[stevierae]

Originally Posted by deepz

God knows, it hurts me to agree with you on anything, JRK, but there it is: the circulator may have charge of the physical OR 'room' but the PATIENT'S guardian is always Anesthesia.

People can be *so* full of themselves.

deepz

Well, I am certainly not one of those people who is full of myself--anything but-- and in my rooms, we work as a team. Split hairs if you must, and of course the anesthesia provider is in charge of the patient's airway (and breathing, and circulation---) and is certainly the one in charge of a code, as he SHOULD be--and no one, NO ONE, (not even surgeons) believes that archaic "surgeon as captain of the ship" rule anymore--but, I have given expert testimony in more than one OR case gone bad where all the finger pointing came down to the operating room nurse not advocating on behalf of the patient, as is her primary role.

It does not bother me one bit to tell a patient that if I were he I would cancel or postpone his surgery if I thought patient care conditions were suboptimal, (lack of proper equipment; inept surgeon; impaired anesthesia provider, nurse or scrub tech) and I would and have done so, and would and have testified to such if I thought another operating room nurse did NOT advocate on behalf of her patient in this regard.

No one suggested that you should "take orders" from the circulator. As I said, you are, at least you should be and are in most states, independent practitioners.

However, if I feel that a patient care situation is a dangerous or suboptimal one, it is my reponsibility--as the patient's advocate, and mandated by most states' nurse practice acts-- to prevent the surgery from moving forward--by simply refusing to bring the patient to the room, or moving up the chain of command if need be, and I expect the OR director to respect my critical thinking skills, independent decision making skills, experience and gut instinct and to back me on it--and if she won't, I have no problem with moving further up the chain of command; all the way up to the hospital administrator, if need be.

Now, if you have no circulator, do you think that you and the surgeon and the scrub can just proceed without one? Of course, you can't--and what makes you think that if one nurse thinks a patient care situation is unsafe or suboptimal that another nurse will agree to do the case?

What makes you think that the surgeon, his Chief, or even the Chief of Surgery will necessarily side with you? What makes you think your own department manager--that is, the Chief of Anesthesia--will, if a situation truly is dangerous, and you insist on moving forward? Do you truly believe that they have no respect for the operating room nurses or the roles we play? There is no place for a "good ol' boys'" network when a patient's life is at stake, (or when a patient's life has already been lost and surgeons/nurses/ anesthesia providers are reluctant to come forward and do the right thing by testifying as to deviations from standard of care and causation--hopefully preventing it from ever occurring again.)

Actually, I think any anesthesia provider has the responsibility to do exactly the same thing if a patient care situation is suboptimal or dangerous--and I think that you also have a reponsibility to testify if you know that to be the situation in regards to another dangerous patient care situation/provider. As a matter of fact, I think if we work as a team, we ALL have optimal patient care as our common goal--and therefore, we are all the patient's guardians (advocates is a much better word.)

Like it or not; interpret it any way you like--if you require interpretation, best get it from AORN. The circulator is in charge of the room. I am simply making this statement in response to the one that said "those circulators think they are in charge." I have no need to be on any particular power trip--if I did, I'd be one of the management yes-men and women that we all abhor. Hear it in a court of law, if you prefer. It is often one of the jury instructions given when they are told how to interpret the scope of practice for an operating room nurse, and our first and primary role as patient advocate is defined in every state's nurse practice act.

[shodobe]

I do like the part about circulators, which are RNs, being "ancillary" staff. just what is the CRNAs definition of ancillary? I work with quite a few CRNAs through Kaiser programs and find them extremely competent and other RNs should not belittle their position. Until you have walked in their shoes one should make rash statements. The same goes for CRNAs, there are alot of them that have never really worked in an OR as OR nurses, so the same goes for them. Make no rash judgments. I think there alot of RNs in the OR that have a "burr" up their butt about CRNAs and maybe should put patient care well ahead of their own opinions. Mike

[jwk]

Originally Posted by stevierae

Well, I am certainly not one of those people who is full of myself--anything but-- and in my rooms, we work as a team. Split hairs if you must, and of course the anesthesia provider is in charge of the patient's airway (and breathing, and circulation---) and is certainly the one in charge of a code, as he SHOULD be--and no one, NO ONE, (not even surgeons) believes that archaic "surgeon as captain of the ship" rule anymore--but, I have given expert testimony in more than one OR case gone bad where all the finger pointing came down to the operating room nurse not advocating on behalf of the patient, as is her primary role.

