BklynHeightsRN

Thank you so much for the feedback, all! Now I know I'm not crazy :-P I will discuss with Olympus if they could provide documentation on why this is best practice. At this point I have given her a verbal warning for insubordination (that's another topic!) and ignoring/refusing to perform my requests. I believe she is just reaching for anything and everything to claim I am wrong, saying there are certain things that are not her responsibility. I even offered to test the scope but told her she needed to make sure she does it in my absence if I am unavailable. She has gone so far as to put a 4x4 written with a sharpie "Don't Touch, thank you" It is a little too much! Thanks again!

Maybe you misunderstood. This isn't something you find in an owners manual and it has nothing to do with scope care, it is not even remotely a mandatory step. It is more of a common sense thing - to test all functions of the equipment before using it on a patient, and avoid having to fumble with getting different buttons or valves or an entirely different scope if you know what hits the fan (pun intended).

Hi all: I've looked everywhere and cannot find anything on recommendations for testing the function of the scopes before the procedure. We use compliance kits and I insist my technician put sterile water in the basin and test suction, and air/water after hanging the scope and connecting it. This is a basic responsibility of the technician everywhere else I've worked. She refuses and insists that it is not needed. I pointed out that we don't want to scramble for another scope if something is not working after the case has started. And she says that she has never seen that happen and if sterile water goes through the scope she has to reprocess it again. I've made the point that since it was taken out of the cabinet and placed in the procedure room, it would need to be reprocessed again anyway. Besides, the only reason it would be taken out of the room is if it failed the testing. She just refuses so I'd like to prove her wrong instead of just being the type of manager who says "it's my way or the highway." Thanks in advance!

Closed eyes doesn't mean unconscious necessarily. I get what you're saying though because when I worked in the ED consciously sedated patients were still in pain and much more responsive. I would just remember that these patients aren't in pain beforehand, and not even during insertion necessarily. Many people do it without sedation at all, and it has been described as an uncomfortable high pressure feeling. The sedation is just to keep them comfortable, and it is to allow for a better exam with a colon that isn't spasmotic. As long as the patient can make purposeful movement from verbal (or a combination of verbal and tactile) stimuli it's considered moderate sedation. Deep sedation is being able to do stuff we do under propofol, like move a patient in awkward positions sometimes to facilitate the passage of the scope, and lift their head up to tape their eye, etc. Basically, deep sedation is dead weight. Personally, given the amount of Versed/Fentanyl it sounds like the patients are getting, I'd be very surprised if they could not open their eyes if you loudly told them to and tapped them on the shoulder. When I have sedated patients for GI procedures, I usually tell them to try to close their eyes and relax and focus on the breathing as I'm pushing the medication. I'm not sure what to make of this (stop the O2?), but what I'm guessing is that you are uncomfortable with how quick the patient is being brought out? I think this largely depends on the setting because I've worked in one where the anesthesiologists bring them out to recovery as soon as the procedure is over, and I've worked a couple of places were the anesthesiologist prefers that they are somewhat alert before pushing them out of the room. All of these areas, however, were with propofol. With just fersed/fentanyl, I would be comfortable with getting the patient out as soon as the procedure is done, but that of course depends on the patient and what the policy is. It is very common to do a procedure and then try to flip the room quickly to prepare for the next. It is all about maintaining the "flow" because a difficult colon is just around the corner that can thrown everyone off. Okay, if the doctor wants to give an order and walk away while it's being carried out, that's up to him. I have no problem with that. However, I do not agree that the nurse should keep giving 25mcg/1mg every 3 minutes until the doctor waltzes back in to start the procedure. As the nurse I would not be okay with that, as it means more medication than is necessary going into the patient. So personally, if I had a doctor do this habitually, I would be forced to speak up. In terms of stopping the medication once withdrawal begins, that is very appropriate. Often, an anesthesiologist will do the exact same thing, unless the GI is going to take 30 biopsies on the way out or something. The discomfort is more during insertion, and withdrawal time usually takes less time (depending on the patient). Either way, you do not want to sedate the patient more as the procedure is finishing up. Giving and following verbal orders is fine in this case since it's dependent on real-time patient response. The doctor signing afterward is all you need. The important thing to look at is whether you're bothered by this common practice because it's not what you are used to, or is it because it actually poses the patient harm? If you are the nurse giving sedation, and you are not comfortable with the every 3 minute ongoing rule of thumb, then let the physician know when 3 minutes has passed and ask him to tell you each time. I would be shocked if any doctor turned his nose up to that. Did they not at least show you where the facility's policies and procedures can be found? You shouldn't have to go digging... you should know where to access it whenever you want. If your facility is performing endoscopy on ASA 4 patients, run for the hills. Have you personally seen an ASA 3 or 4? Methinks that GI doc has no idea what "ASA" is.

