Re: "Troubling Times for Office Surgery" (March, page 28). There were three deaths reported in office surgery between April 2002 and March 2003. One of those deaths occurred in a case in which an RN administered sedation, and two occurred in cases in which a CRNA or MD anesthesiologist administered sedation. Using Dr. Vila's "apples-to-apples" technique, doesn't that indicate that patients are twice as likely to die if a CRNA or MD anesthesiologist administers the sedation than if an RN administers it? Perhaps the regulatory agencies are taking the wrong approach. Or perhaps this just illustrates the absurdity of taking a handful of isolated cases and generalizing them to reach broad, unfounded conclusions and then passing hasty regulations.

Joyce McClintock, RN, PhD
Treasure Coast Cosmetic Surgery Center
Port St Lucie, Fla.
[email protected]

I am developing a distaste for articles that don't examine the basis of patients' deaths, but rather send out a condemning, perhaps unfounded, signal that office-based anesthesia and surgery is unsafe. I continue to be a strong proponent of office-based anesthesia practice, administering IV sedation as well as general anesthesia. When I read about office-based deaths, I'm most often left wondering what really happened. Patients don't simply die. There must be reasons. These may include over-sedated patients, RN-administered IV sedation, cardiac arrhythmia-related death, post-op hemorrhage, combinations of inexperienced surgeons/anesthesia providers, financially driven procedures, abandonment and the tumescent liposuction technique widely used in both hospital and office settings. We anesthesia providers, surgeons and RNs can learn from these unfortunate instances of patient compromise. It's sad that we must (even on rare occasions) learn at the expense of our patients.

Mark Pepper, CRNA
Nashville, Tenn.
[email protected]

The old saw goes that a bad surgeon can only maim, but a bad anesthesiologist can kill. The predominant surgery performed in office suites is minimally invasive. By not using muscle relaxants or regional anesthetics, minimally invasive anesthesia (February, page 57) preserves the muscle pump of the lower extremities and isn't associated with thromboembolic phenomena. While it's disturbing to see patients needlessly succumbing from pulmonary embolic phenomena, this type of patient death from abdominoplasty in a hospital setting never makes the newspapers or articles like Ms. Taylor's. The recent and unnecessary death of the author of the First Wives' Club was one of two anesthesia deaths at the Manhattan Eye and Ear Hospital, yet we haven't seen a similar article decrying plastic surgery deaths in the hospital setting. In none of these cases did the surgeon cause these patients' deaths. The effects of the anesthesia did.

Barry L. Friedberg, MD
Corona del Mar, Calif.
[email protected]

Fight for what you're worth
Re: "What Are Facility Manager's Worth?" (January, page 22). For the 13 percent of your surveyed readers who didn't receive an increase in more than a year and the 40 percent who received no bonus, all I have to say is this: Whose fault is that? Do they expect to the money to just drop into their laps? Negotiate for yourself. You have to itemize everything and make your employer know how much you're worth. At an average of $82,215, I'd say that we facility managers are still underpaid. We should be making more than $100,000 per year for all the money that we make and save for the centers we run.

Rich Elliott, RN
Director of Nursing
Newport Plaza Surgical Center
Costa Mesa, Calif.
[email protected]

Re: "Inside the Morphine Overdose Deaths of Two Boys" (March, page 8). I was a recovery room nurse for more than 10 years at a major Chicago teaching hospital and have used morphine extensively over the years. I find it hard to swallow, if not ludicrous, that the death of a 6-year-old in a Tulsa hospital two days after an outpatient surgery was blamed on morphine given in the recovery room. Was the dose given very high? Yes, but in a normal healthy person that dose would have almost totally (90 percent) been excreted within the first 24 hours. The half-life of morphine is two to three times less than that, which is really what you would look for in the depression of respiration. Which makes me wonder what medications were given at home. I find it grossly insulting and wrong that the nurse is implicated in this death. Nothing narcotic that she gave could have caused this death 48 hours after discharge.

I agree there should be no guesswork in standing orders, but there's always interpretation with the dose and the different narcotics available for the nurse to use. Most importantly, there's always a maximum dose that can be used without contacting the anesthesiologist for additional medication. That's why the recovery room is a highly critical area, and only well-educated and well-trained nurses should work there.

The real story is why that much morphine was given in the first place. Obviously, if a regional block were used, almost no narcotic would have been necessary. And if the proper amount of pain medication were used intra-op, then the amount used in recovery would have been a lot less. Many studies done have shown that if we let patients reach an extreme pain level, then it takes much more narcotic to make them comfortable. In my travels to different hospitals, I've seen some anesthesiologists very sparing in their use of narcotics intra-op (especially in children) so they can wake their patients up faster and keep turnover at a minimum at the expense of the patient. In this litigious world we live in, we must be more critically thinking when dealing with the propagation of fault to those at the bottom of the food chain, the nurse.

Geoffrey Hibbert, RN, BSN
Director of Nursing
Center for Special Surgery
Greenville, S.C.
[email protected]

Mutual respect, please
Re: "Sexual Misconduct in Today's ORs" (February, page 24). Sexual harassment is only one form of harassment in the OR. Unprofessional behavior associated with the frustrations of practicing medicine may jeopardize the teamwork nurses strives for. Our physician-partners expect to be treated with respect. We expect no less from them.

Karen Gabbert, RN, BSN
Clinical Director
Surgery Center of Kansas
[email protected]