Tuesday, June 24, 2008

Clean, not Unclean

Long ago in a hospital far, far away....

It was 1989. I was preparing to enter a hospital room, to support and care for the family of a young man who had died. The parents were at the bedside, focused on their child. The nurse stopped me at the door, clearly agitated. “Be careful not to touch him,” she said. “He has AIDS.”

I knew what he had, of course - would have known as soon as I saw him even if no one had told me. The purple lesions of Kaposi’s sarcoma were clear and plentiful on his skin. I touched both parents to comfort them; and then I placed my bare hand on the young man’s forehead to bless him and commend him to God.

I think of that story frequently enough, and regularly under some circumstances. One of those regular times is my annual visit to Employee Health.

The visit itself is simple enough, and simpler than it used to be. It once meant the annual tuberculosis (TB) test, the small, inordinately painful injection just under the surface of skin. Now that annual testing is no longer recommended (new associates are still tested – indeed, tested twice – but the annual test is no longer recommended), it’s a simple questionnaire to be sure I haven’t been exposed to anyone with TB, whether by patient contact or foreign travel. And there is, of course, the annual “fit test.”

Or at least there is for most people. For most people there is a check to see that an appropriate mask will fit securely over nose and mouth and around the chin, again to protect against TB and other illnesses, like flu, that can spread by spraying droplets from coughing or sneezing. For me, the Employee Health nurse and I simply laugh. Why? Take a look at my picture. The beard prevents any form-fitting mask from sealing completely. I have been tested at times over the past twenty years or so, and the results have always been the same. “Can you smell the test sample?” Yes, of course. Yes, always. I don’t even have that sensitive a sense of smell, but I always smell the test sample. So, there’s no point in the annual review in me actually putting on the mask to see.

There is an alternative. Every few years they come up with an improved sort of mask, and for a while each is suggested as the appropriate choice for someone like me. Now the appropriate choice is, in its way, the definitive answer. It’s a device with a full hood. The hood is attached to a pump and a filter to provide air. The pump and filter fit on a belt, and are about the size of, if a little heavier than, a fanny pack. I had to participate in a class to learn to use the thing. The full hood and the filter should protect me from about anything that might be floating in the air around me and a patient.

And this is where I come back to the story of the patient so long ago, the young man who died of AIDS. By the time I walked into that room we had been living with AIDS as a society for nine years or so. I knew the history and the acronyms that had changed with each new piece of information: “the Haitian disease” and “GRID” and AIDS and HIV. I also knew how difficult it actually was to transmit, and the importance of good hand washing – something, sadly, the nurse in question had apparently forgotten.

I had also heard over those early years the sad stories of how fear had separated those living with AIDS from those who cared for them. “Will no one touch me? Why won’t they touch me?” I never wanted a patient to feel I wouldn’t touch, unless there were real risks. More to the point, I never wanted a patient to fear that since I might not want to touch it meant God did not want to touch. I continue to feel that concern; and so, while I wash my hands frequently and use alcohol-based sanitizer even more, I tend to do it as I leave the room, after I’ve touched the patient, and not before, as I enter. I do it before, certainly; but before I enter the room, outside the patient’s presence.

What, then, should I do about that hood? Notwithstanding my joke over the years about my beard as my own organic air filter, I know that a mask intended to fit only from nose to chin will never provide a complete seal or complete protection. On the other hand, being smaller and used more commonly by others caring for the patient, I think it separates me from the patient much less than what looks for all intents and purposes like part of a hazmat suit. Will the patient notice? Perhaps not; but it seems to me a mask suggests I know the person is ill, while the power-assisted hood suggests I think the patient is non-human.

So, so far I use the standard masks, knowing they’re not perfect. I wash my hands, and even gown and glove if necessary; because if I convey the wrong contaminant into or out of the room I put at risk more people than just me. But I do my best to set as few barriers between me and the patient as are necessary for safety and dignity. It might not be a concern of any given patient; but I don’t want a patient to think I won’t touch because I am afraid. And I don’t want a patient to think that I won’t touch because I think God won’t touch.

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