- Email: [email protected]
Surgical Pearl: Preventing self-inflicted injuries to the dermatologic surgeon
PEARLS Stuart J. Salasche, MD Surgical Pearls Editor
Mark G. Lebwohl, MD Medical Pearls Editor
Surgical Pearl: Preventing self-inflicted injuries to the dermatologic surgeon Zoltan Trizna, MD, PhD, and Richard F. Wagner, Jr, MD Galveston, Texas
A
mong medical and surgical house staff, needlesticks are the most common injuries (74%), with an average frequency of 0.63 per resident-year among nonsurgical residents and 3.8 per resident-year among surgical residents.1 More than 20 pathogens can be transmitted by needlesticks, most frequently hepatitis B and C, as well as HIV.2 The average risk associated with occupational exposure to HIV through percutaneous injury is between 0.2% and 0.36% (ie, one seroconversion per 278 to 500 injuries).3,4 The calculated probability for a surgeon to acquire HIV infection over a 30-year period is between 0.3% and 5.82%.5 The cumulative 30-year risks of contracting hepatitis B and C viruses are 42.7% and 34.8%, respectively.6 The cost of follow-up for a high-risk exposure is almost $3000 per needlestick injury even when no infection occurs, whereas actual infection by blood-borne pathogens can add up to $1 million.7 There are several safety devices on the market, including face shields, fit-over glasses, punctureresistant surgical gloves, finger guards, glove liners, disposable surgical tray organizers, and sheathed needles. However, by improving personal exposure protection alone, the risk of exposure to blood and body fluids can be decreased by more than 70%.8 We have prepared a list of a few important recommendations based on situations repeatedly observed among medical students, interns, and residents performing outpatient dermatologic procedures, such as injection of local anesthetics, intralesional injections, biopsies, and excisions.
RECOMMENDATIONS
From the Department of Dermatology, The University of Texas Medical Branch at Galveston. Reprint requests: Zoltan Trizna, MD, PhD, Texas Tech University Health Sciences Center, Department of Dermatology, 3601 4th St, Lubbock, TX 79430. J Am Acad Dermatol 2001;44:520-2. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/74/110394 doi:10.1067/mjd.2001.110394
Work away from your hands. A sharp or pointed instrument pointing toward the surgeon’s own hand or toward the assistant’s hand (Fig 1) can easily lead to injury. Instruments should point away from the surgeon’s fingers (Fig 2). If stabilization is needed, pull the skin 180 degrees away from the lesion, parallel to the line of injection, with the nondominant hand (arrow in Fig 2 indicates the direction of force). Handle the tissue with instruments only. The surgical needle can injure the surgeon’s hand (Fig 3).
520
Fig 1. A dangerous method of percutaneous injection.
Fig 2. A safe method of percutaneous injection.
J AM ACAD DERMATOL VOLUME 44, NUMBER 3
Pearls 521
Fig 3. An unsafe method of placing a suture. Arrow points to area where the surgical needle is about to pierce the skin.
Fig 4. A safe method of suture placement.
Fig 5. An unsafe method of blotting. Arrow indicates suture needle below the fingers of the blotting hand.
Fig 6. A safe method of blotting. Arrow indicates surgical needle.
Avoid the use of fingers for supporting or stabilizing the tissues. A forceps can be used (Fig 4); alternatively, the free edge of the wound can be held in place by a small toothed forceps. Only one hand should touch a sharp or pointed instrument. The prototype of this risk is blotting when a suture needle or scalpel is in the surgical field (Fig 5). The surgeon and/or the assistant should not exercise a movement toward the same instrument at the same time (Fig 6). Use properly fitting gloves. Improperly fitting gloves create additional obstacles obscuring the surgical field. Various instruments can be caught by loosely fitting fingertips or creases of the gloves (Fig 7). Place all instruments on the tray so that they may be visually recognized at all times (Fig 8). A poorly organized surgical tray can generate a plethora of risks (eg, needles and sharp instruments covered by gauze pads). The haphazard placement of sharp and pointed instruments on the surgical tray is
very dangerous. All instruments on the tray should point away from the surgeon’s hand. Ideally, they should all point in the same direction. This way each of them can be picked up without touching another instrument. No unnecessary objects (eg, soiled gauze pads, needle sleeves) should be left on the tray because they can obscure the instruments. When an assistant is present, a neutral zone should separate the surgeon’s side of the tray from the assistant’s side. Handle removable pointed and sharp items with another instrument. Load the suture needle into the needleholder with forceps, and remove or replace scalpel blades with specially designed instruments. Do not recap needles. Recapping needles is very dangerous and is highly discouraged. Current Occupational Safety and Health Administration policy states that recapping of needles, in general, is not appropriate.9 In certain instances in which recapping is unavoidable, recapping is acceptable (eg, with a
522 Pearls
J AM ACAD DERMATOL MARCH 2001
Fig 7. Ill-fitting gloves. The left hand wears a glove too big; the right hand, holding the instrument, wears a glove that fits well.
