We're doing something a little different this week - a collaboration episode, all about the foundations of endoscopy.
I was invited to join Sam and Amy from Vet Solutions on the Focal Point podcast to talk about one of my favourite topics. Sam is a vet, and Amy is a vet nurse (and their account manager for Scotland), so between the three of us we had a pretty good spread of perspectives.
This is part one of a two-part series. In this episode, we go back to basics - the types of scopes you'll come across, what all the kit actually does, how to prepare it, how to handle it, and how to clean and look after it once the procedure's finished.
In part two, we'll look in more detail at the nursing role during the procedure itself - things like anaesthesia, monitoring, assisting and sample collection, and some of the more specialised endoscopy procedures we can get involved in.
So if endoscopy has always felt a bit intimidating, or you've got a scope hiding in a cupboard at work that nobody quite knows how to use, I know you’ll get a ton of value from this episode.
So why does endoscopy feel so scary to so many of us?
We started the episode by sharing our first memories of endoscopy, and there was a lot of overlap between the three of us.
Amy remembered the vets getting really excited peering down the eyepiece of a fibrescope. As the nurse, her focus was on the patient and the anaesthetic, and when the vet twisted the scope round so she could have a look, the view had already moved on. All that excitement in the room, and back in the fibrescope days, it wasn't really shared - unless you had an external camera to go on.
For me, it was a mix of two things. The first was excitement - especially around foreign body removals. They're still some of my favourite procedures, because getting a foreign body out (often after several attempts!) is incredibly satisfying.
The second was a constant stream of warnings. Don't touch the scope. Don't break the scope. Don't soak the scope. Don't look at the scope the wrong way. So I loved endoscopy, but I was also a bit scared of it at the same time - and looking back, a lot of that fear was misplaced.
Sam had a really similar experience as a newly graduated vet. The kit lived in boxes, full of bits he didn't recognise, and unless someone (usually a nurse) was there to put it all together, he didn't want to go near it. Then there was the cleaning process afterwards, which he knew had to be done in a very specific way but had no idea what the steps were.
We know the fear is real - but where does that fear come from?
When the setup and cleaning feel like a mystery, it's easy to avoid the kit altogether. And if nobody handles it, nobody learns how to look after it properly either.
Where do you start if you don't have much endoscopy experience?
One of the biggest challenges I found early on was that we just weren't taught much about endoscopy in college. Many colleges don't have scopes for students to get hands-on with, so your first impression depends almost entirely on your training practice.
Whether the practice has scopes, which ones, how often they're used, and how confident the team is with them all hugely influence how endoscopy is introduced to you.
So if you'd like more exposure, there are a few things you can do.
Spend a day at a practice that does a lot of endoscopy. Shadowing another team is a great way to see how they work - and it counts towards your CPD hours too.
Find the person in your practice with a keen interest in it. That might be a nurse or a vet. Ask them questions, and get hands-on with the scopes alongside them, where you feel supported.
Lean on your manufacturer or supplier. If your practice has recently bought a scope, the company you got it from will usually provide training and support. Even if the kit has been sitting in a cupboard for years, it's worth getting in touch.
Ultimately, the only thing that's going to get rid of that fear is handling the scopes, learning the right way to do it, and getting comfortable and familiar with them.
Yes, scopes are delicate. They need careful handling and appropriate maintenance. But if we're all too scared to touch them, nobody learns how to do that, and the problem just carries on.
What are the main types of scope we use?
The word 'scope' covers a really wide range of equipment, so it helps to start with the two big categories: rigid and flexible.
Rigid endoscopes do exactly what they say - they don't bend.
They're essentially a firm telescope that you look down, and they're used for things like:
Laparoscopy and other surgical procedures, such as arthroscopy
The upper respiratory tract, like the nasal cavities
Probing wounds
Dentistry, especially in equine practice
Your otoscope is actually a form of rigid endoscope too, if you think about it.
Flexible endoscopes are the ones that bend, and they're by far the most common in practice.
These are usually named after where in the patient we use them, and their diameter dictates what they're used for.
Gastroscopes go down into the stomach. They're a bit wider, so there's room for instruments to grab foreign bodies and take biopsies. Many practices also use their gastroscope for colonoscopy, so they're really versatile.
Bronchoscopes go down into the lower airways. They're narrower, so there's less that will fit down them.
Cystoscopes - very narrow flexible scopes - are used in places like the urinary tract.
So when you're faced with an unfamiliar scope, the first question is whether it's rigid or flexible. From there, its name will usually tell you where in the patient it's used.
