Painting in the OR: The evolution of surgical preparation

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

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

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

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

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

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

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

Another variable is the vigor the nurse will demonstrate during the application process. Male nurses, perhaps trying to display their machismo, paint with such strength and verve that I sometimes wonder if layer of skin has not been removed along with all the nasty microorganisms. They must believe that their added muscle will kill the resident bacteria by shear force. Maybe it does. Some of the newer, less experienced nurses will daintily apply the prep, working only from the edge of the applicator, slowly painting the operative field at the same rate Michelangelo painted the ceiling of the Sistine Chapel. Others insist on two coats, logically concluding that two layers of paint will cover more and kill twice as many potential microinvaders (never proven, however).

Sometimes as the prep is being applied I will offer my critique of the painter’s skill. The most skilled artists have been offered a job painting my house, an invitation which has universally, but politely, been declined.

Finally, the size of the prepped area has changed. Nipples to knees is reserved for only the most major cases: aortofemoral bypasses, Whipples, esophagectomies and such. Most of the time, now it appears that the nurse has decided that a wide and extensively prepped area is either too much work or will cause some sort of terminal illness as they limit the area to a size which sometimes seems barely larger than an Elvis Presley stamp. If I am late getting into the OR room the nurse will be forced to break out a new prep kit and expand the cleansed territory.

Nurses are not the only members of the OR team who are allowed to paint. The truly creative painting is reserved for pathologists. Technically, these doctors are not in the operating room. They may be in a room next door or down the hall, but they are, nonetheless, vital cogs in the surgical process. Their job is to examine specimens after removal, sometimes immediately, and determine if the surgery has removed adequate tissue, most important in cancer operations. It is during the examination of these resected tissue specimens that the pathologist’s true character is revealed.

Theyget to paint the removed organ or tissue; they call it “inking” the margins, but it looks like preschool playtime to me.

The purpose of this inking is to tag the edge of a specimen so that its margin can be clearly identified under the microscope. Different colors are employed based on the pathologist’s preference. Mostly working with primary colors, the intrepid pathologist may mark the superior margin with blue, medial margin with red, and inferior with green and so on. So what? Nothing creative about that.

However, it is the technique that the pathologist employs which is truly fascinating and, perhaps, revealing. For instance, some pathologists prefer finger painting, dipping their gloved hand into the ink and smearing it with glee on the tissue margin. By necessity, either the glove is changed or different fingers are utilized for each color, but the mirth and joy in the lab are almost palpable.

I’ve watched my pathology colleagues almost squeal with delight as they get to do their finger painting. Other pathologists, perhaps a bit more prim, employ wooden sticks to paint their specimens, carefully inking each side and tossing the finished stick away, never using one drop too much or too little to accomplish their task. Still others use a brush, dipping and painting, all the time keeping a watchful eye on the process; doing their best to maintain artistic purity. There is an air of solemnity in the lab as each new tissue inking is created and, once finished, almost suitable for framing.

Sometimes I regret not going into pathology. The inking of the specimens always looks like so much fun.

David Gelber is a general and vascular surgeon who blogs at Heard in the OR and author of Behind the Mask.

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  • Rob Burnside

    Clearly, you’re the John Updike of vascular surgery, and the Jackson Pollock, too. Thanks for a very entertaining, informative post!