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The surgical mask: Another ‘sacred cow’?
A O R N JOURNAL
APRIL 1992. VOL 55. NO 4
Guest Editorial The surgical mask: Another ‘sacred cow’?
0
ne the sacrifices the surgeon and nurse make in the interest of asepsis is wearing surgical face masks. In designated areas (eg, sterile corridors, the OR suite), masks are required. The minute a surgical procedure is finished, however, it is common to see personnel drop their masks and let them dangle on their chests. In the media, almost every surgical team member photographed or depicted in illustrations wears a dropped mask, despite the AORN recommended practice that disparages it.
In a recent publication, an e x c e l l e n t l y designed and executed study on 3,088 consecutive patients was described.’ During 1 15 weeks, 1,537 operations were performed in which face masks were worn in the usual manner by all personnel in the operating room. Another randomly selected 135 1 operations were performed with no one, except personnel with colds or allergic rhinitis, wearing a face mask. No restrictions were placed on operating personnel behaviors ( e g , laughing, t a l k i n g ) . Patients scheduled for open heart cases were excluded as were patients having orthopedic, urologic, and outpatient procedures. It is noteworthy that certain cardiac procedures were excluded from this study. It is my opinion that this in no way disturbs the study’s validity or conclusions. Ethically, it would have been beyond reasonable risk to randomize patients undergoing operations of this acuity to a study that could have subjected those patients to significant mortality and morbidity. When masks were worn, the postoperative
wound infection rate was 4.7%; the rate of infection for cases performed without masks was 3.5%. Cultures from the infected wounds were similar, and the differences in the rates of infection for both groups was not statistically significant. The researchers thus conclude that masks show no benefit for the patient. I have followed the literature on aseptic barriers for many years and have been able to retrieve only one similar study. It was carried out in 198 1.’ In it, masks were deleted for a sixmonth period and then worn for a similar period without any difference in wound infections. Since the surgeon J. Miculicz recommended cloth gloves and mouth masks (ie, mundbinde) in 1897, masks have been an accepted ritual.’ Masks are ubiquitous for surgical personnel
William C. Beck, M D , FACS, FIES, is the presiclciit enieritus of the Gutl?rie Foundution joi. Medicul Reseuix.h, Suyre. Pu. H e received his niedicul degree from Nor.thw*ester.ii University Medicul School, Eimstoii, Ill. 955
A O R N .IOURNAL
APRIL. 1992, VOL 5.5, NO 4
Breathing through a wet mask may result in aspiration of dangerous body fluids. and even for lay people with respiratory infections or those who wanted protection from airborn viri. Originally, the mask consisted of gauze worn over the mouth. F. L. Meleny, MD, thought correctly that nasal discharges were far more contributory to infection than oral s o ~ r c e s , ~ and, therefore, gauze masks were raised to cover noses and mouths. How many layers of gauze were needed? Professor I. Ravdin MB, ChB, FRCS(Ed), of the University of Pennsylvania, conducted a telling experiment. He had layers of gauze added to a mask until he could no longer breathe in comfort. This resulted in an %layer gauze mask with four tie strings. Infections continued, however, so surgeons and nurses began to wear two 8-layer masks. About 1949, a droplet filter of fiberglass was introduced. 1 have, however, discovered a “doubting Thomas” i n the mask controversy. While in medical school i n 1936, Joseph Cady, MD, spent a summer clerking at the Hertzler Clinic in Halsted, Kans, and he remembered specifically that no masks were worn.5 Seeking to confirm this memory, 1 reviewed Dr Arthur E. Hertzler’s delightful best-seller of 1938, The Hoi..se und Buq~qyDoctor and I found that Dr Cady was correct. Dr Hertzler wrote: Cleun, rupid operating will do moi.e to minimize infection thun all thP juce masks e v e r inflicted on a doc*ile profession. Suiyywns hedeck their juces with raimeiit und ,fi’nr linen until the operating rooms look like the p i c t u r e s o j an oriental haiwri. The sight gives me CI ‘pain’.h He maintained that wearing masks was to prevent wound infection from exhaled breath. He did inany experiments (eg, exposing gelatin plates to the air, breathing on them, placing them at different spots in the OR) to determine 956
