Be-littling CRNA's

stevierae · Dec 30, 2004

The way I look at it is when the patient gets into the OR we hook them up to the monitors, no one else and this is the way we prefer it. When we bring a patient to PACU, it's the nurse's territory and usually they have a routine or things they like done first.

Yeah--it just depends on where you work-- you are correct; there are PACU nurses who tend to be pretty territorial--they have their routine, and they don't want anyone disrupting it--they want no one touching their patient. On the other hand, there are those who act all passive-aggressive if the CRNA doesn't help them hook the patient up to monitors while simultaneously giving report. They just need to understand that people are not mind-readers, and, if they want help, just ASK!

I used to work in an OR where it was all private anesthesiologists. We (the circulators) took the patients to the rooms, hooked up all the monitors, and started the IVs in the rooms. THEN, and ONLY then, did we call anesthesia (via intercom) from the lounge. If they came in and something wasn't done, they might say, "Why isn't this patient monitored?" or "Why hasn't the IV been started?" Then they would turn around and leave, saying, "Call me when you are ready." The cool ones would just go read the paper and wait for you to call. The ones who might otherwise be cool but might not like a particular nurse (or were having a bad day) would complain to the OR supervisor, who would later call that nurse aside and "counsel" her because "Dr. so-and-so said you called him to the room, and his patient wasn't monitored."

I am not complaining--that's just the way it was at the place where I worked, and everybody there did it that way--we knew the routine, and we followed it. Imagine my surprise, then, when I was yelled at when I transferred to a place where there were CRNAs, and they preferred to hook up their OWN monitors, as you've described--my first day--"I DON'T KNOW WHERE YOU WORKED BEFORE--BUT HERE, WE PREFER TO HOOK UP OUR OWN MONITORS." And at the new place, the pre-op holding area RNs were very territorial about starting their own IVs.

I agree--can't we all just get along?

Marie_LPN, RN, LPN, RN · Dec 30, 2004

Not a CRNA, but i will say that respect is supposed to be a mutual thing. Treat others the way you want to be treated. Remarks like "Those circulators really think they run the OR and anesthesia" only add fuel to a fire, not to mention it's rude (although, what is true that the circulating nurse IS in charge of the room). If someone makes a comment like that, they shouldn't be surprised at the response they get, and vice versa. :)

I would ask "can't we all just get along?" as well, but i already know the answer to that one.

CRNAMASTER · Dec 30, 2004

Traumnurse,

I appreciate your point of view. I am sure there are rude people on both sides of the fence. I can say I wish it would get better but there are always going to be people who are resentful and jealous. Thanks for your response

stevierae · Dec 30, 2004

Have any jobs open stevie ???
lol

You mean, for CRNAs? If you are serious, you should check out Kaiser in Oakland, CA--those CRNAs are independent practitioners--and the anesthesiologists do not try to micromanage them--I mean, each has his or her own room, and an anesthesiologist is just as likely to come in and ask a CRNA to consult with him as vice-versa. I did a travel assignment there a few years ago.

It was a fun place to work, but, like any teaching hospital, the work was non-stop. No trauma, no hearts, but plenty of vascular, thoracic, big ortho and spinal instrumentation cases.

stevierae · Dec 30, 2004

I dont mind to help out but it really annoys me especially in the OR actions such as tieing everybody up and hanging irrigation and raising the bed or moving this or that. (Hello people, I have a job too. The BP is 60/49 but lets stop and tie up the scrub tech.)

LOL, if the BP is 60/49 before the scrub tech is even tied up, maybe that patient should never have been brought to the room in the FIRST place--or, maybe he's had a bit too much pre-op sedation--or, maybe he's just having a vagal reaction and you need to put the bed in Trendelenberg and turn up the IV fluid anyway.

In any case, the controls are up at the head of the bed, so it only makes SENSE that anesthesia is the one who can raise, lower, or tilt the table!

And, if the scrub tech needs to be tied up, ask him to BACK UP to you--that is, come up to the head of the bed--YOU don't need to go to HIM!

Or ask him to break scrub for a second and help you with the O2 or whatever is needed for your hypotensive patient (and where is your circulator, anyway?)

Or, just say you are busy right now--he can wait a second or two until the circulator comes back, and then SHE can help you BOTH--it is, after all, her JOB. It's not like the scrub can start the case anyway until your patient is stabilized, so what's his big rush about getting his back table set up? Good chance for him to learn a little bit about setting priorities--heck, the case might need to be cancelled or postponed.

Man, some of the anesthesia providers I've worked with are just the opposite--they are TOOO helpful--to the point of trying to be Mr. or Ms. Circulator--that is, you go to put the Bovie pad on--they've done it, sometimes wrong--as well as adjusting your Bovie at the wrong settings, which you have to change to the proper ones--you go to put SCDs on--they've done it---you go to open your prep tray or Foley--they've done it---they give your scrub suture, but they don't add it to the count board or tell you they dispensed it---mostly, I just think to myself, "Whatever. As long as the work gets done..."

I have been lucky; everywhere I've worked, we all try to help each other out in any way we can, without getting on each others' nerves or overstepping boundaries we perhaps didn't even know existed. It's all good.

jwk · Dec 30, 2004

Just FYI--argue with this all you want, but it happens to be the truth--THE CIRCULATOR IS IN CHARGE OF THE ROOM. Don't believe me? Ask your OR supervisor, or an older anesthesia provider--better yet, ask AORN.

Hmmmmmmmmmm, let me ponder that statement.............. :)

Nope, sorry, but I'll respectfully disagree.

The circulator is responsible for his or her actions, and possibly the scrub tech. Although they might be in charge of the nursing functions that take place within the OR, IMHO it's a stretch to say they're "in charge of the room". I'm responsible for my own actions.

Yes, I know, the circulator can control lots of things, in one way or another, just as the managers do above them, yada, yada, yada. But the physicians and anesthetists do not take orders from the circulator, and in particular, are NOT bound by AORN standards. The circulator is no more "in charge of the room" than the surgeon is "captain of the ship".

You're right that the key is teamwork - we all work together. Absolutely no argument there.

deepz · Dec 30, 2004

.....the circulator can control lots of things, in one way or another, just as the managers do above them, yada, yada, yada. But the physicians and anesthetists do not take orders from the circulator......

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

rn29306 · Dec 30, 2004

Hmmmmmmmmmm, let me ponder that statement.............. :)
Nope, sorry, but I'll respectfully disagree.
The circulator is responsible for his or her actions, and possibly the scrub tech. Although they might be in charge of the nursing functions that take place within the OR, IMHO it's a stretch to say they're "in charge of the room". I'm responsible for my own actions.
Yes, I know, the circulator can control lots of things, in one way or another, just as the managers do above them, yada, yada, yada. But the physicians and anesthetists do not take orders from the circulator, and in particular, are NOT bound by AORN standards. The circulator is no more "in charge of the room" than the surgeon is "captain of the ship".
You're right that the key is teamwork - we all work together. Absolutely no argument there.

You should run for office one day. Your answers here and there (you know where...SDN) are always dead on.

stevierae · Dec 30, 2004

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 · Dec 30, 2004

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 · Dec 30, 2004

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 · Dec 30, 2004

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