TRANSPARENCY for EQUAL ACCOUNTABILITY in MEDICINE

KEEPING SURGERY SAFE

kim-sanders-fisher-12-hours-continuously-scrubed-into-surgery-without-a-break1

How Long is Too Long for a Member of the Sterile OR Team to Remain Continuously Scrubbed into Surgery without a break?

Although the general public might not understand that medical professionals, including the Surgeon, must leave the OR briefly during a lengthy Surgery, most conscientious practitioners realize that this is a normal safety measure necessary to combat fatigue. I am trying to get a consensus of feedback, from those who must routinely face this dilemma in the OR, as to what time frame is universally accepted as the maximum period that any member of the sterile team should ever be expected to safely function while scrubbed into Surgery without a break?

I am now enrolled in the National Institute of First Assists, “NIFA,” training program to become a First Surgical Assistant, but even as a Surgical Technologist, performing the “scrub” role, I had to concentrate on anticipating the Surgeons needs during a case. After how long would you consider that scrub role jeopardized by fatigue to the point where I might have lost concentration and focus on the operation? Can we really afford to take such risks and blithely talk of the increased incidence of medical errors as if these issues were completely unrelated?

While a Surgeon can, and should, demand that the person assisting him in Surgery is relieved briefly during a lengthy case, Nurses and Surgical Technicians fall under the control of OR Management. This leaves them vulnerable to the vagaries of inappropriate OR coverage as determined by the Hospital. As a consequence of Hospital “downsizing” to cut costs, redundancy of personnel has been severely limited. This has reached the point where during the off-shifts, especially at night and on weekends; there are no free staff to break people out of Surgery for even a quick run to the bathroom!

At an inner city Level One Trauma Center these off-peak time periods are covered by a minimal compliment of essential experienced medical staff, who must frequently deal with critical trauma cases, emergency returns to the OR and major Transplant Surgery. This was my regular OR shift assignment at my former Hospital for the last 2years of my 5year tenure. With just one Nurse and two OR Techs on duty after 11:30 PM on a Saturday night, this challenging shift already required knowledgeable, highly adaptable and versatile staff. However, inhumane levels of endurance plus the ability to tolerate severe deprivation for extended periods shouldn’t be part of any job description. The real question is, can critical OR personnel maintain concentration during complex cases under such radical extremes as 12hours continuously scrubbed into Surgery? The lack of redundancy among Nursing personnel is harmfully impacting ICU’s and other critical care units of many US Hospitals, but the physical limitations are severest in the OR.

Calling in call team people just to provide relief breaks is considered an unnecessary expense, despite the fact that there is a clearly established link between fatigue and medical errors. The sterile team scrubbed into Surgery must remain trapped without food or water until they are relieved which represents an unacceptable deprivation strain on the body. The inability to urinate when necessary is very unhealthy too. To simply “break scrub” and leave the OR without handing over to an assigned relief scrub and completing the necessary controlled counts is considered “patient abandonment.” However, there are currently no real safeguards within the existing US employment laws or OCHA standards to insure that critical Hospital workers, including those in the OR, are not left for hours of continuous, and dangerous, practice without a break.

Under US law in most States: “Breaks are at the discretion of the employer!”

I was left stranded at the field without relief for 8, 10 and on the worst occasion 12 hours straight during a Liver Transplant while my patient was on bypass! I worked off-shifts in the OR of a busy downtown Hospital famous for its active transplant program. We saw more penetrating Trauma than any other facility in Baltimore, a city with a homicide rate that averaged over 300 a year. These abandonment situations impacted my ability to concentrate as my blood sugar plummeted; each time I reported becoming sick, dizzy and faint to the point of nearly passing out. Who needs to eat at night anyway? My Nurse Manager wanted me evaluated for a “sugar problem!” When I dared to complain that my condition in response to this hardship presented a danger to my patients I was targeted for removal, forced to take unpaid leave and then fired.

Incidents where any member of the OR team is forced to remain on task for that long should be documented in an “Incident Report,” as an extreme of this magnitude presents an unacceptable, and in most cases unnecessary, danger to the patient. How many normal human beings are expected to go for 12 hours without water, food or urination? The Geneva Convention strictly prohibits such inhumane treatment of working POWs! Why is this acceptable for critical Hospital staff.

