Sure…the decision making part of your case history…”A no-brainer? You’d think so”

Now then, this could continue indefinitely.

The truth of the matter is that airway management is far more than just intubation as a reflex reaction.

It is potentially a life changing therapeutic intervention as well as part of a resuscitation algorithm. Definitive investigation and treatment should not be delayed in anticipation of intubation.

There are many patients I am called and literally instructed to intubate. Usually, I come to the A/E department. I discuss the history, I briefly speak to the family. I look at the available investigations and such on the computer system. If I think that intubation is not indicated then I will write a full entry into the notes, by hand, including a signature and a contact if further concern sub-section.

If the intubation request was for a scan, I usually accompany the patient into scan myself.

There are times however, when the anaesthetist is legitimately tied up, either peri-operatively, or carrying out a procedure or just in a hospital location 15min from A/E.

In those cases, calling in the boss from home 20mins away, or waiting 15min for the anaesthetist to arrive/finish procedure when perhaps all that was needed was a quick trip to scan when eg the GCS had first started to drop seems non-sensical just to be presented with this form.

DOI Work experience includes A/E, GenMed, Anaesthesia, and ICM

I’m afraid I must admit to a degree of antipodean colonial parochialism here, as while I have ventured to the northern hemisphere several times, it has always been in a recreational rather than professional capacity, and while I recently experienced my first ever “Is there a doctor on the plane?!” episode (with two casualties/patients within 5 minutes of each other, and both within 5 metres of my seat), happily neither of them required intubation.

So yeah… the idea of “outsourcing” emergency anaesthetic management is (literally) a foreign concept to me. We do invite our anaesthetists to come and play, but it’s usually for particularly complex or weird cases, where certain anaesthetic ninja skills and/or toys are required (e.g. awake fibreoptic expeditions, etc.). In my hospital, the anaesthetic registrar is automatically paged whenever we have a “trauma code” but they are rarely required, and typically after hours the evoked response is “Hi, I’m in theatre with a patient on the table, but do you need me to call my boss in for you?”. We partake of their kindly offered services in perhaps < 5% of such cases. It is, however, nice to know they're there and willing to plunge in when truly tricky stuff is afoot (and I have certainly requested their assistance on many occasions).

And of course we invite them down when there's stuff that's just too cool not to share (steak knife through trachea, etc.), and they'd get all stroppy when they found out afterwards and they didn't get to come and play.

Thank you for outlining the way things work in the UK. It seems to an outsider as if the situation there is largely a result of historical professional role delineation (and the relatively recent birth of emergency medicine as a specialty; indeed, many countries still have no such thing), though I can't help but think factors such as the 4-hour target probably contribute to an environment that is not conducive to UK emergency physicians using and maintaining emergency anaesthetic skills. As you rightly point out, removing a senior clinician from the ED for an indeterminate length of time to look after a ventilated patient can be functionally crippling to an already under-resourced, overcrowded, access-blocked department.

We certainly do spend a fair amount of time battling with other teams to do something (or not do something…. not-going-to-start-on-about-lysing-strokes-in-ED… not going to… not going to…) for our patients. Happily, trying to convince someone else to come intubate our patient for us is not an issue we have to deal with.

It also raises issue of how to deal with conflict in the resus room…

Anecdote-sharing is one way of doing this.

“Ah yes, intubation and ventilation rather than proper history and collaterals”

- nope, thorough evaluation prior to declining intubation was my point, and is written pretty clearly

“Should we also have to document the need not to intubate when a patient has been assessed as fit, well and normal ready to be discharged home following a minor injury such as a burn to the finger? Just because the form exists…”

- no, since the form was only suggested for patients in whom intubation was requested

Granted intubation may buy you time to gather this information, but if we are just allowed to quote personal anecdotes then I shall say that the referrals for the obese, blue, nonagenarian who has slept in a chair for the last 8 years are exactly what this form seems to obviate…common sense decision making prior to referral.

And no that is not age bias, it is physiological reserve bias.

It is impressive how often the confirmation of a definitive diagnosis of a “totally reversible” condition leads to curative care and discharge from hospital to previous functional status.

