[MmacFN]

hey

Oh that isnt the case at all. What i am suggesting is that ER physicians in the majority of hospitals are the only providers whom intubate in the ER and at night. In large institutions there is anesthesia in the Trauma room, however, that is not the norm in every hospital. Also, i would suggest that "difficult" intubation is a skill that is learned over time with experience. Since the majority of anesthesia intubation is elective (read: the OR) these are not, by definition, crash airways. Obviously those anesthesia providers who also do the crash intubations in the trauma room will be the top experts, i just think thats the minority in anesthesia in general.

I may be wrong, but in my experience ER physicians do more difficult intubations (crash) than anesthesia. Then there is the other subset of difficult airways we see prehospital which most ER and anesthesia providers never see at all.

Is that different from the majority of peoples experience?

Originally Posted by London88

MmcFan

What makes you believe anesthesia providers are not experts at handling crash airways? Who do you think responds to codes in many hospitals. Who do you think intubates the patients in many trauma centers in the ER when there is a trauma alert. Maybe this is not the case where you work but do not have the misguided notion that anesthesia cannot intubate or rescue an airway faster or better than an ER doc.

[MmacFN]

Hey jwk

I am a big fan of evidence based practice. If your going to make a statement like that back it up with research or it is invalid. I am more than willing to admitt that i know nothing about anesthesia compared to you. However, I posted a huge cross section study with excellent p and n values opposing exactly what you just said.

Im not pro diprivan without a good intubator (which is why i said we do it in the ER and i have no reservations about it), but even without a qualified intubator, that study shows it is safe. The data dosent lie nor does it have opinion.

Please tell me why you believe it is unsafe for an RN to push the med in the ER for closed reduction with an ER doc in the room. Also, back that up with research. If you cannot do that, your argument, no matter how much i dont know about anesthesia, is absolutely opinion and invalid in the realm of evidence based practice.

Originally Posted by jwk

Remember that in many states, it is illegal for RN's to administer propofol except to intubated patients on the vent.

Mike, you just don't get it. (OMG, deepZ and I are agreeing here). Look at this thread again in a couple years after you're in the middle of your anesthesia training and see if you agree with what you're saying now. Read the other threads on this topic - see how many posts are from SRNA's and CRNA's that used to give propofol and now realize what a stupid idea it was to do it without the anesthesia education they now possess. It's a truly classic case of "you don't know what you don't know".

[MmacFN]

RN

We usually agree on everything. Do you or have you worked in the ER? Of course ER RNs are taught to assess airways. Are they as competant as a CRNA, of course not. That wasent the point. Also, the response was that the ER doc made the final assessment. Do you contend that an ER physician (whom have similar rates of success as MDAs in studies) cannot assess airways and manage them?


ER calls at our facility. CRNA and student go to the ED.

Now that is cool! This hasent been the norm anywhere i have ever worked. Maybe only at large teaching hospitals?

Ask your ED physician friends how many intubations he or she has done in his/her lifetime.

Oh i agree, you probably have done more. Im suggesting that ER Docs are absolutely competant to intubate, not the numbers of intubations they do.

Re-read this post your senior year of anesthesia school and I would challenge you to say that you honestly believe you are still right.


Im gonna have to. Afterall, depending on where you work changes your practice. If you were a CRNA in some hospitals here, all you would do is manage the gas after the MDA intubates or place epidurals in the county hospital. Every state does not have the same experience that is being suggested here as the norm.

Is it really true that the majority of CRNAs and MDAs throughout the country respond to hospital codes, rush to the ER and intubate for the ER doc and work in the trauma room as the anesthesia provider?

[MmacFN]

Please do not insinuate I dont know anything about induction. While many RNs probably couldnt pronounce some of those drugs, im not them.

What intravenous induction agent (propofol, pentothol, ketamine, etc.) given in equipotent doses has the greatest cardiac and respiratory depressive effects?

Thiopental is absolutely the worst. Thiopental causes a significant decrease in cardiac output, systemic arterial pressure and peripheral vascular resistance. The depression of cardiac output is due to a decrease in venous return caused by peripheral venous pooling, as well as by direct myocardial depression.

Ketamine actually does the opposite and increases BP by up to 25%. It causes minor respiratory depression due to its signifigant bronchodilatory effetcs. In fact, ketamine has been the induction agent of choice in the military for a long time due to its miminam effects on cardiac and respiratory systems.

