CE Credit Package 6 12 Credits for $1900

Please submit your completed Master Answer Sheet along with payment to AST Member Services 6 W. Dry Creek Circle, Suite 200 Littleton, CO 80120 Or fax with credit card information to (303) 694-9169. Or scan and e-mail with credit card information to [email protected]. Table of Contents CE Credit Package 6

Ethics in the O.R., Part 1

Ethics in the O.R., Part 2

Safety Concepts in the Surgical Setting

Necrotizing Faciitis

Disasters Follow No Rules

Gangrene: Recognizing and Treating Cellular Necrosis

Ethics in the O.R. Setting: The Other Side of Professional Practice

by Ann Marie McGuiness, CST, MSEd, CNOR

PART 1 n today’s health care practice, technological advances permit the use of interventions and advanced practices that have blurred what once were clear lines of distinc­ I tion between life and death, and between treatment and Editor’s Note: This article will be contin- non-treatment. There was also clear division between medi­ ued in next month’s issue. e author will cal decisions dictated by the physician “for the good of the complete her discussion of medical ethics patient” as opposed to patient-directed care. Today’s health by providing practical examples of ethical care consumers are better educated and often knowledge- situations that surgical technologists may able about the various treatment options available to them. face in the operating room. While these advances have improved the overall quality of health care and have extended the normal lifespan, accom­ panying these changes are the issues of a lack of inexhaust­ ible resources to support these costly treatments and equita­ ble access to these sometimes limited resources. From these dilemmas has risen the field of health care ethics. An ethical dilemma arises when there is no clear-cut right or wrong solution or where there is a no-win situation for all parties involved. It is important, therefore, that the surgical technologist has a working knowledge of what health care ethics entails, some of the considerations that need to be eval­ uated when making ethical decisions, and some of the more commonly encountered ethical situations found in today’s medical and/or surgical setting.

JUNE 2006 The Surgical Technologist 13 270 JUNE 2006 1 CE CREDIT

De nitions ber of individuals within society. Under the prin­ Ethics, in general, is the field of philosophy that ciples of utilitarianism, the need to spend resourc­ studies the morality of human conduct. It is the es on developing vaccines against communicable science of morals: the philosophic and spiritual diseases would take precedence over the expense disciplines that systematically examine the val­ of providing medical support and resources to ues of good or bad, right or wrong, and justice or one patient in need of a liver transplant. injustice in human conduct. Ethics also involves Deontologists believe that decisions should be the study of the cultural, religious, and profession­ based on a moral obligation to each member of al impact of these values on society. In the health society, regardless of the impact to the group as a care field, ethical and moral principles provide the whole. Deontology uses the principle of autono­ basis for the development and implementation of my, or self-rule, and supports the patient’s right professional standards, such as the Association of to self-determination. Using the previous exam­ Surgical Technologists’ Standards of Practice and ple, a deontologist would view the rights of the the AST Code of Ethics (see page 15 ). patient to have access to the care and procedures required to perform a liver transplant equally as important as the right to access vaccines to pre­ vent disease. The deontologic approach is the guiding principle most commonly used in health The deontologic approach is the care practice in the United States today, where we see virtually open access to medical care for guiding principl e most commonl y used all individuals, regardless of any obstacles relat­ in heal th care practice in the United ed to that access. Primary bioethical principles in health care States today, where we see virtually The health care profession, by its nature, is a car­ ing profession, dedicated to assisting patients open access to medical care for a ll in attaining and maintaining an optimal level of wellness. The care provided by health care individual s, regard l ess of any obstacl es practitioners is commonly guided by two basic principles. Today, these two bioethical princi­ related to that access. ples continue to be used to establish criteria for evaluating and implementing all other bioethi­ cal decisions.

Clinical medical ethics is the discipline that Benecence provides a systematic and structured approach The principle of beneficence is the first over­ to identifying, analyzing, and resolving the ethi­ riding and compelling paradigm utilized for cal problems of a particular patient population. determining patient care in the surgical set­ The most common guiding principles used to ting. The principle of beneficence upholds that formulate ethical views today involve the con­ all interventions should ultimately benefit the cepts of utilitarianism versus deontology. patient and that the intent of any action under­ Utilitarianists, also referred to as consequen­ taken on the patient’s behalf has the overall goal tialists or teleologists, believe that the good of of helping the patient more than causing harm. society outweighs the benefit to any one individ­ The action should promote good and prevent or ual. They judge the “rightness or wrongness” of a remove evil. In medicine, rarely is any interven­ decision based upon the predicted outcome that tion totally beneficent. There are generally some what is right is also beneficial to the greatest num­ negative consequences associated with most

JUNE 2006 14 The Surgical Technologist actions, such as the pain associated with starting decisions based on the provision of valid and an intravenous line to administer pain medica­ pertinent information determined without con­ tion or the making of a surgical incision to access straints or coercion, the power to have those deci­ a diseased organ. While the overall outcome of sions supported and implemented by caregivers, the actions is positive, the patient will have to and the expectation that the decisions that have undergo a pain-inducing procedure as one step been determined will be respected and carried in the pain-relief process. out by the caregivers to the best of their abilities. In 1972, the American Hospital Association Non-malecence (AHA) published the Patient’s Bill of Rights. This The principle of non-maleficence is the second document supports and enforces the right of the overriding and compelling paradigm used as patient to access respectful care, to obtain accu­ the basis for all patient care. The overall goal rate information, to be provided with continuity of any medical or surgical intervention should of care, to have confidentiality maintained, and be to do no harm or that any harm done should to have the right to self-determination. not outweigh the overall benefit to the patient. The creation of a surgical incision, outside of the operating room setting and without the patient’s informed consent, would constitute assault and AST CODE OF ET H ICS battery with a dangerous weapon. The incision, though, is an integral step in the removal of an L To maintain the highest standards of professional abscessed appendix. Failure to remove the dis­ conduct and patient care eased appendix would cause greater harm than L To hold in confidence, with respect to patient's beliefs, that caused by the surgical incision and subse­ all personal matters quent removal of the pathology. L To respect and protect the patient's legal and moral right Secondary bioethical principles in health care to quality patient care Prior to the 1970s, the focus of health care was on the preservation of life, no matter the cost. L To not knowingly cause injury or any injustice to those The paternalistic model of physician as both care entrusted to our care provider and “sage” has given way to consumer L To work with fellow technologists and other demands for the right to self-determination in professional health groups to promote harmony and regard to health care. Technological advances unity for better patient care have permitted the extension of “life” beyond the limits of a quality existence, and the dilem­ L To always follow the principles of asepsis mas resulting from this situation have spawned L To maintain a high degree of efficiency through the field of bioethics, including the identification and consideration of the secondary bioethical continuing education principles that impact the delivery of health care L To maintain and practice surgical technology willingly, in today’s society. with pride and dignity

Autonomy L To report any unethical conduct or practice to the The principle of autonomy, or self-determina- proper authority tion, states that a competent person has the right L To adhere to the Code of Ethics at all times in to determine the course of his or her medical relationship to all members of the health care team care, even when that choice is viewed as negative or “unacceptable” and may even result in death. This determination includes the ability to make

JUNE 2006 The Surgical Technologist 15 Under the AHA Patient’s Bill of Rights, the access to health care in the US is not complete­ patient has the right to make decisions regard­ ly equitable. Factors such as urban living versus ing the nature and extent to which interventions suburban living, the cost of health care, medi­ will and will not be performed. These decisions cal technology resources, and medical personnel are based on factual information usually provid­ resource limitations impact the concept of equi­ ed during the course of obtaining informed con­ table health care for all. The recent focus on the sent. Informed consent should be obtained when desire to implement a national health care system the individual is able to sort through informa­ to provide a more equitable distribution of medi­ tion and options in a logical and rational man­ cal resources is an attempt to provide greater jus­ ner. These “rights” also carry over into periods of tice and equity to health care consumers. time when the patient may be incapable of ver­ balizing and monitoring those decisions, such as Morality Morality refers to that part of human behavior that can be evaluated in terms of right and wrong. In relation to ethics, morals are the behaviors demonstrated by the professional group that Assessing the needs of the patient support ethical behavior and practice. Morals are the values about what is good, right, and just. and supporting them in a manner that They are developed based upon the belief system adopted through cultural, religious, or profes­ shows caring and respect are actions sional beliefs and values. Common morality is the communal consensus of a society or culture that are as much a part of the j ob regarding norms of human conduct and human rights. Within health care, there are various pro­ description of a surgical technologist as fessional groups who share a core moral code of support for the patient along with the four basic are scrubbing, gowning, and gloving. principles of ethics – as beneficence, non-malefi- cence, autonomy, and justice.

Moral guides in health care during a surgical intervention. It is during these Condentiality periods, when the patient is unable to speak for The concept of confidentiality involves the main­ himself and the invocation of a living will or tenance of patient privacy. During the course of durable power of attorney is instituted, that the care delivery, it is critical that the staff have access principle of autonomy must be safeguarded and to patient information. Knowing that a patient support for the patient’s decisions regarding care has a history of drug abuse may impact the types must be honored. of anesthetics and postoperative pain medica­ tions used for this patient. Other, less necessary, Justice information may also be included in the medical The principle of justice refers to the concepts of record accessible by the health care staff, such as a equity and fairness. In today’s democratic soci­ prior suicide attempt by a patient during adoles­ ety within the United States, each person is enti­ cence that has subsequently been resolved. tled to equal access to health care, regardless of The professional surgical technologist has a such variables as social status or ability to pay for moral obligation to the patient to treat any per­ such services. While in principle justice is a wor­ sonal information as “privileged” information thy goal, today’s health care crisis has been pre­ to be used only in the direct care of the patient. cipitated, to a degree, by this concept. In reality, Student surgical technologists also need to be

JUNE 2006 16 The Surgical Technologist aware of the importance of maintaining patient ethical view. Instead, you have an obligation to confidentiality in the preparation of education­ notify your supervisor or nurse manager of the al journals, when sharing information during issue in a timely manner, so that substitutions clinical seminars, and during other education­ in scheduling can be made to accommodate the al situations. While it is permissible to discuss needs of the patient. procedures and patient issues with instructors and fellow classmates under the domain of edu­ Integrity and veracity cation, for the purposes of learning, it is impor­ Integrity, the practice of being honest, and tant that patient confidentiality be addressed veracity, the act of telling the truth, are impor­ and maintained. tant moral tenets in the health care profession Copies of patient documents should have and are mutually supporting. A positive rela­ the patient’s name and identifying informa­ tionship needs to exist between the patient and tion removed or disguised. The patient should the health care practitioners in order for optimal be referred to in a “generic” fashion, eliminat­ wellness to be achieved. Patients must be will­ ing the use of patient names. Journaling should ing to enter into a trust relationship with people contain factual information, such as “the patient whom they do not know intimately. They must was a 39-year-old female who presented with feel “comfortable” in entrusting these individ­ the diagnosis of pelvic pain…." All informa­ uals with the information and feedback needed tion obtained during the course of externships to guide their care during the critical time and or clinical seminars must be held in confidence. events surrounding a surgical intervention. The Discussing details of surgical cases without the professional health care practitioner must be intent to educate or provide care for that patient willing to foster and support the development of is a breach of confidentiality. This breech can such a relationship by providing accurate infor­ give rise to legal action on the grounds of inva­ mation during the process of informed consent sion of privacy. without overwhelming patients and by demon­ strating a caring and respectful attitude toward Fidelity and loyalty them and their decisions regarding care. Profes­ Fidelity and loyalty both involve the act of sional moral conduct compels health care pro­ promise-keeping on the part of the health care fessionals to provide patients with information practitioner. Every profession has a scope of and care that is both accurate and truthful in practice that governs those procedures and nature and with treatments that promote well­ responsibilities assigned to each team member. ness and well-being. Some of these responsibilities overlap between professional groups, but professional codes of Respect for persons and for the sanctity of life ethics dictate that health care practitioners, Aeger primo, the patient first, andPrimum non in general, support the desires of the patient, nocere, first—do no harm, are basic tenets of regardless of personal views or opinions. When health care in general and the profession of sur­ a practitioner can not support a patient’s per­ gical technology specifically. The focus of many sonal decision regarding medical care, the surgical interventions is primarily therapeutic, practitioner has an obligation to provide a sub­ providing a cure for disease or illness. There are stitute caregiver. also procedures in which the focus is either pal­ This precedence is seen today in the oper­ liative, a procedure performed to provide bet­ ating room when a patient chooses to undergo ter quality of life without curing the disease, or elective termination of a pregnancy. If personal interventive, a procedure performed to halt the views are not supportive of this procedure, you, progression of a process. Whether therapeutic, as a professional, can not simply choose to aban­ palliative or interventive in nature, the overall don a patient who does not share your moral or intent of any procedure should be to assist the

JUNE 2006 The Surgical Technologist 17 patient in achieving a desired quality and quan­ Compassion and solidarity tity of wellness through the means determined (respect for community) by the patient to be in his or her best interest. Compassion and solidarity are moral principles that address equity of care, regardless of whom The Golden Rule (the rule of reciprocity) the patient is or the patient’s life circumstances. “Do unto others as you would have done unto Compassion, the desire to alleviate patient dis­ you” is an excellent guideline for health care tress, and solidarity, the desire to deliver qual­ practitioners to use when determining moral ity, professional patient-centered care regard­ ethical practice. How would you want to be less of other intervening variables, are desirable treated? Would you want the surgical team qualities commonly identified in health care members to focus on you lying on the operating providers. The homeless person deserves the same consideration and level of care as does the CEO of a giant corporation. The moral prin­ ciples of compassion and solidarity erase dis­ crimination based on anything other than the The recent focus on the desire to urgency of the patient’s medical condition and the team’s ability to act in a professional man­ impl ement a national hea l th care system ner to assist the patient in returning to an opti­ to provide a more equitabl e distribution mal level of wellness. Professional integrity, honesty, and e!ciency of medical resources is an attempt to The surgical patient has every right to expect and receive high-quality care from those profes­ provide greater j ustice and equity to sionals who make up the surgical team. Patients are in a most vulnerable position during surgi­ heal th care consumers. cal intervention, and they may place blind faith in the skills and knowledge of those caring for them. The surgical technologist, then, has the obligation to provide the highest level of patient room bed, or would you want to hear about “last care possible. Patients have the right to know night’s date” or “the fight so-and-so had with that each and every team member will advocate their spouse this morning”? Would you want to for them when they are unable to advocate for be denied information because the team thought themselves. This requires that the O.R. team be you couldn’t handle it? We would be appalled if knowledgeable and supportive of the needs and treated in such a manner; yet one can find just issues of each surgical patient. This advocacy such behavior occurring daily in operating can take many forms, from providing protec­ rooms across the country. tion and a safe environment in which the surgi­ Patients entrust the health care practitioner cal intervention can take place, to ensuring that with their care, in some cases their very lives. competent individuals provide care. If the sur­ Practitioners, in turn, have a professional and gical technologist on a procedure is unfamiliar moral obligation to fulfill that duty to the best of with the equipment being used, the tech with the their abilities. Assessing the needs of the patient knowledge base has the duty and obligation to and supporting them in a manner that shows remain scrubbed for as long as the equipment is caring and respect are actions that are as much a in use. Just because it is 3 pm and time for relief part of the job description of a surgical technolo­ does not mean that the surgical technologist can gist as are scrubbing, gowning, and gloving. leave a patient in the care of someone who does not have the proper knowledge base. The sense

JUNE 2006 18 The Surgical Technologist of professional integrity possessed by health care About the Author practitioners in the surgical setting mandates Ann Marie McGuiness, cst, msed, cnor, is pro­ that they stay and care for the patient. gram director of the surgical technology pro­ gram at Lock Haven University—Clearfield Currency Campus in Clearfield, Pennsylvania, offering Currency in one’s knowledge base is the respon­ both campus-based and on-line entry-level sur­ sibility of each and every surgical technologist. gical technology education (www.lhup.edu). She The operating room is an area where the knowl­ has been a Certified Surgical Technologist since edge base is extremely dynamic, changing some­ 1977. Ann has presented at numerous forums, times as frequently as every three months. While workshops and conferences and has served on the basics of practice stay relatively unchanged, various committees for AST, ARC-ST and LCC­ the introduction of new technology and methods ST, where she currently chairs the LCC-ST Exam demands that the O.R. team undertake continu­ Review Committee. ous education to stay abreast of these changes. The surgical technologist owes the maintenance References of a current and solid knowledge base to them­ 1. Caruthers B. Surgical Technology for the Surgical Tech selves, the team, the profession, and most impor­ nologist: A Positive Care Approach. 1st ed. Albany, NY: Delmar; 2000. tantly, the patient. 2. Edge RS, Groves JR. Ethics of Healthcare: A Guide for Clinical Practice. 3rd ed. Clifton Park, NY: Thompson Surgical conscience Delmar Learning; 2006. During the course of any surgical case, there are 3. National Council on Ethics in Human Research. Facil­ multiple opportunities for undetected errors to itating Ethical Research: Promoting Informed Choice occur. “No one is looking…” or “No one called [communique]. Available at: http://ncehr-cnerh.org/english/ consent/consente.htm#s!a. Accessed May 4, 2006. it…” are empty platitudes to keep a surgical tech­ 4. Phillips N. Berry & Kohn’s Operating Room Technique. nologist who does not possess a strong sense of 10th ed. Philadelphia, Pa: Mosby; 2004. surgical conscience from feeling “guilty” when 5. Fuller J. Surgical Technology: Principles and Practice. breaks in aseptic technique occur or errors are 4th ed. Philadelphia, Pa: Elsevier; 2005. made. Unfortunately, these sayings are erro­ 6. Hwang A. Confounding Gender: Hermaphrodites and neous in that the person who made them has, the Medical Establishment [review]. MSJAMA. Oct 6, 1999.Availableat:http://members.cox.net/fbsi/hermaphrodites. indeed, identified that an error has occurred and html. Accessed May 5, 2006. has gone uncorrected. Again, the standard of the 7. Rothrock J. Alexander’s Care of the Patient in Surgery. “significant other” needs to be the moral guide 12th ed. Philadelphia, Pa: Mosby; 2003. of the surgical technologist – if that happened to 8. Seekingpatients’consent:theethicalconsiderations.Feb- someone you loved, would you find that behavior ruary 1999. Available at: http://www.gmc-uk.org/guidance/ acceptable? Despite the aggravation, the added library/consent.asp. Accessed May 4, 2006. 9. Sexuality: Gender Identity. Available at: ht tp://w w w. efforts, or the extra work required to remedy the emedicine.com/ped/topic"$%&.htm. Accessed May 5, 2006. issue, being able to “look in the mirror with your 10. Standards of Care: The Hormonal and Surgical Sex head held high” is the standard of care the pro­ Reassignment of Gender Dysphoric Persons. Avail­ fessional surgical technologist should deliver in able at: w ww.moss-fritch.com/standard.htm. Accessed May each and every instance. 5, 2006. 11. The American Heritage® Dictionary of the English Language. 4th ed. Houghton Miff lin: Boston, Mass; 2000. Available at: w ww.bartleby.com/'!/. Accessed May 4, 2006. 12. Transgender Health. Available at: www.gayhealthchannel. com/transgender/surgery.shtml. Accessed May 5, 2006.

