Advocating Against Compromised Care
We’ve all worked with someone who is maybe not great at their job, having a bad day, maybe they are just trying to figure things out still, and sometimes there is a legitimate concern with their ability to perform in their role. This can make your day, or call case, a little more stressful. What happens when this compromises patient care?
Background
There are a million situations where this might arise, but I’ll speak about a situation that I just recently experienced. I was floated over to the surgery center to circulate 3 cases. Two of these were local procedures, meaning the patient did not get anything other than local anesthetic, so they were wide awake and (usually) anxious during their procedure. I meet the surgical tech and she’s unsure about almost everything regarding the first procedure. She doesn’t know if the surgeon injects local before prepping, what type of prep he likes, if he wants bipolar cautery, and the list goes on. Mind you, this is a 3 OR ASC and this surgeon works here 2-3 days a week. If this surgical tech was new, I would understand her lack of knowledge. But she wasn’t. She had actually been working there for about 10 years. I worked with this surgeon on a regular basis 2 years ago and knew his preferences well, however as many times as a surgeon says “I do it the same way every time”, they do change their techniques. So I followed the preference card, which matched what I remembered- but whad’ya know, he changed the order he injects and preps locals. He proceeded anyways knowing that previously when I worked with him that’s how he had done it.
Here’s where it gets concerning…
We get through the first two cases. Nothing too out of line happens and no patient safety concerns. Then comes patient 3, a local. Remember, this means the patient is awake. This patient was scheduled to get two lesions removed- one from her upper chest and the other on her neck.
After I get the patients over to the OR table and comfortable, get some vitals, it’s time to start prepping and draping. I saw that the surgical tech had a laparotomy drape which would be challenging to use without covering her face (not ideal during a local), but also challenging to actually create a sterile field. I stopped her before she placed the drape and asked what her plan was so we could keep the patient’s face exposed. She didn’t have one. I suggested a ‘split drape’. She was agreeable so I ran out and grabbed it. I opened it to her then waited for her to place it on the patient. She looked very confused about what to do and just seemed stuck.
I peeked my head out of the door and asked for another nurse to step in for a minute. Once the nurse was in, I put a gown and gloves on and helped her to drape the patient. What I wanted to do was stay scrubbed in and do the rest of the case myself, however I knew I had already overstepped. I asked if she needed anything else before I broke scrub then returned to my role as a circulator.
One of these lesions was being sent to pathology immediately for a frozen section to see if all the margins were clear. While we sat and waiting for the specimen to be read the surgeon steps out and it’s just the patient, the surg tech, and myself. I make conversation with the patient, ensure she is comfortable still, and just try to keep her relaxed.
As I’m doing this, I notice the tech standing at the patient’s side appears to be nodding off. I speak to her directly and ask her questions including her in our conversation. She replies and seems as if she’s been listening. Maybe I didn’t see what I thought I saw. Then it happens again. And again. Not only is she nodding off, but she’s nodding off OVER the patient… I quickly and discreetly as possible get a chair and ask her to sit down. She only sits for a few minutes then stands back up again.
I peeked my head out of the room again and got another nurses attention for her to come in. We had another conversation going at this point and it starts happening again. I have the other nurse go over to the patient while I get the tech away from the field and sitting down. I asked if everything was okay, and she acted as if everything was fine. Once she is sat down and appears to be alert, I stepped out of the OR to seek some answers.
There were a few other surg techs around that usually work with her and I asked if this was her baseline or if something was going on. They said this wasn’t abnormal for her, but it seems like it may be worse today. Definitely didn’t like that answer, how is this acceptable at all? During this time the pathologist called and said the margins were clear- thank goodness, it was time to put a dressing on and clean up.
Follow Up
Afterwards I asked the surgeon is this was a normal day with her, and he said unfortunately it was and that he had gone to administration a few times over it. The other nurse who witnessed some of this behavior and I did go speak with the director about what all had happened. I don’t wish anything bad upon this tech, but I also have to advocate ensure that patient safety is prioritized. I likely won’t know what happens from there, but moral of the story is if you notice something compromising patient safety you HAVE to act on it. It’s not fun, but it has to be done.
UPDATE:
I did find out that this surgical tech was terminated, which means there must have been something substantial enough to warrant it. Not that that makes me feel any better, but it does help knowing a potential poor patient outcome was avoided.
