LEGAL AND

ETHICAL
ISSUES IN
PERIOPERATIVE
NURSING
MARY CHIARELLA
RN. eM. Cert Anaesthetic Nursing
DipNEd,llB(Hons)
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Stories from the Operating Room:
A Call for Courage
Dear friends and colleagues,
I regret to write that this is my last regular column for the
journal, as I am currently finding it difficult to meet all my
academic obligations and provide a reliable and
consistent input to this column. However, I have promised
to continue to offer my pieces of writing on an ad hoc
basis and will always be delighted if the editor finds them
to be 01 value. The linal topic I have chosen to address
tonight is not particularly light, but is one which is very
close to my heart, and was predominant in my doctoral
thesis. I wish to speak to you about the responsibility of
the theatre nursing staff lor the care and safety of the
patient, particularly when they are concerned about some
aspect of the surgeon's management.
So the lirst story i will tell you is a good story. It is a story
of a theatre sister working at Royal Prince Allred Hospital
in 1914 and it provides a vivid picture of the difference
which a good nurse can make.
So I thought that I would begin by telling you a lew stories.
Nurses like to hear stories, as we belong to an oral
stOry1elling tradition.' And the law is olten argued to be all
about stories, stories told by two parties to an argument,
both of whom believe that their story is the truth.'
However, in law one 01 the stories is accepted to some
extent and the other discredited to a similar extent,
because the judge has to IiIter through all the evidence
before him and determine exactly what did happen, either
"on the balance of probabilities" or "beyond all reasonable
doubt" depending on whether he is judging a civil or a
criminal matter.
The sister in the theatre was responsible for counting and
checking sponges and gauze, ... and on the occasion
referred to above I had demanded another roll [to be
produced Irom the wound] and stood my ground until it
was produced. Dr Schlink, the Superintendent, who
happened to be standing in the theatre, came round to me
and asked me if I was sure there was still more to come,
but indeed I was. When all had been recovered, counted
and checked, and everybody was satisfied the surgeon
looked over his glasses at me and said "Sister Morehead,
I shall iove you every day 01 my life!" ,
Now, I am sure that nurses do not expect our surgeons
necessarily to pronounce with such amorousness every
time they perform a proper sponge count, but there is no
doubt that this nurse was probably under considerable
pressure. You can imagine the implied threat of the
eminent Superintendent, asking her il she was sure,
because that tends to imply that other people thought that
she wasn't. Perhaps the surgeon did not want to keep
searching. It would have taken a brave nurse to keep
insisting, wouldn't it? She may not have been sure
whether her legal duty was to obey the surgeon or obey
her instincts. But she knew that her moral duty to the
patient was to keep on searching for that sponge. But
wouid every nurse have been that brave? What if the
surgeon was bad tempered and abusive? Had another list
to go to? Wanted to close?
In fact the law has always maintained that the surgeon
was entitled to rely on the nurse lor the sponge count.
Initially, surgeons used this reliance as a means of
exonerating themselves Irom blame, but more recently,
the emphasis has shifted to the liability of the hospital for
the negligence of the counting nurse. In 1915, in a
Canadian case, the judge quoted the words of an eminent
surgeon "If I cannot trust my nurse, then I must give up
surgery."' In Mahon v Osborne,' a 1939 English case, the
trial judge considered that the nurse played a signilicant
role on which the surgeon was entitled to rely.
The routine is, therefore, that a careful count of all the
swabs is kept by the theatre sister. At a certain stage,
when the surgeon thinks he has extracted all the swabs,
he asks the nurse il all the swabs have been accounted
for. II she says "Yes", he proceeds to sew up the
abdomen. If she says that one or more is not accounted
for, he will search for it, and not close up the opening till it
is found.'
In a 1972 Canadian case, Karderas v Clow,' it was held
that the nurses involved in the swab count and the
assistant resident medical officer had been negligent, but
the senior surgeon had not. He had left the operating
theatre after the technical part 01 the procedure was
completed, leaving the resident to close the wound, which
behaviour was held by the judge to coincide with
"... standard, approved and widely accepted procedures.'"
With regard to the standard of care expected of the
Information contained in this article is for the purpose of discussion only and cannot in anyway be relied upon or used as a substitute for individual
professional legal advice.
ACORN JOURNAL. AUTUMN 2000 49
I LEGAL AND ETHICAL ISSUES IN PERIOPERATlVE NURSING I
assistant surgeon and the theatre nurses in relation to the
sponge count, It was held that they were all in breach of
the reql ';;qdstandard,. _.
