2-19. PERSONAL HYGIENE

Good personal hygiene is of particular importance, since it helps to protect the patient and team members from getting an infection. The OR specialist should shampoo his hair daily because both hair and dandruff harbor bacteria. He should shower at least once a day with antibacterial soap, use a deodorant, and put on clean underwear and socks after each shower. Oral hygiene is also important for the control of both bacteria and offensive odors. The specialist must give special attention to his hands–he should wash and scrub them frequently, and he should keep his nails well trimmed. He should have two pairs of shoes for use in the OR suite and should wear them alternately, allowing one pair to air while wearing the other pair. The specialist should not wear scrub clothes outside of the surgical suite. It should be against regulations for personnel to enter the OR who have infections of the nose or throat, who are known to be carriers of infectious diseases, or who have open sores.

2-20. ETHICAL AND PERSONAL RESPONSIBILITIES

a. Discussion. Ethics can be defined as the study of standards of conduct and moral judgment. It is a system or code of morals of a particular profession. Medical ethics can be guided by the principle–render service to humanity with full respect for dignity of man.

b. Personal. Personal characteristics of honesty, dependability, and integrity are absolutely essential. Each team member is dependent upon and places his confidence in the other team members for the correct performance of duties. The development of a “surgical conscience” is therefore necessary for the OR specialist. The specialist should also possess a desire to learn and to progress from knowledge of simple procedures to more complicated ones. He should be energetic and determined in his efforts to improve his skill in the performance of all his tasks. Skills may be improved through practice, with guidance as necessary by qualified personnel.

c. Medical. The OR specialist has a moral obligation to safeguard the patient against gossip in or outside of the OR. He should not mention a patient’s name and the operative procedure performed to personnel not assigned to the surgical suite; and he should discuss such information with other team members only to the extent necessary in the accomplishment of the work. Another medical aspect of both ethical and moral responsibilities concerns events that take place within the surgical suite. Such events should not be discussed outside the OR. The OR specialist should not reveal confidences and trusts or deficiencies observed in the character of the patient.

d. Legal. The work of an OR specialist also entails legal as well as moral responsibilities. When he is unsure of what to do, he should consult the NCOIC, a nurse, or a medical officer.

2-21. MAINTENANCE OF EFFECTIVE RELATIONSHIPS WITH MEMBERS OF THE OPERATING TEAM

Optimum care of the patient is not possible unless effective working relationships are maintained among members of the OR team. The specialist contributes toward the maintenance of such a relationship by knowing his job and performing efficiently, abiding by departmental policies, and displaying a positive attitude toward both his work and his fellow team members.

2-22. LEGAL CONSIDERATIONS

The number of medical malpractice cases has increased substantially in the past few years, both in the civilian and in the military sectors. Liability for medical malpractice in the military is determined under the Federal Tort Claims Act. Under that act, individuals may sue the Federal Government for the negligent acts of Federal employees who are performing within the scope of their duties or employment. The individual military medical care provider is protected from any personal liability by the Gonzales Bill (10 USC 1089) enacted in 1976, which makes the Federal Government solely responsible for the defense and payment of medical malpractice claims. While the individual service member will not have to pay any money judgment for medical malpractice, the service member may be liable for criminal acts such as negligent homicide or involuntary manslaughter.

2-23. LEGAL INTERPRETATION

a. General. The liability of the Federal Government under the Federal Tort Claims Act for medical malpractice is decided by application of the law of the state where the incident occurred. It is true that the law and court decisions vary from state to state, but the trend is to hold all medical care providers to a high standard of care. NOTE: You are expected to utilize your superior knowledge in performing your duties. You must always carry them out in a manner that meets the high standards of the Army Medical Department (AMEDD).

b. Welfare and Safety of the Patient. All instruction of AMEDD personnel concerning care of the patient emphasizes the welfare and safety of the patient. This is the principle around which nursing care is built. Safe care of the patient results in safety for those responsible for his care.

c. Malpractice. Negligence is the failure to exercise due care. Due care is further defined as the action that a reasonable and prudent person would perform under the same or similar circumstances. Due care takes into consideration the training, experience, education, and capabilities of each person. Negligence of professionals, such as medical professionals, is termed malpractice.

d. Prevention of Lawsuits. Most mistakes or accidents are preventable. Some are so slight that the patients are never aware of them; others can prove fatal. Even if a patient himself is at fault, those caring for him suffer great remorse. You should be cognizant of many hazards and know the safeguards.

