The Case of the Extra Light Handle Cover

It was a day just like any other during my general surgery rotation. The attending I was working with had a full day of cases in the OR. The first operation was an inguinal hernia repair and it proceeded without a hitch. The second case was a laparoscopic cholecystectomy, which also proceeded as planned. After the third patient was rolled back to the OR, transferred to the table, anesthetized, and draped, the attending (already scrubbed and gowned) reached up to adjust the overhead lights. It was then that he realized one of the two lights already had a sterile green handle cover, yet there were still two handle covers on the mayo stand that had not yet been put on the the light handles. “Why are there 3 handle covers in this room? There should only be 2,” he remarked. “Is this handle cover from the last case?” his voice now rising in volume. “The last patient was HIV positive. Now I have scrubbed for this case, and touched a handle cover contaminated with HIV positive blood from the previous case?!?! What is wrong with you?!?” he screamed before storming out of the room. The scrub tech, new to the job, looked like a deer caught in headlights. He mumbled under his breath how he was sorry and must have forgotten to remove that light handle from the previous case. The light handle cover from the previous case was quickly removed, the scrub tech rescrubbed, and the new light handle covers for the current case were put in place. When the attending returned to the OR, the case continued amid lots of yelling and the throwing of an instrument.

Yes, leaving the light handle cover from the previous case, particularly when it was contaminated with HIV positive blood, was a threat to the next patient’s safety. Was yelling and throwing an instrument the best response the attending could have had? Definitely not. The scrub tech, and the other hospital employees who clean and prepare the ORs, are human and made a mistake. The attending realized the mistake and “stopped the line”, but the rest of his reaction did not cultivate an environment of teamwork. I think think there is a situation when it is okay to throw an instrument in anger in the OR. Rather, that cultivating a hostile environment, it would have been more advantageous if the attending had initiated a discussion, either in the OR or after the case, that went something like this, “What did we do well in correcting this mistake?” and “What can we do to ensure this doesn’t happen again?”