Non anesthesia provider providing anesthesia

[EMS/ICU/SRNA]

I overheard an ED attending discussing a policy regarding the administration of propofol w/ an RN at work today. Apparently the policy states that propofol or any other medication may be administered to a non-intubated pt if an attending ED/Pulmonary physician is in the room. This would be done for a procedure ie: reduction of a fx....etc. I asked him why anesthesia personnel would not provide the anesthesia. He responded that the ED/Pulmonary physician is able to provide all services that anesthesia could. What do you guys think about this?

[jenniek]

this is from the arizona board of nursing

http://www.azleg.state.az.us/ars/32/01661.htm

32-1661. administration of anesthetics by registered nurse; definition

a. a licensed registered nurse may administer anesthetics under the direction of and in the presence of a licensed physician or surgeon if the nurse has completed a nationally accredited program in the science of anesthesia.

b. as used in subsection a, "presence" means within the same room or an adjoining room or within the same surgical or obstetrical suite.

seems to me the hospital is using their own definition of accredited program in the science of anesthesia.

i think that's all the evidence i need. i'm done.

[rn29306]

Do you know the difference between propofol and Diprivan?

Diprivan is the injectible option for propofol (emulsion) . It is what is commonly used in the ER.

Generic propofol contains a sulfite. Trade name Diprivan does not.

Do you know what laryngospasm is and how to treat it?

Cord shutting togeather, the Tx is PPV and then lido sprayed on the cords for relaxation. Ive treated it multiple times in dry drowing kids.

PPV then anectine to break laryngospasm. Every first year student knows this. Let me get this straight - the VC snap shut because of some stimulus, then you further manipulate the airway doing a DL in order to spray the cords, the entire time losing precious PPV? It is an anesthesia standard tx of laryngospasm for a reason. Hold PPV. That doesn't work, go to anectine.

Your patient is obese-do you know what that does to gastric emptying time?

not a clue, dosent effect me in my practice.

Then stop giving them propofol if you don't know the answer to this question. Same goes for diabetics and people on narcotics.

What are the ASA fasting guidelines?

Again, this is of no relevance to the ER and an emergent procedure. The ASA has no power in the ER.

It is alarming that you would say this. As one of the two bodies of knowledge most familar with general anesthetics, the ASA has a proven tract record concerning fasting guidelines. You are giving a general anesthetic that renders most patients unconscious, even if for a short while. Admit it, you are not giving propofol for CS, you are giving it for unconscious sedation, (ie general anesthesia). But I guess that concept of conscious vs unconscious doesn't apply to the ER does it?

So you say that propofol is used for closed reductions, but "this is of no relevance in an emergent procedure". Since when did an elective procedure such as closed reductions become emergent?

Do you know what qualities of stomach aspirate make it more or less lethal?

Again, not relevant to my current practice.

Again, then stop giving a general anesthetic to people you don't know crap about. Answer to the question is a pH of less than 2.5 with a volume greater than 0.4ml/kg. This is a question any first year anesthesia student knows. Mendelson Syndrome is a lethal kicker in most instances.

Do you believe the MD you are pushing these drugs for knows all the answers to these questions?

Its an expectation of the job, though many are irrelevant in the emergent tx of an ER patient.

Mike at the top of this initial post, you stated that propofol is used in your ED for closed reductions. I am still unsure of how an elective closed reduction in the ED constitutes "the emergent tx of an ER patient".

[MmacFN]

Hye jwk

Thanks for the sarcasm and judgement as opposed to answering the questions.

I dont know everything about anything. I work with people who have forgotten more than i will ever know. However, what i expect when i pose legitimate questions about opinions and practices that masters prepared people (whomever is masters prepared) can understand the value of research and back up their statements with it.

Im not at all antagonistic to the profession, im challenging dogma which, when you review the data, seems unfounded. Dont you think if it was as dangerous as suggested there would be quantative evidence to back that up?

This conversation is NOT about me or my ability to function in school. You dont know me and are certainly not qualified in anyway to judge me as a professional or a person. Why dont you back off with the personal attack and act like a god damn professional and answer the questions with EVIDENCE.

Geesus.

Mike, why don't you just remain a flight nurse? Really. You know all there is to know about ER and flight nursing, by your own admission. Why on earth are you going to anesthesia school?

