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New: Push Me(ds), Pull Me: Emergency Medicine News

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sedation, best practices, single blanket

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I’m unabashedly proud of how good EPs are at multitasking and task switching (we fight a lot about how we can get out of a code and into the next room without a break), but I never feel this more intensely than when doing a sedation procedure on my own. My ability to push the meds, watch the airway, and then run around the bed and cut something down is what pushes me to my task-switching limit.

Is single physician sedation the safest option for the patient? Hard to say versus sedation when I’m the dedicated airway monitor and someone else does the reduction or procedure. But is it sometimes necessary because of the staff? Unfortunately yes.

More often than not, you could be responsible for sedation and narrowing the places you are celibate. If I’m lucky, if it’s Mon-Fri and open hours and the ortho is already in-house between surgeries, they’ll offer to shoot a dislocation while you push the meds. Usually, you are not so lucky.

One or two documents?

This is my first real job, so honestly, I don’t know how common this one-doc stuff is in the wild. I was interviewed at a single 24-hour workstation that encouraged procedural sedations on discharge when two doctors were there. And I commend them for at least informally encouraging a two-doctor sedation process. (You know the saying “even a broken clock is right twice a day?” Sometimes there are only two doctors in the ER once a day.)

What are the options to make this as safe as possible? In cases where I won’t have easy access to the head of the bed (consider standing on the bed for hip reduction) for some patients at high risk of apnea, I asked a respiratory therapist to come and monitor the respiratory tract or that a CRNA does the sedation. Alternatively, if I can, I contract out the reduction and do the sedation myself if that doesn’t mean calling someone from my house.

Two major CAPE guidelines on procedural sedation address this issue. The 2018 ACEP Clinical Practice Guideline for Emergency Department Procedural Sedation with Propofol (they haven’t written the clinical practice guideline for ketofol yet, it seems) notes in the personnel section: provider who is dedicated to monitoring patient interactive and another that performs the procedure for which the patient is sedated. (Ann Emergency Med. 2019;73[5]:470.)

They then go on to describe the body of literature noting low-risk sedations performed by a single physician as the proceduralist and the one administering the sedation, with the assistance of an emergency room nurse. The 2019 ACEP guideline on unscheduled procedural sedation states that “some procedural sedation guidelines specify that the sedation provider during deep sedation should be fully dedicated to the management of sedation and not involved in the procedure.

“While such practice is optimal for both scheduled and unscheduled procedures, there is a long history of sedation providers (with standard backup of their sedation monitors) simultaneously performing brief unscheduled procedures while managing a moderate, dissociative or deep sedation This practice has been shown to be safe, with no evidence of an increased frequency of clinically important adverse events or outcomes (ACEP. November 2019; https://bit.ly/31WKzTq.)

As safe as possible

I was a little surprised by the data, but this is great news for small stores or independent doctors.

Now two reminders. First, consent. A favorite anesthesia assistant (thanks to Dr. Butz) in medical school used to consent to patients for the worst possible scenarios before surgery, reminding them of the rare but real consequences. I try to consent to patients for procedural sedation complications which I have fortunately never/yet seen.

Second, consider your department’s specific policy on procedural sedation. Does your hospital need two doctors instead of one? (Remember that long sedation policy you probably signed during your credentialing process and didn’t keep a copy or read? Yeah, that document.) Malpractice cases are notorious for quoting a hospital’s policy to the complainant saying: his own hospital’s policy on x/y/z, then this bad result happened.

Although I am reassured by the existing safety data for single-vendor sedation, this will continue to be a case of anecdote rather than evidence for me. I know in my heart that I would rather have one person dedicated to the airway and another dedicated to the procedure, and I will keep trying to phone a friend to make that happen.

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Dr. Heidepriemis a community emergency physician interested in patient safety, medical education, and helping patients through Patient Voting, a nonpartisan organization that offers step-by-step guidance on patient voting rules for each State. Visit his website athttps://www.patientvoting.com. Follow her on Twitter@kellywongmd.