ewattsjt

sounds like prone to me too. even if the pt is positioned correctly but the case is a real long one like multilevel spine surgery, the duration of being prone for so long can do that.

I have no suggestions. Ours is about the same, when it gets nasty enough someone will go through it. I typically do not use ours because it is always so nasty. I bring a large lunch box and leave it sit in the break room. A couple of us do that. Our microwave is in about the same condition but people will clean it more often. There are always signs requesting for the people to clean after themselves. Isn’t it odd that our staff has great patient care and an excellent performance in the surgical theater but they struggle with such simple tasks? I think MamaCheese's facility may have the answer.

It simply takes practice. I am right handed but pass with either hand depending on where I am standing and the where the doctor/assistant is standing. In fact on many occasion, I will be taking one instrument back with one hand while passing to the surgeon with the other. Hand on top is simply a bad habit and you will get used to passing with hand underneath in time. I know that we are supposed to use neutral zones but not everyone does nor is it always possible. If hand is on top while passing suture, you run a huge risk of getting stuck.

We just underwent changes this past fall. My facility had a group of analysis’s come in and audit us to make sure we were within The Joint Commission’s guidelines. A couple of changes that were made were that all our liquids IV or pour are now locked up to prevent tampering and if pour water or NaCl goes in the warmer, it is labeled for 2 weeks out. IV solutions such as Dextrose or Ringers are kept for 48 hours in our warmer because they said that there is a breakdown of electrolytes when exposed to the increased temperature. I never saw the data that reflected our change but assume it is correct.

We do for cases expected to be close to 4 hrs or over. Also on certain procedures we do an in/out to reduce the size of the bladder. We do not do Foley as a routine because of the possibility of UTI.

eent is simply eyes, ears, nose, and throat. it is hard to say with certainty but there should be a lot of different things like for eyes; phacoemulsification and other types of iol replacements as well as retinal banding to blepharoplasty. ears; myringotomy to tympanoplasty to inner ear procedures. nose: deviated septum repair to endoscopic sinus surgery to a balloon sinuplasty http://www.entclinicofiowa.com/sinuplasty-balloon-sinuplasty-video.htm throat: t&a to thyroidectomy to on rare occation something like zenker's diverticula. http://www.nature.com/gimo/contents/pt1/full/gimo41.html to know for sure what they do, you should talk to someone that works at the facility.

My facility has 8, 10, and 12 hour shifts. 8 and 10 are typically day and 12 is typically second shift (lunch relief then finish any running rooms). Our rooms are staggered in shutdown times.

i think it is both not trusting patients, old habits, and lump everyone into one group so nothing gets confused. standard order for my facility is npo after midnight but in cases where the patient does ingest food, they fall back to six hours. i have seen where patients come in and did their npo. they didn’t have any meals but this morning they only ate one bacon strip, half a biscuit, and half a cup of coffee. wasn’t a meal so they were good to go. lol had one patient from the floor who thought the npo wasn’t a big deal and wanted to get their energy up for the surgery and had half a cheese burger before coming to surgery. if patients easily confuse npo with just a little bite of something then how do they react if you say it is ok to have water? it simply adds to their misconception of not being a big deal. the latest data reflects that 6 hr npo is sufficient in most cases. it is however easier and less confusing to everyone to lump everyone into the same group rather than saying that for this person it is 6 hr npo while this one is 8 and this one is 9 and this person can have ice chips or water while this one shouldn’t. the data also reflects that water up to two hours prior to surgery has no effect in most cases. one last thing in my opinion is why would a doctor risk a patient aspirating as well as a malpractice suit for the patients who fall outside this norm? especially when it is proven that npo after midnight works well and has been a standard for years. keep in mind that both the surgeon and anesthesiologist can cancel the case if the patient went outside their npo guideline. maybe the anesthesiologist agrees with 6hr but the surgeon doesn’t. here is a related link http://www.ncbi.nlm.nih.gov/pubmed/10172278

