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.


Anonymous said...

Ether screen? Surely your anesthesiologists have advanced beyond ether!

rlbates said...

I agree, but it still bothers me to see some wear the same scrubs into the OR the had on whe they rntered the surgery center (ie came in from home, their office, or another facility). It's happening more and more as surgery centers and hospitals "push" the laundry costs off onto the workers.

Sid Schwab said...

tom: still called ether screen. Ether long gone.

Anonymous said...

Keeping the highest possible theoretical standards maybe takes away the worst practical violations and keeps sterility at an acceptable level?

A story from my own work as a medical videographer:

I was introducing a new video stand that put my camera up there with the surgical lights. A rigorous cleaning and covering regime was put down for this stand. Washing and disinfection between cases was not enough, I was told. The camera and stand needed to be covered in sterile materials.

After the first operation this regime fell. The surgeons immediately made the covers non-sterile when touching it with their caps, and then making their gloves non-sterile when reaching for the light handle.

I pointed out that the camera was just as clean as the lights without the covers. They agreed.

But would we have reached this acceptable standard if we hadn't started with the highest?

SeaSpray said...

Very interesting post! I am relieved that perfection doesn't have to be attained.

In the hospital where I worked they would be short staffed with housekeeping for various reasons and I would think there is no way they could be doing a 100% although I assumed the OR was the most sterile. I have even wondered how well they wipe down patient beds, phones remotes, etc., and have kind of thought ignorance is bliss.

I have also wondered about those little socks they give pts to wear.

I put them on in SDS, walk across hospital floors to bathroom, back into bed, into OR (no undergarments on), skootch onto OR table with said socks ready to assume the bajingo on display position for urological procedures. Isn't all of that an invitation for those little critters to travel from socks or bed sheets up my legs to the procedure area being worked on?

Or as a pt in my room. Same thing...wearing the socks, walking on hospital floors but then back into bed with contaminated socks.

Still nekkid in the nether regions but also sporting a foley cath. I moved around in that bed plus when getting up from bed now sitting close to area wear feet have been.

Was that scenario an invitation for the bacteria to hitch a ride up the foley cath or directly in since I was sitting over a contaminated area?

I only had one infection. It was in the beginning when I was going through the worst of it all. I had developed an e-coli infection that became resistant to all oral antibiotics. Could doing that have been the catalyst for that infection? At that time I was stented and had foley caths too.

Anyway, I eventually asked a nurse and she said that I shouldn't be wearing the socks to bed. So I just made sure I had flip flops or slide on slippers buy my bed. No one from the medical staff ever cautioned me about the socks even though they would see me walking and then help me get covered up in bed.

Also, when some of them emptied the foley bag they sometimes would sit it on the floor briefly. Is that a good practice? I never said anything but wondered.

One last question. Chuckling as I am thinking about your "put it back!" post where you were discussing shaving the pts. What was the reason you like to shave the patients? Was it because of less chance of infection when doing just before the surgery? Forgive me if I mixed that up a bit. Ha! Ha! I am remembering the drama of the panicked or Staff telling them to put the shaved hair back before you saw it. Too funny! :)

SeaSpray said...

P.S. Thanks for the link. :)

Sid Schwab said...

I didn't have a fetish about shaving. I did it because it saved time, allowing the OR personnel to do other things; and also because I shaved as minimally as possible. But I was perfectly happy to tell someone how much to shave and to let them do it, if they had nothing else to do.

JP said...

Nice post, Dr. Schwab. Scratches - sorta - an itch I've had. Upon being wheeled into surgery last month, the first thing I noted in the OR room were the lights. The woozy meds were just kicking in when the bed cam to a stop. "Lights! Two of them! That makes sense. One for up here (head) and one for... down there. I wonder how sterile..." Out. Woke up in recovery two hours later and that last question's been with me ever since. Oh well, I healed, as you pointed out, just fine.

drsam said...

Well written, Dr. Schwab... It's nice to hear someone else taking a realistic yet sensible viewpoint on this.

"Likewise, if there were no intrinsic ability to repel bugs, we could never safely enter, because we'll never reduce the load to zero."

As someone who is now on chemotherapy, and thus is neutropenic to the point of having 0.0 white blood cells sometimes, I've come to appreciate this fact even more so than I have in my professional life as an orthopaedic surgeon...

SeaSpray said...

Oh I didn't think you had a fetish about it but I thought you were particular about it for a medical reason.

Speaking of lights...reminds me of a post Medblog Addict did on Little blobs of fat looking like corn pops on obese pts which I think she said was based on someone else's post. It had something to do with how one of those "corn pops" must've shot up onto a light, but then dropped down onto the shoulder of another pt who had been brought into the OR and the person who wrote the origiginal post said he acted as if he was helping the pt onto the table so he could knock the blob of fat off the pt but when he did, the anesthesiologist had to duck to avoid getting hit by it.

So much for clean lights!

This is why I would rather read the med blogs then watch TV. :)

Assrot said...

So given that patients come and go, gurneys are wheeled in and out and the OR staff rarely change their outer clothes, is it better to have surgery early in the morning or late at night?

By better, I mean the room the room and equipment is at its cleanest.

I assume that the place gets a decent scrubbing and mopping at least once a day heh?

Sid Schwab said...

assrot: I think it'd be a very interesting study, tracking incidence of wound infection by time of day. On the other hand, as I said, the rooms are cleaned between every operation, so I'd guess there'd not be a correlation. The extent to which rooms are not as sterile as one might think is true across the day; and, within a broad range of parameters, doesn't seem to matter as long as certain things are attended to.