JUNE 2006 The Surgical Technologist 19 Ethical Conflicts in the O.R. Setting

by Ann Marie McGuiness, CST, CNOR, MsEd

PART 2 n the operating room, the surgical technologist is primarily involved with assisting the patient in undergoing a therapeutic intervention to remove Ior correct a pathology. Providing the surgical tech­ Editor’s Note: This article is the second nologist with an opportunity to investigate and exam­ of two parts. The first half of this arti• ine some of the ethical issues that can and do occur in cle appeared in last month’s issue of The the operating room allows the examination of one’s Surgical Technologist. In that issue, the personal value system in relation to the moral and ethi­ author presented an in-depth, comprehen• cal positions commonly espoused in today’s health care sive overview of the bioethical principles, profession. While these values may differ, it is impor­ morals, and ethics that form the founda• tant that the surgical technologist be able to embrace tion of our health care system. the values of health care and be willing to support the In this issue, the author continues this patient and surgical teams in ways that conform to discussion with practical examples of ethical established societal norms. con!icts that surgical technologists may face. The list of ethical issues in health care expands on a daily basis. Technology has provided the means to extend the life cycle beyond points that were once thought to be finite. People are able to survive under conditions that previously would not have support­ ed life. Along with these incredible and far-reaching changes have come many challenges to beliefs and prac­ tices that were previously clear-cut.

JULY 2006 The Surgical Technologist 17 271 JULY 2006 1 CE CREDIT

When faced with an ethical dilemma, there purpose of this section of the article is to briefly are two approaches commonly used to deter­ touch on ethical topics that may be encountered mine the best options for that given situation. when practicing in the surgical setting. It is also Under the utilitarianism system of ethics, one designed to assist you in examining the ethical would describe the issue, list the possible solu­ issue and assessing the potential impact that a tions, and then choose the solution that benefits scenario involving this topic would have on you the greatest number of people. Under the deon­ and your practice. Each topic, in and of itself, tological system of ethical decision-making, one contains many more facets and details than can would describe the problem, list the solutions, be contained in this article. Additional research and review may be required to clarify the con­ cepts and concerns that should be considered when making ethical decisions.

It is important that the surgical Elective abortion Elective abortion involves the deliberate termi­ technologist be abl e to embrace the nation of a pregnancy without medical indica­ tion. In the United States, first trimester (within values of heal th care and be will ing to the first 13 weeks of pregnancy), second trimes­ ter (between the 14th and 27th weeks of preg­ support the patient and surgical teams nancy), and even third trimester abortions are available upon request by the pregnant female. in ways that conform to establ ished In some states, minors may also obtain elective abortion without parental consent. societal norms. First trimester abortions are performed by dilatation and curettage. The cervix is dilated, and a vacuum curette is used to evacuate the products of conception. Second trimester abor­ and compare the solution with the underlying tions involve either the dilation of the cervix principles of self-autonomy and self-determina- and evacuation of the products of conception tion. Patients would base their decisions on their or the injection of concentrated saline solution needs, desires, and requests, regardless of any into the amniotic sac, causing fetal death and external factors or impact on others. expulsion of the products of conception. Third Both of these approaches have benefits and trimester abortions are commonly performed drawbacks when applied to any given situation. as dilation and extraction, where the fetal body A combination of both approaches, with the is delivered, with the exception of the head. application of the concept of the reasonably pru­ A sharp object is inserted into the back of the dent person—that action that another practitio­ fetus’ head, and a vacuum tube is used to extract ners of equal education and preparation would the brain. The remainder of the fetal tissues is undertake in the same situation under the same then delivered. circumstances, is used in the health care pro­ The ethical debate over elective abortion fession to establish recommended standards of hinges on what individuals determine to be practice in ethical situations. the fetal “point of viability”—that point in fetal The following summary of ethical conflicts development when a fetus can live independent­ that the surgical technologist may encounter ly of the mother, albeit with outside technical during practice is by no means comprehensive support. Many health care practitioners feel that or exhaustive. Each clinical practice site will viability is not reached until 20 weeks of gesta­ present its own unique ethical challenges. The tion and is questionable up until the 27th week

JULY 2006 18 The Surgical Technologist of gestation. Others feel that life begins at con- or female patient. Male patients usually elect to ception and that any unnatural act that forces undergo vasectomy, the removal of a segment of early death or delivery of the fetus constitutes the vas deferens, effectively preventing the migra­ murder. The ethical debate becomes complicat­ tion and ejaculation of sperm during sexual inter- ed by today’s technology, where neonatal inten­ course. For the female patient, sterilization can be sive care units daily address the issues of prema­ achieved through occlusion of the fallopian tubes, ture infant survival for infants as young as 22-24 removal of the ovaries, or removal of the uter­ weeks of gestational age. us. The basic underlying principle of all of these Surgical technologists need to examine their methods is the prevention of contact between ethical positions on elective abortion prior to sperm and ova, thereby preventing conception. employment. Many institutions offer staff the Tubal occlusion and/or vasectomy, while not option of not participating in elective abortions, foolproof, are highly effective methods of birth provided that there is alternate staff available to control. Some religions, though, view any arti­ provide services to the patient. The performance ficial interference with procreative abilities to be of elective abortions and the ability to choose morally wrong. elective participation are issues that are best dis­ On rare occasions, a court-ordered steril­ cussed during the job interview process or prior ization may be performed as part of a judgment to accepting a position as a surgical technologist. in a legal case. The patient may not consent to

Therapeutic abortion Therapeutic abortions are those semi-elective pro­ cedures performed to ter­ minate a pregnancy when t he continuat ion of t he pregnancy has a signifi­ cant potential of leading to maternal injury or death. Many of these abortions are performed during the second and third trimes­ ters of pregnancy. The eth- ica l considerations sur­ rounding these abortions may be different from those of elective abortion, in that the risk to the mother may provide moral support to prac t it ioners, suppor t­ ing their performance and participation under these types of circumstances.

Elective sterilization Elective sterilization is a procedure that can be per­ formed on either the male

JULY 2006 The Surgical Technologist 19 the procedure or may not be deemed competent to make decisions regarding self-determination.

Arti!cial fertilization Today’s modern reproduc­ tive technology allows for the fertilization of stored human eggs, sperm, and embryos, with subsequent implantation into a uter­ us for growth and devel­ opment for the purpose of establishing a pregnancy. Genetic coding may soon permit us to manipulate human genes and change the course of human evolu­ tion by eliminating genet­ ic diseases. Ironically, this technology also permits the conception of a “designer baby”—one with desirable features and attributes economic resources, should this procedure only selected from a “pool” of embryos. be available to those who can afford to pay for IVF, in vitro fertilization, involves the use of these services, or is every person entitled to expensive medications and interventions. In the avail themselves of this technology? Is the right face of rising health care costs and dwindling to bear a child, regardless of the cost to soci­ ety, more compelling than the more equitable allocation of monetary resources to meet basic health needs?

In the face of rising heal th care costs Human experimentation Each day, in operating rooms throughout the and dwindl ing economic resources, United States, experimentation on humans is occurring. While non-human trials of new shoul d in vitro ferti l ization on l y be medications and medical devices are undertak­ en before human trials are permitted, the actual availabl e to those who can afford to outcome and long-term consequences of the use of these investigational agents remain unknown pay for these services, or is every until in vivo human testing is done. In the 1980s, one example involved the implantation of intra­ person entitl ed to avai l themse l ves of ocular lenses (IOLs), which were used to correct blindness caused by surgical aphakia. Patients this technology? had to sign special consent forms, and follow-up documentation had to be submitted to the FDA following the implantation of each of these devic-

JULY 2006 20 The Surgical Technologist es. It was only through human trials that the need without the financial means to pay for it? While to redesign lenses with laser ridges and to place the buying and selling of organs is illegal in the lenses in the posterior rather than anterior cham­ United States, there are countries that will sell ber was identified and verified. The knowledge organs on the black market. Will genetic engi­ and insight gained from these early“experiments” neering permit the “growth” of human organs permitted modification of designs and materials, for transplantation? And if so, can society afford permitting a wider application of this technology to support a population that will demand a sig­ to a greater number of candidates. Without the nificant portion of allocated health care dollars? “human” factor, this information may not have been detected as rapidly or effectively. Is it ethical, Substance abuse/recreational drug use then, to use humans as “guinea pigs”? While it is acknowledged that the operating room is a high-stress environment in which to Animal experimentation work, and that health care practitioners are sus­ Monkeys, pigs, and mice have all been used to pre­ ceptible to alcohol and drug abuse, an impaired dict the effect of products, devices, and concepts practitioner has no place in a critical care set- for use in the human body. While some people condone the use of animals for experimentation and learning, at what point does experimenta­ tion become animal cruelty? The administration of lethal doses and pouring toxic levels of sub­ Whil e some peop l e condone the use of stances into delicate animal tissues have all been performed in the name of scientific progress. Yet animal s for experimentation and lives are saved daily by the knowledge gained by performing experimental surgeries on animals, learning, at what point does experimen­ many of whom die as a consequence of testing. tation become animal crue l ty? Organ donation/transplantation The technology to support organ transplanta­ tion has developed dramatically to the point where many organs can now be successful­ ting. Even recreational use of these substances ly transplanted from donor to recipient. The will lead to behavioral issues, such as avoidable demand for organ donations far exceeds the errors and poor decision-making. Professional supply. The resources, both fiscal and tangi­ ethics dictate that practitioners be free of chemi­ ble, needed to support one transplant patient cal substances that could impair judgment or are significant. The procedure, in and of itself, functioning. is costly, let alone the medical follow-ups and The operating room also presents opportuni­ the lifetime supply of anti-rejection medica­ ties for the procurement of controlled substances. tions required. Anyone who has received a kid­ While controlled substances are usually secured, ney, liver, heart, lung, or pancreas tells of the there exists opportunities for health care work­ “double-edged sword”—death is exchanged for ers to obtain controlled substances illegally. This a life of chemicals used to keep the implanted procurement is both illegal and immoral. organ from being destroyed by the body’s own While “whistle blowing” can lead to personal immune system. repercussions, the surgical technologist has an Another area of controversy surrounding the obligation to report known substance abuse. The ethics of organ transplantation is the determina­ duty of non-maleficence states that decisions tion of who will receive the organ. If you can pay must be made based on preventing patient harm. for it, can you get an organ earlier than someone More significant, though, is the fact that the

JULY 2006 The Surgical Technologist 21 health care worker has now become a “patient” ment. Male-to-female SRS consists of the remov­ and is in need of the same intervention and care al of the penis and the construction of a vagina rendered to anyone with a disease. and labia. Although surgical techniques differ among surgeons, generally the tissue of the penis Gender reassignment surgery is kept intact and fashioned into a clitoris, so that Gender reassignment surgery involves proce­ the patient can experience orgasm. Female-to- dures that change a patient’s biological sex. It is male SRS consists of a bilateral mastectomy and performed for the condition known as gender removal of the ovaries. A penis can be created dysphoria, a psychological condition in which using a surgical technique called phalloplasty. the individual believes that he or she is psycho­ Many individuals with gender dysphoria and logically and emotionally the opposite sex. Gen­ ambiguous sexual characteristics live a life riddled der dysphoria is diagnosed by a therapist or psy­ with discrimination based on their issues of sexu­ chiatrist who is experienced in gender issues. ality. The care of these patients in the operating Some individuals with gender dysphoria elect to room setting should not differ from that given to undergo sexual reassignment surgery. Gender any patient presenting for surgical intervention. reassignment is also performed for individuals with ambiguous sexual characteristics and geni­ Care of the HIV/AIDS patient talia, commonly referred to as hermaphrodites. Acquired immunodeficiency syndrome (AIDS), Sexual reassignment surgery (SRS) involves first identified in the human population in 1982, the primary and secondary sex tissue develop- infects an estimated 33 million people around t he world . I nd i v idu a l s with AIDS require routine medical and surgical care as wel l as inter ventions to address the numerous infections that can result from an altered immune system. With reports of patients tak ing up to 17 years to seroconvert from HIV-negative to HIV-pos- itive, it is imperative that health care providers pro­ tect themselves from acci­ dental inoculation with HIV-infected bodily fluids. The operating room, like many other professional arenas, carries an inherent risk of disease transference from patient to staff. You can not tell if a patient has AIDS by looking at them, by their age, or by any other external factors. Patients are not required to reveal their AIDS status, nor can

JULY 2006 22 The Surgical Technologist hospitals require AIDS testing for patients or Refusal of treatment staff. The treatment of HIV-positive and AIDS Provided for in the AHA Patient Bill of Rights patients in the operating room should not dif­ is the right to refuse treatment. A patient may fer from the care delivered under the established choose to refuse any aspect of care, even that policies and procedures defined in the Centers care that will bring about cure from disease. for Disease Control’s Standard Precautions. Patients may also choose to continue engag­ If standard precautions are followed without ing in health-endangering activities. If the eth­ exception, health care workers will be provided ical duties of the health care conflict with the with the maximum amount of protection pos­ patient’s desires, the O.R. team may feel that the sible against contracting this terminal illness. patient is making “poor decisions.” The ethical obligation of the health care team, though, is to Severely disabled newborns support the patient in their decision, to the best The birth of a child is commonly a joyous occa­ of their abilities. sion for many parents. When a baby is born with severe birth defects, such as anencephaly, the dream of a “perfect child” gives way to the reality that such babies are either delivered stillborn or die soon after birth. This tragedy affects not only If you can pay for it, can you get the involved family; it extends its sense of loss and grief to the surgical team as well. Surgical deaths [a donated] organ earl ier than leave an indelible impression on the health care practitioner, whether preventable or not. someone without the financial means The health care team must address the needs of both the family and the neonate during this to pay for it? very stressful period. Time to bond, detach, and grieve may need to be provided in the O.R. suite. On those occasions when organ harvesting for donation can occur, the O.R. team needs to con­ DNR orders in the surgical setting tain their own grief and move to provide for the Patients have the right to determine which, if issues associated with organ procurement. any, extraneous measures will be instituted should they not be able to make these determi­ Quality vs quantity of life nations at the time of the event. Do Not Resus­ When is death preferable to life? This situation citate orders that were traditionally suspend­ usually occurs when a patient has developed a ed in the operating room, due to the nature of terminal disease, and the pain associated with the life support technologies commonly asso­ it turns each day into an “existence” rather than ciated with general anesthesia administration a life. Self-determination permits patients to (eg endotracheal intubation, use of a ventila­ choose which medical interventions they wish tor, use of medications to regulate blood pres­ to have implemented during such situations. sure, etc), are re-evaluated at the time of sur­ While some patients are compelled by religious gery. While the compelling focus of our care or philosophical beliefs that death by any unnat­ is the preservation of life and the omission of ural means is murder, others feel that life without harm, standing back and watching as a patient meaning is nothing more than mere existence. In who chose DNR status undergoes cardiopul­ our society, suicide and assisted suicide are ille­ monary failure and death can be emotionally gal. In the health care setting, though, individu­ and professionally taxing. Every death in the als have the right to refuse treatments when the operating room setting is disquieting for the sole purpose of the treatment is to prolong life. staff, due to the ethical conflict of medicine’s

JULY 2006 The Surgical Technologist 23 based and online entry-level surgical technology educa­ tion (www.lhup.edu). She has been a certified surgical technologist since 1977. Ann has presented at numer­ ous forums, workshops and conferences and has served on various committees for AST, ARC-ST and LCC-ST, where she currently chairs the NBSTSA Exam Review Committee.

primary moral and ethical doctrine of non- References maleficence. 1. Caruthers B. Surgical Technology for the Surgical As surgical technologists, our professional Technologist: A Positive Care Approach. Albany, NY: Delmar; 2000. responsibilities to the surgical patient extend 2. Edge RS, Groves JR. Ethics of Healthcare: A Guide for beyond the instruments, equipment, and envi­ Clinical Practice. 3rd ed. Clifton Park, NY: Thompson ronments to the promotion of health and well­ Delmar Learning; 2006. ness. Our responsibilities extend to assuring the 3. National Council on Ethics in Human Research. Facil­ rights of our patients to expect and receive qual­ itating Ethical Research: Promoting Informed Choice ity, equitable, and appropriate care, with respect [communique]. Available at: http://ncehr-cnerh.org/eng- lish/consent/consente.htm#sa. Accessed May 4, 2006. to the patients’ desires and wishes. We owe it to 4. Phillips N. Berry & Kohn’s Operating Room Technique. our patients to be an integral part of all aspects 10th ed. Philadelphia, PA: Mosby; 2004. of their health care. 5. Fuller J. Surgical Technology: Principles and Practice. 4th ed. Philadelphia, PA: Elsevier; 2005. About the author 6. Hwang A. Confounding Gender: Hermaphrodites and the Medical Establishment [review]. MSJAMA. Oct 6, Ann Marie McGuiness, cst, cnor, msed, is pro­ 1999. Available at: ht tp://members.cox.net/fbsi/hermaphro- gram director of the surgical technology program dites.html. Accessed May 5, 2006. at Lock Haven University—Clearfield Campus in 7. Rothrock J. Alexander’s Care of the Patient in Surgery. Clearfield, Pennsylvania, offering both campus- 12th ed. Philadelphia, PA: Mosby; 2003. 8. Seeking patients’ consent: the ethical considerations. February 1999. Available at: ht tp://www.gmc-uk.org/guid- ance/library/consent.asp. Accessed May 4, 2006. 9. Sexuality: Gender Identity. Available at: h t tp: //w w w. As surgical technologists, our profes­ emedicine.com/ped/topic!"$%.htm. Accessed May 5, 2006. 10. Standards of Care: The Hormonal and Surgical Sex Reas­ signment of Gender Dysphoric Persons. Available at sional responsibi l ities to the surgical www.moss-fritch.com/standard.htm. Accessed May 5, 2006. 11. !e American Heritage® Dictionary of the English Lan• patient extend beyond the instruments, guage. 4th ed. Houghton Mifflin: Boston, Mass; 2000. Available at www.bartleby.com/&/. Accessed May 4, 2006. equipment, and environments to the 12. Transgender Health. Available at www.gayhealthchannel. com/transgender/surgery.shtml. Accessed May 5, 2006. promotion of heal th and we ll ness.

JULY 2006 24 The Surgical Technologist Safety Concepts in the Surgical Setting

A   M M € G  ‚  ƒ „ „ , € „ , €  † ‡ , ˆ ƒ d

he operating room is a place commonly associated with the elimination of disease and restoration of normal body func­ T tion for its patients. It is, though, one area of the health care facility that potentially includes a significant number of haz­ ards for both the patient and the staff. Keeping both groups free from injury is an important component of the surgical experience. The role of the operating room professional mandates that the O.R. staff assure the creation and maintenance of a safe environment before, during, and after the surgical intervention. This article examines the hazards and dangers commonly associated with surgical practice and some of the practices and safeguards in place to assess and address these issues.

JUNE 2008 The Surgical Technologist 253 294 JUNE 2008 2 CE CREDITS

P H Y S I C A L A N D P S Y C H O L O G I C A L H A Z A R D S 1. Never leave a patient in the operating room The primary goal of the patient intervention is to setting (holding area, O.R. suite, PACU, etc) provide a safe and positive operative experience. unattended. An anxious or medicated patient The operating room, by its nature, is an environ­ may “forget” that he or she should not get up ment that contains numerous sources of poten­ or move around, contributing to a fall and tial injury for the patient. In addition, patients possible injury. coming to the O.R. often experience alterations 2. Side rails and/or a patient safety belt should in decision-making abilities induced by stress, always be used when a patient is resting on medications, or other factors that can significant­ a narrow surface (O.R. table) or a moveable ly contribute to iatrogenic injury. It is the duty of surface (stretcher). The safety belt should be the team to ensure that the patient’s O.R. expe­ applied in a position to restrict patient move­ rience is safe. This can be achieved by following ment, but should not be applied so securely health care facility policies and procedures, the that the patient experiences hyperextension proper use of equipment, and the implementa­ of joints or undue skin pressure. For those tion of basic safety practices. patients who are young and might attempt to climb over side rails, an enclosed transport/ crib should be utilized. 3. When the patient is moving between two surfaces, such as the stretcher and the O.R. table, a minimum of two persons, one on each side of the stretcher and the table, should be available to guide the patient in a safe trans­ fer. Reliance on the break mechanism on the stretcher for stability can leave the patient at risk for injury. When the staff is transferring the patient, a minimum of four people, one on each side of the patient, is required for a safe and effective transfer.

