Radiology tech exposes pts to Hepatitis C

[okayplayer]

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http://www.cnn.com/2013/08/13/health/hepatitis-infections-case/index.html?c=us
http://www.salon.com/2013/01/21/the_hospital_tech_who_stole_needles/

Do you PP guys just carry your narcs in your pocket between cases? That's what I've done throughout residency. I was always worried about one of my techs (or maybe a circulator) swiping a syringe and me not being able to account for it, but I never even considered something like this.

Scary stuff. I rotated through one of these hospitals as a med student.

 

[deleted126335]

http://www.cnn.com/2013/08/13/health/hepatitis-infections-case/index.html?c=us
http://www.salon.com/2013/01/21/the_hospital_tech_who_stole_needles/

Do you PP guys just carry your narcs in your pocket between cases? That's what I've done throughout residency. I was always worried about one of my techs (or maybe a circulator) swiping a syringe and me not being able to account for it, but I never even considered something like this.

Scary stuff. I rotated through one of these hospitals as a med student.

You can count on a malpractice suit, excuse me, multiple malpracice suits, against the anesthesia provider(s) who failed to secure their controlled substances. Smart bet is that they will be settled with payment(s) for the plaintiff(s).

 

[okayplayer]

You can count on a malpractice suit, excuse me, multiple malpracice suits, against the anesthesia provider(s) who failed to secure their controlled substances. Smart bet is that they will be settled with payment(s) for the plaintiff(s).

What about propofol? There are documented stories about people abusing propofol. So is it a liability risk to draw up your propofol for the next case and leave it in a syringe on top of your cart? That would be a dramatic change in my practice.

 

[periopdoc]

Although it is rare for me to predraw narcs, if I do they either go in my pocket or in the locked narc stock drawer in the anesthesia cart/ Pyxis.

If I do predraw, I have a specific way of labeling it. Unless you look closely, you will think that it is a syringe of succinylcholine. If there is a syringe on top of my cart with a propofol or narc label, it's a pretty safe bet that there is a nasty surprise waiting for anyone who injects it.

Typically I don't draw up any drug until I am ready to give it, except in the cardiac room where I have emergency drugs drawn up in advance. I have timed it and drawing up my drugs in advance did not significantly decrease my door to tube time which runs 3-5 min for >90% of my patients.

- pod

 

[cchoukal]

What about propofol? There are documented stories about people abusing propofol. So is it a liability risk to draw up your propofol for the next case and leave it in a syringe on top of your cart? That would be a dramatic change in my practice.

JC doesn't allow us to place any drugs in an unmonitored, unlocked setting (e.g., nothing on top of the cart). Our drugs are locked in our carts whenever we are not in the room.

It is absolutely a liability risk to have propofol (or anything) on top of the cart. The average scrub tech or RN has no idea what the drugs are. They could easily grab anything thinking it's an "anesthesia drug" and therefore worth abusing.

 

[deleted126335]

What about propofol? There are documented stories about people abusing propofol. So is it a liability risk to draw up your propofol for the next case and leave it in a syringe on top of your cart? That would be a dramatic change in my practice.

Propofol is not a scheduled drug. IMO you would be on better legal ground (but not completely safe) with propofol than say fentanyl if you left syringes of both unsecured and somebody came to harm from diversion of one of them. I keep drawn up syringes in my locked tackle box when I am not in the room with them. We are respnsible for properly securing and controlling these meds. Failure to do so in a case where somebody diverts meds that were supposed to be under your control that results in patient harm is a strong case for the plaintiff.

 

[Ronin786]

Although it is rare for me to predraw narcs, if I do they either go in my pocket or in the locked narc stock drawer in the anesthesia cart/ Pyxis.

If I do predraw, I have a specific way of labeling it. Unless you look closely, you will think that it is a syringe of succinylcholine. If there is a syringe on top of my cart with a propofol or narc label, it's a pretty safe bet that there is a nasty surprise waiting for anyone who injects it.

Typically I don't draw up any drug until I am ready to give it, except in the cardiac room where I have emergency drugs drawn up in advance. I have timed it and drawing up my drugs in advance did not significantly decrease my door to tube time which runs 3-5 min for >90% of my patients.

- pod

That sounds pretty awesome. But wouldn't it potentially cause problems if someone were to relieve you?

When I rotated through the OR, residents/attendings would either lock the controlled substances or carry them in their pocket. I actually got queried by one of the residents for being out of sight while she had me holding onto a syringe of versed.

Propofol did seem to be too freely left around though. Half-empty 30cc syringes were routinely dumped in the trash and there were numerous pre-drawn syringes lying around most of the time. Its obviously hard to replace propofol with saline, but I'd make sure to empty the syringes into the trash after we were done just in case one of the techs was scavenging.