You're amazingly antagonistic towards an entire profession you claim that you want to be part of. I hope someday, for your sake, you start thinking like an anesthetist, because school is really going to be hell for you if you don't. Your responses to that list of questions, particularly the last few, show an arrogance and cavalier attitude that will not be well tolerated by your instructors. This same arrogance by "sedation nurses" and gastroenterologist, ER docs and even flight nurses who have seen and done everything on their own with no one else around, is what puts patients at risk. They have that same "not a clue, not relevant, doesn't concern me" attitude.

[MmacFN]

Well said Keith :)

I can understand what you are feeling. I have also seen you many times call for eveidence and very little has been posted. I also know how so much research uses statistical clustering to prove what ever point is predisposed in the mind of the writer. I also know there is an extreme legal danger in not following Information like package inserts.

Yes I realise that in your area, the BON and your hospital, as well as the MDA's for providing the inservice have made it in your scope of practice. It seems to me that you are very knowledgeable due to much of your experience. When it comes down to it, when it is cearly in your scope of practice it would be extremely hard to turn down an MD telling you to do a push.

I hope some day to be a CRNA as well, but I'm still on the starting blocks, so to say. Till then I don't think I could in good consience push this med, but that is my choice. One thing I think is very dangerious is doing something your improperly trained for in nursing. That is why Scope of practice is there to try to keep you from doing that. It seems to me very dangerious when the powers that be try to sidestep that in the name of convience or cost effectiveness. Much of the research you have posted seems to be to be a means to do just that. There are holes in it that make me uncomfortable. I don't think there has been really good resaerch posted stating the opposire stance either, but if it were me, or my family in that ER, I wouldn't want anyone but a CRAN or MDA giving me those types of drugs. Live is too precious to thow caution to the side in the name of conveince or cost.

[MmacFN]

hey jen

I actually do not work in the ER much anymore. However, all patients are prepared for the possibily of aspiration. The measures taken when the drug is given are:

- Suction ready

- code cart ready

- intubation equipment ready

- paralytics in room and ready.

- 3 ppl in the room at all times, 2 RNs (one charting one giving the drug) and one physician until pt comes out of sedation.

That is standard where i have worked. However, i cannot say with any certainty this is the case everywhere. Clearly, where anesthesia is avaliable easily, this is a better option, but that is not the norm.

So what patients do you prepare for aspiration?

Or is this not a concern because it is the ER and it's safe?

My concern is that you are giving an anesthetic on the ER, so you need to worry about anesthesia problems, even if you are only giving what you think is a "sedation" dose.

[MmacFN]

Hey Ray

Absolutely. Obviously I dont know about anesthesia, thats what everyone here does (or many do). I am sure as im reading (all those books i bought to learn more before school) i will be amazed with the volumes of stuff i dont have a clue about. Hell, i learn alot here in regards to meds i never use and the profession, it wets my appetite for more.

Im excited to learn about it, thats why im excited to go back to school!

Hey Mike, oh stirrer of the shiat! Need to pick up baby Miller and give it a look...might help you with some of those questions you missed pal.

[MmacFN]

hey jen

this is true. however, the board defines anesthetics differently than concious sedation of which diprivan is the drug of choice in the er. diprivan gievn for the purpose of anesthesia is when it must be a crna or mda, not for the purpose of concious or deep, sedation for procedure.

believe me, i made sure it was ok or i would never do it.

this is from the arizona board of nursing

http://www.azleg.state.az.us/ars/32/01661.htm

32-1661. administration of anesthetics by registered nurse; definition

a. a licensed registered nurse may administer anesthetics under the direction of and in the presence of a licensed physician or surgeon if the nurse has completed a nationally accredited program in the science of anesthesia.

b. as used in subsection a, "presence" means within the same room or an adjoining room or within the same surgical or obstetrical suite.

seems to me the hospital is using their own definition of accredited program in the science of anesthesia.

i think that's all the evidence i need. i'm done.

[MmacFN]

Hey RN

Let me answer your questions.

PPV then anectine to break laryngospasm. Every first year student knows this. Let me get this straight - the VC snap shut because of some stimulus, then you further manipulate the airway doing a DL in order to spray the cords, the entire time losing precious PPV? It is an anesthesia standard tx of laryngospasm for a reason. Hold PPV. That doesn't work, go to anectine.

Yes, i know a paralytic must be given, however, paralytics do NOT always break spasm, ive seen it myself on numerous occasions. When PPV and anectine do not break it, lidocaine is a legitimate tx to numb, and therefore help relax, the cords. Ive done it on multiple occasions in dry drowning patients who do not respond to anectine.

