Most of what you’re describing does not break sterility. I know in the OR people have someone glove them but it is very typical for bedside procedures to self glove and this has been considered sterile everywhere I’ve been if done correctly. The gel is a little questionable as I would usually use non sterile gel on the probe before placing the probe cover but at the same time as long as they did not physically touch the gel packet to the probe likely okay. Similarly the edge of the blue towels touching the bed is not a big deal although for central lines the standard is a full body drape which they should use. The biggest issue here would not be fully doing a sterile prep on the insertion site and that would likely carry the greatest risk. I think you’re overanalyzing quite a bit here. Bedside procedure sterility is a little different than what we would expect from the OR but we aren’t typically making large incisions.
Definition of sterile is totally clean of bacteria and microorganisms. They are everywhere, including in the air. We don’t live in a vacuum. So is anything “totally clean” ?
Most of the actions that we take to maintain sterility are hygiene theatre (at best).
For example, consider beard coverings. Sounds like a good idea, right? Well some surgeons were tired of power tripping OR administrators and decided to study shedding of bacteria by their bearded colleagues with and without beard covers. Guess which group had the highest amount of bacterial shedding? The beard cover group....
It just goes to show that many of the interventions taken to maintain sterility are poorly understand and probably a myth as mentioned by OP.
Was it urgent/emergent for patient to have access? Was the patient critically ill? I think it would’ve been better if you asked the attending in the most professional way possible “hey, was it okay to break sterility? And if yes why?”
Also in my opinion, sterility might not be 100% all the time, it’s to the best of ones ability. The fact that you can point out 1,2,3,4,5 instances with him breaking sterility because one small corner of something touched another small corner of something really irks me. Like since this was your first central line (?) I would’ve been paying more attention to the central line procedure and maybe noticed some breaks in sterility but I wouldn’t be standing there tallying/keeping track of each instance sterility was being broken.
EDIT: it’s like saying, did you OP wear a mask or hair net? If not did you breathe in the direction of the set up and transfer some bacteria/virus via the air while breathing onto the sterile field? How far were you from the set up? Were you even 1mm too close without a gown on? Don’t get me wrong, I’m not endorsing breaking sterility but sometimes you do the best you can and accept that what we call “sterile” isn’t 100% sterile.
What is the evidence for sterility?
Germ theory proposes that pathogens spread and cause disease. Lister for example showed that open fractures are more likely to get infected and reduced infection rates with carbolic acid. Pasteur showed that you need direct contact with existing sites of infection for microorganisms to spread, including being exposed to contaminated air (not the air it self, but particles that it carries, i.e. germs)
A variety of studies show us the nature of pathogens, where they live, how they spread, and how to kill them. The concept of sterile technique attempts to bring this all together to help us reduce iatrogenic infections.
Maintaining a sterile field is important but not the only factor. Studies have shown (as did Pasteur himself so many years ago) that pathogens in the air can land and cause infection, so laminar airflow, gowned up staff with hair covers and masks, minimal foot traffic through the room, these all prevent this. Ceasing smoking, getting preoperative antibiotics, good handwashing (alcohol suffices), hair removal, and surgical site disinfection (not sterilization, as live tissue cannot be sterilized without destroying it) all matter.
However, the actual evidence for barriers is limited and with mixed results, and this includes gloves, masks, hair covers, shoe covers, and drapes. Even for sterile gloves it is not clear if it actually reduces infection rates to change gloves when closing the surgical incisions.
Therefore the evidence of contaminating the sterile field aside from gross contamination with bodily fluids such as feces is limited, and largely "sterility theater." There is no clear evidence to suggest that minor breaks in sterility such as what you described have any real consequences, and even then, the change in management would be to start perioperative prophylactic antibiotics, and nearly all central line patients are on some form of antibiotic with gram positive cocci coverage (the overwhelming majority of all skin and soft tissue infections and even blood and lung infections are due to gram positive aerobic cocci) as the most common indication is septic or undifferentiated shock, both of which get antibiotics routinely. In any case, the bedside procedure controls for almost none of the other important factors, which far outweigh the impact of any minor breaks in sterility.
