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PED-EM-L  February 2008

PED-EM-L February 2008

Subject:

Re: [PHISH]Re: pediatric sedation

From:

Martin Herman <[log in to unmask]>

Reply-To:

Martin Herman <[log in to unmask]>

Date:

Fri, 1 Feb 2008 18:23:04 -0600

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (163 lines)

Carlos, and others, even having a second physician from the same group would
not allow you to bill for both the procedure and the sedation except as
allowed by the 99143-99145 and 99148-99150 codes. 

If the second physician is part of the same group, they are considered one
and the same as their partner/associate. 

Marty
------------------------------------
Pediatric Emergency Specialists, P.C.
Martin Herman, M.D.,FAAP,FACEP
President
[log in to unmask]
PO box 637
Ellendale TN 38029
tel: 901 405 1407
fax: 901 405 1524
mobile: 901 219 9202 
------------------------------------

-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Carlos Abanses
Sent: Friday, February 01, 2008 5:30 PM
To: [log in to unmask]
Subject: [PHISH]Re: pediatric sedation

John,  I guess this is kind of like how many physicians does it take to
screw in a light bulb?  (Insert your own punch line of choice)  But the
truthful answer is it depends on where the light bulb is located, right in
front of you or 60 feet up in the dead center of a large room. If you're
sedating for a CT or MRI it does not take any other physician because you
are directly watching the patient.  If you're sedating for a fracture
reduction or lumbar puncture where you  the physician are doing the
procedure and cannot watch the monitor then that is where you can run into
complications.  There have been case reports published in annals 2005 of
physicians trying to monitor the patient and do the procedure with bad
outcomes.  Hence the AAP and ASA both state "There must be 1 person
available whose only responsibility is to constantly observe the patient’s
vital signs, airway patency, and adequacy of ventilation and to either
administer drugs or direct their administration. At least 1 individual must
be present who is trained in, and capable of, providing advanced pediatric
life support and who is skilled in airway management and cardiopulmonary
resuscitation; training in pediatric advanced life support is
required."(PEDIATRICS Vol. 118 No. 6 December 2006, pp. 2587-2602)  Those
are the only requirements.  The rest becomes your comfort and what you have
to work with.  If I am doing an LP at 3 AM I will have 2 nurses in the room.
One to hold and one to push more medicines as needed after my bolus and to
record vital signs.  Does the other person need to be a nurse?  Not really.
It could be a respiratory therapist that may be more capable of managing the
child's airway.  If you are going to fix a complicated facial laceration
that will take you 1/2 hour then you need one person dedicated to not
helping you but to be observing the patient and pushing your medicine.  This
all assumes that you feel confident in a nurse pushing your medicine and
monitoring the patient and are willing to take that responsibility.  Now if
you have a second physician handy and available, that takes the burden of
responsibility away from you and you can focus on doing your task and not
what's going on with the patient every time a monitor beeps.  A second
physician also helps tremendously when the patient will be sedated for a
long period of time and may need some airway manipulation.  You don't want
to break your sterile field, fix the airway go back to suturing, then break
your field again and so on (assuming you need a sterile field for suturing
completely another debate, then again I see docs with sterile gloves for an
I&D).  Having someone skilled to give the medication without nursing error
and to manage your airway  is a great resource.  Again it's just what you
have available to you and what your comfort level is if anything goes wrong.

