U/S guided regional anestheisa in the ED by ED docs

[bne_12mne]

Wondering if I could have your input.


What do you guys think?

To the OP. I concede that you do seem grateful, if not a little dismissive, of the input you've received thus far. But I think you are being a little bit selfish and shortsighted in your decision. There is no way that what you are proposing to do is good for the specialty of anesthesiology, though in your particular situation it seem good (or at least not detrimental) to you personally. That in particular seems to be everyone's "problem" with what you propose. I don't know how you could have expected the input from this board to be any different.

I hope you reconsider your approach to the request from your ED.

Respectfully,
BNE

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[dhb]

OK, will all the people that do not approve the move provide anesthesia for all types of procedures in the ED that need sedation in any form??

 

[Planktonmd]

OK, will all the people that do not approve the move provide anesthesia for all types of procedures in the ED that need sedation in any form??

No, ER Docs give sedation for their procedures but when an anesthetic more advanced than simple sedation is needed they need to consult the people who specialize in anesthesia.
It is equivalent to them consulting a surgeon to do a surgery or an obstetrician to deliver a baby.

 

[SleepIsGood]

not sure I agree with any of you. But I do appreciate your input


I have never been called to manage acute pain in the ED and these blocks are not for cases that will be coming to the OR so it will not decrease the volume of blocks I do

thanks though

sell out...again, sorry to hear youare doing this. It's not worth the money or how 'hot' the ER doc is. Once your services are not yours any longer, no need to keep you around.

 

[leaverus]

sell out...again, sorry to hear youare doing this. It's not worth the money or how 'hot' the ER doc is. Once your services are not yours any longer, no need to keep you around.

yes, total sell-out. i hope there arent too many anesthesiologists who think the same way as turnup....i love anesthesia and dont want to hand it over to others on a silver platter...

 

[SleepIsGood]

yes, total sell-out. i hope there arent too many anesthesiologists who think the same way as turnup....i love anesthesia and dont want to hand it over to others on a silver platter...

there are guys like this. They're the ones that are ok with CRNA expansion as well. These are the sorts that should get ousted from our societies....Yes, it's about preserving the profession for our own. But ultimately it's about patient care.

An ER doc who learns how to do a block once from TURN UP. Then goes on to do 1 of them every 3 months is no way qualified to adminster these blocks and deal with complications that could harm patients. IF an ER doc does this and has adverse outcomes, he should be prepared to defend himself from plaintiffs' attorneys who will have Board Certified Anesthesiologists tearing him up. Not a good set up...

 

[bne_12mne]

OK, will all the people that do not approve the move provide anesthesia for all types of procedures in the ED that need sedation in any form??

In my current institution, we do provide anesthesia in the ED when called. I'm stating my opinion that performance of a regional anesthetic should be one of those times when we are called. I'm not fighting for every administration of sedation...that battle was lost long ago, and to some degree, thank goodness.

BNE

 

[dhb]

IF an ER doc does this and has adverse outcomes, he should be prepared to defend himself

So we agree: let Darwin do his thing

 

[drccw]

I will tell you- if the ER wants to call me down for a shoulder reduction, I will come down, throw an ISB block in and leave. Fine by me.
CPT 64415
and
CPT 76942

I think that that would be 9 units or work...
though I could be mistaken

I'll come down for every reduction...

drccw

 

[Apollyon]

IF an ER doc does this and has adverse outcomes, he should be prepared to defend himself from plaintiffs' attorneys who will have Board Certified Anesthesiologists tearing him up. Not a good set up...

Actually, in some states, this isn't true - an expert witness from another specialty will not be recognized as an expert witness in those cases, as the standard of care for the anesthesiologist in this instance is higher than that of the EM doc.

At the same time, a "same specialty" EM expert witness will also support that such things as regional anesthesia are outside the scope of EM practice, getting the same result.

