When you are too sick to fly

Air travel is a great way to get free peanuts, a deep vein thrombosis and the worst cold of your life. Plus: baggage fees!

Ever since Andrew Speaker took to the friendly skies with drug resistant tuberculosis, and brave Ebola outbreak workers returned sick to the United States, avid international attention has focused on the infectious risks of air travel, too.

Could the next pandemic spread on planes? 

We should care more about the people who live in areas where millions of people get sick from infectious scourges without having to invoke international travel. Yet it is reasonable for people who travel in rich countries to want to stay healthy as well. 

Proudly quoted in this brief article by Allison Fox of HuffPo.

The missing microbial link

It turns out the oily wind that a subway train brings into a subway station carries its own passengers with it: bacteria DNA.

As passengers step into the car and compete for seats, they do so thickly coated with the DNA of millions of microscopic parasites. 

But do not be alarmed. Recent news stories have reassured us that while DNA for bubonic plague can be found in the nooks and crannies of New York City subways, we should not worry a cross-town ride risks the plague any more than asymptomatic patient Craig Spencer spread Ebola.

We should extend the same logic to hospital infection control.

Every few months there is a new article confirming that doctors, nurses and the things they wear and use are not sterile. NOOO! Stethoscopes, ties and our beloved white coats in particular have drawn ample attention for their unsurprising propensity to - gasp! - have bacteria on them. 

This is useful research, and hypothesis forming. Might doctors and nurses contribute to the epidemic of healthcare-associated infection (HAI) via fomites like these?

Absolutely, they could.

But our reactions to this interesting hypothesis have been far from scientific. We have gone from hypothesis to heartfelt belief in five seconds flat.

One second we know stethoscopes and ties and white coats have bacteria on them and the next we conclude that we should do away with the lot of them. Britain's NHS, for instance, famously adopted a "bare below the elbows" stance in 2008, and US infection control mavens have recommended a similar policy recently.

Where's the science? 

We all want to prevent HAI's, and lord knows the physician fashion index would rise by fully 2.5 points if we left our silly white coats at home (excellent logistical points made by an esteemed surgical blogger aside). But before we invest in nationwide changes to attire and clinical practice, we should convert these reasonable hypotheses into real evidence. 

If going bare below the elbows, or skipping neckties, or burning our white coats, really will protect patients, then we should be able to prove it.

Before we draw conclusions, let's do the damn experiment: compare infection rates in comparable patients cared for by providers who do or do not wear neckties, or who do or do not subscribe to a BBE policy, whatever. Bring on the data!

It's not that easy, you say?

I understand. Science is hard. 

If we can't show the intervention works, why invest in it? It is no great challenge to leave our ties at home, but until we base our recommendations in science the hard work of culture change may not be worth it. Why not just make the change? Well - how well is that argument working so far?

Let's be scientists people, lest we get schooled one day that these stories of stethoscope contamination are as alarming as bubonic plague DNA found in the New York City subway.

How Hospitals Are Getting Safer for American Children

I could tell I was being watched as I walked into the neonatal intensive care unit.

I took off my white coat, folded my stethoscope in a pocket, and hung the coat in a closet. In a nearby sink I washed my hands for a full minute, scrubbing between each finger before drying my hands.

I approached a high-tech isolette and leaned in to examine my patient, the pink baby within.

A voice stopped me: “Doctor!”

There were footsteps behind me. I pulled back and thought, what did I miss? I retraced each step. Coat. Stethoscope. Hands.

The desk clerk pointed a finger. “Your ring, doctor. You forgot to take off your wedding ring.”

She was right. I rolled my eyes, pocketed my ring, washed again, and went back to my little patient.

Small interactions like these make hospitals safer for children by reducing rates of hospital-acquired infections. Now a new article shows exactly how much safer.

To read more, click on my story over at The Atlantic.

Hospitals Are Ground Zero

The MERS coronavirus has now spread from the Middle East to home town USA.

Since both US victims of this resurgent respiratory virus - one in Indiana and another in Florida - are healthcare workers, all eyes have turned to nosocomial transmission. In some locales nosocomial transmission has outpaced the former frontrunner for the MERS transmission prize: camel spit.

Proper infection control, therefore, is hugely important. The CDC recommends special airborne infection rooms, masks, eye protection, gowns and gloves. I remember taking these precautions when the SARS epidemic came through town. In some cases, patients were incredibly sick and it was scary; other times folks with SARS had the sniffles and we made a big deal over very little. Let's hope that as we learn more about MERS, the early reports of 30% case fatality will turn into less sobering statistics. 

Along the way, it's good that the macho culture of medicine has been changing. When I was in training, it was common and even admirable for doctors to work sick. I remember idolizing a medicine resident who did morning rounds with an IV pole at his side. Yet now we know - how could we not have clued in then?!  - that this risks spread of infectious diseases to our fragile patients.

In a nice story just out today titled "Second MERS Case Shows Hospitals Are Ground Zero for MERS," Maggie Fox of CBS News quoted me and others about MERS infection control.