I offered this mandatory Incident Report requirement suggestion to my former Hospital via their Compliance Line, only to be ignored as a terminated and vilified unreliable informant. Healthcare facilities know that the most effective way to deal with concerns and complaints is to just “shoot the messenger!” Compliance Lines were established to allow employees to report negligence, fraud and abuse without fear of retaliation, but in some cases they have become another layer of defense from external scrutiny. No current legislation exists to protect Healthcare Whistleblowers and Hospital Compliance Lines cannot always be trusted with impartial internal investigations when they know there is no potential possibility for independent oversight.

The campaign of silencing a dissenter goes on long after they have been ousted in disgrace. I have contacted JACHO and other Accreditation Agencies as well as the Maryland Board of Nursing, but my warnings are easily discredited by my untimely removal from my job. A minor protocol change needs to be enacted immediately to prevent future incidents like this from becoming more commonplace exposing patients to potential harm through preventable negligent under-staffing. I cannot understand why so many Government agencies remain so complacent in refusing to review this situation rationally in the best interests of public safety.

There is an awful lot of talk about medical errors right now, but far less mention of the toxic work environment that is increasingly encouraging mistakes. This situation is getting steadily worse. While “At Will” employment laws silence those who dare to speak out, lack of a humane break policy condones driving Hospital staff until they drop: No big surprise that fatal or damaging medical errors and “sentinel events” are on the increase? Is it any wonder that a sponge or an instrument is inadvertently left inside the patient when the scrub is almost comatose after a stressful 12hour ordeal in Surgery? All the cross checking and elaborate safeguards are irrelevant if the Hospital staff are trying to function while so severely fatigued, hypovolemic or hypoglycemic that they are at the point of either falling asleep or passing out.

When will the various safety advocacy groups in the US finally address this very real problem and insist on proper protective legislation? There have been advances recently with limiting the Residents working hours and trying to stop mandated overtime for Nurses, but much more emphasis must be placed on eliminating unnecessary fatigue among all of our medical staff. Managers must be held responsible for providing adequate personnel to cover all of their shifts, including a redundancy of staff to relieve OR teams during Surgery and in other critical areas. If a Manager’s failure to provide relief was documented on a routine basis it would no longer be an acceptable form of staffing coverage! Such incidents would become the rare exception, confined as they should be to genuine emergency situations where there is absolutely no other choice.

“No one is more important than the patient unconscious on the OR table.”

This was the statement I gave to Hospital Lawyers at an Arbitration Hearing to determine my reinstatement. For this very prestigious Maryland Hospital the “Nursing Shortage” was a convenient excuse to justify unconscionable Managerial abuse that seriously endangered my patient in the OR. They claimed that the ER was busy and I had not asked for a break. The ER is an unrelated clinical area and just try begging for relief on a phone you cannot even touch! Doctors and Nurses face severe discipline when mistakes occur, but why isn’t a negligent Hospital policy that condones drastic staffing cut backs ever recognized as the real culprit? In some cases the administration even offers financial bonuses to further encourage self-serving Managers to implement inadequate staff coverage: greed works! Then, after clear indications demonstrate that deliberate under-staffing is continually putting patients at serious risk, they fail to hold repeatedly abusive Managers accountable as they drive dedicated staff until they drop.

This dangerous Managerial policy is focused purely on drastically reducing vital staffing costs to save money at the expense of creating a safe patient care environment that saves lives. We need proper safeguards in place to curb this negligent profiteering strategy before more patients are harmed unnecessarily. Additionally, when Healthcare employees are courageous enough to come forward and expose a pattern of ongoing negligent under-staffing practices or other dangers to patients they must be protected from retaliatory Managerial misconduct that threatens their job. If a Hospital’s internal Compliance Hot Line fails in their crucial self-policing obligation by refusing to investigate negligence or provide protection from retaliation they must be held fully accountable.

Whistleblowers should not face the third degree from Government Agencies who are all too easily fobbed off with ludicrous excuses that profess to demonstrate a disgruntled former employee is seeking revenge. In reality very few employees will consider risking jail time to “seek revenge” by making fictitious sworn statements under oath to a States Attorney! All complaints and allegations must be taken seriously by accreditation agencies who’s primary duty is to protect public safety. No medical institution no matter how iconic, prestigious or powerful should be immune from rigorous scrutiny, as this lack of oversight encourages bending the rules, ignoring regulations and cost cutting that is harmful to safe patient care.

