Articles by Kevin Klauer, DO, EJD
Last spring the Centers for Medicare & Medicaid Services (CMS)
published a ruling which threatened to take deep sedation medications
like propofol out of the hands of emergency physicians. This January,
after months of negotations involving ACEP, AAEM and ENA, CMS offered a
clarification that is a clear win for emergency medicine.
One thing is clear in the current political landscape: Americans are fed
up with the status quo and they’re looking for fresh ideas. Those
frustrations laid the foundation for a historic shake-up in Congress
last November, and helped push a man named Joe Heck to a slim victory in
the House of Representatives.
It seems that every time we comply with a regulation someone moves the
finish line. Well, don’t blame the American Board of Emergency Medicine
(ABEM). ABEM answers to a greater being, the American Board of Medical
Steven Stack, MD, an emergency physician from Kentucky, was recently
re-elected to his second term on the AMA Board of Trustees. After this
unprecedented, unopposed election, many emergency physicians are
wondering the same thing: will Steve “Stack” up to our expectations or
just be another great physician sucked into the wheels of bureaucracy,
forgetting his heritage?
Applying the medical literature to the clinical practice of medicine,
via education, can often be like a big game of “Telephone.” You know the
game, the one in which the first person whispers a phrase to the next
person, who, in turn, whispers it to the next, so on and so forth.
Invariably, by the time the final person recites the message, the
meaning is so altered that the original intent is lost.
With the High Tech Act offering dollars for automation, the interest in
emergency department information systems (EDIS) is growing
exponentially. Hospitals are pushing the agenda of EDIS vendors, for the
causes of cost containment and patient safety, the driving forces for
these federally funded incentives.
Contrast protocols, including intravenous, oral and/or rectal contrast,
are just not necessary for abdominal CTs. From my perspective, the only
emergent CTs that warrant IV contrast administration are CT pulmonary
angiograms to identify pulmonary emboli, chest or abdominal CTs to
investigate suspicion for aortic dissection and perhaps for blunt
On February 5th, 2010, the Department of Health & Human Services’ Centers for Medicare & Medicaid Services (CMS) issued a memo entitled Revised Hospital Anesthesia Services Interpretive Guidelines. The guidelines have stirred a lot of interest among emergency physicians for their potential impact on the provision of procedural sedation, specifically as the outlines pertain to the use of drugs such as propofol. Coming on the heels of the overdose death of Michael Jackson by the inappropriate use of propofol, some have speculated that this is a knee-jerk reaction by an overzealous government agency. The guidelines, however, could potentially have a far-reaching effect, that of stripping emergency of the right to determine our scope of practice. “One would ask whether this CMS ruling is in fact a violation of the Joint Commission Guidelines for Specialty self determination,” says Dr. Paul Sierzenski, Chairman of ACEP’s Committee on Government Policy & Public Relations.
Given the importance of running effective resuscitations on critically ill patients one would think our rationale would be firmly grounded in the literature. Unfortunately, the reality is that much of what we do to resuscitate these patients has as much science behind it as burning witches or sacrificing virgins. So, the next time you’re ready to do a rain dance in the resuscitation room, focus on the evidence, make good choices and rely on tradition only where no better answers exist.
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