Should OR RN's be ACLS/PALS certified? - page 2

Ok, remembering that I work PACU my question occurs because out hospital has determined that it is unecessary for the OR nurses to take ACLS etc, except for BLS(basic life support) since there is an... Read More

  1. by   sharann
    I don't think you are ranting at all Mike. I appreciate your input, and it has actually given me reason to re-think my position(though I wasn't really sure of it which is why I posted the question!). I worked for a plastic surgeon for about a week and quit as soon as he tried to get me to circulate, push sedation/twilight meds AND then recover(which is why he wanted me to be ACLS certed....that guy was a schmuck). Anyhow, thanks everyone for all the input and info
  2. by   shudokan-RN
    I am signed up for ACLS, in Sept, and PALS in Oct. My incentive is $1.00/hr
    pay raise.

    marci
  3. by   sharann
    Quote from macox
    I am signed up for ACLS, in Sept, and PALS in Oct. My incentive is $1.00/hr
    pay raise.

    marci
    HA!
    I am REQUIRED to take ACLS and PALS b/c I work PACU, but no pay incentive PLUS I take them on my time with no pay or reimbursement. Yay for me.
  4. by   stevierae
    You have to keep in mind that most codes in the OR are not the chaotic, high drama situations they can be in other departments--because when we have a code, we usually have some warning of it--the patient starts to crash before our very eyes--and we already have a protected airway. Our patient is intubated, and if he is not, he soon will be. In other codes, chaos occurs during multiple attempts to establish the airway; we don't have that problem---it's a very controlled, relaxed environment, or it should be.

    I faithfully renewed my ACLS every 2 years for probably 15 years, and finally let it lapse. There are few codes that the circulator and anesthesiologist cannot handle, even if the circulator is not ACLS certified. In fact, all these busybodies running to the room to "watch" or "help" just get in the way.

    I have been in more than one situation where the anesthesiologist asked the charge nurse, desk person, or whoever among management (or staff RNs and anesthesia) showed up to leave--they just get in the way. They usually just look up and quietly but assertively say, "My circulator and I can handle it." Normally, if need be, the surgeon or even the scrub can give CPR, and the circulator can charge the defibriilator and defibrillate. Truthfully, in all the years I have worked in ORs, nobody ever came and recorded, as they do in ER and on the floors. Anesthesia just charts when the code is over, and we chart what took place in our nursing notes--it does not have to be overly detailed, so as not to be redundant. If I need additional help, I am capable of asking for it.

    I was not aware that one had to be ACLS certified to give code drugs. I have pushed or given IM succs, Lidocaine, Epi, Atropine; Bretylium and Verapamil when those were in vogue, or whatever else needed to be given over the years whether I was certified or not--after all, the circulator assists with induction and gives drugs when the anesthesiologist's hands are tied up for any other reason--why should it be different in a code? We are a team, we function as a unit, and we all trust each other. I think I would have a problem with another nurse coming in uninvited and taking over care of my patient.

    I agree with Shodobe in that, if the OR management knows you are ACLS certified, they expect you to give conscious sedation. I refuse to do an anesthesia provider's job just so they--the suits in management-- can open an extra room. They do not pay me enough to do an anesthesia provider's job, and I think every patient deserves an anesthesia provider at the head of the table in charge of his sedation and his airway--not a nurse. I know what I don't know.

    Also, the "reward" for getting done early here (in Oregon) is either getting sent home early without pay, or getting stuck doing the add ons, which, more and more, are elective cases that should be scheduled on another day. What's the point of busting a** for that? I know in CA people rarely, if ever, get sent home early--CNA considers that an involuntary layoff and worthy of filing a grievance and getting paid for the lost hours--but here, it is very much a reality.
    Last edit by stevierae on Jun 13, '04
  5. by   squeek
    ditto to the protected airway and the cool and controlled environment!

    only code I had trouble with was an anaphylaxis to Abs prior to induction ... couldnt get an airway for that one!

    we never call the code team ...

