Emergency physicians: additional providers of emergency anaesthesia?

Abstract

AnaesthesiaVolume 57, Issue 7 p. 629-631 Free Access Emergency physicians: additional providers of emergency anaesthesia? First published: 13 June 2002 https://doi.org/10.1046/j.1365-2044.2002.02747.xCitations: 5AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat A recent editorial published jointly in the British Journal of Anaesthesia and the Emergency Medical Journal [1] and the setting up of a joint working party on the teaching of airway management to emergency physicians has brought the subject of emergency physician-administered anaesthesia into sharp focus. For the many UK doctors who have worked in Australia or the USA this concept will not be new – in a number of units it has been standard practice for many years [2]. The Association of Anaesthetists of Great Britain and Ireland has considered the question of non-physician anaesthesia in the UK and in 1996 published a robust defence of physician-only anaesthesia [3]. The subject of physicians other than anaesthetists giving anaesthesia has not, however, been given the same attention. What are the practical issues with this proposed change in the delivery of emergency airway care? No comprehensive surveys of opinion have yet been published but it is likely that a wide spectrum of opinion exists among the relevant UK specialists. To appreciate the different viewpoints let us look first at those with a very definite preference for ‘anaesthetist-only anaesthesia’ in the emergency department and those who favour ‘emergency physician-only anaesthesia’. Most in these polarised groups will come from the expected parent specialities but not all – there are a few individuals in anaesthetic practice who will not have performed a Rapid Sequence Induction (RSI – also referred to as rapid sequence intubation in the emergency literature) in the emergency department for many years and would be perfectly happy never to go there again. Similarly, there are undoubtedly some emergency physicians who do not wish to develop and maintain the skills necessary to perform RSI and feel that the anaesthetic departments in their hospitals should continue to provide a comprehensive service. The advocates of ‘anaesthetist-only anaesthesia’ have important issues to address. Emergency medicine is developing rapidly and is inevitably moving towards Australian and US practice. Practitioners of ‘new’ UK emergency medicine correctly believe that advanced airway management is a fundamental skill of the emergency physician. They are taking steps to learn the skills (the US National Emergency Airway Management Course [4], taught entirely by emergency physicians was run in the UK for the first time in Oxford and Leeds in 2000) and are already using them. In some regions, emergency physicians already perform a significant proportion of RSI's [5] and this will inevitably increase. Encouraging the use of these newly acquired skills is the perception by emergency physicians that anaesthetists are frequently not immediately available to assist in the emergency department [5, 6]. This is unlikely to improve in the short term because, in an effort to reduce working hours and out-of-hours operating, many anaesthetic departments are changing working practices and some may have to reduce the number of on-call tiers. Those anaesthetists that remain in the hospital are likely to have increased operating theatre work intensity and are more likely to be busy in the operating theatre when an emergency is admitted. Also, in many departments, the anaesthetists that respond to calls from the emergency department have been provided by the intensive care unit. As intensive care medicine develops as a separate speciality, many intensive care residents will not have anaesthesia as their base speciality so this option may no longer be viable (indeed providing comprehensive 24-h advanced airway skills on the intensive care unit is, in some units, a training challenge in itself). Some emergency physicians also question the level of anaesthetic support that they receive [7]. They rightly see the provision of an inexperienced anaesthetic SHO to deal with difficult emergency patients as less than ideal and suggest that a properly trained emergency physician with an interest in emergency airway management may be more appropriate. Few would argue that every emergency department has a duty to provide advanced airway management (which may include RSI) within a few minutes of patient admission and, if an anaesthetist-only approach is pursued, an experienced anaesthetist without significant operating theatre commitments has to be immediately available. This is a service that many anaesthetic departments will struggle to provide. The ‘emergency physician-only’ approach is the other extreme. No one has yet publicly advocated this approach in the UK but many US departments, including the one from which the National Emergency Airway Management Course originates (The Brigham and Women's Hospital in Boston), operate this system. This would certainly not work in most UK departments at the current time because many UK emergency physicians have not had the necessary training opportunities to achieve competency in RSI. Could it work in the future? There are many potential obstacles. First, if emergency physicians take on the overall responsibility for airway management in their departments they must ensure the presence of a senior appropriately trained individual at all times. This is achieved in US practice by having an attending (consultant) present in the Emergency Department at all times. However, many large US and Australian emergency departments have many more consultants providing senior cover than is currently the case in UK departments of similar size. Also, if anaesthetists are required in the emergency department only on an occasional basis, there is a danger that with competing pressures, immediate