Why Do Surgeons Choose Scrub Over Rub For Surgical Hand Prep?

The combination of high altitude, dehydration and a microbiome that is totally disrupted by yak jerky and fermented yam milk can cause a man’s mind to drift back and truly recall the most buried, obscure and meaningless memory in the recesses of one’s mind.

That is what happened to me. Still waiting for my next time with the Bari Tass, I started delving into the deepest cranial recesses and a vision came to me. There he was, standing at the scrub sink in our center, preparing for his first case at our surgical center. I had had him as a first-year student and now some seven years later, he was the real deal -- credentialed and all -- doing surgery. I remember how I was proud of him and at the same time stunned at how that time from academic infancy to adult doctor passed at warp speed.

That is when it happened. He did the unspeakable.

Yep, he pulled that silver packaged povidone-iodine surgical scrub brush down from the shelf above the sink, opened it slowly and hit the water switch with his knee. Internally, my Tourette’s storm shrieked louder than little Danny McGee did when we got him to pee on an electric fence out at the farm when we were in first grade. (He was a city kid who we liked to take advantage of.) Reining in my utter disgust in the fact that our new surgeon apparently forgot everything we taught him in his first surgery class and simultaneously biting down on a litany of expletives, I reached in front of him and pumped a couple of generous squirts of Avagard (3M) hand sanitizer into my palms.

“Why are you doing that?” I asked while rubbing around the mixture I had just squirted into my hands.

He looked at me sheepishly and said exactly what I expected him to say: “Because that’s the way they did it at my residency.”

Invariably, that is always the answer for a surgeon we question about something he or she is doing. Rarely is it: “Well, I was trained to do it another way but after reading the current science, I realized I could actually do it better if I shifted my paradigm.” He sputtered and stammered for a couple of seconds before telling me he did remember what I had taught him back in the day.

He told me studies had shown that surgical hand rubbing had immediate and longer lasting efficacy in comparison to surgical hand scrubbing, and in fact was more economical for the institution.¹ I knew this “kid” was smart but he then blew me away by citing an obscure urological study that showed improved but not scientifically significant efficacy against infection when comparing Avagard and hand scrub (2/1,800 cases in comparison to 3/1,800 cases) in urological procedures.² More importantly, this study made the recommendation that Avagard is a huge time saver and cost-effective.

“Right on, my man,” I congratulated him. But now as the professor I am, I had to pull out my academic six-shooter as I could not let this newbie outdo me. Trying my best to summon a real academic sounding tone from my totally disrupted microbiome, I had to add this comment. “Additionally, as Huynh published in 2002, surgical hand scrubbing is actually hazardous for the surgeon as it does nothing but damage the barrier function of your skin and can potentially set you up for irritant dermatitis and latex sensitization.”³

Now the young gunslinger was reeling backward from my shots from the hip and I had to go in for the kill. Pity we were at the scrub sink and not out on the dirt main street of Dodge City back in the 1850s with curious onlookers. Anyway, I popped another round into his leather chaps with blink of the eye speed (150 milliseconds for you trivia buffs). “Not only is surgical hand rubbing better economically but it has higher antimicrobial effects as measured by glove juice,” I added.⁴

“Glove juice,” he scoffed. “You must be making that up.”

“No sir, that is in the literature,” I assured him. “You slap those gloves on after a 10-minute scrub with an interrupted epidermis, not to mention bringing all that bacteria up to the surface that had been comfortably and safely ensconced deep down in your hair follicles, do a 30-minute procedure and then pull the gloves off. There’s your ‘microbe-laced glove juice.’”

Lying and writhing in the dirt of Main Street, riddled with bullet holes, I had to get his dying words on why he chose scrub over rub. “Context,” he said as the last breath went out of him.

“Context,” I said to myself as I busted through the saloon door (really the OR door but that doesn’t fit into the story or context right now) with a swagger in my scrubs. Context, folks, is sadly stronger than science in many ways.

I have no financial interest in Avagard or 3M. However, if they ever get an Avagard warmer for those cold ORs, I want a cut of that action.

References

1.      Tavolacci MP, Pitrou I, Merle V, Haghighat S, Thillard D, Czernichow P. Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs. J Hosp Infect. 2006; 63(1):55-59.

2.      Weight CJ, Lee MC, Palmer JS. Avagard hand antisepsis vs. traditional scrub in 3600 pediatric urologic procedures. Urology. 2010; 76(1):15-17.

3.      Huynh NT, Commens CA. Scrubbing for cutaneous procedures can be hazardous. Australas J Dermatol. 2002; 43(2):102-104.

4.      Grabsch EA, Mitchell DJ, Hooper J, Turnidge JD. In-use efficacy of a chlorhexidine in alcohol surgical rub: a comparative study. ANZ J Surg. 2004; 74(9):769-772.