Thursday, January 31, 2008

Bugs, redugs

The previous post, on OR sterility, occasioned an email from a professor of surgery, who informed me of a study of which I hadn't been aware. I quote from his letter:

"I wanted to draw your attention to another surgical/OR dogma that has essentially been put to rest, the wearing of the surgical mask. The Karolinska Institute (and other groups) has evaluated wound infections in two groups, one in which the OR team wore surgical masks, the other without masks. The outcome, as you might predict, was that the infection rates are the same (4.7% with vs. 3.5% without). Here is one of the references: World J Surg. 1991 May-Jun;15(3):383-7; discussion 387-8."

Whereas, in this litigious society, I doubt you'll see anytime soon surgeons and scrub personnel eschewing their masks as a result of this study, I find it unsurprising; not to mention amusing and validating. Part of the inference to be drawn from my previous post is that some of what we do is not much more than ritual -- or, at least, it's unproven even if it makes intuitive sense.

In my earlier days, the ten-minute scrub (washing hands and arms before donning gloves and gown) was standard. So much so, that many ORs had timers above the sinks. Having never seen any studies comparing ten minutes with, oh, eight, or six, I can say I never scrubbed that long, unless someone was breathing down my neck. Later, studies were done: I was right.

Reading the email, I was reminded of a sort-of secret about my practice. For reasons of cost-saving, simplicity, and patient convenience, I did countless breast biopsies in my office, under local anesthesia. These were full-fledged surgical biopsies, not needle sampling (which I also did, in far greater numbers.) I had a small procedure room with a small OR table, a cautery unit (which I rarely used, preferring -- for cost saving, mostly -- the old fashioned suturing of bleeders), and I used instrument packs that we made up and cooked in an autoclave (eventually, after we built a surgery center in our building, we had them process the instruments.) Anyhow, my point is this: I painted the skin with antiseptic, used a small sterile drape, wore gloves and a clean cotton frock, short-sleeved and the size of a shirt. And no mask, unless I had a cold. I'm certain if some credentialing agency were to observe, I'd have been hauled off and boiled in oil. Yet, over a period of twenty-plus years, I never had a wound infection. Got a few hematomata, I'll admit, which I either drained or left alone, depending. But no infections.

I'm not -- repeat: NOT -- suggesting that sterile precautions are unnecessary. Quite the opposite; but I intuit there may well be a level of caution beyond which some measures are less important than we think. (As I said in the previous post, the extraordinary care taken in certain settings is vital.)

A related concept: skin prep. Sterilizing skin before operating is essential. But there are some parts of the process that have always amused me. To wit: it's expected that a reasonable zone of prepped skin will surround the area to be incised. Absolutely necessary and proper -- probably the most important of all the things we do. Yet I've watched with consternation as the prep is done for, say, an inguinal hernia. Unfailingly, the prep is carried all the way to the ribcage or beyond to the north, but only a couple of inches below the groin, where the actual incision will be. Similarly, unless I intervened, the prep for an upper abdominal incision went way down to the pubis or below, but only just above the xiphoid process, topside. I'm not aware (the cop-out that says I haven't looked it up) of studies that compare skin prep distances from incision. I'd guess there is a minimum necessary distance, and a point at the other end of the spectrum beyond which it doesn't matter (taking account of the possible need to extend or make a second incision.)

So what's the lesson? Nothing very important. It just happens to interest me that whereas it's best to err on the side of caution, it seems that much of what we do isn't necessarily grounded in science, nor makes sense. Does that surprise anyone?


Anonymous said...

Dr. Schwab,
I think YOU should think about becoming a professor!!:) I gave my A&P class the link to your site and they were excited about reading!
Thanks for your writing!

Anonymous said...

Should I challenge my scrub nurses by citing this study? One actually hung around to watch me scrub the full 10 min :)

rlbates said...

Dr Sid, good post. I too don't bother with the mask when I do small scar revisions, etc in my office. No infections. And they don't get the preop (periop) antibiotics either.

Anonymous said...

I have heard of a lot of doctors who insist that their patients shower on surgery day with some special soap called Hibi-Clens. It seems kind of crazy to me. They aren't told to dry off using a
freshly cleaned towel (many people use the same one several times before laundering on the theory that they're drying a clean body). Then the person puts on clothing and travels to the hospital, so it's not as if some sterile field will be maintained. Most of that Hibi-Clens'ed skin isn't even going to be exposed, and what will be cut will be betadine'd to death first.

Must be some really fine juju in that Hibi-Clens, eh?!


Sid Schwab said...

Science kid: one challenges a nurse at one's own peril. But if you choose to, you could quote this. There are others.

Sid Schwab said...

celeste: what you say makes sense. I have, however, on a couple of occasions seen to it that there was a hibiclens (or similar) cleansing before coming to surgery. It's when a patient presents with particularly poor hygiene, skankiness discernible from two doors down...

SeaSpray said...

Good post Dr S.-this is all so interesting!

I have wondered about what anonymous 11:30 am said. The PAT nurse tells me to wash with ant-bacterial soap -I think she gives me a little wrapped one on the day of surgery. No lotions afterward.

So I take a really good, long shower the night before, shave, etc. and then really put on the moisturizer and go to bed. Then prior to leaving I take a fast shower, shave once more and quickly use the soap and rinse. Always use a clean towel though.

I think your is probably the immediate prepping prior to surgery that makes a difference.

