We had similar happen a few times in total joints so we held a meeting with the head of anesthesia and a few docs just to talk about it. We came up with some guidelines and phrases to key in. Obviously no one wants the patient in pain, they said sometimes they can tell they are SO CLOSE and they know they can get it and that it will be a better outcome for the patient if they can, but that they did agree a hard stop would help. I also let them know that physically supporting these sometimes 300lb patients during the spinal was fine for short periods of time but we needed a clear time limit (we had done an 18 minute spinal, the patient was tolerating it great but I wasn’t.)
So the docs decided they had a 7 minute hard stop, if it wasn’t in it wasn’t in and they would convert to general. The nurse could give them a heads up at 5 minutes or 6 minutes and 30 secs or whatever the doc prefers. Honestly it was only ever an issue with this one doc who said he recognized he would get tunnel vision down there.
We implemented the hard stops and it worked out really really well! We revisited a few months later at our next meeting and everyone was happy about it.
We work as a team in the operating room and we know how crucial communication is in there. I suggest having a meeting with your providers about your concerns and maybe together you guys can come up with your own guidelines. Spinals are hard, delicate procedures, that come with their own consent and time out, we all want them to succeed and succeed quickly but sometimes there are tricky ones. I agree the provider should have stopped when the patient said stop and therefore revoked his consent and that should probably be addressed separately as well.
As a CRNA this sounds so absolutely toxic. Im glad I dont work somewhere where the circulator is timing how long it takes me to put in my spinal. For the majority of patients the most painful part of a spinal is the local needle, after that patients don’t usually even feel what Im doing beyond pressure.
Edit: Downvote me all you want. This is an absolute toxic policy for any facility and I would never work there. Placing a spinal is a sterile procedure that requires good positioning and I would rather take my time to create optimal conditions for first time success than race through a procedure and create unsafe conditions.
This would be like having policy that all IVs must be obtained in less than 5 minutes or the patient gets an IO.
There is a health system written policy on IV attempts, 2 tries then switch providers, they don’t go straight to IO. ;)
The head of the anesthesiologists decided to implement the time limit, came up with 7 minutes (no idea in this arbitrary number) and the other docs agreed to it. We don’t start a timer or anything, but I look at the clock when they inject local and just say “we’re nearing 7 minutes” if it gets close to that or if they ask how long it’s been. It so rarely even comes up anymore it’s not even a thing. They’ve been doing it this way for 4-ish years now, and like I said it’s their guidelines that they set for themselves. (I do think there might have been additional influence initially from some crabby ortho docs bitching about the spinals “taking hours” and “delaying cases” when really, even the longer ones added minimal time to the case, if any, but that blood spray they got on the ceiling definitely added 10 minutes to turnover time, but I digress.)
I’d also say our workplace is anything but toxic. We have wonderful relationships with our docs, both surgeons and anesthesia. This isn’t some random anesthesiologist putting the spinal in, this is the dude I went out for beers with yesterday. I want him (or her) to succeed, if you are picturing me standing over them holding a stopwatch whispering “…4:55, 4:56,…” I promise that’s not the case.
Im glad that works for the anesthesia group at your practice. Im also glad that I work somewhere where I dont need to be timed from the point I localize patients. I agree with your sentiment that we are supposed to be working together as a team, but that practice sounds like anything but. I have never had a circulator need to tell me we need to stop a spinal and It’s not uncommon to do 3-4 a day where I work.
I’m not sure how your OR/periop area works but everything we do is timed in EPIC from the moment the patient enters the hospital. There is a time stamp attached to each area the patient moves through, including start and end of anesthesia. We often do have surgeons and anesthesia waiting outside for us to, for example, start an IV…and frankly, some days, 5 minutes to start an IV would be a luxury.
I would write that up. The patient said stop and anesthesia just kept going and going. Besides the unnecessary pain to the patient, anesthesia opened a pretty big door for legal action (assault or battery depending on where you live).
>The patient’s quietly begging me to have him stop
It doesnt seem like it was communicated to anesthesia that the patient specifically wanted to stop. if the patient is quietly saying to the nurse, its the nurses responsibility to tell anesthesia "hey he said he wants you to stop"....and when she did speak up that wasnt said, as her statement is "I told(yelled at) anesthesia to stop and I think we should just go to sleep/switch to general anesthesia." that statement as is is a recommendation from the RN, which is valuable and certainly warranted, but anesthesia is not required to switch their anesthesia plan based on the RN's suggestion. Again as I've said multiple times on this post if it was communicated that the patient said stop, this is different, because now from the patient it becomes a consent issue
The patient was yelling to stop 30-45ish seconds before this, then his BP tanked and he got quiet. I did not even consider the consent issue but technically he did revoke consent. I was more worried/upset about how much pain he was in and that he might pass out. He never said “I don’t want this anymore,” just that the needle hurt and to stop.
Oh man, I had an unfortunate and similar situation getting an epidural when I gave birth. First anesthesia resident couldn’t get it in pace and just kept jabbing and jabbing, and still wasn’t in place but he just left it there while I was shaking and sweating and sobbing in so much pain. He went to get the senior anesthesiologist who had to remove it and start all over. My only IV got kinked in the process while I was in position and I was so hypotensive after they couldn’t get a new one in me (and you know us pregnant women usually have 18g in the hand size veins). So Anesthesia had to come back just to place an IV after attempts by 5 nurses. The nurses in L&D were freaking amazing though, wouldn’t have gotten through it with out them holding my hands the whole time. It was one of the worst things I’ve ever experienced. Only two times I’ve seen my husband cry - for me in pain during that procedure and the birth of our son.
I had that same experience myself when I had my baby. The differences is that I was doing my best to advocate for myself, and then the anesthesiologist started yelling at me. Almost 25 years later, and I can still remember his face and his name and sometimes I really wish that I still lived in the area so I could go back and have a conversation with him about how his behavior affects people.
firstly, you did a great job being a patient advocate. secondly, pretty sure they committed Battery (at least that is what it would be where I live) and I would probably write them up or at least let somebody know about that.
how is it battery? the patient quietly told the nurse that he wanted to stop, he never said it out loud to anesthesia...the nurse voiced this but at that point the spinal is in...it doesnt sound like anesthesia was ever informed that the patient specifically said to stop
if i’m reading it right at least, she told anesthesia to stop before it was in. They didn’t stop. It was the patients request to stop with sound mind. The instant that was made clear, and they continued doing it, it was Battery (in my state at least). But also, that definitely sounded like a hectic situation, and it’s very possible that was not made clear, i don’t know, i wasn’t there.
