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Medical Forum / General / General / November 2005Scrubbing for surgeons
I saw an ER episode where a doctor was spending a huge amount of time scrubbing his hands and forearms. What are the rules for scrubbing? Can't you just use soap and water like usual? Do you scrub both before and after an op? >I saw an ER episode where a doctor was spending a huge amount of time > scrubbing his hands and forearms. What are the rules for scrubbing? > Can't you just use soap and water like usual? > > Do you scrub both before and after an op? They use a special scrub brush, already impregnated with betadine. There is a little plastic gizmo in there, for cleaning under fingernails. I'm not a surgeon, but would imagine that I would want to wash my hands, after surgery. As a nurse, I usually wash my hands after doing a procedure, even if wearing gloves. Dawn > I saw an ER episode where a doctor was spending a huge amount of time > scrubbing his hands and forearms. What are the rules for scrubbing? > Can't you just use soap and water like usual? > > Do you scrub both before and after an op? It's been a long time (maybe 28 years) but I have scrubbed in for surgery in an OR. It's a very ritualized procedure--hands run under water, valves worked with elbows. Certain amount of time spent on each surface of each finger, palm, wrist. Sometimes they made us count the strokes with the scrub brush for each surface of each finger. You work progressively from the nails to the elbows, and rinse so that the rinse water always runs UP your arms, not down. When you're through you shut the valves with your elbows, walk away from the scrub sink with your elbows bent, fingers up and walk over to the scrub nurse, who hands you a sterile towel. You use one side on one hand, drying in the same direction you scrubbed, then the other side of the towel for the other hand. You then dispose of the towel, go to another nurse who holds out a surgical gown so you can push your hands through the sleeves without grabbing it yourself, and another who holds out surgical gloves without touching the outside so you can insert your hand straight in. How'd I do, guys? ;-) Steve  SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 >> I saw an ER episode where a doctor was spending a huge amount of time >> scrubbing his hands and forearms. What are the rules for scrubbing? >> Can't you just use soap and water like usual? >> >> Do you scrub both before and after an op? <snip> > You work progressively > from the nails to the elbows, and rinse so that the rinse water always > runs UP your arms, not down. This is interesting. I just took a bloodborn pathogens class this week (I'm working for a school district and it's required for all employees) and they specifically told us (definitely _not_ surgeons, but still...) to rinse so that the water runs down to our fingertips, thus rinsing any remaining bugs off our hands instead of up our arms. Karen E. >>> I saw an ER episode where a doctor was spending a huge amount of time >>> scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 14 lines] > > Karen E. Since you begin with a fresh (sterile) scrub brush on the fingertips, you don't wish to re-contaminate your hands with water dripping down from your elbows. And though the hands are covered (in sterile surgical gloves) we obviously are working with hands, not the elbows. The presumption is that you are disinfecting the fingers first, and they get top priority. Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 > >>> I saw an ER episode where a doctor was spending a huge amount of time > >>> scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 21 lines] > The presumption is that you are disinfecting the fingers first, and > they get top priority. Pretty much right. Hands can be in semi-horizontal position after scrubbing for water rinse, but once rinse is completed, water is turned off with elbows, and hands are held in UP verticle-above-elbows position while walking between scrub sink and acquisition of sterile drying towel (handed off by scrub nurse). This, for more or less the water-drain reasons you mention. SBH >>>> I saw an ER episode where a doctor was spending a huge amount of time >>>> scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 12 lines] >> but still...) to rinse so that the water runs down to our fingertips, >> thus rinsing any remaining bugs off our hands instead of up our arms. > Since you begin with a fresh (sterile) scrub brush on the > fingertips, you don't wish to re-contaminate your hands with water [quoted text clipped - 3 lines] > The presumption is that you are disinfecting the fingers first, and > they get top priority. That makes sense. Thanks. Karen E. >>>>> I saw an ER episode where a doctor was spending a huge amount of time >>>>> scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 23 lines] > > Karen E. Karen, for normal handwashing, you would want the water to drain off the fingers. So, why is the paper towel dispenser so high? the water always runs down my arms. I hate it! dawn Why is it necessary to go thru that extensive amount of scrubbing when the hands and body are going to be covered in sterile coverings? Is it just a precaution in case there's a break? > Why is it necessary to go thru that extensive amount of scrubbing when > the hands and body are going to be covered in sterile coverings? Is it > just a precaution in case there's a break? Yes. Or strike-through from the sleeves. If the sleeves become soaked in blood or other body fluids, bacteria can be transmitted through that soaked fabric or paper from the forearms. It would not be unusual for a surgeon to be inside a patient up to his/her elbows. HMc >> Why is it necessary to go thru that extensive amount of scrubbing when >> the hands and