    I only have BLS certification.

    i work as a team with my anaesthetist ... and scrub team if necc.

    Squeek
  6. by   stevierae
    Quote from squeek
    only code I had trouble with was an anaphylaxis to Abs prior to induction ... couldnt get an airway for that one!

    Squeek
    That's where Benadryl, Epinephrine, possibly Decadron and a trach tray standing at the ready come in handy! Also a Fast-Trach and the fiberoptic laryngoscope! You can call out for somebody to bring the difficult intubation cart, and then it's your call, or anesthesia's, whether they stick around to "help" or not. Or just an oral airway while you wait for the laryngotracheal edema to subside after the Benadryl or, more probably, Epi.

    Or, often a patient layrngospasms and bradys down. Atropine and succs break the laryngospasm, and you can proceed. The anesthesiologist will be busy masking, so the RN will be the one giving the Atropine and succs--ACLS certified or not. Doesn't matter to me-- when seconds count between progression from bradycardia to cardiac arrest, who is going to stand on ceremony? When the laryngospasm breaks, he will be able to intubate.

    What happened in your situation, squeek?

    Often in the OR, a "code" is usually a transient vasovagal reaction and is treated immmediately with O2, Trendelenberg, speeding up the IV fluid, and, if need be, Ephedrine or Atropine. By the time all the busybodies run to the room, we have proceeded with the case.

    "Show's over! Nothin' to see here, people!!" is what you feel like saying.

    I think it makes some of management, especially, feel important to be there--now they can go to one of their endless meetings and tell everybody there was a "code," and they singlehandedly saved the day.
    Last edit by stevierae on Jun 14, '04
  7. by   squeek
    we were about to start a nephrectomy,
    triple Abs before start ... NKA ...

    registrar was pre oxygenating pt,
    anaesthetist gave Keflin ..
    patients face just got bigger and bigger!
    we tried everything, every drug....
    bougie, trachlight, LMA, guedells ... but we couldnt get any air movement.
    finally cut down trachy .. her neck was so swollen by then it was difficult to find landmarks. got the tracheostomy in but it was too late.
    I have an anaesthetist who swears never to give Abs pre op ... wait til the tubes in .. I say whats the rush.

    doesnt matter how many other people were there .. the outcome would have been the same. we were prepared, it didnt help. we knew what we were doing. just real bad luck :stone

    squeek :angryfire
  8. by   stevierae
    Quote from squeek
    we were about to start a nephrectomy,
    triple Abs before start ... NKA ...

    registrar was pre oxygenating pt,
    anaesthetist gave Keflin ..
    patients face just got bigger and bigger!
    we tried everything, every drug....
    bougie, trachlight, LMA, guedells ... but we couldnt get any air movement.
    finally cut down trachy .. her neck was so swollen by then it was difficult to find landmarks. got the tracheostomy in but it was too late.
    I have an anaesthetist who swears never to give Abs pre op ... wait til the tubes in .. I say whats the rush.

    doesnt matter how many other people were there .. the outcome would have been the same. we were prepared, it didnt help. we knew what we were doing. just real bad luck :stone

    squeek :angryfire
    Dang! That was bad luck. I am betting she was one of those rare people who has a cross sensitivity to BOTH Penicillin and Cephalosporins. She may have just forgotten she was allergic to PCN; maybe she had not had it since childhood.

    We don't use Keflin anymore here--at least, I have not SEEN it used in years. We use Kefzol (Ancef.) We always give a test dose to see if the patient has anything resembling an anaphylactic reaction; then, if not, give the rest of the dose.
  9. by   hypnotic_nurse
    In my research group, we are required to have both ACLS and PALS by our federal funding -- but if there's a problem, we are to call 911 stat...we have a crash cart with all the meds, but we are not to use it unless the MD is in house.

    It's not a waste, really, it's nice to know, but the likelihood of me ever using it is next to nil unless I happen to be near an AED when someone's heart stops.
  10. by   jwk
    Quote from shodobe
    Not required here. I did go through the ACLS and let it expire because no reason to have it. I have been around long enough if my gas passer drops dead I think I know what to do. Mike
    Glad you have such a high opinion of yourself in case your "gas passer" drops dead.

