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Painting In The OR: The Evolution Of Surgical Preparation

Tue, 09/17/2013 - 10:02am
David Gelber, M.D.

One would never guess that a frequent activity in the OR is painting. I’m not referring to the application of paint to the walls of a room or house. The painting I’ve seen is limited to the patient and his or her body parts.

I suppose the first application of “paint” would be the initial scribble placed by the surgeon, marking the surgical site. This is a relatively new requirement and is so simple and makes so much sense I’m surprised anyone actually thought of it. The rationale behind this “signature” is that if the surgeon and the patient agree that the hernia, or fractured hip or lipoma is on the right or left or in a certain spot, then wrong site surgery will be eliminated. And, it really does work.

Beyond this, however, and in line with real painting is the OR prep, the act of applying antiseptic solution to the surgical site. This liquid, which goes by a variety of names which may sound antiseptic such as Chloraprep or Betadine, or magical like “Merlin” or perpetual such as “Duraprep” or merely utilitarian, Hibiclens, is applied by the circulating nurse before the patient is draped and the surgery commences. Its purpose is to kill all microorganism which may be residing on the patient’s skin and to continue its destructive ways as long as the case goes on.

Over the years the technique for applying this agent has evolved. In medical school I think the teaching was fairly well standardized. Every surgery I recall from those days started with a ten minute scrub of the site with Betadine soap. This was followed by the application of Betadine solution, which was different from the scrub. It did not contain any soap and was designed to stay on the patient for the entire case. It was always applied in standard regimented fashion.

The nurse would start in the middle of the surgical field and “paint” it on, starting as a small square (and always a square) around the umbilicus and then move out farther from the center with a larger square and then larger and larger until the entire field and a large distance beyond was coated in this yellow-brown covering. Then the painting process was repeated. For an abdominal surgery the area painted usually ran from nipples to knees.

Times change, preps change and painting techniques change. Modern self expression now allows the circulating nurse free reign to demonstrate his or her creativity in the surgical prep area. Of course, the prep material is now more varied. The drab yellow brown of betadine still is a staple of the surgical prep armamentarium, but is often supplanted by the orange or blue green of Chloraprep, the yellow of Duraprep, or pink or white of Hibiclens. The prep consistency ranges from the watery betadine solution to the thick gel found in Prevail.

However, beyond color and consistency, the actual painting technique has evolved. Square painting still is common, but circles are more common. Bold straight lines, vertical or horizontal are also commonplace. The most creative nurses will squeeze the prep fluid out as a squiggle of continuous lines, then meld them together as a “Z” or “W”, before completing the prep by filling in any unpainted areas.

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