What would you do ?

[OR male nurse]

So I'm on call last night doing an ORIF of an ankle when the ER calls into the room and says that one of the surgeons wants to do an immediate surgery of a ruptured appendix. I told them they'd have to wait until we were done or call in a second team. Turns out the surgeon said he'd wait until we were done. So here's the rub. The CRNA starts to tell me that I should start setting up the next operation so we can all get out of there at a decent hour and that she'd watch out for me and give me a holler if they needed anything. I steadfastly refused and told her that I was uncomfortable leaving the room to work on another case while I was in a surgery already. She whined a little bit and said that "everybody else does it." I still told her that it was my license and that I'm not everybody else and I didn't care what the rest did that I wasn't doing it. I'm sure I'll be the jerk of the department this week when everyone hears that I made my team stay later than they should have and refused to be a "team member" I pretty much told the CRNA that if that's the way you guys do it here then I guess I'll look around for a different job because I'm not doing that. I've only been at this job a couple of months and the more I work at this hospital the more I have an eye opening experience. What would the rest of you have done ? Should I report this to the head of the department or just let it go ? I don't want to make waves as the new guy but what the heck ? Do they do it like this at other hospitals ?

Thanks

[brewerpaul]

I think you did just the right thing. It IS your license on the line and more importantly, it's the safety of your patient that's at stake. Granted, an ankle ORIF is not all that critical, but things can and do go wrong. As circulator, it's your job to be in that OR, plain and simple (apart from an occasional quick hop out to get something for that case).

I'm an OR newbie (7 months) so I'm not sure what to tell you about talking to the department head. I do believe however that you must do the job that you KNOW is correct.

[Scrubby]

It's different for me i guess because we have anaesthetic nurses who will cover for us if we have to go and get a few things, and they are trained to scout as well. But if we had techs like you do over in the US i too would refuse to leave the room. Because no one else is going to protect my registration if something happens like a vascular injury etc.

What does the AORN standards say about a situation like this? If people make any comments quote AORN to them, usually works for me. I don't think your refusing to leave is not being a team member. I think you showed responsibility to your patient even knowing that you'd delay leaving work which is an asset IMHO.

[Mourkoth]

Hey, I wouldn't leave the room for anyone, especially if it was a non-emergent case. I'm very new to the OR enviroment, but I've seen night shift call where real emergency cases come in and the nurse starts another. The nurse will get another room going. Almost always, the OR nurse will get on the phone with the supervisor or call a PACU nurse over to sit with the first patient until she gets back. (I've reciently transfered from PACU to the OR).

[Jolie, BSN]

Perhaps you could suggest to her that if she thought a member of your OR team was expendible (to go set up another room while your case was in progress), then she could leave and ask the surgeon to "keep an eye out for the patient in her absence".

Her suggestion was unsafe and unprofessional. Thank you for maintaining your standards of safety for your patient!

[aquarius1]

I would have done the same thing....not leaving the room until everything's finish and besides the surgeon who would like to that case said he would wait, and yes, it's your license that's at stake. You just did the right thing.

Reporting it to the head of the department....i guess better to let go unless they're making a big deal out of it and causing you a lot of hassle then Yes report it to your head. Goodluck

[heather2084, BSN]

As circulator I dont think I've been asked to do so. Our teams have 2 scrubs and a nurse, and if one of the scrubs isn't being used, then they will go and set up the next case. That's not to say that I haven't left the room to do a few things for the next case, but I dont start my cases, abandon them, and then come back at the end. I'm gone momentarily.

[sharann, BSN, RN]

You are responsible for the room and the CRNA is reponsible for the patients airway and vitals. You being in charge of the room includes making sure the surgeon and CRNA are doing their jobs as well as watching for the sterile field integrity etc..

You do not leave short of life threatening emergency in your room(yours or the staff in the case).

Where is the backup emergency team?

Only a trained circulator can break you in your job.

What if the CRNA or anesthesiologist leaves the room and asks you to "watch the patient".

[heather2084, BSN]

You being in charge of the room includes making sure the surgeon and CRNA are doing their jobs

I have never really felt that it was my job to make sure the surgeon and CRNA are doing their jobs. There's so much going on int a room that a lot of times you have no idea if they are comlpetely 'doing their jobs' or not. Sure if I saw them doing something they're not supposed to, then I would let someone know. But it doesnt say anywhere that I'm to see that the surgeon and CRNA are doing their jobs. I'm looking for the patient, always, but if the surgeon isn't exactly doing their job, all I can really do is ask that I be moved to another case.

