06 September 2007

"Poachers and dabblers"

Annals of Emergency Medicine reports this month on a speech given this year by American Society of Anesthesiologists (ASA) president Mark J. Lema: “What are the Current Issues Challenging the Status Quo?”

Among the answers he supplied was:

“Poachers and Dabblers.” By this, he explained, he meant "ER MDs (Emergency Surgery"

Nice. I haven't been in a good turf war since the Latin Kings battled the Vice Lords in Cicero when I was growing up. (I was a Vice Lord, of course.) Actually, I tell a lie. I have been in several turf battles, all of which were with anesthesiologists.

When I started at our practice, not so very long ago, the battle had only recently been won regarding the ability and privilege of ER docs to perform rapid-sequence intubation. This was a fresh issue in our institution, which boggled my mind because the large east-coast academic institutions I had trained at had been utilizing this technique for over a decade, and airway management was definitely viewed as a core competency for graduating ER docs. It was in this context that we launched into the next battle to allow us to perform moderate/deep sedation. The anesthesiologists used the same arguments they had previously used - that ER docs were not appropriately trained to perform these procedures, that it is unsafe for patients, that only a ABA-certified anesthesiologist can safely do so... etc.

I wondered why they put up such a fight. It was exceedingly clear that this was only a marginal economic issue for the anesthesiologists -- such procedures are reasonably uncommon, and in any case, they had never been very interested in coming down to the ER at 0300 to provide the service when asked, and it's manifestly clear that ER docs are in fact trained and capable of providing the service. In the end, I think it was just 'turf.' Sedation -- and control of propofol, the best drug for deep sedation -- was their turf and they took a very proprietary interest in it, even if they were not exercising that prerogative on ER patients.

Ultimately, we won, and have now done thousands of cases without a single adverse event. And every once in a while, I get someone who is ASA class III or IV (i.e. relatively high risk for complications) and I call the anesthetist to come and do the sedation for me. Their response has been quite positive, seeing that we do recognize the limits of our abilities and respect the technical skills they bring to the table. So it is disheartening to see the president of the ASA deride ER docs as "poachers and dabblers."

It may just represent some sour-grapes griping, because the standard has moved strongly towards ER docs providing this service -- all of my friends at academic centers do, and the majority at community hospitals do as well. A small ASA survey indicated that 59% of hospitals do credential non anesthesiologists (largely ER docs and ICU docs) to perform deep sedation. Yet the president of the ASA, as well as the clinical policies of the ASA continue to insist that only an anesthesiologist should administer propofol. It is also true that the primary "target" of the anesthesiologists are GI docs who want to use propofol in office-based endoscopy suites. (A practice which does seem questionable to me. We always have a second ER doc to do the sedation, while the first does the procedure. And I don't know whether a GI doc can manage an airway, but I know I can.) Which makes it doubly insulting to have ER docs lumped in, if that is the primary concern.

Fortunately, we now have a good, collegial relationship with our gas-men; it's pretty clear that we are good at what we do, and that we don't represent either an economic threat or a danger to patients, so there is no likelihood that there will be any attempt to roll back our privileges. And I think the national trend is pretty clear on this as well. Let's hope the ASA can get over itself and allow the feud to pass quietly into the mists of time.

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