Positioning injuries Surgical positioning and the use of position­ ing devices have a potential to lead to physical injury. The anesthetized patient may not be able to “complain” of hyperextended joints or undue P H Y S I C A L D A N G E R S pressure on the skin. It is the responsibility of the Stretchers on wheels, narrow operating room O.R. team to assure patient comfort by imple­ tables, an unfamiliar environment, and sensory menting the following practices: overload can all contribute to a potential for phys­ 1. Never hyperextend a joint or abduct a ical patient injury. The primary causes of physical joint greater than 90 degrees from midline. injury include falls and positioning injuries. Abduction of the upper extremities greater than 90 degrees can lead to brachial plexus Falls palsy and neurovascular compromise. Operating room tables and stretchers are specifi­ 2. Pad all pressure points, especially over cally designed with narrow dimensions to meet bony prominences. the needs of the operating room environment and 3. Never place patient skin against “plastic” the O.R. team. Safeguards that are implemented or non-absorbent surfaces. The moisture to address the concerns related to falls include: secreted by the skin during the operative

JUNE 2008 254 The Surgical Technologist intervention can lead to skin maceration and of using lasers are numerous, the inherent danger breakdown. of controlling light emission is compelling. Stray 4. Use extreme caution when raising and/or laser beams from some types of lasers can travel lowering the foot section of the O.R. table. distances, causing thermal injury at the point of Patient fingers can easily fall across the break contact. Tissues particularly vulnerable to the of the bed, and can result in finger crushing. effects of laser application include the retina of 5. Use care when placing the patient in the the eye, thus laser safety glasses or other appro­ lithotomy position. Ensure that both lower priate eye protection devices are required during extremities are raised/lowered, rotated and laser usage. (See sidebar pg 256.) moved in a mirrored fashion. This prevents hyperextension of any one of the numerous joints involved with attaining this position and subsequent neurovascular injury. It is advisable to have two people involved in positioning the lower extremities, one man­ aging each limb. 6. Never use the patient as a “Mayo stand” by placing large numbers or heavy instruments on a draped patient’s extremities or torso. 7. Monitor and control the position of drains, tubings, and catheters during the patient’s transfer to eliminate accidental dislodgment.

Electrical dangers The energy source for most modern technology used in the operating room suite is electricity. While electricity will flow within a circuit, any dis­ ruption in that circuit, or the creation of an alter­ native pathway to ground, can serve to include the patient within the electrical circuit. This can lead to inadvertent thermal burns from concen­ trated electrical flow. The electrosurgical unit, used in almost every operative intervention today, purposefully passes electrical current through patient tissue for the purposes of coagulation and Mechanical dangers desiccation of tissue. It is important that patient The concepts of pressure and shear force are com­ safeguards are utilized to ensure that the electric­ monly associated with a surgical intervention. ity returns to the generator without unintended Pressure, the application of a force greater than patient injury. This is accomplished by proper the tissue resistance, can decrease blood flow to application and use of patient return electrodes the point of creating ischemia, necrosis, and even (grounding pad) for monopolar electrosurgery, gangrene. Pressure points on the body include and the assurance that all patient skin is not in those areas where bony prominences underlie contact with metal surfaces on the O.R. table. thin adipose tissues and skin layers. Common Lasers, the use of amplified light waves con­ locations for pressure points include the occipital centrated to a point where they can vaporize tis­ area, the ear, nose, chin, elbow, pelvis, and heel. sue and cellular fluids, have added a valuable tool During surgery, the patient is rendered immo­ to today’s surgical setting. While the advantages bile by the use of anesthetic agents and is unable

JUNE 2008 The Surgical Technologist 255 to redistribute his or her weight when increased The use of proper positioning, transferring, and pressure on an area is detected. The goal of the turning techniques will minimize skin injury O.R. team is to reduce the pressure created by an caused by friction and shear forces. immobilized patient on a firm surface. This can be accomplished by using padding, such as gel Thermal dangers pads and pressure relief viscoelastic foam pads Burns under these susceptible areas. Burns, or thermal tissue injury, can occur as a Shear is the force created on skin by the move- result of many activities in the operating room. ment of the underlying tissues. This results in The application of a “hot” instrument from compression of blood vessels, which decreases the “flash” autoclave, fiberoptic light sources, blood flow to the area. Shear force is generated fiberoptic cords placed on drapes or near patient when the body slides on a bed surface, and it tissues, the use of irrigating fluids that have been contributes to skin breakdown in compromised warmed to greater than body temperature, all and immobile patients. It can also occur when a serve as potential causes of thermal injury. The sheet or johnny is “pulled out” from underneath surgical technologist has the obligation to pre- a patient without turning the patient side to side. vent thermal injuries by controlling fiberoptic

Laser Hazards and Eye Protection

A laser serves as a nearly ideal point source of when a laser is bei ng used. ment of cataracts or burns, because the light is intense light. A suffici ently powerful laser beam Lasers are often employed in the operating absorbed by the cornea and lens. can possibly produce retinal intensities that room for excision and cauteri zation of tissue. The Particularly dangerous in the operative envi• exceed conventional light sources, including operating room staff should be very conscious of ronment are infrared lasers which are invisible to those produced when directly vi ewing the sun. the health care facility’s polici es regarding laser the O.R. personnel. The Nd:YAG laser beam, which Consequently, viewing lasers can result in perma• safety. Even the exposure to a small amount of is in the near-infrared electromagnetic spectrum nent blindness. Direct exposure on the eye by a laser light can cause permanent eye inj ur i es. The is commonly used in the O.R. for vaporizing blad• beam of laser light should always be avoided with O.R. team member may be unaware of an expo• der tumors, laser bronchcoscopy and laparoscopy. any laser, no matter how low the power. Eye pro• sure to laser radiati on (part i cularly the invis• If a team member has been exposed, he or she tection requires that O.R. personnel be thoroughly ible light). Some lasers are powerful enough may not feel pain or notice immediate damage to familiar wi th two terms, maximum permissi ble to diffuse the reflection from a surface which his or her eyesight. A pop or clicking noise may be exposure (MPE) and nominal hazard zone (NHZ). can unexpectedly cause damage to the eye. Eye heard indicati ng that the retina was overheated The American Nati onal Standards Institute injuries are primarily the result of the thermal and a localized boiling resulting in a permanent (ANSI) defines MPE as the level of radiation that effects experi enced by the reti na. A transient blind spot may be a consequence. an individual may experience without hazardous increase of only 10 degrees C can cause the pho• effects or biological consequences to the eye or toreceptors i n the retina to be destroyed. Based on the potential for biologi cal damage, skin. The MPE is based on the laser wavelength, Such damage can occur within a fraction of there are four classes of lasers: exposure time and pulse repetition. Accordi ng second because of the low divergence angle of N Class 1 lasers represent the least danger• to ANSI, the NHZ is the space where the level of laser light combined with the focusing mecha• ous applicati ons of light energy and are the direct, reflected or scattered radi at i on dur• nism of the eye which allow the laser light to regarded as incapable of produci ng damag• ing the use of the laser exceeds maximum per• be concentrated i nto an extremely small spot ing levels of laser emission. missible exposure. Essentially, it i dentifies the on the retina. An inj ury may be sustained faster N Class 2 lasers produce visible laser emissions area where safety measures must be mandated. than the blink of an eye. Visi ble to near i nfrared and may be vi ewed directly for .25 seconds In the operating room, the entire space is con• radiation will penetrate the eyeball and cause or less. (The time it takes for a blink of an sidered the NHZ, and appropriate protection is heati ng of the retina. Exposure to lower wave• eye or a head swing). required for any staff member entering the O.R. lengths of laser radiation results i n the develop• N Class 3a lasers are regarded as dangerous

JUNE 2008 256 The Surgical Technologist cords, and checking fluids and instruments for anesthetic gases, such as inhalation agents proper temperature prior to patient application. 3. Caution in the presence of ignition sources, such as electrosurgical pencils and lasers, Fire especially near oxygen sources, such as in The operating room is a prime location for fire surgery of the larynx or mouth to occur. The necessary components for fire 4. Monitoring fiberoptic light cords on the ster- ignition—oxygen, a fuel source, and source ile field, particularly when placed on, or near, of ignition—are all readily found in the O.R. disposable draping materials and the use of environment. standby light settings when light cords are Some of the practices of concern that need to not attached to telescopes be carefully monitored by the health care team 5. Wearing non-cotton garments by O.R. staff, include: which may produce static electricity 1. Care during the use of flammable skin prepa­ 6. Venting heat generated from electrical equip- ration solutions, such as alcohol and tinc­ ment away from the surgical field and the tured or alcohol-based solutions anesthesia machine 2. Care during the use of flammable liquids and

under direct or re!ected vision. These lasers In the operating room, eye protection is de • In addi tion to the O.R. team, the pati ent’s eyes are restricted to the visi ble electromagnetic signed to protect against radiation from a spe• must also be protected by moistened gauze pads, spectrum. cific laser. This generally applies only to Class or appropriate safety goggles or glasses. N Class 3b lasers are consi dered hazardous 3b and Class 4 lasers. The effectiveness of eye• Health care facili ty polic i es w i ll recommend when viewed intrabeam and may extend wear is critically dependent on the frequency of the frequent i nspection of laser goggles in order over the entire electromagnetic spectrum. use. Selecting the right type of eye protection is to detect cracks or breaks A scratched surface N Class 4 lasers are the highest energy class important. Protective eyewear must be able to permits the transmission of laser li ght and pos• of lasers and also extend across the electro• block the laser radiation when it strikes the lens sible inj ury. In addition to the actual operati ng magnetic spectrum; they can cause serious portion, or at the mini mum reduce the radiation room personnel, other employees who walk by damage to skin and eyes. to a permissible exposure level. This protecti on the surgical room must be protected and win• level is defined as the optical density (OD). Two dows are therefore covered as necessary. To pre• In the operating room, the most commonly important factors influence the type of eye pro• vent reflecti on, i nstruments that are not dulled employed lasers belong to class 3b and class 4. tecti on chosen—wavelength coverage and opti• or eboni zed, should be covered with wet towels Below is a list of the potential hazards to eyes cal density. Commonly, these specifications are or sponges. when working with lasers. imprinted on the safety goggles. For example, Surgi cal technologists may be asked to un• Light Source Inj ury to Eye a pair of Nd:YAG goggles may be imprinted with dergo an ocular examination when hired to work Ultravi olet C (0.200-0.280 µm) Photokeratitis “for use with 1064 nm.” It should be noted that in a surgery using lasers and another examina• Ultravi olet B (0.280-0.315 µm) Photokeratitis the lens color of the goggles is not related to the tion upon resignation or termi nation of employ• Ultravi olet A (0.315-0.400 µm) Photochemi cal UV protection against the laser beam. ment. These eye examinations establish neces• cataract For procedures using ultraviolet and infrared sary baselines and protect the employee and Visible (0.400-0.780 µm) Photochemi cal and laser radiation, the OD chosen by the team mem• the hospital. Laser safety should be considered thermal reti nal in j ury bers should provi de full protect i on. For example, a critical priority of the O.R. staff and health care Infrared A (0.780-1.400 µm) Cataract, retinal burns using the chart to the left, goggles rated to pro• facili ty. Inquire about policies where you work Infrared B (1.400-3.00 µm) Corneal burn Aqueous tect against ultraviolet C would not be effective and be sure that you are well informed and up to flare IR cataract protecti ng an individual who was exposed to date regarding laser safety. Infrared C (3.00-1000 µm) Corneal burn only Infrared A.

JUNE 2008 The Surgical Technologist 257 7. Ensuring electrical cords and wall plugs are Cold chemical sterilant use intact and appropriately grounded Activated glutaraldehyde and peracetic acid, 8. Ensuring proper environmental humidity is chemicals used for cold disinfection and steril­ maintained to reduce the potential for static ization of surgical instruments and equipment, electricity formation can be caustic to the skin of both the patient and the health care worker. Care should be taken to Chemical dangers ensure that all traces of activated glutaraldehyde Antiseptic solution use and peracetic acid have been removed by rinsing Antiseptic agents, used to decrease the transient with sterile water prior to contact with patient and resident microbe population of the patient’s skin or mucous membranes. skin prior to, and during, the surgical interven­ tion, can cause skin irritation with prolonged Latex sensitivity and allergy contact and application. Povidone-iodine solu- Natural rubber latex is a chemical used in the tions that have been warmed are more prone to manufacture of supplies employed in the oper­ causing contact dermatitis, especially in patients ating room. The protein in natural rubber latex with delicate skin, such as the young, elderly, or serves an antigen in selected patients, triggering when contacting tissues of the perineum. Anti- an immune system response in susceptible indi­ septics should only contact the skin for as long as viduals. This response can range from contact der- necessary. Excess prepping solution should not matitis to full-blown anaphylaxis, and even death. be allowed to pool on patient skin surfaces and Patients at risk for developing latex sensitive should be removed at the end of the procedure and/or allergy include3: during dressing application.

JUNE 2008 258 The Surgical Technologist 1. Those who possess a known or suspected sues most susceptible to changes from radiation allergy to latex by having exhibited an allergic exposure include the thyroid gland, the lens of or anaphylactic reaction, positive skin test­ the eye, bone marrow, and the ovaries/testes. ing, or positive IgE antibodies against latex In the operating room, radiation is used in the 2. Those with documented history of intraop­ forms of fluoroscopy, X-ray, and radioactive sub­ erative anaphylaxis of unknown etiology stances. Fluoroscopy is a technique that provides 3. Those with neural tube defects including: live images of internal structures during an oper­ – Spina bifida ative intervention. These images are used to guide – Myelomeningocele/meningocele implantable device placement, check for align­ – Lipomyelomeningocele 4. Those who have experienced some inter­ action between their central nervous and immune systems 5. Those who have had multiple operations, particularly as a neonate 6. Those who require chronic bladder catheter­ izations as a result of: – Spinal cord trauma – Extrophy of the bladder – Neurogenic bladder 7. Those who possess some history of multiple allergies including food products, particu­ larly bananas, avocado, celery, fig, chestnut, papaya and passion fruit

Proper care of the patient is essential to his or her safety from anaphylactic reactions and to assure an ideal outcome. Recommended practices should ment of bones, or the recording of images out­ be developed and implemented within each health lined using contrast media. X-rays are used when care facility. These practices may include: live imaging is not necessary, but is less frequently N scheduling a latex-sensitive patient as the used in today’s O.Rs, being replaced by more fre­ first procedure of the day; quent use of fluoroscopy. Radioactive substances N identification of O.R. products and equip­ may be injected into the patient prior to arrival in ment that contain natural rubber latex and the O.R. suite, or may be implanted during a sur­ replacing them with latex-free products, or gical procedure for the detection or treatment of protecting them from contacting patient skin; neoplasms. The effects of radiation seen are relat­ N developing a committee to focus and moni­ ed to the amount and length of an exposure. The tor issues related to latex sensitivity; and goal of protection for both staff and patient is to N using non-powdered gloves in the O.R. minimize exposure to radiation while permitting setting diagnosis and monitoring of interventions. Safety interventions can include minimizing the time Radiation and length of exposure during fluoroscopy and Radiation is invisible. The effects of radiation X-ray; applying lead shielding over the portion of exposure are seen most readily on the cellular the patient’s body that does not need to be viewed; level, where they can change the electrical charg­ tight focusing the radiation beam, whenever pos­ es of atoms within cells, altering genetic material, sible; and protecting the unborn fetus from radia­ even when used in therapeutic doses. Those tis­ tion exposure in the pregnant patient.

JUNE 2008 The Surgical Technologist 259 P S Y C H O L O G I C A L A S S A U L T Through awareness of the dangers present in the The sense of hearing is the last sense to leave and O.R., the surgical technologist can play an instru­ the first to return in the patient undergoing gen­ mental role in providing a safe and positive ther­ eral anesthesia. Patients are acutely aware of the apeutic environment. sounds in the O.R. environment, and “assume” that any and all conversation is related to them S A F E G U A R D S I N S U R G I C A L P R A C T I C E and their care. It is important that the patient Standards of Practice be protected from psychological assault, by the Guidelines for patient safety have been estab­ implementation of the following practices: lished by many organizations both directly and 1. Minimize extraneous O.R. noises and traffic, indirectly related to surgical practice. In 2004, especially when the patient is awake. the AST Education and Professional Standards 2. Focus all conversation within patient hearing Committee began researching practice issues on the issues and needs of that patient. All after it was recognized that there was a need for other conversation should be conducted out­ a comprehensive publication focused on evi- side the patient’s range of hearing. denced-based standards of practice. Recently, 3. Use positive communication techniques dur­ AST published several recommended standards ing patient-focused conversation. of practice, position and guideline statements 4. Avoid the use of “trigger phrases.” both in print and online. In the near future, addi­ tional topic areas will be published. It is antici­ pated that these standards of practice are consid­ ered dynamic and will change as needed to reflect advances in technology and care practices. In addition to AST, other organizations and nursing groups in the US, Canada, Australia, and Great Britain, such as the Association of Periop­ erative Nurses (AORN) have published standards of practice that guide perioperative practice. The Joint Commission requires hospitals to implement written policies and procedures for patient care. Hospitals voluntarily undergo The Joint Commission accreditation review every three years to measure compliance with estab­ lished standards of practice. Successful attain­ ment of The Joint Commission accreditation is a requirement in order for hospitals to receive JUA (Joint Underwriter’s Association) malpractice insurance. In 1965, the US Federal Medicare Act was passed, providing medical coverage to individ­ uals 65 years of age and older, or to those with disabilities. When the Medicare Act was intro­ duced, it included policies and procedures that impact health care delivery. Additional federal agencies that have established policies and pro­ cedures that affect surgical practice include the Federal Food and Drug Administration (FDA) and Occupational Safety and Health Administra-

JUNE 2008 260 The Surgical Technologist tion (OSHA). Other national organizations that Audits have developed regulations, policies, and pro- An audit is a review examination of records or cedures utilized in the care of surgical patients accounts to check their accuracy. In the hospi­ include the National Fire Protection Associa­ tal setting, audits are commonly performed to tion (NFPA), the Association for Advancement determine the level and quality of care delivered of Medical Instrumentation (AAMI), and the to any given patient population. This review indi- American National Standards Institute (ANSI). cates the degree of compliance with the hospital’s established policies and procedures Quality assurance Quality assurance involves the implementation Peer review of methods and processes to measure the quality Fellow employees perform peer audits within a of patient care, based on the standards of practice department. These audits are required by The Joint established by the health care facility. The Ameri- Commission as part of an ongoing assessment can Hospital Association’s (AHA) Patient’s Bill of process. In the operating room, peer audits may Rights states that each and every patient is enti­ be performed to evaluate compliance in apply­ tled to the same level of care, regardless of his/her ing patient safety devices, management of sharps, ability to pay for that care or any other external proper O.R. attire, and many other areas that factor. Hospitals are required to internally and directly or indirectly affect quality patient care. externally monitor the level of quality care deliv­ ered. There are several methods for documenting quality care.