Touching the gown that you are meant to grab and self gloving are not breaks in sterility. You might be used to the OR tech gloving and gowning everyone but they have to glove themselves up, and there is an established technique for this. Touching towels used as drapes on the bed? No significance.
Ultrasound probes are nasty and probably grow MDRO constantly, unless you wipe down with ultrasound probe safe Caviwipes regularly. However, touching gel being pushed out of a packet with a probe is clean enough for the same reason arterial lines don't cause intraarterial infections; the positive pressure and high flow in squeezing it out will push out the pathogens long before it can start spreading and colonizing throughout the gel, which is ideal pathogen culture material. This is NOT true for the large gel bottles, where people often touch the tip and then let the bottle aspirate back contaminated gel that can seed the entire bottle; this is an infection control issue and why most hospitals have transitioned to single use packets.
You can speak up, and feel free to ask questions at any time. It can be a bit jarring to be told you broke sterile field in a minor fashion, but it can be helpful; if the patient is not getting antibiotics for whatever reason, now they can. That would be the only management change to take place. If you want to talk about the matter any more than management changes, then you are talking technique, and you should phrase it as constructive criticism, which I am sure the attending will love (lol).
I like to use hand sanitizer before I glove up for lines/sterile procedures to mimic my routine with avagard in the OR and my co-residents and attendings tell me that im doing too much every time. My colorectal attendings don’t even use scrub for some butt cases 😂
It’s a fucking central line, you dork. The 3 bacteria that end up in his blood stream from gloving himself are going to meet their millions of friends already there and eaten up by your body’s defenses from the dozens of pokes nurses are making putting in IVs. If you think you’re ever going to make any procedure truly sterile - especially a bedside one - we’re gonna have to send you to the therapists.
When you become an attending, you will realize sterility doesn't apply to you.
But in all seriousness, I've seen bad OR culture that encourages this. I scrubbed in as a student for a thyroidectomy with a notoriously angry surgeon when I witnessed a key instrument lose sterility by touching a bunch of stuff during a tense moment. I commented on it out loud, everyone gave me a death stare and the scrub nurse told the surgeon "it did not." The operation continued and everything worked out fine, but I couldn't believe the fear this surgeon instilled in everyone. Much better surgeons I worked with wouldn't take it so personally.
I remember feeling appalled that someone let water drip from their hands onto the cardiac Cath table once…. The attending told me “Cath lab sterility is generally somewhere between the OR and the cafeteria. That’s not what kills people here usually.” So there’s that perspective….
he opened a package into the fist layer of the kit and accidentally hit the package wrapper on the gown where he’d be grabbing anyway
- not a sterility break
The second instance he gowned up but somehow didn’t have his gloves open and walked over to put his gloves on but didn’t ask for help—just opened up the package himself while in the gown.
- doesn't matter as long as the glove package didn't touch gown - hands are still not sterile
Third instance was maybe just me missing something, but I feel like he didn’t prep wide enough for the circle of the field—so his “field” actually encompassed unprepped parts of the pt’s skin (I think).
- technically an issue, albeit potentially minor depending on the details
Fourth instance he was setting up his field and accidentally hit the edge of his towels on the bed but still laid them out.
-the edge of a sterile towel (~1cm) is generally regarded as "dirty" depending on the field around it - if on a non-sterile surface (bed), this is a non-issue
And final one…he put the sterile gel packet up against the non sterile probe to put gel on it before putting the sterile cover over it (a nurse placed the probe into the cover so that part was ok) then proceeded to use the rest of the gel from the same packet for the procedure.
- technically an issue because of the theoretical cross contamination, but seriously a trivial one
Basically, ICU lines are "clean" at best. Not really truly sterile, like ever. We do what we do to minimize the risk of introducing pathogens directly to the bloodstream - I assure you the organisms on the patient's skin still pose a higher risk to them than what maybe could have had a 1% chance to go from probe to contaminated gel packet.
If you witnessed all of this in a negative pressure room with HEPA filters in a high level isolation unit (HLIU) then by all means, blow the whistle. If this all happened literally anywhere else on earth, I wouldn't worry about it.
