Normal practice or unsafe practice?

[DrOwnage]

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The past 10 years I've been practicing (including residency) it's been perfectly acceptable for me to run out of the room to grab meds that aren't stocked in the OR Pyxis, from the central Pyxis (albumin, precedex, ketamine, calcium). Recently someone thought it was unsafe and complained. Among my inner circle of colleagues it seems to be a regular, safe and accepted practice as long as you let the circulator (busy) know, and are close by. Obviously at the right time, stable patient, no risky parts of the procedure. What is your opinion?

 

[JOHNBROCHILL]

That's not a problem. I've stepped out to grab different lead, different chair, to use the bathroom if no one is available to come in. As you said right patient and right time. My buddy was interviewing somewhere and the guy left his patient alone to give him a tour of the OR. Now that one was a bit much.

 

[cittykat]

Likely much more common in physician only practices.

 

[ucladoc2b]

Stable patient? I will leave briefly. But only for the least amount of time possible.

I mean, we step out of the room all the time for CArm, O arm, radiation treatment and other reasons.

 

[NICMAN]

Make the circulator get your drugs. They do that for the surgeon.

 

[Lab Lover]

Not unsafe. Might be a problem if someone wants to use it against you in peer review or your employer wants a reason to discipline you.

 

[coolforschool]

I’ve never done it but don’t blame others for doing it. I’ll usually ask the circulators to grab whatever’s needed. Some of my partners regularly do it for their morning break/lunch, but nobody does it egregiously.

Agree it’s probably safe but can be used against you with the wrong people in the OR (including surgeons).

 

[coffeebythelake]

It's fine to do during a GA case with stable portion of case. Keep it as brief as possible and only under circumstances where there isn't a good alternative

 

[cittykat]

The past 10 years I've been practicing (including residency) it's been perfectly acceptable for me to run out of the room to grab meds that aren't stocked in the OR Pyxis, from the central Pyxis (albumin, precedex, ketamine, calcium). Recently someone thought it was unsafe and complained. Among my inner circle of colleagues it seems to be a regular, safe and accepted practice as long as you let the circulator (busy) know, and are close by. Obviously at the right time, stable patient, no risky parts of the procedure. What is your opinion?

Another solution is to stock those commonly used drugs in the OR Pyxis. More work for pharmacy, I know, but it’s their job. We stock ketamine, calcium, and precedex in the OR. Less running around. Pharmacy doesn’t like us to use albumin so it’s in the central Pyxis.

 

[PpfSuxTube]

Its 100% safe but also frowned upon and would 100% not be defendable. Sorta like using your phone while driving. Never do it around the wrong ppl...

 

[sevoflurane]

I personally never do that. That’s a circulators job. Not too different from a circulator that is getting mesh for a hernia mid case.
That being said, I wouldn’t look down on any of my partners if/when they do that.

 

[Gator7]

MD only practice

If the surgeon demands the room to be snowing then yes I’m going out and cycling warm blankets.

Bathroom I’ve done when alone on call in a forever case when option B is going in my pants. Fortunately there’s a restroom in the OR hallway. In residency i had to run all the way to the locker room because attendings never showed up overnight.

 

[LowWafer8]

MD only practice

If the surgeon demands the room to be snowing then yes I’m going out and cycling warm blankets.

Bathroom I’ve done when alone on call in a forever case when option B is going in my pants. Fortunately there’s a restroom in the OR hallway. In residency i had to run all the way to the locker room because attendings never showed up overnight.

Grab a urinal?? What kind of small bladders do you guys have? I've never once in 15years had to go during a case. My body just knows. I don't leave the room either; the circulator can get whatever. My pt trusts me to be there for the entirety of his care; yes I leave for o-arm but that's very brief

 

[cittykat]

Grab a urinal?? What kind of small bladders do you guys have? I've never once in 15years had to go during a case. My body just knows. I don't leave the room either; the circulator can get whatever. My pt trusts me to be there for the entirety of his care; yes I leave for o-arm but that's very brief

I used to work with a vascular surgeon who would scrub out for a “protamine break” before he started closing every single carotid. Obviously you are not a 60yo man or a pregnant or nursing woman, and you never eat Chipotle or Taco Bell.