JUNE 2008 The Surgical Technologist 261 Pr o f e ssi o n a l Sta n d a rd s Re vi e w O rg a n i z a ti o n hazards and dangers inherently part of the operat­ Quality assurance for recipients of federal Medi­ ing room experience. Minimizing and eliminat­ care and Medicaid programs is overseen under ing hazards in the surgical setting follow one of the auspices of the Professional Standards Review the basic tenets underlying all health care practice: Organization (PSRO). This organization was primum non nocere—first, do no harm. formed by the 1972 amendments to the Social Security Act with the purpose of reviewing the A B O U T T H E A U T H O R quality of medical care received by its beneficia­ Ann M McGuiness, cst, cnor, med, is currently ries, ensuring necessary, appropriate, and con­ serving as the ARC-ST director of accreditation sistent quality of care. The PSRO has the right services. Previously, she was the program direc­ to review patient charts and examines the docu­ tor of the surgical technology program at Lock mentation of care delivered retrospectively, in Haven University, Clearfield Campus, Clearfield, order to audit the level and quality of that care. Pennsylvania. She has been a Certified Surgi­ The Joint Commission, like the PSRO, will cal Technologist since 1977 and has served on also perform routine retrospective audits of numerous committees for AST, ARC-ST and patient charts and review the documentation to most recently was a director of the NBSTSA. assess the level and quality of care. References C O N C L U S I O N 1. A Patient’s Bill of Rights. www.patienttalk.info/AHA-Patient_ Among the many challenges faced by the patient in Bill_of_Rights.htm. Accessed May 1, 2008. 2. AST Recommended Standards of Practice. www.ast.org. today’s operating room, none is of greater impor­ Accessed April 30, 2008. tance than safety. As professional practitioners, it 3. American Association of Nurse Anesthetists Latex is our responsibility and obligation to minimize Allergy Protocol. http://www.aana.com. Accessed May 1, the risk of patient and staff injury from the various 2008. 4. Ball K. Lasers, !e Perioperative Challenge. 2nd ed. St Louis, MO: Mosby; 1995. 5. Frey K, Ross T. Surgical Technology for the Surgical Technologist: A Positive Care Approach. 3rd ed. Albany, NY: Delmar Cengage Learning; 2008. 6. Fuller, J. Surgical Technology: Principles and Practice. 4th ed. Philadelphia, PA; WB Saunders; 2005. 7. Phillips, N. Berry & Kohn’s Operating Room Technique. 11th ed. St Louis, MO: Mosby; 2007. 8. Rothrock, J. Alexander’s Care of the Patient in Surgery. 13th ed. St Louis; MO: Mosby; 2007. 9. US Department of Labor. OSHA Technical Manual. Laser Hazards. http://www.osha.gov. Accessed April 30, 2008. 10. US Department of Labor. OSHA. Guidelines for Laser Safety and Hazard Assessment. http://www.osha.gov. Accessed May 1, 2008. 11. US Department of Labor. OSHA. Surgical Suite Mod­ ule. http://www.osha.gov. Accessed May 1 2008.

JUNE 2008 262 The Surgical Technologist Necrotizing Fasciitis

V! " # $ % & $ R' ( ) & * + # ,

I N T R O D U C T I O N ecrotizing fasciitis is the name of a dangerously fast spread­ ing bacterial infection and is also commonly referred to as the esh eating bacteria. The term necrosis is defined as tis­ sue death. Necrotizing is to cause or undergo tissue death. NThe term fascia refers to the fibrous connective tissue that covers muscle. When the suffix –itis, which means inflammation, is added to the Latin plural form (fasci) to make the word fasciitis, the term means inflamma­ tion of the fascia.

L E A R N I N G O B J E C T I V E S N Identifyi the causes of N necrot zing fasciitis Describe the symptoms of N necrotizingi fasciitis Identdi fy the methods to N agnose NF Compare the treatments N for NF i Explain the relationsh p of NF and MRSA 305

JULY 2008 The Surgical Technologist 295 JULY 2008 2 CE CREDITS

Some historians maintain that necrotizing rium is present on their throat and skin show no fasciitis was first described in the time of Hip­ evidence of an illness. pocrates, who noted problems with erysipelas, This bacterium may sound familiar, because it a superficial bacterial infection of the skin that is the same bacterium that causes relatively mild was known to spread to the deeper tissues. Hip­ illnesses, such as strep throat and the skin con­ pocrates described the infection in this manner, dition impetigo. The majority of GAS infections “…flesh, sinews, and bones fell away in quanti- are not life threatening but occasionally this bac­ ties…fever was sometimes present and some­ terium can produce severe and even fatal condi­ times absent… there were many deaths”5 tions when invading parts of the body where bac­ In 1952, the term “necrotizing fasciitis” was terium is not usually found, such as the blood, officially introduced by B Wilson, md, although muscle or lungs. he never did find the specific bacteria that caused Two of the most dangerous but infrequently the disease.15 Necrotizing fasciitis, although occurring forms of GAS disease are necrotiz­ rare and incredibly fast-acting, has been seen ing fasciitis (NF) and streptococcal toxic shock throughout history. However, because it is more syndrome (STSS). Streptococcal toxic shock syn­ common in third world countries and was not drome presents with a rapid drop in blood pres­ officially identified until after the 1950s, little sure and the kidney, liver and lungs begin to fail. data is available on this uncommon bacterial Approximately, 10% to 15% of patients with inva­ infection. The bacterium that causes necrotizing sive group A streptococcal disease will die from fasciitis enters the body and reacts with other the infection, but more than 35% of individuals bacteria, causing subsequent chemical reac­ with STSS will succumb. Approximately 25% of tions. Toxins are released throughout the body patients with NF will die, and this disease is the focus of the article. Group A hemolytic streptococcus is also known as A streptococcus pyogenes. Streptococ• “The treatments for necrotizing cus pyogenes produces a wide variety of virulence fasciitis must be as aggressive as factors which allow for its rapid multiplication the symptoms, and immediate and progression through the body. “Streptococ• hospitalization is recommended.” cus pyogenes owes its major success as a patho­ gen to its ability to colonize and rapidly multiply and spread in its host while evading phagocyto­ and attack soft tissue layers under the skin. Tis­ sis and confusing the immune system.”17 After sue death then spreads to the nearby fascia that streptococcus pyogenes attacks the body, it is in surrounds the muscle. turn attacked by bacteriophages (viruses that This article will help practitioners understand attack bacteria). The bacteria then break down the symptoms and causes of necrotizing fascii­ and release a gaseous toxin that flows in-between tis, learn the relevant methods of treatment and deep fascial planes and subcutaneous soft tissue. identify methods of prevention. The gaseous toxin then starts to kill the soft tissue, fat, and fascia. After the toxin has festered and the C A U S E S O F N E C R O T I Z I N G F A S C I I T I S tissue is dead, it then flows into the bloodstream. The most common cause of necrotizing fascii­ The toxic blood then moves through the organs tis is group A hemolytic streptococcus, which in the body and causes systemic breakdown.15 appears to be the relevant factor in up to 71% of There are plenty of other bacteria that can all human cases. Also known as “GAS,” this type contribute to, and/or cause, necrotizing fasciitis. of streptococcus is a common bacterium usually One example is a group of rod-shaped anaero­ found on the skin and in the throat. It is interest­ bic bacteria called bacteroides, commonly found ing to note that some carriers where this bacte­ in the human intestine. When these bacteroides

306 The Surgical Technologist JULY 2008 venture outside the intestine, they can create an to fight even a small bacterial invasion. In sev­ abscess filled with pus that usually spreads more eral other cases, the infection started when the bacteria throughout the body. The formation bacteria entered the body through an opening of pus in these wounds is extremely dangerous, in the skin, such as a cut on the hand or infected because if a leak occurs from an abscess, it will foot. “It can also enter through weakened skin, cause infection to organs and muscular tissue, like a bruise, blister, or abrasion. It can also hap­ thus resulting in organ failure and muscular pen following a maj or trauma or surgery, and in deterioration.18 some cases, there appears to be no identifiable Clostridium is another bacterium that aids point of entry.” 11 with the progression of necrotizing fasciitis. Clostridium can produce spores that will secrete powerful exotoxins that multiply the amount of toxins already present in the body. In an immune system that is already being overwhelmed by bacteria, these toxins help the necrotizing fascii­ tis to rapidly spread.2 Peptostreptococcus is the anaerobic partner to streptococcus. Peptostreptococcus also contributes to soft tissue infection. Peptostreptococcus and Enterobacteriaceae are bacteria that have become resistant to some antibiotics, such as penicillin G and clindamycin.14

T R A N S M I S S I O N Hygiene can play a huge role in the transmis­ sion of necrotizing fasciitis although the spread of this disease is extremely preventable. Areas of infection where the skin has broken open carry the highest risk of transmission, especially if the E A R L Y S T A G E S O F S Y M P T O M S infection has any leaking or oozing of pus. In The symptoms of necrotizing fasciitis can devel­ rare cases, the bacteria are occasionally spread op extremely quickly and, in some instances, between people through close contact of bodily symptoms have evolved from mild to life threat­ fluids, such as coughing, direct contact of open ening in merely 24 hours. Due to the origin of wounds and rarely, kissing. “People who live or the infection, which typically festers beneath the sleep in the same household as an infected per­ skin, most patients physically appear to be in son or who have direct contact with the mouth, good health. In many of the cases reported, the nose, or pus from a wound…have a greater risk patients first appeared to have flu-like symptoms of becoming infected.”11 but later complained of severe pains on the body, Necrotizing fasciitis has been known to which later became the area where the infection begin in the bodies of those whose immune sys­ was growing. If the infection is closer to the sur­ tems have been compromised. The infection has face of the skin, initially swelling, redness, and been discovered to affect those who have been sometimes fluid-filled blisters are frequently evi­ diagnosed with comorbid conditions, such as dent. 7 Often, the appearance of these symptoms diabetes, cancer, alcoholism, or who recently may lead physicians to believe that this is a small underwent an organ transplant. Surgical pro­ infection; meanwhile, the body is beginning to cedures may cause tissue injury, and while the decompose from the inside. immune system has been weakened, it is unable

JULY 2008 The Surgical Technologist 307 A D V A N C E D S Y M P T O M S D I A G N O S I S After the third or fourth day, patients tend to notice While early diagnosis and treatment are key to that their symptoms are not decreasing. As the dis­ fighting this disease, doctors and patients often ease progresses, the redness or discoloration of the fail to recognize necrotizing fasciitis, because it skin spreads. The blisters grow, not only by num­ presents flu-like symptoms. In many cases, early ber but in size, and may begin to fill with a yellow diagnosis was not determined because of tests fluid. The patient’s blood pressure may drop caus­ run due to symptoms but by the complications ing them to appear delusional, confused or in a and confusion of symptoms presented. Due to state of shock. In several reported cases, the site of these “red flags,” doctors were able to diagnose infection was directly linked to a wound, such as and provide immediate treatment by adminis­ a burn, cut, or even insect bite. “Scaling, peeling, tering antibiotics that would help fight several other bacteria as well. Unfortunately, most cases of necrotizing fasciitis have not been diagnosed early enough to fight the infection. However there are several ways to effectively diagnose the condition, including laboratory analysis, X-rays and surgical biopsies. Gram stains show a poly-microbial flora with aerobic gram-negative rods and positive cocci. Gram staining may provide a clue as to whether a type I or type II infection is present, thereby providing physicians with an accurate indicator to determine which antibiotic therapy would be the most effective.15 Radiographs detect the presence of gas in subcutaneous fascial planes. However, many fac­ tors can cause these gases, so this method is not regarded as necessarily reliable or time efficient. MRI and computerized tomography (CT) have been effectively used for diagnosing NF. In or discolored skin over the infected area, which combination with the clinical assessment MRI, are signs of tissue death…” often reveal the sight in particular, aids in confirming the presence of of infection, and then allow doctors to identify the NF and whether the patient should undergo sur­ disease and begin treatment. 13 gical debridement.7

C R I T I C A L S Y M P T O M S T R E A T M E N T Once the disease is in its fourth to fifth day of The treatments for necrotizing fasciitis must activity, the body starts to shut down. The patient’s be as aggressive as the symptoms, and immedi­ blood pressure begins to drop dangerously and the ate hospitalization is recommended. Symptoms body experiences “toxic shock.” “Unconscious­ will typically start as flu-like, causing no specific ness will occur as the body becomes too weak to alarm. Once the infection grows enough to rise fight off this infection…” At this point, treatment to the surface of the skin, it will appear as gan­ must be carried out to the fullest. Depending on grene. Immediately, antibiotics must be flushed how aggressive the particular strain of bacteria throughout the patient’s body to prevent the are that initiated the infection, the symptoms may spread of the disease to any non-infected areas. progress much more rapidly. 11 The death rate of necrotizing fasciitis reach­ es nearly 40% in some populations. A quick

308 The Surgical Technologist JULY 2008 response is necessary and several cases reported required prompt amputation of the areas most “While early diagnosis and treatment infected. “Supportive care for shock, kidney fail­ are key to fighting this disease, doctors ure, and breathing problems is often needed…” and patients often fail to recognize as the body begins to shut down after the fourth necrotizing fasciitis.” to fifth day.11

Necrotizing fasciitis and community-associated MRSA8,9

Previously healthy indivi duals who have recent­ In Los Angeles recently, a greater number S. aureus (MSSA) infections. The latter pop­ ly taken antibiotics may be at a greater risk of of infections has been noted involving commu- ulation is characteri zed by a receptivity to contracting methi cillin-resistant S. aureus. This nity-associated methici ll i n-resistant S. aureus antibiotics, and their condition i s more read­ bacterium is resi stant to antibiotics and some (MRSA). ily addressed. The study noted that the MRSA individuals may acquire skin problems and even When examining the records of 843 patients group was seven times more likely to have necrotizi ng fasciitis. Staphylococcus aureus was whose wound cultures grew MRSA over a taken antibiotics i n the last six months. “We previously overshadowed by the more com­ 15-month period, 14 patients showed both found that the use of any antibiotic puts peo­ mon Streptococcal pyogenes when investigat­ clini cal and intraoperative symptoms of necro­ ple at risk for MRSA,” reported Kathryn Como- ing necrotizing fasci itis. tizing fasciitis, necrotizing mysitis, or both. Sabetti, MPH, seni or epidem i ologist, Minnesota The resistance of some bacterium to treat­ Causati ve factors in the patient population Department of Health and Children’s Hospitals ment by antibi otics is a growing concern., include current or past inj ection drug use, pre­ and Cli nics of M i nnesota. because such resistance indi cates that more vious MRSA infection, diabetes, chronic hepa­ In Denver, reports from a study have noted aggressi ve drug therapies must be utilized. titis C, cancer, HIV or AIDs. an increasing number of necrotizing fasciitis Antibiotics, which target specific bacterium, The median age of the pati ents was 46 cases caused by MRSA. Of the five patients are not appropri ate for all bacterial infections. years and 71% were male. in the study, one was an alcoholic, one was a When antibiotics are prescribed i nappropriate­ Medical and surgical therapi es were pro­ diabetic and the other three had been consid­ ly, such as for the treatment of viral or fungal vided as needed to all the patients. There were ered healthy. To remove infected tissue, these infections, then the individual does not receive no fatali ties but several patients experienced patients experienced two to seven surgeri es. the best medical assi stance and also increas­ severe complications. Reconstructi ve surgery “Necrotizing fasciitis is still a rare disease, es the possibility that therapy wi th antibiot­ was required for some cases, and prolonged but MRSA no longer is,” said Lisa Young, MD, ics in the future may not be effective, thereby hospitals stays in the intensive care unit were University of Colorado at Denver, and Health increasing the risk of contracting MRSA. mandated for others. In 86%, wound cultures Sciences Center. MRSA is no longer a challenge faced i n the were monomicrobial for MRSA. When blood It appears that communi ty-associated hospital environment by the elderly and chron­ cultures were obtai ned, 40% of these patients MRSA is a growing cause of necrotizing fascii­ ically ill. Apparently healthy people are con­ showed positive results. tis. In locations where community-associated tacting i t, and some deaths have resulted. In a Minneapolis study, two groups of MRSA infection is endemic, individuals with If the MRSA i s acquired during a hospi tal patients were compared; one group was com­ suspected necrotizi ng fasciitis should be given stay, it is considered a hospital-associated MRSA. prised of individuals who contracted commu- empirical treatment including antibiotics that However, if a healthy individual contracts MRSA nity-associated MRSA infections, and the other have proven effective combati ng this i nfection, outsi de the hosp i tal, the condit i on is referred to was composed of indi viduals who experienced such as vancomyci n. as a community-associated MRSA. community-associated methicillin-sensiti ve

JULY 2008 The Surgical Technologist 309 D E B R I D E M E N T cal procedures and recovered. Another patient at Debridement is a process used to remove the dead the same facility had 40 pounds of diseased tissue tissue of a wound, in order to allow the under­ removed during surgery. lining living tissue to heal. Many different types The staff at the facility is well trained, and they of debridement are available, but the two most are able to recognize the symptoms of NF quickly commonly used in treating necrotizing fasciitis and act immediately, because they regularly treat are surgical and mechanical debridement. Dur­ patients with complex conditions. However, they ing surgical debridement, dead tissue is simply have noticed an increase in the number of NF removed with a scalpel or scissors. This option is cases and speculate that obesity and diabetes may considered to be the quickest and most effective. be linked to the higher incidences. A study is cur­ Mechanical debridement is the oldest and most rently underway. painful method. The infected area is covered with gauze or some other type of dressing and allowed M A G G O T D E B R I D E M E N T T H E R A P Y ! M D T ) to dry overnight. Once the dressing is completely In one reported case of necrotizing fasciitis, debridement was used to remove the infection located on the right side of the abdomen and scrotum of a 46 year-old man who had a history of smoking and alcoholism. First, the patient underwent a series of 10 surgical debridements as well as intense antibiotic therapy. When these were not successful, maggot debridement thera­ py was initiated. In this particular case, a total of nearly 1,200 Lucilia sericata maggots were used in Biobags over a span of 19 days. The process of the maggot debridement therapy, although in this case very productive, is a meticulous and complicated procedure. “Throughout this study, all maggot applica­ tions were performed using the contained tech­ nique (Biobags). In the Biobag technique, lar­ vae are enclosed between two layers of 0.5-mm polyvinyl alcohol hydrosponge, which have been heat sealed. Next, a small cube of spacer material dry, the covering is forcibly removed from the is inserted to prevent bag collapse. The bag con­ wound, taking away not only the dead tissue, but taining the maggots is placed inside the wound. also possibly pulling away healthy, living tissue. A net is placed over the bag and taped to an adhe­ Mechanical debridement is not always recom­ sive on the wound edges. Wet gauze and a light mended because of the inevitable loss of healthy bandage are wrapped over the net. Catheters are living tissue when uncovering the wound. 3 placed inside the bandages in order to wet the In Iowa, a 52-year old farmer inadvertently gauze three times daily with normal saline solu­ hit his shin bone while climbing into a tractor. tion (0.9%) in order to prevent maggots dying After a few hours, he experienced a severe head­ from dehydration. Every three to four days, new ache, fever and uncontrollable pain. His leg was contained maggots were placed on the wound swollen and huge blisters appeared. until thorough debridement was reached.” He went to the emergency room and was sub­ sequently referred to the University of Iowa Burn Treatment Center. He was underwent two surgi­

