending on the site, urgency of intubation, and busyness of the RTs. We aren't intubating stable people, often don't have much time to optimize things like lines/tubing, and often do it in very cramped rooms. I would love to always intubate in a large resus room with ample room around the bed, but that just isn't a reality in many EDs.

As for the phenylephrine, that suggestion perfectly highlights the difference in the worlds of the OR and ED. No pharmacy is giving me a bag of phenylephrine without an order attached to a patient. What is easy to obtain for an anesthesiologist in the OR is not easy to obtain pretty much anywhere else. Everything that comes from pharmacy needs an order including the Pyxis. Overrides on the Pyxis are attached to a patient. The notion that this is an easy ask is just out of touch with life in the ED.

 

[turkeyjerky]

Lets be real, the anesthesiologist would bring his CRNA down to do it for him.

Shots fired!

 

[southerndoc]

And being in the ED makes the airway 10x harder even with the same patient.

It is 10x harder because we're not anesthesiologists. In all seriousness, I feel confident in airway management, but I will never say I'm better than the person who spent 4 years training to manage airways and has been doing so numerous times per day since finishing residency. Any ER doc who thinks they are better at airway management than an anesthesiologist is either fooling themselves or full of themselves. I would never tell a cardiologist I'm better at them than reading an EKG either.

 

[IMGASMD]

Lets be real, the anesthesiologist would bring his CRNA down to do it for him.

How did you know that’s exactly what happened the last time I had to go to ED to bail out an ED physician.

She called the CRNA. CRNA thought if an ED physician called for back up, must be bad. CRNA knows that I stayed in house, asked me to come. I walked into an “angioedema”. Patient is talking, Sat high 90s on RA. Nothing is set up, no suction, no ambu, no difficult airway cart. She was standing there with a glide and thought she was ready to go.

I looked at the ED physician and said, “no thank you, I am out of here.” And told our CRNA to get out of there too. I’d rather be called in a true emergency situation than standing there holding your incompetent a$$’s hand.

Just like there are subpar anesthesiologists, as you have implied here, some of your colleagues probably shouldn’t be practicing medicine especially in “emergent” situations.

 

[ProwlerturnGas]

In the ED, just getting to the head of the bed in most rooms is a challenge. To leave the head of the bed to push meds and then get back in position is not safe. If you have time to set the tubing up to do it at the head of the bed, then maybe, but that is a cognitive load for you, your nurses will be thrown for a loop which is not good in a resus, and there may be protocols in some departments. It also means I can't be bagging the patient and sometimes it is just me and a nurse +/- an RT depending on the site, urgency of intubation, and busyness of the RTs. We aren't intubating stable people, often don't have much time to optimize things like lines/tubing, and often do it in very cramped rooms. I would love to always intubate in a large resus room with ample room around the bed, but that just isn't a reality in many EDs.

As for the phenylephrine, that suggestion perfectly highlights the difference in the worlds of the OR and ED. No pharmacy is giving me a bag of phenylephrine without an order attached to a patient. What is easy to obtain for an anesthesiologist in the OR is not easy to obtain pretty much anywhere else. Everything that comes from pharmacy needs an order including the Pyxis. Overrides on the Pyxis are attached to a patient. The notion that this is an easy ask is just out of touch with life in the ED.

That first paragraph makes me cringe. I am honestly embarrassed for you.

Phenylephrine should be in the arsenal of an ED physician. And be easily obtainable fast. If it’s not then you need to have a frank discussion with your pharmacist.

And BTW, I have much experience in both EDs and ICUs. I do very much know what goes down.

 

[Rekt]

How did you know that’s exactly what happened the last time I had to go to ED to bail out an ED physician.

She called the CRNA. CRNA thought if an ED physician called for back up, must be bad. CRNA knows that I stayed in house, asked me to come. I walked into an “angioedema”. Patient is talking, Sat high 90s on RA. Nothing is set up, no suction, no ambu, no difficult airway cart. She was standing there with a glide and thought she was ready to go.

I looked at the ED physician and said, “no thank you, I am out of here.” And told our CRNA to get out of there too. I’d rather be called in a true emergency situation than standing there holding your incompetent a$$’s hand.