Reductio ad absurdum; Should we also have to document the need not to intubate when a patient has been assessed as fit, well and normal ready to be discharged home following a minor injury such as a burn to the finger? Just because the form exists…

I assume you don’t practice in the UK (apologies if I’m wrong) so, to put things in context, hopefully this is a reasonably balanced explanation that won’t prompt an off-topic debate or slanging match!

It is rare for emergency physicians to be performing anaesthesia in UK EDs. As Dr Reid has alluded to there are a number of reasons for this.

The first is tradition – in the UK emergency anaesthesia has ordinarily been performed by anaesthesia / ICM (which in practice used to be a subspecialty of only anaesthesia though this is slowly changing). The consequence of this is that in the UK the there are relatively few emergency physicians with ongoing experience and expertise in emergency anaesthesia (which I’d differentiate from the act of sticking the tube in). By contrast UK anaesthesia as a body has lots of experience because we do most of the ED and ICU workload and also anaesthetise emergencies in theatre.

Again as a consequence of this traditional set-up, anaesthesia in most places is resourced to provide outreach to the ED and to the wards in order to respond to emergencies. By contrast recruitment, retention and resourcing in emergency medicine seems, at least to an outsider, to be much worse. So in the hospitals I work in it is expected that the anaesthetic/ICU on-call team will be deployed to ED regularly and there are usually two on-call consultants who come in if we’re shorthanded (or if it looks like we might soon be). Whereas in our ED if one of the ED team were to commit themselves one-to-one to anaesthetise a patient and manage them for an hour or two their department would come crashing to a halt.

This is, of course, not the case for some departments and individuals where a combination of skill mix, experience, supervision and resources mean that the emergency physicians do this work. But I think it is fair to say that it is uncommon.

http://emj.bmj.com/content/early/2012/11/07/emermed-2012-202023.full

As someone who really enjoys resuscitation I quite like our collaborative model of managing these patients. I think the patient gets the benefit of at least two doctors with different but overlapping skill sets looking after them and we get involved early with patients who mostly end up coming to us anyway (to theatre or to ICU). From the other side I know that lots of emergency physicians would disagree.

I enjoy a bit of needling, provocation and debate as much as the next obstreperous trainee anaesthetist.

I’ve no doubt these things do really happen when it comes to ICU admissions – I’m just not sure about the importance of the resource / bed problem as a factor. I think there are very few places now that have a proper ED with ICU covered by anaesthetists with no daytime critical care sessions. I’ve only worked at one such DGH and my experience there was that the non-intensivists had a lower threshold for admitting people and dealing with the aftermath the next day. Also, in 5 years of anaesthetics on-call I’ve never once known a consultant refuse to come in when asked (told!).

I think your other point about clinical appreciation is probably the key one and that’s always going to be a problem with any interface between different specialties. We’re better than the “what’s the GCS?” lot, surely?

I’m sure I’m preaching to the converted here but the other point I’d make is that if you got 30-40 anaesthetists in a room and asked them about Making Things Happen in the ED I think you’d probably get a pretty skewed view of UK emergency medicine! Which is not to say that it wouldn’t identify themes for us (and you?) to consider as your exercise has done for me.

Best wishes

Alex

I’m not sure I see the reasoning behind: “sometimes the risks of the procedure outweigh the benefit” when we’re talking about intubation in patients for whom securing the airway is indicated as part of their resuscitation or stabilisation.

Those specialist fellowship qualifications aren’t courses.

Now clearly thee are some ulterior motives, anecdotes etc…that are always going to be present.

But; sometimes the risks of the procedure outweigh the benefit, and as the GMC guidance suggests, there is no obligation to provide treatment that is deemed futile or burdensome.

…or don’t you learn that on your FCEM/FACEM/FESEM courses anymore?

Perhaps we could have one for interventional cardiologists who decline urgent PCI for patients post-AMI/arrest who are “too unstable for the cath. lab.”, too??

On a more serious note, why would we be asking someone from another dept to come intubate the patient, anyway? Certainly there are rare cases with every risk factor in the known universe for a predicted difficult/failed intubation for which me might invite our friendly neighbourhood anaesthetist to the party, but they are few and far between (the cases, not the anaesthetists… we happily have lots of those!). Surely you’d just intubate the patient yourself??

Also, for better or worse, the time-honoured adage of “it’s easier to obtani forgiveness than permission”, having an already intubated patient can often result in the miraculous procurement of an ICU bed that would otherwise be “unavailable”.