 

[inthepound]

Resurrecting an old thread to show the trend in emergency medicine:

http://pointofcare.blogspot.com/

 

[nitroglycerine]

I don't understand why you would want to give this work away. If you have too much work to do, just hire someone. We do lots of closed reductions in the OR, if they can't be done with minimal sedation they go upstairs now or in the AM. I used to do some ketamine, etc in the ED as well at my old place. That was/is EASY money in my pocket.
It starts with shoulders and fingers, next you have pinnings in the procedure room. More lost loot for your group. The ortho guy will be pushing for that when the ED crew can give them blocks, don't doubt that for a second. They may even hire them to moonlight in their clinic to do blocks that you used to do. Don't think so? Why not? We used to do blocks for extremity procedures in our pain clinic. Block in, set up, checked and they went down to the ortho clinic for their surgery with a conscious sedation nurse. You're on a slippery slope, and I don't think you guys even see what could happen a couple years from now. Once they're cleared to do blocks, you've lost control and it will be too late to go back.
Why would any anesthesiologist want anything to do with this. Are you guys short sighted or just too lazy to help them out? You have to pick your battles, and I would fight this to the death, no question.

What we should fight to the death is anesthesia by nurses. ER Docs are MDs and as such can do any procedure they feel comfortable to do and they WILL accept all the responsibility. Get rid of CRNAs, one Anesthesiologist per room, one patient at a time. If I have somebody readily and always available to interrogate pacemaker then great. If not, then I will learn how to do it myself and use some telephonic advice. At my place we MDs try to help each other.

 

[pgg]

Get rid of CRNAs, one Anesthesiologist per room, one patient at a time.

There aren't enough of us.

Are you willing to double your hours? Is the public willing to forego elective surgery, and wait for non-elective surgery?

 

[Hamhock]

What we should fight to the death is anesthesia by nurses. ER Docs are MDs and as such can do any procedure they feel comfortable to do and they WILL accept all the responsibility. Get rid of CRNAs, one Anesthesiologist per room, one patient at a time. If I have somebody readily and always available to interrogate pacemaker then great. If not, then I will learn how to do it myself and use some telephonic advice. At my place we MDs try to help each other.

Exactly

It always amazes me when anesthesiologists go nuts about EM docs using "induction agents" or peripheral nerve blocks in the ED for EM cases (i.e. emergency medicine) when these same anesthesiologists have not done much of anything about nurses doing anesthesia for elective cases in the OR!!

Tomorrow, like every day in our ED, there are going to be multiple traumatic injuries and/or painful procedures that require pain control. I am certain that if an anesthesiologist would like to come down and cover these cases with procedural sedation or general anesthesia or PNB, the ED staff would welcome them...especially if the department is crazy busy. However, I promise you there will be no anesthesiologist there...so the ED docs can either control pain or not...what do you really expect us to do: not do procedural sedation or the peripheral nerve block and just let the patient suffer?

Come on down folks! The ED is waiting!

However, while you are worried about EM docs taking care of patients in the ED, anesthesia (which is your specialty in your department...something ED docs want nothing to do with) is being handled by nurses.

Certainly, there must be some anesthesiologists that see it this way.

HH

 

[sevoflurane]

The problem isn't as simple as anesthesiologist numbers...

The problem is that when we accepted the ACT model there were no parameters to keep it that way. No fail-safe valves, no one way circuits, no filters.... really no checks and balances. We opened pandora's box and some old timers got really wealthy off the idea. We invited the devil to come and sleep with us.

Now CRNA's practice independently... and in desirable areas of the country, not just BFE... and they provide "equal anesthesia care". Our profession has been diluted.

This, my friends, is the single biggest f*&K up in anesthesia. I'm happy to say I did not contribute to this sorry set of events. How many opt out states are we up to? Colorado was one of the recent ones....

Some of those nurses are very lucky....

 

[kmurp]

And you would be wrong. Routine SaO2 monitoring started in the early to mid 1980's. I started anesthesia school in 1979.