Just like there are subpar anesthesiologists, as you have implied here, some of your colleagues probably shouldn’t be practicing medicine especially in “emergent” situations.

If your angioedema is hypoxic then you've made a grave mistake.

I have never and will never call anesthesia for an airway. I don't see the point with current EM training. And I would especially never let some mid level CRNA anywhere near any of my patients in the ED.

 

[Janders]

That first paragraph makes me cringe. I am honestly embarrassed for you.

Phenylephrine should be in the arsenal of an ED physician. And be easily obtainable fast. If it’s not then you need to have a frank discussion with your pharmacist.

And BTW, I have much experience in both EDs and ICUs. I do very much know what goes down.

Please come have a frank discussion with my community hospital pharmacy about giving me access to ANY medication to mix on my own without a patient and an order (aside from 1% Lidocaine, with epi if we like!). Agree it would be nice to have pre-mixed syringes of push-dose pressors, but the suggestion I can just mix a 100mL bag of stuff at the beginning of my ED shift, and carry around some aliquots, is ludicrous for at least 95% of EDs in the country. I understand these things are standard practice in many OR settings.

Hell I can’t even get meds I order myself out of the PIXIS, no access. So sure, if I want to push my own meds I can, but I need to have a RN pull them from the machine first, and hand them to me…

Now I do agree with you, its largely a cultural contrivance that anesthesia (1) has direct med access and (2) draws and pushes their own meds unlike most ED and many CC physicians, and if ED physicians take the role and responsibility of med-pusher we can get away with things that would otherwise cause nursing roadblocks. Certainly it is an ace-up-the-sleeve I occasional play when nursing in the room is uncomfortable with a med/dosage… I’ll gladly push it myself so they aren’t “going to lose their license”.

 

[ProwlerturnGas]

Please come have a frank discussion with my community hospital pharmacy about giving me access to ANY medication to mix on my own without a patient and an order (aside from 1% Lidocaine, with epi if we like!). Agree it would be nice to have pre-mixed syringes of push-dose pressors, but the suggestion I can just mix a 100mL bag of stuff at the beginning of my ED shift, and carry around some aliquots, is ludicrous for at least 95% of EDs in the country. I understand these things are standard practice in many OR settings.

Hell I can’t even get meds I order myself out of the PIXIS, no access. So sure, if I want to push my own meds I can, but I need to have a RN pull them from the machine first, and hand them to me…

Now I do agree with you, its largely a cultural contrivance that anesthesia (1) has direct med access and (2) draws and pushes their own meds unlike most ED and many CC physicians, and if ED physicians take the role and responsibility of med-pusher we can get away with things that would otherwise cause nursing roadblocks. Certainly it is an ace-up-the-sleeve I occasional play when nursing in the room is uncomfortable with a med/dosage… I’ll gladly push it myself so they aren’t “going to lose their license”.

Fair enough and I get your point. I’m shocked that you don’t have personal access to the pyxis. That would be unacceptable to me.

 

[Janders]

Fair enough and I get your point. I’m shocked that you don’t have personal access to the pyxis. That would be unacceptable to me.

Well the worst is going to the floor, where I don’t have PYXIS access and they might not even have heard of / stocked RSI meds…

… remind me of the induction dose of Morphine and Ativan again.

*FUNNY STORE TIME*. Years ago I went to a floor code overnight at a small hospital. Patient actually got ROSC rapidly, but was hypoxic and altered and needed an airway, etc. Hospitalist is screaming at me to intubate them, and I’m calmly explaining its hard to intubate with gramma chewing on my laryngoscope. He stomps off, so I ask the nurses for RSI meds. I list pretty much everything I can think of… etomidate, ketamine, versed, propofol, fentanyl, etc… they shake their heads, say they don’t have any of that on the floor sorry doc. So I ask one of them to run down to the ED, ask any of the nurses for Etomidate and Sux, and they will know whats up and will come help.

About 4 minutes later one of the trusty ED RNs appears with the aforementioned RSI meds, laughing her ass off. Why? The nice floor nurse had sprinted into the ER, saying the ER doc was still upstairs and wanted “THE ATOMIC SUCKS” for the patient STAT.

