Scope of Practice, Single-Use LMA Reuse and an Unreported Needlestick
On a busy endoscopy list in a Kuwait MOH hospital, the anesthesia provider is called to an emergency intubation in the ICU, leaving you (an anesthesia technician) with a stable sedated patient and a second patient waiting. A senior nurse asks you to 'just give 50 micrograms of fentanyl' from a vial you have already opened for the first patient, and to 'wipe and reuse' a single-use laryngeal mask airway because the department has only one size 4 left and the next case starts in 10 minutes. Earlier in the shift, while cleaning a scope, you sustained a needlestick from a used cannula and the area is bleeding. The nurse tells you not to report it because 'it happens all the time and paperwork delays the list'.
1. Address each request - fentanyl administration, LMA reuse and needlestick reporting - with the relevant scope-of-practice, infection-control and regulatory principles.
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Each request must be refused, for different reasons.
- Fentanyl: an anaesthesia technician does not independently administer IV anaesthetic or controlled drugs. Fentanyl is a controlled drug; it requires the anaesthesia provider's order, administration by an authorised person, and a witnessed record under Kuwait MOH controlled-drug rules. Politely say you cannot give it and call the anaesthesia provider or another anaesthetist. If the patient deteriorates, call the emergency team - do not sedate further on your own.
- Reusing the LMA: a single-use laryngeal mask is labelled for single use and must not be wiped and reused. Reprocessing does not reliably remove blood, protein or prions, and the infection-control risk is unacceptable. Use a new size 4, borrow one from another theatre, use a different appropriate airway, or delay the case. Report the stock shortage.
- Needlestick: this is a reportable occupational exposure. Wash the wound with soap and running water, do not squeeze or scrub, and report immediately to occupational health/emergency department so source assessment and HIV/HBV/HCV post-exposure prophylaxis can be started within hours. The nurse's instruction not to report is wrong.
2. What actions and documentation would you take, including who to inform?
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Actions and documentation.
- Inform the anaesthesia provider and charge nurse of all three issues.
- For the exposure: complete the needlestick/incident form, attend occupational health, record the source patient, and keep the result confidential.
- Discard the used LMA in clinical waste; do not return it to stock.
- Document objectively in the anaesthesia record what was requested, what was given/not given, and who was informed; use a separate incident report for the exposure and the infection-control breach.
- Ask the charge nurse to arrange replacement stock and review the delay with the theatre coordinator. Patient safety comes before list speed.
3. How would you escalate if the nurse insists?
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If the nurse insists.
- Restate the policy briefly and calmly: 'I cannot give a controlled drug, and this LMA cannot be reused.'
- Escalate in order: anaesthesia consultant in charge, nursing supervisor, head of department, infection-control team. For the needlestick, go directly to occupational health/emergency department without waiting for permission.
- Offer a workable alternative: borrow a size 4 LMA, use another airway, or delay 10 minutes; call another anaesthetist for the fentanyl order.
- Record the escalation. Kuwait MOH policy and professional codes require reporting of exposures and adverse events, and staff should be protected from retaliation for raising safety concerns. Do not falsify a record or accept a 'verbal order' for a controlled drug without the required authorisation.