It was a requirement in New York as of 1989 if I recall correctly (and we were the first state to require it). As a resident in the mid 80's we had to get in extra early to steal one of the few available SpO2 monitors, so yes it was around but certainly not routine in most places.

 

[kmurp]

I will tell you- if the ER wants to call me down for a shoulder reduction, I will come down, throw an ISB block in and leave. Fine by me.
CPT 64415
and
CPT 76942

I think that that would be 9 units or work...
though I could be mistaken

I'll come down for every reduction...

drccw

You are perhaps not taking into account the high Medicaid percentages in many ERs.

 

[nitroglycerine]

not sure I agree with any of you. But I do appreciate your input


I have never been called to manage acute pain in the ED and these blocks are not for cases that will be coming to the OR so it will not decrease the volume of blocks I do

thanks though

If an MD colleagues ask for help I would go and help, including teaching new techniques.

 

[cowbydoc]

Exactly

It always amazes me when anesthesiologists go nuts about EM docs using "induction agents" or peripheral nerve blocks in the ED for EM cases (i.e. emergency medicine) when these same anesthesiologists have not done much of anything about nurses doing anesthesia for elective cases in the OR!!

Tomorrow, like every day in our ED, there are going to be multiple traumatic injuries and/or painful procedures that require pain control. I am certain that if an anesthesiologist would like to come down and cover these cases with procedural sedation or general anesthesia or PNB, the ED staff would welcome them...especially if the department is crazy busy. However, I promise you there will be no anesthesiologist there...so the ED docs can either control pain or not...what do you really expect us to do: not do procedural sedation or the peripheral nerve block and just let the patient suffer?

Come on down folks! The ED is waiting!

However, while you are worried about EM docs taking care of patients in the ED, anesthesia (which is your specialty in your department...something ED docs want nothing to do with) is being handled by nurses.

Certainly, there must be some anesthesiologists that see it this way.

HH

Very well said. I am an ER attending as well and if anesthesia wants to come down and do their thing, bring it on. The fact of the matter is that procedural sedation reimbursement sucks and the busiest time in the ER is in the evenings so I don't see many anesthesiologists lining up to do a sedation at 10PM for 30 bucks.

 

[deleted126335]

Very well said. I am an ER attending as well and if anesthesia wants to come down and do their thing, bring it on. The fact of the matter is that procedural sedation reimbursement sucks and the busiest time in the ER is in the evenings so I don't see many anesthesiologists lining up to do a sedation at 10PM for 30 bucks.

You and hamhock are both completely correct.

 

[pencan]

From a CRNA?

How do you think the first anesthesiologist learned these skills?

 

[Modanq]

I hate to bring up an old topic but just wanted to relay an experience I had in the ED as a rotator last month. Patient with an elbow abscess. I watched silently as ED Resident attempted an axillary nerve block without a block needle. He looked up the anatomy before attempting. Single injection with 1% lidocaine, barely any needle visualization. Half way through he was paged to a trauma and the block wore off by the time he got back to the abscess, not sure it even worked. In my resident experience I have not done many axillary blocks - A lot more ISB/Supraclav. But I am at the level where I can find nerves, dissect them off a vessel with the needle, visualize the whole needle. Manipulate the ultrasound. It took around 200-400 blocks to really get the skill down.
In your hospital do you have regional team doing ED blocks or is this done by ED...
I was really surprised to find out that ED folks are doing complex blocks.
Do they do enough to see the anatomy. Manage the complications.
I get that the ED is busy and anesthesiologists don't want to roam around there but what are your thoughts.
Is there a balance, should the ED just consult anesthesiologist regional team like they do ortho, neurology, cards, etc.

 

[fakin' the funk]

This is not about the technology. Imagine being the cardiologist who said "using a stethoscope is only the domain of cardiology!" Or the radiologist who said "using ultrasound is only the domain of radiology!" In retrospect, those people look foolish.

