“We need to shampoo the patients’ hair,” said Kristen, a physician assistant with a two-foot flaxen rope of her own. She’s an authority. Operating room nurse Jess seconded the idea. Between the two of them advocating, it needed to happen.
Somehow for the last 23 years, as a man with short hair, I’d always considered a rinse with water or peroxide to be sufficient to clean a patient’s scalp and hair after surgery. We would wash it the day after. That’s just how we’d done things. But why not wash it in the operating room before the patient wakes up? The literature suggests no danger, so I went along with Kristen and Jess, and bought good shampoo and conditioner — minty and herbaceous, deeply cleansing.
The first time we did it, it seemed a little frivolous. If it was about surgical cleanliness, it wasn’t required. We have more antiseptic ways, but they’re terribly astringent and do nothing about detangling.
As we continued to wash patients’ hair after brain surgery, I began to notice the effect it had on everyone else in the room. The doses of shampoo and conditioner we squirted out transformed the OR to a spa for just a few minutes. The patient was the subject of the cleansing, but we were beneficiaries too. It was a quiet, collective feeling, knowing that we were finishing our work well. The fragrance of washing, the manual lather, and the gentle rinse fixed that in our minds.
Neurosurgery is delicate and precise but people don’t generally think about the mess of bone and blood that we create in order to get there. The scalp bleeds a lot and clotted blood clumps in the hair. Peroxide can cause dermatitis and make the hair brittle. Shampoo washes the clot away. Bone dust is a little sticky, stubborn to get out, particularly from wiry hair, but shampoo lifts the particles. I discovered this myself recently. After playfully chiding my fourth grader about something, she shook Parmesan cheese into my short hair. A deluge of water wasn’t enough, but shampoo floated it away.
Neurosurgical haircuts tend to be the sorts that real barbers fix after the patient goes home, closer to assault and battery than stylish and flattering. Patients say they don’t care about hair, but they do. It can be a symbol of power or beauty, as with Samson or Rapunzel. Or it can be an object of envy, something to be truncated, as in F. Scott Fitzgerald’s Bernice Bobs Her Hair, a 10,000-word Cruel Intentions of the Jazz Age. A contemporary example, hair in Namwali Serpell’s novel The Old Drift serves as a symbol of individual and cultural particularity. People definitely care about their hair.
For surgeons like me, hair is keratin strands that need to be removed so we can get to where we need to go. But for patients, hair is much more than that, and it’s hard to escape its symbolism in neurosurgery. Something bad has happened to a patient if I’m considering what to do with their hair. Cutting into the brain is a transformative moment in anyone’s life, and afterward there’s a bad haircut to go along with it. I try to minimize the amount of hair removal or cut it in a way that the rest of the hair can be styled to conceal. Some surgeons remove none, but that creates its own problems with strands getting caught in the wound. Others cut a large swath over half of the head, an abominable, institutional cut. Me, I split the difference and cut a strip so the path of the scalp incision is exposed. Even so, it’s not a cut that anyone would ever request.
After removing a tumor, a blood clot, implanting electrodes, washing the hair with nice shampoo and conditioner symbolizes the beginning of some kind of recovery, a return to a new normal for the patient, cleansing away the bone and blood and the misfortune that caused them to need me.
But it does something for us, too. Once we decided to wash hair, we made a process for it in the OR, to protect a fresh incision, to keep the rinse water off the floor. We send the patient out of the OR with clean, combed hair, knowing and showing that we’d cared for them well. The patient is more than a case — they’re a fellow human, after all. A postsurgical shampoo seems like a good talisman, and it is not frivolous. It’s the least we can do.
Patrick J. Connolly is a clinical associate of neurosurgery at Penn Medicine and neurosurgery chief at Virtua Health. The opinions expressed in this article do not represent those of the University of Pennsylvania Health System or the Perelman School of Medicine.