Tuesday, January 29, 2008
In commenting on my recent post about scrub clothing, Seaspray asked some good questions about operating room sterility. To give an excellent answer, I suppose I'd have to look up the latest studies. Fortunately for me, I'm quite willing to settle for anecdote and opinion, which is a heck of a lot easier. There's no doubt that maintaining sterility in the operating room is a prime directive. It's also true that, to a greater extent than might be expected, it's an illusion.
That's not to say that maintaining proper technique is unimportant, or that breaks in such technique aren't to be avoided like, well, the plague. It's just that there are inconsistencies that might seem strange, but which don't seem to matter all that much, mostly.
I recall a study that was reported when I was in training. I don't remember where it was done -- it could have been there, for all I know. In it, some sort of stuff was placed on the gloves of surgeons and scrub nurses, detectable in some way -- I think it was by Wood's Light. In the course of routine operations, it showed, touches went to places they shouldn't have: the top of the ether screen, IV poles, face-masks, parts of drapes that were close to the floor. (I assume the stuff was applied after all the draping was done, otherwise it would have been meaningless.) From that report I took a couple of messages: one, we could do a hell of a lot better; and two, it might not be as important as we think. Clean is important. Sterile, maybe not so much. After all, at least in the sort of surgery I did, nearly all wound infections (which -- despite what you may be wrongly concluding is a cavalier attitude -- were vanishingly rare in my practice) occur from the patients' bugs, not the OR's.
Don't misunderstand: my point is not that sterility is unnecessary. It's that, other than cooking instruments and using properly packaged attire, there's much that goes on in the OR that falls short of exemplary. But it's also that whereas it's impossible to achieve perfection, you should take heart: it'll be okay. Under most circumstances, being plenty clean and taking various other precautions (such as proper and judicious use of antibiotics) does just fine.
[OK, let me dispense with one situation: when prosthetic joints are implanted, extraordinary steps are taken, and well they should. Often the scheduled room is specially cleaned the night before surgery, and is then shut down. Rooms have laminar airflow, to minimize the raising of dust; surgeons and scrub nurses wear special all-encompassing gowns, along with full head-gear. Traffic in and out of the room is prohibited. This is because when bugs come in contact with implanted foreign material, they are extremely hard to eradicate. And whereas such steps would probably reduce wound infection in any operation, the incidence in routine operations is so low, and the implications so much less ominous, that following such protocols universally surely would not be cost-effective. (I use the word "surely" in the spirit of my opening paragraph.)]
Between cases, floors are mopped, some equipment in the room is wiped down. But people come and go. Some wear shoes that they keep in their lockers only for OR use; but they aren't cleaned, and if shoe covers are used, they may not be changed for days. Gurneys are wheeled in and out. During some operations, despite the claimed water-proofing on gowns, fluids may leak through to one's non-sterile scrubs, or to one's skin. Also, one must presume, back again. And the operating lights? Don't ask! So. Operating rooms simply are never completely sterile, nor, after a time, are most surgical fields.
Once again, we can only marvel at the wonders of the human organism. I've said in the past that were it not for the ability of a body to heal itself, surgery would be impossible. Surgeons are not healers; we are tippers of the balance, setters of the stage. Likewise, if there were no intrinsic ability to repel bugs, we could never safely enter, because we'll never reduce the load to zero. I've always believed that what goes on under the skin is more important that what we do outside it, surgically speaking. Strangulated tissues don't heal, nor resist infection. Brutalized, they can harbor infection. Carelessly handled, bacteria-bearing organs can be made to seed others. Surgical technique matters, at least as much as the pre-incision measures.