It does not bother me one bit to tell a patient that if I were he I would cancel or postpone his surgery if I thought patient care conditions were suboptimal, (lack of proper equipment; inept surgeon; impaired anesthesia provider, nurse or scrub tech) and I would and have done so, and would and have testified to such if I thought another operating room nurse did NOT advocate on behalf of her patient in this regard.

No one suggested that you should "take orders" from the circulator. As I said, you are, at least you should be and are in most states, independent practitioners.

However, if I feel that a patient care situation is a dangerous or suboptimal one, it is my reponsibility--as the patient's advocate, and mandated by most states' nurse practice acts-- to prevent the surgery from moving forward--by simply refusing to bring the patient to the room, or moving up the chain of command if need be, and I expect the OR director to respect my critical thinking skills, independent decision making skills, experience and gut instinct and to back me on it--and if she won't, I have no problem with moving further up the chain of command; all the way up to the hospital administrator, if need be.

Now, if you have no circulator, do you think that you and the surgeon and the scrub can just proceed without one? Of course, you can't--and what makes you think that if one nurse thinks a patient care situation is unsafe or suboptimal that another nurse will agree to do the case?

What makes you think that the surgeon, his Chief, or even the Chief of Surgery will necessarily side with you? What makes you think your own department manager--that is, the Chief of Anesthesia--will, if a situation truly is dangerous, and you insist on moving forward? Do you truly believe that they have no respect for the operating room nurses or the roles we play? There is no place for a "good ol' boys'" network when a patient's life is at stake, (or when a patient's life has already been lost and surgeons/nurses/ anesthesia providers are reluctant to come forward and do the right thing by testifying as to deviations from standard of care and causation--hopefully preventing it from ever occurring again.)

Actually, I think any anesthesia provider has the responsibility to do exactly the same thing if a patient care situation is suboptimal or dangerous--and I think that you also have a reponsibility to testify if you know that to be the situation in regards to another dangerous patient care situation/provider. As a matter of fact, I think if we work as a team, we ALL have optimal patient care as our common goal--and therefore, we are all the patient's guardians (advocates is a much better word.)

Like it or not; interpret it any way you like--if you require interpretation, best get it from AORN. The circulator is in charge of the room. I am simply making this statement in response to the one that said "those circulators think they are in charge." I have no need to be on any particular power trip--if I did, I'd be one of the management yes-men and women that we all abhor. Hear it in a court of law, if you prefer. It is often one of the jury instructions given when they are told how to interpret the scope of practice for an operating room nurse, and our first and primary role as patient advocate is defined in every state's nurse practice act.

We're all patient advocates. That's not what I equate with being "in charge".

Let me tell you my problem with AORN standards. Although AORN would like to think they apply to every person in the OR, they simply don't. They are a set of NURSING guidelines and standards. They're fine to a point - but only to a point. AORN does not dictate anesthesia practice, nor do our professional organizations try and dictate nursing practice in the OR.

Here's an example of a huge upcoming problem for anesthesia that illustrates a similar problem. AANA and ASA believe that propofol for sedation should only be given by anesthesia providers. The GI nurses and docs associations believe it's fine for an RN to administer it after appropriate training. Whose standards apply here? If you're concerned at all about patient safety, it's a no-brainer.

We're really on the same side here, the side of the patient. What you call being in charge I think is simple patient advocacy. Maybe the anesthesia folks at your facility don't stand up for their patients, and if they don't, that's a real shame. I know we do, and we don't have to worry about a "chain of command". We don't do anything if it's not in the patient's best interests.

