Would you stick that laryngoscope blade in your mouth ????

[SSaint]

I do love your list of 15 though, that was great. Just because perfection is not possible, doesnt mean that we shouldnt strive for the higher plateau. Using the logic you present, why bother cleaning anything ?

Oh, I strive for a higher plateau GA.

You're just trolling to get reponses, and people pissed off at you.

Well, guess what?

You ain't gettin' any more than this from me.

[Ace844]

And for the record, Avian flu will be the most infectious pandemic we will ever see, if it occurs. And it is a solely respiratory based disease, spread through droplet form, that will kill 30-50% of people infected. This pandemic is expected to far exceed the death toll from the early 1900s that killed 600 million world wide. Since nothing can be stated in here without a scientific study, please go to www.pandemicflu.gov

But lets not worry about future boogey-men germs -- lets just deal with the ones we have now.

Again, there is nothing there to show that there has been or will be transmittal and spread of this disease via inproperly disinfected medical equipment or laryngoscope blades...WHICH IS WHAT YOU MADE THIS THREAD ABOUT... We're stil;l waiting for your viable response with evidence to support your claim which you have yet to post.

ACE

[JPINFV]

That women shouldnt vote,

[hijack attempt][sarcasm]Change isn't always good. First voting, then driving, then moving out of the kitchen. What will be screwed up next?

[/sarcasm][/hijack attempt][ducks from the bricks being thrown in my direction]

[Ace844]

I would counter that misdirection is what you are using to ignore an obvious fact: Dirty laryngoscopes dont belong in patient's mouths, I dont care if you find 100 scientific studies that allow you to do it, my personal ethics will not allow it.

No one here advocated for the placement of grossly infectious or 'dirty non-cleaned and disinfected equipment' anywhere near a patient. Work on your reading comprehension.

There was a time in the US when the vast majority of people thought:

That slavery was OK,

That women shouldnt vote,

That airplane flight was impossible,

That space exploration was impossible,

That curing Cancer and Polio was impossible,

That Paramedics shouldnt be allowed to intubate patients,

And they all had experts to back their "facts" -- it didnt make it right. Just because it is today's norm, doesnt mean that it will be heralded as a best practice in the future. There was a time when the best scientist of the day thought that leaches and lobotomies were good cures.

Actually in some areas PARAMEDICS were allowed to entubate from the beginning and thats what made them PARAMEDICS instead of funeralhome diesel fuel speed jockies who slapped o2 on and ran to the hospital...

Next, they still use leaches and maggots as medical therepy with grewat effect, educate yourself!!

Lastly, I am asking for evidenced based scientific information which supports your claim and now that you can't provide it you say

"Well... we used to....insert miscellaneous example here.."

Seems to me you tried that arguement with no sucess in another thread...hmm...TRY AGAIN!!

Out Here,

ACE844

[GAmedic1506]

At the end of the day, if I randomly took a laryngoscope blade from all the services that immediately surround you, and asked you to put them in your mouth, you WOULDNT (unless you knew all of them were brand new disposable unused blades). That should be all the proof you need. If it's not good enough for you, its not good enough for your patient. Which doesnt make you a bad medic, or mean that you work for a bad service, but you have to admit, there is room for improvement industry wide. Change usually only occurs when the norm becomes too painful to endure. I hope that it doesnt take the death of a patient(s) to get us to correct this problem. You know that there are EMS stations out there that have had their cleaning agent in the pale or basin for days past its recommended date. You know there are some sloppy folks who do it half-way. You know that there are some poor services that may not have spare blades, and therefore can not allow the blades to soak as long as they need to. You never answered my question regarding whether or not you had personally ever found a dirty blade in your kit (you know we all have).

There will not be any studies that prove that EMS caused a respiratory disease in an intubated patient, as no one would think to look in our direction, they would just assume it was hospital-acquired (and maybe most are). It will take someone from the inside to do that study, which isnt a bad idea: Maybe all of us can take one-blade at random and swab it, have it cultured, and report the results here. I will do it, if you will step up to the plate and do it too.

Everyone in the public assumes that we are using the correct process to clean our equipment, and I imagine most of us are. But I know there are some that dont.

