Scary Endoscopy Situations, Opinions Please

[Babs0512]

Hello, I work PACU, but I also rotate to Endoscopy. We have a couple of Doc's who routinely do what I consider unsafe scopes. Example #1: Elderly man, took his prep so therefore comes in slightly dehydrated for a colonoscopy. Per protocol, we put him on the monitor to get a set of VS, and pre-procedure rhythm strip, start IV, teaching, etc... Noted this man is in a pronounced sinus brady with a HR of 30 bpm. He is pink/warm/dry, alert, BP okay. So basically, asymptomatic. From what I could read of his H&P, his HR in the Doc's office was 60. So, I question the doc about the safety of doing a scope on this man, considering we will be stimulating his vegas nerve and possible make the bradcardia worse? I suggest labs to check his lytes, and at the very least an 12 lean EKG. Was told "Nope, he'll be fine". I wasn't the nurse in the endoscopy room, I was in the prep area and then we'll get the patient after the procedure for recovery. I talked with my nurse manager who spoke with the doc - I got the feeling from her she was going to back down on this case. Was I wrong???

He was given 125mg Demerol, and 10 Versed during the procedure. His HR actually picked up during the procedure, but his BP bottomed out afterward primarily due to meds. The Endo Doc suggested he follow up with his PCP for his low HR. So, this case turned out OK - but I still think it could have been disasterous, and wasn't in the patients best interest to go ahead with the scope without a basic workup.

2nd Situation in same week, different Doc. Patient again elderly, Hx of MI's, Triple bipass, cardiac output 25%. Also hx HTN, NIDDM. Doc scheduled him for a colonoscopy. We again had concerns that fell on deaf ears with our nurse manager. We wanted the patient to be done in the OR with anesthesia involved to properly monitor the patient, but the ENdo doc said no. The group of us working that day discussed it, our boss was off, so we called the critical care educator and got him involved. He agreed with us. This patient needed pre-op testing and proper anesthesia for this procedure, not gorking him with meds. He spoke with the DON, who told the Educator to call the ENDO doc and discuss it with him. The educator "Fred" spoke with "Dr. Spock" and the conversation went something like this: Hi Dr. Spock, this is Fred, the critical care nurse educator at the hospital. We have a concern about one of your patients for monday. "Fred" went on the explain the concerns - "Dr Spock" said "no, we will do him in Endo as planned". "Fred" said, well sir, your could do that, but you will be doing it alone, as the nurses are refusing to help you." Dr. Spock stated "Which nurses?" Fred said "that's irrevelent, we'd like you to speak with anesthesia about setting this up as an OR case and get back to me." A bit later, Dr. Spock called Fred and said "I spoke with Anesthesia, they assured me it would be okay to do in endo suite" Fred said "well, I guess I'll just go upstairs and talk with anesthesia and make sure that is the plan." So Dr. Spock backed down, and the case was done in the OR with a good outcome.

So, here is my concern: If you have a concern about a patient, and your co-workers are giving you a hassle "come on, lets just get this done!!!" How many of you feel comfortable bucking the system and standing your ground?

What would you have done in the above situations?

It must be noted, these Endo Docs do their H&P's over a month in advance, but don't date it until the day before the procedure, so they break procedure all the time (we've reported that too).

Thanks for the vent, looking for some sound advice.

Much thanks

[BelleKat, BSN, RN]

Yikes,that is scary,especially about the man w/ HR in the 30's. That's downright unsafe which is what you're saying.

You walk a fine line when you buck the system,I'm sure to an extent your management appreciates that you care so much and they want to retain you. But if the doctors who refer there start being jerks and say they are going to do this,they have always done this,etc it's them or you nurses it could get dicey. I don't really know how it is there.

I've stood up to doctors for pts plenty of times,I worked in a large teaching hospital and was charge,most residents were fine but a few I had to protect the pts from. Keep the dialog open with management,how you appreciate their backing you with the second pt and how you plan on staying there and are happy.

I hope that helps,keep advocating for your pts,you probably will be saving a few lives.

[icyounurse, BSN, RN]

I definitely agree with you that those situations sound unsafe and I would have certainly questioned the doc on both occasions. I am surprised the doctors don't want to cover themselves better, I mean running a 12 lead and checking some electrolytes wouldn't have taken very long. Better safe than sorry.

[mpccrn, BSN, RN]

i agree, covering your butt and standing up for the patient is your prime objective. having said that, it's ultimately the doc's call. if you are giving conscious sedation, you as the nurse are qualified to deal with adverse effects......preps are brutal especially on the older population and they will need added attention. i've seen the sedation used in these procedures increase over the last few years. is "unconscious" really necessary? perhaps a lighter sedation will render both the patient and the procedure in safer grounds for all concerned. people lived through these procedures long before unconscious was the norm.......just a thought

[RN1989]

i agree, covering your butt and standing up for the patient is your prime objective. having said that, it's ultimately the doc's call. if you are giving conscious sedation, you as the nurse are qualified to deal with adverse effects......

This will not hold up in court. If a nurse allows and even assists with a procedure that is contraindicated, that nurse could still be liable for an adverse outcome. Saying "The doctor gave me an order" is not an excuse for using good nursing judgement.

A staff nurse should be following the chain of command all the way to the chief medical officer and CEO if they believe if they believe that the pt could be in danger. Should the CMO and CEO still insist that the doctor is correct, it would be safer for the nurse to refuse to participate in the procedure and let someone else do it if anyone is willing.

[ToxicShock]

Kind of off topic, but I have gotten endo procedures before where I have been conscious and unconscious. I prefer to be completely out because it is so much easier, and more comfortable for me.

[Babs0512]

Sometimes with Versed, people THINK they were completely out, because it is a hypnotic and amnesiac, so they don't remember.