Tuesday, April 26, 2016

It's time to discuss surgeon headgear again

I received this email last week:

My state has recently banned the time-honored surgical cap,
Timed-honored cap
in favor of the “bouffant” cap.
"Bouffant" is French for "doofus"
I have been wearing the disposable surgical caps for my entire career, and have one of the lowest infection rates of any surgeon at my hospital.

Not only are the bouffant caps uncomfortable, I have now developed a severe allergy to them, making them unwearable. Now they say I must wear a full head/beard cover type cap in order to satisfy their requirements...REALLY? 

Head and beard cover even more uncomfortable than bouffant
I asked the hospital to show me a study that proves that the use of a bouffant cap has ANY advantage at all. Of course they can't, because no such study exists.

I would like to know who is personally responsible for this asinine rule so I can go to their office and give them a piece of my mind. My guess is someone who has nothing better to do and needs job security. Make a rule so that you have something to enforce, and "Violá!" A self justified existence.

I am writing not just for myself, but every surgeon in my hospital, most of whom are apoplectic, but do not have any recourse. We need recourse.

I appreciate your confiding in me, but I'm afraid you will be disappointed.

I feel your pain. You are not alone. We went through the same thing 5 or 6 years ago in my state. I was working as a surgical hospitalist at the time. Before the traditional paper scrub caps were thrown away, I stuck a box of them in my locker.

Because I operated mostly after hours, I wore them until I ran out. The bureaucrats would never inspect the OR after 3 p.m. or on a weekend. By the way, at that time I was shaving my head daily so hair was not an issue.

I hope you have read my blog post about rules without foundation, but if not here's the link. There are several interesting comments from readers about surgeon's caps.

Another post you should look at is "Does OR staff hair cause infections?" on my “Ask Skeptical Scalpel” blog. The comments are also worth reading. Here's the link.

Beyond sequestering as many normal caps as possible, I don't know what you can do. Since every surgeon is involved, maybe a march on the Department of Health would work, but I doubt it.

Your theory that people make rules like this simply to exert power and fortify their position is plausible.

Physicians need to regain some control over medicine. Alas, it may be too late.


artiger said...

Scalpel, did the email say it was his STATE that issued this edict? As in, from its health department? And in your case, was it your state that tried to enforce this foolishness?

If so, in either case, I don't want to move to wherever these places are. Then again, nonsense picks up momentum much faster than common sense and science, so there may be no place to hide.

RobertL39 said...

As long as surgeons allow themselves to be steamrollered by bureaucrats who, without proof, make a rule because *this kinda' makes sense* the steamrollers will keep coming. After all, they have to justify their job somehow. To quote a famous phrase, "Just Say No". I strongly suspect that if all, or even most, of the surgeons in the hospital objected and stopped scheduling cases for a week the rule would change. "Show me the evidence or get rid of the rule" seems like a good mantra. Stand Up or continue to be rolled over.

George Gasman said...

Wait, this is the *state* requiring you to wear the bouffants?


After the last discussion about OR attire, one of my partners tried to find some science behind the regulation. Of course, no such science exists.

If I'm not mistaken, there's also no evidence that wearing a mask in the OR reduces infection. In Great Britain, the only ones wearing masks are the people standing at the table: surgeon, assistant, scrub nurse. Circulator and anesthesiologist are unmasked.

I'm so glad I'm going to retire this year.

Skeptical Scalpel said...

Yes, according to the email I received, the state is mandating no more traditional caps. It's the state. They don't need evidence.

I don't think a protest by all the surgeons in the hospital would do much. It's a state regulation.

I'm happy to be retired too.

artiger said...

Well, fortunately I live in a state that is pretty backwards, and is usually the last to change just about anything. When the edict finally rolls in around here, I'll just use my own purple and gold cap. My hospital won't say a word.

Oldfoolrn said...

Try wearing a "bouffant" hair cover as a beret. Just keep the elastic band above your ears. If the elastic band is too snug just trim down an appropriate number of elastic fibers with your straight Mayos. It's comfortable as a cap and adds an artistic flair to any surgery.

Skeptical Scalpel said...

Artiger, you're in a good spot. Stay with it.

Old, when I had to wear a bouffant, I would gather it up and tie a knot in it. It looked like a man bun and covered about as much of my head as a traditional cap.

michelle said...
This comment has been removed by the author.
Skeptical Scalpel said...

Michelle, I don't think that will work. The state made the rule, not the hospital.

20th century man said...

The practice of medicine should be guided by science. When someone can show me a valid study proving that traditional surgical caps increase infection rates I will happily switch, just as I stopped wearing a white coat and tie.

Anonymous said...

