Microbiology and Sterile Technique Part 1

I consider myself a bit of a scientist. Why? Well, my job requires me to know quite a bit about a lot of different scientific fields. Chemistry, biology, and probably most importantly microbiology. And microbiology is probably one of the more important fields because, among other things, it is the study of pathogens (disease causing organisms) and it is my primary responsibility to make sure that the surgical team does everything they can to ensure that the supplies and equipment we use on a patient is sterile (free from all microorganisms).

There is a ton of information that I'd like to share with you on this subject including the biggest culprits that we try to protect our patients from and what those bugs will do to your body, things that we do to ensure sterility, and how we scrub our hands to rid them of as much resident microflora (things that always reside on and in our skin) as we can. So I'm going to break this into bite size pieces. Let's start with the bacteria that are most commonly cause surgical site infections.

The most common cause of all surgical site infections is Staphlococcus aureus. Staph aureus is frequently part of the skin flora  found in the nose and on skin and about 20% of the human population are long-term carriers of Staph aureus. S. aureus can cause a range of illnesses from minor skin infections, such as pimples, impetigo, boils (furuncles), cellulitis folliculitis, carbuncles, and abscesses, to life-threatening diseases such as pneumonia, meningitis, osteomyelitis (infection of the bone, bone marrow, and/or spinal cord), endocarditis (infection of  inner lining of the heart) , toxic shock syndrome (TSS), and sepsis.

As you can see this can be a very serious infection to contract. But it can get worse. Most simple Staph infections can be treated with  penicillin or another similar antibiotic. However, S. aureus has become resistant to many commonly used antibiotics. Ever heard of MRSA? That's Methicillin Resistant Staph aureus and it is a huge pain to treat.



Another fun bug is Staphlococcus Epidermidis. And as it's name suggests it lives on the outer layer of our skin (the epidermis layer). S. epidermidis is  a major concern for people with catheters or other surgical implants because it is known to cause biofilms that grow on these devices. S. epidermidis is the cause of uriniary tract infections in patients who have had urinary catheters.

Others include Clostridium perfringens which evidence shows is the cause of tissue necrosis (tissue death), bacteremia ( bacteria in the blood), and gas gangrene. Streptococcus pyogenes can cause a wide range of illnesses including pharyngitis (strep throat), impetigo. and necrotizing fasciitis (the flesh eating disease).

I won't bore you with the complete list of bacteria that we fight against everyday but as you can see from just those, there are dangers. That's why it's so important for a surgical tech to know and understand how bacteria are spread, where they live, how they reproduce, and how to kill them. Microbiology is the cornerstone of being a surgical tech.

Learning and practicing sterile technique is also very important because after the supplies and equipment are free of micoorganisms we want them to stay that way. And in part 2 of this post I will explain to you just how we get and keep everything sterile.

Always,
Lisa Marie

I guess it really is a miracle.

I'm still a fairly new surgical technologist so there are plenty of procedures that I've haven't done and there are some that I've never seen or even heard of. During my clinicals I was fortunate enough to get into a ton of surgeries that my follow students never had a chance of scrubbing in on simply because the hospital I was at was a trauma one teaching hospital. I rotated through all the usual services like General, GYN, and Ortho but I also got to Neuro, Cardio, Trauma, and Plastics. By the time I finished I was pretty well rounded in most services so I knew that I would be very marketable when it came time to find a job.

Like I said, I was lucky. Most students don't get that opportunity. At smaller hospitals there are surgeons who do not want students in their room under any circumstances. And trust me, a student doesn't want to be in a room with one of those surgeons. It can be pretty scarring. So often those students don't even get a chance to see the inside of a heart or neuro room. And you can forget about a trauma room.....they don't want to waste time letting the students learn how to handle an emergency.