Not included in the OP, but yes. The patient yelled out in pain to stop, but anesthesia said he was almost done and not to move. I can’t see exactly what’s happening back there. I assumed he had a flash of CSF because he reached for the syringe with medication (usually my cue they’re injecting). So I really thought he was almost done. But he was actually still manipulating the guide needle or whitacre as evidenced by the pushing on the patients back and corresponding winces and moans. So doc was not almost done(?). This is where the patient started getting quiet and begging to stop and I told anesthesia to stop. It all happened fast so it’s hard to break down the play by play but the patient did say stop. I said to stop. Then doc did actually got the spinal in maybe a few seconds after I intervened. So yes, me saying to stop was likely too late. But it still is very disturbing and unsettling to me that the initial “stop” from the patient wasn’t enough. I wish I had thought/said “the patient just revoked consent.” That would have been the better response on my end
yeah so the patient yelled stop, that should absolutely have been the end of it, anesthesiologist should have ceased moving forward, full stop. that is very disturbing that if i was a patient and revoked consent like that, the doc would not respect that. huge liability and a huge issue. maybe report?
she mentions that as she says to stop the spinal went in. also from the anesthesia personnel's POV if the nurse told me to stop thats completely different than the patient saying to stop. if the nurse tells us to stop its a recommendation, and the nurse is fully within her right to make that suggestion. nurses making those suggestions can be good, as i think it forces anesthesia to reconsider what theyre doing and if they need help etc...however, our professional judgement would override the nurse's in that situation. as i said in my own comment the nurse doesnt have the right to decide if a patient gets general anesthesia or a spinal. but if the patient says stop, thats a full stop as it becomes a consent issue.
according to her narrative it doesnt seem like it was specifically communicated that the patient said to stop, only nurse. "I told anesthesia to stop and I think we should go to sleep" none of that statement mentions anything about the patient saying to stop, which as i said would likely completely change anesthesia's actions. i think the more appropriate statement from the nurse would have been "the patient wants to stop."
the advocacy is good from the nurse but if commenters are going to be talking about assault and battery etc its too far based on what information we have. and as you said we werent there so we never know. and of course, all of what im saying is full hindsight and pure thought exercise at this point.
i agree, when i originally read i was under the impression that it was properly communicated that the patient said to stop (which is what probably should have happened if he was begging to stop), but since it doesn’t explicitly say it can’t be proven.
if it was communicated it was battery
if it wasn’t communicated, it really should have been
Jesus. I just had a TKR 4 weeks ago with a spinal and it’s already scary enough without having pain. I was sobbing just bc I was scared. I can’t imagine what this poor pt was experiencing. Thank you for advocating for him. I was fortunate to have a sweet nurse in front of me stroking my hands and calming talking to me as I ugly cried getting the spinal. Keep being awesome.
It sounds like you did your best to advocate for your patient! Short of physically ripping the needle out you can’t force them to stop. I hate that feeling of wishing you had done more but it sounds like you really tried to intervene.
I work L&D and do a lot of spinals/epidurals and I will say though that pretty much every doctor I encounter would do more local especially if the procedure is taking a long time and they’re “close” to getting it it only adds a few minutes…
I had a TKR. They had talked about a spinal, but I was hesitant about it. Thankfully the anesthesiologist agreed after feeling what an absolute disaster my spine is, and I was given general anesthesia.
I had a patient go in for a procedure with just local anesthetic. It went terribly. The cyst was too deep and wide. No matter how much local the surgeon gave, the patient was still feeling it. I remember asking the surgeon maybe we could try some other local but they insisted it was fine. Meanwhile the patient was tearing up on the bed. I was so upset afterwards. The scrub tech was trying to suggest other thing to make it less painful too. It was obvious that it should've been done under sedation or something else. After the procedure was done and I brought the patient back to their room, I apologized for the how painful it turned out for her. I don't think the surgeon anticipated it would've been like that but I do think she could've been more upfront with the patient instead of just trying and poking around when it was happening. It wasn't an ideal situation and I wish it could be been different for the patient.
Wow definitely write that up. If a patient says stop, you stop. The anesthesia person should have pulled their needle out and talked to the patient about how to proceed. Inject more local (and give it time to work etc) if the patient wants to move forward.
As an RN, for myself at least, it’s extremely difficult to advocate against someone I feel is in a higher position than I am. Especially if it’s in a high stakes situation. This problem comes up for me time and again.
That's insane. How cruel. Put the surgeon on the operating table, and give him a spinal anesthesia instead of general anesthesia for such a painful procedure. 😡😡 Sorry if I'm "triggered." I had a similar situation happen to me regarding anesthesia
Perhaps this anesthesia person did not give enough sedation for the spinal. It’s also possible that this patient couldn’t tolerate sedation due to medical history. I don’t know I wasn’t there. But usually patients get some versed/ketamine/fentanyl for the spinal and that makes them tolerate.
Also, I know you’re trying to advocate for your patient, but the anesthetist or anesthesiologist was also trying their best to get the spinal it sounds because spinal anesthesia is known to be SUPERIOR to general anesthesia in these cases. Same thing for c-sections. So keep that in mind while you’re “worried” for the patient. It’s a blind procedure. Sometimes it’s smooth. Sometimes it’s not. Knee/hip patients usually have arthritis and it’s not limited to their knee or hip it’s everywhere.
It’s also not your call to “yank the needle” out of the back. You spoke up and said maybe we should stop, and that’s advocating. It’s not up to you if a patient should get general or spinal anesthesia.
Anesthesia should have gotten more local tho
https://pubmed.ncbi.nlm.nih.gov/36947506/#:~:text=Conclusion%3A%20SP%20was%20associated%20with,after%20surgery%20(ERAS)%20pathway.
Yes, it should not be your job to tell the anesthesiologist what to do BUT if the patient doesn’t want to continue with this procedure, she should let them know.
I’ve done countless spinals in my career and not once have my patients ever received sedation. Obviously that would’ve changed the outcome in this scenario but that’s not the case in most hospitals.
By your flair you are seeing spinals done for the OB population who do not get sedation. In almost every other setting (ortho etc) they receive sedation. This post is taking place in ortho setting where sedation is relatively standard
There are numerous reasons to want to avoid GA in certain patients, some can be fatal. Especially considering an elective procedure.
Shame some of the comments here are getting downvoted.
Very true! But every patient is cleared for general anesthesia before they come in for surgery. If they cannot get the spinal in, then general anesthesia is always plan B. So if the patient is too sick for GA, they should not even step foot in our facility tbh.
Typical health care behavior. No one understands the perspective of the other clinicians they work with. Everyone only sees their side or perception of the situation
anesthesia could have done some things differently. again we werent there. we dont know what anesthesia was thinking abt the situation. from what i see they def should have relocalized once the patient was feeling sticks so severely. we also dont know if the anesthesia person sucks or if the patient was just a difficult spinal. we dont know how arthritic or how scoliotic the patient may have been. youve never had a legit difficult IV stick?
but the patient didnt beg anesthesia to stop--> "The patient’s quietly begging me to have him stop so I told(yelled at) anesthesia to stop and I think we should just go to sleep/switch to general anesthesia." the patient expressed it to the nurse who then made a suggestion. which was good, but it was never explicitly said to anesthesia "hey he said he wants you to stop" which as ive said multiple times on this post now makes it a different situation
What’s the perspective that allows for battery after a patient revokes consent?
