David Brock:
Let me recount my ER horror story:
We were a site for the NINDS rTPA stroke trial (results in recent NEJM), so that we were immediately notified of any acute strokes in the ER. On one occasion I scampered down to the ER to find the staff attempting an awake intubation of a hemiplegic patient with a BP of 260/180. My first concern was that the patient had an ICH and most likely had ICP problems. The junior ER housestaff continued to thrash away with the ET tube under the watchful eye the ER attending. They had not given IV lidocaine to blunt the rise in ICP, nor were they NM blocking the patient. They were giving Lorezepam alone. Then they decided to acutely lower the blood pressure because they were concerned about "hypertensive encephalopathy." At that point I could stand it no more and tried to intervene as I was the neurointensivist who would have to care for the patient if he survived the ER. I was not so kindly told that until the patient was in the Neuro ICU, he was none of my business.
Suffice it to say, the patient died.
The issues as I see it:
Joe Gifford:
Show me the data that shows lidocaine-before-intubation does anybody any good. We've stopped doing it around here, and in Seattle's EMS system.
Tom Bleck:
(1) Intravenous lidocaine clearly blunts the rise in ICP associated with laryngoscopy and intubation in patients with intracranial mass lesions (Hamill JF et al. Lidocaine before endotracheal intubation. Anesthesiology 1981;55:578-581). Class I (RCCT) evidence on the evidence-based medicine scale.
(2) thiopental before intubation is probably as effective, and it is not apparent that the combination of lidocaine and thiopental is better than either alone. Class II evidence (uncontrolled series).
(3) I'm not aware of any direct test of the hypothesis that pre-intubation lidocaine prevents further cerebral damage in patients with elevated ICP. But it seems to me that it is cheap, probably without appreciable risk (single dose, no infusion), and may be life- or brain-saving in a few cases (I'll declare myself an ICP expert and make this class III evidence).
Is anyone else bothered by the lack of evidence that evidence-based medicine improves outcome? It is all based on class III data.
Joe Gifford:
Sorry, i didnt mean to snap at you. my point was that you made it sound like failure to give lidocaine preintubation was defacto evidence of incompetance when in fact that practice is at best controversial. My read of the evidence (cited below) is that:
David Crippen:
Sorry I am late contributing to this thread. For my part, I think lidocaine is the trees rather than the forest. I think the patient needed to be sedated adequately, maybe even paralyzed. Intubation is a decidedly unpleasant experience (if you don'' believe it, try it on yourself). It tends to kick off hyperanxiety, discomfort related hyperactive musculoskeletal activity in addition to catecholamine release, hypertension and tachycardia. All of these conspire to do nasty metabolic things.
I also agree that lorazepam is virtually never indicated for an acute intubation. It takes far too long to get an effect and...... LORAZEPAM IS A VERY WEAK SEDATIVE. Midazolam would have been a much better choice, it gets an effect in three minutes and it is MUCH MORE POTENT THAN LORAZEPAM. Propofol might have been a viable option as well, if the patient was not intravascularly depleted and showed no evidence of heart failure.
Another option would have been to paralyze the patient after controlling the blood pressure with a labetalol drip. You frequently have more time to play than you think once the patient gets settled down with an assisted airway. Five mg labetalol followed by a 5 mg/hour infusion to start. I might have given a bolus of vecuronium (avoids a tachycardic response that can be deleterious to cardiac function) following a fairly big bolus of midazolam. I might then have simply assisted the patient's ventilations with bag and mask while I "waited for the drugs to take effect", as Gregg Allman might have said in earlier sagas. When the patient stopped moving, intubation proceeds simply and easily, as does placing arterial lines, CVP catheters and the like.
One of the most difficult emergency procedures you will ever be called upon to accomplish is emergency airway acquisition and initiation of effective ventilation. This is one of the few emergencies where seconds literally count. My biases is that In a genuine emergency, the most experienced person present should manage the airway. This may mean having to literally push student nurse anesthetists and housestaff out of the way. If I arrive on the scene and a student CRNA or house officer is in the process of intubation I give them time for one shot at it and if they fail, it's immediately my show with no argument. (I don't push anesthesiologists out of the way). Housestaff get to practice intubation on chronically ill patients who get intubated and extubated all the time, and sometimes on stiffs.
