The Ritual

By Eve Purdy (@purdy_eve)

Author’s note: As a disclaimer, I am not a surgical resident and have lived the experience in the OR only as an outsider as both a medical student and off-service resident. The below narrative represents my experience but may not be shared by all those who wash their hands at sinks outside operating rooms.

“Alright, let’s go scrub,” my attending says. We head toward the wash station outside of OR C. I put on a new mask, slowly and deliberately – first tying the top strings, then the ones around my neck. I adjust the nasal bridge. Those first few breaths are stifling. I feel like I cannot get in enough air. I do adapt but know that I will remain unusually aware of my breathing throughout the case. I make sure that my glasses do not fog. “No, not quite good enough,” I think. Another couple of adjustments of the nasal bridge before I am satisfied.

I head towards the sink and I look up to see the staff surgeon and my senior resident already there. They are both standing tall, with heads down, concentrating on their hands. Water is running into the shared trough before them. From behind, for just a moment, it looks like they are praying. I smile, pausing before I grab a small silver package from above the sink. I open the reflective wrapper to reveal the double-sided sponge and nail pick. I hear the clank of metal on metal and feel the cold steel as my left thigh activates the sink. Warmth flows over my hands. I close my eyes for a second as I wet the sponge, and start to feel the soap foam. Then, just as I have been taught, I scrub.

I start by removing the unappreciable dirt from beneath my shamefully bitten nails. With that dirt, thoughts about everything else also start to wash away. A brief moment of reprieve in what has been a harsh week. Time slows. As I start scrubbing each finger of my left hand with the brush side of the sponge the staff surgeon tells a joke. It isn’t particularly funny but the senior resident and I both laugh. I move to the fingers of my right hand. The senior asks a reflective question about a case his team performed yesterday. Left forearm. A quick piece of hard-learned wisdom is transferred from the attending about the case we are scrubbing for. So focused we are on our hands, none of us make eye contact throughout the experience. It is perhaps that degree of detachment that allows her to share vulnerability over a mistake she made years ago as a resident. Right forearm. The staff asks me a question that I don’t know the answer to. More water. More scrubbing. The resident takes a moment to teach me what I should have known. These exchanges are punctuated by comfortable moments of shared silence.

At some point the staff person decides her hands are clean. Time speeds up. Clank. Her tap turns off; the ritual is over. She unceremoniously dries her hands using paper towel. The electronic sound of the antiseptic being dispensed is an unwelcome intruder into what was an otherwise perfectly rudimentary process. Clank. My senior resident follows suit. Reluctantly I force my thigh against the sink. Clank. The water stops flowing. The alcohol stings my nail beds, another reminder of that ugly habit. My hands and arms start to feel cool as the alcohol dries and I smell that strong pungent odour of clean. As I back into the OR, I am sterile. I am ready.

As a scientist, I know the purpose of scrubbing is to ensure that we prevent infection in the patient we are about to operate on. As an anthropologist, I cannot help but wonder if the process results in and represents so much more than that.

Rituals are of interest to most anthropologists, yet are not a particularly agreed upon phenomenon. Though there is not a single definition, in general, rituals are actions with intention that are performed by people from a specific group, in a predictable way. All cultures have them. Rituals can be religious or secular. They can be elaborate or simple. Some believe that culture shapes rituals. Others believe that rituals shape culture. The anthropologic theories that make the most sense to me suggest both of these as potential realities. The works of Victor Turner and Clifford Geertz are worth reading if you want a deep dive into symbolic and interpretive anthropology.

All this to say, medicine is ripe with ritual. Whether it be ward rounds or grand rounds, morbidity and mortality conference, scrubbing in, pre-surgical checklists, or that shared special moment of feedback and camaraderie at the end of an emergency medicine shift, rituals help us make sense of our worlds and the chaos we exist in. The rituals also form who we become and sometimes afford us the opportunity to shape the chaos that is ahead.

The subsequent cases of the day just require cleansing with antiseptic rub alone. The next case is about to start so I head towards the electronic antiseptic dispenser. There is no scrub. This time I do not feel the warm water, there are no honest anecdotes, there is no shared silence. There is efficiency. The alcohol stings my nail beds, another reminder of that ugly habit. My hands and arms start to feel cool as the alcohol dries and I smell that strong pungent odour of clean. As I back into the OR, I am sterile but I’m not quite ready. I can’t help but feel something is lost.

I share this anecdote as a prompt to pay attention to the rituals, mundane and momentous, in our workplaces and education systems. Subtle changes to them, like substituting antiseptic for a full scrub, could have unintended consequences. It is also possible that thoughtful, calculated changes to common rituals may allow us to deliberately shape culture in powerful ways!

What is your favourite ritual in the hospital?

Featured image provided by the editor