Anonymous said...

I make sterile drugs for a living, and loved this post! For years I've listened to doctor friends and TV shows talk about the "sterile" OR, and it always makes me chuckle. To a pharmaceutical manufacturer, here is the *bare mininimum* for "sterile." (We are moving beyond this in some significant ways.)

Design a room that is all airflow in one direction all the time, with the air flowing at 90 feet per minute. All air coming through the room goes through HEPA filters. Build a room around that also with filtered air but without the single direction air. Build another room around that with more filtered air, but less flow. Every time you change rooms, put an airlock to make sure the air from each room doesn't mix with the one outside it.

To get into the center room, put on special clothes and gloves. Don't bother with make-up or jewelry. It's not allowed. Now put on sterile boots, sterile jumpsuit, a hood, a mask, goggles, and another pair of gloves. Do all this without touching the outside of your clothes, ever. Do it yourself, because there are no scrub techs. Check yourself in a mirror to make sure you see no skin at all.

Walk through the door and wait while someone presses culture plates against your suit to make sure you are sterile. If you aren't, you might get fired.

Now, you can mop. Mop everything every day with special disinfectant. Ceilings first, then the walls, then the floor. Make sure all surfaces stay wet for 10 minutes. Remember that someone is going to come in after you and test the walls, ceilings, and floors to make sure they are OK. Sign a log saying that you did all of this cleaning. Now your supervisor signs the log saying he saw you do it correctly.

Leave the area. Getting out and undressed takes about 10 minutes. Go to training and listed to the trainer drill in to you that despite all of this, you aren't sterile and you should never, never, never touch anything that will later touch a patient.

It's a different world. Nothing against the OR, your standards are appropriate for you, but it's nice to see someone recognize the limitations. The risks in a true sterile environment are completely different. If you make a mistake, you can kill a patient. If we do, we can kill thousands....there have to be tighter controls.

Sid Schwab said...

anonymous: thanks! That was an excellent comment, and much appreciated!

Pete said...

Dr. Schwab: It's been well over 20 years since I was in an OR as a Hospital Corpsman OR Tech, yet I still vividly recall many of the sterile procedures we followed which today, are probably quaint. In the early 80's it was still cloth gowns which had to be folded, just so, wrapped twice in cloth surgical drapes, taped with autoclave tape and sterilized in the big autoclaves. In the OR, if the gowns weren't wrapped just right, they wouldn't open up properly, and typcially, it was the Corpsman who caught hell from the surgeon, or worse, the OR Nurse. Hand towels too, were all cloth, laundered, meticulously folded, wrapped, taped and autoclaved. Used not only for drying well scrubbed hands but also used for field draping, held in place with sharp towel clamps (applied through both towel and skin). I spent more time in training learning how to fold surgical laundry so that it was ready to go in the OR, than perhaps any other OR process/procedure. Your post makes me want to dig out my old Navy OR manual and relive the memories (not).

Sid Schwab said...

NH: ah yes, the days of towel clamps and skin... And of each surgeon having his/her own demands about how to drape a given field.

OHN said...

Very interesting post. We have unforunately had two family members become infected in the OR, sutured closed then the infection rages beneath. More than a tad scary. While most surgeons are quite careful, there are surgical staff that are not quite as careful. In my husbands case, 46y/o at the time, he had MRSA after of a routine ACL repair. As he left the OR sutured, it is fairly certain that it was contracted there. The ortho was furious but the hospital didn't respond in any way. Curiously I would love to know if it is possible to see their infection rates--I am guessing they probably are not compliant in reporting or the state would take action. Am I wrong in thinking that simple antiseptic techniques could have prevented what turned out to be life threatening? (Allergy to everything except IV Vanco at home-hardware removal,2 extra debridements, healing by secondary intention with me packing the wound daily--good times I tell ya :) I can't help but wonder who sneezed in his knee.

Sid Schwab said...

OHN: I doubt even the most stringent measures will reduce operative infection to zero. (Note the "anonymous" comment above, on measures taken in other industry.) MRSA infections in surgery can happen for various reasons. Certainly antiseptic techniques were used, but where the breakdown happened would be hard ever to discover. Improper sterilization of tools at the hospital or manufacturer; a missed spot in skin prep; contamination by personnel as you questioned. Air circulates, dust floats. The things we do reduce the incidence to very very low. Horrible things, like what happened to your husband, still can happen.

Anonymous said...

Wow Sid, good way to be political and use a nice bedside manner with Ohn. If you were more inflammatory but possibly more truthful (eg talking to a resident about future infection prevention), you could have said that the MRSA probably came from her husband's skin or nares (do the people in the family get boils or "spider bites") or may have had to do with the ortho (who blamed the hospital?) inadvertently breaking sterility intra-op, traumatizing the skin while reaming the tunnel or the patient touching the wound a lot/bathing too early/ putting all sorts of weird creams and unguents on it. But then again, the blame game is for M&M?
"He left the OR sutured" - it's not like it's a bacteria tight seal! Reminds me of people only debriding the superficial wound - "the fasical sutures appeared to be intact..."

laminar air flow said...

I always enjoy reading your blog posts. You are able to write in a way that, even if you aren't in the medical field like myself, you are able to enjoy and follow along. Thanks for that.


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