Smoke Forced Her Out of the OR - She Then Forced Smoked Out of the OR


Rhode Island nurse pushed hard for mandatory smoke evacuation law.

IT'S THE LAW Julie Greenhalgh, RN, BSN, CNOR, (left) retired from the OR due to breathing problems, but not before helping Rhode Island pass a mandatory smoke evacuation law that went into effect Jan. 1.   |  Julie Greenhalgh, RN, BSN, CNOR

Julie Greenhalgh, RN, BSN, CNOR, began her career in the OR in 1975. After 42 years of inhaling surgical smoke, her lungs couldn’t take it anymore. She left the OR a couple years ago for the smoke-free sanctuary of office-based surgery (where there’s no cautery). Gone are the constant upper respiratory infections and chronic bronchitis she suffered. Gone are the 3 inhalers she needed daily to ease the shortness of breath, chest tightness and wheezing.

Ms. Greenhalgh, 64, may have retired early from perioperative nursing, but she left the OR a much better place. As past president of the Rhode Island chapter of AORN and now its government affairs liaison, she helped lead the effort for Rhode Island to become the first state to pass legislation that requires all hospitals and ambulatory surgery centers to use surgical smoke evacuation systems. The law took effect on New Year’s Day. Facilities have 90 days from Jan. 1 to report that they’ve adopted smoke policies to the Rhode Island Department of Health.

It’s not enough to have smoke evacuation equipment in place. It’s got to be in use — regardless of the surgeon’s preference.

“If you’ve got a surgeon who says, ‘I’m not using it (the smoke evacuator),’ you say, ‘Yes, you are, because the policy states you have to,’” says Ms. Greenhalgh.

Each facility can write its own policies, but they must state that a smoke evacuator must be used during every procedure in which smoke is being emitted from the surgical field.

Where there’s smoke

"If you've got a surgeon who says, 'I'm not using it (the smoke evacuator),' you say, 'Yes, you are, because the policy states you have to.'"
— Julie Greenhalgh, RN, BSN, CNOR

Ms. Greenhalgh began working on the surgical smoke problem around 2005. She wrote her state’s legislators who were supportive of nursing practices and health safety. Testifying before passage of the landmark law, Ms. Greenhalgh held up the plastic bag where she kept her 3 inhalers. “I have a constant cough, bronchitis and asthma,” she told legislators.

Since moving to a smoke-free facility, she hasn’t had to take antibiotics to stave off respiratory infections, and she rarely needs an inhaler.

“That in itself tells you something right there,” she says.

Start at the top

Typically, nurses, CRNAs, techs and anesthesiologists are in the OR more than surgeons, and therefore are exposed to surgical smoke more than anyone else. And because those are the people most affected, that’s who has been speaking up the loudest and most frequently about the perils of surgical smoke.

The International Council on Surgical Plume (ICSP) is working toward educating from the top down — starting at the administrator level


“Unfortunately, many times when we speak to administration, they aren’t even aware of the (smoke) problem,” says Dan Palmerton, executive director of the ICSP, a non-profit with a mission to educate, advocate and legislate in the area of surgical smoke. “They’re not in the operating room every day. And I think there’s a frustration even on their part on how to go about smoke evacuation.”

A number of facilities have plume evacuation systems, but some don’t even know they have them, says Mr. Palmerton.

“I’ve gone into an equipment room where they say they don’t have evacuation products and find they do have them,” he says. “But typically, they’re old and outdated, and they’re not compliant with what we’re using today, equipment-wise.”

Similarly, some facilities have mandatory plume evacuation built into their policies, but they don’t follow them.

“It’s like any other policy that you have in place: If you’re not going to follow it, you might as well not have it,” says Mr. Palmerton.

This Doctor Rigged His Own Smoke Evacuation System
IMAGINEERING When Joshua Lane, MD, MBA, didn't find a smoke evacuation device on the market that suited his needs, he made this one himself.   |  Joshua Lane, MD, MBA

Joshua Lane, MD, MBA, does mostly Mohs surgery — microscopically controlled surgery used to treat common types of skin cancer.

“When I have a patient with a wound on the upper lip, for example, I’m up close and it’s just not pleasant to smell or breathe surgical smoke,” says Dr. Lane, who practices at Lane Dermatology & Dermatologic Surgery in Columbus, Ga., along with his wife, Tanda N. Lane, MD.

Besides being costly, Dr. Lane says the hyfrecator pencils he trialed didn’t provide enough suction. So he decided to concoct his own smoke evacuation device.

It’s basically a smoke hose. He attached clear, flexible plastic tubing to the smoke evacuator on the bottom of his surgical cart. A moveable stand holds the adjustable plastic tubing, so he can position the tubing wherever he needs it during a procedure. “This is just an effort to improve the surgical experience for our patients, my staff and myself,” says Dr. Lane. “It’s not fancy. However, I believe that I made a simple, cheap and better solution.”

— Mike Morsch

Get surgeons onboard

Getting buy-in from surgeons is critical. Not long ago, smoke evacuators were big, ugly gray monstrosity boxes that sounded like jet engines. A surgical tech or a first assist had to hold a big tube during the procedure that would suck up the smoke. It’s not that way anymore. Quiet evacuators are built right into the pencil.

“Oftentimes, if you get the opportunity to hear out the surgeons and you put a good, relevant pencil in their hand that they can use, they’ll tell you, ‘That’s not so bad,’” says Mr. Palmerton.

But getting a surgeon-champion is not as easy as it sounds.

“Surgeons tell me that they’ve been doing this for 30 years and the smoke hasn’t killed them yet,” says Mr. Palmerton.

His response to that? He makes sure the surgeons understand that there are other people in the OR — nurses, techs — some young, some perhaps who may be pregnant, that are also being affected by the smoke.

SECONDHAND SMOKE It's not enough to have smoke evacuators in place. They've got to be in use — regardless of surgeon preference.

“Surgeons will say, ‘You know, that’s a good point.’ The surgeon is just one person, and it’s not really fair that one person gets to not care while everybody else is at risk,” says Mr. Palmerton.

Through that continued awareness, though, there is less and less resistance to smoke evacuation protocol. Although the dangers of surgical smoke have been investigated for decades, Mr. Palmerton says the lack of solid research about it feeds into surgeon resistance.

“That type of research would be difficult to do, but how much do you really need to understand that breathing ablated human tissue that is shown to be carcinogenic, with neurotoxins and that is viral, is bad?” he says. “It gets to the point of common sense. If somebody was standing in the OR smoking a cigarette in the corner, you wouldn’t accept it.” OSM

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