Diprivan decrease bp by up to 30% in most patients and has no place in trauma care where the patient is hypotensive based on all of the avlaible studies


Priority number one is not absence of personal liability but the presence of patient safety.

Which i clearly proved with the citation of a 9000+ patient study.

Please evidence your opinions.

[jenniek]

Originally Posted by MmacFN

What i am suggesting is that ER physicians in the majority of hospitals are the only providers whom intubate in the ER and at night.

So how many hospitals have you worked in that you know so much about this? Where are all these hospitals which you know so much about?

First you are an expert on BSN and ADN programs in the US, now you are an expert on this.
You seem to enjoy stirring the pot, but there are more ways to keep this board alive than that.

[athomas91]

mmacfn..... i too was an experienced ER/Trauma RN - worked in at least 15 different ER/trauma centers... ignorance may be bliss - but you are arguing with those of us who have been where you are - have moved on and realized we had the same misguided arguments...
first of all - most clinical sites i have been WE trained ER residents... and who gets called when the ER docs ***** the airway... oh, anesthesia...
just because your hospital states you can give propofol... do you think when you and the hospital are getting sued and the lawyers pull out... "the package insert clearly states should only be given by trained anesthesia person..." that your hospital will pay what you will owe?? they will sell you up the stream my friend...

due to its miminam effects on cardiac and respiratory systems.

ketamine has the worst of all cardiac effects... that is unless you are referring to the 20 y/o trauma patient who has no underlying heart disease... and even then...it will only cause them to bleed out more.

just for the record... rn's learn how to intubate a dummy in ACLS/ TNCC etc... however, they are not trained in airway evaluation or management.. you may be - but the general ED RN is not.

i will repeat what another poster stated... as a senior SRNA - look back - your views will have turned 180 degrees and it has nothing to do with territorialism... it has to do with not knowing what you don't know... and you can't know it until you have been there... and there is no arguing that.

[MmacFN]

hey

well im suggesting that because of the AANA statement that 80% of CRNAs work in metropolitan areas. Since that is the case it would stand to reason that most hospitals in the USA are not staffed by CRNAs.

Im sorry if what i had to say about the ADN program upset you, clearly your still carrying it around. If im wrong, please refute my statements with evidence. I have never had a problem admitting im wrong i just want people to prove it as opposed to simply having an opinion.

[jwk]

Originally Posted by MmacFN

Also, i would suggest that "difficult" intubation is a skill that is learned over time with experience. Since the majority of anesthesia intubation is elective (read: the OR) these are not, by definition, crash airways. Obviously those anesthesia providers who also do the crash intubations in the trauma room will be the top experts, i just think thats the minority in anesthesia in general.

I may be wrong, but in my experience ER physicians do more difficult intubations (crash) than anesthesia. Then there is the other subset of difficult airways we see prehospital which most ER and anesthesia providers never see at all.

Is that different from the majority of peoples experience?

Mike - again, you just don't know what you don't know. Your "experience" is limited to the ER and flight nursing. Granted, flight nurses get a lot more experience than ER nurses. But anesthesia providers, in ANY hospital, are THE airway experts - period - hands down - end of story. If not, they shouldn't be giving anesthesia. Really, if you go into anesthesia school with this "I've seen it all and I know what the studies show" attitude, they will eat you for lunch. You're changing professions, but you're sure holding on real tight to the old one.

Maybe you're just stirring the pot to keep it interesting...

[Geeg]

Diprivan can have profound cardiac effects also, especially in a pt with many comorbidities. Or, the pt who has just had a huge bowel prep and is dehydrated.

[jenniek]

Originally Posted by MmacFN

hey

well im suggesting that because of the AANA statement that 80% of CRNAs work in metropolitan areas. Since that is the case it would stand to reason that most hospitals in the USA are not staffed by CRNAs.

Im sorry if what i had to say about the ADN program upset you, clearly your still carrying it around. If im wrong, please refute my statements with evidence. I have never had a problem admitting im wrong i just want people to prove it as opposed to simply having an opinion.

It has not upset me. I'm just pointing out previous posts by you. I'm intrigued by all this knowledge you have and wonder what sort of experience you have with all these different nursing programs and ED departments. Please share.

If you can share the majority of hospitals which you know so much about...how many states have you worked in since moving from Canada? You seem to know a lot, but I'm wondering what exactly your experience is? And I'm not referring to your mile long list of specialties. Each state has it quirks as does each states board of nursing. You may be familiar with the Arizona BON, but what about the other 49 states?