310 The Surgical Technologist JULY 2008 After the treatment was over, “…a mesh graft N O N " S U R G I C A L T R E A T M E N T S was used to close the rest of the wound… and When treating necrotizing fasciitis, the first the patient was discharged from the hospital, line of defense is to flush the body full with anti­ returned to work, and has remained in good con­ biotics. Because necrotizing fasciitis is caused by dition for more than three years…”16 so many bacteria working together, a wide panel of antibiotics is needed to counteract all of them. A L T E R N A T I V E T R E A T M E N T S “It is common to see misdirected treatment that A few alternative treatments for necrotizing fas­ is aimed as coexisting flora instead of the caus­ ciitis are available, although none have seemed ative organism.”7 Due to the abundance and use to be as commonly preferred as those described of modern day antibiotics, some bacteria have previously. Hyperbaric oxygen therapy is used become resistant if not immune to antibiotics. when anaerobic bacteria are involved and also This resistance is another reason why the body to increase a patient’s s oxygen level in the must be treated with so many antibiotics.7 blood, which can help prevent tissue death. The most common antibiotics used for treat­ ment are15: N Penicillin G—Stops multiplication and kills susceptible microorganisms. “Necrotizing fasciitis caused by group N Ampicillin—Alternative to penicillin and A streptococci pyogenes is the most amoxicillin. rapidly progressive and devastating N Clindamycin—Attacks staphylococcal infec­ form of the disease.” tion. Stops aerobic and anaerobic strepto­ cocci. Stops bacterial growth. Alternative to penicillin G. With necrotizing fasciitis, the soft tissues under N Metronidazole—Used against anaerobic bac­ the skin and around the muscles are being teria and protozoa. Causes cell death. attacked; therefore, a greater amount of oxygen N Ceftriaxone—Effective against gram negative pumped into the body and blood stream will activity. Used in combination with penicillin. promote healing of damaged tissues and help N Gentamicin—Used in combination with a fight infection. gram positive agent for gram negative effec­ This method involves a patient entering an tiveness. Only used in contradiction to other enclosed chamber where pure oxygen is pumped antibiotics. inside under high pressure. Hyperbaric oxygen N Chloramphenicol—Effective against gram therapy is utilized to treat severe burns, carbon negative and positive bacteria monoxide poisoning, certain infections, sym­ toms of decompression, extreme bloodloss, and M O R T A L I T Y A N D M O R B I L I T Y muscles and soft tissues which have lost their It is difficult to provide a specific mortality rate supply of oxygen. 6 for necrotizing fasciitis. Death attributed to this Very similar to debridement therapy, a fas­ disease is directly correlated to how early diagno­ ciotomy is a procedure that removes dead tis­ sis is made and how soon treatment is initiated. sue. Debridement therapy removes tissue mostly Necrotizing fasciitis caused by group A strep• from the exterior of a wound to enable the living tococci pyogenes is the most rapidly progressive tissue underneath to heal properly. A fasciotomy and devastating form of the disease. If it is not removes dead and damaged fascia, which is the diagnosed and treated immediately, the condi­ “…thin connective tissue covering, or separating, tion results in a large percentage of morbidity the muscles and internal organs of the body.” 4 and mortality. Nearly 50% of adult cases reported signs of toxic shock and multi-organ shut down. At this point, the mortality rate varies from 30%

JULY 2008 The Surgical Technologist 311 to 70%, depending on the severity of other fac­ cases, necrotizing fasciitis constitutes about 6% tors in addition to the disease. The mortality rate to 7%, as compared to strep throat and impetigo, in cases that were treated immediately ranges which are reported to occur in the millions annu­ from 25% to 40%. Since 1883, more than 500 ally. Only a few people who have been in contact cases have been reported in the literature. 7 The with GAS will develop an invasive GAS disease average age of survivors is 35 years old, and the Practicing good hand washing is the best average age of non-survivors is 49 years old. method of prevention, especially after coughing and sneezing or preparing foods or eating. Indi­ C O N C L U S I O N viduals with sore throats should visit a doctor The onset of necrotizing fasciitis is frighten­ who can perform diagnostic tests to determine if ing because it can begin from a common strain strep throat is evident. of Group A Streptococcus pyogenes bacteria but Keep all wounds clean, including scrapes, leave a patient fighting for life within a matter burns, cuts and sores caused by shingles and of days. Whether diagnosis is immediate or not, chickenpox, insect or animal bites. In addition to the previously mentioned symptoms, watch for redness or swelling near the wound. If a muscle has been recently strained or a fever develops, chills or severe pain are experienced, immedi­ ate medical care should be sought, because these could be signs of deep tissue injury. Treatment with anti-inflammatory drugs is to be avoided since these medications may reduce the symp­ toms without treating the actual cause Health care professionals must be vigilant when observing their patients and themselves. This disease is treatable and damage is much less severe if diagnosed early.

A B O U T T H E A U T H O R Valentin Rodriguez lives in Fresno, California and is a a student at San Joaquin Valley College, in Fresno. He is currently enrolled in the surgical technology program and anticipates graduating this disease will change the patient’s life forever. in 2009. Valentin is 26 years old and loves the fact Treatment can be an intense flush of antibiotics that surgical technologists are the practitioners in through the entire system or an extreme proce­ the operating room who are relied on to remain dure of surgical debridement of soft tissues and calm and help the surgeon with every step. He is skin, both leaving the body powerless and feeble. very interested in ophthalmology and finds eyes Although cases of this disease are far and few, the fascinating. condition does not discriminate. It attacks any­ Before enrolling, he never knew such a career one, from the young to the old, the healthy to the existed and as soon as Valentin discovered sur­ chronically ill, diabetics or addicts. When deal­ gical technology, he was unable to consider any­ ing with this infection, medical attention must be thing else. sought immediately. About 9,000 to 11,500 cases of invasive GAS disease occur in the US annually and approxi­ mately 1,000 to 1,800 deaths result. Of these

312 The Surgical Technologist JULY 2008 References 16. Steenvoorde J, Wong Jukema. Maggot debridement 1. Centers for Disease Control. Group A Streptococcal therapy in necrotizing fasciitis reduces the number (GAS) disease. http://www.cdc.gov. Accessed May 29, of surgical débridements. (2007). http://www.woundsre- 2008. search.com/article/. Accessed February 6, 2008. 2. Clostridium. (1995).University of Texas Web site. http:// 17. Todar K. (2005). Streptococcus pyogenes and the strep­ medic.med.uth.tmc.edu/path/.htm. Accessed Feb• tococcal disease. University of Wisconsin-Madison ruary 6, 2008. Web site. http://www.bact.wisc.edu/themicrobialworld/strep. 3. De br id ement , (2 0 0 6) h t t p : / / w w w. h e a l t h a t o z . c o m / html. Accessed February 6, 2008. healthatoz/Atoz/common/standard/transform.jsp?requestURI=/ 18. What are bacteroides. (1999),. East Carolina Univer­ healthatoz/Atoz/ency/debridement.jsp. Accessed February sity Web site. http://borg.med.ecu.edu/~webpage/about.html. 6, 2008. Accessed February 6, 2008. 4. Fasciotomy.(2006). http://www.healthatoz.com/healthatoz/ Atoz/common/standard/transform.jsp?requestURI=/healthatoz/ Atoz/ency/fasciotomy.jsp. Accessed February 6, 2008. 5. Feely EA. Necrotizing fasciitis: diagnostic modalities. (1998). Wake Forest University Web site. http://intmed- web.wfubmc.edu/grand_rounds//necrotizing_fasciitis.html. Accessed June 2 2008. 6. Hyperbaric oxygen therapy. (2007). http://www.webmd. com/hw-popup/hyperbaric-oxygen-therapy. Accessed Febru­ ary 6, 2008. 7. Maynor M. Necrotizing fasciitis. (2006). http://ww w. emedicine.com/EMERG/topic.htm. Accessed February 6, 2008. 8. Miller LG, Perdreau-Remington F, Rieg G et a l. Necrotizing fasciitis caused by community-associ- ated methicillin-resistant staphylococcus aureus in Los Angeles. NEJM. http://content.nejm.org/cgi/content/ abstract///. Accessed May 30, 2008. 9. MRSA linked to recent antibiotic use increasing as a cause of necrotizing fasciitis. Infectious Diseases Soci­ ety of America. http://www.idsociety.org. Accessed June 2, 2008. 10. Necrotizing fasciitis – topic overview. (2005). http:// health.yahoo.com/infectiousdisease-overview/necrotizing-fascii- tis-flesh-eating-bacteria-topic-overview/healthwise--hw. html. Accessed February 6, 2008. 11. Necrotizing fasciitis. (2005). National Necrotizing Fasciitis Foundation Web site. http://www.nnff.org/nnff_ factsheet.htm. Accessed February 6, 2008. 12. Necrotizing fasciitis. http://www.webmd.com/a-to-z-guides/ necrotizing-fasciitis-flesh-eating-bacteria-symptoms. Accessed February 6, 2008. 13. Necrotizing soft tissue infection. http://w w w.nlm.nih. gov/medlineplus/ency/ar ticle/.htm. Accessed May 29, 2008. 14. Peptostreptococcus. (1995). University of Texas Web site. http://medic.med.uth.tmc.edu/path/.htm. Accessed February 6, 2008. 15. Schwartz R (2007). Necrotizing fasciitis. http://ww w. emedicine.com/derm/topic.htm. Accessed February 6, 2008.

JULY 2008 The Surgical Technologist 313 Disasters follow no rules: Preparing your hospital for disaster response

Tony Forgione, lpn

n October 18, 1989, an earthquake, registering 6.9 on the moment magnitude scale, hit the San Francisco Bay Area of California. O The quake lasted only 15 seconds, but caused severe structural damage throughout the Bay Area, including the collapse of portions of double-decker highways, packed with commuters. Sixty-three people were killed and 3,757 were injured in the disaster.

LEARNING OBJECTIVES n Evaluate a hospital’s ability to meet disaster preparedness requirements n Understand your role as a medical professional in a disaster scenario n Compare and contrast different types of disasters and their impact n Evaluate the chain-of- command structure during a mass casualty incident n Recognize the challenges a hospital will face during a sustained surge

© 2008 OCtOber 2008 The Surgical Technologist Association of Surgical Technologists 445 For reprint permission: [email protected] 298 OCtOber 2008 3 Ce Credits

Disasters can be divided into two major catego- WhAT IS A MASS CASUALTy INCIDENT? ries: natural disasters, which include hurricanes, earthquakes and floods; andmanmade disasters, On April 19, 1995, a 5,000-pound truck bomb such as industrial catastrophes and terrorism. detonated in front of the Alfred P Murrah Federal No one can predict the complexity, time or Building in Oklahoma City, just after 9 a.m. The location of the next disaster, however, manmade blast damaged or destroyed 324 buildings within a disasters, especially those involving terrorism, 16-block radius, creating a crater 30-feet wide and have proven to be the most challenging disaster eight-feet deep. There were 168 fatalities and 853 threat for medical providers due to the unpre- people injured in the explosion. dictability of the incident and the number of casualties involved. A mass casualty incident (MCI) is an event that Today’s terrorists have a wide spectrum of produces enough casualties to disrupt the normal threats available to them. They do not necessar- functional capacities of the affected community. ily have to kill people to achieve their goals. They The severity and diversity of injuries, in addition just have to create a climate of fear and panic that to the number of victims, is a major factor in deter- will overwhelm the health care system. A prime mining whether or not an MCI will overwhelm the example is the Saran gas attack in Japan in 1995. local medical and public health infrastructure. Of the 5,000 admissions to hospital emergency There is a myth that all disasters are different, departments, only around 500 patients were actu- but the reality is that there are common, basic ally suffering from the physical effects of Saran. medical and public health issues shared by all The remaining patients were all suffering from disasters, regardless of their etiology. psychological stress related to the incident.1

A National Guardsman and a fireman work side by side in the aftermath of the Oklahoma City bombing. FEMA

© 2008 The Surgical Technologist OCtOber 2008 446 Association of Surgical Technologists For reprint permission: [email protected] Medical issues include: Figure 1. n Search and rescue Triage tag. n Triage and initial stabilization n Definitive care n Evacuation

Public health issues include: n Water n Food n Shelter n Sanitation n Transportation n Communication n Endemic and epidemic disease n Security and safety1

Search and Rescue Local population and assets close to the disas- ter are the initial search and rescue resources. In disasters involving large numbers of vic- tims trapped in collapsed structures, the local response may be haphazard.

On September 11, 2001, two hijacked airliners tional triage provides the greatest good for the were flown into the World Trade Center in New patient, while disaster triage provides the great- York City, in the worst terrorist attack in US his- est good for the greatest number of patients. tory. A third hijacked aircraft crashed into the Pen- Disaster triage requires the response teams to tagon in Washington, DC, and a fourth, believed prioritize and categorize the casualties, allowing to be targeting either the US Capitol Building or for timely rescue, treatment and evacuation in the White House, crashed in a field in Pennsylva- an orderly fashion. They must also optimize the nia. All told, 2,998 people lost their lives and more use of available medical, nursing and emergency than 6,000 were injured. personnel at the disaster site. Finally, they must optimize the use of available logistical support Many countries have specialized search and rescue and equipment. teams as an integral part of their disaster response There are different levels of disaster triage. The plan. These teams consist of a cadre of medical level will be determined by the ratio of casual- specialists and technical specialists knowledge- ties to available resources. During on-site triage, able in hazardous materials, structural engineer- patients are characterized as acute or nonacute ing, heavy equipment operation and technical and are labeled red, yellow or green, respec- search and rescue methodology, including sensi- tively, based on the extent of their injuries and tive listening devices and remote cameras. There the resources at hand. During medical triage, are also trained canines and their handlers.1 rapid categorization of victims at the casualty site is essential, and should be completed by the Triage and initial stabilization most experienced medical personnel available. Triage is the most important mission in a disas- Victims are color-coded (universal among most ter response scenario. Disaster triage is different emergency medical services) according to the than conventional medical triage in that conven- severity of their injuries:

© 2008 OCtOber 2008 The Surgical Technologist Association of Surgical Technologists 447 For reprint permission: [email protected] n Red—(immediate) is used to label those who Definitive medical care cannot survive without immediate treat- Definitive medical care improves, rather than ment, but who have a chance of survival. just stabilizes, the casualty’s condition. It varies n Yellow—(observation) is for those who widely, depending on the magnitude of the disas- require observation (and possible later ter, number of casualties and resources at hand. re-triage). Their condition is stable for the Both small and large-scale mass casualty inci- moment and they are not in immediate dan- dents may require the mobilization of specialty ger of death. These victims will still need hos- medical teams to participate in the field medical pital care and would be treated immediately response or supplement resources in the disaster under normal circumstances. region. Definitive care can be provided in either a n Green—(wait) is reserved for the “walking fixed facility, such as an existing hospital or build- wounded” who will need medical care at ing, or a mobile facility, such as a free-standing some point, after more critical injuries have field hospital. been treated. However, lessons in surge capacity manage- n Black—(expectant) is used for the deceased ment learned in the Iraq War may change the and those whose injuries are so extensive that way certain civilian MCIs are approached. Spe- they will not be able to survive given the care cifically, Iraq’s experience with damage-control that is available.2 (emergency) surgery has shown that more patients’ lives can be saved through temporizing damage-control surgery than if patients received Methods of Evacuation time-consuming definitive surgery.3 Method Cost/Benefit Ratio Ground • Simple and generally available Evacuation • Inefficient (low transport capacity) Evacuation is useful in a disaster as a means of • May remove critical resources “decompressing” the disaster scene, removing the Small Aircraft • High cost and complexity patients who are consuming the most resources. • Inefficient (low transport capacity) Evacuation of seriously-injured casualties to off- • Difficult to provide advanced care site medical facilities not only improves their care, • Aircraft may be better-utilized in disaster area but also allows increased attention to remaining Large Aircraft • Very high cost and complexity casualties at the disaster site. • More efficient (medical crew can manage multiple casualties over long distances) Mass Casualty Incident Response • Possibility of retrograde airlift (use of aircraft to bring supplies to disaster area) On August 29, 2005, Hurricane Katrina made landfall in Southeastern Louisiana. The high In a disaster scenario, all patients should be winds and unprecedented rainfall proceeded to brought to a casualty collection site, which should batter the Gulf Coast, causing nearly every levee in be located close enough to the disaster site for metro New Orleans to breach, flooding 80 percent easy casualty transfer, but far enough away to be of the city. The storm left 1,836 confirmed dead and safe. The collection site should be large enough to 705 missing. adequately handle the number of victims of the disaster. Collection sites should not, ideally, be Response to a mass casualty incident involves on hospital property and should be located a safe many different organizations with different com- distance from any hazards, upwind and uphill mand structures and missions simultaneously from contaminated areas and sheltered from the participating in the disaster response. For exam- elements.1 ple, the New York City Police and Fire Depart- ments, New York and New Jersey Port Authori-

© 2008 The Surgical Technologist OCtOber 2008 448 Association of Surgical Technologists For reprint permission: [email protected] ties, state police, FBI, National Guard and the US INCIDENT COMMAND SySTEM (ICS) Coast Guard, among others, were all on hand for the search and rescue effort after the World Trade On April 16, 2007, a shooting incident occurred on Center attack on September 11. the Virginia Tech campus in Blacksburg, Virginia. A mass casualty response needs to have a con- The shooter entered two campus buildings, where sistent approach to disasters based on an under- he killed 33 students and faculty, including standing of the common features of disasters and himself, and injuring 26 others. The incident is the the response expertise required. A key component greatest shooting rampage by a single gunman in that has brought about this consistent approach is US history. the incident command system (ICS).

S.T.A.R.T.

The simple triage and rapid treatment (START) your way through the remaining victims in a Circulation: The best method for check- system was developed to allow first respond- systematic manner. Each assessment should ing circulation is taking the radial pulse. If it ers to triage multiple victims in 30 seconds or take no longer than one minute. The central is absent or irregular, the patient should be less, based on three primary observations: res- point of disaster triage is to find and tag the tagged red/immediate. If the radial pulse is piration, perfusion and mental status. It allows patients that require immediate care. present, move on to evaluate the patient’s rescuers to locate the most severely-injured mental status. patients in the least amount of time. As more Evaluation Mental status: Mental status can be evalu- man power and other resources arrive on the The START system is based on three observa- ated through the patient’s ability to follow scene, the patients will be re-triaged for further tions: respiration, circulation and mental status. simple commands, such as “open your eyes” or evaluation, treatment and transportation. Respiration: If the patient’s breathing rate “squeeze my hand.” If the patient can follow Triage tags are the easiest way to designate is greater than 30 breaths per minute, a red/ these commands and exhibits adequate breath- a patient’s status on the disaster scene. The immediate tag is used. This respiratory pat- ing and circulation, he or she is tagged as yel- most common types of tags are either colored tern is indicative of the primary signs of shock low/delayed. A patient who is unresponsive to paper tags or colored surveyors tape. There are and needs immediate care. If the patient is not verbal stimuli is tagged as red/immediate. four designated colors for triage tags: breathing, clear the mouth of obstructions and tilt the head to open the airway. Position the Follow up n r Mino Delayed care/can delay up patient to maintain the airway. If the patient This system is designed to find the most seri- to three hours breathes, tag as immediate. Patients who ously injured patients. As resources become n Delayed Urgent care/can delay up to require assistance to maintain an open airway available, patients will be re-triaged for fur- one hour are also tagged as red/immediate. If you are ther evaluation, treatment, stabilization and n Immediate Immediate care/life- threatening unsure of a patient’s ability to breathe, use a transportation. Keep in mind that injured red/immediate tag. If the patient is not breath- patients do not remain in the same condition. n Dead Victim is dead/no care required ing and does not start to breathe with simple Conditions may deteriorate over time, neces- airway maneuvers, tag as black/dead. sitating a patient to be upgraded in status. As The first step in a disaster setting is to tell all the While certain steps in this process may con- time and resources permit, patients should be people who can get up and walk to move to a tradict standard cervical spine guidelines, they re-evaluated as often as possible. specific area. If patients can get up and walk, may be ignored during a mass-casualty triage they are probably not at risk of immediate death situation. This is the only time in emergency References and are indicated with a green tag. However, if care when there may not be time to properly 1. CERT Los Angeles. Simple Triage and Rapid Treatment. a patient complains of pain on attempting to stabilize every injured patient’s spine. March 26, 2003. Available at http://www.cert-la. com/triage/start.htm. Accessed: September 2, 2008 walk or move, do not force them to do so. If the patient is breathing at a rate of less After clearing the green/minor patients, than 30 breaths per minute, the next step in begin moving from where you stand. Work the 30-second evaluation is circulation.