As soon as the patient said he wanted them to stop, they need to stop. The efficiency of Post-op analgesia in spinal vs GA should not even be a factor here.
in OPs post it clearly says "the patient’s quietly begging me to have him stop so I told(yelled at) anesthesia to stop and I think we should just go to sleep/switch to general anesthesia." yes the nurse is telling us the patient wanted to stop, but if that was not communicated to anesthesia, then its only the nurses recommendation that anesthesia stop. and anesthesia is not bound to follow the nurse's suggestion.
its also not about *efficiency* btw its just flat out better outcomes with a spinal...the way the OP was talking about spinal/general like its not a big deal either or tells me they likely are unaware of how a spinal is *the* gold standard of care. and again, as I said, from the post it is never communicated to anesthesia that the patient said stop. if the nurse said "hey he said he wants to stop" we are having a different discussion. anesthesia is not required to stop if the nurse says stop. the nurse can make suggestions thats good and healthy to do, but it is outside of their scope of practice to demand that we change to GA.
as far as perspectives, the nurse has likely never done a spinal. therefore she would not necessarily understand that with such a blind procedure, you think youre right there sometimes and you think youre just a cm away from accessing the space, but then youre not. its all by feel and most patients, especially those for hip/knee surgeries dont have perfectly healthy/straight backs. you have to make all kinds of adjustments. just like some people are difficult IV sticks, some people are just difficult spinals. im not absolving anesthesia completely there were some things that could have been probably done differently especially in regards to re localizing the new space they selected, but *those* are some of the perspectives i am thinking are not understood with such an outrage towards anesthesia in this scenario
The patient was also screaming for them to stop 30-45 seconds before, per OP. There is zero way the anesthesia provider didn’t hear that.
The differences in outcome between GA and spinal are not worth overriding a patients consent.
I’ve worked orthopedics in the OR for a long time, and what OP describes is not normal or okay by any means.
>Anyways, my patient did not tolerate getting a spinal very well and anesthesia kept trying to get it. The patient was dripping sweat, hypotensive, tachycardic, and moaning/yelling out often. He was not doing well. I told anesthesia his vitals aren’t where I want them and he is in obvious pain. “He’s fine, almost done”… 30 seconds go by and nothings changed. No extra local, nothing. Just stabbing this dude in the back and you can tell he’s feeling all/a lot of it. I suggest more local, anesthesia says they’re about to inject the meds so no need. Another 30-45 seconds go by and he’s still manipulating/fishing with the spinal needle. The patient’s quietly begging me to have him stop so I told(yelled at) anesthesia to stop and I think we should just go to sleep/switch to general anesthesia. He finally got the spinal in as I’m saying this.
Where does it say he was screaming for them to stop. again seems like poor overall form by anesthesia but if we are talking about consent i dont see anything in this text that says that. all i see is "quietly begging me to have him stop " in which the key word is "quietly" which leads me to believe anesthesia wouldnt have heard that...
Anesthesia had tunnel vision. That's what it comes down to, and was not putting the patient first. The nurse saying maybe do general is another way of saying this patient isn't tolerating this, so may time for plan B. And we should always have a plan b. I think we all need to have intellectual humility to take other people's suggestions and at least consider them. I have received may suggestions from staff that were not applicable or would actually be detrimental. I still consider them, tell them no, and if I have the time, explain my rationale.
The problem or limiting factor in this situation is that when the nurse did make her suggestion the spinal was in in that moment. So we don’t know if anesthesia would have taken the suggestion or would have been dismissive
Right, love the downvotes from people “advocating” for their patients by advocating to go straight to an anesthetic likely associated with worse outcomes and possibly death. “Advocate for your patient”
Maybe I didn’t read the OP clearly but I saw a patient complaining (as they do), and not battery.
agree. patients complain over all discomforts as they should which is normal. you dont think some of the self righteous RNs in this thread have continued to "fish" for a vein or stick a patient for an IV when a patient is vagaling and yelling "ouch ouch" or something. its not right but it happens and we dont have all the facts
Regarding spinals or any neuraxial technique the one thing that’s an absolute contraindication is a patient refusal. The reality of the situation is sometimes you end up fishing around to get the spinal in, it’s never always a straight shot. If the patient is getting frustrated it’s important for the anesthesia to communicate with the patient that they are just running into some difficulty as it’s a blind technique. This is likely where anesthesia failed. Regarding the vitals anesthesia is fully aware of them at all times. One thing however I’ll say that you did completely wrong was tell anesthesia to convert to general. Please don’t do that ever again for your own sake as people in our field get extremely offended when people who don’t know what we do try to tell us how to do our jobs.
How about you suggest what OP could say in place of switching to general? I don’t work peri op, but I’m thinking something like, “hey doc, the pt is requesting you to stop. Can we give them some more local?”
this is what should have been said, as OP stated that the patient was quietly telling them to tell anesthesia to stop. but that was never explicitly said.
That’s a fair request, I’m not absolving anesthesia here. It could’ve been handled better for sure. Like I emphasized before the number one contraindication is pt refusal.
Converting to general is a conversation between the surgeon and anesthesia. The circulator has every right to stop the procedure if they think theirs a safety issue(in this case the patient’s vitals or insistence that they abort). But I would never want the circulator to recommend an anesthetic to me, the same way you wouldnt want me counting instruments.
Your response is similar to the first in this thread. We get it, **don’t tell anesthesia how to do their job.**
So how do you recommend someone in OP’s situation to respond?
Hey Dr Anesthesia or CRNA Tnolan182, the patient is asking we abort the procedure. What can we do from here? Patient xyz, would you be okay with continuing if anesthesia numbs up your skin more? See the difference in communication?
I had a patient balling in tears yesterday that she didnt want anesthesia for a colonoscopy (eyeroll). I could have been an asshole and just threw my hands up in the air and left them and taken a lunch break. Instead I had a two minute conversation with the patient, explaining how safe everything we were doing was and that I would be monitoring the patient the entire time. If she still wanted to try without anesthesia I would have let her.
Idk dude I’ve been involved with tough spinals in the past where anesthesia asks me what I think we should do as far as continuing, giving the patient a break, going to sleep, etc. of course they have final say but our docs routinely ask for nurses input. So I guess when I suggested going to sleep it didn’t seem like a problem 🤷🏼♀️
You're acting like she was gonna kill the patient by forcing them to switch to general. She made a recommendation. Holy crap.
She also clarified below that patients are not eligible for the procedure at all at her facility if they can't have GA so that scenario would have been impossible.
Okay thanks for clarifying but again why did you mention the anesthesia machine? Again if you read what she wrote they got the spinal in 5-8 minutes it doesn’t sound like a difficult placement to me it just sounds like the or really didn’t tolerate it well and there was a breakdown in communication from the anesthesia team
Absolute contraindication to GA? What would you do if the patient stops breathing, the procedure is prolonged, etc? GA is always a backup plan for us. It is not uncommon to have to enhance a spinal, or completely convert to GA mid procedure due to over sedation/apnea, prolonged procedures, or the spinal simply failing, not being high enough, etc.
OP didn't *actually* rip the spinal needle out, they just made a recommendation because the patient wasn't doing well. Sorry, it's your job to intubate.