As to the standard of care, Dr Clow [the senior surgeon]
said that the nurses' sponge count is relied upon by the
surgeon but he does keep a mental note of how many
have been put in and how many have been taken out. He
removes the sponges and gives them to a nurse until
none can be seen in the operative field but no more is
done in the operative area than is necessary... Dr Whyte
agreed that the surgeon relied on the nurse's count but
that it was normal procedure to feel around in the area to
be sure that ali of the sponges were out.'
...In addition, since the sponge count was in error, I find
that the nurses charged with the duty of making the
sponge count were negligent in failing to make a correct
sponge count."
In a United Kingdom "failure to remove swabs" case in
1984," this concept of joint responsibility for a swab being
left in a wound was accepted without argument and
liability was apportioned equally between the surgeon, the
consultant radiologist and the hospital, vicariously for the
theatre sister.
A 1997 Australian case, involving a private hospital in
Queensland, has confirmed this responsibility for
Australian nurses. In Langley & Anor v Glandore Pty Ltd
(in Uq) & Anor," an appeal was brought by two surgeons
against the decision of a jury in a negligence case, in
which a surgical pack was left in a patient's abdomen
post-hysterectomy. Glandore Pty Ltd, were the owners of
the hospital in which the operation was performed and the
employers of the nurses working in the operating theatre.
They were vicariously liable for any negligence on the part
of the nurses. The surgeon Langley and his assistant
Warren were not employees of the hospital.
At the original trial the plaintiff brought an action in
negligence against the hospital and the two surgeons.
She claimed that the surgeons were negligent in: failing to
advise her appropriately about her treatment options;
negligently performing the surgery; failing to remove the
surgical pack from her abdomen and falling to diagnose
her painful post-operative symptoms as being due to the
presence of the surgical pack in her abdomen. The claim
against the scrub and circulating nurses, and therefore
the hospital, was that they failed to carry out the proper
procedure for counting the surgical packs. However, the
trial judge was very sympathetic towards the nursing staff,
and directed the jury to concentrate on the surgeon's
failure to retrieve the surgical pack, rather than on the
incorrect count itself. The jury found that the hospital (and
therefore the nurses) were not negligent but that the
surgeons were. The amount of damages awarded against
the surgeons was $557,000, of which $527,000 was
awarded for the consequences of the surgical pack being
left in the plaintiff's abdomen.
The surgeons appealed the decision of the jury, but did
not contest the findings of negligence against themselves.
Their argument was that it was virtually impossible to
accept the fact that, since a surgical pack was left in the
wound, the tally must have been wrong; but then not to
find negligence on behalf of the counting nurses. They
argued that ... under the procedures in place and relied
upon by all concerned in the operation, the primary duty
that a correct count had been made of all instruments,
sponges, packs and the like to establish that they had all
been removed from the patient's body at the conclusion of
the operation, lay with the nurses."
The appeal judges referred to the ACORN standard as
50
the relevant established standard for the counting of
sponges, swabs, instruments and needles." These
standards had been produced in evidence at the tr.Lql and
had been accepted as the applicable standard. Evidence
was given at the trial by two nurses, the scrub nurse and
an expert nurse witness. The scrub nurse accepted that
she and her fellow nurse had made an error in the count
but she could not offer any explanation as to how it might
have happened. Although there was some suggestion by
the hospital's counsel that the nurses may have been
distracted by an emergency, no-one, not even the scrub
nurse, gave evidence of any such event happening, The
judges acknowledged that surgeons may be aware of the
number of sponges used in an operation and would
certainly do a manual and visual search to recover any
items, but they described the surgeons as being "...
preoccupied with their own immediate tasks"" and stated
that "...they ali rely upon established counting and
checking procedures that the nurses must undertake." "
They held that "...the nurses clearly, under the procedure
described, had the primary duty for making an accurate
count to ensure that all the sponges used had been
recovered from the plaintiff's body..." "
They expressed extreme discomfort with the jury's verdict
that despite the fact that the surgeon was guilty of
negligence for failing to retrieve one sponge, the nurses,
the "primarily responsible accounting partie,," " were
guilty of no negligence. They held that a finding of
negligence against the nurses (and therefore the hospital)
should be substituted.
