Hello, and welcome to our guide to scrubbing in in preparation to observe and assist in theatres. This will be the longest lesson in the course series and we will break down the various steps you need to perform when scrubbing in. We will be starting from before you even enter the operating department and guide you through to being at the patients side.  Firstly, when entering the OPD, you will need to get changed into clean scrubs and theatre appropriate shoes. Scrub sizing will obviously be up to you and is usually fairly intuitive. It is very important not to forget to change into theatre shoes as you won't be allowed in with normal footwear. Theatre shoes are often open heeled, plastic and look awfully similar to crocs often without holes on the superior surface. There is great variety however. In or around the changing room, there is often a stash of spare or left over surgical shoes for medical students to borrow during their time in theatre. If you feel that you will be spending a lot of time in theatre in the future, it may be worth buying your own that fit well. The last thing you must do before you enter the theatre is don a cap or bouffant. Caps are secured at the back with straps of material that you tie together. Caps are preferable for those with short hair. Bouffants are elasticated hats that are secured with a rim of elastic material rather than straps. Bouffants are preferable for those with long hair.  Now that you're fit to wander around the theatres, it's time to move to the prep room. During the theatre induction lesson as part of this course, you will see that attached to the operating room is a prep room with sinks, gowns, gloves and masks.  ​ You must identify a clean, clear surface large enough to put your gown and gloves on.   Firstly, you'll want to don a new mask. Most of the time it is best to put on a mask with a face shield if they are available. This small shield will prevent material from the patient, such as blood, from making contact with your eyes. These masks are often tied at the back with two sets of straps. Next, you should choose your gown. The exact type of surgical gown required can vary from operation to operation and it may be worth asking the surgeon what type is suitable. The vast majority of the time, a standard blue gown is sufficient. With gowns, our tip is generally to choose a size larger than what you'd usually wear. The gown will be in plastic wrapping. Open the bag, place the folded gown pack onto your clean, clear surface. Now we must open the folded gown pack in a very particular way to ensure it remains sterile. The outside of the pack does not need to be sterile and we must take great care to touch the inside surface minimally. The pack is folded in such a way that the corners are easy to grab and pull to open the pack. Grab the corners only, one corner at a time, and open the pack to expose the gown and towels. We will then leave this for a moment.  Now we must get our gloves ready. You should find two different sets of gloves: under-gloves and white over-gloves. Under-gloves usually have a distinctive colour, often green or brown, so that they are easily visible should the over-glove become pierced during an operation. Sizes will obviously vary from person to person. The average size for a male is around 8, whereas the average size for a female is around 6.5. It may be worth using a sacrificial pair of gloves at this stage to determine what size fits well. It is standard practice to choose an under-glove a 0.5 size larger than the over-glove. For example, I use an 8.5 under-glove beneath an 8 over-glove. Now that you have your two gloves, it's time to put them on your sterile area. Open the plastic wrapping, being careful not to touch the contents, over the area and let them fall.  Now we have all of our PPE and we are dressed appropriately. The next thing is to get sterile. First, grab a surgical scrubber and nail pick, open it, and turn on the taps. It is usually good practice to start by giving your hands and forearms a good general clean even without following the correct procedures that will follow, you can use the sponge side of the scrub for this if you prefer. Now, when washing your hands and forearms for surgery, we adopt a very particular pose: arms out front, elbows bent, finger tips to the sky. You should stay in this position until your hands are completely dry after using the towels. This is because the most important site that has to be kept sterile are the fingertips, and dropping your arms will allow dirty water from higher up the arm to contaminate them. Also, during this stage of scrubbing in, we use our elbows to manipulate the taps and soap dispensers.  ​ Before starting your day operating, use the nail pick to remove any macroscopic debris from beneath your nails and cuticles. Wash that debris off and wet your hands and forearms. Next, dispense either of the two common anti-microbial agents found in theatres onto the brush. Chlorhexidine is pink, iodine is brown. Most theatres have both and both have a very similar efficacy, however some studies show chlorhexidine to be the superior agent. With our antimicrobial on our brush we will scrub our fingertips and nails. Make sure to scrub all five fingertips, including the thumbs. Now we can rinse our hands and repeat that last step. To do this whilst keeping our fingertips as sterile as possible, bring all of your fingertips together like this, face them upwards, and slide your hand and arms through the water as shown. This ensures no water from higher up the arm can travel distally. Do this until all of the suds are washed away. We will repeat that last step. Now we will wash our entire hands and wrists using a particular 7 step technique to ensure all surfaces are adequately covered.  ​ Firstly, Wet your hands and ensure you have plenty of anti-microbial agent. Remember to operate the dispenser with your elbow and try your hardest not to let any water drip from your elbow onto your other hand.  ​ 1. Palm to palm. Rub the agent into your palms for at least 10 seconds. ​ 2. Palm to dorsum. Using a similar technique but this time with one hand flipped. Interlock your fingers. After around 10 seconds, switch hands.  ​ 3. Interlocked fingers. Return to a palm to palm position, but this time interlock your fingers. Ensure all sides of all fingers have been cleaned.  ​ 4. Back of the fingers. Clasp your hands together as shown and rotate your hands against each other, cleaning the back of the fingers and fingertips. ​ 5. Thumbs. Grab each thumb and clean by rotating your opposing hand. ​ 6. Fingertips. Rub your fingertips into the palm of the other hand.  ​ 7. Wrist and forearm. Now grab the wrist, and in one motion move toward the elbow cleaning as you go. Never return back to a more distal point after this. Do this for both sides.  ​ Now rinse your hand using the technique we showed you earlier. This whole process is done at least three times.  ​ There is one important note regarding step 7. Every time you repeat the process, you should clean less and less of the forearm every time, this ensures that you done contaminate your hand, which would mean you'd have to restart the cleaning process. This means that on your final pass, you may only want to clean your wrist and leave the forearm entirely.  ​ Now that we've washed our hands we must dry them. Keeping our hands in position as much as possible, grab one of the two towels from the sterile area. With your hand, only touch one side of the towel. Place the opposing hand into the towel and dry fingers first, then the hand, then the wrist, and finally the distal forearm. Take care not to pierce any holes in the towel doing this. Now throw the towel away. Do the same thing with your other hand.   ​ Identify the folded side of the gown. Grab this side and hold the gown in front of you, ensure you are in an open area where you can spread your arms wide. You should notice two pockets on the gown, slide your hands into these pockets. Open the gown up as if you're opening a book away from you. The gown should unfold downwards. The pockets that your hands are in are actually the beginning of the sleeves, slide your arms into the sleeves. At this point you must take tremendous care not to touch anything with your arms or gown. Do not bring your hands out of the sleeve, instead, keeps your fingertips inside the cuff. At this point, another staff member should tie the back of your gown.  ​ Putting the gloves on with the closed glove technique is tricky and takes practice, don't worry if you struggle initially. For this, we must manipulate everything with our hands from inside the cuff. Open the under-glove wrapping and face the gloves away from you, so the left glove is on the right and the right glove is on the left. With your left hand in a pincer grip, grab the rim of the left glove just by the thumb portion. Hold up the glove. With your right hand, grab the opposite rim and pull the rim over the left hand. Now, your left hand will be inside a glove. It may need adjusting, that can be done soon. Do the same process with your right hand and glove. Now that both of your hands are gloved, you can adjust the gloves.  ​ Putting on the over-gloves is easier as we are now sterile. Open the pack, grab the gloves and slide your hands in. It is really important that your over-glove is pulled entirely over the under-glove. You should not be able to see any of the under-glove. Find another staff member to help tie your belt. Grab the paper ticket on your belt and offer it to them, they will hold it by one end. Let go and spin around, wrapping the belt around you. Now grab the end of the belt, not the ticket, and pull it from the ticket. You should now have two straps that you can tie together.  ​ Now that we are sterile, we should keep our hands in the midline by our lower chest and abdomen when walking around the room. ​ Head to the patient's side and rest your hands on sterile cloth. This way the surgeon can see and locate your hands at all times.  ​ Well done! That is the hardest part of the whole course but also the most important. If there is anything you think you missed, re-watch the video, and if anything is still unclear, ask the trainers during your in person practice lesson.