Anesthesia and Emergency Medicine Should Collaborate For Nerve Blocks in the ED

Originally published by our sister publication Anesthesiology News

HOLLYWOOD, Fla.—To optimally manage pain in patients presenting with acute injuries after hours, anesthesiologists and emergency medicine physicians should collaborate to perform nerve blocks in the emergency department (ED), according to a panel discussion at the 2023 spring meeting of the American Society of Regional Anesthesia and Pain Medicine.

Over the past 10-plus years, a growing number of emergency physicians have been performing regional anesthesia techniques in the ED, most commonly for hip fractures, said William Manson, MD, the medical director of perioperative medicine and an associate professor of anesthesiology at the University of Virginia (UVA) Health System, in Charlottesville.

“There’s been a big push in the emergency medicine world, both from specialty societies as well as corporate groups, to say, ‘We can really improve the care of patients and we can do regional anesthesia for these frail patients in the ED,’” Manson said.

Major medical centers may have anesthesiologists or anesthesiology residents available around the clock to come to the ED for such procedures, but that’s not the scenario at most hospitals, he added. “In my hospital, we would love to do every single regional nerve block in the emergency room because we feel like we could provide really excellent care, but we don’t have the staffing to do that in my regional anesthesia group. So, it’s essential that we engage with emergency medicine physicians so they are appropriately trained in regional anesthesia techniques, they understand systems-based issues around doing regional anesthesia and they can treat complications like anesthetic toxicity.”

While anesthesiologists may have been reluctant to do these types of collaborations in the past, “the tide is changing,” Manson noted. “There are people who really think the best way that we can provide care for patients is to not only allow emergency medicine physicians to do regional anesthesia but to encourage them, and to do it in a collaborative manner.”

Manson has been one of a few physicians promoting the idea to ASRA and the American College of Emergency Physicians, which have been working on a joint statement to outline some of the principles in this type of collaborative work.

“A lot of what we’re doing here is awareness, and changing people’s concepts of who can do regional anesthesia and what the approach should be.”

Arun Nagdev, MD, the director of emergency ultrasound at Highland Hospital, in Oakland, Calif., and an associate clinical professor at the UCSF School of Medicine, in San Francisco, agreed. Experts from both fields need to look at this issue from the patient’s—not the provider’s—point of view, he said. “This is about patient care. If your mom broke her hip or had a really serious injury, and was in the emergency room overnight waiting hours for pain control, you would probably want to do a block. Unfortunately, anesthesiologists are not available 24/7 in every hospital around the country. We have to teach patient-facing providers in order to offer these patients optimal pain control.”

Highland Hospital has been championing these efforts and developing block protocols for the past 20 years or so, Nagdev said. He and other emergency medicine colleagues perform some 500 blocks a year. “The idea is that anesthesia and ED should work together” so that patients don’t have to wait hours for true multimodal analgesia, he said. Using simple techniques, such as ultrasound-guided nerve blocks, reduces the complications that are commonly seen with intravenous medications such as opioids, he added.

“When patients come in with injuries, especially acute injuries, they’re not really concerned who’s addressing their pain,” Nagdev said. “They don’t care what residency program I went to; they don’t really care what my credentialing process is. They just want rapid, safe pain control.”

Data aren’t available on how many hospitals allow emergency physicians to perform blocks, but it is becoming more prevalent, said Alexander Stone, MD, an anesthesiologist at Brigham and Women’s Hospital and an assistant professor of anesthesia at Harvard Medical School, both in Boston.

“The issue is that it’s not always coordinated with the anesthesiology teams,” Stone said. “The important thing is for people around the country to have conversations and be open to collaborating. Ultimately what everyone wants is to take care of patients in the best way we can. Nerve blocks aren’t the end-all be-all treatment; they wear off at some point. What patients really need is comprehensive acute pain management.”

These collaborations may vary depending on the setup of each hospital, the speakers said. At UVA, Manson and other anesthesiologists have trained some emergency physicians in regional anesthesia by doing blocks with them, and those doctors are now taking the training back to their department to expand the skills to additional colleagues.

Brigham and Women’s Hospital has a group of ultrasound-trained emergency medicine physicians who can perform nerve blocks and a 24-hour acute pain service, Stone said. Currently, there is a protocol in place for patients who present with certain characteristics and rib fractures, in which they receive a consult from the acute pain service and anesthesiologists perform nerve blocks or offer other regional options, he said.

“We’re working on training up folks and capturing the patients in the ED,” Stone said. “It takes a multidisciplinary team, people in both emergency medicine and anesthesiology who are curious and interested in working together.” The goal is to intervene early, before patients go for operative fixation, and follow them closely, he said.

However, there are some challenges hospital teams need to sort through, Stone noted. One is determining who is responsible for the patient, which can change whether they go to a medicine service or an orthopedic surgery service, to the operating room or are sent home. Another is determining how to best follow up with patients and capture outcomes. If a patient gets a nerve block and is discharged, follow-up can be difficult, he noted, but it’s essential to make sure patients have resources and available care in case of adverse events.

In establishing collaborative programs, communication is key, the speakers said. Before any regional block is performed by an emergency physician, schedule sit-down meetings with representatives from both departments to design a protocol and make sure everyone feels supported and has clear expectations, Manson advised. Discuss how anesthesiologists will be training and educating emergency physicians and what resources will need to be available in the ED.

By Karen Blum

Manson, Nagdev and Stone reported no relevant financial disclosures.