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Scrubbing up well

March 27, 2013

As a medical student you have to learn lots of procedures. I already blogged about learning to take blood. But even preparing to do a procedure requires training and practice. I am taking about aseptic technique. Where putting on a pair of surgical gloves is an art as much as a neccessity.

Aseptic tecnique is when you have to do everything under sterile conditions. Usually it means you are about to do something that could potentially introduce an infection in to the patient if you don’t make sure everything you use is sterile. So listening to a chest is not going to put the patient at risk of an infection so you don’t need to do that under aseptic technique, but doing a lumbar puncture possibly could so you do. Depending exactly what you are doing and the level of risk of infection (and mess)  will determine whether you just ‘glove up’ or ‘gown up’. If you are going to theatre to do something you will completely ‘scrub up’ to do things in a sterile (not just aseptic or clean ) way. The principle is to ensure that everything that touches the patient is sterile. Your hands, you clothing at the front, the instruments. Once you are ‘gowned up’ you can’t use anything sterile to touch anything non-sterile. So you can’t use your gloved hand to scratch your nose. Or tuck your hair back in to your cap. Or wipe your nose. Someone else who is non-sterile has to do that for you. Similarly if you are in theatre but not scrubbed up and therefore not sterile, you must only touch the things that are non-sterile.  It becomes second nature after you have done it a few times, but it is nerve wracking at first. Terrified to touch the wrong thing and cost the NHS time and money and potentially put the patient at risk.

So the first thing you have to determine is your glove size. They need to fit snugly so there aren’t flapping finger ends that mean you can’t manipulate your tools easily. or so tight that the circulation is cut off to your fingers. They come in various sizes and half sizes and I am a 71/2. But it took trying on a number of different ones and trying them out to work that out.

So when you are going to assist or carry out an operation in theatre, you will be dressed in your scrubs and have your surgical hat and clogs or wellies on and you will go to the scrub room just next to theatre. There you have to  wash your hands (scrub up) and put your sterile clothing on (‘gown up’).

Not as simple as it sounds when you are actually scrubbing them to try to remove any traces of bacteria lingering on your skin. So you start off  by ensuring you have no jewellery on and your arms are clear to your elbows. Turn the taps on to a comfortable temperature. Taps in operating theatres have long handles so you can operate them with your elbows once you’ve started because you musn’t touch anything that isn’t sterile once you start or you go back to the beginning aagin. So you press the pump-operated disinfecting scrub  – often chlorhexidine- based – with your elbow and wash and wash. You will have a sterile scrubbing brush to use that you need to get in every nook and cranny, always holding your hands up as if praying so that the water runs downwards, away from the fingertips. Scrubbing up takes a good few minutes, and your skin can feel sore and raw.  Once everything is rinsed off you need to dry your hands on the paper towels that have come in the pack with the sterile gown you are about to put on. If you are sensible you will have opened this before you start as the outer packaging is not sterile so you can’t touch it once you have scrubbed. If you’ve forgotten, a friendly nurse or ODA might help you if you ask nicely. if you are senior enough they will do it for you automatically.

So you dry your hands with the sterile towels and the next thing you do is put on the sterile gown. You unfold it and feed your arms in to the sleeves but do not touch the outside of the gown with your bare hands or you will make it unsterile and have to start again. Someone else will do it up behind you.

Sterile_surgical_glovesThen come the gloves. There  are various ways to get them on, but this particular technique was the one first taught to me. Someone will open the pack for you and there will be each hand laid out like two pages of a book. The cuffs of the gloves are turned up so that about three inches overlaps. You must not touch the outside of the gloves with your bare hands so you must pick up the first glove by the cuff and wiggle your hand in and esure the glove goes over the sleeve of your gown. . If you haven’t dried it properly this will not be easy. There is a packet of  sterile starch (like snooker players use) if you want to rub your hands in that to make sure they are dry and slippery.

Then, once you have got the first glove on comes the second.  You musn’t let your gloved hand touch the bare skin of your other hand or arm or you’ll go back to the beginning again. So you slide your gloved hand inside the turned over cuff and pick the glove up so the fingers are pointing down the back of your gloved hand towards your wrist. And you slide your second hand in, making sure no skin touches the outside of the glove, or you know what will happen.

Then once the gloves are on you have to get any trapped air out of them and bang them down in between your fingers and make sure your cuffs of the gown are tucked well inside the cuffs of the gloves. No gaps.  meanwhile someone will tie up your mask .

And then once you’ve done all that you need to walk in to theatre itself, always keeping your hands up in the praying position to minimise the risk of you accidentally touching something unsterile and having to start all over again.This usually involves going through double swing doors which you need to reverse in to to make sure you don’t desterilise the front of your gown or your hands by touching the door with them.

So, the first time I was assisting in theatre after spending ten or fifteen minutes laboriously scrubbing and gowning up, no one  was happy when I simply pushed the door with my hand. I was banished back to the scrub room and they did the operation without me. I never made the same mistake again.

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