I'm curious who accredits your facility? AAAASF prohibits RNs (except CRNAs of course) from administering propofol. It is used in the ICU for intubated patients, but for outpatient procedural settings, I didn't think it was allowed so I'm just curious.

I applaud your seeking further understanding of your reaction! You seem to be considering every possible connection both on your own and your manager's end. You're right - she could very well be just eager, enthusiastic and even trying to flex her muscles and show her managers what she can do. If it continues to bother you, however, I wouldn't put your feelings on the back burner where they will simmer and simmer and eventually boil. I think you owe it to yourself and to her (maybe she's not aware) that you prefer she give you feedback in a different way entirely. It doesn't need to be about her age or inexperience, but as has been said, the respect (or lack thereof) of her discussions with you. If you focus just on the issue at hand objectively and for what it is, I think she'd be a fool of a manager not to listen and take heed. Best of luck - I hope it all works out for you!

I have some insight on the other side of things - I am a younger nurse manager than the people I manage! This was the case in my last job as well. I am 35 but have only been a nurse 4 years actually (career change). I think because I have a background in finance and am very comfortable with fast paced admin and financial analysis work, I have morphed into the role of nurse manager. Not to downplay my role or anything, but it's not like I manage a whole unit in the hospital with 30+ nurses and ancillary staff! My last job was managing 4 medical assistants and my current job is managing a technician and one RN. Of course I also do a lot of financial analysis, troubleshooting, planning and I maintain our accreditation, but in terms of actually managing people, it's not rocket science and is probably the least stressful thing of my job. However, all but two people I have managed have been at least 10 years older than me. Currently I am managing a nurse with his PhD in global health and he is seriously one of the smartest people I've known! He has wayyyy more experience than me overall, but I have wayyy more experience than he does in our particular specialty. Because of this, I include him every chance I feel he might learn something new. Only once have I had to speak with him about an issue and I waited until the end of the day, sat him down, and did it in the most respectful way, explaining where I was coming from and why what he did was considered wrong. I then realized that what he did was probably a result of his background in the ICU with standing orders, and asked him if this was the case - he seemed to appreciate that I wasn't implying he was an idiot and we both learned from it. I find that showing everyone respect and keeping an environment of teamwork and collaboration is important. I like to keep things relaxed and light hearted because, well, healthcare is just stressful enough! But I can myself keeping it too light and running into issues with people taking me seriously. I've had some issues with staff in the past, and even had to write someone up once, but we got through it and I am good friends with her to this day. If you consistently ask your staff "what do you think?" "what would you do?" "can you understand where I'm coming from?" in a sort of "help me help you" attitude (and actually MEAN it!).. it probably works out more often than not because they believe you will go to bat for them and do the right thing. I think it's also important to remain flexible - for example, I do everything I can to make sure my technician is comfortable with the supplies we order for her to use. Some of her requests have been a little unreasonable, but I have suggested and ordered samples of things that are similar and I can tell she appreciates me trying instead of just telling her "no, that's too expensive, we're doing it my way." Over the last few weeks we have been able to meet in the middle on certain topics and I find she comes to me with questions in terms of what I'd like her to do and focus on. I'm hoping I stay this lucky as the years go on!

haha! Rock on with yo bad self!

hahahaha!!

that's exactly what I was thinking as well! my job requires me to reposition unconscious patients and move stretchers with patients on them. I'm not saying she should give up on nursing but it seems like a very tough career to pursue if you cannot do chest compressions. Also, as someone mentioned, the mannequin is SO MUCH easier than a real person!