the likelihood of infection from this source. He concluded that There NUS no di8erenr.e in the number cf colonies in the . . . . plates. I iqwuted the experinient marly tinies. Of ( ~ ) i i r . wif, one i s going to tulk [dirxwly] into the wound, or e w n spit into it, the nioutk should he cwiwed. I prefi~r to keep my nioirth shut i le ope i‘u t i 11 g . T h i s m N k e s mu s k s unnewssuiy .’ It is interesting t o note that recently researchers have described a study paralleling those of Dr Hertzler, but with modern methods.x The results are almost identical. They caused Dr G. A. J. Ayliffe of the Hospital Infection Research Laboratory, Dudley Road Hospital, Birmingham, England, to ask editorially: “Masks in Surgery?”‘) T. G. T u n e v a l l , M D , the a u t h o r of t h e Tunevall study and P. Q. Bessey, MD, who was asked to comment on it in the World . I o i r i m l of Surgery, stress that while this study may suggest that the patient derives no benefit from mask wearing, a mask still protects the wearer from splash of potentially infected material. I” I believe that this is poor reasoning. The mask is not impervious to liquid splash. It has been shown that to prevent strike-through barrier material must be waterprooi.” Breathing through a wet inask may result in aspiration of dangerous body tluids. A far simpler method would be to drop a plastic drape from the bottom of the goggle or to wear a ‘splash shield’ purchased from any laboratory supply coinpanY. The authors of the Tunevall study recommend the use of masks by people suffering from nasopharyngeal rhinoviral infections. I certainly would not decry this, as it would presumably prevent nasal drips from entering the surgical field. It also would add to the comfort of the wearer. The ‘splash shield,’ which I sug-
gest, would be an even better protection. On the other hand, it is generally advisable to exclude peoeple with colds from the surgical suite. In addition, rhinoviral transmission has been shown to be spread by handbome contamination, rather than by droplet transfer; this again raises questions about the necessity of a mask. It has been shown that resistance to the passage of a i r through a m a s k c a n be m e a s u r e d directly.12 Breathing through a mask is work, and work is fatiguing. Expending work on the act of breathing is wasteful. The Tunevall study is a landmark in giving us proof that a costly device commonly used in the OR may be another “sacred cow” and could be eliminated. Its elimination would help surgical team members by giving them more energy and, if some form of ‘splash shield’ is made available, would afford comfort and greater protection for the surgical team. WILLIAM C. BECK,MD PRESIDENT EMERITUS
THEGUTHRIE FOUNDATION FOR MEDICAL RESEARCH SAYRE, PA Notes I . T G Tunevall, “Postoperative wound infections and surgical face masks: A controlled study,” World Journal qf Surgery IS (May/June 1991) 383387. 2. N W Orr, “Is a mask necessary in the operating theatre?” Annuls of’ the Royul College oj Surgeons of Englutid 63 (November 198 I ) 390. 3. J Mikulicz, “Das operiren in sterilisirten zwirnhandschuhen und mit mundbinde,” Centr-alhlattf u r Chirurgie 26 ( 1897) 7 14. 4. F L Meleny, F A Stevens, “Postoperative haemolytic streptococcus wound infections and their
relation to haemolytic streptococcus carriers among the operating personnel,” Surgery, Gynecology & Obstetrics 43 (1926) 338. 5. J B Cady, personal communication with the author, 24 August 199 I . 6. A E Hertzler, The Horse und Buggy Doc tor (New York City: Harper Brothers, 1938) 216-218. 7. Ibid. 8. N J Mitchell, S Hunt, “Surgical face masks in
Journal qf Hospital Infection I 8 (July 199 1 ) 165- 166. 10. Tunevall, “Postoperative wound infection and surgical face masks: A controlled study,” 383-387; P Q Bessey, “Invited commentary,” World Journal of Surgery IS (May/June 1991) 387-388. 1 1. Ihid. 12. W C Beck, “Air permeability of surgical masks,” Guthrie Clinic Bulletin 34 (July 1964) 26-
28.
Workplace Sexual Harassment Many employers are making sure they have well-crafted policies on the issue of sexual harassment; however, creating a work environment that is free from sexual harassment and hostility is more important, according to an article in the Nov 20, 1991, issue of Hospifuls. According tho the US Equal Employtnent Opportunity Commission, sexual harassment includes such things as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of sexual nature, especially when such acts are related to a person’s employment status or working environment. According to the article, executives specifically must find ways to prevent sexual harassment from occurring, foster the identification and reporting of all occurrences of sexual harassment, and effectively deal with accusations of sexual harassment. Several situations that could create an illegally offensive atmosphere include hugging and kissing among coworkers, disrespect for coworkers, sexually abusive remarks made under stressful situations, and workplace romances that do not work out.
modern operating rooms-A costly and unnecessary ritual,” Journal of Hospital Infection 18 (July 1991) 239-242. 9. G A J Ayliffe, “Masks in surgery?” (Editorial) 957
APRIL 1992. VOL 55. NO 4
Guest Editorial The surgical mask: Another ‘sacred cow’?
