Misplaced fears

May 24, 2008 at 1:24 pm (Clinical rotations)

There are lots of things in the hospital to be afraid of: violent psychiatric patients who try to attack everyone who looks like their family, homeless patients who cough on you, OB nurses, and attendings who want to tell you about Jesus. Hospitals have a rightfully deserved reputation as a dangerous work environment. Despite all of these things to be afraid of, nothing will throw people into a fit greater than HIV.

Let’s be absolutely clear about the way that HIV is spread. Only a direct insertion of bodily fluids will cause this virus to gain entry. Examples include drug abusers’ sharing needles, unprotected sex, and blood transfusions. What will not cause a spread of the virus is the physical exam. Skin-on-skin contact such as listening to the heart and lungs cannot cause a transmission of HIV unless both the patient and the healthcare provider have open wounds. This concept is pretty easy to understand. Yet despite all of the research and education that goes into this disease, people-including health-care workers-are woefully ignorant about the subject in practice.

Earlier this week I had a nurse stop me during the middle of listening to a patient’s lungs and admonish me for not wearing proper protective equipment such as gloves. I just don’t understand where this fear comes from. Yes, I know that there is a stigma associated with AIDS, but I would expect at lease for a nurse to understand how difficult HIV is to transmit. Mentioning those three letters on one of the nursing floors in my hospital will instantly cause a panic. Staff will begin putting on gowns and masks as if they are expecting a chemical weapon attack. Despite all of the frenzy that a weakly communicable disease causes, many people still will not follow proper precautions in other instances. For example, if a patient has an MRSA infection-requiring contact isolation-many nurses and doctors will continue visiting the patient without wearing the proper gloves and gowns. These health-care providers will then gleefully move onto the next patient’s room and spread all manner of bacteria.

Because of the extremely high number of nosocomial infections in my hospital, management has created several protocols for handling infectious diseases. We have placed alcohol rubs inside of every patient’s room so that people can wash their hands before and after each patient encounter. And while I’m thankful for these devices, I think that we need to do more. First, let’s get rid of the white coat and necktie. Multiple studies over the past few years have indicated that white coats and ties easily transmit disease from patient to patient, so much so that England has banned white coats from clinical areas [1, 2]. Second, let’s force all health care providers to use alcohol swabs on their stethoscopes after every patient encounter [3]. I carry a pocket full of alcohol pads everywhere I go. After each patient, I clean my stethoscope similarly to how I wash my hands. If you’ve never cleaned your stethoscope before, give it a try. You’ll be very surprised by the amount of dirt that comes off in just one pass of the alcohol pad. And stay way from those silver-containing diaphragm covers. The advertisements claimed that by using silver ions, these devices can kill bacteria. In reality, however, these covers are a greater source of infection than regular dirty old stethoscopes [4].

So there we have it. Evidence shows that white coats, neckties, stethoscopes, and artificial nails are a source of infectious disease transmission [5]. My hospital requires medical students to wear white coats, wear neckties, carry stethoscopes with them at all times, and has no policy regarding artificial nails. And the result is that we do a pretty good job of infecting people with C. diff, MRSA, and Klebsiella. Maybe what we should be doing is telling everyone that all of our patients have HIV. That way, they’ll be sure to carefully protect themselves from any communicable diseases.