 

[Mman]

I have timed it and drawing up my drugs in advance did not significantly decrease my door to tube time which runs 3-5 min for >90% of my patients.

- pod

I'm not sure how it's even routinely possible to safely intubate patients in 180 seconds from the time you get them rolling into the OR. Our patients are so unhealthy and obese that it takes more than that just to get them onto the OR table a great majority of the time, let alone the time necessary for preoxygenation.

Our average time for all comers over something near 50K anesthetics a year is about 11 minutes from entering the room to intubation. Some procedures it's closer to 6-8 minutes, others are a bit longer.

3-5 minutes????

 

[IlDestriero]

I like that he's looking at $3m in fines. What a joke. I bet he doesn't have $30 to his name.

 

[excalibur]

Although it is rare for me to predraw narcs, if I do they either go in my pocket or in the locked narc stock drawer in the anesthesia cart/ Pyxis.

If I do predraw, I have a specific way of labeling it. Unless you look closely, you will think that it is a syringe of succinylcholine. If there is a syringe on top of my cart with a propofol or narc label, it's a pretty safe bet that there is a nasty surprise waiting for anyone who injects it.

Typically I don't draw up any drug until I am ready to give it, except in the cardiac room where I have emergency drugs drawn up in advance. I have timed it and drawing up my drugs in advance did not significantly decrease my door to tube time which runs 3-5 min for >90% of my patients.

????

Intentionally encrypting or mislabeling narcotics as a disguise for the potential abusers? This doesn't sound like a good idea to me.

I could see many problems with this

Also if a sly abuser, who could even be a colleague, were going to be very innovative and steal from my narcs stash....if that terrible scenario was going to happen regardless of how well secured the narcs were....then IMO it's best if my drugs for my next case were correctly labeled.

 

[excalibur]

I'm not sure how it's even routinely possible to safely intubate patients in 180 seconds from the time you get them rolling into the OR. Our patients are so unhealthy and obese that it takes more than that just to get them onto the OR table a great majority of the time, let alone the time necessary for preoxygenation.

Our average time for all comers over something near 50K anesthetics a year is about 11 minutes from entering the room to intubation. Some procedures it's closer to 6-8 minutes, others are a bit longer.

3-5 minutes????

Lap chole

Pt wheeled in room on stretcher. Stretcher next to bed and rail down. Pt slides over and lies down. Place O2 mask on with black S and M strap for preO2. Tie BP prongs to BP cuff on R arm and hit start on NIBP monitor. Pulse ox on left finger. Slap five ECG leads on (or have nurse be doing ECG's while you do rest). After that red lead hits the left hip, you hear the ding of the BP measurement. Glance at the BP value. Induce.

Don't see why above cant be done in 3-5 mins.

 

[jwk]

What about propofol? There are documented stories about people abusing propofol. So is it a liability risk to draw up your propofol for the next case and leave it in a syringe on top of your cart? That would be a dramatic change in my practice.

Well of course it is - honestly - I can't imagine you're even asking the question. Really?

 

[jwk]

Propofol is not a scheduled drug.

It is in Georgia.

 

[okayplayer]

Well of course it is - honestly - I can't imagine you're even asking the question. Really?

As I alluded to earlier, at least at my training program it is fairly common for residents/CRNAs to draw up drugs for the next case and leave them on top of the cart (with the exception of narcs which stay on our person), then go see and take back the next patient. And by common, I mean essentially universally done. And this almost always includes propofol. Propofol is not considered a scheduled drug here, as far as I am aware.

So the reason I ask the question is because this prompts me to wonder if this is an unsafe practice and something I need to reconsider.

Our anesthesia carts lock, but it is a simple 4 number code that everyone (anes techs) knows the code to. So locking drugs in there does not seem like it would add any margin of safety.

 

[deleted126335]

It is in Georgia.

I stand corrected. I was under the impression that "scheduling" a controlled substance was under federal purview, not state. Thank you.

 

[bostonblaz]

Don't pre draw any thing that someone can abuse and don't carry stuff around in your pocket. The 19 seconds it saves you are not a big deal and you end up making lots of plastic waste. Take out the vials and leave them sealed. Use one 10 cc syringe and as you need a drug draw it and give it. Blaz

 

[Spinach Dip]

Lap chole

Pt wheeled in room on stretcher. Stretcher next to bed and rail down. Pt slides over and lies down. Place O2 mask on with black S and M strap for preO2. Tie BP prongs to BP cuff on R arm and hit start on NIBP monitor. Pulse ox on left finger. Slap five ECG leads on (or have nurse be doing ECG's while you do rest). After that red lead hits the left hip, you hear the ding of the BP measurement. Glance at the BP value. Induce.