0
ne the sacrifices the surgeon and nurse make in the interest of asepsis is wearing surgical face masks. In designated areas (eg, sterile corridors, the OR suite), masks are required. The minute a surgical procedure is finished, however, it is common to see personnel drop their masks and let them dangle on their chests. In the media, almost every surgical team member photographed or depicted in illustrations wears a dropped mask, despite the AORN recommended practice that disparages it.
In a recent publication, an e x c e l l e n t l y designed and executed study on 3,088 consecutive patients was described.’ During 1 15 weeks, 1,537 operations were performed in which face masks were worn in the usual manner by all personnel in the operating room. Another randomly selected 135 1 operations were performed with no one, except personnel with colds or allergic rhinitis, wearing a face mask. No restrictions were placed on operating personnel behaviors ( e g , laughing, t a l k i n g ) . Patients scheduled for open heart cases were excluded as were patients having orthopedic, urologic, and outpatient procedures. It is noteworthy that certain cardiac procedures were excluded from this study. It is my opinion that this in no way disturbs the study’s validity or conclusions. Ethically, it would have been beyond reasonable risk to randomize patients undergoing operations of this acuity to a study that could have subjected those patients to significant mortality and morbidity. When masks were worn, the postoperative
wound infection rate was 4.7%; the rate of infection for cases performed without masks was 3.5%. Cultures from the infected wounds were similar, and the differences in the rates of infection for both groups was not statistically significant. The researchers thus conclude that masks show no benefit for the patient. I have followed the literature on aseptic barriers for many years and have been able to retrieve only one similar study. It was carried out in 198 1.’ In it, masks were deleted for a sixmonth period and then worn for a similar period without any difference in wound infections. Since the surgeon J. Miculicz recommended cloth gloves and mouth masks (ie, mundbinde) in 1897, masks have been an accepted ritual.’ Masks are ubiquitous for surgical personnel
William C. Beck, M D , FACS, FIES, is the presiclciit enieritus of the Gutl?rie Foundution joi. Medicul Reseuix.h, Suyre. Pu. H e received his niedicul degree from Nor.thw*ester.ii University Medicul School, Eimstoii, Ill. 955
A O R N .IOURNAL
APRIL. 1992, VOL 5.5, NO 4
Breathing through a wet mask may result in aspiration of dangerous body fluids. and even for lay people with respiratory infections or those who wanted protection from airborn viri. Originally, the mask consisted of gauze worn over the mouth. F. L. Meleny, MD, thought correctly that nasal discharges were far more contributory to infection than oral s o ~ r c e s , ~ and, therefore, gauze masks were raised to cover noses and mouths. How many layers of gauze were needed? Professor I. Ravdin MB, ChB, FRCS(Ed), of the University of Pennsylvania, conducted a telling experiment. He had layers of gauze added to a mask until he could no longer breathe in comfort. This resulted in an %layer gauze mask with four tie strings. Infections continued, however, so surgeons and nurses began to wear two 8-layer masks. About 1949, a droplet filter of fiberglass was introduced. 1 have, however, discovered a “doubting Thomas” i n the mask controversy. While in medical school i n 1936, Joseph Cady, MD, spent a summer clerking at the Hertzler Clinic in Halsted, Kans, and he remembered specifically that no masks were worn.5 Seeking to confirm this memory, 1 reviewed Dr Arthur E. Hertzler’s delightful best-seller of 1938, The Hoi..se und Buq~qyDoctor and I found that Dr Cady was correct. Dr Hertzler wrote: Cleun, rupid operating will do moi.e to minimize infection thun all thP juce masks e v e r inflicted on a doc*ile profession. Suiyywns hedeck their juces with raimeiit und ,fi’nr linen until the operating rooms look like the p i c t u r e s o j an oriental haiwri. The sight gives me CI ‘pain’.h He maintained that wearing masks was to prevent wound infection from exhaled breath. He did inany experiments (eg, exposing gelatin plates to the air, breathing on them, placing them at different spots in the OR) to determine 956