© 2008 OCtOber 2008 The Surgical Technologist Association of Surgical Technologists 449 For reprint permission: [email protected] the hospital’s emergency preparedness plan. The HEICS features the same flexible management chart used in the ICS, which allows for a custom- ized hospital response to the crisis at hand.1

The features offered to hospitals are: n Predictable chain of command n Flexible organizational chart allowing a flex- ible response n Prioritized response checklist n Accountability

U.S. Coast Guard Petty Officer 2nd Class Nyxo Lyno Cangemi Lyno Nyxo Class 2nd Officer Petty Guard Coast U.S. n Improved documentation Medics receive a n Common language patient from a Coast The ICS provides a common organizational n Cost effective emergency planning Guard helicopter structure and language to simplify communica- during the Hurricane tion among disaster responders. The goal of the What is my role in a disaster? Katrina disaster. ICS is to utilize disaster resources in the most n Be able to respond efficient manner at the disaster scene. It is a mod- n Know where to respond ular system readily adaptable for all incidents n Know alternate routes to hospital and facilities regardless of the site. Functional n Be flexible requirements, not titles, determine the organi- n Remain calm zational hierarchy, and the structure remains the same regardless of the incident. The ICS should Good intentions alone do not constitute an effec- be started as early as possible to prevent the situ- tive disaster response. Given the complexity of ation from spiraling out of control. today’s medical disasters, medical personnel need to incorporate the principles of the mass casualty Job description of key ICS leaders incident response in their training, regardless of The ICS hierarchy is built around five manage- their specialties or the size of their institutions. ment activities. Command is responsible for all incident or event activities. Operations is respon- ABOUT ThE AUThOR sible for directing the tactical actions to meet the Tony Forgione, lpn, has worked at Massachusetts incident objectives. Planning collects, evaluates General Hospital in Boston for more than 30 and displays the incident information and main- years. He is a member of the International Medi- tains the status of resources. Logistics provides cal Surgical Response Team of the Department adequate services and support to meet all incident of Human Services. As a member of this team, needs. Administration/Financial tracks incident- Forgione has become familiar with disasters and related costs, personnel and equipment records, their aftermath. He was part of the response team and administers any procurement contracts.1 in New York during the September 11 disaster and also traveled to Iran in 2003, to care for vic- Hospital Emergency Incident Command System tims of a massive earthquake. Many hospitals are incorporating the ICS into their emergency preparedness plan. This sys- References 1. Advanced Disaster Medical Response. Harvard Medical Inter- tem is known as the hospital emergency inci- national. 2003. dent command system (HEICS). The HEICS is 2. Critical Illness and Trauma Foundation Inc. START—Simple Triage and Rapid Treatment. 2001. Available at: http://www.citmit. designed to help minimize a lot of the confusion org/start/default.htm. 3. National Center for Injury Prevention and Control. In a Moment’s and chaos experienced by hospitals in a medi- Notice: Surge Capacity for Terrorist Bombings. Atlanta: Centers for cal emergency. It is a plan designed to fit within Disease Control and Prevention; 2007.

© 2008 The Surgical Technologist OCtOber 2008 450 Association of Surgical Technologists For reprint permission: [email protected] Case study: Virginia Tech mass casualty incident Tom Borak

BACkgROUND dead-on-arrival (DOA) and the other, present- ing with a gunshot wound to the head, was trans- On April 16, 2007, a shooting occurred on the ferred to the nearest level 1 trauma center, Car- campus of Virginia Polytechnic Institute and State ilion Roanoke Memorial Hospital (CRMH). A University (Virginia Tech) in Blacksburg, Virginia. medevac was initially requested, but denied due The lone gunman, a Virginia Tech student, entered a student dormitory, where he claimed his first two victims. Nearly two hours later, the shooter made his way across campus and entered an academic building, where he proceeded to murder 30 more students and faculty, before taking his own life.

Blacksburg is a small town in a rural part of Virginia with a population of just under 40,000—including the student population of 25,000. As such, the area does not enjoy the lux- ury of the advanced medical structure available in many large cities. The closest level 1 trauma center is 42 miles away in Roanoke, Virginia. The next closest is in Charlottesville, Virginia, which is approximately 150 miles from the Virginia Tech campus. The three closest hospitals, Mont- gomery Regional Hospital (MRH), Carilion New

River Valley Medical Center (CNRV)and Lewis Times Roanoke The Kim, Alan Gale Medical Center (LGMC) are either level 3 Police officers carry trauma centers or nondesignated.1 to inclement weather: on April 16, 2007, high Virginia Tech student, winds with gusts of up to 60 mph made a medical Kevin Sterne, from EMERgENCy MEDICAL SySTEM RESPONSE airlift impossible, meaning all patients had to be Norris Hall. The former Shortly after 7 a.m., the shooter fired two shots, moved via ground transport. The second patient Eagle scout was shot claiming his first two victims in the West Ambler died shortly after arrival at CRMH.3 through the right leg, Johnson Hall dormitory. The incident was Because the shooting in the dormitory was severing the femoral phoned in to campus police by a student who sus- initially considered an isolated incident, campus- artery. He saved his pected that someone had fallen out of bed. The wide action was not taken. Two hours later, while own life by making a first responders discovered the victims shortly police were still working the initial crime scene, make-shift tourniquet after 7:20 a.m.2 the shooter made his way into Norris Hall, where from an electrical Virginia Tech Rescue requested assistance he chained the three main doors shut and began cord before first from the Blacksburg Volunteer Rescue Squad his rampage on the building’s second floor. responders applied a and both patients were transferred to Mont- At 9:42 a.m., campus dispatch received a real one. gomery Regional Hospital, three miles from the 9-1-1 call reporting multiple shots fired at Nor- dormitory. One of the victims was pronounced ris Hall. Police were on the scene by 9:45. The

© 2008 OCtOber 2008 The Surgical Technologist Association of Surgical Technologists 451 For reprint permission: [email protected] first mutual aid vehicle arrived on campus at n Day surgery patients with early surgery times 9:50 a.m. and staged in the forward staging area were sent home as soon as possible. as directed by EMS command. Additional EMS n The emergency department was placed on was requested via mutual aid with 14 agencies divert for all EMS units except those arriving responding.1 Because of the active shooter, these from the Norris Hall incident. The emer- resources were designated to a second staging gency department was staffed at full capacity. area located less than one-quarter mile from A rapid emergency department discharge campus until the area was secured. Staffing lev- plan was instituted. Stable patients were els were adjusted for all staged ambulances to transferred from the emergency department ensure that each was staffed by advanced life to the outpatient surgery suite.4 support providers.1 At 9:50 a.m., two medics entered the build- The regional hospital coordinator received ing. They were held up in the stairwell for two information from the scene of the shooting at minutes for safety precautions before being 10:13 a.m. and activated the Regional Hospital allowed to proceed.4 They began triage on vic- Coordinating Center (RHCC), at which time tims brought to the stairwells while police were the incident command system (ICS) was set in moving them out of the buildings. The triage had motion.1 At the national level, Homeland Secu- two specific goals: first, to identify the total num- rity Presidential Directives 5 and 8 require all ber of victims who were alive or dead; and sec- federal, state, regional, local and tribal govern- ond, to move ambulatory victims to a safe area ments, including EMS agencies, to adopt the where further triage and treatment could begin.4 National Incident Management System (NIMS), The medics used the Simple Triage and Rapid including a uniform ICS.5 The NIMS is defined Treatment (START) system to evaluate the sever- by Western Virginia EMS Counsel in their Mass ity of the injuries and assign treatment priorities. Casualty Incident (MCI) Plan as: Those tagged as red or yellow were immediately A written plan, adopted and utilized by all transported for hospital care. participating emergency response agen- cies, that helps control, direct and coor- hOSPITAL RESPONSE dinate emergency personnel, equipment and other resources from the scene of an At 9:45 a.m., MRH was notified of shots fired MCI or evacuation, to the transportation somewhere on the Virginia Tech campus. With- of patients to definitive care, to the conclu- out significant information, the hospital initiated sion of the incident.6 a security lockdown procedure as a precaution. At 10:00 a.m., the hospital received confir- A level 3 trauma center, the MRH emergency mation of multiple gunshot victims and a “code department received 17 patients from the Vir- green” (disaster code) was initiated: ginia Tech incident, including the two victims of n The hospital incident command center was the dormitory shooting.4 The first patient from opened and pre-assigned personnel reported the Norris Hall shooting arrived via self-trans- to command. port at 10:05 a.m., presenting with minor inju- n The hospital facility was placed on a con- ries sustained while escaping from the building. trolled access plan (strict lockdown). Only When two more patients arrived via EMS trans- personnel with appropriate identification port at 10:14 and 10:15, the hospital realized that (other than patients) could enter the hospi- they might continue to receive both expected tal, and then only through one entrance. and unexpected patients. In preparation for the n All elective surgical procedures were surge, MRH took the following precautions: postponed. n The Red Cross was alerted and the blood supply reevaluated.

© 2008 The Surgical Technologist OCtOber 2008 452 Association of Surgical Technologists For reprint permission: [email protected] n Additional pharmaceutical supplies and Other hospital planning regions activated a pharmacist were sent to the emergency their RHCCs and logged onto Web Emergency department. Operations Center (EOC), a virtual EOC and n A runner was assigned to assist with bringing bed-monitoring system used throughout the state additional materials to and from the emer- to track hospital resource availability and bed gency department and the pharmacy. accessibility.1 After activating its EOC, LGMC n Disaster supply carts were moved to the hall- canceled some elective surgeries and made hos- ways between the emergency department pital staff available to assist MRH if necessary. and outpatient surgery.4, 7 Between 10:30 and 10:55 a.m., nine additional patients arrived at MRH via EMS. At 11:30 a.m., At 10:17 a.m., the RHCC notified the Virginia a surgeon from LGMC was issued emergency Hospital and Health Care Association and the credentials from MRH to assist with emergency Virginia Department of Health in Richmond, procedures, which is notable because LGMC and Virginia, of the situation in Blacksburg. MRH are not affiliated.4

Table 1. All in a day’s work: Patients presenting from the Virginia Tech incident Hospital Injuries Disposition MRH Gun shot wound (GSW) left hand—fractured 4th finger OR and admission MRH GSW right chest—hemothorax Chest tube in OR and admission MRH GSW right flank OR and admission to ICU MRH GSW left elbow, right thigh Admitted MRH GSW x2 left leg OR and admission MRH GSW right bicep Treated and discharged MRH GSW right arm, grazed chest wall, abrasion to left hand Admitted MRH GSW right lower extremity; laceration to femoral artery OR and ICU MRH GSW right side abdomen and buttock OR and ICU MRH GSW right bicep treated and discharged MRH GSW face/head Intubated and transferred to CRMH MRH Asthma attack precipitated by running from building Treated and discharged MRH Tib/fib fracture due to jumping from second-story window OR and admission MRH First-degree burns to chest wall Treated and discharged MRH Back pain due to jumping from second-story window Treated and discharged CNRV GSW face, pre-auricular area, bleeding from external auditory canal, GCS of 7, poor Surgical cricothyrotomy; transferred to CRMH airway, anesthesiologist recommended surgical airway CNRV GSW flank and right arm, hypotensive Immediately taken to OR; small bowel resection CNRV GSW posterior thorax (exit right medial upper arm), additional GSWs to right buttock OR for surgical repair of left femur fracture and left lateral thigh CNRV GSW right lateral thigh, exit through right medial thigh, lodged in left medial thigh Admitted in stable condition and observed; no vascular injuries LGMC GSW grazed shoulder and lodged in occipital area; did not enter the brain Taken to surgery by ENT for debridement LGMC GSW in back of right arm; bullet not removed Admitted for observation LGMC GSW face, bullet fragment in hair, likely secondary to shrapnel spray Treated and discharged LGMC Shattered tib/fib due to jumping from second-story window Admitted, taken to surgery the next day LGMC Soft tissue injuries, neck and back sprain due to jumping from second-story window Treated and discharged

© 2008 OCtOber 2008 The Surgical Technologist Association of Surgical Technologists 453 For reprint permission: [email protected] To ease communication with EMS at the on a different radio frequency, making dispatch, scene, MRH sent an emergency administrator interagency and medical communication diffi- to determine how many more patients would cult.4 It congested both on-scene and in-hospital be transported to the hospital. The last gunshot situations that could be avoided with more plan- victim was received at 11:40 a.m., and the on- ning and implementation of uniform disaster scene liaison confirmed that all patients had protocol. been transported at 11:51 a.m. The code green While considered an overall success, given was lifted at 1:35 p.m.4 the conditions and circumstances of this disaster, this incident highlights the importance of com- AFTERMATh munication during incident response and pre- By 11 a.m., the hospital had established a base paredness for surge capacity. It also indicates the where staff and counselors could assist fam- importance of constant preparation and regular ily and friends of patients, however, many were training drills for an unforeseeable event. unsure of the status or location of the persons they were trying to find. References MRH established a psychological crisis coun- 1. Kaplowitz Lisa. Reece Morris. Hershey Jody Henry. seling team to provide services to victims, their Gilbert Carol M. Subbarao Italo. Regional Health Sys- tem Response to the Virginia Tech Mass Casualty Inci- families, loved ones and hospital staff.4, 8 dent. Disaster Medicine and Public Health Prepared- All told, 24 patients were treated in local emer- ness. Accessed August 25, 2008. gency departments, including MRH, LGMC and 2. Williams Reed. Morrison Shawna. Police: No Motive CNRV. (Table 1) Found. The Roanoke Times. April 26, 2007. Available at: http://www.roanoke.com/vtshootingaccounts/wb/114655. CONCLUSION Accessed August 25, 2008. 3. Perkins Timothy J. Virginia Tech Mass Shooting Review The overall assessment of the EMS response and Panel Report. EMS Responder.com. July 8, 2008. Avail- hospital preparedness is positive, however, there able at: http://www.emsresponder.com/print/Emergency-- are always improvements to be made. According Medical-Services/Virginia-Tech-Mass-Shooting-Review-Panel- to the report issued by the Virginia Tech Review Report/1$6353. Accessed August 25, 2008. Panel, the hospitals and public safety agencies 4. Report of the Virginia Tech Review Panel. August should have used the RHCC and WebEOC expe- 2007. Available at: http://www.governor.virginia.gov/Temp- Content/techPanelReport.cfm. Accessed August 25, 2008. ditiously to gain better control of the situation. 5. Bush George W. Homeland Security Presidential With rumors and unconfirmed reports concern- Directive/HSPD-8. December 17, 2003. ing patient surge, it would have made coordina- 6. West Virginia EMS Council. Mass Casualty Incident tion of the incident much easier.4 Plan: Ems Mutual Aid Response Guide. 2006. MRH requested activation of the RHCC at 7. Montgomery Regional Hospital. Montgomery Region- 10:05 a.m. It was activated under standby status al Hospital VT Incident Debriefing. April 23, 2007. 8. Heil J. et al. Report to the Virginia Tech Review Panel. at 10:19 a.m. and signed on to WebEOC. At 10:40 Psychological Intervention with the Virginia Tech Mass a.m., the RHCC requested an update of bed and Casualty: Lessons Learned in the Hospital Setting. diversion status from all hospitals in the area. By 2007. 10:49 a.m., however, only LGMC (of the hospi- tals that received patients from the Norris Hall incident) had signed on to WebEOC. MRH did not provide its status until 11:49 a.m., followed by CNRV at 12:33 p.m.4 Communication was also a significant issue during the Virginia Tech incident. Similar to the widely-publicized communication road- blocks on September 11, every service operated

© 2008 The Surgical Technologist OCtOber 2008 454 Association of Surgical Technologists For reprint permission: [email protected] Pandemic disease: The next great disaster? Tom Borak

Perhaps the greatest natural disaster threat is that While SARS was ultimately contained, the of pandemic disease. While it may not cause col- speed with which it spread is an important indi- lateral damage on the scale of a terrorist attack cator of how fast future pandemics may travel. It or a category 5 hurricane, this silent killer has a is critical that the United States health care sys- much greater reach and the destructive power tem is prepared for such a catastrophic event. to devastate any city in any country around the world. These biological agents know no bound- aries and can travel as fast as the hosts that carry them, which in today’s fast-paced world can mean global impact in just a few weeks’ time. In November 2002, severe acute respiratory syndrome (SARS) broke out in the Guangdong Province of China. On November 27, Canada’s Global Public Health Intelligence Network, an electronic warning system that is part of the World Health Organization’s (WHO) Global Outbreak and Alert Response Network, picked up reports of what was being called a “flu out- break,” and notified the WHO.1 Public awareness, particularly in the United States, did not escalate until February 2003, when an American businessman contracted the dis- ease on a flight from China to Singapore. He was taken to a hospital in Hanoi, Vietnam, where sev- eral of the staff that treated him also contracted Archive Press Free Winnipeg the disease, despite following hospital protocol. Free Press newsboys The patient eventually died. ARE WE READy? don protective The WHO issued a global alert on March 12, It is highly likely that hospitals and other health masks during the 2003, followed by a health alert by the US Centers care facilities will be overwhelmed by the sheer 1918 pandemic. for Disease Control and Prevention (CDC). volume of patients at the onset of a pandemic. While widely used, SARS was identified in 29 separate geo- According to Nancy Donegan, rn, director of the masks had no graphic areas. While it was concentrated mainly infection control at the Washington Health Cen- protective effect in China, cases were diagnosed across Western ter in Washington, DC, hospitals can increase against the virus. Europe, Canada and the United States. From their patient care capacity in relatively short peri- November 2002 to July 2003, 8,096 cases were ods of time by “surging in place,” which involves diagnosed, leading to 774 deaths. (Since July 11, rapidly discharging existing patients, cancelling 2003, 325 cases have been dismissed in Taiwan, scheduled elective procedures, and taking steps China. Laboratory information was insufficient to increase the number of patient-care staff in the or incomplete for 135 of those cases, of which facility in order to make additional staffed hos- 101 died.)2 pital beds available for incoming disaster event