body are going to be covered in sterile coverings? Is it [quoted text clipped - 6 lines] > > HMc In obsterics, it's almost a requirement. Sharon > Why is it necessary to go thru that extensive amount of scrubbing when > the hands and body are going to be covered in sterile coverings? Is it > just a precaution in case there's a break? I want those hands to be clean, before they start reaching inside my body to pull out a baby! LOL! Dawn >> Why is it necessary to go thru that extensive amount of scrubbing when >> the hands and body are going to be covered in sterile coverings? Is it [quoted text clipped - 4 lines] > > Dawn One of the first and most productive instances of the application of scientific method to medicine. http://www.answers.com/topic/ignaz-semmelweis HMc > Why is it necessary to go thru that extensive amount of scrubbing when > the hands and body are going to be covered in sterile coverings? Is it > just a precaution in case there's a break? Exactly, gloves get holes in them very easily. Sharon > This is interesting. I just took a bloodborn pathogens class this week > (I'm working for a school district and it's required for all employees) > and they specifically told us (definitely _not_ surgeons, but still...) > to rinse so that the water runs down to our fingertips, thus rinsing any > remaining bugs off our hands instead of up our arms. In nursing school (at UNC-Chapel Hill) we've been taught the way you were. The surgeons are preparing for surgical asepsis, which is a higher standard. For clean technique, or even for a nurse preparing to perform a sterile technique at the bedside, we're supposed to rinse down as you were taught, in part because we don't have assistance like the surgeons do. As I understand it, the rationale for rinsing down as opposed to up like surgeons is this: The concern is that if you hold your hands fingers up, a drop of water will travel up your arm to a contaminated (unwashed) part, and then when you invert your hands it will travel back down and contaminate a clean(er) part. We're not going for sterility here (hence no betadine), just reducing microbes. We wear sterile gloves for sterile procedures anyway. Pardon me if I've gotten some of that mangled; it was from the beginning of the semester and a whole lot of other crap has been jammed into my brain since then. --Patti >>> I saw an ER episode where a doctor was spending a huge amount of time >>> scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 14 lines] > > Karen E. That's because you're not going to be sticking your hands inside someone. The fingers and hands get the most attention during the scrub since those are the parts most likely to contact the patient. And holding the hands higher than the elbows to allow the dirty water to flow away from the hands it the right method. Also, most scrub sinks now have either motion sensors or knee controls so no one risks contamination by touching the knobs with their elbows. To properly scrub for the first time during the day takes 5-7 minutes, subsequently, the scrub can be shortened to 3-4 minutes. Here's a site that includes video: http://cal.vet.upenn.edu/surgery/4600.htm Sharon >>>>I saw an ER episode where a doctor was spending a huge amount of time >>>>scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 16 lines] > > That's because you're not going to be sticking your hands inside someone. That's pretty much what I expected, hence, the note that we're not surgeons. It's good to know the reasoning. Thanks. > The fingers and hands get the most attention during the scrub since those > are the parts most likely to contact the patient. And holding the hands > higher than the elbows to allow the dirty water to flow away from the hands > it the right method. Also, most scrub sinks now have either motion sensors > or knee controls so no one risks contamination by touching the knobs with > their elbows. Karen E> > To properly scrub for the first time during the day takes 5-7 minutes, > subsequently, the scrub can be shortened to 3-4 minutes. It depends on the product. A 5-7 minute scrub will usually leave more active bacteria on the skin than a three minute scrub. Longer than 3 minutes is past the point of diminishing returns. There is a paucity of objective data on the subject and mostly, the concepts of scrubbing one's hands for surgery are based on dogma, history, and tradition rather than real reasoning. Best approach is read the package insert of the scrub product you are using and follow the instructions on it. HMc > > To properly scrub for the first time during the day takes 5-7 minutes, > > subsequently, the scrub can be shortened to 3-4 minutes. > > It depends on the product. A 5-7 minute scrub will usually leave more active > bacteria on the skin than a three minute scrub. Why is that, exactly? >> > To properly scrub for the first time during the day takes 5-7 minutes, >> > subsequently, the scrub can be shortened to 3-4 minutes. [quoted text clipped - 4 lines] > > Why is that, exactly? Stirs 'em up out of crypts, crevices, pores and hair follicles. Not to mention unnecessarily abrading the surgeon's hands. HMc >>>> I saw an ER episode where a doctor was spending a huge amount of time >>>> scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 31 lines] > > Sharon We also have alcohol-based hand sanitizer available, for just freshening up your hands between minor things. I love using it because it's much quicker to rub that on your hands, than it is to actually wash your hands. Every so often, you are supposed to wash with soap and water anyway. I figure I get that after I use the bathroom. We have a bottle of Purell at our nurses station. We used to have it in all the rooms, but don't anymore. I'm not sure why. Dawn http://www.mydna.com/news/news_20051101_yogurt.html I read this article