Hospital protection for EPs

[polygonal]

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So, I have this friend.... (it really isn't me but it has me thinking)

A colleague of mine is dealing with a situation where he is being criticized for not performing a procedure "fast enough." The issue is the hospital did not immediately provide what I would consider to be appropriate personal protective equipment. The best analogy I could provide without disclosing more information would be getting criticized for not emergently placing a chest tube if no gloves were available (sterile or not).

It appears that we should be covered under OSHA, even as ICs. I'm not sure that is a very big stick though. Does anyone have any thoughts and/or resources for this kind of situation?

I'm feeling more and more like an assembly line worker these days but at least if I was working for Ford I would have someone looking after my physical wellbeing.

 

[Doctor Bob]

I guess I can't think of what PPE you'd need that isn't readily available in any ED...
Gloves and a mask with a face shield. Those are pretty darn ubiquitous. For an emergent procedure, I can't think of what else you'd need.
Every ED has masks with a face shield or masks and goggles... those are OSHA/JointCommission things. Even for the non-IC staff (the ED would have to have them for the nurses, etc).

So I'm somewhat at a loss as to what you're alluding to. And without knowing that, I'm not sure how much righteous indignation to have or not have.

 

[Janders]

Agree with above.

And I also haven't worked anywhere that would say a doc was too slow in acting... that then wouldn't accept "no PPE was around!" as a completely valid reason, and then ensure PPE was around in the future...

Peer review? Medical staff review? You are correct you deserve to be protected at work.

 

[GeneralVeers]

I wouldn't do a chest tube without at least gloves and a mask. Though in a true emergency you wouldn't use sterile gloves if you couldn't find them. Honestly if a life is at stake do you care about them getting an infection due to the EMERGENT procedure? I'd go with the purple nitriles hanging on the wall at that point.

 

[polygonal]

Ok. Sorry for being a little obtuse, I hope you understand.

Let's take the chest tube argument. Say your hospital is chronically short on supplies and they don't readily have large gloves. Your hands can't fit into the small gloves that are present. The large gloves are in a supply room somewhere away from the trauma bay. A CEO of a major local company comes in and needs an emergent chest tube. You refuse to do it until you have gloves. Administration then threatens your job.

Thoughts??

 

[deleted245139]

Are the gloves so far away? Also, unless you're at a particularly busy trauma center, are those rooms in use so often that the gloves are just out? Shouldn't those rooms be used the least? Or is this a Rob Peter to pay Paul kinda thing? Just an odd scenario. Lacking the chest tube tray should be a bigger problem than gloves...

 

[deleted77919]

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[e30ftw]

The chest-tube scenario is hard to imagine because every resus room in my ED has multiple pairs of sterile gloves in sizes ~6-8.5 as well as s/m/l nitrile gloves on the wall.

In the honest-to-God situation where someone was dying in front of my eyes from an obvious tension pneumo without the possibility of getting gloves in <1-2 minutes I would just bare-hand it. Intact skin is a fine protective barrier..

The only truly emergent procedure (ie: patient will die or suffer complete neurologic devastation if not performed within 1 minute) that I would not do bare handed if truly necessary (ie, no gloves in the whole ED due to some sort of cataclysmic admin fail) is an ED thoracotomy, and those are pretty much pointless anyway.

 

[Janders]

Two sides to everything, but I wouldn't be terribly fond of that job. And I agree with your initial supposition that firing someone for not performing a dangerous act without PPE sounds like a lawsuit waiting to happen.

 

[Old Grunt]

As a total aside: I now always have a pair of sterile gloves in my glove box after stopping to render medical assistance on the roadside once. I was the first person on the scene and had no PPE and it was certainly needed. Am I the only weirdo that does this?

 

[gman33]

I have a hard time following the hypothetical situations.

If the environment does not have the basic supplies you need for your job, that is a problem.

I've had situations where I needed to intubate someone and couldn't find a face shield.
Not ideal, but I proceeded.

 

[BoardingDoc]

In the honest-to-God situation where someone was dying in front of my eyes from an obvious tension pneumo without the possibility of getting gloves in <1-2 minutes I would just bare-hand it. Intact skin is a fine protective barrier..