© 2008 OCtOber 2008 The Surgical Technologist Association of Surgical Technologists 455 For reprint permission: [email protected] patients.3 However, most hospitals operate at or By the same token, financial constraints have near full capacity, which means they have a very forced many hospitals to adopt “just-in-time” limited ability to rapidly increase the workforce. supply chains for their equipment, which means While this strategy can provide a tempo- that new shipments are scheduled to arrive just rary ability to increase patient care capacity, as the supply is being exhausted. Therefore, in most hospitals cannot sustain such a surge for a sustained surge, as can be expected during a extended periods of time. Individual facilities pandemic, hospitals will face an almost immedi- will quickly become overwhelmed if the disas- ate shortage of critical supplies, including ven- ter involves large numbers of victims present- tilators, personal protective equipment for staff, ing over a prolonged period of time—and most drugs and other supplies.3 projections estimate that a pandemic will last at Since most hospitals are operating on the least a few months. “just-in-time” model, medical suppliers will be One of the most significant reasons for this unable to keep up with increased demand from is insufficient funding. According to the Ameri- all of their clients simultaneously, which will can Hospital Association, approximately one- result in a shortage, and supply rationing. third of hospitals lose money on operations— According to the Center for Biosecurity at the with Medicare and Medicaid under-funding University of Pittsburgh Medical Center, the esti- being a key driver. Another one-third of hos- mated cost of readiness for a severe (1918-like) pitals operate at or near the break-even point. pandemic is $1 million per average-sized hospi- This means that two out of three hospitals are tal (164 beds). The estimated costs include: not able to invest significantly in surge capacity n Develop specific pandemic plan: $200,000 preparation.3 n Staff education/training: $160,000

1918 Influenza pandemic

Margaret Sterling cst, l p n , m a ing overwhelming bouts of delirium. When the fever broke, many survivors suffered from post-influenza depression.4 Influenza, or simply the flu, can be traced through written The impact on the Eastern seaboard was almost immedi- records as far back as 412 B.C.1 Since then, there have been ate. The Boston stock market was closed, a state-wide order numerous outbreaks that have varied in severity. None, how- in Pennsylvania shut down every place of public amuse- ever, has impacted the world with the severity of the pan- ment—including saloons, and the Kentucky Board of Health demic outbreak in 1918-19. Dubbed the “Spanish Flu,” the prohibited public gatherings of any kind, including funerals. disease infected between 20-40 percent of the world’s popu- The dead piled up faster than they could be buried, resulting lation and killed more than 20 million people worldwide in in piles of bodies in the streets and mass graves. The medical less than a year—500,000 in the United States alone.2 community was overwhelmed. By the time the pandemic The US outbreak began at an Army base near Boston in had made its way across the country, and eventually faded September 1918. While it was identified as influenza, the completely, the nation had been devastated. characteristics of the strain were unique. The majority of deaths were due to bacterial pneumonia, a secondary infec- References tion caused by influenza. The virus also killed people direct- 1. Martin P. Martin-Granel E. “2,500-year Evolution of the Term Epi- 3 demic.” Emerging Infectious Diseases. 2006. ly, causing massive hemorrhages and edema in the lungs. 2. Centers for Disease Control and Prevention. Pandemic Influenza. The onset of the 1918 flu was very sudden. A victim February 12, 2004. Available at: http://www.hhs.gov/nvpo/pan could go from good health to being unable to walk within demics/flu3.htm#8. Accessed September 3, 2008. a few hours. Symptoms included general weakness, severe 3. Taubenberger J. Morens D. “1918 Influenza: The Mother of all Pan- demics.” Emerging Infectious Diseases. 2006. aches in muscles, backs, joints and heads. This was often 4. Crosby A W. America’s Forgotten Pandemic. Cambridge University accompanied by a fever that could reach 105 degrees, caus- Press. 1989

© 2008 The Surgical Technologist OCtOber 2008 456 Association of Surgical Technologists For reprint permission: [email protected] n Stockpile minimal personal protective equip- be needed in their own hospitals,3 which, in the ment: $400,000 case of a pandemic, is exactly the scenario that n Stockpile basic supplies: $240,000 would likely occur. n Total: $1 million3 Another consideration is that just because hospital staff work in a medical environment, it On top of that, the center estimates that annual does not make them immune to the pandemic. costs to maintain a state of readiness could reach Staff will be exposed to the disease both inside approximately $200,000 per year. Based on these and outside of work. Some will likely become numbers, the total for the nation’s 5,000 general infected themselves. Others may choose not to acute care hospitals for initial pandemic pre- show up for work at all, instead opting to stay paredness—not including annual maintenance home with family. Until the severity of the pan- costs—is about $5 billion.3 demic is understood, there is no way to know The US government’s National Bioterrorism exactly how it will impact the workforce and hos- Hospital Preparedness Program has recognized pitals’ ability to serve. the problem and is working to increase the cash Despite these shortcomings, it is critical that flow to the hospital system, although it is a very all hospitals and health care providers maintain slow process: a state of readiness for a potential pandemic out- Preliminary estimates in 2002 suggested break. It is advisable for facilities to follow the that hospitals would require approximate- three pillars of the National Implementation Plan ly $11 billion to obtain a basic level of “all whenever possible: 1) preparedness and commu- hazard preparedness.” Since then, Con- nication, 2) surveillance and detection, and 3) gress has appropriated about $500 mil- response and containment.3 lion per year for the program and the fis- For more in-depth research and additional cal year 2007 request is $487 million. This details on the national strategy, the National amounts to $2.1 billion over five years, or Strategy for Pandemic Influenza Implementa- about $100,000 per hospital per year to tion Plan can be found at http://www.whitehouse. fund preparedness. However, the amount gov/homeland/nspi_implementation.pdf. that hospitals have actually received is sig- nificantly less due to dollars allotted for References the federal government’s administration 1. Mawudeku A. Blench M. Global Public Health Intelli- of the program and overhead funds that gence Network. mt-archive. 2005. 2. World Health Organization. Summary of probable the state grantees have retained.3 SARS cases with onset of illness from 1 November 2002 to 31 July 2003. The other significant factor is man power. While 3. Donegan Nancy. Testimony of the American Hospital there are national plans to improve hospital staff- Association before the US Senate Special Committee ing numbers during a surge by expanding the on Aging. Preparing for Pandemic Flu. May 25, 2006. Medical Reserve Corps and the Public Health Available at http://www.ucop.edu/riskmgt/documents/aha_ panflu_testimony.pdf. Accessed July 7, 2008. Service Commissioned Corps, it becomes a moot point when the call for help simultaneously arises from hospitals across wide geographic areas. In addition, since the Medical Reserve Corps and other advanced registration programs for volun- teers often recruit their medical volunteers from hospital staff, it is unlikely that the volunteers’ “home” hospital would permit them to deploy elsewhere if there is an expectation that they will

© 2008 OCtOber 2008 The Surgical Technologist Association of Surgical Technologists 457 For reprint permission: [email protected] Gangrene: Recognizing and treating cellular necrosis

Brittany Stapp-Caudell

n 1996, Beck Weathers, a doctor from Dallas, Texas, was a member of an expedition making an assault on the summit of Mount Everest. In I what would become the greatest tragedy in the history of the moun- tain, eight climbers lost their lives in a storm on May 11. Weathers had retreated from the ascent early due to deteriorating vision. While he was waiting for his guide to return from the summit and lead him back to camp, a storm enveloped the mountain, creating whiteout conditions. Weathers headed back towards camp with four fel- low climbers. They got lost in the snow and were forced to stop searching for camp and huddle together for warmth. When a lull in the storm came, the most able-bodied of the group went for help. When he returned several hours later, Weathers was in a hypothermic coma. Unable to carry him back, the group left him for dead. He spent the night exposed to the elements, frostbite devouring his nose and both of his hands. The next day, two team members found Weathers alive after chipping blocks of ice from his face. Still unrespon- sive, they were unable to carry him and returned to camp to report his LEARNING OBJECTIVES imminent death. n Distinguish the variations of Miraculously, Weathers awoke from the coma and dug himself free gangrene of his would-be grave. With one eye swollen shut and the other unable to n Identify complications that can contribute to gangrene see more than three feet in front of him, he made his way back to camp, n Recognize treatment options where he was treated for severe frostbite and airlifted back to safety. that are alternatives to Beck Weathers escaped Everest with his life, but the dry gangrene surgery caused by the frostbite cost him his right arm, which was amputated n Examine the methods of diagnosis for gangrene halfway below the elbow. He also lost all four fingers and the thumb on n Explore Maggot Debridement his left hand and had his nose amputated and reconstructed with tissue Therapy as a treatment option from his ear.

© 2008 deCember 2008 The Surgical Technologist Association of Surgical Technologists 547 For reprint permission: [email protected] 300 deCember 2008 2 Ce Credits

Gangrene is a general term that can be used to introduction of antibiotics and enzymes as accept- describe a number of conditions that involve able treatments for surgical, chronic and traumatic the death and subsequent decay of tissue in one or accidental wounds. Recently, however, maggot regional portion of the body.1 A complication of therapy has regained some credibility and is some- necrosis, gangrene can arise as a result of critical- times employed with great efficacy in cases of ly insufficient blood supply,2,3 which is often asso- chronic tissue necrosis and gangrene infections. ciated with comorbid conditions such as diabetes and long-term smoking. It can develop when the CAUSES blood supply is cut off to the affected area of the Gangrene occurs when a body part loses its blood body as a result of various processes, including supply. The affected tissue may be the skin, mus- infection, vascular disease or trauma. If the gan- cles or internal organs. Blood provides oxygen grene is widespread, shock can occur, and if left and nutrients to feed the tissue cells and immune untreated, it can result in death.4 Due to its ten- system components, such as antibodies, to ward dency to spread quickly and the possibility of the off infections. Without a substantially function- necrosis of entire appendages, urgent diagnosis ing blood supply, the cells struggle to survive and treatment of the condition is necessary for and ultimately die.2 This necrosis, or cell death, the well-being of the patient. Antibiotics, wound can result when a portion of the body’s tissues debridement and surgery are the primary treat- become infected, injured or constricted, inter- ments for gangrene. rupting the blood supply. In addition, tissue in a particular region of the body may have a decrease ABOUT gANgRENE in the amount of blood supply due to a number There are several types of gangrene, but the of diseases or conditions such as arteriosclerosis, three most common variations are wet, dry and diabetes, smoking or wound infections – includ- gas gangrene. Less common variations include ing those related to surgery.1 Any of these afflic- internal and Fournier’s gangrene. Gangrene tions can significantly increase a person’s likeli- can involve any part of the body, but the most hood of contracting gangrene. Another indicator common sites include the toes, fingers, feet and for susceptibility is a suppressed immune sys- hands.3 Additionally, gangrene can affect the tem. Patients with HIV or who are undergoing muscles and internal organs.2 The best treat- chemotherapy are at a far greater risk of infec- ment for gangrene is revascularization of the tion due to the weakened state of their immune affected tissue, thus reversing some of the effects system. Severe burns or frostbite can also cause of necrosis and ultimately allowing healing of gangrene in body tissues due to the necrosis that the damaged tissue. Other treatments for gan- results from such injuries or conditions. grene include debridement and surgical ampu- tation. The chosen method of treatment is gen- SyMPTOMS erally determined depending on the location of The symptoms of gangrene depend on both the the affected tissue and extent of tissue damage, location and cause of the condition.1 If the skin death or loss. Although gangrene can be poten- is involved, or the gangrene is close to the skin, tially fatal, the prognosis for recovery is good if the symptoms may include discoloration (blue or gangrene is identified early and treated quickly.2 black if the skin is affected; red or bronze if the affected area is beneath the skin), foul-smelling hISTORy discharge and/or loss of feeling in the area.1 If the Before the introduction of antibiotics, fly maggots affected area is inside the body, the symptoms were commonly used to treat chronic wounds or may include, but are not limited to, confusion, ulcers. The maggots were utilized to debride the fever, gas in tissues beneath the skin, a general necrotic tissue without harming the healthy, liv- ill feeling, low blood pressure and persistent or ing tissue. This practice largely died out after the severe pain.1

© 2008 The Surgical Technologist deCember 2008 548 Association of Surgical Technologists For reprint permission: [email protected] A condition called septic shock can occur if a greater risk of contracting dry gangrene. bacterial infection that originated in the gangre- The early signs of dry gangrene are a dull ache nous tissue spreads throughout the body.2 Symp- and sensation of coldness in the affected area along toms of septic shock include low blood pressure, with pallor of the flesh. If caught early, the process an increased heart rate, lightheadedness, short- can sometimes be reversed by vascular surgery. ness of breath and confusion.2 However, if necrosis sets in, the affected tissue must be removed just as with wet gangrene. TyPES OF gANgRENE Dry Gangrene Wet Gangrene Dry gangrene is caused by a reduction in the Wet or moist gangrene develops as a complica- blood flow through the arteries of certain tissues. tion of an untreated bacterial infection, such as It typically appears gradually and progresses in an open wound. Swelling, blistering and a wet slowly. In most people, the affected area does not appearance are common features of wet gan- become infected. In this type of gangrene, the grene. It can develop in victims of severe burns, tissue becomes necrotic, cold and black, begins frostbite or other injuries in which blood supply is to dry, and eventually compromised.2 In addi- sloughs off as a result tion, wet gangrene often of the decreased blood presents in patients with supply to the said tis- A severe injury or trauma can comorbid conditions sue.2 Dr y gangrene increase the risk of gangrene. It such as obesity or dia- is commonly seen in causes trauma to the tissues by betes, where the patient patients who suffer impeding blood flow and increases u n k n o w i n g l y g e t s from arteriosclerosis, a the possibility of introducing a injured and then the result of increased levels malicious bacteria to the wound. wound becomes infect- of cholesterol, diabetes, ed. Wet gangrene needs cigarette smoking and to be treated immedi- other genetic factors. ately because it spreads Dry gangrene typically begins at the distal part quickly and can be fatal.2 of the limb, due to ischemia, and often occurs in Swelling resulting from the bacterial infec- the toes and feet. This type of gangrene usually tion causes a sudden stoppage of blood flow, spreads slowly until it reaches the point where the which causes tissue necrosis. Cessation of blood blood supply is inadequate to keep tissue viable.1 flow facilitates invasion of the muscles by bacte- Macroscopically, the affected tissue becomes dry, ria, which multiply because disease-fighting cells shrunken and blackened. The dark coloration is (white blood cells) cannot reach the affected part. due to the liberation of hemoglobin from hemo- Wet gangrene occurs in naturally-moist tis- lyzed red blood cells, which are acted upon by sue and organs such as the mouth, bowel, lungs, hydrogen sulfide that is produced by the bacteria cervix and vulva. Bedsores occurring on body that causes gangrene, resulting in formation of parts such as the sacrum, buttocks and heels are black iron sulfide that remains in the tissues. The also categorized as wet gangrene infections. In line of separation usually brings about complete wet gangrene, the tissue is infected by saprogenic severance between the healthy and necrotic tis- microorganisms that cause tissue to swell and sue, ultimately resulting in the gangrenous tissue emit a fetid smell. Wet gangrene usually develops falling off if it is not surgically removed. rapidly due to blockage of venous and/or arterial If the blood flow is interrupted for a reason blood flow. The affected part is saturated with other than severe bacterial infection, the result stagnant blood, which promotes the rapid growth is a case of dry gangrene. People with impaired of bacteria. The toxic products formed by bacte- peripheral blood flow, such as diabetics, are at ria are absorbed causing systemic manifestation

© 2008 deCember 2008 The Surgical Technologist Association of Surgical Technologists 549 For reprint permission: [email protected] of septicemia and finally, death. Macroscopically, skin may become pale and then later evolve to a the affected part is edematous, soft, putrid, rotten purple or red color.5 The skin may additionally and dark. The darkness in wet gangrene occurs begin to bubble and crackle upon touch due to due to the same mechanism as in dry gangrene. the accumulation of the toxic gas bubbles cen- tralized beneath the skin.2 If the bacterial toxins Gas Gangrene spread into the bloodstream, the patient may Gas gangrene is a type of wet gangrene, common- develop a fever, increased heart rate and rapid ly caused by an anaerobic, gram-positive, spore- breathing, signifying an infection of the blood. forming bacillus of the bacterium family known as Clostridia.5 Clostridia are a type of infection- Internal Gangrene causing bacteria that grow only in the absence of If a gangrene infection spreads to or affects the internal organs, such as the intestines, gallblad- der or appendix, it is referred to as internal gan- grene. This type of gangrene occurs when blood flow to an internal organ is blocked, such as with a hernia or a twist in the gastrointestinal tract.2 Symptoms of internal gangrene are often a high fever and excruciating abdominal pain. Internal gangrene is treatable, but if left untreat- ed, can potentially be fatal.2

Fournier’s Gangrene Fournier’s gangrene is an uncommon type of gan- grene that affects the genital organs of an infected patient. While it typically affects the genitalia of men, women can also be infected with this par- ticular form of gangrene.6 Fournier’s gangrene usually arises due to an infection in the genital X-ray of a foot area or urinary tract and causes genital pain, ten- presenting with gas oxygen. As it grows, it produces poisonous toxins derness, redness and swelling.2 gangrene. and gas, hence the designation of gas gangrene.5 It is usually an internal condition, typically affect- R IS k F ACTORS A FFECTIN g g A N g RENE ing the patient’s muscular system.2 Numerous factors can contribute to a patient’s The anaerobic bacteria typically enter the likelihood of contracting a gangrene infection. body through an open wound caused by an inju- Age is one such factor. Older patients tend to ry or surgery.2 This particular gangrene infection contract gangrene with a higher frequency than spreads rapidly as the gases produced by the bac- the younger population.4 Previously-mentioned teria expand and infiltrate healthy tissue in the conditions, such as diabetes, obesity and vascular surrounding vicinity. Gas gangrene can cause damage or disease can also greatly increase the necrosis, gas production and sepsis.5 Progression risk of a gangrene infection by interrupting blood to toxemia and shock is often very rapid. Due flow to certain regions of the body, primarily the to the bacteria’s ability to spread quickly to sur- periphery regions, and contributing to necrosis. rounding tissues, gas gangrene should be treated A severe injury or trauma, including surgery, can as a medical emergency.5 increase the risk of gangrene due to the fact that The patient suffering from gas gangrene may it causes trauma to the tissues by impeding blood present with intact surface skin over the infected flow and increases the possibility of introducing a area. As the condition progresses however, the malicious bacteria to the wound.1 Finally, immu-

