Fear of Contagion

[portann]

May 21, 2009
Doctor and Patient
Fear of Contagion

By PAULINE W. CHEN, M.D.

Early on in my internship, a senior doctor pulled me aside after hearing a couple of other interns grouse with me about our workload. “Caring for patients is a privilege, a calling,” he said. “Remember, no one forced you to sign your contract.”

For years those words came to mind whenever I cared for patients who had lethal, and potentially contagious, infections, patients like Jean (not her real name), who was in her 50s when I met her. She had contracted hepatitis C from receiving a vaccination with a contaminated needle years before, and the symptoms of her end-stage liver failure had become increasingly difficult to tolerate over the last year. She itched constantly from jaundice; her memory had deteriorated; and she had had episodes of life-threatening bleeding that had landed her in the intensive care unit on two separate occasions. According to the nurses, Jean had walked into the hospital on the night she was to receive a liver transplant, bubbling over about the new start on life she would have with the new organ.

Despite Jean’s optimism, she ended up suffering from a series of devastating postoperative complications and infections. By the time I came onto her surgical team as one of the interns, she had spent three months in the hospital.

One morning soon after I began taking care of her, one of the nurses noticed that Jean had become short of breath. A chest X-ray showed fluid in her lungs, fluid that I could drain to help her breathe. The drainage procedure wouldn’t take long once the needle was in her chest; but because everything would be done using sterile technique, once the procedure started, I could not leave Jean’s side or touch anything other than the instruments I was using.

My beeper went off the moment I slipped on the sterile gloves. I tried to ignore it, forging ahead with the procedure. I disinfected Jean’s skin, laid down sterile drapes and began numbing her skin with a syringe filled with anesthetic solution.

Over and over again, my beeper went off. And I continued ignoring it until the fifth page, when I began to worry that there might be an emergency elsewhere in the hospital. I wriggled my hips against Jean’s nightstand, trying to dislodge the beeper from my waist without touching it or contaminating the sterile field. I shouted for help, but no one answered my calls.

Finally, when my pager went off for the sixth time, I pulled off my left glove and reached down, groping for the beeper hanging on my right hip while walking toward the door to find a phone.

I felt a sharp sting. Looking down, I saw a small scarlet drop emerging from the tip of my left index finger. I had stabbed my finger against the needle I had just used to anesthetize Jean’s skin, a needle I still held in my right hand.

I stared at the tiny red bloom on my fingertip. And for a moment, I felt the floor beneath my feet give way, pulling everything — Jean, my heart, my work, my life — down with it. I stood there paralyzed, staring at the puncture wound on my fingertip and unable to stop the movie playing in my mind’s eye, a movie of a future like Jean’s. Jean would never leave the hospital and, a few months later, would die in the I.C.U., succumbing to a final, massive infection.

Over the years, I have been stuck, cut, coughed on, scratched and splashed several more times. Each time, I feel the floor and my life fall away. I have never contracted a life-threatening infectious disease; but sometimes I catch myself wondering if it’s only a matter of time. During the SARS epidemic a few years back, for example, health care workers were disproportionately affected; certain hospitals in affected areas reported that over half their workers contracted the disease.

And then every day there is news that swine flu may still reach pandemic proportions.

When I think about the possibility of becoming infected with a potentially deadly disease during the course of my work — when I allow myself to think about it — I struggle to reconcile my beliefs about a doctor’s responsibilities and my fears about my own safety.

But, always, I arrive at the same conclusion. Like that senior doctor, I believe it’s a privilege, a calling, to take care of patients. And I believe that in deciding to practice medicine, I have consented to an unspoken contract with the public, one that requires that I take care of those who are sick.

Lately, however, I have also begun to think that there is another side to that contract. Maybe there are obligations that the general public has to its health care workers.

Four years ago, Dr. Kent A. Sepkowitz from Memorial Sloan-Kettering Cancer Center in New York and Dr. Leon Eisenberg from Harvard Medical School published a study on occupational deaths among health care workers. They estimated that anywhere from 17 to 57 deaths per million workers occur annually in the United States as a result of occupational exposures. When placed in the context of other occupations, this calculated death rate was more than the national average, less than that of policemen and firefighters, and much less than that of the most dangerous occupations like fishing, construction, flying and being a part of the military. (Lawyers and waiters, interestingly enough, came at the bottom of the entire list with some of the safest jobs.)

But with some nine million people working in the health care industry, health care workers end up with one of the highest numbers of total deaths, upwards of more than 300 per year.

There is a flaw, however, in all of these comparisons. And it is that the estimated annual death rate for health care workers is, well, just that — a calculated guess that is an underestimate at best. Despite the very real risk that exists for all health care workers, the actual number of deaths from occupational injuries or infections is unknown. Unlike policemen and firefighters and other high-risk occupations, health care workers have no national registry to track deaths caused by infections or injuries acquired on the job. As Drs. Sepkowitz and Eisenberg are quick to point out, the figure they use is based on their best educated guess regarding occupational deaths from only four infectious diseases: hepatitis B, hepatitis C, H.I.V. and tuberculosis.

