Anesthesiology in Emergency Medicine

As of 2021, the U.S. alone has approximately 70,000 actively practicing anesthesiologists and emergency medicine physicians ^1,2. The intersection of these two clinical specialties remains a dynamic terrain with rapidly changing standards of training and clinical practice. Anesthesiology plays an important role in emergency medicine, as well as critical care broadly.  

Across most clinical settings, the main interface between anesthesiology and emergency medicine consists of the emergency management of a patient’s airway. Anesthetic assistance is generally sought for any airway intervention beyond the most basic situation, such as when an airway is compromised or when drugs need to be administered to facilitate tracheal intubation. In such cases, it remains standard protocol for a trained anesthesiologist to carry out airway management procedures.  

Despite the increasingly evident importance of early and effective airway management, there often remain delays in obtaining anesthetic assistance ^3,4. In addition, the emergency medicine physician may be more experienced, depending on the facility. Therefore, in emergency departments across the U.S. and Australia, and increasingly so in the U.K., emergency physicians tend to perform advanced airway interventions – including the administration of anesthetic agents and muscle relaxants for tracheal intubation ^5,6.  

However, key challenges in such situations persist. First, advanced airway management is complicated. Patients may have a full stomach, be unable to provide their medical history, or have trauma complicating their airway management. Second, the equipment to deal with such events may not always be immediately accessible. Third, emergency physicians may not have the skills to longitudinally manage a patient who requires continuing anesthesia. The reported incidence of failed and difficult intubations in the emergency department is estimated to be three times higher than in the operating room ^7,8. It is thus critical for those practitioners with ample training and experience to perform rapid sequence induction and intubation whenever possible.  

Meanwhile, as early as the 1990s, the number of anesthesiology residents pursuing critical care medicine fellowship training was found to be decreasing – making the pool of anesthesiologists with a strong skillset for emergency medicine procedures increasingly small. Research has suggested, however, that improved training and curricula, supporting student loan deferment programs, and introducing medical trainees to the intensive care unit earlier on in their education may buoy interest in critical care medicine ⁹.  

First, it is important to train anesthesiologists in acute care – including emergencies, trauma, and critical care. Second, given the variability in exposure to trauma and emergency surgeries during training, a protocol needs to be developed to standardize the preparation of anesthesiologists for acute care. One proposal has been to require that anesthesiology residents complete two additional years of training following their third year of residency, possibly through programs in hospital or emergency medicine in combination with anesthesiology ¹⁰. Another has been to restructure anesthesiology training to include a subspecialty focus in critical care or pain medicine during their third year of residency ¹¹.  

Airway management and similar situations in the emergency department will likely be the shared responsibility of anesthesiologists and emergency physicians. In the meantime, it remains critical for both specialties to keep communicating well and co-creating best practices – strengthening the interface and collaboration between the two.  

References 

1. Anesthesiologists. Available at: https://www.bls.gov/oes/current/oes291211.htm. (Accessed: 23rd June 2022)
2. Emergency Medicine Physicians. Available at: https://www.bls.gov/oes/current/oes291214.htm.
3. Butler, J. M., Clancy, M., Robinson, N. & Driscoll, P. An observational survey of emergency deparment rapid sequence intubation. Emerg. Med. J. (2001). doi:10.1136/emj.18.5.343
4. Teale, K. F. H., Selby, I. R. & James, M. R. General anaesthesia in accident and emergency departments. J. Accid. Emerg. Med. (1995). doi:10.1136/emj.12.4.259
5. Gwinnutt, C. L. The interface between anaesthesia and emergency medicine. Emergency Medicine Journal (2001). doi:10.1136/emj.18.5.325
6. Sakles, J. C., Laurin, E. G., Rantapaa, A. A. & Panacek, E. A. Airway management in the emergency department: A one-year study of 610 tracheal intubations. Ann. Emerg. Med. (1998). doi:10.1016/S0196-0644(98)70342-7
7. Crosby, E. T. et al. The unanticipated difficult airway with recommendations for management. Can. J. Anaesth. (1998). doi:10.1007/BF03012147
8. Benumof, J. L. Management of the difficult adult airway: With special emphasis on awake tracheal intubation. Anesthesiology (1991). doi:10.1097/00000542-199112000-00021
9. Durbin, C. G. & McLafferty, C. L. Attitudes of anesthesiology residents toward critical care medicine training. Anesth. Analg. (1993). doi:10.1213/00000539-199309000-00002
10. Kuhn, C. M. The Innovative Anesthesiology Curriculum. Anesthesiology (2010). doi:10.1097/aln.0b013e3181c92279
11. Wasnick, J. D. Back to the future: Redesign of the anesthesiology residency curriculum. Anesthesiology (2010). doi:10.1097/ALN.0b013e3181eab585