Surgical masks: evidence, image, and art
Tel Aviv, Israel
* E-mail: azriel.perel{at}sheba.health.gov.il
Editor—During a recent visit to London, I had a chance to visit an exhibition of Damien Hirst. Among the various works of art in this exhibition was a series of paintings called the Birth Paintings. In this series, which depict the birth of the artist's son by Caesarean section, the artist confronts, as he puts it, ‘the intense joy and deep-set anxiety we can all feel in hospitals, where we are surrounded by both creation and decay’. In one of these large paintings, showing the operation in progress, with the surgeon, assistant, and nurse basked in dramatic light, in the left lower corner, sits a middle-aged gentleman who is busy scribbling. Besides being off-centre, this person is the only one who does not wear a surgical mask. After a minute, it occurred to me that this is the anaesthetist! Since where I trained and practice all personnel in the operating room is required to wear masks after the sterile trays are open, I thought that it is very unfortunate that the anaesthetist was caught embarrassingly ‘off-guard’ in this painting.
Later that day, I shared my impressions of this painting with some senior anaesthetists from the UK and elsewhere. To my great surprise, they have all said that ‘there is no evidence that wearing a mask decreases the incidence of infection’ and that, therefore, anaesthetists in the UK are not required to wear masks throughout the operation.
My first thought was ‘how much lack of evidence is needed to produce enough evidence to justify not wearing a mask’. I went through the literature on this topic and, in all fairness, found it to be inconclusive and controversial. El Mikatti and colleagues1 found that only about 35% of the responding UK anaesthetists wear masks regularly, and that anaesthetists rated their potential for transmitting or contributing to patient infection as rather low, even though, the article goes on to say, that a high proportion of anaesthetists continue to administer anaesthesia, despite suffering from various infections. In addition, some studies have definitely shown that surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway.2 Furthermore, a few studies that showed that wearing a surgical mask may not decrease the danger of transmitting infection have a very limited number of observations, and cannot be regarded as conclusive, in view of the fact that producing reliable ‘evidence’ when it comes to low incidence events is quite difficult. In view of this information, my question is why not err on the safe side when it comes to such a major change in our working practice? In the same vein, we could also say that there is no evidence that leaving the anaesthetized patient unattended for 3–5 min affects patient outcome.
Let me conclude by adding a comment about the possible effects of not wearing a mask on the anaesthetist's public image. Anaesthetists worldwide have been preoccupied with their public image. This has always been a sore spot for us since many of our patients are unaware that anaesthetists are medically qualified. Many of these discussions have dealt with the impact of the anaesthetist's appearance and attire. One concludes that the level of ignorance about anaesthesia has not changed significantly in recent years and that this may be as a result of the anaesthetist's portrayal on television.3 The painting I was referring to is ‘art’ and not ‘television’; hence, it will probably be seen by not too many people. Nevertheless, to me at least, the damage to our image is done.
Editor's comments: During my training, everyone in theatre wore a mask all the time. In the past 10–15 yr this has changed steadily so that now few, other than the operating surgeon, wear them. In some body surface operations, the surgeon wears a visor rather than a mask. My surgical colleagues assure me that their audits show there has been no increase in the incidence of wound infection. Indeed, the only time I wear a mask in theatre now is when placing a spinal or epidural, as there is evidence that this has an effect.4 If there was a painting in the series showing the epidural being placed, I hope the anaesthetist was wearing a mask.
References
1 El Mikatti N, Dillon P, Healy TEJ. Hygienic practices of consultant anaesthetists: a survey in the north-west region of the UK. Anaesthesia (1999) 54:13–8.[CrossRef][Web of Science][Medline]
2 Philips BJ, Fergusson S, Armstrong P, et al. Surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway. Br J Anaesth (1992) 69:407–8.
3 Tanser SJ, Birt DJ. Who is watching over me? Was the public's perception of the anaesthetist changed by National Anaesthesia Day? J R Nav Med Serv (2000) 86:134–41.[Medline]
4 Grewal S, Hocking G, Wildsmith JAW, Epidural abscesses. Br J Anaesth (2006) 96:303–9.
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