August 1 roundup


  • The source blog post from WhiteCoat criticizing the rule that tourniquets may not be reused because some waiting rooms have communal toys does not fairly present the issues involved.

    A tourniquet is used in close proximity to an open wound, since it is used for blood draws. That is very different from a communal waiting room toy: an injection site is always sterilized after a patient could touch a toy, but might not be after a worker touches a tourniquet.

    Furthermore, the problem with a tourniquet that becomes infected is that the tourniquet is touched by the healthcare worker just before drawing blood. If the tourniquet carries germs, and the worker makes just a small slip or error, these germs can be transferred to the patient’s blood stream.

    This is so even though the health care worker sterilizes the site.

    It may be true that patients play with communal toys, but then the injection site is sterilized. A healthcare worker does not play with communal toys just prior to drawing blood, at least not without sterilization / heavy hand washing.

    Finally, the blog suggests, at least to people unfamiliar with blood draws, that the main danger the rule guards against is infection of the patient. But in fact a much more common and also quite serious problem is contamination of the blood sample. This can cause false positives for infection in the blood test which can lead to incorrect and dangerous treatments.

    The rule about discarding tourniquets is reasonable for another, subtler reason. Many healthcare technicians – nurses, blood draw technicians, and so on – are extremely sloppy, uneducated, and rushed. Lots and lots of hospital borne infections are caused by sloppy techniques of these people. Asking them to learn and perfectly carry out a complex set of rules about exactly what is sterile and what is not is doomed to failure. A simple, easy to understand, easy to implement rule: always use a new tourniquet – is far more likely to be correctly implemented than some case by case basis.

    Hospital-caused (nosocomial) infections, contamination of blood samples and medical instruments, and sloppy hospital techniques are serious and well-known problems. The rule about discarding tourniquets after use seems like a very reasonable and inexpensive way to try and cut down on these. Even if the rule is not reasonable, the blog’s complaint that a tourniquet used for a blood draw is like a communal waiting room toy is a red herring: the issues involved are different. The very fact that the blog poster does not seem to grasp the issues involved underscores why a simple, clear rule is necessary to try and cut down on nosocomial infections and sample contamination.

  • First, regarding your “open wound” comment in the second paragraph, I call “horsefeathers.” Microbes aren’t fleas. They can’t jump. They don’t have wings. They can’t magically teleport from a tourniquet to the 1mm x 1mm “open wound” caused by the sterile needle. As for the remainder of your second paragraph, I suggest you look up the definition of “non-sequitur.”

    Regarding your third paragraph, tourniquets don’t become “infected”. Infections occur when microorganisms invade bodily tissues. Tourniquets may become “contaminated,” but your choice of terminology tells me that you have little knowledge about the issues upon which you opine.
    The premise of the rest of your assertion in your third paragraph is that bacteremia can occur with blood draws as a result of contamination by tourniquets. Again, I call “horsefeathers.” During blood draws, a sterile needle is passed through skin which has been cleansed with alcohol. A phlebotomist’s fingers don’t come near the site. And bacteria don’t jump. There is not one iota of scientific evidence for your assertion that a “slip or error” will cause bacteremia or that discarding tourniquets reduces the incidence of bacteremia. Even if bacteremia does occur, in the small number of cases where a few bacteria do enter the bloodstream, those bacteria would, to a reasonable degree of medical certainty, be opsonized and destroyed by phagocytes.

    Your fifth paragraph states that a “much more common” problem is contamination of blood samples from tourniquets. “Much more common”? Are you serious? First of all, the only time that “contamination” has any clinical significance is for blood cultures. It makes no difference if a CBC or serum chemistry test has been contaminated by bacteria. If there is contamination of blood cultures, in most instances, the contamination can be identified before “incorrect and dangerous treatments” have been instituted. It is uncommon for such contaminants to have any clinical impact. Your assertions have no factual basis, are misleading, and again demonstrate that you have little knowledge of the issues about which you opine.

    Regarding your sixth paragraph, thank goodness we have people like you to save the world from all of us “sloppy” and “uneducated” health care professionals. I’m glad that people like you made easy-to-follow decisions for us. However, I still can’t figure out how surgical nurses, surgical techs, and surgeons are able to “carry out a complex set of rules about what is sterile and what is not” during surgeries while the neanderthal nurses and phlebotomists (not “blood draw technicians”) elsewhere in the hospitals pick the lint from their respective butt cracks and wonder what an alcohol wipe is. Can you explain this discrepancy?

    You are the one who does not understand the issues. Both waiting room toys and tourniquets are fomites. The issue raised in the post was why some fomites are perfectly acceptable while other fomites are considered diabolical instruments of death. Why aren’t blood pressure cuffs discarded after every use? Why aren’t stethescopes discarded after every use? Why aren’t pens that patients use to sign their HIPAA releases discarded after every use? The distinctions you create make no sense and you don’t even realize that they make no sense.

    One of the biggest problems in healthcare is that people with little or no clinical or analytical knowledge repeatedly create inane regulations and impose inane policies on the healthcare industry because those people *THINK* they know what is best for everyone else. In a vast majority of such cases, their regulations and policies have no rational basis, are unresearched, and are counterproductive.

    Your manner of thinking is part of the problem, not part of the solution.