“Bloody” Specimens as Safety Concern

Some surgical pathology specimens are “bloodier” than others especially received in a fresh state. Among bloody specimens, the first, of course, is placenta. Everyone, who has cut placenta in a fresh state, experienced a burst of blood on hands, arms, or PPE. Although it looks rational immediately put fixative in the placenta specimen upon receiving, the old protocol is not right under conditions of modern surgical pathology with ancillary studies. Or in a case of monochorionic placenta, there might be a necessity for dye injection. Again, the face mask is obligatory as a part of PPE.

Uterine curretage (“product of conception”) is usually submitteed in a devise SafeTouch Tissue Trap (Figure 1). Opening the lid of the container requires some effort due to negative pressure created by vacuum curreting. The blood can spread on and around the table. However, the most dangerous, as a source of infection exposure, are specimens of sinus suction which always are sent in SafeTouch Tissue Trap container. Those are real sources of spreading meningococcal and other infection materials. The lid should be open far from the breathing area as much as possible, close to water and exhaust backdraft ventilation and, of course, in the mask without any exception.

 

 

 

 

 

 

Figure 1. SafeTouch Tissue Trap with sinus aspirate.

Amputated extremities, predominately legs, require intensive sectioning with exposure of vessels and inevitably spreading bloody content on the grossing table. Effective immobilization not only provides better conditions for examination but prevents spreading blood or potentially infectious material. There might be different stands for this purpose (see MOPEC’s stands). However, it seems that a simple bucket with water can provide immobilization and accumulation of blood effectively (Figure 2).

 

 

 

 

Figure 2. A laboratory backet with water as a stand for grossing an amputated leg.

(See more details at the link Equipment, Instruments & Gadgets “Support for amputated extremities”)

gross only specimens often carry bloody tissue fragments that require attention for infection exposure. Although they are treated lightly in practice, in reality all PPE and cleaning procedures should be in place.

The protection mask

The protection mask was mentioned many times in the previous text. It is time for closer look at this critical element of PPE as far as infection exposure prevention is concerned.

OSHA’s Standard requires protection for eyes, the mucous membranes of the face and upper respiratory tract from exposure. Depending on the degree and type of anticipated exposure, the protection for the face would consist of a surgical mask in conjunction with goggles or eye glasses with solid side shields or, alternatively, a chin length face shield.

Health care practice uses different kind of masks which are often defined interchangeably. This terminology confusion is not helpful in informed choice of the protection mask. Three terms are in common use: surgical mask, protective mask, and respirators.

A regular surgical mask has two layers (the external thin water permeable, the internal to the face is thick water resistant).   It is obvious that the surgical mask is designed to protect the operative wound from potential infection that stems from the worker. In other words, the aim is to prevent the wearer from infecting others. Thus, if the wearer sneezes, coughs, drools, spits or talks excitedly, his or her infected fluids will be trapped in the mask and will not infect others. It used now by dental hygienists and even by tellers in banks for mutual protection.

In surgical pathology we have a specific goal due to different working conditions. The regular surgical mask’s size and composition is not sufficient. A fountain like splash can be in surgery, but surgical pathology handles specimens with rare occasions (placenta, big cysts) of splashes.

The respirators, or N95 masks, are two grades: for industrial use and fluid resistant mask for use in clinical settings. The nomenclature N95 comes from the fact that these masks are supposed to filter at least 95% of all particulates that are 3 microns or larger. The N95 mask was recommended by the Centre for Disease Control & Prevention (CDC) and World Health Organisation (WHO) as the respiratory protection for the bird flu virus. This mask requires individual fit-testing to be functional according their design and purpose. Reasonable in theory, the N95 mask is cumbersome, uncomfortable, and therefore unpractical for a regular surgical pathology laboratory work.

The third type of protection masks are different variants of shield masks. The most popular is Kimberly-Clark TECNOL FLUIDSHIELD mask. It has five layers. Both, internal and external (orange stripes) are water permeable. Three layers between them have different degree of water resistance. Although the company advertises them as LONCET breathable film, these layers, in my experience, make the mask uncomfortable for a prolonged use because the area between the mask and the face is overheated and over saturated with exhaled carbon dioxide that decreases the percentage of oxygen in the inhaled air.

As it was already mentioned, the frozen section laboratory is the most dangerous area for infection exposure. CLSI guidelines unequivocally state that “an N-95 particulate respirator should be worn during frozen sectioning.” 2However it is an unrealistic recommendation for many reasons (difficult to breathe, individual fit-testing, necessity of permanent communication); although for some exquisite cases such an option should be on hand. Even a Kimberly-Clark FLUIDSHIELD mask is superfluous, except for initial sections of a cystic formation or other possible splash specimen. A regular surgical mask with earloops is obligatory and should be enforced on technicians and pathologists without any exception.

While handling “bloody specimens”, the worker would definitely benefit from face shielded masks like Kimberly-Clark (Figure 3.).

 

 

 

 

Figure 3. Kimberly-Clark FLUIDSHIELD mask with blood spots

Bone grossing requires Kimberly-Clark mask, because so called “ballistic trajectory particles” of bone dust ought to be prevented to reach not only mucous membranes but also the skin of the face and neck.

While doing biopsies with hematoxylin inking for visibility during embedding, I noticed droplets of stain that often appeared on the upper part of the protective gown. When I turned the mask upside-down, those droplets appeared on the plastic shield.  I realized that it is more reasonable to wear the Kimberly-Clark mask with the plastic shield upside- down. 3The chin and the neck are more protected from splashes and spatters. Additionally, the area of air circulation is larger in this situation. The shield reaches the ubiquitous blue protective gown like Convertors (ALLEGIANCE’s Impervious Gown w/Thumb hooks, Universal). One lower fold of the mask can be loosened to make the mask longer or the plastic shield can be cut to make it shorter if it is necessary for the individual adjustment. The lower strips can be tightened or loosened around the neck depending on the type of the processed specimen. The protective glasses should be worn above the strings of the mask to get more protection. The use of protective glasses with solid side shields is both, the OSHA’s requirement and a necessity without any exception (Figure 4.).

Figure 4. Kimberly-Clark TECNOL FLUIDSHIELD mask upside- down

 

 

 

 

 

 

A protective mask for the surgical pathology laboratory still is waiting a special design. It requires a different conceptual approach keeping in mind specifics of surgical pathology specimens, hours of work, and versatility of functions during grossing and frozen section. (More details in “The upside-down Kimberly-Clark FLUIDDSHIELD Mask” at the link Equipment, Instruments, Gadgets.)

See also the implication in the post Ebola highlights work place safety.

 

 

 

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