Rules to Practice By: Safety First and Cleanliness is Close to. . .

 

At a time of such profound disappointment over the Supreme Court’s decision that set back women (at least temporarily) from achieving contraceptive equity, it is perhaps difficult to focus on more mundane issues. However, there have been several new developments in the areas of infection control and patient safety in the office setting that I thought a brief review of some of those highlights might take our minds off the larger societal issues.

What are you wearing?

For a long time, clinicians have known not to wear rings or other hand jewelry while they are seeing patients, but now it is clear that we must also avoid any wrist wear—including bracelets and wristwatches. Nail polish and nail extenders are great places for pathogens to hide and are also on the “do not wear” list. What about ties for the guys and scarves for the ladies? You guessed it—anything that could drag into the field or touch a patient is not allowed. What about long sleeved clothing (blouses, shirts, etc.)? Similarly not advised, not only because they can spread material on anything they brush up against, but also because they block the ability of the clinician to properly wash his hands completely. What about our white coats? Right again! The current recommendation is to have the sleeves come no lower than the elbow. What are we to do with all our long sleeved coats? If we cannot stand to chop them off and re-hem them, at least roll them up high on the arms.

What do we have on the examining table?

Paper drapes are wonderful, but do they cover the entire surface of the exam table? Do all our patients fit onto that slender runway and not spill, even a little bit, onto the plastic cover of the table underneath? Does the exam paper ever rip as the woman moves down the table into the lithotomy position? Yes, we are supposed to wipe off the table between patients with an appropriate antiseptic agent. And what about those feet holders? I’m sure we all can remember putting oven mitts to cushion the woman’s foot as she rested it in these cold metal support structures. However, that practice is a definite no-no, unless we change the mitts with each patient, or unless the woman leaves her shoes on, but then, what would be the point? Maybe we can cover the metal with exam gloves. That does work and patients seem to appreciate the thought. If we do nothing, then we must remember to cleanse those surfaces between patients too. Note: pillows to prop up shoulders for breast exams or to lift heads during the pelvic exam are already on the extinct list.

What toys do the woman’s children play with in our office while she is answering the myriad of questions we have for her? Years ago we learned not to let the little ones play with small pieces they could choke on, so we all bought wall mounted games they could play with to keep them occupied. Do we wash those down between patients?

How do we greet our patients?

Certainly not with a handshake! Now that the office has been declared a “handshake-free” zone, there will be no hand-to-hand contact.^[1] Not even any “high fives” after a pain-free IUD placement! Nope, we need to find some way to touch our patients to build that interpersonal bridge without providing a pathogen pathway. What about we embrace the Latin cheek kissing greeting habits? No, that might be a little too intimate just before the pelvic exam. Maybe we’ll have to explain to our women why we want to rub elbows with them; most patients I’ve approached with elbow outstretched have accepted the gesture with good will, but it does take a moment’s explanation.

Finally, to what poisons have we been inadvertently exposing our patients?

Better check your pockets and your walls. First OSHA ruled that the guaiac developer was a poison and should not be taken into patient care areas. No problem, we just switched technologies for testing for occult blood. After that, OSHA declared that KOH is also poisonous and cannot be kept in patient care areas. Fortunately, we do not need KOH for microscopic evaluation of vaginal specimens. Diluting the specimen in normal saline is much more effective for visualizing the pseudohyphae of candida albicans, for revealing clue cells, and for maintaining the morphology of the trichomonads. But then, we were told to remove from our walls the ampuls of ammonia and to remove them also from the crash carts. It seems that breathing ammonia can trigger severe attacks in asthmatics, as can the fumes from alcohol wipes. All we are left with in reviving women who have suffered vasovagal reactions is physical stimulation and oxygen therapies. We can be more aggressive in trying to prevent such loss of consciousness by telling women about lower body skeletal muscle tensing maneuvers before we start procedures that might lead to a syncopal event.^[2,3,4]

Bare-handed, bare-forearmed with form-fitting clothes, and we rub elbows with our patients and swab down the exam table and all the surfaces her germ-laden progeny may have contaminated before we let the next round of folks into our exam rooms. So there we have it. I am reminded of the TV commercial with the little beagle kept by his family in a long clear plastic tubing to protect him from insect infestation until they discover the advertiser’s product and free him. We cannot put our patients in germ-free bubbles in our offices, but we can rethink many of our traditional professional and social practices to reduce their exposure to potential pathogens. Old habits will be hard for us to break, and may be even harder for us to explain to our patients. But Hippocrates is here to guide us, “First, do no harm.” Let’s do a virtual high 5 for good luck.

References:

1. Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the Handshake From the Health Care Setting. JAMA. 2014 May 15. doi: 10.1001/jama.2014.4675. [Epub ahead of print]
2.  Krediet CT, Go-Schön IK, van Lieshout JJ, Wieling W. Optimizing squatting as a physical maneuver to prevent vasovagal syncope. Clin Auton Res. 2008;18(4):179-86.
3. Krediet CT, de Bruin IG, Ganzeboom KS, Linzer M, van Lieshout JJ, Wieling W. Leg crossing, muscle tensing, squatting, and the crash position are effective against vasovagal reactions solely through increases in cardiac output. J Appl Physiol (1985). 2005;99(5):1697-703.
4. France CR, France JL, Patterson SM. Blood pressure and cerebral oxygenation responses to skeletal muscle tension: a comparison of two physical maneuvers to prevent vasovagal reactions. Clin Physiol Funct Imaging. 2006;26(1):21-5.

—Anita Nelson, MD, Professor of Obstetrics-Gynecology, David Geffen School of Medicine at UCLA