Microbiology and Sterile Technique Part 3

Now let’s go back to the operating room. Like I said before, when our instruments and supplies come to us they are sterile. It’s now our responsibility to make sure they stay that way.

A surgical tech is the person who sets up all the equipment so we have to learn how to do that and keep it sterile. It’s called sterile technique. And commonly we are the only person in the room when we set up. So if we accidentally touch the sterile field before we’ve scrubbed, gowned, and gloved no one knows it but us. It would be easy to contaminate the field and just act like it didn’t happen. But that exposes our patient to infection so we develop something called surgical conscience.

Surgical conscience is what tells us to break down that setup and start over rather than risk infecting our patient. Our motto is “When in doubt, throw it out”. We don’t play when it comes to sterility because that could cost someone their life. So if we suspect something has been contaminated, if someone else tells us there’s been a break in sterile technique, or if we just aren’t 100% sure we will consider it contaminated and we will get a new one or start all over.



Our sterile technique starts before we even go into the operating room. We put on clean scrubs when we get to the hospital, we cover our hair with scrub caps, and before we open the sterile equipment we put masks on.



The first thing we open is our back table pack (which includes the drapes we’ll use, gowns, towels, and other sterile equipment) touching only the outside of the package leaving everything on the inside sterile. We open all our instrument sets, other sterile supplies, and our own gown and gloves the same way.



Once everything is open, we scrub. One of the first skills we learn in school is how to scrub. Scrubbing renders our hand and arms (up to two inches above the elbow) surgically clean. Not sterile. that’s important because it’s impossible to kill and the microorganism on and in our skin. That’s why we have to wear a gown and gloves.




We use sterile scrub brushes that are impregnated with either Chlorahexidine or iodine and we methodically scrub our hands and arms for five minutes. We are very careful to keep our hands about our elbows so that the soapy lather and water runs off our elbows. This keeps our hands and the cleanest part. We make sure we don’t bump against anything which would contaminate us. We rinse and back into the O.R. make sure our arms remain above waist level.





Then it’s time to put on our gown. The gown is folded so that when we pick it up we only touch the inside of the gown. This keeps the outside of the gown sterile. Our hands remain inside the sleeves of the gown while we glove ourselves. And if it sounds difficult it’s because it kind of is. It’s gets much easier with practice though.

Once we have our gown and gloves on we are considered sterile from waist level to nipple line and from our fingers to two inches above our elbows. Only the front of our gown is considered sterile because we can’t properly monitor our backs so we consider them unsterile.



Now we can touch all that sterile stuff that we opened before we scrubbed. But we can only touch that sterile stuff. So then it would be time to organize our back table and put all our instruments out. We also will be gowning and gloving all the surgical team members who will be participating in the surgery.

From here it’s just all about monitoring the sterile field we just created. It’s my job to constantly be aware of how close nonsterile people and things come to my field. And any extra equipment I need also need to be sterile. And this keeps up until the surgery is over and the patient has been stitched up and has a dressing over the incision site. Every patient, every time.

We don’t do this because it’s fun. We do it to protect our patients. So before you starting reading this blog you may not have ever heard of a surgical tech. But if you’ve ever had surgery you can bet you had a surgical tech looking out for your health and well-being. My job is a lot of fun and I get to see some really cool things, but I also have a lot of responsibility

MIcrobiology and Sterile Technique Part 2

Hopefully by now you all understand why it's our number one priority in the operating room to make sure all our equipment and supplies are free of microorganisms. And if you are ever a patient in the O.R. you'll really appreciate the work we do to ensure your safety. In this post I'd like to share with you the many processes we go through to ensure sterility.

Let's start with all the work that gets done in the Central Sterile department. Obviously when we get the instruments they've been sterilized already. We use them on a patient and send the now dirty instruments to Central Sterile (C.S.). The first step in the journey back up to the O.R. is obvious.....the instruments need to be cleaned. So they go straight to decontamination.

In decontamination each instrument is thoroughly cleaned using FDA approved cleaners, brushes, and specialized equipment like an Ultrasonic Washer. This is the most important step because if even one instrument isn't properly cleaned and there is bioburden (dried blood, bone, ect) stuck in a crack or crevice and it is put in a set and sterilized...the entire set is contaminated. If it isn't caught and that set is used on a patient, we are exposing that patient to all those nasty bugs we talked about.

This is an Ultrasonic Washer. It's filled with water and a detergent is added. When the washer is turned on it sends shockwaves through the water. This causes bubbles to form on the surface on the instruments and the bubbles lift the bioburden off the instruments.

After the instruments are hand cleaned they are put through a washer sterilizer. It's basically a big dishwasher and it cleans the instruments enough that they are safe to handle without gloves. From here, they go to processing.

This is a washer sterilizer.

In processing the instruments are double checked to ensure that they are 100% free of bioburden. After they've been checked, they get reassembled and put together as a set. They are either put into an instrument tray, peel packed, or wrapped. Then those packages are sterilized.

This is an example of an instrument tray.

This shows supplies being wrapped.