The 1st time I ever went into an OR I was 24 and it was for a laparoscopy to help determine why I was unfertile at that time. My room mate and I had to take showers in some community shower down the hall prior to our going in the OR. After we returned...I had the bright idea to slather KERI lotion all over my body so I would be soft going into the OR. I shared it with her too. This Kerri lotion was really thick. a little sticky and kind of made you glisten and feel slippery. So I imagine that we were two germ magnets rolling off to the OR that day. good thing we didn't slide right off the table! ;)

Dr Schwab...I REALLY want to know the answer to this.

Why can't a female pt where some light makeup into the OR? What would a little light foundation, light mascara or light lipstick do that would negatively impact the surgery? It might help the woman to go in feeling a little better. Is that also probably part of the old school OR traditions or is there some scientific basis to it?

GDad said...

Dr. Schwab,

Surely you're not suggesting that doctors have to fight against magical thinking just like us normal humans?

I have to go lie down.

p.s. Love the "Redugs."

Sid Schwab said...

seaspray: for the most part, it's anesthesia-related: powder, etc, can get in the eyes when you're asleep. Not too likely, given the precautions taken. But possible. As to lipstick: there are still a few anesthetists who pay attention to lip color as a way to monitor status. With all the pretty-much failsafe devices now in use, it could matter extremely rarely, if at all. Still... (There used to be a few anesthesiologists who visited hereabouts. Maybe one could comment....

Gdad: thanks. I liked that, too. I also like some of my links, about which no one EVER comments. Hint: some are funny. Or so I like to think.

Anonymous said...

Interesting study the professor sent you. Brave patients to agree to surgery without masks!

PS. Your links ARE funny ;)

SeaSpray said...

Oops! I put just a tiny little light pinkish skin tone kind of stain on my lips with a lip pencil the last time I went in the OR. First and only time I ever did that.

BUT...when I asked the PAT nurse if I had to take my light pink nail polish off because I know they look at skin tones etc., she laughed and said if it was darker yes and they have more sophisticated equipment they use now in the OR. However, she didn't tell me it was ok for the lips...I did that on my own. and one other thing since my eyelashes are naturally black I figured they wouldn't notice if i put the tiniest amount of pencil liner on. BUT a couple months before that...I also watched that movie She Wore Red Lipstick (I think that was the title but not sure)where a woman who was scheduled for a mastectomy was allowed to wear red lipstick and makeup into the OR because it made her feel better and I guess it was also her way of being defiant against the disease. So...those are the two reasons I figured it was ok. I really would like to know what every one else thinks or does.

Hey...Dr Schwab... I see you will be on TalkRadio with Dr Anonymous tonight! I am really looking forward to it and really going to try to listen live and if I can't I will most definitely catch it on his archives. Have fun with it! I know it will be interesting! :)

Sid Schwab said...

It's a week from tonight -- 2/7. If the creek don't rise.

SeaSpray said...

Yes...sorry about that...I read something wrong! That creek better not rise...we all want to hear you! :)

Anonymous said...

What about the swabbing of skin with alcohol before an injection? It does nothing at all, right? And yet doctors still do it.
Is it because patients will think them neglectful if they dont?

Sid Schwab said...

Beuxzeaux: the alcohol kills a few bugs. It's not as potent as, say, povidone, but I'd guess if every injection were given with no skin prep, there'd be some local infections. On the other hand, when I was in the service, along with a bunch of docs I had to self inject in a poison gas drill. We had to stab a needle through our clothes into our thighs; I was the only one headed to Vietnam, so I had no problem doing it. Figured I better learn everything I could. About half the docs couldn't force themselves to do it -- no skin prep.

Anonymous said...

loved these posts - thank you! It's fascinating to see how much thought and care is devoted to keeping things 'clean' during procedures, only to have it all go to h*ell when the pt ends up tucked up in bed handwashing between patients, anyone? Not to imply that you would ever do this, but I've seen it happen many many times.

Anonymous said...

Hi Sid,

I think this anecdote is pretty fascinating (comes from a first hand account of Civil War surgical experiences):

"The cleanliness of wounds, except in respect to the gross forms of foreign matter, was regarded as of little or no importance. The injured man covered his wounds as best he might with a dirty handkerchief or piece of cloth torn from a sweaty shirt...

Tables about breast high had been erected upon which the screaming victims were having legs and arms cut off. The surgeons and their assistants, stripped to the waist and bespattered with blood, stood around, some holding the poor fellows while others, armed with long, bloody knives and saws, cut and sawed away with frightful rapidity, throwing the mangled limbs on a pile nearby as soon as removed. Due to a frequent shortage of water, surgeons often went days without washing their hands or instruments. Despite these fearful odds, nearly 75 percent of the amputees survived."

Sid Schwab said...

Val: thanks. Pretty graphic. Says a lot for leaving wounds open, which I must assume they did.

Assrot said...

Hmmm... I always thought surgeons wore masks to keep themselves from getting infected by an accidental splatter of some bodily fluid from the patient.

I never thought there would be a need for a mask otherwise unless of course the surgeon has a cold or some other repiratory ailment and is hocking and spewing all over the O.R.



Anonymous said...

I was interested in how the mask study was carried out.

I reckon this is the abstract from the published article:

It explains some of the methods.

Still wonder if the patients were asked if they would agree to subject themselves to surgery without masks, in order to find out if that caused more infections?

Do you know?

Sid Schwab said...

sterileeye: I don't know. Here's an interesting thing I hadn't noticed until you provided your link (although it was there in my post!): the article was from 1991. So it hasn't exactly taken the world by storm.

Anonymous said...

My mother used to make me wash my hands before dinner, even though I used a fork to move the food to my mouth. Her argument had to do with the distance germs could migrate during dinner. I suggested longer forks.
Thanks -- haven't checked in since Christmas, good to see you out and posting!

Sid Schwab said...

Tom: well, welcome back to us both. Longer forks. Excellent!