© 2008 The Surgical Technologist deCember 2008 550 Association of Surgical Technologists For reprint permission: [email protected] nosuppression can increase the likelihood of a TREATMENT gangrene infection due to the fact that the body In general, treatment of gangrene infections cannot effectively fight off a pathogenic invader.2 should include the removal of necrotic tissue in an attempt to allow healing of the surrounding DIAgNOSIS living tissue. It is also an important step towards The diagnosis of gangrene is based on the patient’s the prevention of further infection. The treatment history, physical examination, blood tests and options of the various types of gangrene, however, other exams.4 The practitioner must investigate differ due to the different natures of the condi- the patient’s history of injury, history of any and all tions.1 Antibiotics are usually administered intra- possible chronic diseases or conditions (especially venously to a patient suffering from gangrene in an those that affect the vasculature of certain regions, effort to control the spread of an aggressive infec- such as diabetes and tion. Additionally, pain arteriosclerosis), sur- relievers are adminis- gery, cigarette smoking tered to control the pain and possible exposure Gas gangrene is incredibly aggres- of the infection, while to extreme cold is usu- sive and potentially fatal. The anticoagulants are given ally investigated when infection can progress quickly and to prevent blood clot- attempting to diagnose once it invades the bloodstream, ting. Intravenous fluids, 1 a gangrene infection. the potential fatality rate rises to such as dextrose in solu- A physical exami- approximately 20-25 percent. tion and isotonic saline nation of the affected are dispensed to replen- area is performed in an ish electrolytes and attempt to look for pos- reestablish fluid balance sible local signs of a wet gangrene infection. The within the infected individual’s body.4 Because patient’s blood test results will ultimately show an the cause of dry gangrene is a lack of blood flow increase in the number of white blood cells if the to certain tissues, restoring the blood supply is a patient is suffering from a wet gangrene infection vital characteristic of effective treatment.1 as the body attempts to fight off the bacteria. If For a wet gangrene infection, surgical debri- possible, a sample of drainage from the gangre- dement, or removal of the dead tissue from the nous wound is examined to identify the bacteria infected wound, can be performed to evacuate causing the infection.1 If the analysis of the drain- any dead tissue. Additionally, intravenous antibi- age from the wound of a wet gangrene case does otics are administered to potentially control the not initially yield the cause of the condition, a cul- infection causing the wet gangrene. ture will be taken and grown in an attempt to iden- Due to the threat of rapid spreading of the tify the type of pathogen present in the wound, as gas gangrene infection via the bloodstream of well as aiding in possible treatment options. the affected individual, this condition needs to In order to diagnose a potential case of gas be treated aggressively and quickly. The wound gangrene, an X-ray can be used in an attempt to resulting from gas gangrene requires immedi- examine the affected tissue for the presence of gas ate debridement. Additionally, antibiotics are bubbles, signifying a potential case of gas gan- administered immediately to the affected patient grene. Imaging studies, including but not limited in an effort to both control and kill the imped- to a CT scan or an MRI, can additionally aid in the ing infection. Depending on the area that has the determination of the extent of tissue damage as gangrene, the person’s overall condition and the well as the amount of gas present.1 In people with cause of the gangrene, treatment may include dry gangrene, an arteriogram may be performed amputation of the infected body part. Emer- in order to visualize any obstruction in the artery gency operations to locate and debride any and that supplies blood to the affected part.1 all dead tissue, surgical interventions to improve

© 2008 deCember 2008 The Surgical Technologist Association of Surgical Technologists 551 For reprint permission: [email protected] blood supply to the given area, and repeated deb- people in whom the infection has spread through ridement operations to remove all affected tissue the blood stream.1 in an attempt to reduce the risk of the spread of Gangrene is usually curable in the early stages the infection to healthy surrounding tissues are with intravenous antibiotic treatment and debri- standard operating procedures. dement of the infected wound. In the absence of If the infection cannot be controlled with surgi- treatment however, gangrene may lead to a fatal cal debridement and the consecutive administra- infection once the pathogens invade the blood- tion of antibiotics, amputation of the affected part stream and affect surrounding, healthy tissues becomes necessary to prevent further deteriora- and organ systems. If treatment is delayed, the tion of the surrounding, healthy tissues. Amputa- gangrene is extensive, or the person has other tion is usually the last effort to be exhausted in the significant medical problems, he or she may die.1 treatment of gangrene, but due to the infection’s Gas gangrene, in particular, is incredibly rapid spread and aggressive presentation, a large aggressive and potentially fatal. The infection can handful of patients routinely lose appendages or progress quickly and once the infection invades the possibly limbs as a result of gangrene. bloodstream, the potential fatality rate of the con- dition rises to approximately 20-25 percent. How- ALTERNATIVE TREATMENT OPTIONS ever, if it is diagnosed and treated early, approxi- One alternative to standard practice is the use of a mately 80 percent of people with gas gangrene hyperbaric oxygen chamber as a means to reoxy- survive without the need for any amputation.1 genate the damaged tissues. In this method, the Alternatively, patients suffering from dry gan- patient is entirely enclosed in a pressure chamber grene usually have many other comorbid condi- breathing oxygen at a pressure greater than one tions that ultimately complicate recovery and can atmosphere, a process known as hyperoxygen- prove fatal. ation.7 Breathing oxygen at three times the nor- mal atmospheric pressure can deliver up to 15 ABOUT ThE AUThOR times the amount of physically dissolved oxygen Brittany Stapp-Caudell is a second term surgical as breathing regular air. This extra supply of oxy- technology student at San Joaquin Valley College gen dissolved in the blood plasma generates new in Fresno, California. She is scheduled to begin capillaries in the wound area. Hyperbaric oxygen her clinical experience in February 2009, and will therapy has also been shown to inhibit the growth graduate in September 2009. of many anaerobic and aerobic organisms. This effect, known as bacteriostasis, complements the References 1. Carson-DeWitt R. Gangrene. 2007. Available at http://www. improved ability of the host to combat disease and bidmc.harvard.edu/YourHealth/ConditionsAZ.aspx?ChunkID=11839. is useful in conditions where resistance factors are Accessed September 20, 2008. compromised, such as dysvascular conditions and 2. Diseases and conditions: Gangrene. 2007. Available at http://www.mayoclinic.com/health/gangrene/DS00993. Accessed 7 immunosuppressive disorders. Patients receiving September 18, 2008. hyperbaric oxygen therapy must be monitored 3. Ho H. Gas Gangrene. 2006. Available at http://www.emedicine. com/med/topic843.htm. Accessed September 18, 2008. for symptoms of oxygen toxicity, such as profuse 4. McGuigan B. What is gangrene? 2003. Available at http:// sweating, difficulty breathing and convulsions.2 www.wisegeek.com/what-is-gangrene.htm. Accessed Septem- ber 18, 2008. 5. Sitham SO. Gangrene. 2008. Available at http://www.nlm.nih. PROgNOSIS gov/medlineplus/ency/article/007218.htm#Causes,%20incidence,%20 The outlook for a person with gangrene depends and%20risk%20factors. Accessed September 18, 2008. on the portion of the body that is affected, the 6. Uppot RN. Case 54: Fournier gangrene. 2001. Available at http://radiology.rsnajnls.org/cgi/content/full/226/1/115. Accessed extent of the gangrene, the cause of the infection September 18, 2008. and the overall health of the patient.1 Addition- 7. Wound Care Institute Newsletter. 1996. “Commonly Asked Questions on Hyperbaric Oxygen Therapy.”Available at: ally, the outlook for the patient recovering from a http://www.woundcare.org/newsvol1n3/ar8a.htm. Accessed gangrene infection is generally favorable except in October 27, 2008.

© 2008 The Surgical Technologist deCember 2008 552 Association of Surgical Technologists For reprint permission: [email protected] Maggot Debridement Therapy: Biosurgical Treatment for Infected Wounds

Tom Borak

A patient hobbles into the private exami- nation room at her doctor’s office and carefully seats herself on the examination table. It has been two days since her last visit and she is anxious to check on the status of the diabetic ulcer that is threaten- ing to claim her foot. She has exhausted all possible remedies for her ailment, including antibiotic regimens and surgical procedures to remove the necrotic tissue. Nothing, however, has been able to force the growing wound into remission. Her doctor enters the room with a smile and asks how she’s feeling. “I have a slight tingling sensation in my foot,” she says, “but overall, I feel fine.” The doctor nods, pulls up a stool and sits in front of her. A medical assistant Greenbottle fly. positions a trash can beneath the patient’s ly larvae, or maggots, are making a comeback foot and the doctor begins to remove in the modern medical community. Once a the covering from the wound site. As the Fvery common and popular means of clean- gauze pad is slowly pulled away from the ing infected wounds in the United States, mag- wound, a wriggling ball of maggots falls got debridement therapy (MDT) fell out of favor from the wound into the trash can below. with the mainstream medical establishment with Unfazed, the doctor examines the the development of advanced pharmacological wound. The necrotic tissue that had been antibiotic treatments after World War II.1 prevalent two days earlier is completely The practice was revisited in the 1970s and gone. Live, pink tissue is all that remains. 80s, used only after all other means of wound The doctor smiles at the patient and says, care had been exhausted, and ultimately led to “Even better than I expected!” the first modern clinical studies of the practice in 1989.1 The results of those trials, and the studies and reports that followed, indicated that MDT is still an extremely viable treatment tool for cer-

© 2008 deCember 2008 The Surgical Technologist Association of Surgical Technologists 553 For reprint permission: [email protected] tain types of wounds. In addition, the studies cies are much less aggressive. The species most suggest that MDT does not need to be an option commonly used in MDT is the blow fly (Lucilia of last resort. In fact, while published accounts sericata), commonly called the greenbottle for its of “pre-amputation MDT” show a limb salvage metallic green color.2 rate of more than 40 percent, the success of MDT When introduced to the wound, the blow when used earlier in the course of treatment is fly larvae produce a mixture of proteolytic even more dramatic.1 enzymes,2, 4 including collagenase, which breaks MDT serves three primary functions: down the dead tissue into a semi-liquid, which is n Clean the wound by dissolving dead and reabsorbed and digested.2 The larvae will not bur- infected tissue. row under the skin or attack healthy tissue and n Disinfect the wound. Preliminary studies sug- there is no danger that they will stay within the gest that maggots are even able to eradicate wound and breed. A mature larva must leave the antibiotic-resistant wound to pupate (the bacteria, such as stage before it becomes MRSA, from infect- an adult insect) or else it ed wounds.2 This MDT is still an extremely viable will die. In fact, once the theory is currently treatment tool for certain types larvae are fully grown under investigation of wounds… While published they will come to the and could have seri- accounts of “pre-amputation MDT” surface of the wound, ous implications for show a limb salvage rate of more where they are easily post-surgical infec- than 40 percent, the success of MDT removed.2 tion patients. when used earlier in the course of The application pro- n Speed the rate of treatment is even more dramatic. cess is very simple. A healing.1 It is also dressing is created by believed, though making a tracing of the it has not yet been wound on a sterile plas- confirmed in a clinical trial, that the larvae tic sheet, which is then cut out and transferred to actually stimulate the production of granula- a hydrocolloid dressing. The shape of the wound tion tissue,2 the perfused, fibrous connective is cut from the hydrocolloid and discarded.2 The tissue that replaces a fibrin clot in healing sheet with the wound-sized hole is then applied wounds and aids vascularization. This effect to the patient. This dressing serves two func- has been previously reported in historical tions. It provides a sound base for the second records and possible mechanisms for this component of the dressing system and protects occurrence are currently being sought. the healthy tissue from the potent proteolytic enzymes released by the maggots. Of course, the thought of introducing maggots The larvae, initially about 2 mm long, are to an open wound is difficult for some patients— introduced to the wound using a sterile piece of and even some practitioners—to handle. Com- gauze to transfer them from their shipping con- mon misconceptions include maggots generat- tainer. The number of maggots used depends on ing bacteria and increasing the risk of infection, several factors, including the size of the wound burrowing deeper into the tissue and breeding and the amount of necrotic tissue that is pres- more maggots. All of these fears, however, are ent. General guidelines indicate that the wound unfounded. should contain no more than 10 maggots per While it is true that certain fly species, such square centimeter.2 as the screw worm fly, hatch larvae that burrow After the larvae have been introduced to the down into the living tissue, causing massive tis- wound, a sterile piece of fine nylon mesh, a lit- sue damage and sometimes death,2, 3 many spe- tle larger than the wound, but smaller than the

© 2008 The Surgical Technologist deCember 2008 554 Association of Surgical Technologists For reprint permission: [email protected] hydrocolloid dressing, is applied to the back of In addition to the health benefits associated the hydrocolloid with adhesive tape.2 An absor- with MDT, patients can receive this therapy in bent pad is also applied to the outer surface of the comfort of their own home or on an out- the net to catch any liquefied necrotic tissue. The patient basis, which can reduce or eliminate the outer absorbent dressing can be changed as often costs associated with hospitalization. It should as required. Because the net is partially transpar- always be remembered, however, that MDT is a ent, the activity of the maggots can be determined potent therapeutic tool and should be used with without removing the primary dressing.2 caution by properly-trained staff. The maggots are typically left in the wound for 24-48 hours. Their natural instinct tells them References to leave the wound once the dead tissue is gone or 1. Sherman Ronald A. Maggot Debridement Therapy (MDT). 2008. Available at: http://www.medicaledu.com/ they have consumed all that they can eat. When maggots.htm. Accessed October 30, 2008. the dressing is removed, most of the maggots will 2. Jones M, Jones S, Shutler S, Thomas S. Maggots in crawl out of the wound on their own. Any that Wound Debridement—an Introduction. 1999. Avail- are left behind can be easily removed with gen- able at: http://www.smtl.co.uk/WMPRC/Maggots/maggots. tle irrigation or forceps. If necrotic tissue is still html. Accessed October 30, 2008. present, additional applications of fresh maggots 3. Hall M, Smith K. Diptera Causing Myiasis in Man. In: Crosskey Roger W, Lane Richard P, eds. Medical can be used as necessary. The contaminated mag- Insects and Arachnids. 1995, 429-469. gots should be disposed of by the same means as 4. Ksander G, Lee R, Vistnes L. Proteolytic Activity of other biological waste. Blowfly Larvae Secretions in Experimental Burns. Before they can be shipped to medical facili- Surgery. 1981. ties around the country, the maggots must be raised in a sterile envi- ronment. The external Preliminary studies suggest that surface of the fly’s eggs maggots are even able to eradicate are normally contami- antibiotic-resistant bacteria, such nated with bacteria, as MRSA, from infected wounds. which must be removed This theory is currently under or killed before the eggs investigation and could have seri- hatch if the emerg- ous implications for post-surgical ing larva are to remain infection patients. sterile.2 The eggs are collect- ed on raw liver in a con- trolled environment. They are then cleaned and sterilized under aseptic conditions, using equip- ment that is more commonly used for the produc- tion of sterile pharmaceuticals. 2 The sterilized eggs are then transferred asep- tically to sterile flasks, which contain an appro- priate substrate on which they will hatch. The substrate is formulated to maintain the viability of the larvae without allowing them to grow too rapidly. With sufficient oxygen, the larvae can be stored in a cool place for extended periods of time until they are ready for use.

© 2008 deCember 2008 The Surgical Technologist Association of Surgical Technologists 555 For reprint permission: [email protected]

Answers CE CREDIT PKG 6: 12 CONTINUING EDUCATION CREDITS

■ Certified Member AST Member No: ______

Name: ______Certification No: ______

Address: ______City: ______State: ______ZIP: ______

Telephone: ______Email: ______

CE CREDIT PKG 6: 12 CONTINUING EDUCATION CREDITS The fee is $19. This package is only available to AST members.

■ Check Enclosed Yes, I want to pay by credit card: ■ Visa ■ MasterCard ■ AmEx Card #______Expiration Date______Signature______

Ethics in the O.R., Part 1 a b c d a b c d a b c d a b c d 1. ■ ■ ■ ■ 4. ■ ■ ■ ■ 7. ■ ■ ■ ■ 10. ■ ■ ■ ■ 2. ■ ■ ■ ■ 5. ■ ■ ■ ■ 8. ■ ■ ■ ■ Mark one box next to each number. Only one correct or best answer can 3. ■ ■ ■ ■ 6. ■ ■ ■ ■ 9. ■ ■ ■ ■ be selected for each question.

Ethics in the O.R., Part 2 a b c d a b c d a b c d a b c d 1. ■ ■ ■ ■ 4. ■ ■ ■ ■ 7. ■ ■ ■ ■ 10. ■ ■ ■ ■ 2. ■ ■ ■ ■ 5. ■ ■ ■ ■ 8. ■ ■ ■ ■ Mark one box next to each number. Only one correct or best answer can 3. ■ ■ ■ ■ 6. ■ ■ ■ ■ 9. ■ ■ ■ ■ be selected for each question.

Safety Concepts in the Surgical Setting a b c d a b c d a b c d a b c d 1. ■ ■ ■ ■ 4. ■ ■ ■ ■ 7. ■ ■ ■ ■ 10. ■ ■ ■ ■ 2. ■ ■ ■ ■ 5. ■ ■ ■ ■ 8. ■ ■ ■ ■ Mark one box next to each number. Only one correct or best answer can 3. ■ ■ ■ ■ 6. ■ ■ ■ ■ 9. ■ ■ ■ ■ be selected for each question. Necrotizing Faciitis a b c d a b c d a b c d a b c d 1. ■ ■ ■ ■ 7. ■ ■ ■ ■ 13. ■ ■ ■ ■ 19. ■ ■ ■ ■ 2. ■ ■ ■ ■ 8. ■ ■ ■ ■ 14. ■ ■ ■ ■ 20. ■ ■ ■ ■ 3. ■ ■ ■ ■ 9. ■ ■ ■ ■ 15. ■ ■ ■ ■ Mark one box next to each number. Only one correct or best answer can 4. ■ ■ ■ ■ 10. ■ ■ ■ ■ 16. ■ ■ ■ ■ be selected for each question. 5. ■ ■ ■ ■ 11. ■ ■ ■ ■ 17. ■ ■ ■ ■ 6. ■ ■ ■ ■ 12. ■ ■ ■ ■ 18. ■ ■ ■ ■

Disasters Follow No rules

a b c d a b c d a b c d a b c d 1. ■ ■ ■ ■ 9. ■ ■ ■ ■ 17. ■ ■ ■ ■ 25. ■ ■ ■ ■ 2. ■ ■ ■ ■ 10. ■ ■ ■ ■ 18. ■ ■ ■ ■ 26. ■ ■ ■ ■ 3. ■ ■ ■ ■ 11. ■ ■ ■ ■ 19. ■ ■ ■ ■ 27. ■ ■ ■ ■ 4. ■ ■ ■ ■ 12. ■ ■ ■ ■ 20. ■ ■ ■ ■ 28. ■ ■ ■ ■ 5. ■ ■ ■ ■ 13. ■ ■ ■ ■ 21. ■ ■ ■ ■ 29. ■ ■ ■ ■ 6. ■ ■ ■ ■ 14. ■ ■ ■ ■ 22. ■ ■ ■ ■ 30. ■ ■ ■ ■ 7. ■ ■ ■ ■ 15. ■ ■ ■ ■ 23. ■ ■ ■ ■ Mark one box next to each number. Only one correct or best answer can 8. ■ ■ ■ ■ 16. ■ ■ ■ ■ 24. ■ ■ ■ ■ be selected for each question.

Gangrene: Recognizing and Treating Cellular Necrosis a b c d a b c d a b c d a b c d 1. ■ ■ ■ ■ 7. ■ ■ ■ ■ 13. ■ ■ ■ ■ 19. ■ ■ ■ ■ 2. ■ ■ ■ ■ 8. ■ ■ ■ ■ 14. ■ ■ ■ ■ 20. ■ ■ ■ ■ 3. ■ ■ ■ ■ 9. ■ ■ ■ ■ 15. ■ ■ ■ ■ Mark one box next to each number. Only one correct or best answer can 4. ■ ■ ■ ■ 10. ■ ■ ■ ■ 16. ■ ■ ■ ■ be selected for each question. 5. ■ ■ ■ ■ 11. ■ ■ ■ ■ 17. ■ ■ ■ ■ 6. ■ ■ ■ ■ 12. ■ ■ ■ ■ 18. ■ ■ ■ ■

Directions: Complete all 6 answer keys for the exams. Include your check or money order made payable to AST or complete credit card information with the appropriate amount and mail to Members Services, AST, 6 W Dry Creek Circle, Ste 200, Littleton, CO 80120-8031. If paying by credit card, you can fax in the answer keys and credit card payment to AST at 303-694-9169.