Coincidence, conscious sedation, CAEP and ketamine

Letters

CJEM 2000;2(1):9

To the editor:

As I write this letter, I’m about to write a cheque and once again renew my membership to this august national organization, the Canadian Association of Emergency Physicians (CAEP). Each year I ask if this is really necessary, and each year I write the cheque anyway. This year I have something new to contemplate.

About 8 years ago, our ED introduced ketamine for procedural sedation. Predictably, we were met with protests from the anesthetists, which we ignored. We were glad when the matter was referred to our Medical Advisory Committee (MAC) and ecstatic when the MAC appointed sympathetic people to review the issue. We were prepared with arguments for efficacy and patient safety, but not for what the anesthetists actually threw at us. They argued that there was no legal context in Canada for us to use a drug reserved, up to that time, to general anesthesia. Furthermore, they suggested that if the hospital were ever sued, there would be no legal defence for allowing us to use it. They were correct, and our sympathetic panel apologized one by one, then voted to support the anesthesia motion. That ended our experiment for 8 long years.

When the CAEP sedation guidelines were published in early 1999,¹ I sensed that the landscape had suddenly changed. With national standards published and supported by our specialty society, the legal position of our department and of the hospital changed overnight. We reinstituted the use of ketamine and, predictably, the anesthetists challenged us again. Once more, the matter was referred to the MAC, and then to another subcommittee. This time we had the published guidelines as evidence, along with a list of Canadian hospitals using ketamine and propofol. This time the decision went in our favour. Within a few days, Anesthesia withdrew their objections and indicated they would no longer interfere with our department’s internal policies.

It occurs to me that during those two years of struggle, when CAEP was negotiating with the Canadian Anaesthetists’ Society and the guidelines were being born, there may have been times when the participants wondered if it was all worth it, and whether they would really make a difference. I want to tell you that Yes, it was, and Yes, it has. This year I have no doubt at all about the reasons for signing another cheque for my CAEP membership.

On behalf of all my colleagues, thanks to all the members who worked on the sedation guidelines project.

Les Vertesi, MD
Chief of Emergency Medicine
Royal Columbian Hospital
New Westminster, BC

Reference

1. Innes G, Murphy M, Nijssen-Jordan C, Ducharme J, Drummond A. Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines. J Emerg Med 1999;17:145-56.