[BigDave]

Wow, this is quite an angry thread. Back to the original problem. I agree that you should confront the nurse professionally right on the spot. God knows, I've hauled 5 MDs out in the hall in the past two weeks...they've shaken my hand and apologized after seeing how their actions are perceived. If that doesn't work, try what a previous poster said--document the exact words, situation, date, and nurse involved. Do it on paper right there (if you have time). You could even have that party initial what you wrote. This is probably a last-ditch effort and you will probably just have the angry comments moved till after you leave the PACU, but at least you will not have to listen to it!

Maybe ask other anesthesia providers if that is happening to them as well. Ask them what is their view of their responsibilities in the PACU. If it is not just you involved, maybe arrange a meeting with the PACU manager and review expectations during admission. I think this is the best long-term solution. Unfortunately, if you find out that it is only you having this problem, you may need to adapt to the norm.

I also agree with jewelcutt, when I land OR patients in the ICU, nobody from the OR (anesthesia, nurses, techs) ever helps hook up a patient. They might help pull their Propaq off, but that is about it. This has been consistent in the 10 ICUs that I've worked in. It has never bothered me. I actually appreciate them watching the monitors and sometimes doing some last-minute touch ups (squirting something out of their pocket into the IV line).
I just don't see the issue?? In the ICU, other nurses come and help hook up the patient. Lots of times I don't even help with my own patient. I get a brief update from anesthesia (EBL, I&O, meds...) and go right into an assessment. I've never worked in the PACU--do other nurses help land a patient there? That would seem like the logical thing to do??

Good luck, it is never easy working where there is little harmony.
Dave

[forane2001]

Thanks Big Dave,

I think for now I will just document the incident in my own file and have it ready in case something else pops up. It would not be appropriate to bring this topic up in front of the other pacu staff-probably will have more of them on my case if I write her up anyway. It is my hope that other facilities are not this way-very depressing if it is. Like I said, we CRNA's seem to be invisible at this hospital but the cardiology PA's and other disciplines are in the "click" if you know what I mean. For instance-the other day-and I may have mentioned it before-sorry if I did, I came into PACU with Vancomycin hanging (not running). It was a case where the BP was a little low no matter what I did so I told the surgeon the Vanco had to go until the vol anesthetic was off-so we could figure out what the source of hypotension was. He was cool with that. So in PACU I explained why the Vanco was off-well that was not good enough. The RN started it right back trying to get it in. I told her to leave it off due to the BP situation. I had to physically take the dial-a-flow away from her and turn off the Vanco before she killed him. Then she said" well I never heard of Vanco causing low BP. I had to explain to her about the histamine release yada yada. Why didnt she do as I told her to start. Who does she thinks controls these meds in the OR anyway?? I guess enough of this topic guys. thanks for the responses. I hope I didnt make people mad but you will never understand being a CRNA until you walk in our shoes.

Originally Posted by BigDave

Wow, this is quite an angry thread. Back to the original problem. I agree that you should confront the nurse professionally right on the spot. God knows, I've hauled 5 MDs out in the hall in the past two weeks...they've shaken my hand and apologized after seeing how their actions are perceived. If that doesn't work, try what a previous poster said--document the exact words, situation, date, and nurse involved. Do it on paper right there (if you have time). You could even have that party initial what you wrote. This is probably a last-ditch effort and you will probably just have the angry comments moved till after you leave the PACU, but at least you will not have to listen to it!

Maybe ask other anesthesia providers if that is happening to them as well. Ask them what is their view of their responsibilities in the PACU. If it is not just you involved, maybe arrange a meeting with the PACU manager and review expectations during admission. I think this is the best long-term solution. Unfortunately, if you find out that it is only you having this problem, you may need to adapt to the norm.

I also agree with jewelcutt, when I land OR patients in the ICU, nobody from the OR (anesthesia, nurses, techs) ever helps hook up a patient. They might help pull their Propaq off, but that is about it. This has been consistent in the 10 ICUs that I've worked in. It has never bothered me. I actually appreciate them watching the monitors and sometimes doing some last-minute touch ups (squirting something out of their pocket into the IV line).
I just don't see the issue?? In the ICU, other nurses come and help hook up the patient. Lots of times I don't even help with my own patient. I get a brief update from anesthesia (EBL, I&O, meds...) and go right into an assessment. I've never worked in the PACU--do other nurses help land a patient there? That would seem like the logical thing to do??

