Re: "Problems With Promethazine IV" (November, page 12). I read with interest the article on the Institute for Safe Medicine Practices urging the FDA to re-examine the product labeling for promethazine. Back about 40 years ago when I was a junior resident, the same problems were noted with inadvertent intra-arterial or subcutaneous administration of hydroxyzine (Vistaril). The FDA removed its approval for IV use. We used it widely in small doses to treat or prevent nausea and vomiting and, like promethazine, it was quite effective.

Both of these drugs were used by thousands of anesthesiologists and anesthetists without problems. The ISMP should concentrate on educating individuals who give IV injections to check the IV site and to ensure free flow of the IV fluids. Arterial lines should be carefully marked and injection ports should be taped over or locked except when drawing blood or injecting dilute heparin. While the arms aren't always visible during surgical procedures, experienced anesthesia providers can generally recognize by observation of the drips and feel of the injection when an IV is not working well. When this is noted, no medications should be injected until the IV site is checked out. Many other medications still in common use cause significant burning even on IV administration. These most likely cause even more discomfort when injected subcutaneously or intra-arterially.

ISMP has misdirected its efforts to ban IV injection of promethazine. I'm sure if they looked closely, they'd have many other valuable drugs to remove from IV administration so that the very few people who inject medications into lines without ensuring that the lines are in veins won't make that error again. Once again, patients won't benefit from the desired properties and rapid action that come from IV drug administration. It is unfortunate that anyone suffered injury, but we must be proactively educating, not reactively banning.

Jack Egnatinsky, MD
Anesthesiologist
Christiansted, U.S. Virgin Islands
writeMail("[email protected]")

Attack on Surgeons Unnecessary Roughness
Re: "The Ten Commandments of Surgery" (December, page 88). I am a board-certified plastic surgeon and owner of an ASC. I must say I was utterly shocked when I read Ms. Watkins' scathing attack on surgeons. While her own personal prejudices may be welcome fodder in the nurses' lunchroom, they have no place in a periodical that many surgeons read and value. If a surgeon wrote such a column about nurses, your lawyers would probably be scrambling. I myself have many stories of the reverse, but I would never dream of publishing such a vindictive diatribe. I'm glad Ms. Watkins is not a member of my OR team. Civility goes a long way!

Heather Furnas, MD
Plastic Surgery Associates of Santa Rosa
Santa Rosa, Calif.
writeMail("[email protected]")

Here's to Vigilant Scope Reprocessing
Re: "Scope Reprocessing: 4 Corners You Just Can't Cut" (November, page 55). This excellent article emphasized the recognized standards and the fact that lack of standardization is at the root of errors. It was also a fair and balanced representation of products on the market. Good challenge: Don't cut corners.

Pegi Wasserman, RN
Clinical Education Consultant
Advanced Sterilization Products
writeMail("[email protected]")

Mastery Over Post-op Pain
Re: "4 Ways to Outsmart Post-op Pain" (November, page 45). I will save this article and give it to my first- and fourth-semester nursing students. This information will enhance what they learn in the textbooks.

Mark Kucharek, RN, MSN
Resident Faculty
Mohave Community College
Kingman, Ariz.
writeMail("[email protected]")

In my freestanding ambulatory center, a pain management task force provides staff education. We have created large laminated cards that have three pain scales - faces, word descriptors and the 1-to-10 scale. We show this to patients pre-op so they're familiar with it, because right after surgery they can be too fuzzy to pick a number. We also ask patients pre-op what would be their pain level goal to go home. This is an important part of the plan of care.

Kelli Sheeran, RN
Grand Valley Surgical Center
Grand Rapids, Mich.
writeMail("[email protected]")

Code of Conduct a Valuable Tool
Re: "When Generations Collide in the OR" (November, page 18). As a new ASC manager, I've been somewhat frustrated with some of the staff (very few actually) having conflicting work ethics and styles and dissimilar values. Ms. Carey-York's question on how to stop them from being impatient with each other is what really caught my eye. I seem to have the problem of staff members griping that they seem to do everything and someone else is quite frequently not doing their share. I decided after reading her suggestions that what she had instituted sounded like good sound judgment and I could easily envision how I could make this work. I plan on typing it up and having every staff member sign a copy to indicate an understanding of what is expected of them, along with a commitment to focus on teamwork. This understanding will help them not only to see that they are a significant member of our team effort, but also to understand that everyone's efforts are needed to make the staff function as a well-oiled machine. Since we're a high-volume ophthalmology practice, it takes all of us to make this work. I have an excellent staff that functions extremely well on its own, but there's always room for improvement because sometimes it only takes one staff member to muddy the waters. Thank you, Annamarie Carey-York, for sharing your code of conduct.

Pamela Morgan, RN
Ambulatory Surgery Center Manager
The Eye Associates
Bradenton, Fla.
writeMail("[email protected]")

Wonderful article! I plan to post it in my center for all to read and, hopefully, to understand.

Patricia Dickey, RN
Director of Nursing
Cypresswood Surgery Center
Houston, Texas
writeMail("[email protected]")