I would just stab a 14 gauge or two in their chest while the nurse ran to the supply closet.

 

[deleted547339]

I have a hard time following the hypothetical situations.

If the environment does not have the basic supplies you need for your job, that is a problem.

I've had situations where I needed to intubate someone and couldn't find a face shield.
Not ideal, but I proceeded.

You use a face shield to intubate?

 

[BoardingDoc]

You use a face shield to intubate?

I had the same thought when I started residency. Then I saw a patient cough/vomit/have CPR force bloody sputum at the face of the person who was intubating.

Yeah. Wear a mask. Or don't. They're your mucus membranes.

 

[deleted547339]

I had the same thought when I started residency. Then I saw a patient cough/vomit/have CPR force bloody sputum at the face of the person who was intubating.

Yeah. Wear a mask. Or don't. They're your mucus membranes.

Do you always do it? Or just active cpr?

 

[shoal]

I always wear a mask, plus or minus faceshield but I wear glasses.

Sent from my VS986 using Tapatalk

 

[RustedFox]

As a total aside: I now always have a pair of sterile gloves in my glove box after stopping to render medical assistance on the roadside once. I was the first person on the scene and had no PPE and it was certainly needed. Am I the only weirdo that does this?

Not anymore. I'm putting gloves and a facemask in my car right now.

I still laugh at that post of yours where you called me an aristocrat (drink after a nightshift thread). Thanks. 🙂

 

[BoardingDoc]

Do you always do it? Or just active cpr?

I do it all the time now to create the habit. It takes 5 seconds, the shield doesn't interfere with my ability to intubate, and it provides me with another layer of protection that I could conceivably need during airways.

 

[emergentmd]

Story sounds fishy. We get over abundance of protection where I work.

Anyhow, All procedures should have goggles. I use it on EVER procedure. LPs, sutures, Intubation, abscess. If there is fluid involved, I wear goggles.

Me: resident, intubated old guy. Dude vomited blood all over me including my face.
Resident friend during HIV abundance - LP, fluid blew up in his face.

So Always protect myself.

If the Ops story is completely true, and there was no gloves I could use. I would not do it. Fire me, I will find a better job tomorrow.

 

[DrDrummer]

I'm guessing it's a different procedure, and maybe they didn't have sterile gloves in the right size or protective glasses for something like an LP? I agree with everyone who posted that they wear eye protection regularly in messy procedures / traumas because one HIV/TB/Hep/Zika+ arterial spray or regurgitation to the eye is enough to really ruin your day. We're in a specialty that prides itself on being able to function in the "austere environment" -- so I'd hope that most people could and would find a way to get most things done. If this person couldn't, there's some pretty bad systemic dysfunction going on, or there were other reasons the procedure didn't get done.

 

[gro2001]

Ok. Sorry for being a little obtuse, I hope you understand.

Let's take the chest tube argument. Say your hospital is chronically short on supplies and they don't readily have large gloves. Your hands can't fit into the small gloves that are present. The large gloves are in a supply room somewhere away from the trauma bay. A CEO of a major local company comes in and needs an emergent chest tube. You refuse to do it until you have gloves. Administration then threatens your job.

Thoughts??

I understand that chest tube and gloves are not the procedure/PPE situation that your friend specifically encountered, but since you chose that analogy... I just don't see a situation he couldn't have made work well enough if he really wanted to. Using your analogy:

If this CEO needs an emergent chest tube, AND I decided I can only do it with sterile gloves, AND no sterile gloves of ANY size are available (I have large hands, I prefer large gloves but they stretch pretty well and in a pinch I will grin an bear wearing smallish gloves for the duration of the procedure) AND no one can find any to bring in a reasonable amount of time... Can I open any of the kits that typically have sterile gloves in them? LP trays, many central line kits, delivery kit, some suture kits, etc sometimes have sterile gloves. I am not saying it's ideal to always be opening an LP kit in addition to the chest tube kit every time you need a pair of sterile gloves, but if I really needed them and couldn't wait, I'd find a way...

It sounds like your friend was maybe frustrated at his hospital not being chronically crappy at stocking supplies and was making a passive aggressive point by making his patient wait for a chest tube until he had the 'right equipment'. If that's the case, that is a very poor judgement call.