Nor is it about technical skills. There is no Oracle On The Mount for learning new techniques and subdomains. Anesthesiologists can do bedside TTE and diagnostic bronch, if they are properly trained -- possibly even by other anesthesiologists!

It's about DON'T JUST GO TO THEM AND TEACH THEM ALL OUR $H!T MAN

 

[nimbus]

You are perhaps not taking into account the high Medicaid percentages in many ERs.

But it literally takes 5min. Even with Medicaid it's good $$.

And I would happily teach ER Docs to do their own blood patches but they never show any interest.

 

[FollowTheMoney]

Why is it that anesthesiologists have the least common sense of any medical profession? Teaching nurses and other doctors how to do your job is idiotic, but I guess that never occurred to anyone. Why would you give away the only value you have? If we didn't have people trying to take our jobs or business, we would have a much better job market and much more job security. I don't see any other specialty going out of their way to train people outside of their profession to do their job.

 

[waterbottle10]

You think a GI doc would go there to teach ED docs Colonoscopies and egds?

 

[Hoya11]

I hate to bring up an old topic but just wanted to relay an experience I had in the ED as a rotator last month. Patient with an elbow abscess. I watched silently as ED Resident attempted an axillary nerve block without a block needle. He looked up the anatomy before attempting. Single injection with 1% lidocaine, barely any needle visualization. Half way through he was paged to a trauma and the block wore off by the time he got back to the abscess, not sure it even worked. In my resident experience I have not done many axillary blocks - A lot more ISB/Supraclav. But I am at the level where I can find nerves, dissect them off a vessel with the needle, visualize the whole needle. Manipulate the ultrasound. It took around 200-400 blocks to really get the skill down.
In your hospital do you have regional team doing ED blocks or is this done by ED...
I was really surprised to find out that ED folks are doing complex blocks.
Do they do enough to see the anatomy. Manage the complications.
I get that the ED is busy and anesthesiologists don't want to roam around there but what are your thoughts.
Is there a balance, should the ED just consult anesthesiologist regional team like they do ortho, neurology, cards, etc.

Anesthesiologists are experts at certain things. ER docs are experts at certain things.

When the ER docs do a procedure that we anesthesiologists are experts at (tubes, lines, PNBs), they seem foolish, naturally, as this isn't their forte.

First off, its a weird choice to do an axillary block for an elbow as opposed to a home run SCB. Wierd choice of local anesthetic as well. You can tell that this is all being done by someone who is novice... but its OK....

How are you at reading xrays and picking up subtle fractures? Personally Im not very good.

How about suturing big open wounds? Same.

Id look foolish if I had to do those things compared to someone with much more experience doing that particular thing.



Also, the goal of a PNB in the ER and a PNB prior to the OR is different..

For us anesthesiologists, if the block fails, you have to give lots of narcotic, possibly re-block, the patient is unhappy, stays in PACU forever, etc.. so the block is very important for peri-operative smoothness. We do many blocks and we have to be precise each and every time.

For them in the ER, they do this crappy block in conjunction with high dose dilaudid and other systemic pain medicines, and if it works a little bit for 2 hours great, if not thats ok they tried no big deal, maybe by next month they will get another elbow injury patient and try it again.

I wouldn't be offended by it.

Im more offended when they send up a critical patient with a 22g iv that doesnt work

 

[pgg]

Is there a balance, should the ED just consult anesthesiologist regional team like they do ortho, neurology, cards, etc.

The ED is staffed by licensed and credentialed physicians who can do whatever they feel is in the best interest of their patients, within the bounds of what they are licensed and credentialed to do.

It's not our place to tell them when they need to consult other physicians vs perform a service themselves, unless what they're doing explicitly runs afoul of hospital-wide policies.