And I get why they might think like this. Students mess up. Sometimes a lot. They might forget that they can't let their hands fall below their waist level or that they can't scratch their nose when it itches. They also might hand up the wrong instrument or forget to replace the surgeon's sponge when it gets full of blood. For an experienced tech or a doctor, this can be the most frustrating thing in the world. But I think it's important to remember that this is how people learn. If a student never gets to scrub in on an Ortho case how can they be expected to know all the extra things that go along with that service when they finally graduate and get a job? And I also think it's important to for all those doctors, nurses, and seasoned techs to remember that they were students once too. There was a time when they didn't know everything there is to know about surgery and they made mistakes. It's hard to be a student and it's hard to be the new person. So let's try not to make it any harder.

A few days ago I got the chance to scrub in on a procedure that I had never seen or done before. And I can't tell you how excited I was! I've always wanted to do one but the hospital I trained at had their own separate team on an entirely different floor so I never got the chance. This now strikes me as funny because a c-section is actually ranked as the second most frequently performed major surgical operation in the U.S. So that morning when I saw that I had been assigned to my first C-Section I was ecstatic. Because I had never done one I was in the third assist role, which meant that I was to stand beside the surgeon and retract the tissue to aid in visibility. And this was just fine with me because it meant that I got to learn without having to worry about pass instruments.

The patient was brought into the room and was put onto the O.R. table in what we call Fowler's position (sitting). This was so that the anesthesia provider could administer the epidural. Once the epidural was in the patient was quickly laid down on the bed because it doesn't take long for them to totally lose sensation from the midsection down. Then the patient's skin is prepped and they are draped.

The surgeon I was working with wasted no time. He made a pfannenstiel incision (a horizontal cut below the bikini line) and dissected down to the muscle layer. Once he reached the rectus and pyramidalis muscles he put down his knife and told me that it was time for me to help. He grabbed one side of the muscles, instructed me to grab the other and he yelled "Pull!" We both tugged the muscles in separate directions to expose the underlying transversalis fasica and peritoneum.

I'm sure this strange to you. Why in the world would we pull the muscles apart instead of cutting them? Well there are actually a few advantages to this method. First of all, there is less postoperative pain for the patient. Also, because the blood vessels are being stretched instead of cut there is less bleeding. And healing time is much faster this way.

After the surgeon opened the peritoneum he moved the bowel, omentum, and bladder out of the way so that we could access the uterus. He palpated the uterus to determine the size and presenting part of the fetus and then opened the uterus with a knife. Um....at this point I was glad I had decided to wear the booties over my shoes because fluid went everywhere! You really don't realize just how much there is. It was now time to pull out the head. The first assistant then aided by putting pressure on the fundus of the uterus and pushing down.

When the head had been delivered all time kinda stopped. There it was...this brand new little human. I grabbed the bulb syringe and handed it to the surgeon so that he could aspirate the nose and mouth so that the tiny little being could breathe. Once he cleared the airway, little man started to cry and it was the sweetest sound in the world. The doctor carefully pulled him out the rest of the way and rested him on top of his mother. He clamped the cord twice and cut in between. Then things got really exciting.

He lifted the baby, turned to me, and said "Put your arms out". Hesitantly I did and he said "You are not going to drop this baby. Okay? You're not going to drop him. Take him over and place him on the blue drape." He handed me this brand new baby! I really wanted to just cry. Here I was holding this brand new person.....he had only been here for a few seconds and I was holding him. Amazing. And no, I did not drop him!

The rest of the procedure was kind of a blur. We closed the new mommy back up and took the baby to NICU to make sure he was okay (and I checked later, he was perfect).

I have to tell you I don't usually get overwhelmed about a surgery. I have had a few that have almost made me sick (I promise I will tell you all about those) but never one that touched me in that way. I love kids but I've seen a vaginal birth and there was nothing beautiful about it. But this......was just something else.

He was covered in goo and grossness but I was so happy that I got to hold him and carry him for those few seconds. He will never remember that I was the very first person to hold him to my chest and welcome him into the world. But I sure will.


Always,
Lisa Marie

First day.......boobs!

I recently started my first hospital surgical tech job and I can’t tell you how excited I am about it. Granted, up to now I had been dreading it because I love my job at the college and I didn’t want to have to cut back on that but I’ve since changed my mind. The minute I scrubbed in on a surgery the other day all the love and excitement for the clinical aspect of my job came flooding back.

