I was lying on my back on a gurney, getting my abdomen washed by the nurse.
She dipped Q-tip-like sticks into the brown antiseptic and then swirled them on my skin where the physician would make his incision. He would penetrate layers of skin and muscle to get into my liver and extract cells. He would send the cells to the laboratory to assess what kind of cancer I had. Eight days earlier, I had learned I had masses in my abdomen and chest. Three days earlier, I had learned the masses were cancer. That day I was on the gurney getting prepped for a liver biopsy, to find out what kind of cancer it was.
While one nurse washed my incision site, another nurse prepared the room. She was adjusting the lights, surgical equipment and my gown. And she rubbed her nose with her hand. Everyone rubs their nose. Humans unconsciously touch their nose or mouth more than 3.6 times per hour.
When we do this, we spread germs into our body from whatever we were touching before and spread germs from our body onto whatever we touch next.
I laid there and wondered if I should say something to her.
In medical school in the early ’90s, I had learned about the risk of normal nose bacteria infecting surgical sites. While on the gurney that day, I remembered a story about a patient with a massive infection in his surgical wound site. The hospital searched for the source of his Staph aureus. They found it in the surgeon’s nose. This story was told to us to remind us of the dangers of what we were seeing on the wards in medical school — which was still full of old-school clinicians who drew blood without gloves and washed their hands only intermittently.
Today things are supposed to be different. Hand washing before and after touching a patient is mandatory. And before and after walking into a patient’s room or touching medical equipment. The compulsory annual online classes for all clinicians include specific directions on how to wash your hands. There are signs on the walls and screen savers on the hospital computers reminding us to wash our hands.
But there I was, flat on my back, wondering if I should say something to the nurse. I was afraid she’d be upset with me if I said something — I was all but naked, lying on my back and pretty much in her hands. The hands that had just wiped her nose. I didn’t say anything. I tried to get my courage up to say something — but couldn’t. A few minutes passed. I decided it was too late to say anything. But I told myself if she did it again, I would say something to her.
And then she did. She rubbed her nose with her hand and then reached for the equipment table with that same hand. The equipment that would be in my liver in a few minutes.
I called her on it.
“Excuse me, you just wiped your hand on your nose and then touched the equipment.”
“I didn’t touch my nose.”
“You did. Can you please wash your hands?”
“I didn’t touch my nose.” She looked knowingly at the other nurse. She walked over to the sink and washed her hands. I was sure she was doing it begrudgingly and I worried how she would treat me going forward.
There are conflicting recommendations for hand washing. All involve soap or an alcohol-based hand rub and all emphasize the importance of friction between the hands. A new report just found that the World Health Organization’s six-step method is more effective in reducing hand bacteria than the CDC’s three-step method. But not surprisingly compliance with both techniques is limited.
At Yale-New Haven Hospital, where I both work and get my cancer care, the recommendation is that if we are asked by a patient to wash our hands, we should do it without question. Even if we know we have just washed them, the amount of time it takes to wash is well worth the trust and respect it shows for the patient and her sense of control.
After the liver biopsy, I got a bloodstream infection. I had a high fever, chills, a headache and had to stay in the hospital for four days to get IV antibiotics. The bacteria infecting my blood came from my liver: Cancer cells in the liver make a hospitable home for Clostridium septicum, and I learned it’s not uncommon after a liver biopsy for these bacteria to infect the bloodstream. I knew that a bloodstream infection was a risk I was taking by having a liver biopsy. No procedure is without risk.
But while feverish and shaking with the chills in my hospital bed — before I knew which bacteria had infected my blood — I worried that it might have been bacteria from the nurse’s nose.
And perhaps more importantly, I worried that the blood infection was my fault because I didn’t insist the nurse wash her hands as soon as I saw her rub her nose.
It wasn’t her nose bacteria in my bloodstream and it wasn’t my fault.
But do we really want our sick patients to spend any mental energy wondering if speaking up for themselves could have made their outcomes better? And when they do speak up, do we want them worrying that their nurse or doctor might be angry with them for speaking up?
We need to make it easier for patients to speak up, but we also need to make it unnecessary.
The websites of most hospitals and many advocacy groups are full of language encouraging patients to speak up when they note errors — in hand hygiene or otherwise — and hospitals try to teach their staff to respect an assertive patient in improving patient safety.
When patients speak up, we want to know errors will be acknowledged and remedied. And that we will not be treated any differently for having done so. But the truth is, most people don’t want to shame the person who is about to examine them or draw their blood or perform their liver biopsy. The glance I saw one nurse give another as she started to wash her hands was painful for me.
So where does that leave us?
We in health care need to take responsibility. We need to make safety a part of our culture, and that includes focusing on it, rewarding it when appropriate, and giving negative feedback when deserved.
We should no more depend on patients to check up on their clinicians than we should depend on passengers to ask their pilot if she’s gone through a safety checklist. It doesn’t make sense.
When patients are assertive, we need to be respectful and take action. When they don’t seem assertive, it should be because we have carefully and thoughtfully attended to all matters of safety and that includes hygiene.
Marjorie S. Rosenthal, M.D., MPH, is assistant director of the Yale Robert Wood Johnson Clinical Scholars Program, associate research scientist in the Department of Pediatrics at the Yale University School of Medicine and public voices fellow with The OpEd Project.