We called it THE ATOMIC SUCKS for a while after that. {don’t worry, they started stocking RSI go-bags in the inpatient unit PYXIS’s afterwards, yay opportunities for improvement!}

/end story time.

PYXIS access is something we discussed trying to get in the COVID-times, due to RN shortage, so that if need be we could pull meds either to get patients discharged quickly (TDAP, say) or if they are super sick and no one else is around (watch me mix a levophed drip like I know what I’m doing!). I’m of slightly mixed opinion, as I don’t want scope-creep where I’m expected to dose EVERY medicine, and also don’t want ED docs mixing weird drips and attaching them to pumps they have no business messing with… but I think liberal access to life-saving meds is a good thing…

 

[lucid_leprechaun]

Fair enough and I get your point. I’m shocked that you don’t have personal access to the pyxis. That would be unacceptable to me.

I have better access to code cart so easier to make epinephrine infusions/pushes. But certainly have to make dirty epi drips/ push dose epi almost every other shift. Thankfully most of our difficult airways are physiologic rather than anatomic.

 

[southerndoc]

Fair enough and I get your point. I’m shocked that you don’t have personal access to the pyxis. That would be unacceptable to me.

It's pretty much unheard of for most ED physicians to have access to a Pyxis/Omnicell.

 

[Apollyon]

If your angioedema is hypoxic then you've made a grave mistake.

I have never and will never call anesthesia for an airway. I don't see the point with current EM training. And I would especially never let some mid level CRNA anywhere near any of my patients in the ED.

You might not want to be so dogmatic. To say "never" or "always" is hubris, and is a formula for failure. Are you willing to let a patient die, because you refuse to call for help? You're at the beginning of your career. You don't know what is coming. And, I can tell you, 10 years ago, six years out of training, an anesthesiologist colleague saved my ***. More help is better than no help.

One facet of confidence is, "I can do it". Another is, "I've done my level best, but, it's not enough. I admit where is my property line. It ends here. I need assistance."

Or, alternately, are you saying, "If I can't get the tube, then no one can", and you go to cutting the neck? Trust me, you don't want to go there. Do you want to be known as "the hero", or "the assassin"? I'm not your enemy. Experience is my basis.

 

[IMGASMD]

If your angioedema is hypoxic then you've made a grave mistake.

I have never and will never call anesthesia for an airway. I don't see the point with current EM training. And I would especially never let some mid level CRNA anywhere near any of my patients in the ED.

Really? Is that how you suppose to evaluated respiratory failure?

I am sure you’re very good.

She sure wasn’t.

 

[WilcoWorld]

I'm worried this thread is a microcosm of what may doom physicians' future in this country - a thread gets started to discuss a topic that sits abreast two or more specialty's wheelhouses, and instead of mutual respect the discussion devolves to mudslinging and a lack of understanding.

For the record, I'm not claiming to be better at intubating than an anesthesiologist, or better at reductions than an orthopedist, or better at managing head bleeds than a neurosurgeon, or better at reading ECG's than a cardiologist. However, if I have an MI that causes me to syncopize and I fall, sustaining an elbow dislocation and an intracranial hemorrhage that causes me to stop protecting my airway and I'm brought in by EMS with the only history available being "found down"...I want the first doctor that sees me to be an Emergency Physician.

 

[Rekt]

You might not want to be so dogmatic. To say "never" or "always" is hubris, and is a formula for failure. Are you willing to let a patient die, because you refuse to call for help? You're at the beginning of your career. You don't know what is coming. And, I can tell you, 10 years ago, six years out of training, an anesthesiologist colleague saved my ***. More help is better than no help.

One facet of confidence is, "I can do it". Another is, "I've done my level best, but, it's not enough. I admit where is my property line. It ends here. I need assistance."

Or, alternately, are you saying, "If I can't get the tube, then no one can", and you go to cutting the neck? Trust me, you don't want to go there. Do you want to be known as "the hero", or "the assassin"? I'm not your enemy. Experience is my basis.

I don't think I'm better than anesthesia and there's plenty of ER docs with more tubes. I think it's just differences in how I trained. We don't have in house MD anesthesia at night afaik and it's a sleepy mid level for L/D. Our anesthesia is very much in the princess shift community mindset. We get called to floor for difficult airways. I've thankfully had a a lot of experience with all the fancy scopes and extra airway modalities along with different kind of meds as talked about in this thread. I think we have the ability to call them but it's typically a 45m-1hr response time which just isn't appropriate imo. Maybe my next shop will be more helpful.