You do not leave short of life threatening emergency in your room(yours or the staff in the case).

As far as this goes, I dont know about you, but I often have to leave to retrieve items needed, to call out for an anesthesiologist, etc.... There are many reasons short of an emergency that we have to leave the room for. And yes, where I work, it's not uncommon to have someone else step in the room for me if I need a bathroom break. Though I wait for the right time and don't leave during important parts of the surgery.

What if the CRNA or anesthesiologist leaves the room and asks you to "watch the patient".

The CRNA should NEVER leave the room asking you to 'watch the patient'. I've only had a CRNA leave the room on me once and I was extremely uncomfortable with the situation, even though the patient wasn't intubated. The pt was sedated and while yes I am able to monitor vital signs, I feel the CRNA should be there to act quickly if need be. This particular CRNA left the room to talk about some other issue going on among his co workers. Tell me, how many times have you had a CRNA ask you to 'watch their pt'?

[sharann, BSN, RN]

Heather,

I wasn't clear whenwriting about the circ not leaving the room. I made a mistake using the words "never".Of course you have to leave for supplies and equipment.

In regards to the Surgeon and others CRNA/MDA doing their jobs, I think in a way one is responsible a s a patient advocate though. You see a CRNA talking on the phone on reading a novel (or the patient moving perhaps) and I think you would notice because you are highly aware of the goings on in the room. You would say, "excuse me would you like to push some more propofol doctor?". Or if the surgeon seems to be oh, intoxcated looking or weaving or cutting into the wrong side of the abdomen, would you not be "responsible" for saying "STOP! ...insert expletive..."

This is what I mean by responsible.

You really are in charge of the room circulators, no matter what you are told by the NM's or Docs.

Hope I reedemed myself a bit.

[core0]

Heather,

I wasn't clear whenwriting about the circ not leaving the room. I made a mistake using the words "never".Of course you have to leave for supplies and equipment.

In regards to the Surgeon and others CRNA/MDA doing their jobs, I think in a way one is responsible a s a patient advocate though. You see a CRNA talking on the phone on reading a novel (or the patient moving perhaps) and I think you would notice because you are highly aware of the goings on in the room. You would say, "excuse me would you like to push some more propofol doctor?". Or if the surgeon seems to be oh, intoxcated looking or weaving or cutting into the wrong side of the abdomen, would you not be "responsible" for saying "STOP! ...insert expletive..."

This is what I mean by responsible.

You really are in charge of the room circulators, no matter what you are told by the NM's or Docs.

Hope I reedemed myself a bit.

The discussion on the circulator leaving the room brings up this which was shared with us by ewattsjt

http://www.medscape.com/viewarticle/433873_2

In particular:

"In French v Fischer,[11] Rebecca was born May 2, 1959, at Methodist Hospital, Memphis, Tennessee. On May 17, 1959, she began to have severe vomiting attacks. Her parents called in Dr. Allen, who diagnosed the baby's ailment as pyloric stenosis and advised the parents that an operation was needed. The operation was scheduled and done that evening at Baptist Memorial Hospital. During the operation, the doctor sent the circulating nurse out of the operating room. The circulating nurse had difficulty completing the job he gave to her and was gone for most of the operation. The scrub nurse verified the count of sponges used and removed from the incision, but she made a mistake and one of the sponges remained. On June 2, 1959, Rebecca was taken to LeBonheur Hospital because of problems. She was found to have a sponge in her abdomen and had to have two thirds of her small intestine removed. Her parents filed suit. The courts stated that Tennessee had elected to follow the cases, which made the counting of sponges an administrative function and not the result of the surgeon's control over the operation. However, the court did find that there was negligence individually on the part of both the doctor and the scrub nurse. The doctor was held for his own individual negligence and Baptist Memorial Hospital was held for negligence of the scrub nurse under the theory of vicarious liability.[11]"

Granted it only applies in Tennessee but finding the surgeon responsible for essentially interfering with the circulator by sending the nurse out of the room is an interesting take that I had not thought about. You could always bring that up to the manager if they really insist. I bet the physicians would be particularly excited about the hospital increasing their liability.

David Carpenter, PA-C