26 Patient prep LAB- Clip, Scrub, Open Glove, Quarter Drape

Patient Prep, Open Glove, Quarter/Corner Drape (huck towel placement) Lab:

shows 4 sterile blue paper drapes

Clinical TID BIT Always a good idea to let owners know there will be a shaved area and estimate the size, briefly explain the sterile procedure.  Scalp lacerations in humans for example are not always shaved, so this might be an expectation of the owners for their pets!

What we will do in this lab:  NOTE! FOR FALL 2023, THE TTT (Teaching technician Team) will clip hair for you so you can concentrate on step 1 and 4-15! Clip hair, scrubbing the skin, and place quarter drapes (usually huck towels) around the area, creating a surgical window, through which a given surgical procedure is performed.  This is a fundamental skill used often in veterinary surgery for both open gloved procedures and closed gloved procedures.

Why learn these skills?: While most of the time you’ll have a CVT prepping the surgical site, we as vets are often called to help out when needed, or will train CVTs, so it is important to be able to perform these skills, and to fully appreciate what it takes to do this task well!

How does this fit into your training?: Later in semester you’ll learn scrub/gown and closed gloving, suturing, and other skills.  Next semester you’ll build on these skills and perform a mass excision in lab, participate in two surgery labs, then at the end of next semester you’ll participate in a mass excision assessment. 

Goals for today’s lab: is to go through once to learn the steps, then reset and repeat scrub, open outer pack, open glove, open inner pack, place quarter drape as many times as time will allow! Get the technique correct, then can practice with a partner at home using hints above!

OPEN GLOVED generally quick procedures, superficial    CLOSED GLOVED generally enter into body cavity, bone, joint, spinal column etc… Pay attention to what procedures are open and closed glove as you visit practices!
Introduction:
The drapes are secured to the patient on clipped and scrubbed skin, using penetrating towel clamps that go through sterile paper drape or sterile huck towel and pierce the prepped skin to hold the drapes/huck towels in place.  Caution must be used to avoid superficial blood vessels that can be punctured by penetrating clamps, as well as close inspection for signs of inflammation or infection as these conditions warrant rescheduling surgery until resolved, or in some cases may require wider margins than planned.
The benefits of draping off an area in this manner generally outweighs the minor risk of infection at the puncture sites in the prepped skin. Iodine impregnated adhesive film called Ioban is quite commonly used in human surgery, and also used in veterinary surgeries when skin is delicate, surgeon preference or absolute sterile field is imperative. In general, adhesives don’t stick as well to veterinary patient skin as they do human patients…
The huck towels (quarter or corner drapes) cover the borders around the prepped skin and cover the non-prepped skin to decrease risk of contamination of the “surgical window.” Usually an additional water resistant paper drape is placed on top of the huck toweled area and clamped to the underlying quarter drape clamps with non-penetrating clamps.(many vets use penetrating clamps for both quarter drapes and paper…idea is that fewer holes means less likely contamination). The added paper drape provides a larger surface area to keep suture material from being dragged over or through an un-prepped area.  In cases where surgery enters spinal canal, abdomen, joint etc.. the entire patient may be covered by a paper drape, or a limb amputation may have a quarter drape around its base, with a sterile bandage on it that is passed through large pre-fenestrated paper drape. Alternatively many private practitioners and high volume spay/neuter practitioners use pre-fenestrated cloth drape  as is a faster alternative to quarter draping with huck towels-remember huck towels can be washable and autoclavable cloth, or sterile water resistant paper drape.  Shelter vet modification- Often Dog and Puppy neuters are performed using a sterile pre-fenestrated heavy drape (weight of drape holds in place) without attaching to the skin with penetrating clamps due to superficial vessels and delicate skin in the peri-testicular region, these drapes are large enough that suture contamination is not an issue.  Caution as if patient moves unexpectedly contamination can occur
A nice touch is to hide the towel clamp under one of the overlaying huck towels to get it out of the way-occasionally only quarter drapes are used to perform a surgery and tucking the clamp ends under huck towels prevents suture from getting tangled in clamp. Try this in lab!

 

Key Takeaways so far!

  • Know your anatomy and plan ahead-do you have the surgical ability and technique mastery to do the procedure?
  • Look before you clamp! Avoid puncturing superficial vessels with penetrating clamps, and ONLY clamp skin, not underlying structures
  • Rule of thumb for small benign masses as a place to start is one clippers width around the mass (more on this next semester!)
  • Penetrating clamps can ONLY be placed on clipped and prepped skin!
  • Make sure there is enough room in surgical window framed by the sterile huck towels to do a given procedure AND apply clamps within prepped area! Think of the image of Framing Your Masterpiece!
  • Ideally use non-penetrating clamps to clamp larger paper drape onto quarter drape clamps to hold in place.

 

PLEASE COME PREPARED FOR LAB

Read this chapter, click on blue bolded underlined text for pictures, further explanations or videos!