I would like to start by saying that many facilities have varying takes on flashing. The AORN recommends against flashing unless there is a real need to flash something. Before the patient is in the room the case can be delayed without much consequence to the patient. Once the patient has been given meds, it is typically better to run the case than to recover and try again (not only because of the meds but also psychologically as well). Sometimes it is a legal issue too (if they started and aborted-some facilities consider it a new case and the patient can’t sign another consent until after 24hrs because of the meds administered). Central’s autoclaves are set up somewhat different (some are pulse pressure) so while they do similar things, they work on a different scale and sometimes a different system. Two types of flashes are gravity and prevacuumed and the autoclaves are either in a sterile core (where the scrub can retrieve it directly or in another area where it is transported in a pan). As you can see, the second doesn’t really make sense unless you do not want to keep the patient under for an additional 20-45 min. (depending how central’s flash is set up). Ideally, flashes are: gravity for single items and batteries, prevac. for items with lumens or several items ran together (typically 4 or 5). Flashes like in the surgical unit are not designed for the entire set (regardless of how it is used) so full sets should be ran through central. Implants can be ran in a flash on the unit but it has to be prevac. and biological has to be ran with it. Once again this is recommended against unless in a pinch. This is a matter of weighing additional gas time against chance of infection. Facilities base what they do with flashing on the entire recommendations of groups like IAHSCMM, AORN, The Joint Commission, etc.. . There are many more reasons and much more detailed explanations but what I listed is the basics. While this didn’t really answer your question, I hope this helped you to understand that there is more though in the process than sometimes we can and other times we can’t and why it seems to vary in different facilities!

My facility is great and rarely sends pts. with jewelry or undies. If they do, there is a good reason.

As Linda stated, ask your facility. A part of the RNFA is getting an agreement (MOA) between the school and your facility to do an externship there. Most facilities who allow it will also allow you to get the cases while working. That is not a given and you may have to do the cases on your own time (slight probability but still could happen). A requirement for the RNFA programs is to be a CNOR or at least eligible to sit and pass before the program is completed (and a passing of the CNOR exam before the certificate is given). You have to check with the school for that one. A requirement of eligibility for CNOR is two years in the OR. You stated that you are new to the OR so you have time to work it out with your facility. Best of luck!!!!

A gown left tied can lead to pressure sores from impeded circulation just as and unpadded boney prominence so regardless of positioning, the gown should be untied and pulled from underneath because of possible bunching. Typically this is best accommodated while the patient is still conscious. It may have been done while you were conscious but you don’t remember that part because of the Versed. If you were positioned prone, the same rules apply about the gown bunching and it should be removed (my facility waits until the patient is unconscious because of embarrassment but maintains the patient’s dignity and covers as soon as positioning is completed). Bruising on the elbows can range from unpadded boney prominences to a combative patient to you simply bruise easy. There are too many variables to speculate on this.

Just playing devil’s advocate---what constitutes a stable patient after surgery. We all know and have seen patients crash in the blink of an eye. How defendable can the tech be if their patient crashes while they were on an unrelieved break? How defendable is the RN who sends the tech or allows it? The team is supposed to respond during a crash, everyone having their jobs that may be as little as grabbing a crash cart (but a big part) or calling out of the room for help while the others administer CPR. How big could a wrongful death be against the team? As I have posted before, the tech can and sometimes is made an example but in law suites, they tend to go after the docs and nurses more because they tend to have more $$$ and a license to loose. We have a vascular doc that does not have the techs to stay sterile or maintain the backtable in carotids. His reason is that he always does testing that takes about 45 min. and he wants a new setup if he has to go back. If I scrub with him on one of these, I maintain the field. Part of being able to defend in court is if it is reasonable practice (is it done that way in other areas (sometimes regionally and sometimes nationally). I know that the standard is to maintain the field so I do it to protect the team and every time the doc acts like I am a crazy man because I refuse. My point is that if something happens can you defend it in a court? If you don’t think you can, then you need to rethink what you are doing.

At my facility it is a big deal. The scrub is supposed to assist in the transfer of the patient. The patient always is the first priority.

Also if you are thinking of going further with your education and possibly into different areas. The general nursing degree is better for that ASN/ADN or BSN while the surg tech programs are diploma and associate. The advancement opportunities are limited for the surg tech. They include but are not limited to central supply, decontamination, materials management, sales rep., instructing, etc. while the RN can typically transfer to almost anywhere in the facility and if BSN or higher go into instructing etc. Most the facilities in my area pay RNs about a quarter more than techs (Ie. If the tech makes $15 hr to start the RN will make about $20. So as you can see, there would be more money made as well as more advancement opportunities. A downside is like at my facility; the RNs are allowed to circulate and scrub but seldom get the chance to scrub as that role is typically filled by CSTs (policy that surg techs have to make certification within a year of graduation). One would rarely get the chance to scrub unless they became a CRNFA or there were staffing issues. Having said that, places are different across the US and these are generalized statements and area specific statements. You should check for what the differences are at the facility you are looking at. Managers typically will talk to potential employees.