 

[BoardingDoc]

Fair enough and I get your point. I’m shocked that you don’t have personal access to the pyxis. That would be unacceptable to me.

I've worked in 5 different EDs. I have never had access to the Pyxis anywhere. Anesthesia is fairly unique in the whole "access to all of the meds" thing.

 

[Arch Guillotti]

How did you know that’s exactly what happened the last time I had to go to ED to bail out an ED physician.

She called the CRNA. CRNA thought if an ED physician called for back up, must be bad. CRNA knows that I stayed in house, asked me to come. I walked into an “angioedema”. Patient is talking, Sat high 90s on RA. Nothing is set up, no suction, no ambu, no difficult airway cart. She was standing there with a glide and thought she was ready to go.

I looked at the ED physician and said, “no thank you, I am out of here.” And told our CRNA to get out of there too. I’d rather be called in a true emergency situation than standing there holding your incompetent a$$’s hand.

Just like there are subpar anesthesiologists, as you have implied here, some of your colleagues probably shouldn’t be practicing medicine especially in “emergent” situations.

Serious question. How did you bail her out if you did nothing? We all get ridiculous calls and requests sometimes. What happens when you walk away and then you are called back emergently?

 

[Rekt]

Serious question. How did you bail her out if you did nothing? We all get ridiculous calls and requests sometimes. What happens when you walk away and then you are called back emergently?

Because it's likely embellished and/or made up. "Everyone clapped. Obama was there."

 

[RustedFox]

I've worked in 5 different EDs. I have never had access to the Pyxis anywhere. Anesthesia is fairly unique in the whole "access to all of the meds" thing.

7 different EDs here. Never had pyxis access.

That's not a thing in the ER.

 

[BoardingDoc]

What happens when you walk away and then you are called back emergently?

You get the S*** sued out of you and lose. I'm not saying that this ED doc knew what they were doing, and maybe it was a BS consult. But as @Arch Guillotti said, you'd better be really damn sure of the outcome before you say "no thank you, I am out of here" as you're refusing a consult, committing an EMTALA violation by doing so and will be crucified in court if things actually go south.

It sounds like it didn't, so yay there.

 

[turkeyjerky]

How did you know that’s exactly what happened the last time I had to go to ED to bail out an ED physician.

She called the CRNA. CRNA thought if an ED physician called for back up, must be bad. CRNA knows that I stayed in house, asked me to come. I walked into an “angioedema”. Patient is talking, Sat high 90s on RA. Nothing is set up, no suction, no ambu, no difficult airway cart. She was standing there with a glide and thought she was ready to go.

I looked at the ED physician and said, “no thank you, I am out of here.” And told our CRNA to get out of there too. I’d rather be called in a true emergency situation than standing there holding your incompetent a$$’s hand.

Just like there are subpar anesthesiologists, as you have implied here, some of your colleagues probably shouldn’t be practicing medicine especially in “emergent” situations.

That person sounds like a clown. Either that or it's a case of malicious compliance after "peer" review. But since anecdotes are like dinguses....

I've seen an anesthesiologist in the ED twice during my career:

Colleague had a patient w/ angioedema. Fat lady, moderate tongue swelling but progressive symptoms over 30 min and now barely able to speak, suggestive of laryngeal involvement, but normal pulse ox. As an aside, I swear to god, that place saw more angioedema than anywhere else in the country. It was like one out of every 3-4 ****s. Usually a double coverage site, but there were 3 of us on for some reason and the other two of us are hanging around being 'helpful'. He calls the anesthesiologist, who then repeatedly tries to intubate the patient w/ propofol-only sedation ("awake look"), with progressively worsening desaturations interspersed w/ inadequate BVM and he's getting visibly frustrated.

Inexplicably, just at that moment, some administrator comes into the room, tells him that there's a "situation" in the OR that requires his attention. So what does he do?