Beyond the scope itself, what other kit do we need?
As Amy explained, every endoscopy set-up needs three main things:
A light source
A way to view the image
The scope itself
Most newer systems project the image onto a monitor, and older scopes can often be adapted to do the same, by adding an external camera head to the eyepiece of the scope.
After that, what you need depends on two things: the type of scope you're using, and what you're planning to do with it.
For GI endoscopy, we need a few more things alongside the scope and the tower.
To visualise the GI tract properly, we need to inflate it - distending the oesophagus, stomach, small intestine or large intestine, depending on where we're scoping - so that we can assess the mucosa and choose areas to biopsy.
That means we need:
An air source, which is usually built into the light source
A water source - a bottle of distilled water that comes with your endoscope
Suction, so we can remove the air at the end of the procedure (overdistending the stomach can cause anaesthetic complications, and it's uncomfortable for the patient afterwards), and remove any fluid that's obscuring the view
Valves or buttons on the scope, which let the clinician control the air, water and suction
Then we need channel instruments, depending on the procedure. In most GI scopes we're taking biopsies, which means biopsy forceps that pass down the instrument channel. For foreign bodies, it depends on what we're dealing with:
A retrieval basket for something like a stone
A snare for longer, thinner objects - an oval loop of wire that's placed around the foreign body and tightened to trap it
Grasping forceps to grab the end of the foreign body and pull it out
Airway endoscopy usually needs less.
Foreign bodies are less common in the airways, although we've just come out the other side of grass seed season and have definitely seen a few. Grasping forceps are the usual go-to for these.
We don't tend to take biopsies from the lower airways. Instead, samples usually come from an airway wash or bronchoalveolar lavage (BAL), instilling saline either straight down the instrument channel or through an aspiration catheter passed down it.
Suction lets us retrieve that fluid back up through the scope, and a mucus trap sits between the scope and the suction to collect it aseptically, ready to send to the lab.
That's a lot of kit - how do we get organised?
I've worked in internal medicine for over 10 years now, so endoscopy doesn't feel overwhelming to me anymore. But I clearly remember watching a medicine specialist scope a patient for the first time and thinking ‘this is NOT what I remember endoscopy being’.
First, ask questions.
Talk to your clinician about what they're doing, step by step, and why. Over time, you'll start to see what they need and anticipate what they'll reach for next.
Next, build equipment lists for each procedure.
This was one of the first things we did in my practice. We created a list for each type of scope we perform - upper GI endoscopy, colonoscopy, bronchoscopy and so on - covering:
Which scope to use
What's needed to set that scope up
The accessories and consumables that go with it
And include photos of each item. That way, even if you don't know the technical name of an instrument, you can find it quickly.
Amy compared this to learning surgical instruments when you first start out. You look at pictures and posters, you learn which kit goes with which procedure, and it takes time - but it does come.
Sam made a really good point here too. Accessory catalogues look enormous, because the same instrument comes in different lengths and with different tips. But for any one procedure, you'll only need a handful of them. It's either something to remove a foreign body, or something to take samples.
And don't worry if you haven't got everything out in advance.
I still get this with foreign bodies. I'll get out what I think the clinician needs, then the foreign body sits at an awkward angle and they need something else. That's fine, because I know where it is.
Throughout the procedure, I'll check in with the clinician - do they have everything they need, or do they want to try something else?
We store our channel instruments in plastic drawers, organised by the scope they go with. Worst case, I take the whole drawer out, pop it on the trolley, and the clinician picks what they want.
Then think about the consumables.
These include:
Mouth gags for any scope going into the airway or GI tract. Bite and crush damage are among the most common causes of insertion tube damage, so this is a really easy way to protect your scope.
Sample pots and tubes, since collecting, handling and processing samples is a big part of our role (we'll cover this in part two).
Everything you need for anaesthetic support, which is of course a huge part of our role as vet nurses.
Finally, use a checklist - and check the scope before the patient is anaesthetised.
In my practice, this developed into a patient safety checklist, and it's something I'd really recommend. Before induction, we:
Leak test the scope
Check its functions - for a GI scope, that water comes out of the tip normally, air is flowing, and suction is working
Confirm we have everything we need, and that the clinician is happy
Check any specific premedications the patient needs for the procedure have been given
Calculate emergency drugs
The checklist also covers things like mouth gag placement and patient positioning.
The last thing you want is an anaesthetised patient on the table and a scope that isn't working. Checking beforehand means you're not troubleshooting under that pressure.