Now this is an important decision for nurses, as it gives
them the express authority to do exactly what that nurse
did in 1914. But no-one can override their concern about
. an incorrect sponge count and insist that the wound be
closed if the nurse is unsure. The wound cannot be closed
until the nurse is satisfied that the count is correct. The
scrub nurse is the "primarily responsible accounting party"
for the sponge count, and that is the law.
But let us turn to some other stories, less heroic, but
equally compelling, because It is here that I beiieve we
still have much work to do. It is my contention that there
are nurses who are still reluctant to put their duty to the
patient before their duty to obey the surgeon, particularly
where the surgeon is dlffficult or unpleasant.
A 1967 case which highlights this problem Is a joint
appeal against the decisions of the Medical Tribunal
which found two doctors guilty of infamous conduct in a
professional respect." Dr's Anderson and Johnson were
suspended from practice for twelve and six months
respectively. The reason for their suspension related to
the death of a patient undergoing a surgical procedure for
the removal of a thyro-glossal cyst by her surgeon, a
partner of Dr Anderson. Dr Johnson was an employee of
the partnership. Although Dr Anderson was nof a qualified
anaesthetist, he regularly performed anaesthetics for the
surgeon, and he was to give the anaesthetic to the
patient.
At induction, there was considerable difficulty with the
intubation, and at that point Dr Anderson handed over
management of the anaesthetic to Dr Johnson. When the
operation was all but completed, Dr Johnson handed the
management of the anaesthetic over to yet another
doctor, who continued to ventilate the patient, but then
paused to see if there was any spontaneous respiration.
As there was none, he resumed hand ventilation, but then
paused again when he was asked by the surgeon to
check the pulse. The senior theatre sister who was in
charge of the operating theatres was standing by the
ACORN JOURNAL, AUTUMN 2000
I
LEGAL AND ETHICAL ISSUES IN PERIOPERATIVE NURSING I
patient's left hand, and she felt for the pulse, announced
that it was absent and left to get another doctor. It was
found at the inquest that the patient had been clinically
dead for the duration of the operation, having suffered a
cardiac arrest during intubation.
This case is compelling from a nursing perspective
because it is clear from the evidence that the nursing staff
were concerned about this patient from the beginning of
the operation. At the time of incision, the darkness of the
blood brought comment from the scrub nurse;" the lack of
bleeding was also commented on because of the small
number of artery forceps used." In addition, the speed of
the operation was commented upon by the circulating
nurse, to which the surgeon replied that this was due to
the lack of blood." There seemed to be little doubt that the
operation was conducted in an atmosphere of concern
and anxiety, with the doctors asking each other if the
patient was all right, with three changes of anaesthetist,
and the nursing staff attempting to alert the surgeon to
their concern for the patient's cardiovascular status.
It is therefore somewhat remarkable that the sister in
charge of the operating theatres, in calling for a second
opinion, should have been described by the judge as
possessing "commendable courage." " It seems unlikely
that the judge considered that a nurse in charge of the
operating theatres would require courage to act on behalf
of a patient whom she had reason to believe was in mortal
danger, due to the fact that the patient was pale, pulseless
and had dilated pupils." Thus, it can be presumed that he
was referring to the fact that she would require courage to
seek a second opinion from a doctor other than the one
who was managing the case. That such an act should be
described as courageous is an indication of the power
'chich doctors," 8 ' / e r ~ dcctors who were seen to be putting
patients at risk, are acknowledged by the judges to
possess.
In the second case, an inquest held in 1994," the patient
died of haemorrhage due to perforation of the aorta during
surgery. He was admitted to hospital for laparoscopic
cholecystectomy, and was anaesthetised uneventfully.
Shortly after the anaesthetic had been given, the
anaesthetist noted that the blood pressure was very low,
and on observing the operative site noticed that there was
abnormal profuse bright red bleeding. The surgeon did
not clearly respond to the anaesthetist's question as to
whether or not there had been any gross bleeding. When
the laparoscope was inserted, the television screen was
obscured by bright red blood. Without informing the
anaesthetist the surgeon proceeded to perform a
laparotomy, which revealed a large amount of blood in the
abdominal cavity, which the surgeon attributed to a tear at
the base of the small bowel mesentery. The scrub nurse
gave evidence to the fact that she considered the amount
of blood present to be far more than would equate with
such an injury. She also gave evidence to the fact that she
observed to the surgeon that the abdominal cavity was
still moist when he pronounced it quite dry, and that when
she offered him either a Redivac drain or a bore drain, the
surgeon announced that he would not insert a drain into
the abdomen at all, and closed the cavity.
