Q. Two or Three; What should it be?

When doing laprascopic cases, such as lap choles and lap appys, how many people are needed at the field? Two (a surgeon and a scrub, with the scrub holding the camera) or three (a surgeon, scrub and someone else to hold the camera)? If a third person is required, should it be another surgeon or another scrub? Often these cases are so quick only two people are needed. Sometimes, the case does not go so great, and the scrub has to do additional tasks, so a third person may be needed.

 

A: When doing any laparoscopic cases we always use three people. (surgeon, first scrub, second scrub). I do agree these are quick cases, but the first scrub is there to pass the instruments, not to hold the equipment. And what happens when there’s an emergency and another set of hands are needed but no one is available? I myself have scrubbed these types of cases with just a surgeon but find it much easier with an extra set of hands.

A: We provide one scrub person but many times, the surgeon will request for “extra pair of hands.” This can be a difficult most times since our staffing is lean, enough to provide one scrub person for a case, but not many “float staff” to serve as second scrub.

A: We use three people – an RNFA, a circulator and a scrub. The RNFA is there in case the procedure is converted to an open, and she can also insert the trocars and close the incisions.

Q: Students in the OR

At what age do you allow students in the OR?
A: We allow high school students that are in a career search type of class. We carefully select the cases and staff that they observe.

A: We do not let high school students in the OR, but will accept a student shadowing an MD if the student has gone through our education department for all the proper background/immunization checks.

So to answer your question, there is no age limit. We base it on the maturity of the student. If they are still in high school, we will put them in the PACU areas or ambulatory surgery area to see the patient immediately post-op.

Q: Handling injectable mixtures of medication in the OR

We are looking at our policy/process for combination medications that are injected intra-operatively. We currently have a number of orthopedic surgeons that are injecting a combination of meds for post-op pain control, which the scrub mixes together based on the surgeon’s “recipe.” I am concerned that mixing these meds together could be extrapolated to be “compounding,” and I have concerns about the appropriateness of the scrub (RN or tech) combining these medications. Given that possibility, our preference would be to get out of the “compounding business” and have our pharmacy department mix these meds under a hood but the pharmacy is not amenable to doing this as there are no USP standards regarding these medications being mixed and used in combination. One of the surgeons stated that he has data he can provide regarding efficacy and improved patient outcome/experience but not what the pharmacy feels they would need to move ahead. Therefore, although I will be looking into whether AORN has a RP, I’d like to know how other facilities handle surgeon requests for multiple drug mixtures that they inject intraoperatively. Do your staff combine these meds in the OR, or does your pharmacy department shoulder the responsibility?

 

A: I asked our orthopedic resource nurse to answer your question, and her reply is below: Here at our facility we do use a Ropivicaine “recipe.”

However, our pharmacy mixes it and places it in the pyxis refrigerator for dispense on the morning of the surgery.

A: There is a difference between reconstituting a medication – like mixing a med with water or saline – and compounding. Our Board of Pharmacy considers it compounding if there are three components – like lidocaine, Marcaine and a steroid. Compounding can only be done by a pharmacist. (Not sure if physicians are allowed to do this but I would guess yes.) Sometime even when there are only two meds – like with pain pumps – those must be filled by a pharmacist under a hood (according to ISMP) or it changes from a medium-risk device to a high-risk device which most hospitals do not have a designation/permission to use. Hope that helps!

A: Our staff does mix medications as injections under the surgeon’s approval.

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