    Can you mask a patient? Adequately?

    Can you intubate a patient or place an LMA?

    Are you aware that Lidocaine is NOT a first line drug?

    Do you know what Vasopressin is, when it's used, the dose?

    Are you aware that Bretylium isn't even available anymore?

    ACLS standards change over the years. The move is to base the recommendations much more on "science" than just doing things "the way we've always done it". 25 years ago, one of the first drugs we gave was two amps of Bicarb on everyone who arrested, even if it only lasted 30 sec.

    Our hospital doesn't currently require ACLS for OR nurses. However, they don't stand around during a code either. Each person in the room has an assignment during a code so no one stands around wondering what to do. Anesthesia is generally in charge since they control the A/W and drug administration during the case anyway. The scrub usually does chest compressions, the circulator gets the crash cart an at least an additional RN to help. One of the RN's keeps track of each event - drug, defib, start/stop compressions, etc. Those notes/records are compared and combined with the anesthesia record to produce accurate records of the entire code. If you think an accurate record isn't important, you're dead wrong, because particularly if the patient dies, some attorney will be looking at it sooner or later.

    RN's certainly may push IV medications during a code. They do not have to be CERTIFIED in anything. It certainly is not outside their scope of practice - it might conceivably be against hospital policy.
  11. by   jwk
    Quote from squeek

    anaesthetist gave Keflin ..

    I have an anaesthetist who swears never to give Abs pre op ... wait til the tubes in .. I say whats the rush.
    For those wondering about cross-allergy with PCN and cephalosporins - it is certainly not rare. It's on the order of 10-15%.

    However, severe anaphylactic reactions are unusual. And not all cases get an ETT, so your anesthetist's assertion is somewhat ridiculous.

    Finally - the latest recommendations for antibiotic usage in surgery recommend that the antibiotics be given not less than 30 minutes prior to skin incision. That's easy for drugs like PCN and Cephs, which can be given fairly rapidly after a test dose. Others like Vanco and Cipro need to be given much more slowly, so we try and start them 1 hr prior to going to the OR so that they will be fully infused by the time of the incision. The timing does make a difference in post-op infection rates.
  12. by   shodobe
    jwk, it seems to me you have a higher opinion of yourself than I do of myself. I am confident enough in my self to know what to do when it is necessary. This is not about what I know and don't know. It is about wether OR nurses need to be ACLS or PALS cert. My OPINION is, no. You obviously are more intelligent than I and keep up on all the drugs and changes. I, on the other hand, am just a grunt worker paid to do what he is told to do during a code, just like you're supposed to do. I think you might be confusing me with a previous post because it sounded like you thought I and my co-workers just stand around doing nothing. We have the same protocol as your hospital has and we still don't need PACU rescuing us because we all know are part of a code. As you can see your response has the hairs on the back of neck standing u. End of discussion.
  13. by   stevierae
    Quote from jwk
    For those wondering about cross-allergy with PCN and cephalosporins - it is certainly not rare. It's on the order of 10-15%.

    However, severe anaphylactic reactions are unusual. And not all cases get an ETT, so your anesthetist's assertion is somewhat ridiculous.

    Finally - the latest recommendations for antibiotic usage in surgery recommend that the antibiotics be given not less than 30 minutes prior to skin incision. That's easy for drugs like PCN and Cephs, which can be given fairly rapidly after a test dose. Others like Vanco and Cipro need to be given much more slowly, so we try and start them 1 hr prior to going to the OR so that they will be fully infused by the time of the incision. The timing does make a difference in post-op infection rates.
    Gosh, jwk, we are not rookies here! I think we all know about recommendations for when antibiotics should be given before surgery; as well as the fact that NaHCO3 is not given routinely any more (always based on blood gases) and we all know the infusion recommendations for Vanco; to avoid Red Man's Syndrome.

