I’ve been an emergency room doctor for 35 years. I have probably washed my hands over 150,000 times. What the heck? How much is enough? What would happen if I just didn’t wash my hands?
Well, first, the hand-washing police (yes, there is such a thing … they wander around the hospital watching for clinicians who don’t wash their hands) would record that I had committed a violation, and I would be put on the “bad doctor list.” This list would then be turned over to my chairman, who would be obliged to call me in to have one of those uncomfortable meetings where I would be threatened with being fired if I didn’t stop endangering patients. And if I didn’t abide? I’d be out on the street, looking for a new job where hand washing wasn’t so important. Maybe a city sanitation officer?
All this process occurs because we clearly understand that bugs are spread from patient to patient by a clinician—even if their hands “look” clean (because only Superman has microscopic vision). Thus, to prevent the sharing of bugs, I will douse my hands in alcohol-containing foam before every single patient. This is to ensure that my hands are as clean as I can make them to prevent spreading bugs among all the patients I see. Does this work? For the most part, yes, hand washing does decrease the spread of pathogens.
But then, the craziest part occurs: After meeting my next patient and talking to them for a bit, I will take out my stethoscope, which hasn’t been washed since medical school, and I will rub it on their chest. My stethoscope, with the exact same bugs as my hands, is essentially an unwashed third hand. Hmmm. Where is “Captain Ironic” to point out that my stethoscope might actually be spreading the pathogen du jour from my last patient onto my next and thus completely negate all this hand washing? Does this sound absurd? Of course, but it is actually the current standard of practice in the house of medicine.
A reasonable person would ask, “Why don’t those clinicians wash their stethoscope with alcohol, just like they wash their hands?” Unfortunately, there are two challenges to what otherwise seems like a commonsense answer: First, recommendations suggest 60 seconds of cleaning are necessary, which means that if a clinician sees 50 patients a day, that is almost an hour per day added to their workload that they will not be paid for. Second, washing doesn’t even work. We know this because when stethoscopes are cultured after being washed with alcohol, 50 percent still harbor pathogens. This is because it is very difficult to clean the junction between the stethoscope rim and diaphragm, which ultimately means we aren’t going to be able to wash our way out of this.
If making clinicians wash their own stethoscopes doesn’t work, what about the “plan B” of using disposable stethoscopes? Never mind that they are dangerous and have the acoustic properties of a potato (one study of more than 800 disposable stethoscope uses found a subsequent misdiagnosis rate of almost 11 percent of patient contacts).
It is believed that by having a stethoscope dedicated to an individual patient that is shared among the staff, the bugs will be kept isolated in the patient’s room. But in actuality, it doesn’t work that way. Rather, disposable stethoscopes simply spread really nasty bugs between the staff. Culturing the earpieces of disposable stethoscopes finds all sorts of obnoxious pathogens. We don’t share toothbrushes, underwear, or forks. Why would we share stethoscopes? (It’s a good thing that OSHA hasn’t figured out the risk of the shared stethoscope.) So now we have a choice: share bugs or make diagnostic errors. Why are either of these acceptable?
It’s clear that we can’t wash our way to stethoscope hygiene, and disposable stethoscopes amount to malpractice, so what is the alternative? One solution that actually has a significant amount of data in its support is the application of a single-use disposable barrier that covers the stethoscope diaphragm. Like a condom for the stethoscope, these inexpensive barriers place an impervious partition to absolutely protect the patient from pathogens at every single point of contact. They don’t alter the acoustic properties of the stethoscope, and when applied from a touch-free dispenser, they are aseptic 100 percent of the time. Best of all, they are affordable, take only two seconds to apply, and make stethoscopes touch-free for patients.
Why are we currently using expensive, ineffective alternatives to simulate protecting patients from getting a hospital-associated infection from the last patient their doctor examined? If we are going to protect patients, and if we are going to protect staff, we need to have a solution that is efficacious, cost-effective, and doesn’t impair workflow. Touch-free, single-use disposable barriers seem to be the next best thing in all of hygiene.
W. Frank Peacock is an emergency physician.
