MODERN ART Piercings are a unique form of expression, but pose dangers in the OR.

Surgery and piercings don't mix, so your facility's policy on body jewelry should be straightforward: Patients must have it removed before they arrive at your facility. Unfortunately, getting them to comply with that hard-and-fast rule isn't always so simple.

What's the big deal?
Piercings don't pose problems; it's the metals they're made from that could cause trouble during surgery. If a piercing is made of implant-grade titanium, the likelihood of its conducting electricity is minute. However, you can't know for certain the quality of metal used to craft patients' piercings. In fact, I'd approximate that less than 15% of piercing studios use implant-grade metals, which can live within the body and be exposed to biological fluids without deteriorating or causing allergic reactions. That means there's a good bet most modified patients present with piercings made from cheap metals that increase risk of stray burns during electrosurgery and, in the event of an emergency, defibrillation. Piercings in the lip or tongue, regardless of metal quality, can also cause issues during intubation.

NEVER ASSUME You might be surprised by who's pierced.

RESPECT THE ART

Piercings Mean More Than You Think

Ask all patients if they have any piercings during pre-op phone calls. And never assume you know who may or may not be pierced, no matter the patient's age or demographic. I'm in my 50s and have multiple modifications, and when I owned a piercing shop, many of my clients were local business leaders, lawyers, doctors and nurses — not punk rock kids. You never know why a piercing was done, so keep that sensitivity in mind. Not everyone who wears body jewelry is an attention-seeking radical. Piercing is a way to mark different times or events in someone's life. Don't freak out or make jokes if you see an intense modification, and don't ask to touch it.

— David Vidra, CLPN, WCC, MA

Patients with piercings should have them professionally removed before the day of surgery. Of course, some might forget or opt to keep jewelry in for personal reasons. Your facility's policy should state that no jewelry is to be worn in the OR. If patients refuse to remove piercings, have them sign a waiver that indicates they've been told of the dangers their piercings pose and chose to ignore your warnings. If a patient is adamant about keeping piercings in throughout the procedure, discuss his reasons for wanting to. Include the surgeon and anesthesia provider in the conversation. Hopefully, you'll be able to impress upon him the safety reasons behind your policy and talk him into having the piercings removed. Inform patients who are afraid of losing fresh piercings if jewelry is removed that their piercer can insert plastic or quartz (inert substances that are safe for the OR) retainers in the holes to keep the wounds from closing.

Remove carefully
Patients are continually showing up for surgery with jewelry in place, despite being warned not to, so your staff may have to remove some pieces. Always lubricate jewelry before removal so it slides out easier and won't stick in the fistula. If you see a tube of white scar tissue coming out with the jewelry, apply more lubricant. Before removing any piece of jewelry, use sterile gauze or a sterile cotton swab to wipe the area around the piercing with dynarex benzalkonium chloride (BZK) antiseptic solution.

Do your absolute best to avoid damaging jewelry during removal, but don't be overly concerned if pieces get bent or slightly damaged, especially if patients were warned about having piercings removed before arriving (their safety is more important than their jewelry). Your policy should state that no item can be kept in the body that might conduct electricity, and your facility isn't responsible for any damage that might occur to items during removal.

Clean off removed pieces of jewelry with a disinfectant wipe, place them in a plastic bag, clearly identify whom the items belong to on a piece of tape or label attached to the bag and keep it with the patient's personal belongings. Don't reinsert jewelry after surgery, unless your staff is specially trained to do so. Patients should return to their professional piercers to have that done properly.

Treat piercings the same as you'd treat any valuable. Some body jewelry, especially the gold pieces, is expensive. Some of it may also be sacred to the wearer, having the same symbolism a wedding band carries.

LATEST TRENDS

What You're Likely to See

More and more individuals are presenting with dermal anchors, which are placed in the uppermost part of the dermis, not the hypodermis, meaning they're not deep piercings. Dermal anchors aren't implants, which live totally under the dermis with no outside exposure. They can be taken out, regardless of what a patient might tell you. Never use a scalpel (I've seen that done by a doctor who obviously didn't care for the piercing). A disc exposed to the air is attached to a piece of U-shaped metal that sits inside the skin. Some scar tissue can form in that open center, making removal difficult. Don gloves, palpate the skin around the piercing, unscrew the disc, lock a hemostat onto the jewelry's stem and apply pressure to gently work it out. Once removed, apply direct pressure to the opening to stop the bleeding; there's no reason to suture the hole.

What about other piercings? The jewelry is the same, no matter where it's placed in the body: some form of barbell — straight, circular, curved or ringed. Nose piercings are usually done with a nostril screw, which is a straight piece of jewelry bent inside of the nose. Navel piercings are comprised of curved barbells and rings of various forms. Eyebrow piercings are often done with a curved barbell or ring.

When removing barbell pieces, unscrew 1 or both balls. If the barbell's shaft has threads on its outside surface, lubricate it before pulling it through the wound. If you don't use lubrication, the threading will tear the scar tissue that has formed the fistula that holds the jewelry. Captive jewelry — many lip or navel piercings, for example — ?is held in place by pressure. To remove these piercings, insert a hemostat inside the ring and slowly open it. That will open the ring, take the pressure off the ball holding it in place and let you slide the piercing out.

— David Vidra, CLPN, WCC, MA