For example, at many hospitals, there is a hospital-wide "sedation" policy that is composed by a committee that includes anesthesiologists. In those settings, our input to the policy is going to be grounded in OUR standard of care. If the hospital then adopts our recommendations as policy, the other departments are obligated to follow it also. In this case, an anesthesiologist will have some influence over how an EM physician practices. This influence extends in other ways too, e.g. pharmacy committees deciding what drugs will be on formulary and available in the facility.

But in general ... not our place to get angsty or critical of what they do in their world.

 

[twoliter]

The ED is staffed by licensed and credentialed physicians who can do whatever they feel is in the best interest of their patients, within the bounds of what they are licensed and credentialed to do.

It's not our place to tell them when they need to consult other physicians vs perform a service themselves, unless what they're doing explicitly runs afoul of hospital-wide policies.

For example, at many hospitals, there is a hospital-wide "sedation" policy that is composed by a committee that includes anesthesiologists. In those settings, our input to the policy is going to be grounded in OUR standard of care. If the hospital then adopts our recommendations as policy, the other departments are obligated to follow it also. In this case, an anesthesiologist will have some influence over how an EM physician practices. This influence extends in other ways too, e.g. pharmacy committees deciding what drugs will be on formulary and available in the facility.

But in general ... not our place to get angsty or critical of what they do in their world.

But the question is would you teach them to do sedation/regional/etc?

 

[pgg]

But the question is would you teach them to do sedation/regional/etc?

Sure.

I'm not the least bit worried about an EM physician ever competing for my job.

We have med students, interns, and residents rotate through anesthesia all the time. Of course it's OK to teach them.

 

[Planktonmd]

Sure.

I'm not the least bit worried about an EM physician ever competing for my job.

We have med students, interns, and residents rotate through anesthesia all the time. Of course it's OK to teach them.

You are right! If nurses are already doing your job why would you worry about others doing it?
Actually I go a step further and suggest that anesthesiology should become a domain anyone can learn online if they so desire. I bet the ASA would be happy to provide the online training material for a reasonable fee.

 

[Carbocation1]

You are right! If nurses are already doing your job why would you worry about others doing it?
Actually I go a step further and suggest that anesthesiology should become a domain anyone can learn online if they so desire. I bet the ASA would be happy to provide the online training material for a reasonable fee.

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[Carbocation1]

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Coming soon!

 

[pgg]

You are right! If nurses are already doing your job why would you worry about others doing it?
Actually I go a step further and suggest that anesthesiology should become a domain anyone can learn online if they so desire. I bet the ASA would be happy to provide the online training material for a reasonable fee.

Yeah, let's get carried away and paranoid about EM docs doing half-assed blocks in the ER to supplement their "conscious sedation" with etomidate.

Honestly man, do you really feel threatened by them doing either of those things?

The risk to anesthesiology isn't from EM physicians doing stuff in the ER. I can't believe we're even discussing this. It's as if because we've been bitten so hard by the AANA and their coven of militant nurses encroaching on our practice that it's ingrained a reflex pearl-clutching "oooh noooes" response any time another doctor does something sorta related to the things we do. Deep breaths, man, deep breaths.

 

[Carbocation1]

It's a slippery slope. EM docs will learn anesthesia, then GI docs will be next. Next thing you know, the anesthetic will be ordered by the surgeon to be carried out by the CRNA/McSleepy.

When will the ASA sack up and take control of the specialty?

 

[pgg]

EM docs will learn anesthesia

How often are you getting called to the ER to provide anesthesia now?

How much business do you fear losing to them when they are providing their own anesthesia-like services?

Before the EM guys started doing blocks for their procedures, they weren't calling the anesthesia department down to do interscalenes or other blocks. They were pushing etomidate to sedate the patient through whatever painful reduction or other procedure they were doing.

There is literally no loss and no threat to us here. This is a stupid hill to gaze upon, much less die upon.

 

[Arch Guillotti]

Who cares what they are doing? Let them do whatever they want. Just don't call me!

 

[Urzuz]

How often are you getting called to the ER to provide anesthesia now?

How much business do you fear losing to them when they are providing their own anesthesia-like services?