Sam is also a big advocate of written checklists and SOPs for cleaning and leak testing. In the chaos of a normal day in practice, it's easy to miss a step, and ticking boxes as you go makes a real difference.
So are scopes really as fragile as we've been told?
If I had a pound for every time I'd heard 'don't break the scope' in practice, I'd be a millionaire and already retired.
Amy explained that older fibrescopes are more fragile, because the image travels along glass fibres from one end of the scope to the other. Even so, a scope can lose some fibres and still give an image. And there are still plenty of fibrescopes out there in practice today.
Newer scopes transmit the image electronically, through wiring, which makes them a lot more robust.
The distal tip is the part to be most careful with.
In a flexible videoscope, the tip houses the camera lens, the chip that captures the image and the angulation wires, so there's a lot packed into a very small space.
But overall, scopes are much tougher than many of us were led to believe. They go in and out of stomachs, out onto farms with equine vets, and in and out of cases. Amy has seen scopes that are 40 or 50 years old and still in great working condition.
Put it in context.
I think nurses tend to be especially worried about damaging scopes during cleaning and handling. But compared with what a scope goes through during a procedure - being torqued, navigated around every corner of the GI tract, and having instruments passed down it - cleaning is pretty gentle.
That doesn't mean we stop being careful. We still protect against bite damage, we don't force instruments through when we feel resistance, and we make sure the insertion tube doesn't get caught in the cupboard door when we put the scope away. But scopes are built to withstand a lot.
How should we handle and carry them?
The main answer from both of us was practice. Muscle memory only develops by getting hands-on.
Amy works with equine gastroscopes, which can be 3.5 to 4 metres long. Her advice is to coil the insertion tube loosely so it's all together, and make sure it isn't dragged along the floor or knocked against surfaces as you move around the practice.
I'm grateful that I only work with small animal scopes! The way I hold mine is:
The control body in my hand, held with my thumb and first couple of fingers
The distal tip of the insertion tube tucked into the same hand, held with my ring and little finger, so it can't be knocked, slip, or bang against the table or the floor
On a gastroscope, there's also the umbilical cord (where the light guide plug, suction and water bottle connect). You can hold that in your other hand, and with practice, you'll be able to hold all of the tubing together with the scope body in one hand.
Take the scope out of its box or off its hanger, and practise. You'll quickly find what feels comfortable and safe.
What happens to the scope after the procedure?
This is the part Sam described as a 'magic cleaning ritual' when he first qualified. In reality, it comes down to two main stages: a patient-side clean straight after the procedure, and a full clean afterwards.
First, the patient-side clean.
Looking back on my time in general practice, this probably wasn't something we were as aware of as we should have been. But I'd argue it's one of the most important steps of all.
Think about everything sitting inside that scope after a procedure - fluid, proteinaceous material and, if you've taken biopsies, tiny bits of tissue dragged up into the instrument channel. That solidifies quickly, and it can cause significant blockages. These can be really challenging to clear in practice, and sometimes the scope ends up going back to the manufacturer or supplier to be unblocked.
Our patient-side clean involves:
Suctioning and flushing the channels with a cleaning solution approved by the manufacturer for that scope
An initial brush through the channels with an appropriately sized channel brush
Wiping over the insertion tube with the cleaning solution
This also buys you some time, so you can help recover the patient (or recover them yourself, depending on your role and the support around you) before coming back to the full clean.
Amy admitted that, back in practice, a thorough scope clean was never top of her list - a scope used first thing might not get cleaned until 3pm if she could help it! But this step matters, and she's especially keen for the equine teams to do it before the scope goes back in its case for the journey back to the practice.
Then, the full clean.
The process depends on the type of scope. Rigid scopes don't have a working channel, but many have an operating sheath with ports that need cleaning. Flexible scopes have working channels that need brushing and flushing.
It can sound like a lot when you've got 16 other things to do. But it's got so much quicker. I remember when it was 30 minutes in each solution with a rinse in between, and depending on the chemistry, some products now have contact times of around 10 minutes. Some practices also have automated reprocessing tools, but even manual cleaning takes far less time than it used to.
For a flexible scope, the process looks like this:
Leak test the scope. We leak test before use too, but it's important to repeat it afterwards. In my experience, leaks almost always develop during the procedure - for example, when an instrument is advanced through the scope while it's bent, or during a tricky foreign body removal. A scope isn't going to start leaking while it's hanging clean in the cupboard.
Brush and flush the channels and wipe over the scope with your cleaning solution.
Submerge the scope in the cleaning solution for the manufacturer's recommended contact time.