 Third point is that you can not bill for doing the procedure and the
sedation.  So at times some physicians will prefer to use a second physician
so not to take on the aforementioned increased nursing and medical risk
without any increased compensation (fee for service groups).  Other
facilities will prefer their doctors to have a second doctor sedate to
generate more income for the hospital. Hope this helps Juan Carlos Abanses,
MD
 > Date: Thu, 31 Jan 2008 08:44:03 -0600> From: [log in to unmask]>
Subject: Re: pediatric sedation> To: [log in to unmask]> > I am
wondering if the discussion group could comment on whether a 2nd physician
must be present to do the sedation, or if it's okay, for anticipated brief
procedures, that the one physician do both the procedure and the sedation.
Thanks.> > JGBoulet > ----- Original Message ----- > From: Carlos Abanses >
To: [log in to unmask] > Sent: Wednesday, January 30, 2008 10:42
PM> Subject: Re: pediatric sedation> > > I understand the issue of emesis
with ketamine but why treat it with benzo and not a antiemetic like Zofran
prior to the procedure? If you premedicate with zofran you might find you do
not have the RN puke scale or the longer stay or increased risk for
desaturation. As for the emergence reaction it tends to be far less common
in younger children and more common in females. Sherwin et al in Ann Emerg
Med. 2000 Wathen et al Ann emerg med 2000 both showed no difference in
emergence reaction with versed. A trick taught to me during my years in KC
was a bit of simple guided imagery prior to sedation. I'm not usually the
touchy feely type but asking kids what they want to dream about and telling
them to start thinking about it just takes seconds and seems to work well.
Additionally letting the parents know that they will have vivid dreams as
they awake and to talk to them about things they like and enjoy helps.> > >
§ > –> As for ETCO2 monitoring it is a helpful adjunct that can give you a
good idea of how deeply sedated the patient is for a simple non-painful
procedure like MRI or if the patient is needing airway repositioning. Also
if you completely lose your wave form you know you either have a malfunction
or laryngospasm prior to their desaturation. It can be much less reliable
then pulse oximetry at times for patients that continue to breathe out of
their mouths or when sedating for endoscopy where the scope often interferes
with the ETCO2. > And at other times like during an MRI when you may have a
brief time where the pulse ox is not picking up well it is reassuring to
have ETCO2. Thus it is a nice safety and back up that can give you a lot of
information by just watching the wave form that helps in assessing the
overall gestalt of how the patient is doing.> > Juan Carlos Abanses, MD>
Date: Wed, 30 Jan 2008 09:40:58 -0800> From: [log in to unmask]> Subject: Re:
pediatric sedation> To: [log in to unmask]> > I have to echo Jay's
sentiments here. I was a rabid "no evidence for benzo's" person for a long
while and felt they just contributed to prolonged recovery times, but my
patients also had an unusually high incidence of emesis during recovery,
especially for patients who required more than one dose of Ketamine because
of unexpected delays in completing the given procedure. Of course, my
reticence regarding benzos had to do with the lack of evidence of their
mitigation of "emergence phenomenon," but when I looked closer, there did
appear to be reasonable evidence that they might reduce vomiting during
recovery. I began using Versed at a dose in the 0.05mg/kg range and have
anecdotally experienced a large drop in the amount of vomiting my patients
have experienced.> > While I don't have data to back up my impression, we
are all aware of the "RN's complaining about cleaning up puke" scale and I
can safely say that the reduction of noise along these lines has been
significant....> > > R. David Smith, MD> Medical Director, Pediatric
Emergency Services> Children's Acute Care> Cape Fear Valley Medical Center>
Fayetteville, North Carolina> > > > AS WE KNOW, NO STRONG EVIDENCE FOR MIDAZ
USE , ESPECIALLY IN THE YOUNG > (PREADOLESCENT AGE)....> > I disagree with
you here. It depends on what you define as "strong" evidence. I would >
refer you to Dr. Roback's work that showed that in controlled trials the
group > that received midazolam prior to ketamine had a lower incidence of
nausea & emesis during recovery. This may have to do with GABA receptor
inhibition in the chemoreceptor trigger zones for emesis.> > > Thanks> > Jay
(Pershad)> Le Bonheur> > For more information, send mail to
[log in to unmask] with the message: info PED-EM-L> The URL for the
PED-EM-L Web Page is:>
http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> > >
____________________________________________________________________________
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http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ > > For more
information, send mail to [log in to unmask] with the message: info
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http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html>
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