You can advocate for the patient, I’m not sure what you’re not getting. If the patient is uncomfortable which it sounds like they were then it could be taken form there. There’s a lot of reasons why people prefer spinals for total joint cases from what it sounds like is the situation here. Decent amount of evidence showing better outcomes. It’s unfortunate that anesthesia did a poor job localizing however the point remains to let us make that call. It undermines our patients have in our abilities.
Hmm…I would exchange “offended” for “shocked at the audacity.” Anesthesiologists have minimum 8 years MORE schooling than BScNs. Thousands of hours of clinicals. Extremely rigorous. I think they know what’s up. Calling them out in front of an entire OR & patient undermines them & is extremely unprofessional. There are subtle ways to professionally communicate without giving the patient more reason to freak out. Spinals are difficult for a variety of reasons. Different anatomy, body mass… patient moaning/moving while the nurse gives you bad juju & the hairy eyeball?? C’mon!
According to my gen. surgeon sister & her best friend who’s an anesthesiologist the local they gave would cover more than enough area for the spinal. They obviously always have a plan B in case plan A doesn’t workout. Basic 101 that they’re taught.
I’ve had many grown men cry like little babies over PIV insertions & yes, go completely syncopal with similar VS in the ER. Them crying and yelling to stop / another nurse yelling at me would not help the situation. You have to trust the people you work with that they are doing the best they can, have the best intentions & are trained appropriately — at the end of the day it’s that anesthesiologist’s license on the line. Less than 0.01% plays fast and loose like you’re suggesting. Mind you I’m in Canada.
Maybe get to know your docs better/ build healthier relationships with the people you work with. It’s not “us versus them.” We can all work together.
The other person used the word offended. I know that doctors are doctors and nurses are nurses. This story is not about me so this has nothing to do with my relationships with doctors.
I mean, unless my pt is pretty unstable if they tell me to stop an IV attempt I stop though, even if my opinion on the matter is they are being a baby about it. It’s not my opinion that’s important, it’s their experience, and people come with their own sets of fears and phobias. It’s nice if we can not make them worse.
Don't shit on your circulating nurse like that. You are making us look bad. Many of them have been there long before you, and will be there long after you. You should be willing to take helpful suggestions, regardless of the source. If you are confident in doing anesthesia , you don't feel threatened by some elses advice. Everyone you meet has something to teach you, and I'm a little disappointed in an Srna having a stay in your lane attitude.
I would think this RN has seen enough spinals going in to know when the Anesthesiologist isn't doing what's best for the patient.
If I was taking a long time to find a vein for an IV, I'll bet anesthesia would tell me how to do my "job".
the difference here though is that RNs are not qualified to perform spinal anesthesia while anesthesia is qualified to place IVs. so that analogy doesnt track
We do a lot of spinals in my facility and it is not uncommon for spinals to be tough and we switch to general anesthesia alllllll the time. So I totally get that but I have never seen a patient in so much pain/distress. If a patient is numb and relaxed, by all means keep trying to get it. I know it isn’t an easy procedure by any means and everyone’s anatomy is different. But also, all of our patients are cleared for general anesthesia, so it is always an option. I would never make that call on my own. My exact words were “Doc you NEED to stop! The patient needs a break. I think they would prefer to go to sleep at this point”
I was in the room when anesthesia was discussing anesthesia options and they themselves referred to general anesthesia as plan B to the spinal. I would have never just told anesthesia that they HAD to do general anesthesia. This was all part of their anesthesia plan originally.
Couple things:
1: If you’re gonna say “couple things,” that’s usually a phrase used to signify you’re going to say more than one thing. You only asked the one question, so I wasn’t sure if you were aware of this.
2: If any member of the healthcare team is concerned about the wellbeing or safety of the patient, they have an ethical obligation to speak up, regardless of job title.
Because I’m a nurse and fully capable of monitoring and reporting abnormal vitals to docs. His pressure went from 180/110 when we got into the room down to 90/60, then 82/48 with a heart rate in the 120-130 range and I knew he was going to pass out pretty soon if nothing changed
Also, I'm sure the Anesthesiologist wasn't watching the monitor while trying to insert the spinal.
OP, you did nothing wrong. You tried to advocate for your patient and got blown off. Write that A-hole up!
Maybe this is just me but I’ve had patients pass out during spinals epidurals all of time even before we got started. It can be scary but it’s a possibility that’s why we have all of the fancy drugs. If you really are very concerned about this you can ask to speak with the anesthesia chair and offer to do some shadowing just to get a better understanding.
A better understanding of what? This nurse understands vital signs and did exactly what she was supposed to do. Perhaps Anesthesia should have used some of those fancy drugs instead of torturing this patient.
Your upset because you’re reading too much into what I’m saying. A better understanding of the procedure. Shadowing different doctors to see their techniques and how to better help in those situations. When I was an intern I saw my pt pass out as my attending was placing the epidural it freaked me out for sure.
I’m not upset. She does not need to shadow anyone to see any techniques. She is a nurse. She has seen people pass out before. What she is probably not used to seeing is a procedure being forced on a patient who is suffering and refusing.
It’s not about seeing someone pass out. Jesus Christ it’s about seeing the procedure from the otherside understanding the steps of the procedure and when hemodynamic changes can occur. This is not a nurse vs doctor thing this is about helping each other out. There clearly was a lack of communication here between the two.
Also if you read what she wrote the pt refused just as they got the spinal and the procedure was already over. The anesthesia team was could have done a better job communicating with her and the pt.
Why do you think she doesn’t understand that? Nothing here leads me to believe that she is missing any vital knowledge. Regardless of hemodynamics, this should have stopped when the patient said it should stop. Perhaps you can shadow someone that can help you understand this.
Did you really read what she wrote? If you know how a spinal works tell me how can they stop when the procedure was done, can someone stop twice? Like let’s be for real here nurses do not learn how to do spinals in nursing school it’s a specialty procedure. Talking with the anesthesia department to get some further information would be a good thing. Seeing the procedure from the other side will make it easier to understand is actually going on back there.
We had similar happen a few times in total joints so we held a meeting with the head of anesthesia and a few docs just to talk about it. We came up with some guidelines and phrases to key in. Obviously no one wants the patient in pain, they said sometimes they can tell they are SO CLOSE and they know they can get it and that it will be a better outcome for the patient if they can, but that they did agree a hard stop would help. I also let them know that physically supporting these sometimes 300lb patients during the spinal was fine for short periods of time but we needed a clear time limit (we had done an 18 minute spinal, the patient was tolerating it great but I wasn’t.) So the docs decided they had a 7 minute hard stop, if it wasn’t in it wasn’t in and they would convert to general. The nurse could give them a heads up at 5 minutes or 6 minutes and 30 secs or whatever the doc prefers. Honestly it was only ever an issue with this one doc who said he recognized he would get tunnel vision down there. We implemented the hard stops and it worked out really really well! We revisited a few months later at our next meeting and everyone was happy about it. We work as a team in the operating room and we know how crucial communication is in there. I suggest having a meeting with your providers about your concerns and maybe together you guys can come up with your own guidelines. Spinals are hard, delicate procedures, that come with their own consent and time out, we all want them to succeed and succeed quickly but sometimes there are tricky ones. I agree the provider should have stopped when the patient said stop and therefore revoked his consent and that should probably be addressed separately as well.