Rinse.
Repeat the process with a high-level instrument disinfectant, for its contact time.
Rinse again with distilled water.
Dry the scope thoroughly and store it, ready for next time.
What if the leak test fails?
If the leak test fails or you're at all worried that the scope might be leaking, don't go ahead with the full clean and don't submerge it. Contact the manufacturer for advice first - the scope may well need to go back to them.
Can damaged scopes be repaired?
In a lot of cases, yes. Scopes can be damaged in lots of different ways - on the outside, on the inside, or where the different tubes connect - so it really depends on where the damage is.
If you have a service contract, that's your first port of call. If not, contact your manufacturer or supplier, who should at least be able to point you in the right direction.
Endoscope service engineers are highly trained and can strip a scope down and rebuild it, a bit like a mechanic with a car engine. Replacement parts are often available too, which helps keep scopes up and running for a long time.
How else can we build our confidence with endoscopy?
Use the support that's available to you.
No company is going to hand over a scope and leave you to it. They want you to get the best out of that equipment, and they want the whole team - vets, nurses, and patient or veterinary care assistants - to feel confident using and maintaining it. So there will be training resources, and people you can speak to if you have concerns.
I work in a clinic with a high endoscopy caseload and some really challenging procedures, so relative to the number of uses, we probably see more scope damage than a general practice would. I've phoned the company we got our scopes from before and said I felt we were having more issues than we should.
That turned into site visits. I sent them our protocols for setting up, cleaning and handling our scopes. Sometimes, someone came in and watched me assist with a procedure from start to finish. The support you can get is often a lot more than you'd expect.
Make your own simulator.
Sam suggested this, and I love it. You don't need a patient on the table to practise. A cardboard box with a hole in it and something inside (a stone works well) is enough. Set up your scope, connect everything, put it in the box and have a look around.
It's a great way to get used to how the controls move and how instruments are introduced. And yes, you can absolutely call it a simulator, even if it's a cardboard box with a stone in it.
Practise communicating as a team.
Sam pointed out that communication is often overlooked when people are new to endoscopy. People often ask where they should put their hands, and what happens when an instrument is introduced. Getting used to talking to each other as you introduce and adjust things is part of that.
Early in my career, I was so scared to speak up. I didn't want to ask a question in case I looked like an idiot, or point something out in case they already knew. That is absolutely not the case now (probably much to the dismay of some of my vets!).
Now I'll say things like:
'Do you want me to advance these forceps, or are you going to do it yourself?' Sometimes they will, and sometimes they're not in a position to. If I'm advancing them, I'll go more slowly and cautiously than they would, because they have a better feel for how things are moving down the scope.
'I've hit resistance, so I'm going to stop - can you take over and have a feel?' It might be that the scope angle needs adjusting in the patient before the forceps will advance.
No matter how many scopes you've done, it always feels like there aren't enough hands to hold everything. Vets don't want to do it all on their own, and they're grateful for the help - we just don't always speak up about how much we can do.
What were our take-home messages?
To finish, Sam asked each of us for the one thing we'd want vet nurses to remember about endoscopy.
Amy's was to get involved. Get the kit out, get familiar with it, and touch that scope - it's not as scary as we think it is.
Mine was very similar: don't be afraid, get hands-on, and ask questions.
So that's the foundations of endoscopy covered - the kit, how to prepare it, and how to look after it.
To sum up this episode:
Scopes are either rigid or flexible, and flexible scopes are usually named after where in the patient they're used - gastroscopes, bronchoscopes and so on.
A basic set-up needs a light source, a way to view the image and the scope itself. For GI work, we also need air, water and suction, along with channel instruments like biopsy forceps, baskets, snares and graspers.
Equipment lists with photos, organised storage and a pre-procedure checklist make preparation much easier - and checking the scope before induction avoids troubleshooting with an anaesthetised patient on the table.
Scopes are more robust than many of us were taught, especially newer videoscopes. Take particular care with the distal tip, use a mouth gag, and never force an instrument through resistance.
A patient-side clean straight after the procedure helps prevent blockages. Leak test again afterwards, and if there's any concern about a leak, don't submerge the scope - contact the manufacturer.
Lean on the support around you, from colleagues and other practices to your scope manufacturer or supplier, and get as much hands-on practice as you can.
In part two, we'll look at the nursing role during the procedure itself - anaesthesia, monitoring, assisting and sample collection. And a huge thank you to Sam and Amy at Vet Solutions for having me on Focal Point!
Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!
Thanks for learning with me this week, and I’ll see you next time!