Don't see why above cant be done in 3-5 mins.

I see a new sport in the making: Competitive Sedation!



On topic: When I was shadowing at hospital XYZ, there were vials of propofol 'just sitting around' frequently. Opiates and benzos, though, were always in a breast pocket or under lock and key.

 

[jwk]

I stand corrected. I was under the impression that "scheduling" a controlled substance was under federal purview, not state. Thank you.

No expert here - my understanding is that individual states can also define certain things as controlled substances or how to manage them. The "synthetic marijuana" would be an example. Schedule V drugs (cough syrup with codeine for example) are OTC in some states, Rx only in others.

 

[jwk]

As I alluded to earlier, at least at my training program it is fairly common for residents/CRNAs to draw up drugs for the next case and leave them on top of the cart (with the exception of narcs which stay on our person), then go see and take back the next patient. And by common, I mean essentially universally done. And this almost always includes propofol. Propofol is not considered a scheduled drug here, as far as I am aware.

So the reason I ask the question is because this prompts me to wonder if this is an unsafe practice and something I need to reconsider.

Our anesthesia carts lock, but it is a simple 4 number code that everyone (anes techs) knows the code to. So locking drugs in there does not seem like it would add any margin of safety.

It's unsafe practice to leave any drugs on top or your cart and leave the room, controlled substances or otherwise. Sorry - I'm just really surprised that in this day and age that anyone, and especially an entire institution, is this cavalier about this. Pick an inspector - TJC, CMS, DEA, state drug agencies (all have been in our OR's at one time or another) - they would have a field day if they walked in your OR's and saw drugs lying out on top of carts without the provider being physically present in the room.

Our carts lock as well, and everyone in the anesthesia department knows the code. It is not common knowledge with the rest of the staff. You have to keep the temptation away. It takes just a moment to swipe a syringe off the top of the cart and it could even be done with someone else in the room. It takes a little longer to enter a code and open a drawer and is not nearly as subtle an action, and, attracts a little more attention.

 

[Mman]

Lap chole

Pt wheeled in room on stretcher. Stretcher next to bed and rail down. Pt slides over and lies down. Place O2 mask on with black S and M strap for preO2. Tie BP prongs to BP cuff on R arm and hit start on NIBP monitor. Pulse ox on left finger. Slap five ECG leads on (or have nurse be doing ECG's while you do rest). After that red lead hits the left hip, you hear the ding of the BP measurement. Glance at the BP value. Induce.

Don't see why above cant be done in 3-5 mins.

So you spent 30 seconds getting the patient from the door to positioned on the OR table. Even assuming all monitors can be placed on patient and BP cuff finish cycling, you still don't have enough time to preoxygenate the patient adequately. I mean 150 seconds from the start of preoxygenation until the tube is in? Really? It takes at least 30-45 seconds from the time you start pushing the drugs until you are doing a laryngoscopy even with the most rapid of RSI. Plenty of literature suggests that 4 deep breaths isn't the same preoxygenation as several minutes of 100% FiO2.

3 minutes is exaggeration IMHO unless you aren't safe. 5 minutes is probably closer to the bare minimum on young healthy patients and for most patients it's going to average closer to 6-9 minutes (at least).

 

[excalibur]

So you spent 30 seconds getting the patient from the door to positioned on the OR table. Even assuming all monitors can be placed on patient and BP cuff finish cycling, you still don't have enough time to preoxygenate the patient adequately. I mean 150 seconds from the start of preoxygenation until the tube is in? Really? It takes at least 30-45 seconds from the time you start pushing the drugs until you are doing a laryngoscopy even with the most rapid of RSI. Plenty of literature suggests that 4 deep breaths isn't the same preoxygenation as several minutes of 100% FiO2.

3 minutes is exaggeration IMHO unless you aren't safe. 5 minutes is probably closer to the bare minimum on young healthy patients and for most patients it's going to average closer to 6-9 minutes (at least).

Noted.

We hit tabs on our computers that mark In Room Time and Induction time. I guess I hit induction time right before induction. So the time between those two events can be done just under 5 mins. If 3 mins of preoxygenation (and placing monitors during preO2), then you have 2 mins to get from door onto table.

 

[dhb]

It's unsafe practice to leave any drugs on top or your cart and leave the room, controlled substances or otherwise.

Very different here in Europe Sufenta is in our carts unlocked although at some hospitals you have a locked box but generally people would open it in the morning and close it in the evening.

 

[RN2DO]

So I worked at the hospital where this happened...there were no Anesthesiologists involved. It was in the cath lab and nurses were giving medications....he took the syringes and used them and returned them to the field....it wasn't just exposure but transmittal of hep C to 30+ patients. It was not the hospital's fault...