I was once called to another monitored unit in the hospital to deal with a problem and found that a consulting pulmonologist had beaten me to it. He had given the patient one milligram of lorazepam and was busily chasing the patient all over the bed trying to get the blade in his mouth. Politically, for me to push him out of the way would have not been in my best interest. SO I simply helped him out. I had the nurse give the patient a real sedative, which began to work quickly, I helped bag and ventilate, I held the tube and pulled the side of the mouth out so he could get a better view. Once things settled down, he managed to get it done. If he had not have gotten it on the SECOND try. (Yes...attendings get two tried before I jump on them...), I would have had to bite the bullet and give him the bums rush.
I am a really aggressive bastard in real emergencies and I don't lost arguments on this turf.
Louis Brusco:
In our institution, the anesthesia service manages ALL airways except for the ER. There, they have recently (2-3 years) started an EM program, and, this year, took on their own airways. This despite the fact that I would trust few of their attndings to intubate a cat (I hate cats). Frequently, at least 2-3 times a week, we get called down to the ER after at least two of their residents and two of their attendings have macerated an airway. The other day I got called down by my resident to help intubate a 14 month old in status epilepticus. Two of their residents and one of their attendings had tried, failed, and backed off after causing pharyngeal edema and bleeding. They decided to quit as the baby was breathing and saturating. We were only called when the pediatricians took over, took the baby to their ER across the hall, and we took over the airway.
Steve Streat:
Here (this hospital) almost all ED intubation (other than for in-ED cardiac arrest) is done by Critical Care staff (3-7th year registrars - PGY5-9 for the Americans, half of whom have anesthesia fellowship, or specialist intensivist - doesn't matter which primary specialty) using a proper anaesthetic crash induction technique (Eg pre-O2, possibly local spray to cords, cricoid pressure, dose (depending on CVS state) thiopentone, sux 1mg/kg, wait till flaccid, tube, check, cricoid off, panc, morphine, diazepam, sort the CVS etc and get-the-patient-out-of the-ED and into the OR or the ICU where they belong). We do about 500 ED intubations per year as half of our 1000+ ICU admissions come straight from the ED. If we anticipate that the situation will be nasty (eg need for IPPV with trauma and airway injury but not immediately likethreatening) we ask our anaesthetic colleagues to take the patient to the OR stat and there, with full difficult intubation preparation - fibreoptic laryngoscope, lotsa blades, introducers, bicycle clips (Caution : Humour, Poms will understand) , prepped for trache if necessary etc the patient has a controlled intubation by a specialist anaesthetist with a surgeon scrubbed ready to perform surgical airway.
In NZ hospitals without intensivists ED intubation is done by anaethestists. We are only just experiencing the rise of the ED Specialist here in the last few years and (so far, touch wood) this is not an area they have taken over and stuffed up. Downunder even the Emergency Medicine people think that being anaesthetised for intubation is pretty good for you. Watch this space.
The (all too commonly heard) American stuff about boys (and girls) in short pants (or skirts) straight out of TV soap operas shoving tubes at the airways of unanaesthetised people who are coughing, crying, thrashing, hypertensive, bleeding, aspirating, blue etc is anathema to us. I am amazed to hear that this sort of thing can go on and not be stopped by your Departments of Risk Management (if not by your clinicians). Why ? What is wrong with the idea of controlled conditions in the USA ?
What about patients who have had SAH ? or trauma or have a belly full of beer - is it still done for them that way in the US of A ??? (Yeah, I know, its a big paradoxical country - it might be different in some places).
Kim Agee:
About 3-4 times yearly, our Emergency Department has "problems" with an unexpected anatomically difficult airway, ending up callingn Anesthesia with resultant recriminations and bad feelings. Seems it usually involves mis-assessment of the anatomy, inappropriate use of certain drugs (in a hemodynamically unstable patient, etc.), and/or multiple, time-consuming and airway-bloodying attempts prior to the cry for help.
The EMD folks claim to have no need for advice, consultative input, or even something so seemingly innocuous as the occasional profferred airway lecture for their housestaff by the Anesthesia people. Since they are training EMD residents, they seem to feel that they need to cultivate a "do-it-all" mindset. The Anesthesiologists are usually pretty hot, feeling that they have basically been handed someone else's bad result over and over. There is no reimbursement issue as we are a military facility.
Up in the ICU, we do a fair amount of airway management, but we call Anesthesia liberally for anticipated problems (ICU staff=4 pulmonary intensivists, 4 surgical types, 1 lonely anesthesia intensivist). We encounter difficult airways too, but usually with bronchoscope in hand and/or Anesthesia friends nearby. Seems to me we have a good relationship with Anesthesia (running buddies, etc.).