attendance will become less of a priority for those who influence departmental anaesthetic resources. Breakdown of the relationship between anaesthetic and emergency departments could lead to hazardous gaps in service provision. The procedure of RSI is not just about induction and intubation. Some of the emergency medicine literature confuses the whole issue by attempting to differentiate between emergency anaesthesia and Rapid Sequence Intubation. Making the decision to intubate a patient and conducting drug-assisted RSI followed by maintenance of sedation (with or without muscle relaxation) for ‘at least the first half an hour’[1] after admission without doubt constitutes emergency anaesthesia. Care of the intubated, sedated patient also requires the constant presence of an appropriately trained doctor or nurse, as in any other area of the hospital. This potentially ties up an emergency physician or commits the emergency department to a significant training programme for its nurses. In some countries where emergency anaesthesia is administered by emergency physicians, the commitment goes further and the frequent postinduction trip to the CT scanner is escorted by emergency department staff. This seems logical if skills are available and many anaesthetists would feel reluctant to provide immediate attendance for escort to the CT scanner if they had not been requested for the earlier stages of management. However, we question whether UK emergency consultants who often have limited ‘on-the-floor’ resources are going to devote them to a small number of patients for extended periods of time. The joint working party has taken on the task of developing and implementing a competency-based training programme in emergency airway management for emergency physicians [1]. Problems that have already been highlighted are whether enough RSI's are performed in UK emergency departments to develop and maintain skill levels. The exact amount of time that should be spent in anaesthetic training is unclear and the value of operating theatre-based experience has also been questioned [1]. Any recommendations made will really only effect doctors in training. Established consultants are likely to have to decide whether they have the appropriate skills on an individual basis. Although the Faculty of Accident and Emergency Medicine has recognised the importance of RSI training for all specialist registrars, until RSI is adopted as a core skill for emergency department consultants, the provision of RSI by emergency physicians will be patchy. The points considered so far emphasise that the exact pattern of emergency department RSI in the UK will take some time to emerge. We feel that the issues outlined make it very unlikely that an ‘emergency physician-only’ or ‘anaesthetist-only’ model will develop. The interim period of ‘up to 5 years’[1] will be an important time. Anaesthetists need to recognise that the speciality of emergency medicine has set itself a challenging task – to oversee a system that provides excellent advanced airway management starting with a group of individuals in the speciality that possess very variable advanced airway skills. By their nature most advanced airway interventions will come under the close scrutiny of other speciality groups as the patient moves on from the emergency department. Mechanisms for highlighting problems that occur in the interim period are in place in the UK – clinical governance, audit and critical incident reporting will all have their part to play. In the USA, a National Emergency Airway Registry was set up in 1996 [8] which has collected comprehensive data on over 10 000 emergency department intubations from 35 centres. Anaesthetists have performed only around 3% of these intubations (personal communication, R.M. Walls, Principal Investigator). Major mishaps in airway management are mercifully rare but potentially catastrophic when they occur and the patient group seen in the emergency department include many recognised to be in airway ‘high risk’ groups [9]. A national database could provide invaluable information in the UK and ensure that the way that the system develops is shaped by national data rather than local anecdote. The UK Joint Working Party is piloting a national audit shortly [10]. The speciality of intensive care is developing an effective multispeciality approach to the critically ill. The intensivist controls overall care of the critically ill patient and involves other specialities whenever appropriate to achieve the best clinical outcome. It seems appropriate that a similar approach should be encouraged in the emergency department, emergency physicians having the same co-ordinating role and calling upon anaesthetists and ICU doctors whenever their presence would enhance patient care. This may vary with the problems of specific patients and with local resources available in either department at the time of admission. It is imperative that every emergency department provides a doctor with advanced airway skills and the ability to perform RSI in the first few minutes after admission of the critically ill patient. The specialities of emergency medicine, anaesthesia and intensive care medicine have an opportunity to work closely together to achieve and maintain these aims. Acknowledgements The authors would like to thank Dr R.M. Walls and Dr J. Nolan for their comments. D. J. Lockey Consultant, Anaesthesia and Intensive Care Medicine, Frenchay Hospital, Bristol BS16 1LE J. J. M. Black Consultant, Emergency Medicine, John Radcliffe Hospital, Oxford OX3 9DU References 1 Clancy M, Nolan P. Airway management in the emergency department. British Journal of Anaesthesia 2002; 88: 9– 11.CrossrefPubMedWeb of Science®Google Scholar 2 Walls RM. Rapid Sequence Intubation comes of age. Annals of Emergency Medicine 1997; 29: 573.PubMedGoogle Scholar 3 Anaesthesia in Great Britain and Ireland. 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