He mumbles, "Okay I'll be there. Wake the patient up." Then he walks out. Meanwhile, the patient is obtunded, being actively bagged. We were dumbfounded, staring at each other, "WTF just happened". We quickly performed a double set-up and my colleague RSI'd the patient w/ ease.

 

[turkeyjerky]

The second time I called one, he saved my ass, btw.

 

[Arch Guillotti]

That person sounds like a clown. Either that or it's a case of malicious compliance after "peer" review. But since anecdotes are like dinguses....

I've seen an anesthesiologist in the ED twice during my career:

Colleague had a patient w/ angioedema. Fat lady, moderate tongue swelling but progressive symptoms over 30 min and now barely able to speak, suggestive of laryngeal involvement, but normal pulse ox. As an aside, I swear to god, that place saw more angioedema than anywhere else in the country. It was like one out of every 3-4 ****s. Usually a double coverage site, but there were 3 of us on for some reason and the other two of us are hanging around being 'helpful'. He calls the anesthesiologist, who then repeatedly tries to intubate the patient w/ propofol-only sedation ("awake look"), with progressively worsening desaturations interspersed w/ inadequate BVM and he's getting visibly frustrated.

Inexplicably, just at that moment, some administrator comes into the room, tells him that there's a "situation" in the OR that requires his attention. So what does he do?

He mumbles, "Okay I'll be there. Wake the patient up." Then he walks out. Meanwhile, the patient is obtunded, being actively bagged. We were dumbfounded, staring at each other, "WTF just happened". We quickly performed a double set-up and my colleague RSI'd the patient w/ ease.

I despise angioedena “consults” in the ER. Must be a local culture thing. Every one I can ever remember intubating was done with the patient awake. Congrats on doing an RSI although if the pt. is bad putting them to sleep is fraught with risk. The anesthesiologist who did the “awake” look with propofol is a clown and should be hauled before peer review.

 

[turkeyjerky]

I despise angioedena “consults” in the ER. Must be a local culture thing. Every one I can ever remember intubating was done with the patient awake. Congrats on doing an RSI although if the pt. is bad putting them to sleep is fraught with risk. The anesthesiologist who did the “awake” look with propofol is a clown and should be hauled before peer review.

We had already proved we were able to ventilate the patient...

Also the actions of the preceding physician had led to a 'forced to act' scenario.

 

[GassYous]

We had already proved we were able to ventilate the patient...

Also the actions of the preceding physician had led to a 'forced to act' scenario.

That doesn't mean you will be able to 2 minutes later

 

[IMGASMD]

Serious question. How did you bail her out if you did nothing? We all get ridiculous calls and requests sometimes. What happens when you walk away and then you are called back emergently?

Because it's likely embellished and/or made up. "Everyone clapped. Obama was there."

You get the S*** sued out of you and lose. I'm not saying that this ED doc knew what they were doing, and maybe it was a BS consult. But as @Arch Guillotti said, you'd better be really damn sure of the outcome before you say "no thank you, I am out of here" as you're refusing a consult, committing an EMTALA violation by doing so and will be crucified in court if things actually go south.

It sounds like it didn't, so yay there.

The discussion was, if this is truly angioedema, I will do it in the OR with surgeon at standby. If it’s not, which I suspected it wasn’t, then she doesn’t need us there. The only symptom that she worried about was a subjective tinkle in the back of the patients throat. I voiced that I respected her diagnosis of angioedema, then we will treat it as a real thing. She insisted that she will be intubating, we’re there only to back her up, if she gets in trouble. That’s when we left.

So to address all of your criticisms. I treated the situation as serious as I can. I assess the patient, made my recommendations. She rejected my recommendations to intubate in the OR and won’t relinquish her responsibilities as primary attending nor proceduralist. What’s the purpose for us being there? If I am called to intubate, I intubate. I am trained to obtain an airway and I will do it. I am not there to hold your hand, nor have my employee, ultimately me be responsible for your disaster.

Is it angioedema or not?! To me that’s the question. If I fuk up, it’s mine and I will own it. None of this in between stuff, stand-by, back up bullshlt.

 

[Arch Guillotti]

The discussion was, if this is truly angioedema, I will do it in the OR with surgeon at standby. If it’s not, which I suspected it wasn’t, then she doesn’t need us there. The only symptom that she worried about was a subjective tinkle in the back of the patients throat. I voiced that I respected her diagnosis of angioedema, then we will treat it as a real thing. She insisted that she will be intubating, we’re there only to back her up, if she gets in trouble. That’s when we left.

