Making Surgical Care Better: Hard Work, Small Gains

Three papers in this issue of the journal illustrate areas of active concern and academic inquiry for surgeons and their colleagues from epidemiology who are committed to the complex task of designing incremental reductions of surgical-wound infection risks. After reading the articles, one has an opportunity to ponder some difficulties that can complicate or derail searches for clinically useful truths that support practices of benefit to patients. In 'The Evolution of the Surgical Mask: Filtering Efficiency Versus Effectiveness, Belkin1 provides a detailed review of the 100-year history that underpins current surgical-mask-design features. At issue in the essay is the difference between constructions that feature maximal filtering effect and those that assure minimal droplet spread from the wearer, as measured in actual provocative testing. Obviously, the availability of modern synthetic materials has led to newer designs, compositions, and product choices. In the operating room area of my hospital, no fewer than four kinds of masks are available above each of the 50 scrub sinks. Thankfully, the old cloth mask used by early 20th-century surgeons can be regarded as a museum item. Reconfirming the old principle is no free lunch is the finding in Belkin's review that attempts over the years to make masks ever more restrictive to passage of bacteria-laden moisture or air expired by the wearer ultimately yielded mask prototypes that effectively channel exhaled air or spittle (and presumably pathogens) to the sides of the mask, challenging there the skin-mask interface. Wearing two masks-a not uncommon practice in some modern operating rooms--will give a similar paradoxical result. Once again, the laws of physics are immutable! Although the author is not a surgeon, he clearly has been in touch with operating room workers, because h rete ls a familiar anecdote concerning what to do in the operating room if you are scrubbed in and suddenly feel that you are about to sneeze. Predictably, most f us instinctively turn away from the sterile field, probably assuring that, ironically, leakage of our sneeze blast will be straight out the mask-skin interface and aimed directly at the open incision. Victorian manners are habits to break. In the modern operating room, of course, everybo y wears a mask, beginning before the outset of procedures in which sterile equipment and the patient's s erile tissues will be open to the room environment. In addition to scrub nurses and surgeons who actually are working in the sterile field and handling instruments and anatomic structures, anesthesia personnel, circulating nurses, and any visitors to the room are masked continuously. The period of this faithfully practiced ritual ends when the incision is closed and dressed, just before patient transport to the recovery area. I agree with the author that there is a widespread, and probably random, assortment of ways in which I and my surgical coworkers do not uniformly observe rigid protocols for assuring mask fit and function. I strongly disagree that we should question mask use as a ritual element of operating room behavior. It will surprise some who do not work in operating rooms that only a very long tradition in surgery-and not science-says that wearing a mask reduces the chance of wound infection in the patient. When I say hard science, I specifically mean clinical trials in which the wound infection surveillance was blinded, the surveillance assuredly checked every sin-