Anesthesia and the ER: sedation of a class III/IV patient

[Calfax]

You just gotta love the night shift....when everything that can go wrong will and when reality is far stranger than what's playing the TV in the waiting room.

Check this: it's about 1 AM on a Saturday night and we're still rocking and rolling with the usual suspects.....not overloaded, but nobody's sitting down yet.

The code beeper goes off......neo-nate code in L&D. Although we respond to inpatient codes, this isn't our juristidiction. About 15 minutes later, I get a frantic call for the ER charge RN. I pick up the phone, at the other end is the senior medical resident, urgently requesting an ER nurse to come up to L&D immediately. Sure, ok, we'll help out in a baby code, no probs (so we thought) So I and a tech wander up to L&D with our jump bag. We get up there and L&D looks like a tornado hit it....nurses frantically preparing to C-section a delivering mother as the resident is scrubbing up. We ask what's going on, and the resident says he needs to do an emergent c-section and can we consciously sedate the patient for the procedure. I was completely taken aback. Didn't know what to say.....except: "Well, where's anesthesia?" "He's not here yet." "What the hell do you mean, anesthesia's not here?" "He doesn't stay in-house. We've called him but he's not here yet." It turns out that the only con-sed nurses at night were working in the ER.

Then they're like tugging on me, you have to sedate her right now because the baby's in distress (decelling?), they need to get that baby out. I have them page the house supervisor and I call down to the ER and talk to the ER doc......what should I do? What would you do? The nursing supervisor comes up......and I tell her that while I am con-sed certified, it in no way qualifies me to provide anesthesia during a major surgical procedure. The ER doc said, hell no, he wasn't going to do it, either.

Like I have any idea what agent to use for a pregnant patient and I just run around all day witha big bottle Versed and Fentanyl or Diprovan.

So now, they're really upset because I'm refusing to do the procedure, the nursing supervisor is telling me that I need to suck it up and that we do "what we have to do". Like try to kill people, I guess. At that moment, the CRNA finally shows up, *****ing and moaning because he had to come in and the whole thing becomes moot, thank God. I asked them what's the standard procedure if this happens and anesthesia's not there. Busy L&D dept, should have a contingency plan. "Well, this has never happened before." Anesthsia was able to successfully sedate the pt and both the mother and baby are doing fine, BTW.

But now I'm mad.....and in very acid tones tell off the CRNA and the nursing supervisor...and was informed that it's policy for the anesthesia provider to not have to be in house but must respond in 30 mins. When I told them what I thought of that, I was instructed to watch my tone or I'd be suspended.

Yeah. So, it's time to hand in my 2 weeks notice. I looked up the con-sed SOP and photocopied the parts that clearly were violated as well as the part from the state law about anesthesia and wrote 2 letters to the CEO and director of nursing. I clean out my locker this weekend. "You can take this job and shove it....I don't work here no more......"

But let me put it you all......what's your policy for anesthesia providers in house? Do you think this is a reasonable demand to make of an ER nurse or in fact, any nurse? Is your ER routinely called to clean up the mess when other dept's screw the pooch? In this situation what would have been the reasonable and prudent thing to do?

If any CRNA's do read this, please comment, too.

[CIRQL8]

Wow!!

All I can say, in my institution, we have anesthesia in house 24/7/365.

Sorry you had to go through that...

-Dave

[Stitchie]

You know when they start that "watch your tone" crap that it's 'them' getting defensive.

We have anesthesia 24/7 also; if not an attending then a resident or moonlighter.

[carcha]

Hey, Calfax, time to go I'd say. What a dump.!

[NCgirl]

Oh my gosh, run like the wind!!! That hospital's admin needs to seriously evaluate why they're too freakin cheap to staff the hospital with a CRNA at all times....it's a lawsuit waiting to happen. You were right (if you want to keep your license) to refuse to be the anesthesia provider for that case. And please don't think all of us in anesthesia would catch attitude over that....I'm behind you all the way, even if it is only as a SRNA.

[BabyRN2Be]

Within the last month or so there was a thread over in OB/GYN nursing about a situation like this, and that they had to use conscious sedation for a c-section. Most agreed that they would never want to be a part of something like that again.

I'm sorry that this happened to you, and it sounds like a good time to get out.

[Calfax]

Glad to hear there are like-minded people out there......

However, for the sake of argument....let's say you had to do an emergent C-section......what would be the drug of choice for this? It would have to be fast acting, fast to wear off, and not affect the baby as much as possible. Also, if the mother's not hemodynamically stable.....what do you use then?

My hunch would say Diprovan because it wears off so quick or maybe Etomidate.........but I don't know what the pregnancy catagories would be....have to cruise on over to the OB/GYN threads, thank you.

[luanne123]

WOW, that totally sucks. Don't forget to send a copy of your letters to the state board of Nursing. Would be interestong to hear what they have to say.

[LynneCRNA]

You were right to refuse. I was taught that if there was a crash section and anesthesia wasn't available, the OB can do the procedure under local. Can you imagine the outcome had the pt. been "con. sedated" and lost her airway or aspirated? In my hospital there is a CRNA and MDA in house, with backup call at home. But, in many small hospitals, call is taken from home and each hospital establishes how quickly the response time should be. Usually 30 min. or less.

[veetach]

WOW! What a nightmare! First I would like to say that you did the right thing. I am con-sed credentialed also, but would never EVER give con-sed for a general surgical procedure. That is way out of our scope of practice and I can guarantee you that no one would attempt to support you if something went wrong.

In our hospital, situations like this are handled by the house supervisor. Anesthesia is called in. They usually dont like it, if it is after 9:00pm but thats their problem. They are required to come in.

I think that resident should have been a little bit more in control of the situation and called Anesthesia in sooner than he did. Thank goodness the outcome was good.