The patient was transferred to the Recovery Ward. Prior
to his transfer the scout nurse had been instructed by the
I LEGAL AND ETHICAL ISSUES IN PERIOPERATIVE NURSING I
scrub nurse to leave the operating theatre and warn the
Recovery Room staff that the patient may still be bleeding
internaliy, and that he would therefore require very close
observation. On arrival in the Recovery room the patient's
blood pressure was very low, and unable to be recorded
with an automatic blood pressure monitor. The
anaesthetist was informed, and steps were taken to
attempt to improve the B.P. The recovery nurses became
concerned that the patient's abdomen was becoming
distended, and informed the surgeon, who prodded the
patient with one hand and explained that it was because
he was lying on his side. The anaesthetist remained with
the patient and the recovery nurses throughout and
continued his attempts to resuscitate the patient.
The recovery room staff eventually became so concerned
about the patient that they called the Theatre Manager
and expressed their serious concern over the ill patient.
The Theatre Manager was described as a person with
"extensive experience in the nursing management in the
peri-operative situation." "
She examined the patient's abdomen, which she
considered to be visibly distending, obtained ail the facts
from the Recovery nurses, and determined that the
patient should be returned to the operating theatre. The
Coroner acknowledged her role in taking the initiative to
return the patient to the operating theatre.
The Theatre Manager concluded that the patient was
haemorrhaging and, in the absence of any decision
having been made by either the Surgeon or the
Anaesthetist, told the Surgeon that the patient needed to
return immediately to the operating theatre. The Surgeon
made no response. The Theatre Manager instructed the
nursing staff to prepare for an emergency laparotomy.
The surgeon still appeared to be reluctant to comply with
the decision of the Theatre Manager, although at the
inquest he claimed that he had been monitoring the
patient carefully and had everything under control.
The deceased was taken back into Operating Theatre No.
1. The Theatre Manager ailocated additional nursing staff
to assist in the operating theatre. On entering the
operating theatre the Theatre Manager found that the
Anaesthetist and the nursing staff were present but the
surgeon was absent. The Theatre Manager left the
theatre and saw the surgeon in the corridor outside the
operating theatre. He had not scrubbed in anticipation of
the emergency operation, and the Theatre Manager
asked him to scrub, saying that his patient was ready for
surgery. He did not reply. He entered the theatre shortly
after.
27
The surgeon did not heed the observations of the Scrub
Nurse who was assisting him during the second operation
either.
While the surgeon was applying sutures, the Scrub Nurse
was using a sucker to extract blood from below the site so
that the Surgeon was abie to see where he was suturing.
She informed the surgeon that she was sucking up bright
red blood from deeper in the abdomen. The surgeon
made no reply to the Scrub Nurse. He then indicated that
he intended to ciose the abdomen. The Surgeon has
stated that the bleeding appeared to be controlled by this
stage. The Scrub Nurse stated in evidence
that the abdomen was moist and appeared to stili have a
lot of fiuid in it. The wound was closed."
The post mortem examination revealed an unsutured
6mm penetration of the aorta directly below the tissue
underneath the sutures in front of the aorta. By the time
that the wound was closed the patient's pupils were fixed
and dilated and the Anaesthetist announced generally
52
that further efforts were useless. He further stated that at
t h ~ t ~ t a g e he pronounced life extinct, but this was not
cunfirmed by anyone else in the operating theatre. The
Surgeon closed the abdomen and left the theatre and the
Anaeslhetislleft a short time later. The nurses were left in
the operating theatre with the patient still attached to an
E.C.G monitor, still intubated and on a ventilator and with
a blood transfusion and drip still running. None of the
nursing staff had heard that the palient was dead, but they
all considered that he would not recover, and therefore
they brought his wife into the operating theatre to see her
husband.
The Anaesthetist stated that he had left the ventilator and
the two drips connected in case they might resuscitate
him again, but also conceded in evidence that there was
no chance of improving his condition.
The Coroner made recommendations about the
importance of communication between surgeons and
anaesthetists in general" and made specific comment
upon the need to communicate with nursing staff when a
decision was made to return a patient to theatre.
It was the responsibility of the surgeon to initiate the
removal of a patient from an operating theatre after an
operation and to direct the return of a patient to the
operating theatre. The actual decision to return a patient
to the operating theatre would normally be made in
consultation with the anaesthetist and with nursing
staff....1f return to theatre was a possibility, the surgeon
would be expected to liaise with nursing staff so that this
could be done efficiently.'"
