Taking Their Last Breath

This article originally appeared in Outpatient Surgery Magazine.

You can see it and smell it, it can make your eyes sting and your throat sore, yet surgical smoke hangs thick in the air of countless ORs across the country, a health hazard that's harder to get rid of than a pushy salesman. It seems nothing has worked and everything's been tried — from passionate pleas from OR nurses tired of working a job that requires them to inhale the smoke of burning tissue to national campaigns and a push to pass laws requiring surgical plume evacuation.

Meanwhile, hospitals and surgery centers have trumpeted that they've gone smoke-free, banning smoking anywhere in the facility or on the grounds. Yet how many smoke-free facilities have also enforced a surgical smoke filtration policy in their operating rooms? A long-time OR nurse at Baystate Medical Center in Springfield, Mass., is on a crusade to make surgical plume in her ORs disappear just as the ashtrays by the entranceway vanished.

Baystate has been smoke-free for years — "with one glaring exception to this rule: the operating room," writes Maureen Fournier, BSN, RN, CNOR, in an interdepartmental newsletter. "Unfortunately, we cannot come in to work and request a non-smoking room if we work as operating room staff."

Ms. Fournier is normally "pretty reserved," but she has stepped up to champion the cause. She and her colleagues at the Chestnut Operating Room, a 12-OR hospital outpatient department connected to the main hospital, are hoping a grassroots effort will propel change. They've had large and small group discussions, and created bulletin boards and posters at the scrub sink to help educate and inform.


Driving Home Your Point

After you make a commitment to go smoke-free, expect some resistance from surgeons. To help drive home the danger of surgical smoke, a facility manager purchased 2 hot-pink e-cigarettes and a nicotine-free strawberry vaping liquid. During a clinical committee meeting, she and the medical director began to smoke the e-cigs while discussing the dangers of surgical smoke. "At first, everyone was shocked, but they soon were asking questions and joining in on the discussion," she says. "The presentation worked — the next morning we heard our physicians talking to staff about the importance of evacuating surgical smoke."

"We have brought our concerns to management as well as [to] surgeons and anesthesia providers to work together to implement a plan of action to use smoke evacuation for all smoke-producing procedures, both open and laparoscopic," writes Ms. Fournier.

Pencils with built-in suction

Part of the problem is surgeons are not fond of the old-fashioned smoke evacuation system currently in use at the facility. The evacuator comes in 3 separate pieces that snap onto the cautery pencil. It's loud, the tubing is bulky, the filter is attached to a video tower and you can only pass it off the field at the head of the patient. Other than that, it works great.

Ms. Fournier is hoping that her surgeons will be impressed when they trial new devices with built-in or clip-on tips that suction up surgical smoke as it's produced. The quiet devices look and feel like a standard ESU pencil.

She looked in on an orthopedic surgeon trialing the device during a shoulder replacement. "You could just see how well it was working," she says. "You couldn't smell smoke in the air."

Can OR nurses convince surgeons to use smoke-evacuating devices?

Then a bump in the road. The pencil's built-in smoke evacuator has a thicker-than-normal tip that made it difficult for the surgeon to maneuver as he got deeper into the tight spaces of the shoulder. Good news, though: You can remove the inch-long tip and the pencil will still evacuate the smoke at the site — just not quite as close, says Ms. Fournier.

After the trials, the next step is for the OR director to talk with surgeons and anesthesia, stressing that they're moving toward evacuating smoke on every case that has plume.

"It's something they don't want to do, but they have to do it," says Ms. Fournier. "Just like the pushback we got with dry time with preps — nobody wanted to wait 3 minutes, but now they do."

Outpatient Surgery Magazine InstaPoll: Mandatory Smoke Evacuation?

Hopes are high that smoke evacuation will one day become the law of the land, according to the 268 respondents of our recent online poll.

Will smoke evacuation ever be the law of the land?

yes ................................ 82%
no ................................. 18%

Not waiting around

Last year, both California and Rhode Island nearly passed laws requiring surgical plume evacuation, but Ms. Fournier and her colleagues aren't waiting for a legislated solution.

"Maybe removing plume one day will become the law of the land. We can all hope that happens," she says. "Meanwhile, we're still inhaling surgical smoke. By the time a law passes, we'll all be retired or maybe have some sort of respiratory illness. In the meantime, every surgical facility can start a grassroots effort."

Ms. Fournier is dedicated to the cause, determined to see the day when surgeons use smoke-eliminating devices and she can breathe in the clear air of the OR. She's even dreamt of doing something dramatic to drive home the point to surgeons who ignore the risk of working in a hazardous environment full of toxic smoke. What if, she wonders, all the techs and nurses walked into the OR where a surgeon was cauterizing and coughed up a storm?

"That might not go over too well," she says, "but nothing else has worked."

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