Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor
Dept. of Podiatric Medicine
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences
St. Pomona, CA

Sacred Cows — Mooove Over

Sacred cows. Routine practices.

There are things we do in medicine that have existed for a long time, and we continue to do them. Our teachers did them. Our attendings did them. So we do them.

But WHY do we do them?

In today's modern practice of patient care, many of these sacred cows remain, but sometimes you have to stop and wonder if some of these cows should be sacrificed to advances in science and reason. Do we perform these functions because there is a logical, proven reason or because someone before us did?

Cow #1 – How many people should be allowed in an OR?

Recently, I was doing a surgical procedure at one of my local hospitals. I had a resident and a student with me. The resident and I had scrubbed and were about to get started when I heard some talk from the other side of the OR that my student was not allowed to scrub because there were "too many people in the room." In fact, they were not even going to let him in the room (there were exactly five people – anesthesiologist, scrub tech, circulator, resident and me).

So, seconds before I was about to make the skin incision, the nurse educator that made my student wait, comes into the room (after I demanded to see her), and we began debating the issue. Of course, the hospital has no formal policy on the number of people who can scrub for a surgery or the number of people who can be in the OR during a procedure. After I angrily related this – along with my extreme anger at distracting the entire operative team from my patient, a safety issue in my opinion – she relented.

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Most likely, at some point in the past some administrator decided two people plus a scrub tech was an appropriate number scrubbed into a case. What science is this based on? None.

On the contrary! A study performed in 2008, published in the Journal of Bone and Joint Surgery looked at contamination rates of open surgical instruments based on length of open time and foot traffic rates.¹ There was no difference in contamination rates between trays exposed to high or low traffic. What did matter was the length of time the trays were exposed to the open environment, not how much room activity was witnessed.

Cow #2 – Swabbing skin with alcohol before injection

How about a classic sacred cow – swabbing skin before needle injections. We all do it, but is it necessary? I know what you're thinking. "Of course it's necessary. Do you want to infect your patients? Are you nuts?" My answer to those last two questions is "no" and "probably."

What does the research say? A quick search demonstrates this has been a topic of discussion for many years, as far back as the 1960's (and likely before that). Dann, in 1966, tracked the number of infections after 2000 injections without any skin preparation by two practitioners over a two year period.² How many infections were there? Absolutely none! Zero. Zilch. Nada. Nil.

Now I'll grant you that the rest of the body is not the foot. I would hazard to guess that the majority of injections performed in the primary care setting are given in the arms, belly, or buttocks (maybe that last one isn't the cleanest). Unfortunately, there just isn't any science to answer the question for the lower extremity. Here's your next research study! I'll hazard another guess that swabbing the skin on the foot before injections is also unnecessary as long as the foot is not visibly soiled.

Cow #3 – Covering/wrapping toes during surgery

How about covering/wrapping the toes during surgery? This one seems to be popular within the orthopedic community and with a portion of the podiatric community. Many surgeons like to cover the toes with Coban™. Does this matter? A Pub Med search found exactly ZERO studies looking at clinical outcomes (i.e. infection rates) in patients undergoing foot or ankle surgery with covered toes. I can tell you in a completely unscientific anecdotal way that I have been doing foot and ankle surgery in practice for 7 ½ years, and I've never once covered the toes, and my infection rate is low (around 2%) – no higher than anyone else.

Cow #4 – Sterile prep for toenail procedures

How about one last sacred cow. What about sterile prep for toenail procedures? Useless.

Oh, you don't like that one?

Cow #5 – Minutes to perform a preoperative hand scrub

Ok, how about the number of minutes to perform a preoperative hand scrub? Hingst, et al.,1992 found the three minute hand scrub to be as effective as the five minute scrub using seven different preparations.³ So, is three minutes the number? What if I told you that O'Shaunessey, et al.,1991 found no advantage to scrubbing greater than two minutes?⁴ They looked at chlorhexidine gluconate 4% scrubs at two, four and six minute intervals and found scrubs greater than wo minutes did not confer any greater antimicrobial protection than at four or six minutes. It makes one wonder how protective one minute or less would be?

I'll finish this attack on our sacred cows with a comment about preop handwashing. If you look at this from a historical perspective, you will recall that when Joseph Lister popularized the antiseptic technique, doctors did not wear gloves at all. That came years later as a result of William Stewart Halstead at Johns' Hopkins. It was important then to wash hands, because they would come in direct contact with the surgical field. It may also be interesting to note that the operative use of gloves was started not to protect patients from infection, but to protect Dr. Halstead's scrub tech (later his wife) from dermatitis commonly caused by the phenol used to wash the hands preoperatively. Today we use gloves, preventing any contact between the surgeon's hands and the patient's skin. It is most likely that this barrier is what really protects patients from our dirty hands rather than any preoperative hand scrub. I'd love to see the study that compares the current preoperative hand wash technique with simple water and soap. I'll bet almost any amount of money that there will be almost no difference between the two.

This example places into stark contrast that much of what we do is not based on science or rational thought, but rather chance, history, and the fact that someone did it before us. By the way, how sterile is that water coming out of the scrub sink with which you're washing preoperatively? Hmmm. I wonder...

Mooove over, sacred cows.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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References

Dalstrom DJ, Venkatarayappa I, Manternaach AL, et al.Time-depdendent contamination of opened sterile operating-room trays. J Bone Joint Surg Am. 2008 May;90(5):1022-1025.
Dann TC. Routine skin preparation before injection: an unnecessary procedure. The Practitioner. 1966 Apr;196(174):546-550.
Hingst V, Juditzki I, Heeg P, Sonntag HG. Evaluation of the efficacy of surgical hand disinfection following a reduced application time of 3 instead of 5 min. J Hosp Infect. 1992 Feb;20(2):79-86.
O'Shaughnessy, M, O'Malley, VP, Corbett, G, Given, HF. Optimum duration of surgical scrub-time. Br J Surg. 1991June;78(6):685-686.