However, he did acknowledge the fact that the surgeon
did not take up the offer of the Scrub Nurse.
Had the Surgeon accepted the offer made by the Scrub
Nurse to place a drain in the abdomen of the deceased
this would, of course, not have stopped any bleeding, but
it might have revealed that bleeding was continuing."
In his conclusions, the Coroner made positive comments
about the behaviour of the nursing staff.
3. After the deceased was transferred to the Recovery
Room, it should have become clear to the Surgeon that
the condition of his patient was deteriorating, that it was
highly likely that there was significant haemorrhage
continuing and that further surgery was necessary. This
situation was recognised by experienced nursing staff. I
find that it was the Theatre Manager who took the initiative
to have the deceased returned to the operating theatre for
further surgery."
and later-
8. The evidence at this Inquest shows that the nursing
staff carried out their duties in an efficient and appropriate
manner.
33
These two cases are significant because they highlight
the difficulties which nurses encounter when they are
concerned about the medical management of a patient. In
the first case, the scrub nurse mentioned the darkness
of the blood;" the lack of bleeding, the small number of
artery forceps used" and the speed of the operation."
Why did the scrub nurse not simply speak directly to the
surgeon "Excuse me, but I think this patient is hypOXic?"
In contrast to the absence of blood in the first case, in the
second case, during the initial surgery, the Scrub Nurse
was obviously concerned that the patient was still
bleeding. She mentioned the fact that the abdomen still
looked moist when the surgeon observed that he thought
it looked dry, and offered the surgeon a choice of drain
prior to closing the wound, which would seem to imply
either an expectation of further drainage, or a need to
ACORN JOURNAL, AUTUMN 2000
.." . , LEGAL AND ETHICAL ISSUES IN PERIOPERATIVE NURSING
monitor lor lurther drainage. He clearly did not heed her
tactfully couched concerns, as he declined her offer, and
proceeded to close the wound. That the theatre nurses
were veri concerned about the patient's condition was
borne out by the fact that the scouf nurse was sent out in
advance to warn the Recovery Room staff to expect a
patient who "...may still be bleeding internally.""
If the scrub nurse and other nursing staff really suspected
that this was the case, as their evidence indicated that
they did, why did they not insist that the surgeon search
further? Why did they not argue with the surgeon about
the use of a drain to better monitor the patient's blood
loss? This is not morning tea at the Ritz. Etiquette is
surely not that important il we think someone is bleeding
to death.
No criticism is made of the nursing staff by the Coroner,
but the fact remains that they did not prevent a surgeon
from closing a patient's abdomen when they had strong
grounds to suspect that the patient was stili
haemorrhaging. One has to wonder what has gone wrong
with a system when one group of experienced
professionals feel unable to express their concerns about
a patient's safety because of the hierarchical nature of
their reiationship with another professional. The very fact
that the Coroner makes no criticism of the nurses, but
rather praises them lor carrying out their duties in an
"efficient and appropriate way,"" indicates that he actualiy
recognises their perceived inability to intervene in a
situation where they manifestly knew that the patient was
at risk. The Implication is that it was "appropriate" for the
nurses not to conlront the surgeon about their concern lor
the patient in the operating theatre, and that it was only
"appropriate" for the Theatre Manager to intervene post
hoc in an assertive way as a form of damage control.
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If the behaviour 01 the theatre nurses was "appropriate,"
this condones a lorm 01 institutionaiised powerlessness
whereby it is more important to comply with the etiquette
01 the operating theatre hierarchy than it is to intervene
actively when the patient is at risk. In addition, the
description of "efficient" seems odd since two operations
were performed when only one might have sufficed if the
scrub nurse's beliel that the patient was still bleeding
internally had been heeded and investigated. This
analysis is an attempt to highlight the way in which the
inabiiity 01 the scrub nurse to intervene activeiy was
accepted as the status quo by the Coroner, to the extent
that her behaviour was not singled out, but collectively
described as efficient and appropriate.
