universal precautions

Monday, July 14, 2014

It was on the screen for just a few seconds and was a reminder that for all the swan dives, flops, histrionics and theatrical death seasons, soccer players are a tough lot. The Brazilian and Dutch players went up for the ball, banged heads and Dirk Kuyt fell to the ground, blood dripping from the scalp laceration. The medical team walked him to the sideline, washed and stapled the cut, no need for anesthetic, and Mr. Kuyt returned to the field cleansed of blood and good to go.

Look closely because something is not quite right:

world cup laceration

Photo attribution: Bleacher Report UK Twitter feed

 

There is a trust relationship that exists between physician and patient and the expectation is that the doctor will do no harm and the patient will not withhold important information. Somehow, in the heat of the moment, the physician was able to get gauze and water to briefly wash the wound, open a staple gun to close it but forgot the gloves. Washing hands and wearing gloves should be routine, even if care does not happen in a doctor’s office or hospital. Just where are the gloves on those healing hands?

Philosophically, the purpose of wound care has little to do with closing the skin to provide a nice scar but instead to diagnose any injuries that might underlie a laceration and to prevent infection. All wound will heal…eventually. In caring for wounds on the field of play, it is not unreasonable to take on a temporary fix and do a more thorough job after the game is done, but the expectation should be that certain basic tenets of medicine be followed. For a scalp laceration, it is reasonable to anesthetize the area and thoroughly wash out the wound to minimize the risk of infection. It is also reasonable to explore or look inside the wound to make certain that there is no underlying skull fracture. Part of the process may include sticking a finger into the cut and feeling for any bone edges.

 

Universal precautions are the medical shorthand for having health care workers use barrier clothing (gowns, gloves, face shields) to avoid contact with a patient’s bodily fluids, including blood, and prevent transmission of infections like hepatitis and HIV. These precautions are situation specific. Doctors and nurses would not gown up with a face shield and gloves to look after a small laceration, but likely would to care for a major trauma victim. The worry that a health care worker could be infected by a patient heightened in the early years of HIV-AIDS, when the disease could barely be treated and controlled. Just as important as gloves and gowning, was the idea that diseases should not be transferred from one patient to another. Hand washing became another mainstay of infection control, since the vector of transmission in hospitals was often the medical staff, carrying an infection from one room to another.

The other side of the trust equation is patient honesty. The Greg Louganis incident happened more than a generation ago in the 1988 Seoul Olympics. The American diver hit his head on the springboard lacerating his scalp, requiring sutures. Mr. Louganis knew that he was HIV positive but did not tell his doctors, including the one who sutured his wound…without wearing gloves. He wrote in his autobiography: “I wanted to warn Dr. Puffer but I was paralyzed. Everything was all so mixed up at that point: the HIV, the shock and embarrassment of hitting my head and an awful feeling that it was all over.” He returned to diving competition and won gold.

At the end of the day, most people do the right thing. Doctors and nurses wash their hands, wear gloves and treat every patient as if they are disease ridden. Everybody is treated in the same manner and judgments do not need to be made about an individual patient. Many hospitals and clinics now have their providers use cleansing gel or wash their hands in front of the patient, not only for hygiene but also to build trust. However, the lesson to learn is that the patient or their advocate also need to be vigilant and ask for things that they know to be appropriate. Even the most fastidious doctor can forget want is normally habit and should not take offence if the patient asks them to wash or wear gloves. At the end of the day, those who don’t ask, don’t get.

 

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