[GAmedic1506]

Well lets you and I let the others weigh-in, I feel comfortable that most will see it my way. But if I am wrong, and the majority of folks see it your way, I will kneal before this computer screen and apologize for my transgressions. And as far as belittling my contributions to this forum, I would ask you to look at the number of views and posts that my four topics have generated. Sure, none of them are siginificant enough to cure Cancer, but they have sparked good debate. And I dont see this as soapbox preaching, as most have agreed that the problems outlined are occuring, and I have never taken a position of superiority. I have admitted that I was guilty in every instance of making the same mistakes.

[ncmedic309]

You never answered my question regarding whether or not you had personally ever found a dirty blade in your kit (you know we all have).

Sorry, I must have missed that question. Yes, I have found dirty blades and other equipment that was contaminated more times than I can remember. It still tends to happen to this day, but it's much less likely to be a dirty blade, because we use disposables now. You might find a dirty handle from time to time. If you want to make a discussion, let's look at the entire ambulance and see just how clean it is. I can take a clean white towel on most occasions, and wipe off nothing but the seats in the cab and the steering wheel, and afterwards, the towel is brown. I haven't even touched the patient module yet. There's something in each one of our ambulances now that's contaminated. Somewhere in that bus, there's something sitting that we missed. I'm sure some people don't think that's possible, but even when you practice good cleaning habits, your not always going to get everything, mainly because everyone else does not practice those same habits. It would be nice to have a perfectly clean and sterile environment each day, but it's just not possible...

[ptemt]

What procedures do you use to insure your blades are clean ? Do you autoclave, soak in cleaning agent, or use disposable. Would you stick any of the blades that are currently on your bus, in your own mouth. If not, why do your patients deserve less ?

Ace,

It seems that GAmedic lives rent free in your head, and others for that matter. Some of your replys to this thread are easier to read than others as your type face gets bigger and more colorful.........I almost feel as if you are shouting at us, the collective readers on this forum. You repeatedly ask GAmedic to answer your questions regarding documentation.............I dunno.....so

"What procedures do you use to insure your blades are clean ? "

If you answered all of his questions and I somehow missed it then please feel free to shout back at me!

[GAmedic1506]

I agree NC, and I am not calling for our trucks to be sterile by any means. All I ask is that we do the best we can; I am just not sure that we are consitently doing that with blades or any of our equipment that we dissinfect. So even if no one in here is concerned about what the patient is being exposed to, you should be concerned about what YOU are being exposed to. Actually, the nastiest objects in your workplace are telephone receivers, computer keyboards, and door handles, which is why when one person gets sick at work, it tends to spread throughout the rest of the staff, even though no bodily fluids were exchanged (atleast you are usually wearing gloves when you handle equipment in the truck; in the office, you are not). We are fortunate that we have not had to deal with many of the third-world diseases that are currently killing thousands on other continents. But with the illegal exotic pet trade on our continent, and all of the intercontinental airline flights, our day is coming.

[AZCEP]

GA,

You are completely ignoring the fact that the laryngoscope is not a viable route for the transmission of infection. The articles you quoted don't even support your view, and yet, you offered them as evidence.

Perhaps you need to concede the point that the laryngoscope is not a great source of infection. Maybe we should look at other, more commonly used pieces of equipment.

Could Part Of The Alarming Rise In Nosocomial Infections Have Anything To Do With Today's Often Careless Airway Secretion Management Approach?

Rafael Velez MD

Attending Anesthesiologist

Westmoreland Regional Medical Center

--------------------------------------------------------------------------------

Citation:

Rafael Velez: Letter To The Editor: Could Part Of The Alarming Rise In Nosocomial Infections Have Anything To Do With Today's Often Careless Airway Secretion Management Approach?: The Internet Journal of Anesthesiology. 1998; Volume 2, Number 4.

--------------------------------------------------------------------------------

This question is quite relevant, since millions of patients require airway suctioning during the course of their care -- be it in: anesthesia, critical care, emergency room, endoscopy unit, nursing home, rehabilitation center or ambulance settings.

Saliva, airway secretions and the suction tubes they are aspirated with are contaminated with blood, bacteria, viruses and fungi. Unfortunately, these tubes and secretions are often not contained adequately. Behind closed doors and curtains, used suction tubes often hang unprotected from the anesthesia machine, are pushed under a mattress, or lie by the patient where they brush against equipment, work surfaces and personnel. In this type of contaminated environment, supposedly sterile intravenous catheters, central venous lines and endotracheal tubes may provide ready avenues for nosocomial infection. How many pneumonias or septic episodes might not be prevented with better techniques? Thousands of patients and billions of dollars are needlessly lost to hospital acquired infection every year, in the USA.