It should be disposable or reusable following the manufacturer’s directions as well as facility policies. Also it should be reported to the proper chain of command and followed up. I am sure that infection control or whatever your equivalence is would love to hear about that. Alcohol doesn’t kill all spores and is ineffective against certain microbes such as C. diff. We use it for surgical foam in when scrubbing because microbes on our hands are reduced to an irreducible minimum meaning that some are still there and thus we wear sterile gloves protecting both ways. The alcohol foam is only to be used after an initial scrub. It is not to be used after restroom breaks, eating, leaving the OR suite etc.. because it is not as effective as people think. So even if it was allowed; alcohol would not be the proper agent. Even the laryngoscopic blades that anesthesia use are sterilized between patients or used as disposable (at least that is how it is supposed to be). T&A instruments, sinus instruments, myringotomy sets, cysto instruments, etc are supposed to be processed sterilely between patients even if it isn’t a sterile procedure because of the possibly of cross contamination of harmful microbes. I personally can’t see why a laser fiber optic would be different.

I have no idea of what the incidence difference between the two departments are. I can say that in at my facility in the OR there is a lot of moving patients, positioning for the procedure (lifting legs into stirrups, rolling the patient laterally or to a prone position) as well lifting instrument sets and moving equipment in and out. If you are at a facility where the RNs scrub, you may also be scrubbed in on long cases. We have a spine surgeon whose quick cases are four hours and his longer cases are over a shift. So it would be standing except lunch. I have had a couple of spinal fusions and no matter what I do; his room on long cases kill my back. Sometimes if you are scrubbed, you simply have to use poor body mechanics. We have on GI doc that when he is doing rectal cases, he positions in Lithotomy and he sits while you stand over his R shoulder and retract, pass, assist, etc.. There is no way you can maintain good body mechanics. Does your facility offer cross training? If so, you could train there to cover overtime or call and see if it is better on you. If not, ask if you could shadow a couple of days to see if you would like it (if it would be easier on your back). I wish you well on your decision.

I don’t think techs should be licensed to give them more clout or bigger paychecks. They should be licensed to hold them to a high standard that is enforceable and regulated for the safety of the patients. Right now a tech can screw up in one state and move to another (sometimes a different area of a state) and begin practicing again. This should be stopped. The way to hold them more accountable and to the high standard is through licensure. The AORN in some states are lending support to make sure the techs have to attend a formal accredited program and to have the CST certification (mandatory for entry level for scrub). I feel that licensing the techs does not take away from the RN any more than a LPN/LVN does (even though some states do need to bolster their current laws in regard to what the RN does in surgery). It simply holds the techs to a regulatory body that oversees that profession.

As coreO stated, the Surgical Assistant and Surgical First Assistant are the same term. It is the position in the field. Surgeons, NPs, PAs, RNs, CSTs and LPN/LVN can all perform this role. There are some states that have regulation on the practice of assisting while others have nothing. So check with state law and facility policy. The only assisting titles for the CST that is recognized by the Association of Surgical Technologists (AST) are the CFA (by the NBSTSA) and CSA (by the NSAA). If someone calls themselves a CST/FA or CST/SA their professional organization does not officially recognize it. To be a CRNFA an RN has to hold a bachelor degree (in anything since Aug of this year), passed and maintain CNOR, assisted in 2000 documented case hours, and of course passed the certification exam (by the CCI). The RNFA has attended the program but does not meet ALL of the above requirements. CNOR eligibility is typically required for the admissions and most require CNOR pass by completion of the program. LPN and LVN are also eligible for the CFA or CSA exams if they attended a CAAHEP program which typically requires a couple of years in the OR. In certain areas of the country such as mine, not anyone can scrub. All the facilities around me have policies that require new hires for the scrub role to be RN, LPN/LVN with 2 years proven OR experience or a CST (pass exam within a year). I think South Carolina just passed a law that requires one to be a CST for entry to the profession.

My facility uses surgical technologists to scrub and assist. Only when there is a staffing issue does an RN get to scrub except for a CRNFA who assists.