 

[DirtDocMD]

I don’t leave for a long time, but a quick trip to the hall Pyxis, or a 60 second “pee break” (only after informing the circulator of exactly where I’m going) on a stable patient during a stable part of the case, is something I have occasionally done, especially when on my own at the hospital. We leave critically ill patients in the care of ICU nurses, all the time, often on propofol drips/narcotics/ventilator, for hours/days. Is 30-60 seconds an increased risk?

“Legally defensible”??? Dunno, but if it’s my “legal responsibility” to stay trapped in the same room for 6-8 hours, on a long case, with no ability to relieve myself, then perhaps that needs to be addressed in the hospital subsidy (to allow for a “backup”) or with OSHA regulations, or JCAHO needs to require a bathroom be placed in between each OR room, along with a vitals monitor screen, in all new hospital construction….

 

[ucladoc2b]

I don’t leave for a long time, but a quick trip to the hall Pyxis, or a 60 second “pee break” (only after informing the circulator of exactly where I’m going) on a stable patient during a stable part of the case, is something I have occasionally done, especially when on my own at the hospital. We leave critically ill patients in the care of ICU nurses, all the time, often on propofol drips/narcotics/ventilator, for hours/days. Is 30-60 seconds an increased risk?

“Legally defensible”??? Dunno, but if it’s my “legal responsibility” to stay trapped in the same room for 6-8 hours, on a long case, with no ability to relieve myself, then perhaps that needs to be addressed in the hospital subsidy (to allow for a “backup”) or with OSHA regulations, or JCAHO needs to require a bathroom be placed in between each OR room, along with a vitals monitor screen, in all new hospital construction….

The surgeons will certainly scrub out mid-case if they have to (and it’s safe).

 

[coffeebythelake]

Someone has to watch the patient. In a stable GA case that can be a circulator nurse, briefly, while you go to the toilet to take a dump

 

[abolt18]

Generally will ask the curculator to get whatever I need, though I would have no problem with someone stepping out at a safe time to grab something from the pyxis. Equally, I have asked the nurse to watch the monitor for a moment while I step into the bathroom to pee when no one was available to get me out and it's a long case with no end in sight. It's a very rare occurrence but has happened.

 

[Teillard]

How often do people need to leave the room for supplies and drugs? Sounds more like a stocking problem than anything else. We certainly don't leave to grab blood just down the hallway 'cause there's someone whose job that is...

 

[aneftp]

Bathroom breaks i understand leaving briefly.

I don’t think getting drugs in the core Pyxis is defendable if something goes wrong

Attorney will always ask. Is there another alternative method to get the drugs. U will be hosed becuase the alternative is to have rn in the room grab it for you

 

[DG51]

Bathroom breaks i understand leaving briefly.

I don’t think getting drugs in the core Pyxis is defendable if something goes wrong

Attorney will always ask. Is there another alternative method to get the drugs. U will be hosed becuase the alternative is to have rn in the room grab it for you

How would leaving for a bathroom break be any more defendable? If something happens and you are out of the room, for whatever reason, you are screwed either way.

Full disclosure, I am ok stepping out if absolutely needed, but this happens incredibly rarely, like once a year.

 

[pgg]

Make the circulator get your drugs. They do that for the surgeon.

I do, except for controlled substances. For some reason ketamine and the 100 mL propofol bottles aren't stocked in the ORs.

And I tell the circulator, and ask that they watch the monitor and yell real loud if they need me.

Perfectly OK to step 10 feet into the core to get drugs (or anything else, or to dodge xrays).

 

[TheLoneWolf]

Never done it myself though partners have done so.

 

[coffeebythelake]

How would leaving for a bathroom break be any more defendable? If something happens and you are out of the room, for whatever reason, you are screwed either way.

Full disclosure, I am ok stepping out if absolutely needed, but this happens incredibly rarely, like once a year.

It is more defensible because the circulator isn't able to pee or take a dump on your behalf. We are Not robots. We are human beings and there are legitimate bodily functions that take place.

 

[Ronin786]

"Because of the rapid changes in patient status during anesthesia, qualified anesthesia personnel shall be continuously present to monitor the patient and provide anesthesia care. In the event there is a direct known hazard, e.g., radiation, to the anesthesia personnel which might require intermittent remote observation of the patient, some provision for monitoring the patient must be made. In the event that an emergency requires the temporary absence of the person primarily responsible for the anesthetic, the best judgment of the anesthesiologist will be exercised in comparing the emergency with the anesthetized patient’s condition and in the selection of the person left responsible for the anesthetic during the temporary absence."

