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?

[deepz]

......There isnt any need for an anesthesia person at all.

.........

Whoa. That's a rather broad assertion, don't you think, Mike? The GI folks' literature is full of their protests that they can order any damn thing they please and it WILL be safe. That just ain't necessarily so. These are the same docs who, in the days before oximetry, loaded up grandma and grandpa with Valium and Demerol ... and then turned out the lights! Literally and figuratively. Despite many arrests and deaths, that was considered a safe practice then, by their sometimes cavalier standards.

Now, I admire your gung-ho attitude, Mike, and I understand it as only a fellow adrenalin-freak can, but let me warn you: too much of that attitude on display and you'll not make it through a CRNA program. I'm sure you are very familiar with the old adage about pilots -- that there are Old Pilots and there are Bold Pilots, but there are NO old bold pilots. Eager beaver SRNAs get weeded out.

Your categorical statement above only serves to show me how much you have yet to learn. Sounds like you are on the path. I hope you will eventually come to see how challenging so-called Bread-and-Butter cases can be. Best of luck.

All IMHO, of course.

deepz

[midwestsrna1]

Actually, it isnt a concern to me.

Not only are there inservices for new RNs in the ER who are pushing diprivan (i often teach them), but it is backed by hospital policy and state nsg board regulations. There isnt anything to be concerned about. Secondly, there is an ER doc in the room or just outside of it (if its a GI doc in the rm) 100% of the time. There isnt any need for an anesthesia person at all.

Does someone assess the patient's airway before pushing the propofol? Are RNs trained in airway assessment? What happens if you can't ventilate the patient? Who is going to do the emergent cricthyrotomy on the pt?

Mike, you should be careful to distinguish the advanced skills you have as a flight nurse from the skills of the rest of the RNs who are in this situation. I'm sure that you are perfectly capable of managing these sorts of situations with your background but that doesn't mean that other nurses.

While ER docs might be prepared to intubate, anesthesia remains the experts on airway.

It sounds like Arizona has clearly made a statement on this situation but I'm guessing that other states have a lot of gray areas. Sorry, I don't have time to look for facts on any of this. I have an exam to study for.

[MmacFN]

Hey Deepz

Yup, that did not come out as i had thought i had written it.

What i was trying to say was that in the ER, when we are doing a closed reduction utilizing diprivan with an ER physican in the room there isnt a need for an anesthesia provider and the anesthesia dept of the hospital agrees with this.

Whoa. That's a rather broad assertion, don't you think, Mike? The GI folks' literature is full of their protests that they can order any damn thing they please and it WILL be safe. That just ain't necessarily so. These are the same docs who, in the days before oximetry, loaded up grandma and grandpa with Valium and Demerol ... and then turned out the lights! Literally and figuratively. Despite many arrests and deaths, that was considered a safe practice then, by their sometimes cavalier standards.

Now, I admire your gung-ho attitude, Mike, and I understand it as only a fellow adrenalin-freak can, but let me warn you: too much of that attitude on display and you'll not make it through a CRNA program. I'm sure you are very familiar with the old adage about pilots -- that there are Old Pilots and there are Bold Pilots, but there are NO old bold pilots. Eager beaver SRNAs get weeded out.

Your categorical statement above only serves to show me how much you have yet to learn. Sounds like you are on the path. I hope you will eventually come to see how challenging so-called Bread-and-Butter cases can be. Best of luck.

All IMHO, of course.

deepz

[MmacFN]

Excellent questions, i will try to answer them for you.

Does someone assess the patient's airway before pushing the propofol?

Yes, the ER physician

Are RNs trained in airway assessment?

All ER RNs are trained in airway assessment but the onus falls on the ER physician to make the final determination as the higher level of care.

What happens if you can't ventilate the patient? Who is going to do the emergent cricthyrotomy on the pt?

If that were to happen the ER physician would take over the airway. These skills are not in the hospital policy statement for ER RNs.

Mike, you should be careful to distinguish the advanced skills you have as a flight nurse from the skills of the rest of the RNs who are in this situation.

Well, when i work in the ER or ICU im under the same rules as every other RN. I only get to do procedures im trained in as a flight nurse if it is ordered by a physician (which rarely happens).

While ER docs might be prepared to intubate, anesthesia remains the experts on airway.

I would agree. However, i would also suggest that ER physicians are probably more experienced at managing "crash" airways than most anesthesia providers (as this is not the majority of practice in anesthesia but is in the ER). I would not be concerned about their skill level should a patient crash.

I have an exam to study for.

Good luck!

[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.

[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".

[rn29306]

All ER RNs are trained in airway assessment..

This is laughable.

I would agree. However, i would also suggest that ER physicians are probably more experienced at managing "crash" airways than most anesthesia providers (as this is not the majority of practice in anesthesia but is in the ER). I would not be concerned about their skill level should a patient crash.

See above. Airway management is what we DO. ER calls at our facility. CRNA and student go to the ED. Student usually intubates. This tees the ED physician off to no end but that is how we do it. And it works.

Ask your ED physician friends how many intubations he or she has done in his/her lifetime. I gurantee you I have more now than they do. Then add 10 years experience to that for most CRNAs.

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.

[maturner]

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".

well said!

Hey mike, I don't want to harp but I have one question.

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

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

[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?

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.

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.