Relentlessly abusive Managers are a very valuable tool in generating increased revenue by facilitating staff downsizing without obvious layoffs. I call this the spineless approach to cost cutting, but it makes our Hospital working environment extremely dangerous for the patients. The current so called, “Nursing crisis” has come about through a deliberate and calculated policy of dangerous downsizing to target Nursing staff, but particularly the most experienced Nurses who are higher paid. Minimally trained assistive personnel are plugging the gaps, working under the direction of overwhelmed new Nurse Graduates who are being forced to take on responsibility they are ill prepared to face. The creation of a toxic work environment is driving Nurses to leave their chosen profession in droves. When Nurses are powerless to change under-staffing, and powerless to report negligent practices, the only way to refuse the dangerous policy of keep taking unnecessary risks with patient care is to leave: hence the Exodus.

The US does not have a “Nursing Shortage” it has a “Nursing Exodus!”

The US healthcare industry is still consistently expecting all of our medical professionals to take bigger risks by making do with unsafe staffing practices. This important patient safety issue desperately needs to be addressed immediately, so please consider signing the Petition mentioned below and post your comments on this subject directly on the Petition itself.

THE PETITION SEEKING AN INVESTIGATION INTO THIS SERIOUS PATIENT SAFETY CONCERN CAN BE ACCESSED VIA THIS LINK: http://thepetitionsite.com/takeaction/938995258

A personnal letter of appeal and explanation from the author can be read at Care2.com via this Link: http://www.care2.com/c2c/share/detail/91853

The author is still struggling to overcome the severe damage that wrongful termination as a Whistleblower inflicted on her professional reputation. In August 2005 she returned from Tsunami ravaged Aceh Province, Indonesia where she had worked for six month as an unpaid Medical Volunteer in Surgery at Cut Nyak Dhien Hospital in Meulaboh.

This conscientious and dedicated Medical professional is calling for your help in the hopes that her Petition will precipitate meaningful debate on important issue like Under-staffing, Compliance and Whistleblower protections for Healthcare employees; eventually becoming a catalyst for new legislation of vital regulatory safeguards. While it will be gratifying just to make a tangible difference, personal vindication might remove the remaining barriers that still prevent her from reestablishing a worthwhile career as an NGO Medical Volunteer overseas. The author is also in the process of writing a book called: “ICONIC IMMUNITY,” detailing her experiences and the lessons learned. Please post your comments on this important issue.

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2 Comments »

  1. I think anything after 12 to 16 straight hours of work being “scrubbed”in is about my limit, although the hospital I work at requires us to sometimes work 24 straight hours and tells us to call in the other call team for relief even when they to have worked just as many hours as we are. It also gets me that RN’s can not be mandated to work, scrubs can. Why is this? we are performing a role just as important in the OR as the nurse. I feel unsafe and if I were a patient on that bed knowing how long the staff had been working I’d run not walk to the nearest exit.

    Comment by m morris — July 10, 2008 @ 12:44 am

  2. Thank you for your input, although I must say I am shocked to hear that the demands on you were even more extreme than in my case. It begs the question how prevalent is this type of exploitation. I am curious to know what area of Surgery you are in that has such lengthy cases? At Johns Hopkins there were some radical Neck dissections that ran for as long as 24 hours. There are often several different Surgical teams involved in such cases and the public should realize that no Surgeon would ever attempt to remain on task throughout an entire case of this length. The regulations differ from state to state, but in most states Nurses are subject to mandatory overtime.

    However, the Nursing staff, including Surgical Techs, are vulnerable to the excesses of cost cutting Hospital Management. The general public are blithely unaware of the extremes we are forced to endure while at work and they would be horrified to learn the truth. Bear in mind that the Geneva Convention prohibits such inhumane treatment among working POWs, but somehow this is still permissible for Medical staff performing critical roles in Surgery! The needs of the patient are always given as the excuse why we must remain continuously scrubbed into Surgery without a break. What must finally be understood is that this is not just a cruel and unhealthy deprivation and excessive demand being made of the staff; it presents a very serious risk to the patient unconscious on the OR table.

    Comment by Kim Sanders-Fisher — July 10, 2008 @ 5:23 pm


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