Good luck, it is never easy working where there is little harmony.
Dave

[Tenesma]

1) PACU RNs... I find that trying to give report to an RN until the patient is settled is pretty much useless, because they are focusing on all of their tasks. I therefore make it a point to teach my residents to assist the PACU RN in hooking up the patient, getting the urinal/vomit basin, etccc... so that together they can expedite the settling-in of the new PACU arrival and then move on to report. The PACU RNs appreciate it, Report is given sooner - and is a LOT more effective as now the RN can actually focus and register and remember what you have reported, and on to the next case

2) Circulator is the boss in the OR.... from an administrative point of view for elective case, I will give you that. ANY deviation from that: ie: patient is unstable, trauma, or for ANY anesthetic (justifiable) reason what so ever the ANESTHESIA provider trumps the circulator. In fact, Surgeons and I have started cases without circulators because it was in the patients best interest.... However a good circulator can actually PLAY a HUGE difference in patient outcome, whereas a bad circulator can literally kill me and the patient

3) Disrespect.... Respect is earned - especially in medicine, with time and sweat and blood. I find that the more I communicate with circulators, scrubs, surgeons, etc.... the better they understand my concerns and the better we work together. So you might perceive it as disrespect, which it may be - but it also may be worth looking at your own communication skills. This belief that now that you are a CRNA and no longer a nurse is silly.... I'll tell you why: Because a CRNA or an Anesthesiologist has to be a good nurse before they can be good Anesthesia Providers...

[stevierae]

Originally Posted by jwk

The GI nurses and docs associations believe it's fine for an RN to administer it after appropriate training. Whose standards apply here? If you're concerned at all about patient safety, it's a no-brainer.

I don't believe that Propofol sedation is safely given by ANYONE but an anesthesia provider, and have written extensively against the practice, both on this BB and in articles and letters to politicians, patient safety commissions, CRNA organizations, etc. In fact, I have filed a complaint with the Board of Nursing in Oregon to try to get the practice stopped at the gastroenterology lab in Southern Oregon that does this.

Most gastroenterologists of my aquaintance don't agree with the practice, either. I am at a loss to understand why so many GI nurses have a need to put their licenses at risk to do an anesthesia provider's job without adequate training and not enough pay. Maybe it makes them feel important or something. Not all of us have a need to feel important, and there are stupid, reckless people everywhere.

[stevierae]

Originally Posted by forane2001

The RN started it right back trying to get it in. I told her to leave it off due to the BP situation. I had to physically take the dial-a-flow away from her and turn off the Vanco before she killed him. Then she said" well I never heard of Vanco causing low BP.

As I said--there are stupid people everywhere----hard to believe a PACU nurse is not familiar with Red Man's Syndrome, since we give Vanco all the time (heck, we gave it all the time throughout nursing school, and presumably so did she!!) and infuse it over an hour in the perioperative setting--but, if true, obviously she is clueless, and should not be working in PACU--in fact, maybe she shouldn't be working in patient care, period....

[jwk]

Originally Posted by stevierae

I don't believe that Propofol sedation is safely given by ANYONE but an anesthesia provider, and have written extensively against the practice, both on this BB and in articles and letters to politicians, patient safety commissions, CRNA organizations, etc. In fact, I have filed a complaint with the Board of Nursing in Oregon to try to get the practice stopped at the gastroenterology lab in Southern Oregon that does this.

Most gastroenterologists of my aquaintance don't agree with the practice, either. I am at a loss to understand why so many GI nurses have a need to put their licenses at risk to do an anesthesia provider's job without adequate training and not enough pay. Maybe it makes them feel important or something. Not all of us have a need to feel important, and there are stupid, reckless people everywhere.

I was just giving you an example of conflicting guidelines and standards. Obviously, the GI docs and nurses will trot out their "experts" in a lawsuit someday soon, showing that "their standards" mean that it perfectly acceptable for RN's to administer propofol. That's why I have a problem with AORN standards - it's not that they're bad, just that they don't apply to me since I'm not an OR nurse.

[Mike1991]

admin note: Rude comments removed, a reminder to everyone, please be polite and not inflamatory.