Although it has taken health-care providers almost a decade to become used to wearing non-sterile gloves, many are still dripping airway secretions throughout the medical workplace. While the CDC has already provided “Universal Precautions” guidelines and OSHA has published “The Blood Borne Pathogens Standard,” most examiners still seem to be overlooking this all too common fault in suctioning technique. Nevertheless, it is hopeful that in an issue of “Briefings on Hospital Safety” (June 1997), Carole Paterson, the JACHO’s department of standards Deputy Director, says “...environment of care implementation and design and infection control are on the random unannounced survey list for nearly all JACHO accreditation programs.”

Even the lay press is raising concerns regarding the emergence of more resistant micro-organisms. A recent review in JAMA identifies a failure to use basic infection control practices as a major cause. The New York Times Magazine lead article from August 2nd entitled Superbugs The BACTERIA Antibiotics Can’t Kill, describes how the CDC is currently closely monitoring the threat posed by some strains of Vancomycin Intermediate-Resitant Staphylococcus Aureus. They consider this sitituation to represent the bacterial world’s most potent counterattack against antibiotics. As we all know, staph is a particuarly common organism, which lives on the skin and in the nostrils of otherwise healthy people. It is part of what is considered our normal flora, were it is relatively harmless. If it gains access to the body through scrapes, incisions, etc. it can cause serious problems. Should VISA strains become widespread the problem would become far more severe. Health care workers can transmit staphylococcus when their hands become infected from contact with patients or body fluids. Clearly, for all of the above reasons, we need to examine our routine practice and heighten our consciousness about the very real risks posed by airway secretions and suction tubes. Although it is not widely known yet, oral suction tube holder disposable devices are now available to better manage this contamination risk.

Airway Secretions and Blood

An Anesthesia / Critical Care Perspective

I am not sure that many physicians have considered the serious opportunity for nosocomial infection provided by our often improper management of airway secretions in the peri-operative period. Although anesthesia, critical care, and other medical staff are well aware of the potential spread of bacteria, viruses, and fungi from saliva, other upper airway secretions and blood during oro-pharyngeal manipulation, too much complacency still exists. After some thought, most would agree that this daily danger needs to be urgently addressed in a more practical and standardized manner.

A recent study in Anesthesia and Analgesia showed that 33% of anesthesia equipment surfaces were contaminated with blood, and that visual inspection was not a reliable means of detection. Part of the problem is that non-sterile reusable equipment is often difficult to clean thoroughly between procedures. 1 This unfortunate reality is aggravated by dripping airway suction tubes, which often hang precariously from the anesthesia machine, are pushed under the operating table mattress, or lie by the patient’s head where they brush against the caregiver. 2 , 3 Clearly anesthesia and critical care equipment, work surfaces, personnel, and worse....the next patient may and do become infected. In this type of environment supposedly sterile intravenous catheters, central venous lines and endotracheal tubes provide ready avenues for infection. How many post-operative pneumonia’s or septic episodes might not be prevented with better technique? 4 , 5

In 1992 nosocomial infections contributed to the death of over 58,000 patients in this country alone.4 More than 5.6 million American health-care workers risk potential exposure to AIDS and to hepatitis B during the course of their workday. Of additional concern is the resurgence of tuberculosis and the development of other resistant micro-organisms in hospitals.4 From 1980 to 1992 the death rate due to infectious disease as an underlying cause increased 58%, and more specifically, the mortality rate due to respiratory tract infections increased by 20%. 6 These statistics, and knowledge that intubation and mechanical ventilation greatly increase the risk of nosocomial pneumonia (because they alter the first line defenses) provide a potent incentive to examine our routine practice. 7

Very troubling is a recent review in JAMA of strategies to prevent the spread of resistant organisms, which identifies a failure to use basic infection control practices as a major cause.5 Patient and health-care workers’ safety is paramount. Despite all the cost cutting and time pressures for increased efficiency in operating room turn around time, we cannot afford to let our guard down when it comes to infection. It has been estimated that 6% of hospitalized patients in the United States contract nosocomial infections annually, at a cost of 5 to 10 billion dollars. 8

The CDC has already provided guidance by stressing the need for UNIVERSAL BLOOD AND BODY FLUID PRECAUTIONS. OSHA refers us to the blood-borne pathogens standard, which requires that engineering and work practice controls be used to eliminate or to minimize employee exposure.4, 9 By now most of us have become used to wearing gloves and teaching new residents and nurses about the value of this practice.4,8, 10 Likewise we need to develop a similar consciousness about airway secretions. Therefore, I urge medical institutions to formulate an exposure determination plan for the safer handling of oral suction tubes...whether in the anesthesia, recovery room, critical care, or emergency room setting.