So to address all of your criticisms. I treated the situation as serious as I can. I assess the patient, made my recommendations. She rejected my recommendations to intubate in the OR and won’t relinquish her responsibilities as primary attending nor proceduralist. What’s the purpose for us being there? If I am called to intubate, I intubate. I am trained to obtain an airway and I will do it. I am not there to hold your hand, nor have my employee, ultimately me be responsible for your disaster.

Is it angioedema or not?! To me that’s the question. If I fuk up, it’s mine and I will own it. None of this in between stuff, stand-by, back up bullshlt.

I agree 100% with assuming management of the airway if you are asked to “consult”. If the ER doc or whoever wants them intubated and I am called to assist, I am doing it every single time. I don’t get taking an angioedema pt. to the OR for an intubation though. Just do an awake nasal in the ER.

 

[IMGASMD]

I agree 100% with assuming management of the airway if you are asked to “consult”. If the ER doc or whoever wants them intubated and I am called to assist, I am doing it every single time. I don’t get taking an angioedema pt. to the OR for an intubation though. Just do an awake nasal in the ER.

It’s just how our shop do it. Very cultural thing I think.
Most of the partners take home call, usually they will not come in for any ED stuff. So the hospital is trained to book an OR, get the surgical residents ready in the OR. The last time any of them did an awake nasal, was probably not in this century.

 

[BoardingDoc]

The discussion was, if this is truly angioedema, I will do it in the OR with surgeon at standby. If it’s not, which I suspected it wasn’t, then she doesn’t need us there. The only symptom that she worried about was a subjective tinkle in the back of the patients throat. I voiced that I respected her diagnosis of angioedema, then we will treat it as a real thing. She insisted that she will be intubating, we’re there only to back her up, if she gets in trouble. That’s when we left.

So to address all of your criticisms. I treated the situation as serious as I can. I assess the patient, made my recommendations. She rejected my recommendations to intubate in the OR and won’t relinquish her responsibilities as primary attending nor proceduralist. What’s the purpose for us being there? If I am called to intubate, I intubate. I am trained to obtain an airway and I will do it. I am not there to hold your hand, nor have my employee, ultimately me be responsible for your disaster.

Is it angioedema or not?! To me that’s the question. If I fuk up, it’s mine and I will own it. None of this in between stuff, stand-by, back up bullshlt.

This is a very different story than the first one. I agree with everything in this version.

 

[thegenius]

This is a very different story than the first one. I agree with everything in this version.

Yea I agree...if the anesthesiologist said he will take the pt to the OR to intubate, and the ER doc said no?!?! I think that's kind of daft.

When I was in residency at a major, leading academic institution we were always taught to "call for backup and have them standby". There isn't anything wrong calling for backup and that is often the right thing to do. However in reality...it doesn't make sense to call other doctors (who are more experienced) for backup and have them sit there for 30 minutes just looking on while you do first attempt. That is a residency, theoretical type position to take.

In the community, if I call someone for a "consult" I'll do whatever they say barring it isn't grossly negligent. So if I call anesthesiology and they want to take the pt to the OR, I'm fine with that! WTF am I going to do, argue with them?


I've called Anesthesiology 2-3 times in my career. One was for angioedema. The pt's tongue was so puffy I could barely see the anterior roof of his mouth. Pt couldn't talk. It was truly scary. I have no advanced intubation tools except a glidescope and bougie. Anesthesiology along with Gen Surg went to the OR and I was surprised to learn that they had no problem using a glidescope and passing an ET tube.

The other time was someone with epiglottitis. I suspected they had it and I called ENT to look via nasopharyngoscopy and confirmed it. ENT called anesthiology and pt went to the OR for a tube.

 

[thegenius]

I'm worried this thread is a microcosm of what may doom physicians' future in this country - a thread gets started to discuss a topic that sits abreast two or more specialty's wheelhouses, and instead of mutual respect the discussion devolves to mudslinging and a lack of understanding.

