Thursday, December 31, 2009

On Reflection at the Turn of the Year: 1

The end of the year is a time for remembering and reflecting.  Several things are on my mind these days.

This year I will be hitting several “30’s:” aspects of my professional life that in 2010 I’ll have been about for thirty years.  There are a number of ways in which I know that, but one of them is literally in my hands.

I don’t mean that this theme in my work is simply in my control.  I mean that I can see the evidence in the skin on my fingers.  My skin is always dry, and frequently cracked.

The issue is hand washing, but the point is not hand washing itself.  I don’t want to suggest that thirty years ago we weren’t concerned about washing our hands, or about a safe, sanitary environment.  Still, some things have changed.  We have always had gloves around, and we’ve always used them for sterile environment.  We’ve always washed our hands, but now every room, and almost every wall in the hospital has one variety of sanitizer or other.

We know, of course, what stimulated that change: AIDS.  AIDS has been with us thirty years, too, or almost.  I remember the early days, when we first heard about “the Haitian disease,” and then about GRID.  Point by point we learned more about this disease.  Those who cared for the sick learned about one opportunistic disease after another.

Eventually, we learned about the virus, HIV.  However, all along we have been washing our hands.  We found by experience that it worked; that is, that health care workers who followed good procedures, including washing their hands and wearing gloves, didn’t get sick.

Not everyone got that message, even once the virus had been identified.  I remember attending the death of a young man from Kaposi’s sarcoma.  A good nurse almost lost her wits when I laid my hands on the young man’s head to pray.

Again, it wasn’t that we weren’t washing our hands before, or wearing gloves in circumstances we thought to need a sterile field.  However, we were making assumptions, and based on those assumptions were washing our hands less, and especially using gloves, less.

We were also washing them out of the sight of the patient.  While much of the time that was because the sinks were simply fewer and farther between, sometimes we did it intentionally.  We did it intentionally with AIDS patients.  Some AIDS patients, already suffering stigma related to their disease or hiding their disease to avoid it, felt that washing hands in their presence suggested that they were somehow “dirty.”  So, to avoid adding to the stigma, or making more uncomfortable patients who were anxious enough already, we didn’t wash our hands in front of them.  We certainly washed our hands, both before and after seeing the patient.  We just did it out in the hall.

We also began to speak of such precautions as being really appropriate all the time.  We began to speak of “universal precautions,” appropriate for all conditions and not simply for AIDS.  Precautions weren’t a comment on the patient, but an effort to keep all patients and all caregivers safe.

In the intervening years that provision has been shown to be wise.  A range of other conditions – resurgent TB, and its drug resistant forms; SARS; Bird Flu; and most recently Swine Flu – demonstrated the propriety of having precautions that were truly universal.  In the meantime, with new medications and better knowledge we discovered AIDS was a disease one could live with, not simply die of.  So, in thirty years even our language has changed.  We now speak not of “universal” precautions but of “standard” precautions; and good hand washing has been complemented with hand sanitizers in various forms in hospitals and homes and virtually everywhere.

And so my hands are always chapped and dry, but my patients and my colleagues and I are safer.  I’m conscious of that a certain prejudice contributes to that: I could use hand cream, but I was raised with the sense that rough hands were a sign that someone actually worked for a living.  I also wonder sometimes whether extending standard precautions from hospital and kitchen to everywhere won’t have other less favorable consequences (Hygiene Hypothesis, anyone?  I wonder….).  But I wash my hands, and rub on the alcohol foam and gel.  And I’m conscious of the changes I’ve seen in my work in thirty years – changes I can literally see in my hands.

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