Busy, Busy, Busy

Yes, I'm still here!! I know it's been a little while since my last post and I just wanted to take a second to assure you that there is more on the way. Between the job at the hospital and the one at the college I've been pretty swamped the last few weeks but I've been taking notes and writing down ideas for new posts. I am in the middle of writing a new one now so you can expect that in just a few more days.

Thanks for being patient and I promise the wait will be worth it!

Always,
Lisa Marie

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

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