2-24. POTENTIAL LEGAL INVOLVEMENTS

a. Loss of Sponges. Loss of sponges is a frequent cause of lawsuits. In a few states, the responsibility for accounting for all sponges before closure rests with the surgeon. However, the law in most states is that each member of the surgical team is responsible for his specific duties. Therefore, in a case where the surgeon has performed correctly but a sponge is left in the incision, the circulator or scrub may be held responsible.

b. Burns. Burns are another frequent cause of lawsuits. A burn may occur from the use of a hot instrument such as a mouth gag or a heavy retractor. The scrub should have available a basin of cold saline solution for cooling instruments and should cool the instruments when necessary before handing them to the surgeon. A burn may also occur from a light, a thermal blanket, or an electro surgical inactive electrode.

c. Falling. Falls are another frequent cause of lawsuits. Observe the usual safeguards for children or disoriented or sedated persons, whether in wheelchairs, in bed, or on the operating table. Use special care when patients are moved from bed to table and back to bed again, as well as those being moved about on litters or wheelchairs.

d. Patient Identity. Many serious situations may arise in the hospital as the result of carelessness in checking patient identity. The right medication or treatment for the wrong patient may or may not be serious, but sometimes takes on great proportions. Be sure of the patient’s identity.

e. Unconscious Patients. Since a great number of patients in the ORreceive a general anesthetic and are therefore unconscious, great vigilance is needed. If the patient is injured while unconscious, negligence may be presumed, which may require those caring for the patient to show that due care was followed during the entire period of unconsciousness.

f. Aseptic Technique. Each person on the surgical team must take the utmost care to carry out strict asepsis. Dust control, proper cleaning of floors and furniture, and sterilization of instruments and equipment are essential, along with scrub, mask, glove, and gown technique. Any break in asepsis at any point nullifies all the care taken in other ways.

g. Drugs. The same strict rules observed on the ward in regard to drugs must be practiced in the OR. The scrub frequently has dangerous drugs such as phenol or cocaine on his table. Special care must be taken to ensure that these are not used improperly. Each drug used is checked by two persons as it is prepared, and the scrub repeats the name of the drug to the surgeon as it is handed to him.

h. Abandonment. A patient left alone or a child unguarded may injure himself by an electric shock, burns, drugs, lacerations, falls, or a variety of other things. The sources of such injuries should be removed whenever possible and a patient who might injure himself carefully watched.

i. Explosions. Great care must be taken in the OR to prevent explosions.

j. Tissue Specimens. The loss of a biopsy specimen could mean the possibility of a second surgical procedure to obtain another. Improperly labeled specimens could mean a mistaken diagnosis, with possible critical involvement for two patients. The loss of a specimen could be vital if diagnosis is not made and proper treatment not given. A report from pathology on a specimen is a permanent record on the patient’s chart that a certain piece of tissue or a stone has been removed.

k. Foreign Bodies. Care for these according to local policy. They often have legal significance outside the hospital, and frequently are claimed by civilian or military police. A receipt should be required of anyone taking them.

l. Consent for Operation. As a rule, witnessed written consent for an operation or procedure is signed by the patient before the surgery or procedure is performed. The patient must understand the details of the agreement fully. If the patient is a minor, unconscious, incompetent, or intoxicated, the nearest of kin or some other authorized person must sign. If a true emergency exists and no one else is available to sign the consent, the Judge Advocate’s Office should be contacted. When this is not possible, the hospital administration may give permission for the procedure or surgery.

