Yes, the Scrub Nurse is Laughing at You

The dreaded day has arrived. You are on your first surgery rotation. After a brief orientation you are told to report to the operating room to “scrub in” for your first surgey.

Get ready to run the gauntlet. You have the potential, in the next few hours, to screw up pretty much everything. Either that or you will do everything right and blend into the woodwork which is about as much as you can hope for on your first day.

I just want to give you a few general guidelines about what to do as a medical student in the OR. By all means take what I say with a grain of salt because I am not a surgeon, local customs vary, and maybe your surgeons are caring, compassionate souls who will calmly take you by the hand and lead you gently into the world of surgery.

Or not.

The operating rooms are generally clustered in one part of the hospital. Street clothes and more importantly, street scrubs (the ones you wear to and from the hospital) are not permitted in this area. Even before you enter the OR itself you will need to change into clean OR scrubs, shoe protectors, and a hair covering of some kind.

Now, while it is true that the OR suites are not sterile, the idea is to minimize the introduction of environmental pathogens. When you are in the hallway outside the OR it is not generally necessary to wear a mask. On the other hand, everytime you go into the OR itself you must have a cap and a mask on at a minimum even if you are not scrubbed in.

In other words, if you are asked to help position the patient you can enter in just scrubs, shoe covers, a mask, and a cap. Likewise if you are just observing from outside the sterile field as you will often do.

You will notice also that the nurse or tech who is prepping the patient will not scrub in but will wear sterile gloves as he shaves, swabs, and otherwise prepares the patient.

But you are instructed to scrub in. What do you do?

Outside the OR you will find the scrub sink. Obtain a scrub pad, open it, and place it on the ledge over the sink. (Usually these pads are pre-loaded with hibi-cleanse or other surgical scrub soap.) Next put your mask on because once you scrub your hands you can’t touch anything that is not sterile and your mask, my friend, is a hotbed of bacteria and other nastiness.

Usually either goggles, glasses with side-shields, or a mask with a transparent face shield are required in the OR. These things will all fog up on you quickly if you don’t take certain steps. Most surgical masks can be fitted to your face by bending the nose guard. Still, I always found that either the face shield or my glasses would fog up no matter what I did. Consequently I started putting a two inch strip of tape across the bridge of my nose, taping the mask flat and sealing it to my nose.

Do whatever it takes. You may laugh but you might want to take a mask home and try this to see if you can get it right. I prefer goggles to the face shield so unless your residents tell you otherwise as long as you have a mask on and your eyes are shielded you can do whatever you want.

Put everything on right and make sure they are comfortable because once you start scrubbing in you can’t touch your face or anything on it for the duration of the operation…and I have been in some that lasted almost eight hours.

Unless it is emergency surgery (as you may do on a trauma surgery rotation) scrubbing your hands should take you at least five minutes. This is why their is a clock over the scrub sink. If your residents and attendings only scrub for two minutes that’s their perogative but you, my friend, need to do it right.

First take the pick out of the scrub package and clean under your nails. The water is usually turned on by a foot valve or other no-touch mechanism. You will not touch anything non-sterile from now on.

Next, carefully and methodically scrub your hands and arms up to the elbow. First use the brush side of the pad to scrub your fingernails. Then, systematically scrub every finger, the palm, and the back of each hand in turn. Scrub hard with the sponge side.

Oh wait. Did you take off your watch? How about your rings? Sorry. All rings and jewelry below the elbow must come off. Better to leave these things at home. I put my wedding ring on a loop attached to my ID badge. Do not leave anything on the scrub sink that you don’t want to walk away.

After scrubbing one rinses, starting at the hands and letting, as much as possible, the water run down your arms away from your hands. Just do what your residents do. Do not touch the sink, the faucet, or anything else for that matter. Keeping your hands away from your body enter the OR by opening the door with any part of your body but your hands.

I should also mention that before you scrub you need to let the circulating nurse know your glove size so the scrub nurse will have them for you once you enter the OR. Typically you will wear green indicator gloves under your outer gloves. The green indicator gloves provide an extra protective layer and also show you if your outer glove is torn.

Since your hands are still wet, the scrub nurse will hand you a sterile towel. Keep the towel away from your body. Start at the top of your arm and dry in one direction. Then reach under the sterile towel to the hanging end opposite from the side you used and switch hands to dry the other hand. Drop the towel somewhere, where depends on your OR’s procedures but don’t touch anything while you do it.

While gowning and gloving without assistance is a skill you need to learn, in the OR the scrub nurse will hold your gown up for you to put in your arms. Put them into the sleeves but do not extend anything more than the fingers past the cuff. Usually the circulating nurse will tie your gown for you in the back. Note that only the front of your gown, your arms, and hands are going to be considered sterile so a non-sterlile person can tie you up in the back.

At this time the scrub nurses will hold up your first glove oriented for you to put in your hand. Reach deep into the glove but don’t touch the floor for god’s sake. For your other hand the scrub nurse will hold the glove up for you but in this case you will reach under the cuff with your gloved hand and open it up for your other hand.

Sometimes your fingers will go in the wrong fingers of the glove. Don’t worry and do not reach over with your ungloved hand to adjust your glove. Even though you have scrubbed your hands, all you have done is knocked down the number of colonies. Your hand is non-sterile even after scrubbing and if you touch your gloved had with it you will be asked to scrub out and repeat the whole procedure.

Once you have both hands gloved you may, with perfect aplomb, adjust your gloves to your heart’s content as your gloved hands are both sterile.

Now here’s the tricky part. The front of your gown has a cardboard tab attached to the wrap-around ties. Grab one tie with one hand (pulling it free of the tab) and hand the red end of the tab with the other tie attached to it to the circulator (or anybody) being careful not to touch your gloved hand to the non-sterile person you hand it to. Spin once to wrap the closure around your gown, hold the two ends of the closure and let the circulator pull the tab off of the cord. Tie your gown with the cord.

There you go. You are now scrubbed in. Keep in mind that the scrub nurse, the circulator, and anybody else who loves to harrass medical students will be watching you intently to catch you in a mistake. Maybe you touched something non-sterile. I once, for example, reached up to adjust my goggles and had to “scrub out” and repeat the whole procedure from the top.

Don’t take it personally. While it is legitmate fun to pick on medical students, the insides of the human body provide an ideal culture medium for bacteria, spores, and viruses. Surgical infections are serious business and the best way to deal with them is not to let them happen.

A word about the sterile field. You will note that the patient will be completely draped in sterile coverings leaving only the operative site exposed. The operative site will have been scrubbed before the drapes went on. The sterile field extends to all sides of the operative site which are covered by a sterile drape. Your hands, your arms, and the front of your gown from slightly above waist level to about the clavicular line are part of the sterile field. Never drop your hands below your waist. It is acceptable to fold your arms if you are just going to be standing around. Never touch anything above your waist which in not part of the sterile field.

By all means rest your hands on the sterile field. That way you will not get into any trouble. You can play a game of soitare on the sterile field (if the cards are sterile natuarally) without comprimising sterility as long as you never touch anything outside the field.

The scrub nurse’s table is part of the sterile field and is covered in a sterile drapes upon which sterilized instruments are placed. These instruments are passed back and forth between the patient and the table but as long as they don’t leave the sterile field they are sterile.

Are you seeing a pattern here? Everything in the OR is structured to keep a small area of the room sterile. The point of entry is the scrub nurse who always takes her job seriously. She may be defferential to the attending but she is not afraid of residents, interns, and least of all medical students. Do what she says in regard to protecting sterility. If you are in doubt, politely ask her what you should do.

Next: Retracting 101.