Scrubbing, Gowning, Suturing Surgical Scrubbing: ideal scrubbing time is 3 minutes • Preparing to scrub: General instructions: 1. Wear your surgical mask, theatre hat (with hair tied up), glasses and ID badge. Remember: they will not be adjustable after scrubbing. 2. Remove watches and rings. 3. Open your gown and gloves pockets before you scrub using the edges of the paper and keep them in the sterile area. • Scrubbing procedure: 1. Run the tap to an adequate temperature and flow of water (use your knee to run and turn it off). 2. Open the package containing the (nail brush/scrub sponge) and the (nail pick). Nail brush/scrub sponge has 2 types: Betadine (many people are allergic to it) and Chlorhexidine. Nail pick Nail brush/Scrub sponge 3. Rinse the hands and arms thoroughly, allowing the water to run from the hands to the elbows. 4. Start by cleaning under the nails with the nail pick and then discard it in the bin. 5. Moisten the nail brush with water. 6. Use the bristle side (rough side) of the nail brush, scrub the spaces under the fingernails back and forth. Avoid using the rough side on other parts of the hand as it causes scratches. 7. Use the sponge-side of the brush to scrub the (palm, lateral side of the fingers, medial side of the fingers, dorsum of the hand, then the forearm up to the elbow), then repeat the same steps on the other hand and forearm. Scrubbing the medial side of fingers Palm scrubbing Dorsum scrubbing 8. Discard the nail brush in the bin. 9. Wash your hands from the tip of the fingers to the elbow. Don’t move arms back and forth in the water. 10. Keep your hands away from your body and above the level of the elbow. Helpful video: https://www.youtube.com/watch?v=WpZqLbWL0c0 In case the nail brush is not available, we use the soap instead and we follow the following steps: 1. Wash your hands and forearms up to the elbow with water. 2. Apply a good amount of soap on your hands. 3. Clean the soap into the hands as follows: i. Palm to palm with finger interlaced ii. Palm to dorsum with finger interlaced iii. Rotational rubbing backwards and forwards with clasped fingers iv. Rotational rubbing of the thumb v. Rubbing the fingertips of the hand on the palm of the other hand vi. Continue rubbing with the rotating action on the forearm to the elbow. 4. Wash your hands from the tip of the fingers to the elbow (don’t move arms back and forth in the water) 5. Keep your hands away from your body and above the level of the elbow. After scrubbing either by the nail brush or by the soap, hold one end of the towel with one hand and dry the fingers of the opposite hand then move to the dry area of the towel and continue in this manner down the forearm to the elbow. Gowning + Gloving: 1. Pick up the entire folded gown from the wrapper by grasping the gown through all layers, being careful to touch only the inside top layer. 2. Carefully insert your arms partway into the gown one at a time, keeping hands at shoulder level away from the body. Be careful that no part of the hand protrudes from the sleeve cuff. 3. A theatre assistant will fasten the gown behind you to secure the gown at the neck and upper back. 4. Open the inner glove packet. 5. Pick up one glove with your sleeve-covered hand. Remember: you are not allowed to touch the external surface of the gloves with your bare hands. 6. Wear the gloves using the closed technique as shown in this video (to 1:14) https://www.youtube.com/watch?v=7x2xPc7YsF4 Note: the doctor said it’s ok to use the open technique as well which is shown in the following video: https://www.youtube.com/watch?v=CvAsZolGF8I 7. After gloving, do final tying of your gown by detaching the cardboard slip from the short tie, ensuring you keep hold of the short tie in your left hand. 8. Pass the cardboard slip to the theatre assistant, ensuring not to make direct contact with their hand. 9. They will pass the long tie around your back, let them pull the cardboard off the tie so that you can tie a bow at your waist. Suturing: Needle holder (Needle driver): hold it with your dominant hand as shown in this picture Toothed forceps: hold it like a pen Scissors: position your index finger at the base of the blades to make your movements more precise. Suture set: we use the non-absorbable synthetic type of sutures for skin wounds. Sutures have different sizes depending on the wound area, some patients have much thicker skin than others and will require a larger suture to facilitate wound closure, but the usual size is (2-0, 3-0). In cornea, we use a smaller size (100). Pain management: 1. Make sure the wound area is sterile with betadine. 2. Locally inject lidocaine (1% or 2%) around the wound before suturing. 3. For 1% lidocaine, give ½ of the patient weight. If the patient is 60 kg, he will be given 30 mL of lidocaine that will be distributed around the wound area. Exceeding this dose can cause toxicity which results in preoral numbness, hypotension, coma. 4. For 2% lidocaine, give ¼ of the patient weight. 5. Before infiltrating lidocaine into the edge of the wound, aspirate to make sure you are not infiltrating into a blood vessel. 6. Try to move to the next area that is close to the previous anesthetized area to minimize the sensation of pain. Simple interrupted suture: 1. Hold the needle in one-third two-thirds from the needle tip. 2. Lift the skin with the forceps and pierce the skin surface with the needle perpendicular (90°) to the skin at approximately 1 cm from the wound edge. 3. Supinate your wrist so that the needle passes through the dermis and rises out of the middle of the wound (1 bite). 4. Use toothed forceps to hold the needle. 5. Re-grasp the needle in the same place (one-third two-thirds) with your needle holder 6. Lift the opposing skin edge gently with toothed forceps. 7. Reinsert the needle perpendicularly through the dermis from inside to outside with equal distance (1 cm). 8. Pull the suture through so there is approximately 10 cm of length on the opposing side. 9. Hold the suture in your non-dominant hand and the needle holder in your dominant hand. 10. Loop the suture around the needle holder twice, then grasp the suture end with your needle holder. Pull the needle holder towards you and push your nondominant hand away to lay the first knot (fixation knot). 11. Loop the suture around the needle holder once, then grasp the suture end with your needle holder. Pull the needle holder away from you and push your nondominant hand away to lay the second knot. Repeat this step twice to end up with 4 knots. Don’t forget to change the direction of the needle holder while you’re pulling it, one knot it must be pulled towards you, and the other knot away from you. 12. Cut the suture 1 cm in length. 13. Repeat the same steps and keep 1 cm between knots until you cover the whole wound. Helpful video: https://www.youtube.com/watch?v=z8oWv-nVO6g Done by: Fatimah Al Mazrou Med217 (F2)