It's important to note that not everything can be sterilized the same way. Depending on the type of instrument, material, and other factors it may require steam, gas, or chemical sterilization. It is the responsibility of the people who work in C.S. to know which sterilization process is required.

Those are wrapped instruments that are being loaded into a sterilizer.

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After the sets have been sterilized they are stored until they need to be used again.

There are usually at least five people who handle the instruments along this journey back to the O.R. Don’t let this post fool you, it takes a good amount of time to get things through these process and the people who do it go through a lot of training to ensure that everything is done correctly. Chances are patients never see these people and they never think of what goes on behind the scenes. But I’m here to tell you, we would never be able to do what we do in the O.R. if it wasn’t for the work being done in Central Sterile.



I know I orginally said this would be a two part post but after I started writing this part I realized how much I had left to talk about. So there will be one more post to follow in order to finish up.

LIttle Bugs, Big Mess

Being a surgical tech is hard work. I'm just now realizing this. It's not just a physically demanding job. Oh no that would be easy. This job also gets you mentally and emotionally. After an eight hour day at the hospital I am just spent. And its taken two months working at the hospital as a surgical tech for me to finally start feeling like I'm hitting my stride and that I can fly solo on most of my cases. And I'm excited about it.

Most days I really like my job. I don't like working the 7am to 3pm shift because I am in no way a morning person but I'm tolerating it. I have very few bad days where I just hate what I'm doing and question if this is where I want to be. However, a little while back I had a very bad day that I'd like to share with you because it ties in to my previous post about microbiology. I will pick back up on that two part post next time but I wanted to really shed some light on what all those nasty little bugs can do to a person’s body. *Caution- a few of the pictures may be a little graphic*

Not long ago I was working in General surgery with my favorite doctor and was having a routine day of laparoscopic cholecystectomys (where we take out the gallbladder through a series of little ports called trocars instead of one big open incision).

These are the trocars that we use for laproscopic surgery. They are put through the tissue layers and gas is instilled in the abdomen to inflate it to give us room to work. Then long, thin instruments are passed through the trocars.

Around lunchtime the charge nurse came into our room and told us that after lunch we were getting an add-on case. It was a woman with a decubitus ulcer or a bedsore on her butt that had gotten infected with staph. Typically, these things are fairly small so we didn't think it was going to be a big deal.

After I got back from lunch I set up for this case thinking that the rest of my day was going to be a breeze. Boy was I wrong.

Let me give you a little background on my patient. The patient was a female in her late thirties, about 400 pounds, who suffers from muscular dystrophy (refers to a group of hereditary muscle diseases that weaken the muscles that move the human body). Because of the disease she couldn't walk or really get around by herself. However, she managed to live by herself. Which was just fine except for the fact that she had no sensation below her waist and had no idea this ulcer had formed.

Decubitus ulcers are lesions caused by many factors such as: unrelieved pressure; friction; humidity; shearing forces; temperature; age; continence and medication; to any part of the body, especially portions over bony or cartilaginous areas such as sacrum, elbows, knees, and ankles. Although easily prevented and completely treatable if found early, bedsores are often fatal – even under the auspices of medical care. They can be very serious and most of the time they are discovered quickly because they are very painful for the patient and because for those at high risk there are normally caregivers who check for them.

In this case, the patient had no caregiver and no lower body sensation to alert her that something was wrong. She was wheeled into the room and she was in very high spirits. I thought this was going to be routine until the other nurses who were trying to move her onto the O.R. table shifted her to one side. I couldn't see the ulcer but I could smell it. Try to think of the worst smell you've ever come across. Now multiply that by about 1,000. No I am not exaggerating, it really was that bad. The first wave hit me and I had to immediately regroup before I threw up in my mask. The smell was literally that of rotten flesh and I was not at all prepared for it.

This shows the four stages of these ulcers. As you can see the longer they go untreated the deeper they go. This patient had a stage 4 ulcer.
As they worked on getting her onto the table, one of our team members began to frantically search for the children’s Chap Stick that we keep around. When you rub the Chap Stick on the outside of your mask the fruity smell helps to cover up the nasty one.

Finally they got her on the table and under general anesthesia. They rolled her onto her side and for the first time we got to see what we were working this. This was not a small ulcer. It was her entire backside from the bottom of her back to the top of her legs.  It was so bad that the only thing the surgeon could do was remove all the dead tissue, clean it the best we could, and put a dressing over it. There was nothing left to suture together. The ulcer was so deep in the tissue that we could see her coccyx (her tailbone) and the infection had gotten into the bone so the end of it was so soft that it broke off when the doctor gave it a little tug.

The staph bacteria from her skin thrived in this wound because the ulcer had given it an ideal place to live. It was dark, moist, and wasn't regularly cleaned. All these bugs need are a place to get into our bodies and they can quickly get out of control, as was the case with this patient. No, in this case the infection wasn't cause by something we did in the O.R. but a surgical incision is nothing more than a break in the skin (and unbroken skin is our first line of defense against bacteria). This is why we are so crazy about sterile technique.


Always,
Lisa Marie