December 8, 2013

The Infectious Disease Emperor Has No Clothes!

The following are some thoughts that I first put down in an email to a friend.  It was precipitated by a mistake on my part.  A small mistake and one that has a 99.99% chance of being of no consequence.  But a mistake nonetheless:  I forgot to change gown and gloves.

The incident is that I arrived at Duke 7800, gowned, masked, and gloved, and dropped off a tray of coffee and dropped my coat in one patient's room, literally not physically touching anything - consciously not doing so.  Then I went down the hall to another patient's room and chatted with her.  I should have changed the gown and gloves, according to protocol.  (On return, you can bet I did everything correctly.  Not wanting to rock the boat here.)  While I feel that in this one case there was zero chance of transfer of any germs, I have to admit I broke not only the hospital's protocol, but my own. 

Hell, I'm cautious because I'm protecting myself as well!  I don't want to pick up any germs from my two friends and make my precarious position on the list untenable.  So I'll make sure the protocols aren't broken again.

What's frustrating is that I don't feel like these isolation protocols go far enough.  The CF patients are in more danger from the doctors on rounds and the food service people than they are from me, I think.  The established precautions deal with gowns and gloves - but aren't they for naught if there is no change of mask as well?

Not that I've seen any of the staff wearing those!  Call me ignorant or uninformed, but if you've got a patient on droplet protocol, YOU should be wearing a mask when tending to them!  Your own breath can be a vector for disease transmisison, especially if you are in close contact giving insulin shots, listening to chests with stethoscopes, etc.  And pants and footwear aren't isolated, either. The gowns reach to the knees on most people, but that's all.  And the pens and hair-touching... Am I crazy here?

Having worked in pristine white Christmas windows during setup, I'm coming to realize that I have a keener awareness of how contamination spreads than most of the medical community, because I've seen it in a visual form, both in terms of dirt tracked in, wet paint transferred from surface to surface, and glitter tracked literally everywhere. In 2011, I lit a set of windows for Macy's that were generally squeaky clean white, with portion covered in various kinds of fake snow or colored glitter.  We are extremely careful to use clothing protection, booties, gloves, etc.  We are extremely careful handling anything with glitter glued to it.  And yet, there was a single set piece using a particular red glitter that I was exposed to ONCE.  And six months later was finding that glitter AT HOME.  Theoretically, it shouldn't have been possible.  But the proof was before me.

If I could get Infectious Disease at Duke to come load in white, glittery scenery for a week, they'd be horrified at how lax their infection control protocols really are. And don't get me started on what I've seen so far of the horrific infection control gaps in ICU and step down, judging from pictures and anecdotes of recently transplanted friends.  I'll post soon enough on my own first-hand experiences in that realm, and with more surety.

And then I'll probably write a long and angry letter to hospital administration.  Why?  Because it is apparent to me that Duke Infectious Disease cherry-picks what protocols to follow, especially as concerns CFers. The result is highly convenient for the staff, and pays lip-service to infection control, but is largely smoke and mirrors. Their wards aren't set up correctly to provide the infection control required, so they go at it with what could be termed half-measures.  And it is simply not valid to have good isolation protocols on 7800 for CFers and then ignore it all in clinic and pulmonary rehab.  I wonder if the reason Duke Transplant doesn't work directly with Duke's CF center (!!) is partly because they can't handle the CFF guidelines for patient isolation?  The one time I asked, I had sunshine blown up my ass. "Well, our Infectious Disease department doesn't feel those precautions are entirely necessary..."  Oh, really?  With a patient population seeking lung transplant BECAUSE intractable infection has destroyed our lungs, you don't feel you should work a little more on at least requiring masks on all your CF patients in clinic and in rehab?  It's fucking nuts!

Sorry. But this just hits one of my most sensitive buttons. And if you ever come visit me, you'll find me behind a mask whenever there's another CFer in the vicinity.  It just makes sense.  If Duke sees sense in changing gowns and gloves between every room, then what is their hangup regarding masks?

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