Fig 8. A disorganized surgical tray. Various sources of danger can be identified: recapped needle and surgical needle (short arrow), curet (long arrow), and skin hook (open arrow).
self-sheathing needle), but should otherwise be avoided. The use of double gloves is controversial. Whereas most surgeons do not routinely use double gloves, both the size and type of the needle and the depth of penetration influence are related to the amount of the blood inoculum. Two gloves were more efficient than one glove at removing blood from all suture needles, including cutting needles.10 In a setting of aesthetic surgical procedures, the outer glove was perforated in 25.6% of cases, whereas the inner glove was perforated in only 10% of cases. Double gloving reduced the risk of exposure to blood by 70% when compared with single-glove use.11 Risk of exposure to body fluid because of glove manufacturing defects is likely diminished by double gloving because small glove defects are unlikely to exactly overlap. Against the routine use of double gloving is the potential loss of dexterity and discomfort. Some also argue that the potential loss of dexterity might result in more rather than fewer injuries. In our experience many surgeons adapt readily to double gloving after a few days. Blunt instruments could replace sharp instruments serving similar purposes. For instance, instead of skin hooks, forceps can be used.
HIV infected blood: the CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993;118:913-9. Raahave D, Bremmelgaard A. New operative technique to reduce surgeons’ risk of HIV infection. J Hosp Infect 1991; 18(Suppl A):177-83. Pietrabissa A, Merigliano S, Montorsi M, Poggioli G, Stella M, Borzomati D, et al. Reducing the occupational risk of infections for the surgeon: multicentric national survey on more than 15,000 surgical procedures. World J Surg 1997;21:573-8. TNA Facts page.Texas Nurses Association Web site. Available at: http://www.texasnurses.org/news/press/needle.html. Accessed Nov 28, 2000. Smoot EC. Practical precautions for avoiding sharp injuries and blood exposure. Plast Reconstr Surg 1998;101:528-34. Occupational Safety and Health Administration Standards Interpretation and Compliance Letters (06/20/1991). Requirements for recapping of needles. Available at: http://www. osha-slc.gov/OshDoc/Interp_data/I19910610.html. Accessed Nov 28, 2000. Bennett NT, Howard RJ. Quantity of blood inoculated in a needlestick injury from suture needles. J Am Coll Surg 1994; 178:107-10. Greco RJ, Garza JR. Use of double gloves to protect the surgeon from blood contact during aesthetic procedures. Aesthet Plast Surg 1995;19:265-7.
REFERENCES 1. Heald AE, Ransohoff DF. Needlestick injuries among resident physicians. J Gen Intern Med 1990;5:389-93. 2. Occupational Safety and Health Administration. Needlestick injuries. Available at: www.osha-slc.gov/SLTC/needlestick. Accessed Nov 28, 2000. 3. Gerberding JL. Management of occupational exposures to blood-borne viruses. N Engl J Med 1995;332:444-51. 4. Tokars JI, Marcus R, Culver DH, Schable CA, McKibben PS, Bandea CI, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to
5.
6.
7.
8. 9.
10.
11.
Direct all Surgical Pearl submissions to Dr Stuart J. Salasche, 5300 N Montezuma Trail, Tucson, AZ 85750.
Direct all Medical Pearl submissions to Dr Mark G. Lebwohl, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1048, New York, NY 10029.