Then stop giving them propofol if you don't know the answer to this question. Same goes for diabetics and people on narcotics.

I can answer for drugs and diabetics. The gastric emptying time issue, however, is not a contraindication to propofol adminsitration from my understanding of millers.

It is alarming that you would say this.

It shouldnt be RN. The ASA has no pervue in the ER. Their information applies to the practice of anesthesia in the OR not the ER. Just like when a code occurs in the OR you dont call the ER doc to manage it. This isnt my policy, this is the ACEP policy which ends up as hospital policy in the ER or not based on the hospital.

Admit it, you are not giving propofol for CS, you are giving it for unconscious sedation, (ie general anesthesia).

Wow. That is not true at all. I have only once had to bag a patient we gave propofol to. I have only given it in the er maybe 20 times. The intent, and the dose, is meant for concious sedation. Are you suggesting the emergency physicians and ACEP are lying?

Since when did an elective procedure such as closed reductions become emergent?

So the patient with a closed hip dislocation who has an anterior dislocation is at risk for what? Yes, severe nerve and vascular damage due to the dislocation. Secondly, that patient is in extereme discomfort. It is emergent because the patient is in pain and at risk. This decision is beyond me and you, it is a medical decision made by the ER physician. If it they feel it is elective, they have (in the past) simply admitted the person. That happens rarely.

Again, then stop giving a general anesthetic to people you don't know crap about.

Thats right, i didnt know that off the top of my head. Instead i make the assumption that any aspiration is potentially leathal. That covers my bases.

[austin heart, BSN, RN]

the board defines anesthetics differently than concious sedation of which diprivan is the drug of choice in the ER. Diprivan gievn for the purpose of anesthesia is when it must be a CRNA or MDA, not for the purpose of concious or deep, sedation for procedure.

It sounds to me like you and or your facility are bending the rules to meet your purpose.

I would like to know why our Anesthesia/CRNA guys even take the time to come over and do an assessment of the patient including ASA before pushing propofol on our ER peeps when it really doesn't make a difference. I guess they just didn't have anything better to do with their time. Hey guys why don't yall just kick back and take a much needed coffee break instead of working up your patient next time. Whatever.

[MmacFN]

hehe

Ok, I guess the hospital, the ER Docs all the RNs and all the MDAs will soon be going to jail eh? Of course its legal or they wouldnt take the risk.

As opposed to answer your question why they do it there, where is the evidence that makes a difference in the ER on outcomes? Please post it so i can evaluate if i need to bring it as an issue to the ER director. Since it clearly would totally discredit the current evidence that ACEP and the ENA are going off of when they made their policy and joint statement (as i posted earlier).

Just so you know. Not all hospitals have anesthesia in such supply to do that in the ER daily. Its not always a viable option.

It sounds to me like you and or your facility are bending the rules to meet your purpose.

I would like to know why our Anesthesia/CRNA guys even take the time to come over and do an assessment of the patient including ASA before pushing propofol on our ER peeps when it really doesn't make a difference. I guess they just didn't have anything better to do with their time. Hey guys why don't yall just kick back and take a much needed coffee break instead of working up your patient next time. Whatever.

[MmacFN]

Ok

I am all for the spirit of discussion/debate, argument and professional sabre rattling. Its fun. I also learn alot from it. I enjoy challenging norms and learning the whys behind things. Challenging and asking the questions is how you (I) learn.

What im not ok with are personal and professional attacks directed at me questioning both my competance and ethical practice. This is not only unfounded but unprofessional and not the least of which mean-spirited. It quickly indicates how some react to the inability to defend their position, its classic "i'm right and your wrong and i dont have to prove it" behavior. An oppression nursing has long fought to get out from under yet is perpetuated here on this forum.

[susswood]

Mike-just so you know, I didn't post those questions specifically for you, but thanks for answering anyway, you really helped prove my point.

BTW, I think most of what we are talking about here refers to the guy in the ER with a dislocated shoulder, or the kid with the penny in his nose kind of sedation..... sorry, but I there is plenty of time for an anesthesia consult. These people have a right to quality anesthesia care. Let's step up to the plate and be patient advocates.

Also, I would like to see some "sedation nurses" respond to my post and admit they don't have a clue what I am asking. Come on.... who has the guts?

Any takers on the pop quiz? I still haven't seen a good enough post regarding the differences between Diprivan and propofol.