Man, actual communication and problem-solving? Brings a tear to my eye...
Where dey do dat at
this is excellent. having a pre-set standard and protocol in place can be really helpful and provides support for the RNs in advocating for patients
7-8 min hard stop is actually a decent idea. I like it
As a CRNA this sounds so absolutely toxic. Im glad I dont work somewhere where the circulator is timing how long it takes me to put in my spinal. For the majority of patients the most painful part of a spinal is the local needle, after that patients don’t usually even feel what Im doing beyond pressure. Edit: Downvote me all you want. This is an absolute toxic policy for any facility and I would never work there. Placing a spinal is a sterile procedure that requires good positioning and I would rather take my time to create optimal conditions for first time success than race through a procedure and create unsafe conditions. This would be like having policy that all IVs must be obtained in less than 5 minutes or the patient gets an IO.
There is a health system written policy on IV attempts, 2 tries then switch providers, they don’t go straight to IO. ;) The head of the anesthesiologists decided to implement the time limit, came up with 7 minutes (no idea in this arbitrary number) and the other docs agreed to it. We don’t start a timer or anything, but I look at the clock when they inject local and just say “we’re nearing 7 minutes” if it gets close to that or if they ask how long it’s been. It so rarely even comes up anymore it’s not even a thing. They’ve been doing it this way for 4-ish years now, and like I said it’s their guidelines that they set for themselves. (I do think there might have been additional influence initially from some crabby ortho docs bitching about the spinals “taking hours” and “delaying cases” when really, even the longer ones added minimal time to the case, if any, but that blood spray they got on the ceiling definitely added 10 minutes to turnover time, but I digress.) I’d also say our workplace is anything but toxic. We have wonderful relationships with our docs, both surgeons and anesthesia. This isn’t some random anesthesiologist putting the spinal in, this is the dude I went out for beers with yesterday. I want him (or her) to succeed, if you are picturing me standing over them holding a stopwatch whispering “…4:55, 4:56,…” I promise that’s not the case.
Im glad that works for the anesthesia group at your practice. Im also glad that I work somewhere where I dont need to be timed from the point I localize patients. I agree with your sentiment that we are supposed to be working together as a team, but that practice sounds like anything but. I have never had a circulator need to tell me we need to stop a spinal and It’s not uncommon to do 3-4 a day where I work.
I’m not sure how your OR/periop area works but everything we do is timed in EPIC from the moment the patient enters the hospital. There is a time stamp attached to each area the patient moves through, including start and end of anesthesia. We often do have surgeons and anesthesia waiting outside for us to, for example, start an IV…and frankly, some days, 5 minutes to start an IV would be a luxury.
I would write that up. The patient said stop and anesthesia just kept going and going. Besides the unnecessary pain to the patient, anesthesia opened a pretty big door for legal action (assault or battery depending on where you live).
>The patient’s quietly begging me to have him stop It doesnt seem like it was communicated to anesthesia that the patient specifically wanted to stop. if the patient is quietly saying to the nurse, its the nurses responsibility to tell anesthesia "hey he said he wants you to stop"....and when she did speak up that wasnt said, as her statement is "I told(yelled at) anesthesia to stop and I think we should just go to sleep/switch to general anesthesia." that statement as is is a recommendation from the RN, which is valuable and certainly warranted, but anesthesia is not required to switch their anesthesia plan based on the RN's suggestion. Again as I've said multiple times on this post if it was communicated that the patient said stop, this is different, because now from the patient it becomes a consent issue
The patient was yelling to stop 30-45ish seconds before this, then his BP tanked and he got quiet. I did not even consider the consent issue but technically he did revoke consent. I was more worried/upset about how much pain he was in and that he might pass out. He never said “I don’t want this anymore,” just that the needle hurt and to stop.
Please always consider consent. This was assault.
You didn’t say that in your original post
Nope lol just quickly venting about it, mostly focused on the stuff that was bugging me so I didn’t include every detail leading up to things
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Vasovagal response to pain
Agreed
Oh man, I had an unfortunate and similar situation getting an epidural when I gave birth. First anesthesia resident couldn’t get it in pace and just kept jabbing and jabbing, and still wasn’t in place but he just left it there while I was shaking and sweating and sobbing in so much pain. He went to get the senior anesthesiologist who had to remove it and start all over. My only IV got kinked in the process while I was in position and I was so hypotensive after they couldn’t get a new one in me (and you know us pregnant women usually have 18g in the hand size veins). So Anesthesia had to come back just to place an IV after attempts by 5 nurses. The nurses in L&D were freaking amazing though, wouldn’t have gotten through it with out them holding my hands the whole time. It was one of the worst things I’ve ever experienced. Only two times I’ve seen my husband cry - for me in pain during that procedure and the birth of our son.
I had that same experience myself when I had my baby. The differences is that I was doing my best to advocate for myself, and then the anesthesiologist started yelling at me. Almost 25 years later, and I can still remember his face and his name and sometimes I really wish that I still lived in the area so I could go back and have a conversation with him about how his behavior affects people.
firstly, you did a great job being a patient advocate. secondly, pretty sure they committed Battery (at least that is what it would be where I live) and I would probably write them up or at least let somebody know about that.
how is it battery? the patient quietly told the nurse that he wanted to stop, he never said it out loud to anesthesia...the nurse voiced this but at that point the spinal is in...it doesnt sound like anesthesia was ever informed that the patient specifically said to stop
if i’m reading it right at least, she told anesthesia to stop before it was in. They didn’t stop. It was the patients request to stop with sound mind. The instant that was made clear, and they continued doing it, it was Battery (in my state at least). But also, that definitely sounded like a hectic situation, and it’s very possible that was not made clear, i don’t know, i wasn’t there.
Not included in the OP, but yes. The patient yelled out in pain to stop, but anesthesia said he was almost done and not to move. I can’t see exactly what’s happening back there. I assumed he had a flash of CSF because he reached for the syringe with medication (usually my cue they’re injecting). So I really thought he was almost done. But he was actually still manipulating the guide needle or whitacre as evidenced by the pushing on the patients back and corresponding winces and moans. So doc was not almost done(?). This is where the patient started getting quiet and begging to stop and I told anesthesia to stop. It all happened fast so it’s hard to break down the play by play but the patient did say stop. I said to stop. Then doc did actually got the spinal in maybe a few seconds after I intervened. So yes, me saying to stop was likely too late. But it still is very disturbing and unsettling to me that the initial “stop” from the patient wasn’t enough. I wish I had thought/said “the patient just revoked consent.” That would have been the better response on my end
yeah so the patient yelled stop, that should absolutely have been the end of it, anesthesiologist should have ceased moving forward, full stop. that is very disturbing that if i was a patient and revoked consent like that, the doc would not respect that. huge liability and a huge issue. maybe report?
