Monday, April 8, 2013

Sterility In The Operating Room. Hey It's All Relative.

I don't often reply to a comment that people make after reading one of my posts. And I have never before written a whole page to counter what people thought about my writing. But I think this one deserves an exception. An irate reader took me to task for making recommendations for what types of food would be acceptable for consuming in the operating room.

The author of the comment only signed himself or herself as "Anonymous". But he, for simplicity sake, starts off by berating me, and my readers, by writing, "Shame on all of you." He goes on to claim that surgeons and nurses sometimes work for 8 to 12 hours at a time without a break. Therefore anesthesiologist should just tough it out and do the same thing or talk to the administration to hire more anesthesiologists to give us breaks. He chastises us for bringing food into the operating room and possibly jeopardizing the sterility of the surgical field.

Okay, I don't know if Anonymous is a surgeon, a hospital administrator, or a Joint Commission lacky, but his statement that nurses work without a break for half a day is clearly ignorant. I don't know of any operating room nurse who works that long without being given some time out of the room. As a matter of fact, during a single four hour case there may be as many as three or more shifts of nurses moving in and out of the room. Most states have pretty strong rules about how often nurses are supposed to be given relief. And if a hospital is found in violations of overworking their nurses, major lawsuits can ensue.

As for the surgeons not getting breaks, well that is their choice. They can operate twelve hours straight if they wanted to but the truth is that they have options. In a long case, there is always some point where the surgeon can scrub out and take a quick five to ten minute break to go to the bathroom or get something to drink. Rarely is a procedure so intense for the entire period that the surgeon cannot leave for even a few minutes. In addition, the surgeon usually has an assistant in the room that can continue working or at least watch the patient until he comes back.

By contrast the anesthesiologist is almost always working alone. By moral and legal grounds he can never leave the operating room with the anesthetized patient unmonitored. While the surgeon is making a quick run to the restroom, the anesthesiologist is watching the patient diligently to make sure every is going well. It doesn't work the other way around.

Now let's get to the crux of the matter, the reason food is banned from the operating room. Like I said in the original post, food is never, ever, ever permitted in the OR. And the reason for this is the fear that it would somehow contaminate the sterility of the operating field. But is that really the case?

Not a hospital operating room
People have to know that the OR is considered sterile, but the sterility is not as strictly enforced as you might believe. Sure the surgeon and the scrub nurse gown and glove up with the utmost care to ensure absolute cleanliness but it is still far from the true sterility that you might find in say a computer chip manufacturing facility. There, particles measuring micrometers in diameter are efficiently whisked out of the factory to prevent damage to the impossibly tiny tolerances required of modern technology.

By contrast, really the only sterile part of the operating room is the few inches surrounding the patient's open wound and the instruments and hands that reach in. The surgeons gown up mainly to protect their own clothing. Nobody wants to get splattered with disease ridden blood and body fluids. If you wanted to you could operate in your street clothes and I bet the infection rate would not change as long as you wear sterile gloves. As for the mask, think of it as more of a sneeze guard than a true protector of sterility.

For the same reason I find it hard to believe that me eating a little grape under my mask behind the ether screen will somehow contaminate the operating field. I'm usually at least six feet away and frequently BELOW the level of the the open wound while being behind a sterile drape. The surgeons' bushy eyebrows, which are obviously uncovered, are within inches and above the patient's wound. Same goes for the caps they wear on their heads. Those caps are definitely not sterile, nor are the tendrils of hair that often peek out from under the edges of the caps. Should all surgeons shave their heads to prevent dandruff and stray hair from falling out and infecting the patient?

Now I'm not advocating that anesthesiologists should be allowed to bring in gourmet lunches into the operating room. And again pretty much all hospitals frown upon any food or drinks in the OR's. But most see the practicality of allowing some sustenance for the anesthesiologist. As long as one practices common sense and and discretion, a few snacks are usually tolerated. Otherwise cases will just have to be delayed so that the anesthesiologist can go to the cafeteria and eat to prevent his blood glucose levels from collapsing. Which wouldn't really matter to the surgeon or the hospital but it might endanger patient safety, which you know, might not look so good on the local evening news.


  1. I am a director of surgical services in a small rural hospital, 6 ORs. I previously ran a larger 21 room OR in a large metropolitan city. I compare myself to the school hall monitor. Do I want to be this person that must watch everyone’s step? No, it is not in my personality. However, I am being paid to insure best practices are be met.
    Any time a practice is recommended by our governing body, AORN, physicians that disagree with it usually reply, in so many words, that is a nursing journal, we don’t support or agree with nursing.
    Because of this it can be very hard getting physician buy in when we attempt to provide the best possible environment of care for our patients. If it negatively affects their behavior, then it is a battle.
    I agree with every comment you have made about the actual situation in the OR. On weekends, we (the OR team, RN/Tech/Anesthesia provider) take 30 minutes to eat together between cases during the day (obviously, not true emergencies). In the large facility, the Anesthesia group had float providers that gave lunches, assisted on difficult intubations, evaluated the patients in PreOp, and signed out the patients in PACU. In the smaller facilities I have worked, this model was not feasible and allowances are made so they can grab a quick bite (15 minutes, not fair, but usually we ask what they would like and get it from the cafeteria so it is waiting in their break room for them.
    The patient would not be compromised if grapes and such are eaten behind the “ether screen”. No increase in infection rate would occur if we wore clean jeans and t-shirts in the OR. No major event would occur if the team did not wear masks (for sure the no sterile team). It wouldn’t matter if we had civilians walking behind the red line and used it as a hall for getting from point A to point B.
    My point is, we do our best to control the environment. We draw lines and declare behind this line we will behave in this fashion. We will do our best to do no harm.
    Once we say, “well….lets turn our back on this part, and ok, this part too….” It is like a dam, we are picking away at the foundation, and before you know it, something happens, the RCA looks for deviations in standard practice and ask, “how did the Junior Mint get in there?”.
    In of itself, your point is correct. From my perspective, I agree, but my job is to make sure no Junior Mints are in the OR, no dogs are in the hall way, and our patients can count on our facility to do best practice and figure ways to get our team taken care of without bending rules to make it happen.
    I enjoy your posts and look forward to your response.
    Scott Alder, RN, MSN, CNOR

  2. lets say the surgeon is tired and dehydrated during a long surgery, are they allowed water/ or coffee brought to them?