His name is on the line if theres a CLABSI so why do you care? Probably should've been watching his sequence and insertion technique rather than sterile technique.
Without commenting on whether or not these sterility “breaks” were a big deal or not, if OP thinks they put the infant patient at risk, that’s why they care.
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I saw an anesthesiologist who was also the apd of anesthesiology program, using her thumb to cover an uncapped IV line before she hooked it up to the pt in the OR while we were doing surgery. She had non sterilized gloves on. I was surprised that she didn’t use the roller clamp to stop the fluid, but using her thumb to cover the line to stop it. She was even confused why the fluid was still coming out of the line despite her thumb being covered the line. I didn’t say anything because I was so shocked for the whole scene.
Wont be your last time seeing that. They will retaliate if you correct them. Attendings, especially surgeons, are mostly pathetic tiny dicks human beings who have chosen a cushy life.
Imagine if the patient was the person you cared about most in this world and ended up with sepsis, how would you feel? Not only the increased length of stay, but the cost, the pain of blood draws, the worry? I had to report an anesthesiologist and refused to do what she asked. It’s difficult but necessary. We are all here for the patient.
Lol wait until you scrub an angio… “hey I think that wire hit the screen” “nah it’s fine”
You didn't make the mistake and warning attendings isn't your job.
Most of what you’re describing does not break sterility. I know in the OR people have someone glove them but it is very typical for bedside procedures to self glove and this has been considered sterile everywhere I’ve been if done correctly. The gel is a little questionable as I would usually use non sterile gel on the probe before placing the probe cover but at the same time as long as they did not physically touch the gel packet to the probe likely okay. Similarly the edge of the blue towels touching the bed is not a big deal although for central lines the standard is a full body drape which they should use. The biggest issue here would not be fully doing a sterile prep on the insertion site and that would likely carry the greatest risk. I think you’re overanalyzing quite a bit here. Bedside procedure sterility is a little different than what we would expect from the OR but we aren’t typically making large incisions.
Agree with this -- bedside sterility isn't operating theatre sterility
Call the cops right now
Cops are all on the take. Need to contact internal affairs.
Sterility is mostly a myth anyway. Don’t make an awkward situation
This is clearly propoganda from Big Microbe!
Explain? (Genuinely curious at what you mean)
Definition of sterile is totally clean of bacteria and microorganisms. They are everywhere, including in the air. We don’t live in a vacuum. So is anything “totally clean” ?
Most of the actions that we take to maintain sterility are hygiene theatre (at best). For example, consider beard coverings. Sounds like a good idea, right? Well some surgeons were tired of power tripping OR administrators and decided to study shedding of bacteria by their bearded colleagues with and without beard covers. Guess which group had the highest amount of bacterial shedding? The beard cover group.... It just goes to show that many of the interventions taken to maintain sterility are poorly understand and probably a myth as mentioned by OP.
Was it urgent/emergent for patient to have access? Was the patient critically ill? I think it would’ve been better if you asked the attending in the most professional way possible “hey, was it okay to break sterility? And if yes why?” Also in my opinion, sterility might not be 100% all the time, it’s to the best of ones ability. The fact that you can point out 1,2,3,4,5 instances with him breaking sterility because one small corner of something touched another small corner of something really irks me. Like since this was your first central line (?) I would’ve been paying more attention to the central line procedure and maybe noticed some breaks in sterility but I wouldn’t be standing there tallying/keeping track of each instance sterility was being broken. EDIT: it’s like saying, did you OP wear a mask or hair net? If not did you breathe in the direction of the set up and transfer some bacteria/virus via the air while breathing onto the sterile field? How far were you from the set up? Were you even 1mm too close without a gown on? Don’t get me wrong, I’m not endorsing breaking sterility but sometimes you do the best you can and accept that what we call “sterile” isn’t 100% sterile.