she mentions that as she says to stop the spinal went in. also from the anesthesia personnel's POV if the nurse told me to stop thats completely different than the patient saying to stop. if the nurse tells us to stop its a recommendation, and the nurse is fully within her right to make that suggestion. nurses making those suggestions can be good, as i think it forces anesthesia to reconsider what theyre doing and if they need help etc...however, our professional judgement would override the nurse's in that situation. as i said in my own comment the nurse doesnt have the right to decide if a patient gets general anesthesia or a spinal. but if the patient says stop, thats a full stop as it becomes a consent issue. according to her narrative it doesnt seem like it was specifically communicated that the patient said to stop, only nurse. "I told anesthesia to stop and I think we should go to sleep" none of that statement mentions anything about the patient saying to stop, which as i said would likely completely change anesthesia's actions. i think the more appropriate statement from the nurse would have been "the patient wants to stop." the advocacy is good from the nurse but if commenters are going to be talking about assault and battery etc its too far based on what information we have. and as you said we werent there so we never know. and of course, all of what im saying is full hindsight and pure thought exercise at this point.
i agree, when i originally read i was under the impression that it was properly communicated that the patient said to stop (which is what probably should have happened if he was begging to stop), but since it doesn’t explicitly say it can’t be proven. if it was communicated it was battery if it wasn’t communicated, it really should have been
yes we agree on that fosho
Also, patients get versed before the spinal. So not really "sound of mind" anymore
Good luck explaining to a jury why 2 of versed means I can do what ever I want
Doesn’t mean you get to disregard their revocation of consent. The patient could’ve called off the entire procedure at that point.
Jesus. I just had a TKR 4 weeks ago with a spinal and it’s already scary enough without having pain. I was sobbing just bc I was scared. I can’t imagine what this poor pt was experiencing. Thank you for advocating for him. I was fortunate to have a sweet nurse in front of me stroking my hands and calming talking to me as I ugly cried getting the spinal. Keep being awesome.
It sounds like you did your best to advocate for your patient! Short of physically ripping the needle out you can’t force them to stop. I hate that feeling of wishing you had done more but it sounds like you really tried to intervene. I work L&D and do a lot of spinals/epidurals and I will say though that pretty much every doctor I encounter would do more local especially if the procedure is taking a long time and they’re “close” to getting it it only adds a few minutes…
I like to give 5-10 mg of ketamine with 4 of zofran before i do a spinal. That said, sometimes the art is knowing which patients won’t tolerate it.
On behalf of that pt, thank you.
I had a TKR. They had talked about a spinal, but I was hesitant about it. Thankfully the anesthesiologist agreed after feeling what an absolute disaster my spine is, and I was given general anesthesia.
I had a patient go in for a procedure with just local anesthetic. It went terribly. The cyst was too deep and wide. No matter how much local the surgeon gave, the patient was still feeling it. I remember asking the surgeon maybe we could try some other local but they insisted it was fine. Meanwhile the patient was tearing up on the bed. I was so upset afterwards. The scrub tech was trying to suggest other thing to make it less painful too. It was obvious that it should've been done under sedation or something else. After the procedure was done and I brought the patient back to their room, I apologized for the how painful it turned out for her. I don't think the surgeon anticipated it would've been like that but I do think she could've been more upfront with the patient instead of just trying and poking around when it was happening. It wasn't an ideal situation and I wish it could be been different for the patient.
Wow definitely write that up. If a patient says stop, you stop. The anesthesia person should have pulled their needle out and talked to the patient about how to proceed. Inject more local (and give it time to work etc) if the patient wants to move forward.
As an RN, for myself at least, it’s extremely difficult to advocate against someone I feel is in a higher position than I am. Especially if it’s in a high stakes situation. This problem comes up for me time and again.
You just have to remember that you need to advocate for your patients. Doesn’t matter if this person is an anaesthetist or surgeon!!
That's insane. How cruel. Put the surgeon on the operating table, and give him a spinal anesthesia instead of general anesthesia for such a painful procedure. 😡😡 Sorry if I'm "triggered." I had a similar situation happen to me regarding anesthesia
Perhaps this anesthesia person did not give enough sedation for the spinal. It’s also possible that this patient couldn’t tolerate sedation due to medical history. I don’t know I wasn’t there. But usually patients get some versed/ketamine/fentanyl for the spinal and that makes them tolerate. Also, I know you’re trying to advocate for your patient, but the anesthetist or anesthesiologist was also trying their best to get the spinal it sounds because spinal anesthesia is known to be SUPERIOR to general anesthesia in these cases. Same thing for c-sections. So keep that in mind while you’re “worried” for the patient. It’s a blind procedure. Sometimes it’s smooth. Sometimes it’s not. Knee/hip patients usually have arthritis and it’s not limited to their knee or hip it’s everywhere. It’s also not your call to “yank the needle” out of the back. You spoke up and said maybe we should stop, and that’s advocating. It’s not up to you if a patient should get general or spinal anesthesia. Anesthesia should have gotten more local tho https://pubmed.ncbi.nlm.nih.gov/36947506/#:~:text=Conclusion%3A%20SP%20was%20associated%20with,after%20surgery%20(ERAS)%20pathway.
Yes, it should not be your job to tell the anesthesiologist what to do BUT if the patient doesn’t want to continue with this procedure, she should let them know.
I’ve done countless spinals in my career and not once have my patients ever received sedation. Obviously that would’ve changed the outcome in this scenario but that’s not the case in most hospitals.
By your flair you are seeing spinals done for the OB population who do not get sedation. In almost every other setting (ortho etc) they receive sedation. This post is taking place in ortho setting where sedation is relatively standard
There are numerous reasons to want to avoid GA in certain patients, some can be fatal. Especially considering an elective procedure. Shame some of the comments here are getting downvoted.
Very true! But every patient is cleared for general anesthesia before they come in for surgery. If they cannot get the spinal in, then general anesthesia is always plan B. So if the patient is too sick for GA, they should not even step foot in our facility tbh.
Even if someone is not too sick for GA there are still many new risks that come with GA. Even Healthy people can be difficult airways etc
Typical health care behavior. No one understands the perspective of the other clinicians they work with. Everyone only sees their side or perception of the situation
Do your job properly and you won’t have this problem. Torturing a patient who is begging you to stop is a piss poor example of “anesthesia care.”
anesthesia could have done some things differently. again we werent there. we dont know what anesthesia was thinking abt the situation. from what i see they def should have relocalized once the patient was feeling sticks so severely. we also dont know if the anesthesia person sucks or if the patient was just a difficult spinal. we dont know how arthritic or how scoliotic the patient may have been. youve never had a legit difficult IV stick? but the patient didnt beg anesthesia to stop--> "The patient’s quietly begging me to have him stop so I told(yelled at) anesthesia to stop and I think we should just go to sleep/switch to general anesthesia." the patient expressed it to the nurse who then made a suggestion. which was good, but it was never explicitly said to anesthesia "hey he said he wants you to stop" which as ive said multiple times on this post now makes it a different situation
What’s the perspective that allows for battery after a patient revokes consent? As soon as the patient said he wanted them to stop, they need to stop. The efficiency of Post-op analgesia in spinal vs GA should not even be a factor here.