Mark G. Lebwohl, MD Medical Pearls Editor
Surgical Pearl: Preventing self-inflicted injuries to the dermatologic surgeon Zoltan Trizna, MD, PhD, and Richard F. Wagner, Jr, MD Galveston, Texas
A
mong medical and surgical house staff, needlesticks are the most common injuries (74%), with an average frequency of 0.63 per resident-year among nonsurgical residents and 3.8 per resident-year among surgical residents.1 More than 20 pathogens can be transmitted by needlesticks, most frequently hepatitis B and C, as well as HIV.2 The average risk associated with occupational exposure to HIV through percutaneous injury is between 0.2% and 0.36% (ie, one seroconversion per 278 to 500 injuries).3,4 The calculated probability for a surgeon to acquire HIV infection over a 30-year period is between 0.3% and 5.82%.5 The cumulative 30-year risks of contracting hepatitis B and C viruses are 42.7% and 34.8%, respectively.6 The cost of follow-up for a high-risk exposure is almost $3000 per needlestick injury even when no infection occurs, whereas actual infection by blood-borne pathogens can add up to $1 million.7 There are several safety devices on the market, including face shields, fit-over glasses, punctureresistant surgical gloves, finger guards, glove liners, disposable surgical tray organizers, and sheathed needles. However, by improving personal exposure protection alone, the risk of exposure to blood and body fluids can be decreased by more than 70%.8 We have prepared a list of a few important recommendations based on situations repeatedly observed among medical students, interns, and residents performing outpatient dermatologic procedures, such as injection of local anesthetics, intralesional injections, biopsies, and excisions.
RECOMMENDATIONS
From the Department of Dermatology, The University of Texas Medical Branch at Galveston. Reprint requests: Zoltan Trizna, MD, PhD, Texas Tech University Health Sciences Center, Department of Dermatology, 3601 4th St, Lubbock, TX 79430. J Am Acad Dermatol 2001;44:520-2. Copyright © 2001 by the American Academy of Dermatology, Inc. 0190-9622/2001/$35.00 + 0 16/74/110394 doi:10.1067/mjd.2001.110394
Work away from your hands. A sharp or pointed instrument pointing toward the surgeon’s own hand or toward the assistant’s hand (Fig 1) can easily lead to injury. Instruments should point away from the surgeon’s fingers (Fig 2). If stabilization is needed, pull the skin 180 degrees away from the lesion, parallel to the line of injection, with the nondominant hand (arrow in Fig 2 indicates the direction of force). Handle the tissue with instruments only. The surgical needle can injure the surgeon’s hand (Fig 3).
520
Fig 1. A dangerous method of percutaneous injection.
Fig 2. A safe method of percutaneous injection.
J AM ACAD DERMATOL VOLUME 44, NUMBER 3
Pearls 521
Fig 3. An unsafe method of placing a suture. Arrow points to area where the surgical needle is about to pierce the skin.
Fig 4. A safe method of suture placement.
Fig 5. An unsafe method of blotting. Arrow indicates suture needle below the fingers of the blotting hand.
Fig 6. A safe method of blotting. Arrow indicates surgical needle.
Avoid the use of fingers for supporting or stabilizing the tissues. A forceps can be used (Fig 4); alternatively, the free edge of the wound can be held in place by a small toothed forceps. Only one hand should touch a sharp or pointed instrument. The prototype of this risk is blotting when a suture needle or scalpel is in the surgical field (Fig 5). The surgeon and/or the assistant should not exercise a movement toward the same instrument at the same time (Fig 6). Use properly fitting gloves. Improperly fitting gloves create additional obstacles obscuring the surgical field. Various instruments can be caught by loosely fitting fingertips or creases of the gloves (Fig 7). Place all instruments on the tray so that they may be visually recognized at all times (Fig 8). A poorly organized surgical tray can generate a plethora of risks (eg, needles and sharp instruments covered by gauze pads). The haphazard placement of sharp and pointed instruments on the surgical tray is
very dangerous. All instruments on the tray should point away from the surgeon’s hand. Ideally, they should all point in the same direction. This way each of them can be picked up without touching another instrument. No unnecessary objects (eg, soiled gauze pads, needle sleeves) should be left on the tray because they can obscure the instruments. When an assistant is present, a neutral zone should separate the surgeon’s side of the tray from the assistant’s side. Handle removable pointed and sharp items with another instrument. Load the suture needle into the needleholder with forceps, and remove or replace scalpel blades with specially designed instruments. Do not recap needles. Recapping needles is very dangerous and is highly discouraged. Current Occupational Safety and Health Administration policy states that recapping of needles, in general, is not appropriate.9 In certain instances in which recapping is unavoidable, recapping is acceptable (eg, with a
522 Pearls
J AM ACAD DERMATOL MARCH 2001
Fig 7. Ill-fitting gloves. The left hand wears a glove too big; the right hand, holding the instrument, wears a glove that fits well.
