Despite centuries of scientific and medical advancement, we're still not entirely sure how important it is to wash your hands.

Despite centuries of scientific and medical advancement, we're still not entirely sure how important it is to wash your hands.

Like a lot of fundamental truths, the truth of that statement depends in large part on the context in which you say it. In a medieval fantasy setting, hand hygiene is likely to be one of the biggest lapses in medical care. A lot of ancient medical was actually reasonably sophisticated; ancient Egyptians had a mastery of certain surgical techniques, pre-Christian Europeans and Native Americans had extensive understanding of the medicinal uses of local plants, and the Greeks of Galen's era had, in some ways, better physical exams than most modern physicians. From the other side of things, we know that at least a thousand years ago, archers were dipping their arrows in their latrines because they knew that a certain percentage of the people who survived the arrow would subsequently die of infections. Somehow, though, the idea of washing one's hands didn't catch during those thousands of years. Scattered records from throughout history suggest that the occasional barber or wise-woman noticed that their patients lived longer in clean environments, but nobody really found "proof" of the benefits of hand washing before the mid nineteenth century, and it took another century or so for the evidence to start piling up to the point that it changed hospital practices. Prior to this, hand washing and sanitation in general were often rather hit or miss according to the era, the nation, and the individual healer. Let's also not forget that for much of human history, it was widely believed in the West that diseases were caused by demons and that demons could be driven away by foul odour, such that people believed that washing before they eat -- or any other time, for that matter -- was actually harmful to your health.

The best data available today suggests that outside of the OR, in the regular clinic or hospital room, doctors are still terrible at remembering to wash their hands between patients, and that this leads to a measureable increase in patient infections. Nobody wants to think about that too much.

The place where this gets kind of interesting is in the operating room, or in a fantasy game setting, quite possibly the barbershop, the common room of the tavern, or the middle of the forest. Let's assume that your characters know that they need to have clean hands before they bandage someone's wound or, for that matter, remove their appendix. How clean do their hands have to be? The truth is, we don't know. Now, I'm not a surgeon, but back in medical school, between my training in obstetrics and gynecology, general surgery, and orthopedic surgery, I spent about 16 weeks working in the operating room, learning to cut and suture (and more than anything else, hold a retractor and not move for an hour). Like all medical students, I learned the official way to wash hands outside of the OR, which involves a thorough hand-washing and nail-cleaning with soap and disinfectant. Once our hands were clean, we were taught to hold them in the air and not let them come into contact with anything at all until we were in the OR, where a nurse would put two pairs of special sterile gloves onto us and then wrap us up in a full-body gown. God help you if you needed to adjust your glasses once this process was over, because you couldn't touch them, or else you would have to "scrub out" and repeat the entire process.

The funny thing is, there's actually never been good data collected on whether we have to go to all this trouble. We know that washing hands is better than not washing hands. We have data on whether alcohol-based scrubs are better than traditional soap and water, and we know that it probably takes at least two full minutes of careful scrubbing to get the hands reliably de-germed. We know that patients seem to have more post-surgical infections when the doctors wear rings and nail-polish. We know that outside of the OR, patients get sick more frequently if doctors and nurses walk from one bedside to the next without washing hands, but we don't know if the act of putting on sterile gloves and a gown obviates the need for a two-minute hand-scrub. The problem is, we're very limited in finding ways to test this. You *could* design a study wherein surgeons are randomly assigned to either wash their hands for two minutes or five minutes, and then see whether there's a difference in outcome for their patients after surgery, but it's hard to imagine this proposal getting past an ethics committee. We can study the outcome of a change in the type of disinfectant used during hand-washing, as long as we use something that we think works; we can't do a study of what happens when people don't wash their hands and just put on the sterile gloves very carefully. And so, by the same token, nobody can really say if it's enough for the party cleric to wash his or her hands with iodine before suturing a wound closed, or if they also need soap and water and to scrub under their fingernails. You certainly want your cleric to wash hands before closing you up, but it's hard to say how long they need to do it.

The great thing about a magical setting is that this may not matter whatsoever. Presumably, someone somewhere has either researched or paid someone to research magical means to reliably clean themselves prior to surgery. In advanced settings, where there's a grasp of the scientific method, scholars may have even conducted randomized controlled trials and tested what spells lead to the best patient outcomes. Whether it's a level 9 Annihilate Microorganisms spell or just a level 0 Prestidigitation spell used for a full minute to clean the hands, magical cleaning is probably at least as effective, if not more so, than what doctors are actually using in modern hospitals. What we don't know is whether it has to be.

Four years ago, Dr. Eris Lis, M.D., began writing a series of brilliant and informative posts on RPGs through the eyes of a medical professional, and this is the one that appeared here on June 8, 2013. Lis is a physician, gamer, and author of the Skirmisher Publishing LLC OGL sourcebook Insults & Injuries, which is also available for the Pathfinder RPG system.