I work in Boston's Longwood Medical Area, one of the densest concentrations of hospitals in the country, and I often have this reaction when I'm out on the street among my work neighbors: "Dude. Ew."
As in: Do you have something nasty on those scrubs or booties and is it going to get on me if I walk past you? Isn’t that supposed to be sterile? Can you really just stand under the cafeteria grease-trap vent and smoke a cigarette in disposable medical protective gear and then go back to work? Dude! Ew!
I'm an academic administrator, not a medical professional, and I don’t work in an actual hospital. I've always assumed scrubs were meant to protect the wearer from transmission of disease. Hollywood has filled my head with images of beautiful doctors in blue or green scrubs getting splattered with bodily fluids during a particularly harrowing Code Blue.
So when I see people wandering around public spaces, like fast food restaurants or grocery stores, it’s hard not to imagine all the stuff that might be on their outside that used to be in someone else’s inside.
I decided to do a little poking around. Should I be scared of scrubs? And what are they doing outside of the OR, anyway?
What I learned reassured me: People wearing scrubs in public places likely aren't coming directly from an operating room. They probably aren't violating any kind of policy, because it's unlikely their facility has one. And yes, the scrubs probably have bacteria on them, but no, it probably won't make me sick to be near them. Still, there is a lingering yuck factor.
First of all, it turns out Hollywood left me with the wrong impression. Scrubs are actually not considered personal protective equipment at all. Occupational Safety and Health Administration regulations state that, “Scrubs are usually worn in a manner similar to street clothing, and normally should be covered by appropriate gowns, aprons or laboratory coats when splashes to skin or clothes are reasonably anticipated.” (On TV, the emergencies are never anticipated.)
'You Don't Take The Time To Duck Into A Closet'
Scrubs came into broad use in the operating room in the mid-2oth century. They were white so any stains or splatter would be easy to notice. But the brightness of an all-white operating room added to surgeons' eyestrain, so the color was changed to a pale green, and the modern scrub design has stayed much the same since the 1970s.
These days, medical supplies and clothing are available to anyone, really. My dental hygienist wears brightly colored sets with floral patterns. I recently stopped in to a mall Work N’ Gear store, and found that I, too, could look like a medical professional for about $25. Or I could go for the celebrity look with a designer set of "Grey’s Anatomy"-brand scrubs for over $50.
Might people wear them around and about to show off? "Look at me," they might be saying. "I'm a medical professional over here!" I emailed Dr. James Hamblin, senior health editor at The Atlantic and a former UCLA radiologist, to check that theory, and he thinks it's more about convenience. “Some hospitals don’t readily provide changing rooms and showers for doctors,” he wrote. “It was easy to just want to leave so badly at the end of a night shift that you don't take the time to duck into a closet.”
Scrubs On A Plane
But medical staffers really should take that time, says Dr. Frederick Greene of the North Carolina School of Medicine, host of the American College of Surgeons' audio show, “The Recovery Room.”
He argues that most medical institutions need better procedures to ensure clean and professional work attire. “Most hospitals have no statement and no regulations on what should be worn in the operating room,” he said in a phone interview. “[They] haven’t been pushed by anybody to have regulations.”
Dr. Greene shared this opinion last week in General Surgery News, noting that on a recent flight he was on, "a young man walked down the aisle of the plane in a fairly wrinkled blue scrub suit and took a seat."
"Now, I cannot say if he was a surgical house officer, a community surgeon, a department of surgery faculty member, a company representative going home from a laboratory skills course or just someone who liked to dress in OR scrub suits," he writes, "but it seemed a little strange to have him sitting wearing a scrub suit on a plane in a fairly closed environment with 200 other people. I thought about the possible variety of pathogens and fomites that he might be shedding!"
Greene says he is heartened by the recent interest that the medical community seems to be taking in professional medical dress codes. In August, the American College of Surgeons released new guidelines for appropriate OR attire. Among the recommendations: Remove all jewelry, change scrubs once a day, and never have a surgical mask dangling under the chin. It also states specifically, “OR scrubs should not be worn at any time outside of the hospital perimeter.”