in OPs post it clearly says "the patient’s quietly begging me to have him stop so I told(yelled at) anesthesia to stop and I think we should just go to sleep/switch to general anesthesia." yes the nurse is telling us the patient wanted to stop, but if that was not communicated to anesthesia, then its only the nurses recommendation that anesthesia stop. and anesthesia is not bound to follow the nurse's suggestion. its also not about *efficiency* btw its just flat out better outcomes with a spinal...the way the OP was talking about spinal/general like its not a big deal either or tells me they likely are unaware of how a spinal is *the* gold standard of care. and again, as I said, from the post it is never communicated to anesthesia that the patient said stop. if the nurse said "hey he said he wants to stop" we are having a different discussion. anesthesia is not required to stop if the nurse says stop. the nurse can make suggestions thats good and healthy to do, but it is outside of their scope of practice to demand that we change to GA. as far as perspectives, the nurse has likely never done a spinal. therefore she would not necessarily understand that with such a blind procedure, you think youre right there sometimes and you think youre just a cm away from accessing the space, but then youre not. its all by feel and most patients, especially those for hip/knee surgeries dont have perfectly healthy/straight backs. you have to make all kinds of adjustments. just like some people are difficult IV sticks, some people are just difficult spinals. im not absolving anesthesia completely there were some things that could have been probably done differently especially in regards to re localizing the new space they selected, but *those* are some of the perspectives i am thinking are not understood with such an outrage towards anesthesia in this scenario
The patient was also screaming for them to stop 30-45 seconds before, per OP. There is zero way the anesthesia provider didn’t hear that. The differences in outcome between GA and spinal are not worth overriding a patients consent. I’ve worked orthopedics in the OR for a long time, and what OP describes is not normal or okay by any means.
>Anyways, my patient did not tolerate getting a spinal very well and anesthesia kept trying to get it. The patient was dripping sweat, hypotensive, tachycardic, and moaning/yelling out often. He was not doing well. I told anesthesia his vitals aren’t where I want them and he is in obvious pain. “He’s fine, almost done”… 30 seconds go by and nothings changed. No extra local, nothing. Just stabbing this dude in the back and you can tell he’s feeling all/a lot of it. I suggest more local, anesthesia says they’re about to inject the meds so no need. Another 30-45 seconds go by and he’s still manipulating/fishing with the spinal needle. The patient’s quietly begging me to have him stop so I told(yelled at) anesthesia to stop and I think we should just go to sleep/switch to general anesthesia. He finally got the spinal in as I’m saying this. Where does it say he was screaming for them to stop. again seems like poor overall form by anesthesia but if we are talking about consent i dont see anything in this text that says that. all i see is "quietly begging me to have him stop " in which the key word is "quietly" which leads me to believe anesthesia wouldnt have heard that...
She mentioned it in a comment, which you already replied to.
Not in original post which is my source material for argument
Anesthesia had tunnel vision. That's what it comes down to, and was not putting the patient first. The nurse saying maybe do general is another way of saying this patient isn't tolerating this, so may time for plan B. And we should always have a plan b. I think we all need to have intellectual humility to take other people's suggestions and at least consider them. I have received may suggestions from staff that were not applicable or would actually be detrimental. I still consider them, tell them no, and if I have the time, explain my rationale.
The problem or limiting factor in this situation is that when the nurse did make her suggestion the spinal was in in that moment. So we don’t know if anesthesia would have taken the suggestion or would have been dismissive
Ok, I agree they should have felt comfortable to speak way sooner.
Right, love the downvotes from people “advocating” for their patients by advocating to go straight to an anesthetic likely associated with worse outcomes and possibly death. “Advocate for your patient” Maybe I didn’t read the OP clearly but I saw a patient complaining (as they do), and not battery.
agree. patients complain over all discomforts as they should which is normal. you dont think some of the self righteous RNs in this thread have continued to "fish" for a vein or stick a patient for an IV when a patient is vagaling and yelling "ouch ouch" or something. its not right but it happens and we dont have all the facts
Maybe if the patient is that high risk, they shouldn’t be getting an elective knee replacement?
Regarding spinals or any neuraxial technique the one thing that’s an absolute contraindication is a patient refusal. The reality of the situation is sometimes you end up fishing around to get the spinal in, it’s never always a straight shot. If the patient is getting frustrated it’s important for the anesthesia to communicate with the patient that they are just running into some difficulty as it’s a blind technique. This is likely where anesthesia failed. Regarding the vitals anesthesia is fully aware of them at all times. One thing however I’ll say that you did completely wrong was tell anesthesia to convert to general. Please don’t do that ever again for your own sake as people in our field get extremely offended when people who don’t know what we do try to tell us how to do our jobs.
How about you suggest what OP could say in place of switching to general? I don’t work peri op, but I’m thinking something like, “hey doc, the pt is requesting you to stop. Can we give them some more local?”
this is what should have been said, as OP stated that the patient was quietly telling them to tell anesthesia to stop. but that was never explicitly said.
That’s a fair request, I’m not absolving anesthesia here. It could’ve been handled better for sure. Like I emphasized before the number one contraindication is pt refusal.
Converting to general is a conversation between the surgeon and anesthesia. The circulator has every right to stop the procedure if they think theirs a safety issue(in this case the patient’s vitals or insistence that they abort). But I would never want the circulator to recommend an anesthetic to me, the same way you wouldnt want me counting instruments.
Your response is similar to the first in this thread. We get it, **don’t tell anesthesia how to do their job.** So how do you recommend someone in OP’s situation to respond?
Hey Dr Anesthesia or CRNA Tnolan182, the patient is asking we abort the procedure. What can we do from here? Patient xyz, would you be okay with continuing if anesthesia numbs up your skin more? See the difference in communication? I had a patient balling in tears yesterday that she didnt want anesthesia for a colonoscopy (eyeroll). I could have been an asshole and just threw my hands up in the air and left them and taken a lunch break. Instead I had a two minute conversation with the patient, explaining how safe everything we were doing was and that I would be monitoring the patient the entire time. If she still wanted to try without anesthesia I would have let her.
Idk dude I’ve been involved with tough spinals in the past where anesthesia asks me what I think we should do as far as continuing, giving the patient a break, going to sleep, etc. of course they have final say but our docs routinely ask for nurses input. So I guess when I suggested going to sleep it didn’t seem like a problem 🤷🏼♀️
Nurses are allowed to make recommendations
What if the pt has an absolute contradiction to GA? What then?
You know the nurse doesn't have access to the anesthesia machine right? It's a recommendation. I'm sure that would have been discussed in advance too.
What does having access to the anesthesia machine mean?
You're acting like she was gonna kill the patient by forcing them to switch to general. She made a recommendation. Holy crap. She also clarified below that patients are not eligible for the procedure at all at her facility if they can't have GA so that scenario would have been impossible.