What the Coroner and the judge wouldn't know, but what
you and I can imagine, is the anguish 01 the theatre
nurses alter those deaths, and the unresolved anger that
they would have felt about the lact that they did not do
more at the time. The courts have recognised the fact that
doctors are entitled to rely on nurses to be competent,
and that the doctors are not heid responsible for nursing
mistakes. It would be easy to use this argument in
reverse lor the two above cases and say well, these were
medical mistakes, the nurses were not held responsibie
for them and that is as it should be. To a cehain extent I
would agree, but then I am taken again to the mental
image of the two scrub nurses subtly suggesting drains,
commenting on excessive bleeding or the colOur or
amount of the biood - why did they not just speak out and
express their concerns? And furthermore, why was there
no infrastructure to enable them to insist that there
concerns were heeded while the patient was still on the
table? At the moment such a decision to intervene seems
to be purely personality based - a more receptive surgeon
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LEGAL AND ETHICAL ISSUES IN PERIOPERATIVE NURSING
might have listened to the scrub nurse, a more confident
scrub nurse may have managed better, been more
assertive. But personality is no basis for ensuring patient
safety; there should be no doubt at all in the minds of
even the most timid nurse faced with the most obnoxious
surgeon that her primary duty is to ensure patient safety.
But no scrub nurse is an island: such clarity or purpose
comes from a system where concerns expressed by
nurses are backed up to the hilt even if they turn out to be
incorrect, and where no surgeon is ever allowed to get
away with bullying behaviour. People who are afraid of
other people's moods and tempers learn ways of avoiding
them, methods of evading confrontation. What these
cases tell us is that even in a major teaching hospital in
1994 the culture did not accept as the norm that a nurse
should intervene at a time when she clearly suspected
the patient's life to be in danger.
Conclusion
So there you have it. A series of stories, pretty shocking,
but true. I would imagine that each nurse who reads this
column would have at least one such similar story in their
repertoire. What do these stories tell us? They tell us that
nurses have not yet sorted 'out to whom they owe their
primary duty of care. Some nurses still believe that the
duty to obey the surgeon overrides the duty to protect the
patient. Some nurses are still too afraid to confront the
surgeon, because it can be unpleasant and threatening.
My final message from this column to you is that concern
for the patienf's safety should be paramount and ought to
drive all actions in the perioperative suite. I wish you
courage.
References
1 Lumby J Threads of an emerging discipline in Gray G & Pratt R
(Eds) (1991) Towards a Discipline
of Nursing Churchill Livingstone, Sydney, at 473
2 Farber DA and Sherry S, 'Telling stories out of school: an essay on
legal narratives' (1993) 45 Stanford Law Review, 807
3 Weston in Armstrong D. (1961) The First Fifty Years, Australasian
Mad!",.! Publishing Ce;. Ltd: SIebe,
at 312-313
4 Lavere v Smiths Falls Public Hospital (1915) 26 DLR 347 at 349
5 [1939J 1All ER 535
6 Ibid. at 556
7 (1972) 32 DLR (3d) 303
8 Ibid. at 311
9 Ibid.
10 Ibid. at 312313
11 1984 Medical Defence Union Annual Report, 24-25
12 (1997) Aust Torts Reports 81-448 a164, 560
13 Ibid. at 64,564
14 Ibid. at 64,567
15 Ibid. at 64,566
16 Ibid.
17lbid. at 64.567
18 Ibid. at 64,568
19. Rs Anderson and the Medical Practitioners Act 19381964 and
Re Johnson and the Medical
PractitionarsAct 1938-1964 (1967) 85 WLR Pll (NSW) 558
20. Ibid. al 563
21. Ibid. at 570
22. Ibid.
23. Ibid. at 565
24. Ibid. at 564-565
25. heard at Perth Coroner's Court on 7th April 1994 belore David
Arnold McCann S.M.
26. Ibid. at 9
~ 7 . Ibid. at 10
28. Ibid. at 11
29. Ibid...t 17
30. Ibid. at 17
31. Ibid. at 15
32. Ibid. at 20
33. Ibid. at 20
34. Ibid. at 563
35. Ibid. at 570
36. Ibid. at
37. Ibid. at 5
38. Ibid. at 20
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Card Number:
0000000000000000
Expiry Oal.: DODD
ALSO AVAILABLE
Video Education of Anaesthetic Assistants and Recovery Room
Nurses!
Anaesthesia $18 each .
(An overview for Anaesthe1ic Assistants)
Recovery Room Nursing
in Summary
Complete Set of 2 Videos
NUMBER TITLE
.......................................................................................Pestcede ..
Name on Card: ...............................................................
Phone Fax .
Signature: Oate: .
,.. Please send completed order form to: ACORN SECRETARIAT, 111a Main South Road, O'Halloran Hill, SA 5158
54 ACORN JOURNAL, AUTUMN 2000