The other day, on my way in to work, I passed a woman walking outside in full scrubs, a bouffant disposable hair covering, and a surgical mask that was dangling under her chin. Inside the hospital, in line for coffee at the lobby restaurant, I saw three people in full scrubs, two people in scrub pants and civilian tops, and one woman in full scrubs, a paper disposable gown, hair covering and booties.
It seemed like a bad idea to approach potentially stressed-out, exhausted medical staffers and ask, "Excuse me, why are you wearing those scrubs?" So I decided to poll my Facebook friends who work in health care to find out why they change or don't change.
My cousin, Barbara, a registered nurse who says her hospital has no defined policy, says she wears hers home because she’s exhausted at the end of a shift. A veterinary tech friend said he wore his to and from work and on any errands that came in between. Everyone seemed to agree, however, that if they noticed any contamination on their scrubs at any point in the day, they would change into fresh scrubs immediately.
Barbara framed it like this: “If I were walking around covered in bacteria from one patient, I couldn't safely take care of another patient. And, obviously, I'm protecting my family, too.”
Right. I tend to think the people I see in scrubs wouldn’t knowingly jeopardize their loved ones — or a skittish civilian like me standing near them in public. But what if they just didn’t know the danger because the hospital doesn’t highlight it with procedures?
Give A Wide Berth?
I tried to ask representatives at some major Boston hospitals what their regulations and recommendations were. Most didn’t get back to me quickly, but I did speak with Dr. David Hooper, chief of the Infection Control Unit at Massachusetts General Hospital. The hospital doesn’t have restrictions on health care professionals wearing scrubs outside the buildings, though it does have specific rules for operating rooms. Dr. Hooper believes encouraging and enforcing hand hygiene is a better way to control the spread of infection outside the hospital.
When it comes to transmitting disease, “hands are the most direct vector,” he said. Scrubs are not really about being sterile or protective in any way, Dr. Hooper says; they are just a “convenient, washable thing to wear that’s comfortable.”
I asked Dr. Hooper if I should give a wide berth to anyone in scrubs I see in public. “No,” he said without hesitation. “There’s no need for that whatsoever.”
That was reassuring. At the same time, the American College of Surgeons guidelines do "strongly suggest" no scrubs outside the hospital perimeter.
But why? Are scrubs any better or worse at harboring the types of bugs that hang around hospitals causing trouble? How much of those could you find on a pair of scrubs at any given time?
The answer, from the very small number of studies that actually look at contamination of scrubs (and all but one studying scrubs worn by nurses, not doctors), appears to be: a lot, and many of those bugs can live on fabrics for days and even weeks. Nurses' scrubs that were tested at the end of a clinical shift tended to turn up bugs, including some scary ones. From a 2012 study that tested 10 nurses' scrubs:
After 48 hours, MRSA positives were present on 4 of the day shift and 3 of the night shift uniforms. Additional bacteria identified include: Bacillus sp., Micrococcus luteus, Staphylococcus aureus, Staphylococcus epidermidis, and Micrococcus roseus. The significant presence of bacteria on the uniforms 48 hours after the shift ended necessitates further study, discussions and policy consideration regarding wearing health care uniforms outside of the work environment.
As concern rises over infections acquired in the hospital, I expect more people probably will be assessing the risks and the policies. In the meantime, what am I supposed to think when I see someone strolling around the supermarket in their medical blues squeezing all the avocados?
I suppose what I should think, given what I've learned, is that anyone outside a hospital in seemingly clean scrubs is probably not fresh out of surgery, and is most likely not violating a hospital regulation. I should remember that anyone can purchase scrubs and they are used in a multitude of non-infectious settings. And I should probably assume there are some bacteria on their clothes, but if I’m healthy and I’m not licking them, I’ll probably be fine.
That’s what I should think. What I do think is still: Dude. Ew.
Readers, what do you think?