We’ve run amok with wearing gloves in the hospital. And by “we” I mean every health care worker in sight. I see people putting on gloves before they’ll give a patient a clean warm blanket. This is not only ridiculous, it’s actually harmful. Here’s why.
We learned the hard way in the 1980s, during the early days of the AIDS epidemic, that the HIV virus and other potentially lethal microorganisms are carried in blood and body fluids. The Centers for Disease Control and the World Health Organization developed the concept of “universal precautions,” which applies during all patient-care activities that may involve exposure to blood, body fluids, mucous membranes and non-intact skin. Observing “universal precautions” means that you always wear gloves in those situations because you may not know ahead of time if a patient carries HIV, hepatitis, or any other infectious disease. You don’t want to get infected yourself, or inadvertently infect another patient.
But when did “universal precautions” come to mean that you have to wear gloves before you touch your patient at all?
The downside of hand hygiene campaigns is that they discourage us from normal human contact with our patients. If you’re worried that the hand hygiene police will detect a deviation from protocol and report you to your hospital’s Infectious Disease authorities, there’s an easy way to avoid the problem. Steer clear of the patient. And with the advent of the ubiquitous electronic health record, doctors and nurses are under tremendous time pressure to complete all the required data entry fields and move patients through the system. When you think about it, not touching the patient saves time that could be more efficiently spent at the computer keyboard. There’s a win-win situation, you might think. But is it really?
There’s an old adage most of us heard in medical school: “When all else fails, examine the patient.” What this means is that all the tests, scans, monitoring equipment, and every other marvelous technology at our disposal can’t replace a skilled and experienced physician taking a history and examining the patient. If you can’t figure out what’s going wrong, go back and examine the patient again. It’s still good advice.
In anesthesiology, we’re always under time pressure to see our patients as efficiently as possible and get surgery underway. Years ago, patients came into the hospital the night before surgery, and we had time for a personal interview at the bedside. Today, patients come in on the morning of surgery even for the most life-threatening operations, and we have only a brief interval to meet the patient, complete an examination, decide on a plan of care, explain it to the patient and family, and obtain consent. Yet the preoperative assessment is a key component of anesthesia care, and it may be your only chance to learn critical information about your patient.
I’m in the old-fashioned (some might say quaint) habit of wearing a stethoscope around my neck. I listen to every patient’s heart and lungs before surgery. On a number of occasions, I’ve heard a heart murmur that caught my attention and sent me back to the patient’s old records for further information. Heart conditions like aortic stenosis, which increases the risk of anesthesia tremendously, may not always be noted in an abbreviated history and physical done by the admitting orthopedic surgeon or gynecologist who is focusing on the patient’s other problems.
I think, though, that listening to the patient’s heart and lungs is important for another reason: it’s a time-honored ritual and a moment of personal connection between physician and patient. It creates a cocoon of silence, however brief, and reassures patients that I understand their physical condition and am fully focused on their problems. I have only a few moments to convince them that they are in good hands and may safely put their lives in my care.
Do I put on gloves when I place my stethoscope on the patient’s chest? Of course not, unless the patient has an infection such as methycillin-resistant staph or c. difficile. There is no health care standard stating that gloves are indicated for contact with intact skin. The downside of using gloves in a brief external physical examination is that it sends this message to the patient: “You are unclean. I don’t want to touch you, but if I must, I’m going to protect myself.” This is not the way to create a patient-physician bond.
After you examine a patient, it’s common sense to wash your hands and wipe down the stethoscope bell before you move on to the next patient. But what I see happening in the hospital today has gone way beyond common sense. There is no need to put on gloves before you place a blood pressure cuff or EKG electrodes on a patient. As the World Health Organization points out, “The use of gloves when not indicated represents a waste of resources and does not contribute to a reduction of cross-transmission.” And it can’t be good for the environment to have billions of gloves unnecessarily used and discarded.
So here are a few thoughts I’d like to leave with young anesthesiologists-in-training:
Touch your patient. Don’t wear gloves.
Shake hands when you meet, or take the hand of a frail old lady and just hold it for a moment.
Listen to the patient’s heart and lungs with a good quality stethoscope that’s your own, not a cheap plastic one you found hanging somewhere.
Don’t turn your back to the patient in order to type on the computer.
As you stand at your patient’s head and get ready to induce anesthesia, make sure the room is quiet. Put a hand gently on the patient’s shoulder, cheek, or forehead before you apply the oxygen mask and start giving medications, to let the patient know you’re there.
Remember that your voice and your touch are the last thing the patient consciously experiences. Make your words calm and reassuring, but don’t lie. Never say, “You’re going to be fine,” because truthfully you don’t know that. It’s better to say, “We’ll be right here with you,” because that’s a promise you can keep.
There was a time when touch and comfort were about all that a physician or nurse could provide for most patients, since effective medicines were few and technology nonexistent. Thankfully, we don’t live in those times. But some of the physician’s art can’t be replaced. If we let gloves or anything else come between us and our patients, everybody loses.
For an excellent presentation on the art and deeper meaning of the physical examination, listen to Dr. Abraham Verghese’s TED talk, “A doctor’s touch.”