ASA Standards for Basic Anesthetic Monitoring


Interpret as you wish.

Standards for Basic Anesthetic Monitoring

www.asahq.org

 

[Simba1711]

I’ve stepped out for taking a piss or grabbing narcotics. Only the Pyxis near the OR desk had certain narcotics. If I step out I let the circulator know and the patient is stable. Under ga paralyzed and not at a crucial step of the surgery. 30-60 sec usually.

I’m not stepping out to take a dump like others have posted. Thats too much time.

 

[coffeebythelake]

I’ve stepped out for taking a piss or grabbing narcotics. Only the Pyxis near the OR desk had certain narcotics. If I step out I let the circulator know and the patient is stable. Under ga paralyzed and not at a crucial step of the surgery. 30-60 sec usually.

I’m not stepping out to take a dump like others have posted. Thats too much time.

If it's about to touch cloth, it only takes a few seconds to take a dump.

 

[Coffee PRN]

I’ve never done it but don’t blame others for doing it. I’ll usually ask the circulators to grab whatever’s needed. Some of my partners regularly do it for their morning break/lunch, but nobody does it egregiously.

Agree it’s probably safe but can be used against you with the wrong people in the OR (including surgeons).

They leave and go get breakfast/lunch?? I occasionally stepped away for a quick piss/poo before but can’t imagine being gone more than 5 minutes…I make sure they are paralyzed before I go and let the circulator know

 

[UscGhost]

Never done it myself though partners have done so.

What do you do if a partner is having an airway issue next door?

 

[TheLoneWolf]

What do you do if a partner is having an airway issue next door?

If I'm solo in a room, I can call the coordinator to go help but I wouldn't leave my patient. If I'm available, I will go help.

 

[UscGhost]

If I'm solo in a room, I can call the coordinator to go help but I wouldn't leave my patient. If I'm available, I will go help.

Most solo docs dont have a free MD (coordinator) floating around.

The generally accepted practice is to leave the room to help (for a limited time, if your patient is stable, intubated, appropriate time in the case

 

[JoelJoel84]

This may be an age/ generation thing, but there are some very surprising answers here.

I don’t think anyone in my group (or here ) under 40-50 , myself included, would think twice about leaving the OR briefly in a stable patient.

Do it all the time to grab something in the central Pyxis, quick pee when solo and on call, need something from central anesthesia storage room, etc.
Just let the circulator know, you’re still physically there and immediately available

 

[zizzer]

I don't think that's a big deal at all if the patient is stable, but if somebody is going to complain about you, then stop being nice and just make the circulator grab the meds.

 

[AKMD_1984]

depends on the facility
if you gotta go, just go

i turn the anesthesia up - tell the surgeon and have circulator watch the patient that i’ll be back in a few minutes and then i go - no one cares. they know how hard we work and how tough solo md anesthesia can be in private practice. we don’t have partners or backups.

is it ideal? no. is it negligent? depends? are you leaving when the patient is unstable or anticipated to be unstable? then no.

your comfort level and mental acuity is important too. if you’re distracted by needing to pee/poop and getting hypoglycemic…i weigh that against everything

never had a bad outcome or anything even close to it

 

[AKMD_1984]

This may be an age/ generation thing, but there are some very surprising answers here.

I don’t think anyone in my group (or here ) under 40-50 , myself included, would think twice about leaving the OR briefly in a stable patient.

Do it all the time to grab something in the central Pyxis, quick pee when solo and on call, need something from central anesthesia storage room, etc.
Just let the circulator know, you’re still physically there and immediately available

yeah …as always it’s about using your best judgment and common sense…

i agree with meds…i actually prefer to get my own opioids or meds from central pyxis…

 

[AKMD_1984]

"Because of the rapid changes in patient status during anesthesia, qualified anesthesia personnel shall be continuously present to monitor the patient and provide anesthesia care. In the event there is a direct known hazard, e.g., radiation, to the anesthesia personnel which might require intermittent remote observation of the patient, some provision for monitoring the patient must be made. In the event that an emergency requires the temporary absence of the person primarily responsible for the anesthetic, the best judgment of the anesthesiologist will be exercised in comparing the emergency with the anesthetized patient’s condition and in the selection of the person left responsible for the anesthetic during the temporary absence."