Before the EM guys started doing blocks for their procedures, they weren't calling the anesthesia department down to do interscalenes or other blocks. They were pushing etomidate to sedate the patient through whatever painful reduction or other procedure they were doing.

There is literally no loss and no threat to us here. This is a stupid hill to gaze upon, much less die upon.

We get called by the ED to put fascia iliaca blocks/catheters in elderly hip fracture patients, per the request of our ortho trauma surgeons. So though everyone's experience may be different, we definitely do get called by our ED.

And I am part of a private practice to be clear, so them doing a block is 100% money out of my pocket.

 

[Mman]

But it literally takes 5min. Even with Medicaid it's good $$.

We collect in the neighborhood of $50-$60 for a medicaid interscalene nerve block. If I had to draw up drugs, collect equipment, and roll an U/S down to the ED to do a block it would definitely take me longer than 5 minutes of total time.

 

[Arch Guillotti]

But it literally takes 5min. Even with Medicaid it's good $$.

And I would happily teach ER Docs to do their own blood patches but they never show any interest.

The block itself takes less than that.

Getting to the point where I could go do a block is an entirely different matter:

Finish up whatever tasks I am doing.
Get ahead on whatever tasks need to be done.
Get drugs and equipment.
Make sure it isn't a bad time to leave the OR.
Trudge down to the ER.
Talk to the patient.
Get a nurse, do a time-out, etc, etc, etc.
Position the patient.
Make sure all the monitors are appropriate.
Dictate a note, etc.
Haul crap back to OR.
Catch up on whatever I am behind on.

No thanks.

 

[Arch Guillotti]

We get called by the ED to put fascia iliaca blocks/catheters in elderly hip fracture patients, per the request of our ortho trauma surgeons. So though everyone's experience may be different, we definitely do get called by our ED.

And I am part of a private practice to be clear, so them doing a block is 100% money out of my pocket.

Do you have Intralipid readily available? Or do you just not worry about it?

 

[nimbus]

We collect in the neighborhood of $50-$60 for a medicaid interscalene nerve block. If I had to draw up drugs, collect equipment, and roll an U/S down to the ED to do a block it would definitely take me longer than 5 minutes of total time.

But for others you can get $600. It would be interesting to see how it averages out.

 

[AdmiralChz]

How often are you getting called to the ER to provide anesthesia now?

Ugh we get asked several times a week (at least in July with the new fellows) by GI to come provide sedation for a "quick" EGD/colonoscopy that the ED refuses to sedate for. Other random services call as well for procedural sedation since there's a policy that the attending has to be in the room until the procedure and sedation is complete (so they don't get very excited about doing it, especially in the late afternoon when the ED is blowing up). Thankfully it's an easy "no" since the ER isn't an anesthetizing location for us. And at least half of those "5 minute" EGDs end up being a 90 minute food bolus retrieval into the final frontier of nastiness.

 

[Mman]

But for others you can get $600. It would be interesting to see how it averages out.

Well sure, your post said that even with Medicaid it was good $$$. I'm saying it isn't good money with medicaid. The good money is on the privately insured patients. And how it averages out basically depends on the payer mix of trauma patients in an ED. Ours would be truly awful. I don't have the exact ED numbers but we probably have something like 10-20% of trauma patients that are privately insured. It's a far worse mix than our global surgical population.

 

[Noyac]

This is stupid.
US is useless.
I'll teach them how to do regional without US.

 

[Urzuz]

Do you have Intralipid readily available? Or do you just not worry about it?

Yes we have intralipid in our block carts.

 

[dhb]

The block itself takes less than that.

Getting to the point where I could go do a block is an entirely different matter:

Finish up whatever tasks I am doing.
Get ahead on whatever tasks need to be done.
Get drugs and equipment.
Make sure it isn't a bad time to leave the OR.
Trudge down to the ER.
Talk to the patient.
Get a nurse, do a time-out, etc, etc, etc.
Position the patient.
Make sure all the monitors are appropriate.
Dictate a note, etc.
Haul crap back to OR.
Catch up on whatever I am behind on.