Take pre-lab quiz, and bring these items to lab:

  1. Wear scrubs, lab coat and name tag on scrub top
  2. 2 pr. surgical gloves in your size from gloves that were ordered specifically for you (1 extra pair, we will reset and reuse as is learning time)
  3. Dissection kit w/your 4 penetrating towel clamps-will wrap with 4 huck towels in 2 “sterile” towels to simulate a surgery instrument pack-we’ll show you how to do this on Mayo table (small instrument table on each end of surgery table)

We are going to simulate preparing a cadaver patient for a surgical procedure.  Students will work in pairs, each will perform the tasks themselves and assist each other as needed.  The site of your surgical prep area could be anywhere, as animal patients can have lacerations or masses anywhere on the body!  We’d like each student to:

  1. Set up 4 penetrating clamps from your dissection kit, 4 provided huck towels & the all important steristrip in the center of 2 crossed towels on a Mayo stand.  This 2 towel wrap simulates a sterile instrument pack for easy practice! Follow the instructions seen here to set up your dissection kit w/ We’ll help you set this up on a mayo table at your surgery table.
  2. TTT will perform this step before lab! Wear Lab Exam gloves and lab coat to protect scrubs and Clip video 1 clipper’s width around a small marker on the fur.  Make an even edged square (remember an even clip and tidy incision line are the only markers of the quality you used that your client will see).  Keep skin taught with non-dominant hand and generally clip against the direction of hair growth.
  3. TTT will perform this step before lab! Cleanup hair from site (use hair rollers stored in drawer under clippers) and place in garbage.  Clean clippers by brushing blade and spray clippers with Clippercide while holding over a garbage can.  *Last lab of the day use small container of clipper oil and immerse teeth of clippers into clipper oil with the clipper on, wipe excess oil off blade wrap cord around clippers and replace for others to use. Wipe your exam gloves clean with moist towel to remove hair! Next, remove your lab coat (store in storage cubbies or tables in anesthesia prep area depending on what lab space is being used.
  4. If not done already, tie hair back, place surgery cap and place surgical mask. Masks are considered optional in some clinics when clipping a patient-care must be taken not to have clipped hair land on your mask, where it could later fall off…During covid masks were worn during clipping, and double checked before entering surgery suite or changed before entering surgery suite.
  5. Wear exam gloves and Scrub video surgical site starting in center along incision line in middle of clip and make widening circular motion outward, stopping when you hit the hair on edge,  diagram of scrub pattern.  Use the pick hand (non-dominant hand) to take gauze from Chlorhexidine scrub bowl, form into Hershey’s kiss shape, grasping gauze to form Hershey’s Kiss shape by grasping the corners, squeeze a bit out so no big drips and drop into the scrub hand (dominant hand) to scrub, follow the pattern shown in video and diagram above, then repeat the process with chlorhexidine rinse. repeat this scrub/rinse cycle 2 more times (3 total).  If area is very dirty, a pre-scrub is used before the 3 cycles is begun. Total contact time is key! Dry exam gloves, while wearing them with paper towel, then remove them and re-set them (pull off and turn right side out for reuse during next practice drill).
  6. Open outer layer of sterile pack (pinch outer surface only) and unfold wrap (towel) , walk around Mayo table and unfold each side of wrap, don’t reach over the open pack.  Sterile column rises from margins of open pack to the ceiling.
  7. Remove gloves from plastic wrap and open paper wrap like a book.
  8. Perform pretend scrub; pick under fingernails, hold fingers up elbows down, arms away from sides, foam from fingers to elbows, then start clock, “scrub” fingers-elbows with sponge side of brush, Using the Rule of 4; Rinse fingers to elbows in one sweep passing through the water stream, no tilting elbow up/down or back and forth under the water! Total contact time is only 3min (you have already scrubbed in today!) Need a hand scrub refresher? Click here
  9. Dry hands, working down from fingers to elbow, don’t go back up your arm! Rock the baby technique to change ends of the towel, be careful not to hit the towel on anything and only use the end of the towel. Remember to bend forward at the waist when drying.
  10. Place gloves using Open glove,Open inner layer of pack –Rules for huck towel placement
  11. Open inner layer of pack and perform 4 quarter/corner drape with huck towels-Place quarter drapes video order doesn’t really matter, however helpful to place drapes on slope first then others across as drape can have a bit of Velcro action… Generally when place 2 drapes perpendicular to each other place a clamp to hold in place in corner created, bifurcating the right angle vs. placing all 4 drapes then clamping at corners to hold.  Huck towels are folded accordion style along long axis in thirds, then folded accordion in a short stack to handle easily.  The corner drapes should frame the shaved area-be sure to allow enough room to place clamps and protect your gloved hands from contamination!  When placing drapes have 1/3 towel folded inward toward the patient-protect fingers from being contaminated and pull huck towel tight so not sagging, when lined up over prepped skin drop in place.  Rules for moving drapes and placing drape clamps: you can move drape away from center BUT not toward-this would bring contamination to center of the shaved area.  The towel clamp can be opened and repositioned, as long as not pulled through the huck towel, but once opened and removed from the huck towel, they need to be discarded and replaced with new sterile clamp.
  12. Place a sterile light handle-instructor will open the pack for you. Wearing gloves, lightly press and turn the light handle into the light handle spigot, some lights have a release button on the end of the sterile light handle, others are “righty tighty” to screw on and “lefty loosey” to remove. This allows surgeons to move their own light during surgery! Click here for fun bicycle part threading tid bit
  13. Move around aseptically, concentrate on what you can touch-sterile surfaces, & what you can’t!
  14. Reset station and reposition gloves in paper holder and repeat the steps goal 2-3 times!
  15. Please reset the station for the next group entering the lab as you found it. Thanks!

Instructors will be present to help you and will help to reset after first round, then practice going through steps 5-11 again! Please ask questions and help each other! And of course enjoy and learn.

You can practice manipulating huck towels at home, old dish towels work well (as long as you don’t mind holes), and can use a rolled up old towel or T-shirt for a body.

Be sure to clean penetrating clamps with soap and water and dry before packing back into dissection kit, and of course wash hands before leaving lab with soap and water.

Goals for today’s lab: is to go through the steps once to learn the steps, then reset everything as if was repacked and re-autoclaved, then repeat the following steps; patient scrub, open outer pack, open glove, open inner pack, place quarter drape as many times as time will allow! Get the technique correct, then can practice with a partner at home using hints above!

 

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Veterinary Clinical Skills Compendium Copyright © by Susan Spence. All Rights Reserved.

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