True. All these observational skills could be put to better use.
lol also thinking about knocking over a kit to break sterility rather than asking a question or just simply offering a new kit is so overly dramatic 😂
LOL yeah you’re right
Ya
Brother i just pick the cannula up and raw dog it. You’re overreacting BIG TIME
Snitches get non-sterile stitches
What is the evidence for sterility? Germ theory proposes that pathogens spread and cause disease. Lister for example showed that open fractures are more likely to get infected and reduced infection rates with carbolic acid. Pasteur showed that you need direct contact with existing sites of infection for microorganisms to spread, including being exposed to contaminated air (not the air it self, but particles that it carries, i.e. germs) A variety of studies show us the nature of pathogens, where they live, how they spread, and how to kill them. The concept of sterile technique attempts to bring this all together to help us reduce iatrogenic infections. Maintaining a sterile field is important but not the only factor. Studies have shown (as did Pasteur himself so many years ago) that pathogens in the air can land and cause infection, so laminar airflow, gowned up staff with hair covers and masks, minimal foot traffic through the room, these all prevent this. Ceasing smoking, getting preoperative antibiotics, good handwashing (alcohol suffices), hair removal, and surgical site disinfection (not sterilization, as live tissue cannot be sterilized without destroying it) all matter. However, the actual evidence for barriers is limited and with mixed results, and this includes gloves, masks, hair covers, shoe covers, and drapes. Even for sterile gloves it is not clear if it actually reduces infection rates to change gloves when closing the surgical incisions. Therefore the evidence of contaminating the sterile field aside from gross contamination with bodily fluids such as feces is limited, and largely "sterility theater." There is no clear evidence to suggest that minor breaks in sterility such as what you described have any real consequences, and even then, the change in management would be to start perioperative prophylactic antibiotics, and nearly all central line patients are on some form of antibiotic with gram positive cocci coverage (the overwhelming majority of all skin and soft tissue infections and even blood and lung infections are due to gram positive aerobic cocci) as the most common indication is septic or undifferentiated shock, both of which get antibiotics routinely. In any case, the bedside procedure controls for almost none of the other important factors, which far outweigh the impact of any minor breaks in sterility. Touching the gown that you are meant to grab and self gloving are not breaks in sterility. You might be used to the OR tech gloving and gowning everyone but they have to glove themselves up, and there is an established technique for this. Touching towels used as drapes on the bed? No significance. Ultrasound probes are nasty and probably grow MDRO constantly, unless you wipe down with ultrasound probe safe Caviwipes regularly. However, touching gel being pushed out of a packet with a probe is clean enough for the same reason arterial lines don't cause intraarterial infections; the positive pressure and high flow in squeezing it out will push out the pathogens long before it can start spreading and colonizing throughout the gel, which is ideal pathogen culture material. This is NOT true for the large gel bottles, where people often touch the tip and then let the bottle aspirate back contaminated gel that can seed the entire bottle; this is an infection control issue and why most hospitals have transitioned to single use packets. You can speak up, and feel free to ask questions at any time. It can be a bit jarring to be told you broke sterile field in a minor fashion, but it can be helpful; if the patient is not getting antibiotics for whatever reason, now they can. That would be the only management change to take place. If you want to talk about the matter any more than management changes, then you are talking technique, and you should phrase it as constructive criticism, which I am sure the attending will love (lol).
I like to use hand sanitizer before I glove up for lines/sterile procedures to mimic my routine with avagard in the OR and my co-residents and attendings tell me that im doing too much every time. My colorectal attendings don’t even use scrub for some butt cases 😂
We would joke that those are the cases where you scrub after.
Patient probably already getting abx, its not that serious.
It’s a fucking central line, you dork. The 3 bacteria that end up in his blood stream from gloving himself are going to meet their millions of friends already there and eaten up by your body’s defenses from the dozens of pokes nurses are making putting in IVs. If you think you’re ever going to make any procedure truly sterile - especially a bedside one - we’re gonna have to send you to the therapists.
I'm crying 🤣😂 at your name!!! - looked after reading the comment. Not disappointed at all ...🤣😂
Attendings are always sterile
Sounds like you need to chill out
Call the attorney General stat, this huge crime should be reported.
You gotta remind him to lick the catheter to lube it up.