No thanks.

Or you can have the patient sent up to the OR and do the block there. That's what i did the other day : ISB 10cc of lidocaine and i pulled on the shoulder 5min later since the surgery resident didn't show up fast enough.

 

[FollowTheMoney]

The block itself takes less than that.

Getting to the point where I could go do a block is an entirely different matter:

Finish up whatever tasks I am doing.
Get ahead on whatever tasks need to be done.
Get drugs and equipment.
Make sure it isn't a bad time to leave the OR.
Trudge down to the ER.
Talk to the patient.
Get a nurse, do a time-out, etc, etc, etc.
Position the patient.
Make sure all the monitors are appropriate.
Dictate a note, etc.
Haul crap back to OR.
Catch up on whatever I am behind on.

No thanks.

I'm sure the Neurosurgeon would rather not work 80 hours a week and have someone else do the 12 hour crani, but then thought to himself... if he taught someone else how to do this he wouldn't get paid 1 million dollars a year anymore. The problem with our specialty is that we are lazy as **** (collective generalization) compared to most of the other specialties and the urge to be lazier gets more tempting the longer you do it.

 

[Arch Guillotti]

I'm sure the Neurosurgeon would rather not work 80 hours a week and have someone else do the 12 hour crani, but then thought to himself... if he taught someone else how to do this he wouldn't get paid 1 million dollars a year anymore. The problem with our specialty is that we are lazy as **** (collective generalization) compared to most of the other specialties and the urge to be lazier gets more tempting the longer you do it.

I am not teaching anyone to do a block.

I simply have zero interest what an ED doc decides to do with his patients. I am busy enough without having to go to the ED. In my case, they aren't stealing any business from me. Unless surgeons start operating in the ED I could care less about what they do.

 

[epidural man]

Wondering if I could have your input.

I have been asked to speak to our ER dept about regional anesthesia. The dept uses a lot of ultrasound and are interested in nerve blocks. My plan is to teach them as I feel it is in their scope of practice but I will do so with a word of caution as they should not be taken lightly.

Also they need to check with their malpractice, hosptial privledges, and dept befor starting the blocks

What do you guys think? I did find a few artlces suggesting it can be done

.Blaivas.. M, Lyon M. Ultrasound-guided ..interscalene.. block for shoulder dislocation reduction in the ED. Am J ..Emerg.. Med. 2006;24:293–6. [..PubMed..].​

. .​

.
.
.Liebmann.. O, Price D, Mills C, Gardner R, Wang R, Wilson S, et al. Feasibility of forearm ..ultrasonography..-guided nerve blocks of the radial, ..ulnar.., and median nerves for hand procedures in the emergency department. Ann ..Emerg.. Med. 2006;48:558–62. [..PubMed..].​

. .​

.
.
.Ultrasound-guided nerve blocks in the emergency department. J ..Emerg.. Trauma Shock. 2010 Jan–Mar; 3(1): 82–88. .​

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Stone MB, Wang R, Price DD. Ultrasound-guided ..supraclavicular.. brachial plexus nerve block ..vs.. procedural sedation for the treatment of upper extremity emergencies. Am J ..Emerg.. Med. 2008;26:706–10. [..PubMed.

Yeah - I'd teach them.

It doesn't hurt our field - it never would. (in fact, it helps it...because no one wants to go to the ER and do a nerve block ...and this isn't taking patients from the OR in any stretch of the imagination).

Lanes of practice always blur for the skilled and curious physician.

Here is a motto that I think works well in ALL situations. Treat others the way you would want to be treated. What if you wanted to learn something you where super interested in, but just didn't want the whole kit and kabootle of that specialty? Wouldn't you be super thankful for the unselfish physician who imparted the hard-earned knowledge to you? Of course you would.