Did I do the right thing??

[Loxam10]

Ive been a nurse in a pediatric OR for two years now. Friday was one of the most difficult days I have ever had, not because of a difficult case but because a situation arouse and I did not feel supported by my management. I am sorry this is so long but I feel like you need all the details.

We were doing an excision of a scalp lesion on an otherwise healthy teenager with an ENT doc. Prior to me coming into the room the surgeon told the orientee scrub tech that this was just a clean case and he could use wall gloves to set up. This was brought to the attention of our charge nurse who spoke with the surgeon. The surgeons arguement was that this was not a big belly case or joint replacement, it did not need to be sterile. Charge nurse tells him she is making an executiive decision, the set up needs to be scrapped and start over for a sterile case.

I picked up the patient and now the orientee has been relieved by a very good/veteran scrub tech. The case is set up in a sterile manner. I prepped the patient with hibiclens and the surgeon is scrubbed/gowned. He asked me to lift the head so that he can place a sterile towel underneath. He then begins to place the split drape and in the process grabs the anesthesia circut and places it on top of the drape. The scrub tech and I look at each other in confusion and she says "Sir your glove is now contaminated". He responds "I know. This is not a sterile case, its ok." I immediately call my charge nurse back into the room. I tell her what happened and she leaves to go get the director of our department. A minute later she calls into the room and says "Do not let him proceed, do not hand him anything, we are coming." Surgeon asks for the local and we inform him of what we have been told, you can see the confusion and irritation on his face. Less than two minutes later my charge nurse calls back into the room, "Per the director - Continue with the case but make sure you document his refusal to fix the contamination. We are going to report him."

At this point the scrub tech and I are extremely uncomfortable with this situation and I think the surgeon could tell. Thankfully he says "if it will make everyone happy we will start over and do everything sterile." Everyone agrees to this and we completed the case without further contamination.

Here comes my issue. The scrub tech and I have now been placed in a position we should never have to be in. After the case we went to the director and asked why in less than two minutes was the decision made to allow him to do a surgery knowing he was contaminated. We were told that sometimes you have to pick and choose your battles. She felt like the risk of the child being under anesthesia was greater than the risk of infection. That if the child came back with a wound dehisence or infection it would be on the surgeon not on us because we documented our disapproval.

Two things: This was an otherwise healthy teenager who had an uneventful intubation. For the director/charge nurse to come into the room and talk to the surgeon we are talking about adding less than 30 minutes onto the anesthesia time NOT hours. I spoke with the attending anesthesiologist in the room. He agreed with me that the risk of infection far exceeded the risk of anesthesia. This child was already asleep and stable. Second thing, in a court of law I would be liable too because I knowingly allowed the surgeon to continue after he was contaminated.

So our management team, the people who are always preaching patient safety over all else and saying they will always have our backs when we stand up to surgeons, were not there for us. They put us between a rock and a hard place. Yes it all ended ok and the patient was not harmed in any way. But we were put in a position where we would have had to decide to step away from the case (oh wait the patient abandonment and illegal) or knowingly allow a surgeon to put a patient at risk (also not good!). Being asked to be relieved/removed from the case was not an option since this was later in the day and the only other team was already in another OR (but that would put them in the same hard spot we were in).

I filled out an incident report like my director said to. I stated all the facts and noted my discussion with the anesthesiologist. Only problem is that those reports go directly to our management team. So I felt like I had to reach out to the medical director of the hospital and request a meeting. But now I am completely stressed out and know that I am really putting my neck on the line with going over their heads.

It just feels so wrong to me that they put us in that position and did not even have the decency to come into the room. Maybe its my lack of experience but I also cannot understand why they were ok with putting my patient at risk.. I know I did the right thing for my patient but did I do the right thing for me by escalating this?

[Rose_Queen, BSN, MSN, RN]

You never should have been put in that position, and I can't believe your management agreed to allow the surgeon to continue with a contaminated setup on an elective case where the patient was stable. What would your facility's infection control nurse say?

However, I doubt that your management is the only one who receives the incident report- I'll bet it goes to risk management before it gets to your management team. I would have contacted risk management before going to the medical director of the hospital- don't you have a chair of ENT surgery and then a chair of the department of surgery or at least the chair of the department of surgery? Follow the chain of command as well before going straight to the top.

[Loxam10]

Thank you for your response (I knew if anyone who reply it would be you!). We are a smaller hospital so we do not have a chair of the department. I realize now that I skipped the the CNO in going to the medical director. However, the medical director has emailed me back and said thank you for reaching out and gave me the contact info I need to be able to schedule an appointment with him.

So Tuesday I go into work and after about an hour of being there I get called into my directors office. For the next 20 minutes I get for lack of a better word attacked. She immediately started in on my about how my incident report was inappropriate, that I was intentionally trying to throw her under the bus. She did not understand what i was trying to protect myself from. If there was anything resulting infection it would come back on her because she told me to allow him to continue. I still disagree with this, I was the nurse in the room and I am the one signing that chart. In a court of law I could try to agrue that I was told to let him continue but at the end of the day I allowed him to. She wanted to know why I consulted with the attending anesthesiologist, that I do no answer to him, she is my superior. She wasnt sure why I was questioning her, she has been going this for a long time and brought up the fact that I started there as a new grad. Also if I was going to disagree with her I should not have but it in my incident report. I started to bring up my patients safety, she intrupted me saying "Dont you think I was thinking about his safety too?" She also said that she doesnt think she could trust me anymore.

I left her office after what felt like hours crying and feeling completed defeated. I tried as hard as I could to hide it but it was obvious I was upset and I still had about 10 hours left in my shift. The charge nurse that was originally involved pulled me aside to find out why I was upset. After talking to her I felt a little better knowing that I was not the only one confused about the whole situation. She believes there are politics at play in this and my director is mad because I made her look bad. She kept apoligizing for how discouraging this situation is. She doesnt understand the directors reasoning about risk of anesthesia being more of a risk than infection. Especially since this is the same director who allowed another surgeon on Monday to have a patient taken to the OR and put to sleep when the surgeon was not even in the hospital. The kid was asleep and waiting for the surgeon to arrive for 50 minutes.

So now im in my next predicament. I obviously am not in a good position with my director. So I could email the medical director back, thanking him for his response but telling him I have spoken with my director and am confident with the outcome. Which would not be true but it would close the situation and keep me from getting in more trouble. Or I could continue to meet with him in hopes that my director would not be allowed to be a bully and do this to any other employee. But i feel like this is a risky move especially being so early in nursing career. Im so confused.

[SQueenRN, BSN]

I'm curious why an ENT doc was doing a scalp lesion excision?

[Rose_Queen, BSN, MSN, RN]

I'm curious why an ENT doc was doing a scalp lesion excision?

Probably around the ear. My ENT surgeons will do excisions of periauricular lesions, and if it's behind the ear, then it very well could be in the scalp.

[Loxam10]

Sorry I did not see this reply. I'm not sure why an ENT surgeon was doing this either. The lesion was not prearicular. It was towards the top of his head in the middle.

[ggoodman]

you did the right thing. Politics are what they are and it sounds like you have the situation figured out. If you want to stay I would just keep working and not worry about it. All in all this is a fairly minor altercation in an otherwise crazy at times environment. document document document who told you to do what and when. It does not have to be on an incident report the patients chart is just as obtainable in a law suit and you as the OR nurse are subject to the higher authority of your superiors... charge, director, and even the MD. As long as you don't give the patient anything meds etc and directed on patient positioning and sterility and you document your covered.