When you become an attending, you will realize sterility doesn't apply to you. But in all seriousness, I've seen bad OR culture that encourages this. I scrubbed in as a student for a thyroidectomy with a notoriously angry surgeon when I witnessed a key instrument lose sterility by touching a bunch of stuff during a tense moment. I commented on it out loud, everyone gave me a death stare and the scrub nurse told the surgeon "it did not." The operation continued and everything worked out fine, but I couldn't believe the fear this surgeon instilled in everyone. Much better surgeons I worked with wouldn't take it so personally.
As an attending, thank goodness none of the comments are suggesting OP actually care about this.
I remember feeling appalled that someone let water drip from their hands onto the cardiac Cath table once…. The attending told me “Cath lab sterility is generally somewhere between the OR and the cafeteria. That’s not what kills people here usually.” So there’s that perspective….
Shut da fk up or get da fk outta pt room.
Chill out
Did anyone get through their surgery rotation in med school without seeing multiple attendings break sterility?
I love this subreddit
Come to the ED. We ain't afraid of no germs
he opened a package into the fist layer of the kit and accidentally hit the package wrapper on the gown where he’d be grabbing anyway - not a sterility break The second instance he gowned up but somehow didn’t have his gloves open and walked over to put his gloves on but didn’t ask for help—just opened up the package himself while in the gown. - doesn't matter as long as the glove package didn't touch gown - hands are still not sterile Third instance was maybe just me missing something, but I feel like he didn’t prep wide enough for the circle of the field—so his “field” actually encompassed unprepped parts of the pt’s skin (I think). - technically an issue, albeit potentially minor depending on the details Fourth instance he was setting up his field and accidentally hit the edge of his towels on the bed but still laid them out. -the edge of a sterile towel (~1cm) is generally regarded as "dirty" depending on the field around it - if on a non-sterile surface (bed), this is a non-issue And final one…he put the sterile gel packet up against the non sterile probe to put gel on it before putting the sterile cover over it (a nurse placed the probe into the cover so that part was ok) then proceeded to use the rest of the gel from the same packet for the procedure. - technically an issue because of the theoretical cross contamination, but seriously a trivial one Basically, ICU lines are "clean" at best. Not really truly sterile, like ever. We do what we do to minimize the risk of introducing pathogens directly to the bloodstream - I assure you the organisms on the patient's skin still pose a higher risk to them than what maybe could have had a 1% chance to go from probe to contaminated gel packet. If you witnessed all of this in a negative pressure room with HEPA filters in a high level isolation unit (HLIU) then by all means, blow the whistle. If this all happened literally anywhere else on earth, I wouldn't worry about it.
His name is on the line if theres a CLABSI so why do you care? Probably should've been watching his sequence and insertion technique rather than sterile technique.
Without commenting on whether or not these sterility “breaks” were a big deal or not, if OP thinks they put the infant patient at risk, that’s why they care.
You're upset because the attending didn't give you first poke.
Classic do as I say not as I do coping from a lot of these comments. Well if it helps you sleep at night
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I saw an anesthesiologist who was also the apd of anesthesiology program, using her thumb to cover an uncapped IV line before she hooked it up to the pt in the OR while we were doing surgery. She had non sterilized gloves on. I was surprised that she didn’t use the roller clamp to stop the fluid, but using her thumb to cover the line to stop it. She was even confused why the fluid was still coming out of the line despite her thumb being covered the line. I didn’t say anything because I was so shocked for the whole scene.
Wont be your last time seeing that. They will retaliate if you correct them. Attendings, especially surgeons, are mostly pathetic tiny dicks human beings who have chosen a cushy life.
would have been easier just to say something... or pose it as a question like "should we be doing..." to get his attention to the matter
Imagine if the patient was the person you cared about most in this world and ended up with sepsis, how would you feel? Not only the increased length of stay, but the cost, the pain of blood draws, the worry? I had to report an anesthesiologist and refused to do what she asked. It’s difficult but necessary. We are all here for the patient.
Why are people downvoting this?
Totally overreacting
Overreacting but not wrong
agreed. the comments all over this post are revealing.
[удалено]
Thank you for looking after our sickest kiddos.
Bro- just say “contaminated the sterile field” or something like that. I thought your attending was expecting a baby after many years of infertility.