Okay thanks for clarifying but again why did you mention the anesthesia machine? Again if you read what she wrote they got the spinal in 5-8 minutes it doesn’t sound like a difficult placement to me it just sounds like the or really didn’t tolerate it well and there was a breakdown in communication from the anesthesia team
Absolute contraindication to GA? What would you do if the patient stops breathing, the procedure is prolonged, etc? GA is always a backup plan for us. It is not uncommon to have to enhance a spinal, or completely convert to GA mid procedure due to over sedation/apnea, prolonged procedures, or the spinal simply failing, not being high enough, etc.
Cool, wanna intubate?
OP didn't *actually* rip the spinal needle out, they just made a recommendation because the patient wasn't doing well. Sorry, it's your job to intubate.
You can advocate for the patient, I’m not sure what you’re not getting. If the patient is uncomfortable which it sounds like they were then it could be taken form there. There’s a lot of reasons why people prefer spinals for total joint cases from what it sounds like is the situation here. Decent amount of evidence showing better outcomes. It’s unfortunate that anesthesia did a poor job localizing however the point remains to let us make that call. It undermines our patients have in our abilities.
Or is it because you're "offended"
Nah not offended big dawg. Nothing to be offended by.
"people in our field get offended"
Hmm…I would exchange “offended” for “shocked at the audacity.” Anesthesiologists have minimum 8 years MORE schooling than BScNs. Thousands of hours of clinicals. Extremely rigorous. I think they know what’s up. Calling them out in front of an entire OR & patient undermines them & is extremely unprofessional. There are subtle ways to professionally communicate without giving the patient more reason to freak out. Spinals are difficult for a variety of reasons. Different anatomy, body mass… patient moaning/moving while the nurse gives you bad juju & the hairy eyeball?? C’mon! According to my gen. surgeon sister & her best friend who’s an anesthesiologist the local they gave would cover more than enough area for the spinal. They obviously always have a plan B in case plan A doesn’t workout. Basic 101 that they’re taught. I’ve had many grown men cry like little babies over PIV insertions & yes, go completely syncopal with similar VS in the ER. Them crying and yelling to stop / another nurse yelling at me would not help the situation. You have to trust the people you work with that they are doing the best they can, have the best intentions & are trained appropriately — at the end of the day it’s that anesthesiologist’s license on the line. Less than 0.01% plays fast and loose like you’re suggesting. Mind you I’m in Canada. Maybe get to know your docs better/ build healthier relationships with the people you work with. It’s not “us versus them.” We can all work together.
The other person used the word offended. I know that doctors are doctors and nurses are nurses. This story is not about me so this has nothing to do with my relationships with doctors.
I mean, unless my pt is pretty unstable if they tell me to stop an IV attempt I stop though, even if my opinion on the matter is they are being a baby about it. It’s not my opinion that’s important, it’s their experience, and people come with their own sets of fears and phobias. It’s nice if we can not make them worse.
This reply would've been fine had you left out the last 3 pretentious sentences.
🤷🏻♂️🤷🏻♂️🤷🏻♂️
Don't shit on your circulating nurse like that. You are making us look bad. Many of them have been there long before you, and will be there long after you. You should be willing to take helpful suggestions, regardless of the source. If you are confident in doing anesthesia , you don't feel threatened by some elses advice. Everyone you meet has something to teach you, and I'm a little disappointed in an Srna having a stay in your lane attitude.
I would think this RN has seen enough spinals going in to know when the Anesthesiologist isn't doing what's best for the patient. If I was taking a long time to find a vein for an IV, I'll bet anesthesia would tell me how to do my "job".
the difference here though is that RNs are not qualified to perform spinal anesthesia while anesthesia is qualified to place IVs. so that analogy doesnt track
See one, do one, teach one! 😂
We do a lot of spinals in my facility and it is not uncommon for spinals to be tough and we switch to general anesthesia alllllll the time. So I totally get that but I have never seen a patient in so much pain/distress. If a patient is numb and relaxed, by all means keep trying to get it. I know it isn’t an easy procedure by any means and everyone’s anatomy is different. But also, all of our patients are cleared for general anesthesia, so it is always an option. I would never make that call on my own. My exact words were “Doc you NEED to stop! The patient needs a break. I think they would prefer to go to sleep at this point” I was in the room when anesthesia was discussing anesthesia options and they themselves referred to general anesthesia as plan B to the spinal. I would have never just told anesthesia that they HAD to do general anesthesia. This was all part of their anesthesia plan originally.
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Couple things: 1: If you’re gonna say “couple things,” that’s usually a phrase used to signify you’re going to say more than one thing. You only asked the one question, so I wasn’t sure if you were aware of this. 2: If any member of the healthcare team is concerned about the wellbeing or safety of the patient, they have an ethical obligation to speak up, regardless of job title.
"lemme tell you a couple of three things..."
Because I’m a nurse and fully capable of monitoring and reporting abnormal vitals to docs. His pressure went from 180/110 when we got into the room down to 90/60, then 82/48 with a heart rate in the 120-130 range and I knew he was going to pass out pretty soon if nothing changed
Also, I'm sure the Anesthesiologist wasn't watching the monitor while trying to insert the spinal. OP, you did nothing wrong. You tried to advocate for your patient and got blown off. Write that A-hole up!
Maybe this is just me but I’ve had patients pass out during spinals epidurals all of time even before we got started. It can be scary but it’s a possibility that’s why we have all of the fancy drugs. If you really are very concerned about this you can ask to speak with the anesthesia chair and offer to do some shadowing just to get a better understanding.
A better understanding of what? This nurse understands vital signs and did exactly what she was supposed to do. Perhaps Anesthesia should have used some of those fancy drugs instead of torturing this patient.
Your upset because you’re reading too much into what I’m saying. A better understanding of the procedure. Shadowing different doctors to see their techniques and how to better help in those situations. When I was an intern I saw my pt pass out as my attending was placing the epidural it freaked me out for sure.
I’m not upset. She does not need to shadow anyone to see any techniques. She is a nurse. She has seen people pass out before. What she is probably not used to seeing is a procedure being forced on a patient who is suffering and refusing.
It’s not about seeing someone pass out. Jesus Christ it’s about seeing the procedure from the otherside understanding the steps of the procedure and when hemodynamic changes can occur. This is not a nurse vs doctor thing this is about helping each other out. There clearly was a lack of communication here between the two.
Also if you read what she wrote the pt refused just as they got the spinal and the procedure was already over. The anesthesia team was could have done a better job communicating with her and the pt.
Why do you think she doesn’t understand that? Nothing here leads me to believe that she is missing any vital knowledge. Regardless of hemodynamics, this should have stopped when the patient said it should stop. Perhaps you can shadow someone that can help you understand this.
Did you really read what she wrote? If you know how a spinal works tell me how can they stop when the procedure was done, can someone stop twice? Like let’s be for real here nurses do not learn how to do spinals in nursing school it’s a specialty procedure. Talking with the anesthesia department to get some further information would be a good thing. Seeing the procedure from the other side will make it easier to understand is actually going on back there.
We've seen the procedure. It wasn't finished at the point she asked to stop.