Yes, there is still a certification. As a resident, we all had to pass it this year, be color blind tested and what not. It was about a 30 minute in service, but still annoying.

OTOH, I can’t ever imagine sedating someone for a BM. That’s a little beyond the pale for me.

I have come around on this one after it being discussed on EM:RAP a few months ago (a very popular EM CME podcast). Every disimpaction I have done with just narcotics on board has had the patient howling. Even with a solid dose of fentanyl its still horrible for the patient. In correctly trained hands, why not use propofol? (I’ll get to that in a second). Its an immensely painful and uncomfortable procedure that we tell the patient to just suck it up. Why should we do that when we have an extremely safe drug that will take away the patient’s suffering while we are wrist deep in their rectum?

I and Ds can be immensely painful- especially in the axilla- and local anesthesia doesn’t do squat when you have to explore and break up loculations (although that new loop abscess technique looks promising for not doing exploration but you can’t use it on the smaller abscesses). I wanted to do procedural sedation on an 11 year old with an abscess in the axilla but got shot down because “we don’t have enough staff, just use fentanyl, blah blah blah.” Never again. I caused a lot of unnecessary pain and suffering to a nice kid.

I just got done a rotation at a Peds hospital. They don’t even have a papoose in their ED. Doesn’t exist. They use intranasal versed/fentanyl and its not even considered procedural sedation that requires a 1:1 nursing. (*Audible gasp from most people reading this*) No IV, no pain, a little stinging in the nose, and you have a child that will hold still for any lac repair anywhere on their body. Its beautiful, its fantastic. They are on monitors but they don’t desat. Even if you just give versed intranasal without the fentanyl most get relaxed enough to let you sew their face. No more kicking and screaming, no more holding kids down on a papoose board- its awesome. Ready for primetime at a small community ED?- maybe not but it could be done with the right motivations and procedures in place. I would also encourage people not to automatically shoot down this idea if you start hearing about it. Watch it one time and you will be a believer.

I understand that not everyone has done an EM residency and while its the best way to learn things like procedural sedation, it’s not the only way. You can go to a course and do some cases with anesthesia in the OR. Just because you haven’t done EM training doesn’t mean that you can’t learn how to do this safely and effectively. Maybe you don’t work with the brightest bulbs at your shop and that will always be the case but you shouldn’t blindly bar all non-EM trained docs from doing something that they can be taught to do safely. Should that same non-EM trained doc not be allowed to use a glidescope just because they didn’t train on it during residency? How are you supposed to progress your knowledge and skills if you don’t keep up with the literature and newest skills?

There’s nothing magical about learning how to use propofol- where people run into trouble is not having a plan and being prepared for a complication. The nurses sometimes roll their eyes when I ask for the RSI kit at the bedside for all of my procedural sedations. However, if something goes wrong (like severe masseter spasm and myoclonus from etomidate) and I need to intubate, I don’t want to wait for someone to grab the RSI kit so I’m always prepared.

You seem to be very concerned with propofol. That’s fine- suggest ketamine instead. Since it preserves your respiratory drive people rarely get into trouble unless you push it too fast (causes apnea) and very rarely laryngospasm (usually transient and will respond to bagging). Its even used for general anesthesia in 3rd world countries. It won’t get you as deep as propofol to put a hip back in but it will work fine for most procedures. You could give ketamine to the most incompetent EM doc out there and even without using monitors they would probably go their entire career without having a problem.

Alright- this is long enough. But its great to see a good discussion on these topics- its a good thing.

BELIEVE IT OR NOT, BUT NOT ALL DOCTORS WORKING IN AN ER WERE TRAINED IN EMERGENCY MEDICINE, AND, EVEN THOSE THAT WERE MIGHT HAVE BEEN TRAINED BEFORE PROPOFOL AND ALL THAT WERE INVENTED. I think only half of the doctors in my ER ever did an ER residency. Some of the older doctors are even throwbacks to the era where ER doctors were people whose licenses in internal medicine or surgery were taken away.