Is there any possibility that bouffant manufacturers or some other commercial interest is behind this, like in the hand dryer/paper towel post? Maybe the "invisible hand" behind this thought all caps are created equal and no one would notice.

Whatever the reason, RobertL39 is spot on.

Skeptical Scalpel said...

20th, I'm not sure that white coats and ties increase infection rates, but at least there are some studies that show they may be contaminated with bacteria.

Anon, maybe you are on to something.

Anonymous said...

When it was mandated years ago at my hospital to wear the bouffant, I tried many things to "modify it for comfort" including the "man bun" you described earlier. The best compromise I found was by pure accident as I was rifling through cabinets trying to locate a new box. In the very back were bouffants so large I couldn't imagine them on even the largest of heads. Combining the impractically large headwear with the "man bun" resulted in the most comfortable compromise I have found. The elastic is comfortable, and bun gathers up all of the loose material. It looks ridiculous, but it's the best I could come up with and stay within the rules. My infection numbers didn't significantly change (what a surprise!).

Relating to this topic, shoe covers (or shoes that specifically stay in the OR wing), headgear, and a full mask is required of all personnel within the entire dept, even if one is only running down to the surgical pathology lab to quickly check something (completely avoiding the scrub-in area and ORs). I find it absolutely ludicrous, and I believe it can even be detrimental at times. The hassle of changing shoes or putting covers on every time one goes through the doorway causes many staff to avoid travelling down to view results in person, visit the patient in recovery (technically part of our hospital's OR wing, and thus under the same rules), or any other reason where it normally would be more efficient to just quickly check something yourself. Even going to just to look at the schedule board would technically require it due to the location of the board. I've noticed myself and colleagues completely avoiding checking something in person to avoid the hassle of PPE. It hasn't happened to my knowledge yet, but I can easily picture a mistake made where it could have easily been avoided had one just gone down to look in person rather than call someone and ask them to look/read something to you. Anyway, sorry for the nonsensical babbling - I didn't intend to start a rant, but it seems I did all the same.

Skeptical Scalpel said...

Anon, I enjoyed your comments. It looks like you work in one of those hospitals where rules without justification prevail. Sometimes these rules have unintended consequences as you so clearly pointed out. Discouraging people from looking at their own pathology slides or monitoring the operating room schedule seems like a good illustration of that.

Don't worry about ranting. I do it all the time. That's why I blog.

Anonymous said...

As someone said it is rule writing just for the sake of it to justify one's job. Why? Why did I become a physician?

Skeptical Scalpel said...

Yes, rules without foundation. You might enjoy this post of mine: https://skepticalscalpel.blogspot.com/2012/05/rule-without-foundation.html

Unknown said...

I'm late to the party here, but if this is a state mandate, the effected surgeons need to lobby for a change. Many professional associations have a paid lobbyist already. If not, they at least should have a committee that handles prospective legislation. Those folks should already be familiar with the process in-state and can guide the push for change.

Granted, it's not like Legislators care one whit about evidence when creating laws that regulate medicine. Or maybe that's just my state...

Skeptical Scalpel said...

Sorry for the delayed response. I was out of the country. I agree with you. I would not expect much from the state legislature or any state agency but the only recourse is to try to influence them.

Anonymous said...

It's funny to see people,I presume are atleast 15-20 yrs older than me, fret about having to wear a 'bouffant' I would gladly wear, while some of us here still live in the era of autoclaving our cotton gowns along with the headgear. Shouldn't we have switched places? It is comfortable for female surgeons(I'm not one yet) or female OT staff I guess. Very similar to a shower cap. I for one stock them up whenever I find them. I don't know how well infection can be controlled in the US. However, hairfall can happen with anyone and if that hair happens to fall into an open wound during surgery, all you can do later is wonder that why did you not get your head tonsured and offer your hair to some god. Just an opinion.

Skeptical Scalpel said...

Anon, thanks for the comment. Over the years I have seen hair fall into a wound several times. The wounds never got infected. You are free to wear as many bouffant caps as you want. Be sure they cover all of your have though. Don't be like the women in the photos shown on this post [http://skepticalscalpel.blogspot.com/2016/08/or-head-covering-controversy-acs-vs-aorn.html].

George Gasman said...

When I worked at the university, we had an orthopedic resident who had alopecia totalis.

They made him wear a (bouffant) cap.

Because it's the rules.

Skeptical Scalpel said...

Rules are rules. As I said in the post, they wanted me to wear a bouffant when my head was shaved.

Frank H. Weeden said...

We are mammals. We have arm hair, pit hair, eyebrows, ear hair, hair, hair, hair. I shaved my face because I got sick of the asinine beard covers that I was made to wear. Those things are ridiculous and have gaps all over them, but oh no: Can't have *gasp* facial hair!! Perish the thought!

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