ASA Standards for Basic Anesthetic Monitoring


Interpret as you wish.

Standards for Basic Anesthetic Monitoring

www.asahq.org

“shall be”
not “must be”

 

[DG51]

It is more defensible because the circulator isn't able to pee or take a dump on your behalf. We are Not robots. We are human beings and there are legitimate bodily functions that take place.

I'll agree with you, this is more defensible. The point I'm trying to make is that you're going to be **** out of luck either way when an attorney asks you what you were doing outside of the operating room when the surgeon hit the portal vein, the patient suffered a massive PE, etc.

Sure, it sounds better to say that you needed to emergently use the restroom and no relief was available versus you were stepping out to grab meds. But you're losing that case either way.

 

[UscGhost]

I'll agree with you, this is more defensible. The point I'm trying to make is that you're going to be **** out of luck either way when an attorney asks you what you were doing outside of the operating room when the surgeon hit the portal vein, the patient suffered a massive PE, etc.

Sure, it sounds better to say that you needed to emergently use the restroom and no relief was available versus you were stepping out to grab meds. But you're losing that case either way.

Would be pretty difficult to prove that you were gone, and that being gone contributed to the patients complications. Even if the ETT or lma disconnects...30 secs isnt long enough to cause an issue.

Nothing you could do in 30 secs to correct a bleeding issue

Assuming you stepped put for 30 secs to pee. (Going to eat is different)

 

[DG51]

Would be pretty difficult to prove that you were gone, and that being gone contributed to the patients complications. Even if the ETT or lma disconnects...30 secs isnt long enough to cause an issue.

Nothing you could do in 30 secs to correct a bleeding issue

Assuming you stepped put for 30 secs to pee. (Going to eat is different)

If you can get to the restroom and take a dump in 30 seconds, good for you, I cannot.

 

[coffeebythelake]

If you can get to the restroom and take a dump in 30 seconds, good for you, I cannot.

Gotta bring a bedpan into the OR then

 

[UscGhost]

If you can get to the restroom and take a dump in 30 seconds, good for you, I cannot.

Gotta get more fiber

 

[Coffee PRN]

If you can get to the restroom and take a dump in 30 seconds, good for you, I cannot.

Chronic diarrhea from all the caffeine helps with that!

 

[coolforschool]

Would be pretty difficult to prove that you were gone, and that being gone contributed to the patients complications. Even if the ETT or lma disconnects...30 secs isnt long enough to cause an issue.

Nothing you could do in 30 secs to correct a bleeding issue

Assuming you stepped put for 30 secs to pee. (Going to eat is different)

I actually don’t think it would be all that difficult to prove. They’d just depose the circulator, scrub, or surgeon, assuming something bad happened within those 30 seconds. Chances of all three parties agreeing you weren’t gone (when you were) approaches zero.

IMO, it’s not the actual harm itself that matters but the perception/possibility of it. Hard to defend in court, speaking as someone who agrees leaving the OR to pee or grab meds if needed is reasonable. It is always a risk, but as someone mentioned above, we’re all human.

 

[Gator7]

Circulator monitoring the patient is about as helpful as no one. Actually probably worse.

I’m not notifying anyone to step out for 30 seconds. Chances anyone notices is near zero.

 

[MalloryWeiss]

Everyone's thoughts on stepping away during a c-section?

Assume patient is not intubated, baby is out, spinal/epidural working effectively. Now sewing the uterus/fascia/skin. Reasonable to step out for a bathroom break / Pyxis / give an epidural bolus?

 

[Account1]

How would leaving for a bathroom break be any more defendable? If something happens and you are out of the room, for whatever reason, you are screwed either way.

Full disclosure, I am ok stepping out if absolutely needed, but this happens incredibly rarely, like once a year.

Never heard of a malpractice case due to a 2 minute absence during a stable case. Not like people are peaceing out to pee while drying up after coming off bypass

 

[Account1]

Everyone's thoughts on stepping away during a c-section?

Assume patient is not intubated, baby is out, spinal/epidural working effectively. Now sewing the uterus/fascia/skin. Reasonable to step out for a bathroom break / Pyxis / give an epidural bolus?

Leaving an awake patient is a terrible idea. No explanation would ever satisfy them.