For the record, I'm not claiming to be better at intubating than an anesthesiologist, or better at reductions than an orthopedist, or better at managing head bleeds than a neurosurgeon, or better at reading ECG's than a cardiologist. However, if I have an MI that causes me to syncopize and I fall, sustaining an elbow dislocation and an intracranial hemorrhage that causes me to stop protecting my airway and I'm brought in by EMS with the only history available being "found down"...I want the first doctor that sees me to be an Emergency Physician.

Absolutely 100% agree!

 

[Dantrolene FC]

In the ED, just getting to the head of the bed in most rooms is a challenge. To leave the head of the bed to push meds and then get back in position is not safe. If you have time to set the tubing up to do it at the head of the bed, then maybe, but that is a cognitive load for you, your nurses will be thrown for a loop which is not good in a resus, and there may be protocols in some departments. It also means I can't be bagging the patient and sometimes it is just me and a nurse +/- an RT depending on the site, urgency of intubation, and busyness of the RTs. We aren't intubating stable people, often don't have much time to optimize things like lines/tubing, and often do it in very cramped rooms. I would love to always intubate in a large resus room with ample room around the bed, but that just isn't a reality in many EDs.

As for the phenylephrine, that suggestion perfectly highlights the difference in the worlds of the OR and ED. No pharmacy is giving me a bag of phenylephrine without an order attached to a patient. What is easy to obtain for an anesthesiologist in the OR is not easy to obtain pretty much anywhere else. Everything that comes from pharmacy needs an order including the Pyxis. Overrides on the Pyxis are attached to a patient. The notion that this is an easy ask is just out of touch with life in the ED.

At my hospital, I just go to the OR pharmacy, ask for meds and the pharmacist just hands it to me, no questions asked. After hours, I just go into the pharmacy and get whatever I need.

 

[nimbus]

I heard from an anesthesiologist that people feel like **** when they emerge from being tubed from sux. If I recall properly.

They do. Body ache for 1 week.

 

[nimbus]

I agree 100% with assuming management of the airway if you are asked to “consult”. If the ER doc or whoever wants them intubated and I am called to assist, I am doing it every single time. I don’t get taking an angioedema pt. to the OR for an intubation though. Just do an awake nasal in the ER.

Angioedema is one of those situations where the first shot can be the only shot and the most experienced available person should do it.

 

[nimbus]

I’m glad the subject of push dose pressors came up. Almost 30 years ago, during the 1st month of anesthesia residency, I was taught never to induce anybody without phenylephrine and ephedrine drawn up and immediately available. Also those in academics will notice anesthesia residents carrying backpacks or toolbags when they respond to airway calls. They contain airway toys, induction agents, and pressors. A lot of stuff we learn during residency is nonsense, but patients do become hypotensive on a regular basis with induction and intubation. Even ASA1 patients with healthy hearts will sometimes dump their BP when you take away all their adrenergic drive. Not to anticipate this is malpractice in my opinion. Push dose pressors should be immediately available at every intubation, it should be protocolized and included with every intubation “kit” along with the induction agent and paralytic.

 

[Fox800]

I’m glad the subject of push dose pressors came up. Almost 30 years ago, during the 1st month of anesthesia residency, I was taught never to induce anybody without phenylephrine and ephedrine drawn up and immediately available. Also those in academics will notice anesthesia residents carrying backpacks or toolbags when they respond to airway calls. They contain airway toys, induction agents, and pressors. A lot of stuff we learn during residency is nonsense, but patients do become hypotensive on a regular basis with induction and intubation. Even ASA1 patients with healthy hearts will sometimes dump their BP when you take away all their adrenergic drive. Not to anticipate this is malpractice in my opinion. Push dose pressors should be immediately available at every intubation, it should be protocolized and included with every intubation “kit” along with the induction agent and paralytic.

Thank you. I have a very low threshold to give push dose epinephrine myself for these situations...typically 25-50 mcg (0.25-0.5 mL of a 10 mL pre-mixed syringe that you use for cardiac arrests).

 

[Robotic Wis-Hipple]

Can... can I have neo sticks?

This cracks me up about the ED vs OR workflows.

In the OR I just make a 10mg (single mL) phenylephrine vial in 100mL NS bag for the day. Gives you a readily accessible 100mcg/mL supply of push dose phenylephrine.