m. Right to Privacy. This right exists either by law or by custom. Hospital charts and records, X-rays, and photographs are for use by the surgeon and other hospital personnel who are directly concerned with that patient’s care. Suits can be, and have been, brought by patients for violation of this right. Unauthorized persons are not permitted to observe operative procedures. Suits have been brought by patients when unauthorized persons, out of curiosity, have been permitted to witness procedures of interest only to professional persons.

n. Confidential Information. You have a moral and legal obligation to hold in confidence any information gained from the patient during medical care. However, as there is no medical privilege in the military, you may be required to divulge confidential information upon request by proper authority.

o. Personal Property. Generally, the patient comes to the OR without any personal property. However, you should check to make sure that the patient has no eyeglasses, dentures, contact lenses, watches, wigs, or glass eyes that should be removed before surgery. Be sure to follow locally prescribed procedure in handling these articles. Be sure to obtain a receipt for any such articles when they are given to ward personnel for safekeeping. A patient who has hair clipped owns the hair that is removed, and you are responsible for its safekeeping also.

p. Records. Inaccurate record can be a source of legal action against the person responsible.

q. Defective Equipment. Operating room specialists are responsible for certain equipment checks. Any defect that was noticeable and remained unrepaired has legal connotations in case of an accident. Be sure you can prove that equipment defects were properly reported.

2-25. THE OPERATING ROOM SPECIALIST AND BEREAVEMENT

Another consideration that must be taken into account is the OR specialist’s handling of bereavement. Any person who works in a hospital may be called upon to deal with a bereaved person. The dynamics of bereavement and grief are essentially the same whether the loss is of a person, a limb, or simply of the powers that make one able to maintain his normal routine. While these are the same in their dynamics, there is obviously a variation in the depth of the experience. Whatever the depth of loss, the OR specialist may find himself frequently in a position of helping people cope with grief in a constructive way.

2-26. DYNAMICS OF GRIEF

If one is to integrate a loss, he must come to terms with his objective loss and with the threat that loss poses for his life and well being. He must also contend successfully with the fear and anger which results. There are both positive and negative aspects of every relationship so that in bereavement, both positive and negative feelings will be present. The “unacceptable” feelings of anger toward a person who has been valued, loved, and now lost may make the expression of grief a very difficult task, complicating it with guilt. Also, a person may be afraid of any deep feelings. Although grief is trying, it is a healing phenomenon. It is our way of being separated from someone or something with which our life is intimately entwined. It involves the process of withdrawing ties and establishing new ones. All the rituals surrounding death and burial are designed to help us do this important work of mourning.

2-27. HELPING THE BEREAVED

a. One central question concerns the expression of feelings. Most people can express some of their feelings, but still deny and repress others. Some will recoil from any strong feelings. After the initial period of shock, these feelings will have to be expressed or the person’s well being may be gravely compromised.

b. Frequently, it may be important to consider whether the person feels adequate to face life and go on, whether he feels valuable or worthless, or whether he is optimistic or pessimistic about the future. If he feels that things will work out and that he is a person of value who is adequate in dealing with life, he is more likely to be able to abandon himself to grief and do the work of mourning without panic. It is also important for him to see that his pain has purpose and is useful in some way.

c. The bereaved person should bear the responsibility for making decisions and choices, although he may need considerable support. Making decisions about funeral arrangements helps the bereaved to face the fact of death.

2-28. MEDICAL PERSONNEL AND HOSPITAL AS SCAPEGOATS

a. There are certain cases where the bereaved may justifiably blame the doctors or the hospital and its staff for the loss of a patient. On the other hand, there are a great many cases in which the doctors and hospital personnel have done all that was reasonably possible to save a patient, yet are vehemently blamed for his death. A malpractice suit may even result. This can be a baffling experience unless the dynamics underlying this response are understood.

b. As mentioned above, relationships are never all positive or all negative. Given the ambivalence of relationships and our natural tendency to deny negative aspects of relationship, death of a loved and valued person brings about a critical situation. Anger because the person has left through death is added to the unresolved anger in the relationship, and at the same time expression of this anger becomes unacceptable. In their deep need to express this kind of anger, people often transfer it to the doctor and hospital.