    We also, even if one is not certified in ACLS, know that Bretylium has not been around for quite some time (check any code cart and you won't see it. I haven't seen it in probably a decade.)

    And I do know that the cross sensitivity to both cephalosporins and PCN is reported to be around 10%. Never seen it quoted as high as 15%, but that could be true; not disputing you.

    What I guess I meant to say is, regardless of the rate at which it is reported in the literature, one can go one's entire career and NEVER see a case of a cross sensitivity to BOTH cephalosporins and PCN. In fact, I have seen only ONE in almost 30 years of practice. In the '80s, you never saw an anesthesiologist even bother with a test does; cross sensitivity was thought to be so uncommon. Only in the '90s did I start seeing anesthesia providers give test doses, and that was by no means across the board. I have to say that CRNAs, as a rule, are more cautious, which is a good thing, then many anesthesiologists, who can get a little cavalier. I have seen an anesthesiologist delibeerately push Vanco to prove to a nursing student his theory that Red Man's syndrome doesn't always happen as reported in the literature. He literally said to her, "I don't believe in that one hour rule. Anesthesiologists push much more dangerous drugs than this. I push EVERYTHING. Watch." Well, it happened, and he treated it appropriately, but she left with a different impression of him than I am sure he would have liked her to have.

    I really found your post to be quite condescending, even if you are an anesthesia provider. Many of us are very experienced operating room nurses; many of us (myself included) do other types of nursing and are nurse educators, as well. I am an IV nurse educator as well as a legal nurse consultant. I also keep up with the literature and, of course, with new evidence based practices, and modify my own practices accordingly.

    Are you an anesthesia provider? I certainly hope you don't treat the OR nurses in your OR with the same condescending, contemptuous attituted with which you seem to view us.

    And, as a matter of fact, I can mask a patient very well, whether pediatric or adult, as well as start both pediatric and adult IVs skillfully and efficiently. I can also put in an airway, and, during my years as a Vietnam era corpsman, have done a stab trach or two to save a life. Any OR RN who has worked with private practice anesthesiologists can mask and start IVs; in peds cases, it used to be just the circulator and the anesthesiologist; one would start the IV and one would mask; either could fulfill either chore equally well. if you didn't know how, you soon learned.

    I cannot intubate, and wouldn't. Learning in ACLS on a fake patient is not the same as the practice anesthesia providers and EMTs and RTs get on human patients. I know my limits.

    Also, FYI---as an LNC, I have sat in on more than one depo involving an OR death after an arrest. Never, NEVER, has the "code record" been asked for or entered into evidence. The anesthesia record tells its own story. That is all that has ever been asked for in a request for document production. It is more than sufficient for the medical examiner, as well, at least wherver I have practiced. I cannot speak for Georgia or the rest of the South. I have done cases in Florida, however, where it was not requested; again, all that was looked at as a record of events was the anesthesia record.

    As a circulator, I, too, chart a brief description of what occurred; of course I make sure that what anesthesia documents and what I document are the same.

    I'll say this again: most "codes" that occur in the OR are on a patient who already has a protected airway; hence, they are not the high drama people make them out to be. Also, they are often transient and not "codes" at all--more often PEA due to some transient problem (i.e., knocked of a bleb during intubation; tension pneumo results; stick an IV catheter in the intercostal space (think it's 4th or 5th; not sure) to relieve the tension pneumo; PEA reverts to NSR. Then, if need be, you can put in a chest tube and either continue with or cancel the surgery.

    Or, it's a vasovagal reaction. Or, the pulse oximeter falls off or an EKG lead gets displaced and people freak out when alarms ring and the datascope looks like Vfib (but is really artifact.) The code cart is pulled in and everybody realizes: We didn't look at the patient, only at the monitors. Everybody looks sheepish and embarrassed. In any case, most "codes" in OR are over before one can "record" anything on a code record.

    "Show's over! Nothin' to see here, people!"
    Last edit by stevierae on Jun 16, '04

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