We effectively learn from failures, not successes. Yes, a medication error, but it's not like it was IV potassium chloride. Some people may say there's no difference but I disagree. For high alert meds I doubt any of us would take a verbal order, and we would confirm confirm confirm. I don't consider D5W a high alert fluid necessarily (unless maybe the patient were diabetic but even then, insulin can correct that, it's not like that patient would die from the error). The one and only time I made a medication error was in the ED when I gave the wrong patient a standard dose of PO Tylenol. It was also a verbal order from a PA and he also told me Bed A when it was Bed B. I know I should have, but I did not report it. I was so scared to! It freaked me out enough to learn from it though, that's for sure! I have only been a nurse 4 years, but I'm sure it will happen again at some point (though I will try my hardest to not let it)! I think the physician should also be sat down and debriefed. Physicians have just as much responsibility to follow protocol and not expect anything to be given without a written order. Far too many facilities just don't do this and the issues will continue to happen, especially among new and easily intimidated nurses. It is both party's responsibility in a sense and he should be alerted that it happened. He needs to think twice before barking orders moving forward and realize mistakes happen and it's his patient too. Another anecdote - I worked with a doctor who literally yelled and belittled nurses, and I even witnessed him throwing patient charts on the ground! He was an absolute monster! He was leading a code and I noticed that the rhythm had changed briefly from asystole and he screamed "YOU DON'T KNOW ANYTHING, THAT'S JUST PEA!!" Sure enough, the patient's pulse returned shortly after that, though he went back into V Fib and ended up dying eventually. It made me so livid that he tried humiliating and dismissing me like that! Everyone has a voice, especially in a code, and everyone is an integral part of a team. Anyway, I reported the incident to my ADN, and he pretty much just kept his mouth shut for the rest of my working there. He was still unpleasant to work with, but he was no longer insulting, so I have to think someone sat him down and explained his behavior was unacceptable.

totally agree - I am also short (5'2") and every clinical area should have a stool for instances such as these... and that's only if the patient is in the bed. It sounds like in the OP's case the patient was on the ground?

Oh my! It sounds like your colleagues were looking out for you but not thinking ahead, and neither were you. The IV fluid thing is something you should probably own up to. You technically stole from the ED and knowingly accepted them without a doctor's order (it's technically a medication). But your supervisor also advised that you lay down - were there any witnesses to this? Did any of your colleagues get written up for supplying you with the fluids? If the claims they are making are truly false, they sound really extreme and they are probably trying to push you out for whatever reason. I agree on getting your hair tested to show you have no substance issues, and deny the alcohol thing. Also, doesn't your state have a law regarding the maximum hours you're allowed to work consecutively? 5 consecutive days of 12 hour shifts, damn. If your manager approved that, he/she might be violating something. Best of luck!

I never worked in the OR but it seems like the same type of set up only not sterile, and no scrubbing or counting so that sounds like it's a plus for you. TONS of specimens, depending on the patient and procedure. There are a lot of technical skills to learn with obtaining specimens and doing injections, tattooing and placing clips, but I find it super interesting and not necessarily hard, just requires some practice. Depending on the patients you get it could be straight forward stuff or a little more complicated (endoscopic ultrasound, fine needle aspirations, ERCP, etc.) In my experience, the endo techs are amazing and have very specialized skills. They will most likely be training you in the procedure room, in fact. You should respect the sh!t out of them because they're in charge. It depends on the facility, but like the others have mentioned, you might be rotating between pre procedure, procedure and recovery. I find that procedure is the most interesting of course, though the recovery room is also interesting and likely includes a lot of opportunity for patient teaching, which I love. Endoscopy is very very fast paced and most of the procedures are relatively short so maintaining the flow is a huge priority.