Mark Wedel:
I offer only these observations after 20 years of going round and round 'bout issues like this:
First, do whatever you do with a smile. No need to add angstroms of coronary disease feeling paranoid. Anybody can do the easy intubations. The reason you got called is because you're good and this is a tough one.
Second, in this day and age, assume responsibility for anything someone else wants to give you. Frankly, there's not enough work to go around. If someone wants to default something, immediately volunteer. Its called job security. For you, not them.
Third, avoid the aggravation of learning the ED has decided to equip themselves with a bronchoscope so they can "do the tough ones." If you leave a vacuum, someone else will fill it. If you think you find the current system disagreeable, just sit on the sidelines. I guarantee you your frustrations will get worse when they get their own bronchoscope.
Fourth, in answer to your question re who does the airways in our individual hospitals, the answer: anyone capable. Discipline is irrelevant. Skill is paramount.
Finally, remember that all of us are learning every day. So smile when you respond and watch the muddlers do their thing. At least you'll learn how NOT to do it. And the ability for all of us to hone our skills on the tough cases is an experience money can't buy.
Daniel DeBehnke:
I agree that better communication is required between all consultants and the ED attending (this is a 2 way street however). Discussion of patient care issues at the bedside, joint conferences and multidisciplinary conferences to discuss problem/interesting cases are just a start to break down some of the communication barriers that we (as a specialty) have been dealing with for years.
I disagree with your comment that "difficult airways" need anesthesia to intubate. In some situations this may be the case but the truly emergent airway is the forte of the emergency medicine specialist. Most anesthesiologists have not had enough experience with the truly emergent airway ( such as massive facial trauma, penetrating wounds to the face/neck etc). I have had significantly more experience in managing these airways than the anesthesiologists and residents who you suggest that I call for management. Also, getting a timely response from our anesthesia colleagues in an emergency situation has been (in my experience) fraught with difficulties.
Each EM training program is different but my training program required 3 months of med/surgical ICU, 1 month of pulmonary ICU, 1 month of pediatric ICU and ICU experiences on my Neurosurgical, Cardiology and Trauma surgery rotations. These rotations were under the watchful eye and expert teaching of intensivists from surgical, anesthesia and medicine training. I believe that they taught me appropriate management principles for critically ill/injured patients.
Your discussion of pharmacologic aids to intubation is interesting given our experience as a specialty. It is certainly under debate whether lidocaine has any effect on ICP during laryngoscopy and any effect on intubation induced hypertension/tachycardia. I many times use it because it probably "won't hurt" anything. In many programs the reason that NMB agents are not used is moreso a "turf" issue with anesthesia where they will not allow ED physicians to use the agents (despite appropriate training). IF you want good patient management then these "turf" issues should be put aside and all EM residents should be appropriately trained in their use. I refer you to an article I recently published: Ma OJ, Bentley B, DeBehnke D: AIrway management practices in Emergency Medicine Residencies. Am J Emerg Med. 1995;13:501-504.
We are here to stay as a specialty and as we graduate more residency trained EM physicians there should be less issues of patient mismanagement. The interdepartmental turf issues will probably remain until our colleagues understand who we are and our scope of practice. Many physicians still have the view of the "Emergency Room" where interns and/or residents in various specialties manage (term used loosely!) patients. Thankfully, those days are gone and EM specialists are practicing in ED's across the US. I think the problems stems from a misunderstanding on both ends of the rope (we don't fully understand you and your practice and vice versa).
Just a friendly reminder, daily on our emergency medicine discussion list there are similar posts regarding a "surgical horror case" or "neurology horror case" etc. You can substitute any specialty in the sentence and we have all seen them. The point is that these problems will always occurr because we are humans practicing medicine. The solution, as I see it, is to try to get along as specialties and practice to a level that warrants the respect that we desire.
David Brock:
Since I posted my account of a problem in the ED to the Critical Care mailing list I have received a large volume of mail from ED physicians because the story was picked up and posted to the Emergency Med mailing list. First, let me say that I did not attempt to slander our fine ED. My account happened several years ago before we had an established residency program so it does not reflect current practice at our institution. I appreciate the large number of respondents who offered their constructive thoughts and criticisms. To those of you were offended and responded angrily about your problems with neurospecialists, I can only offer my condolences.
All in all, my posting did do what I intended, which was to get a discussion started about joint care of patients who from the outset in the ED are certainly going to an ICU. The responses I have received from ICU physicians have suggested the problem I described is not an isolated one. The firestorm I am receiving from the EMED list shows me that ED physicians also have concerns. I would appreciate all suggestion about how we can jointly improve care of critically ill patients.
Joe Gifford: Here are some references I pulled up.