Being new is never fun but I’ve tried to make the best of it. So when the “mentor” I had been assigned to for the day told me that I could jump in whenever I was comfortable I knew that it was do or die time. See, the O.R. is a lot like high school. You have your groups of people who stick together no matter what, you have your catty women who you know you need to watch out for, you have the jocks that make you swoon, and you even have the silly boys who always go for the cheap laughs. And just like back in high school, these people can smell your fear. When you’re new, you can’t hesitate when someone gives you the chance to show your skills. It’s a timing thing. If you try to observe and learn the lay of the land for too long…..it’s going to be a feeding frenzy. And just like high school, you’ll never recover from it.

So anyway, I knew when she told me to take over when I was ready it was time for my first test. So I observed for another three to five minutes and I took over the table. At this point the surgery was underway so I didn’t have to worry about setting up my table or draping or anything like that. All I had to do was run the table, pass instruments, handle specimen, and maintain the sterile field. After the first minute or two of holding my breath, I exhaled, relaxed, and found my groove. It was fantastic and I didn’t realize just how much I missed it until right then.

The case I took over was a bilateral mastectomy with breast reconstruction. What does that mean? Well basically the patient was at high risk for developing breast cancer and decided her best chance would be to have both of her breasts surgically removed and then have a plastic surgeon reconstruct them using implants. This is what we call a prophylactic surgery-surgery done to prevent a disease. At first it may seem like a pretty radical step when thus far the patient was healthy but when you’re faced with the knowledge that there is a very good chance you could develop cancer you look at it as a live saving decision.

This was not the first mastectomy I’ve done and they have never bothered me before ( I know that sounds harsh but in order to cope with this job, once the patient goes under and is draped out I stop thinking of them as a whole person. Otherwise, I’d never be able to stop thinking about what the patient might be going through.) Anyway, recently I had a student drop out of my program after observing a mastectomy because it disturbed her so much that she decided she was on the wrong career path.

So, as I worked on this woman I got to thinking about what this might do to her psychologically. Would she wake up and feel like less of a woman? Would she feel undesirable and be afraid to let her husband see her? Would she feel ashamed every time she went bra shopping because those weren’t really “her” breasts?

Let’s face it- what is one thing that makes most women identify as a woman? I’ll give you a hint…look down. Yep, breasts. And why wouldn’t they be an identifying factor? I don’t know if you’ve noticed but our society is obsessed with them. Water bras, cleavage baring tops, those “chicken cutlet” inserts, Pam Anderson….and every day woman have elective cosmetic surgery to enhance their own, um, assets. These things not only make them feel better about themselves but can also make a difference in how other people look at them.

My point is breasts are not just an accessory that just happens to be connected to our chests. They make us feel feminine. They instantly set us apart from men and are desirable objects. What would it do to the way we identify with ourselves if they were suddenly gone? Would you feel like damaged goods?

All of this ran though my mind from the first incision. The tissue was dissected away from the skin with the cautery and removed and a pocket for the implant was created below the pectoralis major muscle using cadaver skin. As the first implant was inserted, I realized that this patient should not feel like any less of a woman after surgery. She made a decision that will potentially save her life, not to mention spare her the heartbreak of developing cancer. She opted for reconstructive surgery so that she’ll still look the same physically but even if she hadn’t, she could have altered herself perception. One body part doesn’t make you who you are.

By the time this amazing plastic surgeon finished, we had used 124 sutures (which was super fun to keep track of by the way), two pieces of Alloderm (cadaver skin), three implant sizers, and two silicone implants.  From first incision to wound dressings the surgery took about four and a half hours and seven surgical team members. It was routine. But what we gave that patient was anything but. When she woke up in the post-surgical recovery until, she had piece of mind that she had just undergone something that will save her life. She won’t have to worry every time she does a self exam or has a mammogram. She doesn’t have to live in fear of that “C” word.

Yes, being a surgical tech is a job. It pays well and it’s fun. But it also gives us a chance to help people in more ways than you could ever imagine.

Always,
Lisa Marie