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.



  1. medschoolmemoir said,

    Thanks for this interesting post… you raise some good points that I’ve never thought about before. I think that when it comes to the possibility of spreading infections, it’s always best to err on the side of caution. So, your suggestion that essentially all patients be treated like they have HIV–while obviously a joke–isn’t a half bad idea in that it might reduce nosocomial infection rates by a good amount. At the same time, however, I wonder how doctor-patient (or nurse-patient, or whatever) interaction might suffer if all patients had to be treated as infectious risk hazards. I don’t know, do you think that would be a worthwhile trade-off? Just a thought.

  2. joey said,

    Yea that was pretty interesting, never knew neckties and whitecoats could cause problems. Doesn’t your hospital have a way of bringing this sort of thing to the management’s attention? Like a suggestion box?

  3. labrat said,

    The ID attending I shadow refuses to wear a white coat and tie. The rest of the ID faculty, however, still dutifully wear their white coats, and most still wear ties. You’d think, of all the divisions in an academic hospital, the division of ID would get it…

  4. anonymous said,

    Half, when my dad was dying he had MRSA and staff would come in all the f-ing time sans protective gear. A PT would come in with the stuff on and then dramatically fan herself with a hand claiming menopause (like I wanted to hear about THAT!) and take it off then do her PT on him,which involved a lot of physical contact. She’d go to the next person.

    At one point I was in the room when they changed his cath. My dad, always mindful of boundaries, didn’t want me looking but didn’t want me to leave. I turned when I heard something fall and saw that the nurse or CNA (I don’t remember what she was) had dropped the cath and was about to reinsert it! (I came unglued.)

    These same people were neurotic about everything else– covers on the steths, gloves for handling his personal items– I tripped stepping off the elevator and scraped myself up and they wanted me to sign papers stating that I’d not hold them responsible and to get treated in the emergency room, since my dad’s MRSA was airborne, they weren’t too crazy about me even being with him with my scrapes, but I told them that I trusted devout Catholics praying at roadside shrines more that their staff to take care of me. (They should have worked for Tony Soprano with better results! For my scrapes I went to Walgreens and got sterile bandages & A&D, and changed at the hotel and covered myself under my clothes and changed when I went back.) No one knew how my father got MRSA, the head of the hospital explained, but that was probably because they couldn’t narrow it down!

    I think that warmth can be conveyed through all the protective gear in the world. When I was with my dad, he was happy when I got cheery-aggressive and insisted that they take precautions with him and cover up.

  5. Michael Rack, MD said,

    Anonymous, I am glad you and your father encouraged the staff to gown up. I commend your altruistic nature. Covering and gowning up does nothing for the person with MRSA, it is done to protect other patients from MRSA.
    “I think that warmth can be conveyed through all the protective gear in the world.” I disagree with this. The protective gear distances the care giver from the patient and makes it harder for him/her to care for the patient.
    “When I was with my dad, he was happy when I got cheery-aggressive and insisted that they take precautions with him and cover up.” I am glad your father obtained some happiness from protecting the other patients.
    Gowning up is necessary to prevent the spread of MRSA.

  6. DocJohn said,

    Ironic that in talking about “misplaced fears” and one condition, you malign another with a commonly held myth — that anyone who is violent in a hospital must be a “violent psychiatric patient.” There is no empirical connection between an increased risk of violence and mental disorders (except with a concordant substance abuse diagnosis). Sadly, your subtle implication that there is only reinforces this myth and increases the stigma of people with a mental disorder.

  7. S said,

    “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.”

    Universal precautions. Or has that been forgotten?

  8. halfmd said,

    Yes, we have forgotten about universal precautions—hence the need to scare everyone into doing what’s right. Heck, I have seen gyn residents who don’t wash their hands after performing PAP smears. But once you mention that someone has HIV, everyone else will go into panic mode and put on all sorts of body armor to protect themselves from a disease that’s very hard to catch.

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