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Scrub-Sink Wisdom

For one doctor, washing his hands before surgery is a quiet ritual that allows him to direct his focus solely to the task at hand.

By David Sable, M.D.

Between five and ten times a week, I wash my hands for surgery. I start the water by pressing a metal plate with my knee. I squeeze a sealed bag with a scrub brush inside until it pops and makes a pffffft sound, then remove the brush and run it under the water. The brush is soft and spongy on one side, sharp and bristled on the other; the soft side has pink soap painted on top, which bubbles up when I press in with my fingers. I sponge on the soap, scrub with the bristles, then rinse. For five minutes, I wash from elbows to fingertips, the same way I was taught in medical school 21 years ago. The sponge is always soft, the bristles always sting, and the water is usually cold.

Sometime between the years of my training and my current practice, the scrub sink changed from a site of nervous anticipation to one of calm. Surgical skills evolve: At first, we tell our hands what to do and our hands do their best to comply; over time, we become less conscious of them-they cut, sew, apply pressure, and retract on their own, confident in what they have done successfully and gently so many times before. Later, the mind begins to learn from the hands. No longer needing to calculate the amount of pull on each end of a knot or the depth of an incision, it can instead focus on more substantive matters: How much stress has the tissue sustained so far? How will it heal later? How is my work affecting the surrounding structures? How will my decisions over the next few minutes affect the conflict between healing and scarring that will occur as the body recovers from this intrusion?

Time stands still during surgery, and hours pass unnoticed. The sequence of decision-action-decision-action smooths out; thinking and doing meld into one activity, beginning the moment I press the metal plate to start the water to wash my hands. Now, when I teach surgery to residents, I encourage them to use the time at the scrub sink for more than just washing. We discuss the case as we wash: why the patient needs surgery, what we plan to do, complications we might encounter. I try to add something about the patient herself, something to help remind my junior colleagues that there is a history and a personality and a soul behind what we will actually see inside the abdomen.

But more important than what we say is the focus that our five minutes of scrubbing imposes. It tells us that the next 30, or 60, or however many minutes that we're in the operating room belong not to us but to the patient—that nothing else going on in our lives will be as important as the procedure at hand. It's a liberating idea: no prioritizing, no pondering the mysteries of life, no multitasking. We have one task and one task only.

Surgical gloves used to be lined with powder, which we washed off after the procedure, before shaking hands with the family and reassuring them that everything went OK. The powder is now gone, but out of habit I still rinse my hands afterward. There are several things to juggle—orders to write, notes to dictate, calls to return—and the cold water signals that it is now time to scatter my attention in different directions. There is much to do and never enough time in which to do it. Because after the orders, the notes, and the calls, there will be another patient, one with her own history and personality and soul. So I will press the metal plate once again, and start to focus.

David Sable is director of the Division of Reproductive Endocrinology at St. Barnabas Medical Center in Livingston, New Jersey.

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