References

1. James R. Hall, MD; Blood Contamination of Anesthesia Equipment and Monitoring Equipment: (Anes. Analg, 1994, 78) pp. 1136-1139

2. L. John Busch, MD ; Residual Contamination of Anesthesia Workplace by Oral Secretions Called Serious Threat: (Anesthesiology News, Infection Control Section, March 1996)

3. Rafael Velez, MD ; Ask the Experts : (Facility Care, August 1998, vol 3, #7) pp 5

4. Arnold J. Berry, MD; Infection Control in the Practice of Anesthesiology, ASA. (Annual Refresher Course Lectures, 1995)

5. Donald A. Goldman, MD; et.al.; Strategies to Prevent and Control the Emergence and Spread of Antimicrobial-Resistant Microorganisms in Hospitals, (JAMA, January 17, 1996, 275, No. 3)

6. Robert W. Pinner, MD; et.al.; Trends in Infectious Diseases Mortality in the United States, (JAMA, January 17, 1996, 275, No. 3)

7. Ofelia C. Tablan, MD; et.at.; Guideline for Prevention of Nosocomial Pneumonia, CDC, (Respiratory Care, December 1994, 39, No. 12)

8. Alan R. Tait, PhD, and Dale B. Tuttle, MBA, Preventing Perioperative Transmission of Infection: A Survey of Anesthesiology Practice, (Anesth Analg., 1995 80) pp, 764-769

9. OSHA, Department of Labor, Occupational Exposure to Bloodborne Pathogens; Final Rule, (Federal Register, 56, No. 235 Friday 6, 1991)

10. Recommendations for Infection Control for the Practice of Anesthesiology, (ASA, 1994)

Now, as we can all see, the risk of infection is there. Good point. The problem lies with proving that EMS equipment is any more responsible for it, than hospitals. I'd wager that the prehospital equipment maintains a higher degree of cleanliness than hospitals, due to having less equipment to clean. You should also realize that the warning that was given was directed toward the healthcare providers that use the contaminated equipment, not the patients.

Role of anaesthetic equipment in transmitting nosocomial infection.

Richard VS, Mathai E, Cherian T.

Department of Clinical Microbiology, Christian Medical College Hospital, Vellore.

There is a potential risk of bacterial and viral infection being transmitted through anaesthesia circuits. Several studies have shown contamination of parts of anaesthetic equipment with bacteria that colonise the mouth and upper airway. A definite relationship between such contaminated anaesthetic equipment and subsequent lung infection remains to be established. Various factors contribute to the transmission and pathogenesis. Among the recommendations for preventing transmission of infection through anaesthetic circuits are using a bacterial/viral filter for every patient or using disposable circuits. Owing to financial constraints, all these recommendations may not be practical in India. Possible guidelines for India may include discarding endotracheal tubes after single use and rigorous cleaning and disinfection of masks and laryngoscopes. Corrugated tubings used in the expiratory limb of the circuit may be washed with soap and water after each patient and dried before use. It is advisable to disinfect all such tubings in 2% glutaraldehyde, and then to wash in water and to dry before use at least once a day or when they are visibly contaminated.

Potential risk has to be highlighted here. NOte that most of the transmission of bacteria are related to the ventilator circuit, not the laryngoscope. There again, the problem does not carry over to EMS too well. The ventilator circuit, is commonly replaced after each use. I've yet to see one reused prehospital. Anyone that is following the recommended guidlines has done plenty to reduce the risk.

Now, if we want to do more, then we will have to bring a cleaning crew with us. I don't see any other way to eliminate the risk of infection when dealing with the envirnomental challenges that we face. If we don't have a clean room to perform in, then of course we are going to increase the risk of infection.

This is not something that is taken lightly, but you need to realize the limitations of the environment before making more blanket statements.