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complaining that it isn’t available (rather than silently blaming themselves for not checking earlier to be sure it was ready), and they piddle back and forth in the wound looking at stuff they’ve already done while waiting for the lights to come on and tell them what to do next.

Think Ahead: An efficient surgeon is always thinking at least one or two steps ahead in the surgical procedure, to be certain the instruments he/she needs next are available and ready for use without delay.  Thinking ahead and communicating to the OR staff what will be needed next (i.e. “the next thing we will need on power is a .062 k-wire) will go a long way toward improving the efficiency of your surgical procedures.  (Note: a good assistant also thinks ahead, ideally anticipating what will be needed next for the primary surgeon.  Don’t “zone out” because you are “just the assistant”).

Anatomy:  “To hell with the anatomy, stay close to bone.”  This common quotation refers to the fact that there are no important neurovascular structures between the periosteum and the bone.  The surgeon should always remember, however, that a major portion of the blood supply to the bone comes through the periosteum and that needless stripping of the periosteum results in a marked delay in fracture healing and an increased infection rate.  

Wound irrigation: “The solution to pollution is dilution”:

Antibiotic wound irrigation: Antibiotics are agents which kill procaryotic cells (bacteria), but do not kill eucaryotic cells (human cells).  Topical antibiotics (such as the Bacitracin, Polymyxin, and Neomycin found in orthopaedic antibiotic irrigating solutions)

Antiseptic wound irrigation: Antiseptics are agents which destroy all living cells, i.e., alcohol, iodine, phenols, Clorox, hydrogen peroxide, etc.  As opposed to antibiotics, most of the antiseptic agents are more toxic to eucaryotic (us) cells than they are to procaryotic (bacterial) cells.  These agents are suitable for washing the floor and some of them for washing the already dead epidermis prior to surgery, but are not advisable for washing wounds.  While it is true that these agents will kill bacteria within the wound, they will also kill the patients’ tissue, creating more necrotic material for bacterial growth postoperatively.  

“Sterile” vs. “dirty”: Sterile (without life) is not the antonym of dirty.  If you take dirt and autoclave it, it becomes sterile but remains dirty.  

OR floor: A surprising but important fact to recognize is that the OR floor may be dirty, but is a nearly sterile environment.  This is because it is mopped between each case with powerful antiseptic solutions.  The liquids evaporate away, but the antiseptics remain on the floor and are very toxic to bacteria there.  Cultures of OR floors show few colony forming units of bacteria.  This means that if you drop an especially important piece of the patient on the floor, such as a graft, that it may well not be heavily contaminated with bacteria.  In one study where bone graft specimens were purposely dropped on the OR floor, left for one minute, and cultured, 50 out of 50 were negative,

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