about a week or so ago. I thought it was relevant to the present discussion. Alida > Also, most scrub sinks now have either motion sensors or knee controls > so no one risks contamination by touching the knobs with their elbows. If I ever had the money to custom-build a house, I'd get a couple of those sinks with the knee controls. That'd be great. (Maybe not so great if we had kids, OTOH. :-) > It's been a long time (maybe 28 years) but I have scrubbed in for >surgery in an OR. [quoted text clipped - 5 lines] >runs UP your arms, not down. When you're through you shut the valves >with your elbows, walk away from the scrub sink with your elbows bent, And then you to down operate on the patient and the patient dies from infections he gets from the elbows. In recent years they have faucets that turn themselves off after a few seconds of non use. ------------------------------------------ http://www.barnabascollins.blogspot.com >I saw an ER episode where a doctor was spending a huge amount of time > scrubbing his hands and forearms. What are the rules for scrubbing? > Can't you just use soap and water like usual? > > Do you scrub both before and after an op? There are a variety of procedures. The days when it was a ritualized 10 minute procedure are long gone. The particular disinfecting agent is variable and related to cost, performance and preference. Recomendations vary from place to place and also depend on what antimicrobial agent is being used to scrub. Some surgeons prefer betadine-soaked packaged sponges with a nylon bristle brush on the other side. Some prefer the same sponge with no disinfecting agent and use it with a different agent such as chlorhexidine (Hibiclens). Three minute scrub starting with nails and working upward to elbow. Most of the agents have a persistent antimicrobial action for 2-4 hours and after the first scrub with the brush, many surgeons prefer to use a foam or other liquid antimicrobial that is just worked into the hand like hand lotion for subsequent operations. Hands are generally kept elevated to drain down the arms, and don't touch anything with the hands on your way into the room. Generally, it's a good idea to wash hands after an operation too. HMc >>I saw an ER episode where a doctor was spending a huge amount of time >> scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 22 lines] > > HMc If nothing else, even non powdered gloves leave a residue and the skin on your hands feels really dry once you remove the gloves. I always wash my hands and put on lotion in PACU, otherwise, my skin would be even drier than it already is. As mentioned above, there is now a waterless product that comes in an aerosol can that can be used to replace the formal sink scrub and takes less time. Most of the folks where I work don't use it for their first scrub of the day although the manufacturer says it can be used for that, but it does save the hands to use it at least some of the time when you're doing multiple cases. Sharon > I saw an ER episode where a doctor was spending a huge amount of time > scrubbing his hands and forearms. What are the rules for scrubbing? > Can't you just use soap and water like usual? Dude, not to be insulting here, but seriously: Do you honestly want some guy in your guts up to his elbows who's no more than "Zestfully clean"? > Do you scrub both before and after an op? Only before. After all that harsh scrubbing, there's nothing that rejuvenates the skin better than dried human blood. ;-) : I saw an ER episode where a doctor was spending a huge amount of time : scrubbing his hands and forearms. What are the rules for scrubbing? : Can't you just use soap and water like usual? : Do you scrub both before and after an op? I seem to recall a first season episode (forget the title) in which Carter was going to see he first OR, although not participate. Peter gave him step by step instructions, only to have him (Carter) tap Peter on the shoulder in the OR and therefore have to go through the whole thing again. Which always raised the question to me, wouldn't Peter's scrubs be clean anyway? Are they really that paranoic in an OR? Brad > : I saw an ER episode where a doctor was spending a huge amount of time > : scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 10 lines] > > Brad They REALLY are that paranoid! There is a tag on the ties for a surgical gown, that a non-sterile person can grab and wrap the tie around a person to tie it. As a newbie nursing student, I grabbed the wrong thing and the person had to go scrub again. They weren't too happy with me, but I never made the mistake again! ESPECIALLY with orthopedic surgery since the sterile thing is taken up even another notch so people don't get bone infections! Abdominal surgeries are a more "dirty" surgery. Dawn > : I saw an ER episode where a doctor was spending a huge amount of time > : scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 10 lines] > > Brad Once hands are scrubbed and/or gloved, you can't touch anything that's not sterile. "Clean" isn't good enough...the scrubs aren't sterile. And a resident's scrubs might not even be clean. What always amused me, back in the days I used to watch that show, was how the "surgeons" always scrubbed their hands at the scrub sink with their masks down. HMc > : I saw an ER episode where a doctor was spending a huge amount of time > : scrubbing his hands and forearms. What are the rules for scrubbing? [quoted text clipped - 10 lines] > > Brad They are really that paranoid because there really is a signifcant risk of infection. The only part of a surgeon's gown that is sterile is the front of it above the waist. Touching the back of a sleeve or anywhere below the waist is indeed going to contaminate someone who has scrubbed. Sharon |
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