Be-littling CRNA's

forane2001 · Dec 30, 2004

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.

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 · Dec 30, 2004

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 · Dec 30, 2004

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 · Dec 30, 2004

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 · Dec 31, 2004

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 · Dec 31, 2004

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

Mike1991 · Dec 31, 2004

I apologize to everyone who read my posting. What I meant to say isn't actually how it appeared. Once again I'm sorry.

athomas91 · Dec 31, 2004

as an SRNA i have encountered (already) great circulators and great PACU RN's as well as very very bad ones...

i don't know if this will be helpful or not - but recently i have started writing on the PACU paperwork (time of arrival - meds i gave - fluid in/out - blood loss etc) while the PACU RN's are hooking the patient up - they are very appreciative and can focus on hooking the patient up as well as patient assessment without having to immediately chart -

i find it shortens my time as well - as my report is mostly already written for them -

it has cut the time i spend in pacu down drastically.

versatile_kat · Dec 31, 2004

as an SRNA i have encountered (already) great circulators and great PACU RN's as well as very very bad ones...
i don't know if this will be helpful or not - but recently i have started writing on the PACU paperwork (time of arrival - meds i gave - fluid in/out - blood loss etc) while the PACU RN's are hooking the patient up - they are very appreciative and can focus on hooking the patient up as well as patient assessment without having to immediately chart -
i find it shortens my time as well - as my report is mostly already written for them -
it has cut the time i spend in pacu down drastically.

That's a great idea ... reminds me of when we would admit open hearts and about 5 people were giving report (chest tubes, pacing wires, lines, etc.) and one person was outside the room writing everything down while the primary nurse was hooking the patient up. I'll remember this when clinicals start and see how it's received. Thanks for the advice!

- Kat

deepz · Dec 31, 2004

..... a CRNA or an Anesthesiologist has to be a good nurse before they can be good Anesthesia Providers...

Hear, hear.

http://www.gaspasser.com/unique.html

deepz

Pete495 · Jan 1, 2005

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....

I'll be honest, I'm a pretty seasoned Open heart RN, and I'm not familiar with Red Man's Syndrome either, and I give Vancomycin about every other day. I think I may have heard of the syndrome associated with vanco, but that's it. I have to agree that I've never seen a low blood pressure associated with vancomycin, but I also respectfullly agree that you know more about it than I do. I don't think it makes her clueless or stupid however. If you educated her on the finer points, and gave her the appropriate rationale, than you did your job. If she is ignorant to your rationale, than her ignorance is what makes her stupid.

Maybe you could enlighten us youngbe's on Red Man's Syndrome anyway?

Thanks in advance.

jwk · Jan 1, 2005

I'll be honest, I'm a pretty seasoned Open heart RN, and I'm not familiar with Red Man's Syndrome either, and I give Vancomycin about every other day.

Could be because "Red Man's Syndrome" is just a slang term someone has come up with. I doubt you'll find it in a medical dictionary or textbook.