In a recent e-mail, Dr. Sepkowitz confirmed that four years after the publication of their paper, we still do not know what the actual occupational death rate is for health care workers. No federal or national organizations have stepped up to the plate and taken on the task of tracking these deaths. Without those numbers, without a clear idea of just how many people are affected, there is no way any of us can come up with better ways to protect those workers who put themselves at risk to care for others.

I recently spoke to Gerald M. Oppenheimer, a historian who has written extensively about the doctors who chose to care for AIDS patients just as the disease was emerging in the 1980s. It was a frightening period; no one understood how the illness was transmitted or infected.

“We are so used to seeing heroes as different, as people who are larger than life and who prepare all their lives for this event. But it’s not that at all,” Dr. Oppenheimer said. “[These doctors] were ordinary people who were responding to something that appeared to be very dangerous. And they were willing to take that risk because of their beliefs.”

Supporting a national registry of occupational deaths in health care workers would go a long way toward recognizing and supporting some of the extraordinary decisions of ordinary individuals. And that registry, I believe, should be part of the agreement between health care workers and those they serve.

http://www.nytimes.com/2009/05/21/health/21chen.html?_r=1&hpw=&pagewanted=print  

[portann]

In what way exactly was that a 'mild' departure from the article I posted? :)

Nosocomial infections are ghastly and I think affects one in ten patients.

As you well know, the patient's perspective and iatrogenic transmission are discussed here on the board almost exclusively and in great depth.

My intention in this instance was to throw some light on the risk that health care providers face on a daily basis. Vascular surgeons, for example, face enormous risk ten hours a day in a way that I never do.

I had the bad luck to need a gamma globulin shot in the wrong place at the wrong time but exposure to HCV and other infectious risks was never part of my job description.

[Willy50]

Thank you for the excellent read.

I think that they should somehow track such infections.  I think it could lead to more awareness and perhaps better or more stringent protocols in the health care field.

By the way...... mildly off topic.... but it is a double edged sword of sorts.  I wish that somehow *they* could better track nosocomial infections (hospital-acquired infections).  The very word itself suggests the concept that hospitals dare not speak aloud.....and so the concept is shrouded in a term that very few people know the meaning; nosocomial infection.

There is a dramatic or even romantic sense that gets attributed to a doctor who becomes infected while working with infected people.  It's great "copy" and it was inspirational reading.  When patients get infected in hospital settings however, the reverse situation may come into play.

I'm aware of a diagnosis situation where a woman denied past drug use and so the doctor moved down to the next infection risk (and in his *mind* that was....) and accused her of being a sexually loose woman.

On this Memorial day...... I wonder how many of our vets (whom we ostensibly honor today) may have been infected or who may have also succumbed to HCV during the not-so-innoculous innoculation process using air injection guns.  Many of these same vets faced the denial of blame.  They must have infected themselves somehow; drug use?  Our medical records fastidiously record such data if we volunteer it.  Those same records seem blase about interest in how many times we have been given injections by doctors or dentists.  They don't seem to need to track such vectors for transmission.  Worse yet, they don't seem to even care, not quite enough anyway.

There is a part of me that thinks that they don't really want to know.

As recent as this year there has been another VA  scandal of sorts about inadequate sterilization process and protocols in cleaning of colonoscopy equipment (over about a 5 year period) which resulted in multiple new and totally preventable HCV infections.  

Would not on this Memorial Day honoring our Vets with proper health care serve as a means of "honoring" them?  

Perhaps an editorial on this type of infection might serve as a sort of companion piece to such an article as the Times posted.

In this case we would have the heroic sort, a patriot who enlisted to serve their country, who became infected and who ultimately became neglected.  For years the VA has resisted taking responsibility for the infections caused by airgun injections.  It was easier to suggest that vets had gotten the infection through some other source.  For years these same veterans suffered far lower success rates with being treated than the regular populace.  I'll skip over the vital stats on the infection rates during the 60's and 70's but there were many, many people, mostly veterans who were infected by the very people whom they sought to serve; the military and ultimately our country.

.....A mild departure from the topic; the excellent article you posted.

I only wish that the topic that I wrote of would have gotten the same notice for World Hepatitis Awareness Day (May 19).......and doesn't that fit neatly with Memorial Day (May 25 this year?  Perhaps in time we will see some tracking and attention to this cause as well.  It merits the same attention and it could serve a much larger group of equally heroic *servants*.

Thank you for the article.  Happy Memorial Day and lest we forget...... World Hepatitis Awareness Day.

Best.
Willy