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Can't We Tweak Sterile Technique?

Paul S. Koch, M.D.

I got into a lot of hot water a few years ago when I made a flippant comment regarding one of our major nursing organizations, describing it as the "group that won't let us do anything now that wasn't done 30 years ago." That it was obviously tongue-in-cheek and delivered with a chuckle did not protect me from the angry crowd's wrath.

The topic of that day was one discussed in this issue, sterile technique. I had described how I used foam between cases, and you would have thought foam was a synonym for manure. Loud comments from the floor made it clear that the standard, the only standard, this organization recognized was a 10-minute scrub, including above the elbows, before the first operation and an additional 5 minutes before each subsequent case.

But, I teased them, why should I scrub above the elbow? I'm not thrusting my arm into the eyeball. "No excuse," shouted the crowd. "That's the standard for every operation." Isn't the 5-minute subsequent scrub to cover the half-hour break between general surgical cases? Is it necessary when running between rooms for cataract surgery? "That's the standard," they hollered. I agreed that scrubbing is supposed to decontaminate our hands, but doesn't rinsing them with tap water contaminate them all over again? Perhaps we should use foam and then put our hands directly into gloves, bypassing the sink altogether. When you think about it, why scrub at all if we're going to wear gloves? (That really got them going!)

The standards also discourage flash sterilization unless necessary. Well, which is it, I asked? Is flash sterilization adequate or not? If yes, we should be able to use it all the time, and if no, we should never use it. And how far away does someone have to be to talk in the room without wearing a mask? Why don't patients have to wear masks? How come my religious medal under my scrub suit is forbidden, but nurses can wear earrings? Why am I supposed to cover my sideburns? Why don't maintenance men have to change into scrubs?

Our Work is Different than Other Surgeons'

The general standards for sterile procedures are excellent guidelines, but many are not applicable to the work we do. They remain on the books mainly because no organization seems interested in looking at them critically. We live with them even though a lot of them are tradition and not supported by reality.