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OSAT  “Obligatory Surgeon Fool Around Time”: There should be none!  The surgeon is ultimately responsible for the patient’s welfare and, if he/she is doing his/her job correctly, will be in the room, having reviewed the instruments and equipment, having gone over the surgical plan with assistants and scrub personnel, and ready to proceed with the positioning and prep as soon as the patient is asleep (if not during anesthetization).  The surgeon should not rely on the OR staff to call him when the patient is asleep -- if he/she is not in the room by then, OR time ($1000/hour) is being needlessly wasted.

Thought process: Rather than letting your mind idle while you are scrubbing, think your way through each step of the surgical procedure again. This is another chance to remind the nursing personnel of any unusual instruments you may need prior to the very moment you need it. Going over it several times in your mind leads to a quick succession of steps and rapid decision making while you are actually performing the operation – the indecisive surgeon is a slow surgeon!

Scrub:  Many surgeons are surprised to find that Chlorhexidine scrub soaps are more bactericidal than iodine containing scrub soaps.  Skin bacterial counts continue to drop with prolonged scrubbing, but the rate of drop diminishes rapidly (geometric progression) so that a ten minute scrub is not much better than a three minute scrub, and a three minute scrub is not much better than a one minute scrub.  In addition, repeatedly scrubbing for long periods of time causes skin abrasions and dermatitis, and thus this irritated skin has a higher colony count before the next scrub.  Thus, a relatively short one to three minute scrub is much better when a surgeon is scrubbing repeatedly.  Bacterial counts on the skin rise rapidly again once surgical gloves are applied and the skin begins to sweat; however, these tend to be skin saprophytes and not as likely to be pathogenic as the casual bacteria found on your skin prior to the scrub.  

Preparing the patient’s skin: This topic takes on epic, near religious significance with different surgeons and each will chose his own method; however, a few observations are in order.  Shaving uniformly increases operative infection rates.  The longer it is done before the surgical procedure, the more bacteria will grow in the numerous small skin “nicks” caused by the shaving procedure and the higher the infection rate will become.  Obviously, in hairy surgical areas, some of the hair must be removed, but this is best done with clippers immediately prior to the surgical procedure.  If a razor must be used, a very light pressure to avoid nicking the skin makes good sense.  It is not necessary to remove every hair, only the hairs that will curl into the wound and interfere with the procedure itself, as hair is more susceptible to antiseptic sterilization than the skin itself.  Of the antiseptic solutions used on skin, alcohol appears to be the most bactericidal, unfortunately it evaporates rapidly and leaves nothing to kill any bacteria which sweat out of the pores later in the case, so for long procedures, some form of antiseptic that remains on the skin is desirable.  In studies, plastic sterile “sticky” drapes have not lowered infection rates.  This is presumably due to the fact that they cause increased skin sweating, liberating bacteria from the pores and almost always peel

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