Four Things We Do That Make No Sense
A surgical mask should cover your mouth and your nose.
Photos courtesy of Dr. Phil Zeltzman.
Arguably, we all do strange things in daily practice. Some are acceptable, and some…not so much. Let’s go over four classic no-nos.
1. Wearing a mask that covers your mouth, but not your nose. I have seen several doctors and technicians wear a surgical mask that covers their mouths, but not their noses. The explanation is typically that they “can’t breathe” when the mask covers their noses. Since there is no reported case of someone suffocating while wearing a surgical mask in the history of modern medicine, it is imperative to understand that masks are important to protect our patients as well as ourselves.
The mask decreases the risk of microbes being blown onto or into our patient. This is especially critical at a time when a strikingly high percentage of healthcare professionals have been found to harbor MRSA in their nostrils.
Scott Weese, a board-certified internist-turned-infectious disease specialist at the University of Guelph’s Ontario Veterinary College (Canada), agrees: “The nasal passages harbor a wide range of bacteria, including a multitude of opportunistic pathogens. If someone is taking precautions to prevent contamination from oral bacteria, it makes no sense to neglect nasal bacteria, since the chance of contamination is probably similar.”
2. Turning monitoring alarms off. At some clinics, the alarm of monitoring equipment has been turned off—mainly ECG and pulse oximeter. When quizzed, people who do this invariably say that they “can’t stand the beeping sound.”
This clearly defeats the purpose of the alarms. Although, admittedly, we should never strictly rely on machines, the beeping sound can reassure us that our patient is alive and stable. Sure, the sound may be annoying at first, but it is designed to make us very aware of it. It eventually becomes unconscious, an indescribable yet reassuring sense that everything is OK.
In fact, in some ORs, listening to music is forbidden. Why? Usually because once upon a time a patient was lost because the music was so loud that the beeping could not be heard. The patient became unstable, the sound or the rate of the beeping changed, but nobody heard it.
So for the sake of your patient, please keep beeping and alarms on the “on” position.
3. Bandage a joint above and a joint below. This is one mantra of bandaging that “everybody” has learned, yet that doesn’t always make sense.
“Bandage a joint above” may not be possible, or at least not easy. This is why trying to bandage an elbow or a stifle is not very useful at best, and risky at worst. Whether you bandage a front leg after repairing an elbow fracture (or distal humeral condylar fracture) or a hind leg after repairing a distal femoral condylar fracture, it will not do much good since the bandage (or even worse, the splint or cast) cannot physically extend far proximal to the elbow or the stifle. Only a “spica” splint would achieve that. It may even cause some harm as it will add weight and can act as a fulcrum.
“Bandage a joint below” is very misleading as well. All bandages should extend to the toes, to the exclusion of the nails of digits 3 and 4 so that the client can be taught how to monitor swelling of the toes.
4. Pushing the oxygen “flush” valve. When a patient wakes up during surgery, doctors and technicians often push the oxygen valve in order to quickly fill up the breathing bag, so they can squeeze it and “breathe” for the patient. This, however, is counterproductive.
The flush valve provides a high flow of oxygen to the patient while bypassing the flow meter and the vaporizer. So what reaches the patient is pure oxygen, at a flow rate of 35-75 liters/min. Hardly the best way to anesthetize a patient. Compare that to a more common flow rate of 1 liter/min.
So when should the oxygen flush valve be used? There are only two logical situations: when you are testing a machine for leaks preoperatively, and when you are trying to wake your patient up postoperatively.
When I asked an anesthesiologist why so many people feel compelled to push the flush valve at the wrong time, the answer was something like, “At that time, the patient is waking up, the surgeon may get worried, and the anesthesia person is stressed out and doesn’t know what to do. Maybe the ‘woosh’ sound of the high oxygen flow makes them feel like they’re doing something!”
Sheilah Robertson, a board-certified anesthesiologist at the University of Florida College of Veterinary Medicine, suggests to never use the O2 flush valve unless you are sure the pop-off valve is open and never with a Bain (non-rebreathing) system. “Even if we do use it (rarely when attached to a patient), then we do it carefully and keep an eye on the pressure manometer. At the end of a procedure we usually squeeze out the reservoir bag, turn up the O2 flow and repeat this several times to eliminate the inhalant form the circuit.”
Dr. Robertson prefers the following steps if you think your patient is waking up:
• Make sure your patient is indeed waking up. You could think that a too-deeply anesthetized dog that is starting to do abdominal breathing is waking up.
• Increase the flow rate (Bain system) and/or vaporizer setting (circle system) to increase the inhaled gas concentration.
• Alternatively, you could give a small IV dose of propofol or consider additional analgesia.
Dr. Phil Zeltzman is a mobile, board-certified surgeon near Allentown, Pa. His website is www.DrPhilZeltzman.com. He is the co-author of “Walk a Hound, Lose a Pound: How You and Your Dog Can Lose Weight, Stay Fit, and Have Fun Together .”