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As emergency medication has emerged as a definite medical self-discipline, there was a shift in duty for a key job in emergency departments: managing emergency airways to assist sufferers get sufficient oxygen. However how widespread is that shift?
That is the important thing query {that a} pair of College of Colorado Division of Emergency Drugs physicians and a medical pupil got down to reply by a survey of their friends nationwide. They wished to be taught whether or not it is anesthesiologists or emergency physicians who oversee airway administration for trauma sufferers in emergency departments throughout the nation.
Joseph Brown, MD, FACEP, an assistant professor of emergency medication, and Cody McIlvain, MD, an emergency medication teacher/fellow, led the research. Each Brown and McIlvain apply at UCHealth College of Colorado Hospital (UCH).
They had been joined within the analysis by Ethan Coit, MD, who on the time was a med pupil and is now within the Denver Well being Residency in Emergency Drugs, the place Brown is an affiliate program director.
Brown has skilled and labored at 4 completely different educational medical facilities, “and each one was slightly different in how they managed this. When I was at University of California, San Francisco, for example, anesthesia and emergency medicine would alternate every other day on who would manage trauma airway issues.”
He provides, “On the heels of COVID-19, there has been additional interest in airway management in the emergency department. And at some of our national meetings, the question of who’s doing what in trauma contexts had come up. So, we decided to get the current lay of the land.”
Their analysis, “Navigating trauma airway responsibilities in the modern emergency department: A survey of emergency physicians,” is revealed within the American Journal of Emergency Drugs.
The daybreak of emergency medication
In emergency departments, endotracheal intubation is the commonest technique of emergency airway administration for sufferers in respiratory failure (unable to oxygenate, ventilate, or defend their airway). It includes inserting a tube by the mouth or nostril and down the affected person’s windpipe, or trachea, to ascertain and preserve an open airway. If wanted, oxygen is pumped by the tube to the lungs.
It is estimated that greater than 413,000 endotracheal intubations are carried out yearly in U.S. emergency departments, representing about 1% of ED visits. They’re performed both within the case of trauma that inhibits respiratory or for different circumstances inflicting respiratory failure, resembling extreme pneumonia or a drug overdose.
“I’d say we probably intubate at least one person almost every day in the emergency department,” McIlvain says. “For trauma-specific cases, it’s probably a handful a week.”
Traditionally, anesthesiologists had been accountable for performing emergency airway administration of critically unwell sufferers. That custom dates again to a time earlier than emergency medication was established as a singular specialty.
“In the house of medicine, emergency medicine is relatively junior,” Brown says. “As a specialty, we really didn’t exist until the 1970s. Until then, physicians from internal medicine and other specialties were moonlighting in the emergency department, and in that setting, the anesthesiologists were experts on all things airway.”
Then, within the Seventies, medical faculties started to supply specialised coaching in emergency medication. Denver Well being, a CU Division of Emergency Drugs scientific accomplice, established one of many nation’s first residencies in emergency medication in 1974. 5 years later, the American Board of Medical Specialties acknowledged emergency medication as a definite specialty.
The first driver
With the rise of specialised emergency medication, it has change into more and more commonplace for emergency physicians, as a substitute of anesthesiologists, to carry out emergency airway procedures in trauma settings, notably at establishments with emergency medication residencies.
Brown, McIlvain and Coit knew from earlier research that there was no important distinction in charges of success or issues in endotracheal intubation of trauma sufferers in emergency departments, whether or not carried out by an emergency doctor or an anesthesiologist.
What they did not know was how extensively the transition to emergency doctor duty for airway administration had been adopted. There hadn’t been a nationwide survey of the present state of affairs in america in nearly a decade.
The researchers despatched a questionnaire to all 317 members of the Society of Educational Emergency Drugs’s airway curiosity group, of which Brown was chair on the time. They obtained 39 responses, largely from emergency physicians at educational facilities. Virtually all respondents apply at Stage I trauma facilities.
Almost 90% of those that replied reported that emergency physicians carry out airway administration for grownup sufferers in trauma conditions at their emergency departments. Particularly, 61.5% stated anesthesiologists aren’t current until requested, and 28.2% stated anesthesiologists are current however do not take part in airway administration. Percentages had been related for pediatric trauma sufferers.
“In our survey, we found that emergency physicians are the primary driver in managing traumatic airway responsibilities in most places across the country,” Brown says.
Advocating for a shift in apply
However, based on the research, 5.2% of respondents stated that anesthesiologists nonetheless deal with airway administration for grownup sufferers of their emergency departments. For pediatric sufferers, the share was 5.9%.
“These institutions deviate from the prevailing practice pattern for trauma airway management in emergency departments across the U.S.,” the research concludes.
“Considering the body of evidence demonstrating the capability of EPs [emergency physicians] to consistently and successfully manage trauma patients requiring ETI [endotracheal intubation], we advocate for a shift in practice at these outlier institutions. We propose a model in which EPs are the primary physicians responsible for intubating trauma patients while acknowledging the potential for scenarios that may still benefit from collaborative airway management between anesthesiologists and EPs.”
So, given how busy emergency physicians can get, would not they like handy over airway administration to another person?
“That’s an interesting question, and I would answer it this way,” McIlvain says.
“We reside within the emergency division, and we’re there to deal with each affected person who comes by the door. Anesthesia operates within the working room, which is mostly on the second ground or larger in most hospitals. We would be asking them to go away their house and are available into ours to handle a job that we’re greater than able to managing.
“It seems to me that it wouldn’t be great for patient care to ask someone else to do a procedure on a patient whose care we’re managing. Having one doctor manage that care is probably better for patients overall.”
The authors word there have been comparatively few responses to their survey representing smaller, rural emergency departments that lack residency applications, so the research doesn’t clearly reply what practices are at such locations. However Brown says that at smaller amenities with restricted sources, an anesthesiologist may not be out there across the clock.
“Having spoken with many colleagues who work in smaller emergency departments, I think there are many places where, when there’s major trauma, no one else is coming to help,” he says. “And so, making sure that our trainees and graduates are fully prepared for managing all aspects of the care of their patients is one of the biggest educational missions that we have.”
Coit says, “I’m grateful to have had the opportunity to work with Dr. Brown and Dr. McIlvain on this project as a fourth-year medical student. I relied on their expertise to learn about the history and context of emergency airway management in trauma patients while writing the article. And now, as an emergency medicine resident at Denver Health, it has been an incredible experience to learn from them directly in the same situations we were referencing in our work.”
Extra info:
Ethan J. Coit et al, Navigating trauma airway tasks within the Fashionable Emergency Division: A survey of emergency physicians, The American Journal of Emergency Drugs (2025). DOI: 10.1016/j.ajem.2024.11.019
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