Fig 8. A disorganized surgical tray. Various sources of danger can be identified: recapped needle and surgical needle (short arrow), curet (long arrow), and skin hook (open arrow).
self-sheathing needle), but should otherwise be avoided. The use of double gloves is controversial. Whereas most surgeons do not routinely use double gloves, both the size and type of the needle and the depth of penetration influence are related to the amount of the blood inoculum. Two gloves were more efficient than one glove at removing blood from all suture needles, including cutting needles.10 In a setting of aesthetic surgical procedures, the outer glove was perforated in 25.6% of cases, whereas the inner glove was perforated in only 10% of cases. Double gloving reduced the risk of exposure to blood by 70% when compared with single-glove use.11 Risk of exposure to body fluid because of glove manufacturing defects is likely diminished by double gloving because small glove defects are unlikely to exactly overlap. Against the routine use of double gloving is the potential loss of dexterity and discomfort. Some also argue that the potential loss of dexterity might result in more rather than fewer injuries. In our experience many surgeons adapt readily to double gloving after a few days. Blunt instruments could replace sharp instruments serving similar purposes. For instance, instead of skin hooks, forceps can be used.
HIV infected blood: the CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993;118:913-9. Raahave D, Bremmelgaard A. New operative technique to reduce surgeons’ risk of HIV infection. J Hosp Infect 1991; 18(Suppl A):177-83. Pietrabissa A, Merigliano S, Montorsi M, Poggioli G, Stella M, Borzomati D, et al. Reducing the occupational risk of infections for the surgeon: multicentric national survey on more than 15,000 surgical procedures. World J Surg 1997;21:573-8. TNA Facts page.Texas Nurses Association Web site. Available at: http://www.texasnurses.org/news/press/needle.html. Accessed Nov 28, 2000. Smoot EC. Practical precautions for avoiding sharp injuries and blood exposure. Plast Reconstr Surg 1998;101:528-34. Occupational Safety and Health Administration Standards Interpretation and Compliance Letters (06/20/1991). Requirements for recapping of needles. Available at: http://www. osha-slc.gov/OshDoc/Interp_data/I19910610.html. Accessed Nov 28, 2000. Bennett NT, Howard RJ. Quantity of blood inoculated in a needlestick injury from suture needles. J Am Coll Surg 1994; 178:107-10. Greco RJ, Garza JR. Use of double gloves to protect the surgeon from blood contact during aesthetic procedures. Aesthet Plast Surg 1995;19:265-7.
REFERENCES 1. Heald AE, Ransohoff DF. Needlestick injuries among resident physicians. J Gen Intern Med 1990;5:389-93. 2. Occupational Safety and Health Administration. Needlestick injuries. Available at: www.osha-slc.gov/SLTC/needlestick. Accessed Nov 28, 2000. 3. Gerberding JL. Management of occupational exposures to blood-borne viruses. N Engl J Med 1995;332:444-51. 4. Tokars JI, Marcus R, Culver DH, Schable CA, McKibben PS, Bandea CI, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to
5.
6.
7.
8. 9.
10.
11.
Direct all Surgical Pearl submissions to Dr Stuart J. Salasche, 5300 N Montezuma Trail, Tucson, AZ 85750.
Direct all Medical Pearl submissions to Dr Mark G. Lebwohl, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1048, New York, NY 10029.