In my area, the word of a CST is carried with the same weight. I guess it goes to different ideas of the level of professionalisms and education standards in different areas of the country. In my area the RNs are mostly associate and the majority of techs are associate as well. The prereqs are the same (A&P, Micro, Chem, Psychology, Microbiology, Pharm, etc...) the difference being the core classes NUR or SUR. It is typically also recognized that the ST program focuses on surgery only while the NUR program only does a two day observation in surgery and all other experiences are learned on the job as the RN orientates. When I started the last post, I said that with the exception of a few states... What that means is that CA, NY, and WA have laws that specifically address the role of the Surgical Technologist and Surgical Assistant. There are other states that see the need for education of the tech as well as some kind of regulation (mandated accredited education, certification, etc). There are also many states that have absolutely nothing except requiring an RN to fill out documentation or requiring an RN to be in the room. This information can be found on the AORN website and one can see where the AORN thinks that the laws in regard to RNs in the OR are good, need to be reworded, or need legislation because none exists. While I agree that there is a pecking order; it is not that cut and dry for the majority of states. Here is a good example where I work (which has no law in regard to the scope of practice for surgical technology or assisting). Most of the time (unless there is a staffing shortage) we have an RN for the circulator, a CST for the scrub role and we provide an assistant to the surgeon which is a CST or CFA and we do have one CRNFA. During turnover and setup, the techs and/or CRNFA are under the supervision of the circulator because someone has to coordinate and it would be disastrous if everyone ran around independently doing their own thing. When the patient is brought into the room, whoever is assisting will second circulate which is also under the supervision of the RN but when it comes to positioning and prepping, the assistant is responsible for making sure the surgeon's preferences are carried out. Once the procedure has started it is impossible for the circulator to document, keep assessing the patient, run for needed supplies, etc and supervise the techs. While it sounds good, in reality it is impossible. The surgeon is the person supervising at this point. Moving to the assistant; an assistant in Indiana can cut tissue, ligate vessels, use ESU or chemical hemostasis, etc, etc, etc, under the direction of a surgeon. They can do a saphenous vein harvest while the surgeon works on opening the chest and preparing the heart. They can also close all body planes except closing a cavity itself which the surgeon must do. During the closing of surgical procedures the surgeon has to be immediately available which means that they have to be in the surgery unit (PACU, Lounge, Dictation station, etc...). Given this assisting scenario, it is clear that the assistant is under the direction of the surgeon during the procedure. As the staffing of one RN and two techs has become the norm for my facility, most RN's hardly ever scrub if ever at all. They have to scrub for a week during on orientation and typically only hold retractors but that is it. How can someone supervise if they have no clue to what is actually happening? I have also seen where the RN doesn't know their medical terminology enough to know what procedure is listed. How can they supervise a case they simply don't know? I don't want to sound disrespectful but most our RNs don't even know what instrument sets are needed for what case. They do know were they are kept. How can one supervise another's performance with out knowing what the case is about, what instruments will be involved, etc.. Having said all that, the RNs and CSTs where I work have a great relationship and function as a team for the best outcome of a patient. There really isn't a RN-CST divide. We each know that we contribute our special knowledge and skills of each profession for the best outcome for the patient. This will probably be my last post to this subject as it is one that has been around for ages and it keeps going in circles.

This reply is only for the USA as laws and guidelines in other countries vary. With the exception of a few states, during a wrong count the ST or CST is held just a liable as the RN. While there are some states with law with regard to the practice of surgical technology; most have no law governing the practice of surgical technology. In those states when a suite if filed; everyone who was in the room is named and things are sorted out during depositions. Since there is no regulatory boards for surgical technology (most states do not even require program accreditation or certification), they are sometimes dropped but also sometimes fried as an example. Typically the tech is dropped because they do not have anything worth going after. The RN has a license and is regulated by a board in every state. They have rules that must be followed and the AORN recommended standard of practice is what is used for acceptable duties if no law or facility policy states what is in question. Since the RN has a license (something of value to loose and typically more malpractice insurance because of it, they are a better target (like a surgeon is a better target than a RN). If a ST or CST is named in a lawsuit for most states; it is not the end for them as they don’t have as much to loose. They can simply move and take up the practice again (may have to be in another state) because there isn’t much regulation across the country with this profession. Getting back to my point--- They are named and are responsible but not typically sought after.

I have to agree that some docs want the same staff because in their minds, the room runs smoother. Because self-fulfilling prophecies will make or break the surgeon; they should get their room. BUT---When it is the room staff that is dong the “my room” or “my doc”, it kills me. We have some people who would place setting someone up in “their room” over being a patient advocate. I don’t have a favorite but I am assigned to a few most always and others say that they are “my doc”. As a patient advocate, when someone gets one of my docs and if I can; I try to have everything on the case cart the doc’s whiney butt could ever ask for so that the patient receives the best care possible.

hate that line and would love using that response just once!!!

No offensive taken with me. I only make $2 hr on call too. It doesn’t pay for my gas there and back, let alone meals. We are a small facility so if we do not have any cases (which sometimes happen), it is only the $2 per hour. So I actually sometimes loose money when on call. The other thing is that there is not any work at giving call away. I simply place a sticky on the call list stating anyone wanting my call can have it and it goes within a week. I don’t worry about loosing my skills in other specialties as I am the person that gets moved and dumped on like no tomorrow. No one has done one??? It has been years since one has been done here?? The new person is uncomfortable?? No one has done one with this doc. The scrub in the room feels queasy?? Etc….They pull me from my room and send me in, so I get my fair share and then some. LOL