Latest blog post:Contact Precautions and its Not-So-Invisible Risks
It was a busy morning in the hematology ward. We were about to enter the room of Mrs. Jackson, our first patient of the day. From the window emanated the shadow of a young lady wrestling with her pain. She was an African-American woman with sickle cell disease. For the past 4 months, Mrs. Jackson had lived in that tiny space called room number 5. The images on the walls told the story of a vivacious wife and mother of two. But that was not what her family now had. Mrs. Jackson looked bad. She radiated sadness. And, above all, she seemed to be absorbed in her state of misery. The hematology fellow sensed her despair. "Mrs. Jackson. Remember we talked about the inflammation in your pancreas that led to that tear in your duct? We decided not to put a stent there as the latest CT showed it was healing well on its own. You are on the right track to getting better. OK?" With no energies to mount a vocal reply, Mrs. Jackson nodded lightly. We removed our masks and gowns and left her room.
The following weeks continued to shift our attention to the care of Mrs. Jackson. We engaged in intensive debates about the plausibility of a major operation to correct the ruptured pancreatic duct, when she showed signs of decline. We involved dieticians and social workers to ensure she continued to receive total parenteral nutrition when she was finally back home. Basic guidance was given to her husband about how to inject blood thinners. And other concerns were addressed as well, including quantifying the reasonable fat content in her diet, and even leading a meticulous campaign to make sure Mrs. Jackson would have keys to her house on the day of discharge.
While riding the metro one evening, I couldn’t help thinking about Mrs. Jackson. Her care seemed flawless to me. What could have been done differently? Were there any correctable pitfalls in her care, after all?
A few days later, while examining Mrs. Jackson's abdomen, I was caught off-guard. "Please take off your mask. Show me your face”, she said. The voice of an infectious disease internal advisor reminded me of Mrs. Jackson's depressed immune status and the grave danger of infection. An opposing psychological aide put the contagion fear in proportions. I decided to respect her request. Several feet away from Mrs. Jackson's bed, I removed the mask. "So beautiful, I missed seeing a smiling face!”, she said. A few seconds turned into 2 minutes as her genuine remark hit me. Endless months of adherence to strict contact precautions have sucked away her pleasure of enjoying a smiling face or being part of a genuine two-face interaction. Could that have been part of the reason why Mrs. Jackson's recovery was so much slower than the average person with the same condition? What would have happened if every fourth or fifth day a 4-hour "precaution holiday" had been allowed for her? Would the risk of an imminent infection be too high? Or would fighting foes such as isolation and dehumanization be legitimate side goals of care for Mrs. Jackson and similar patients?
The next patient that day confused me with the fellow hematologist. Another patient complained of not being able to recognize different teams of doctors. I realized it wasn't just the encouraging gesture of a caring physician or a nurse that was missed. It was the instrumental bond between the patient and his or her caretaker that was at risk.
The all-important contact precautions may oftentimes detract from the vital patient-physician interaction and overall quality of care. The literature strengthens this argument, showing that patients in isolation and those on contact precautions have fewer interactions with physicians and more delays in care. If we focus too aggressively on reducing the risk of infections, we may end up boosting non-infectious complications like pressure ulcers and falls, depression and anxiety, as studies do show. So how do we handle this trade-off? How do we approach this conundrum? We certainly need more healthy debate on that.
Ohad Oren is a graduate of the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology
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