1mg Epi in 100mL bag is 10mcg/mL Epi push dose.

4mg NE vial in 250cc bag is 16mcg/mL push dose.

But I don’t have near the number of RNs or clipboard warriors running around to cite me.

But if I was an ED doc that’s probably what I’d do at the start of a shift…..

 

[Robotic Wis-Hipple]

--most of the time we don't have access to a patient's prior medical history, thus cannot accurately determine a lack of contraindications. Plus, it's not unusual for obtunded patients to come in w/ an incidental AKI and a K of 5.9 or so. It's a form of cognitive offloading, as well as safer, to make Roc your default. Additionally, as alluded to above, Roc simplifies post-intubation vent management, allows you to get accurate measurements of Pplat and auto-PEEP and facilitates other procedures as well as imaging.

I’ll give you K+ of 5.9 in an undifferentiated pt not known to have CRF, but otherwise this has been studied, Sux raises serum K+ 0.5 transiently. 4.5–>5 for 5min isn’t killing anybody but the faster tube might be beneficial. But what other contraindications are you talking about? Old stroke? Should be mostly notable on exam unless completely obtunded/comatose. Crush injury? Not if in the last few hours I wouldn’t think. Im not being facetious, I’m just asking what concerns you have.

Now with sugammadex I guess the argument becomes mostly academic as Roc, even RSI dosed Roc can be reversed instantly, and the Roc helps you guys with all your post ETT procedures/scans so that in addition to the negatives of Sux likely make Sux a very niche drug (it’s becoming that in the OR too in hospitals that don’t hoard or restrict sugammadex use).

 

[Robotic Wis-Hipple]

I really respect @Arch Guillotti so please don't take this the wrong way:

Anesthesiologists are clearly the experts on OR intubation, but when it comes to the management of undifferentiated, crashing patients Emergency Physicians are the experts. Of course, that doesn't mean we can't be wrong or get better. But let's remember that the ER =/= the OR

This comment unsurprisingly derailed the multi specialty paralytic use convo into our typical us vs them BS. And this is despite you saying with all due respect 🧐

Yet I’ll repeat it lol. I respect the hell out of EM docs, anyone that thinks you’re not a specialist is an idiot. I wouldn’t want to do your job, and much of that is due to the many ED vs OR differences that have come up in this thread.

With that said I hate this trope where people think all OR intubations are optimized or worked up perfectly, the pt has the ability to be preoxygenated to the full 8min of apneic desat time etc. Or that our head of the bed is free of cables, wires, etc 🙄

Have you ever read an orthobros H&P for their elective coming from home revision surgery? Let me tell you, if cardiopulmonary or head&neck history let alone recent status is provided you shouldn’t read it.

ENT? You’d think their notes would be reassuring. Closest to a clean kill I ever saw in residency; pharyngeal mass for debulking. Guy seen tripod-ing in preop, can barely breath. ENT says they nasal scoped him in the office last week, no laryngeal involvement, they’ll be there, no need to AFOI. Attending anesthesiologist takes their word, RSI glidescope was plan. As soon as glidescope passed posterior tongue giant exophytic friable mass seen occluding everything, blade barely touches tumor, mouth fills with blood.

Just recently on call I got a ruptured AAA that presented to ED. Guys pale with BP by NIBP in 70’s (40’s MAP as we all know the SBP is made up like Who’s Line points), an 18g PIV in each AC with a pressure bag pRBC on each. Guys mentating, answers questions appropriately etc. Airway is decent but looks anterior. Wasn’t intubated “because he’d crash”. Took to OR, awake a-line. 16g PIV added with crystalloid running wide open, NE infusion started in line with 16g. 2mg versed, Preox, NE push dose, prop/roc RSI induction, glidescope, ETT.

We go to the ICU to intubate unstable/crashing pts, we respond to airway conditions in some hospitals, we are familiar with having to take the stupid head of the bed off etc.

The point is it’s lazy and professionally dishonest to attempt to paint our airway experience as optimized chipshots in an optimized location with optimized support. Just like it’s dishonest and posturing to say you guys are just generalists or airway hacks. We each have our weak links, but on average I’d say it’s not true for both sides.