the likelihood of infection from this source. He concluded that There NUS no di8erenr.e in the number cf colonies in the . . . . plates. I iqwuted the experinient marly tinies. Of ( ~ ) i i r . wif, one i s going to tulk [dirxwly] into the wound, or e w n spit into it, the nioutk should he cwiwed. I prefi~r to keep my nioirth shut i le ope i‘u t i 11 g . T h i s m N k e s mu s k s unnewssuiy .’ It is interesting t o note that recently researchers have described a study paralleling those of Dr Hertzler, but with modern methods.x The results are almost identical. They caused Dr G. A. J. Ayliffe of the Hospital Infection Research Laboratory, Dudley Road Hospital, Birmingham, England, to ask editorially: “Masks in Surgery?”‘) T. G. T u n e v a l l , M D , the a u t h o r of t h e Tunevall study and P. Q. Bessey, MD, who was asked to comment on it in the World . I o i r i m l of Surgery, stress that while this study may suggest that the patient derives no benefit from mask wearing, a mask still protects the wearer from splash of potentially infected material. I” I believe that this is poor reasoning. The mask is not impervious to liquid splash. It has been shown that to prevent strike-through barrier material must be waterprooi.” Breathing through a wet inask may result in aspiration of dangerous body tluids. A far simpler method would be to drop a plastic drape from the bottom of the goggle or to wear a ‘splash shield’ purchased from any laboratory supply coinpanY. The authors of the Tunevall study recommend the use of masks by people suffering from nasopharyngeal rhinoviral infections. I certainly would not decry this, as it would presumably prevent nasal drips from entering the surgical field. It also would add to the comfort of the wearer. The ‘splash shield,’ which I sug-
gest, would be an even better protection. On the other hand, it is generally advisable to exclude peoeple with colds from the surgical suite. In addition, rhinoviral transmission has been shown to be spread by handbome contamination, rather than by droplet transfer; this again raises questions about the necessity of a mask. It has been shown that resistance to the passage of a i r through a m a s k c a n be m e a s u r e d directly.12 Breathing through a mask is work, and work is fatiguing. Expending work on the act of breathing is wasteful. The Tunevall study is a landmark in giving us proof that a costly device commonly used in the OR may be another “sacred cow” and could be eliminated. Its elimination would help surgical team members by giving them more energy and, if some form of ‘splash shield’ is made available, would afford comfort and greater protection for the surgical team. WILLIAM C. BECK,MD PRESIDENT EMERITUS
THEGUTHRIE FOUNDATION FOR MEDICAL RESEARCH SAYRE, PA Notes I . T G Tunevall, “Postoperative wound infections and surgical face masks: A controlled study,” World Journal qf Surgery IS (May/June 1991) 383387. 2. N W Orr, “Is a mask necessary in the operating theatre?” Annuls of’ the Royul College oj Surgeons of Englutid 63 (November 198 I ) 390. 3. J Mikulicz, “Das operiren in sterilisirten zwirnhandschuhen und mit mundbinde,” Centr-alhlattf u r Chirurgie 26 ( 1897) 7 14. 4. F L Meleny, F A Stevens, “Postoperative haemolytic streptococcus wound infections and their
relation to haemolytic streptococcus carriers among the operating personnel,” Surgery, Gynecology & Obstetrics 43 (1926) 338. 5. J B Cady, personal communication with the author, 24 August 199 I . 6. A E Hertzler, The Horse und Buggy Doc tor (New York City: Harper Brothers, 1938) 216-218. 7. Ibid. 8. N J Mitchell, S Hunt, “Surgical face masks in
Journal qf Hospital Infection I 8 (July 199 1 ) 165- 166. 10. Tunevall, “Postoperative wound infection and surgical face masks: A controlled study,” 383-387; P Q Bessey, “Invited commentary,” World Journal of Surgery IS (May/June 1991) 387-388. 1 1. Ihid. 12. W C Beck, “Air permeability of surgical masks,” Guthrie Clinic Bulletin 34 (July 1964) 26-
28.
Workplace Sexual Harassment Many employers are making sure they have well-crafted policies on the issue of sexual harassment; however, creating a work environment that is free from sexual harassment and hostility is more important, according to an article in the Nov 20, 1991, issue of Hospifuls. According tho the US Equal Employtnent Opportunity Commission, sexual harassment includes such things as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of sexual nature, especially when such acts are related to a person’s employment status or working environment. According to the article, executives specifically must find ways to prevent sexual harassment from occurring, foster the identification and reporting of all occurrences of sexual harassment, and effectively deal with accusations of sexual harassment. Several situations that could create an illegally offensive atmosphere include hugging and kissing among coworkers, disrespect for coworkers, sexually abusive remarks made under stressful situations, and workplace romances that do not work out.
modern operating rooms-A costly and unnecessary ritual,” Journal of Hospital Infection 18 (July 1991) 239-242. 9. G A J Ayliffe, “Masks in surgery?” (Editorial) 957