Isolation, an Ancient and Lonely Practice, Endures

By ABIGAIL ZUGER, M.D. Published: August 30, 2010

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Historically speaking, people with the bad luck to develop an infection have never had it so good. Modern medicine can deploy a vast array of antibiotics and other tools for their benefit.
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Joanna Szachowska

For some of them, though, our shiny, state-of-the-art treatment includes a direct carryover from the Middle Ages. These are the people who are not just infected on the inside but also infested on the outside, covered with germs. And when they are hospitalized we hustle them into an isolation room, and no matter how much they may protest and complain, and no

matter how cumbersome it makes the rest of their medical care, we never let them out. Isolation must be one of the oldest medical tools, and in some ways it is one of the most brutal. Purists routinely point out that no one has ever definitively proved that it accomplishes its goals any better than, say, assiduous hand washing and the enthusiastic use of bleach. But isolation is probably too primal and entrenched a practice ever to be studied in the usual dispassionate way. We have at least improved a little on standard 14th-century medical practice by understanding more about how germs behave. So we keep patients with active tuberculosis in rooms specially ventilated, so that in theory, germs do not rush out into the public corridor when the door is opened. All visitors wear tight-fitting masks, but gloves and gowns are unnecessary, as TB does not spread by touch. Touch does, however, transmit methicillin-resistant staph, or MRSA, and the other antibiotic-resistant bacteria that are the bane of many hospitals these days. In ours, some of the isolation rooms go to people harboring these germs, but most now are occupied by patients with the intestinal infection called C. difficile colitis. This organism is a spore-former: it makes small, hard seeds that cling to surfaces and parachute all over the place. Patients are, to use the unusually evocative technical terms, covered with a fecal veneer and they move in a fecal cloud. A microscopic version of Google Earth, scanning them in and out, would show a small, malevolent universe consisting of a human being surrounded by a shimmering, human-shaped cloud of bacteria. When patients turn in bed, giant waves of bacteria rise and travel on air currents all over the room, landing on bedside tables, on adjacent beds and on the people in those beds. The palms of people who touch these patients turn gritty with bacteria, and every time those caring hands touch another patient, the bacteria stick fast. Our hospitals current policy for avoiding the resulting outbreaks of infection is typical of most: every patient with diarrhea is isolated until we have proven C. difficile is not causing the problem. Each goes into a private room, with boxes of disposable gloves and gowns by the door, which remains closed. These gowns are thick yellow paper smocks individually wrapped in plastic, with cotton-knit cuffs and ties that wrap around the waist. The gloves are standard-issue vinyl, packed into boxes of S, M and L. Putting on the gloves and gowns takes a

couple of minutes (unless the supplies are missing or we are down to the ridiculously tiny size S gloves, in which case the search for replacements can go on quite a while). Then you have to take it all off again: the gown is untied and peeled over the gloves, which go off last, optimally sequestered in a bundle of contaminated surfaces all facing inward. The bundle must be stuffed into the red can of contaminated garbage, which is invariably full. Then the hands are washed (with soap and water, as clostridial spores laugh at alcohol-based cleansers). Then it is on to the next patient and, often, the same ritual. Isolation is an immense nuisance for everyone. For a nurse rushing in and out of patients rooms dozens of times a day, all that dressing and undressing is just not possible. Nurses learn to change their routines to get everything done in fewer visits. Meanwhile, patients with diarrhea need a lot of nursing care. They may begin to complain they are getting very short shrift in that department and, come to think of it, are not seeing the doctors much either. These patients feel terrible anyway, and they feel even worse feeling terrible all alone. Any intimation that isolated patients are at risk of substandard medical care will elicit passionate denials from all individuals and institutions involved. But some data argue otherwise. Researchers have repeatedly demonstrated that doctors and nurses alike visit the isolated less often. One study found that isolated patients had six times the usual rates of hospital-associated complications like pressure sores and falls. Some isolated patients say they enjoy the privacy, but most complain of feeling lonely and stigmatized. On one survey, isolated patients consistently responded less enthusiastically than others to nearly every question about their hospital experience (although they did not complain enough to make a statistical difference). On the surface, after all, all sick people are pretty much the same: disheveled, unhappy men and women lying in bed, wishing they were somewhere else. For centuries, the doctors challenge has been to see the individual patient lying within the cloud of illness.

But for isolated patients, the challenge has become just the reverse: the doctor must turn away from the individual and minister primarily to that invisible, evanescent cloud. It is hard to say which is the more difficult. A fragile old woman was admitted to our hospital not long ago, sick and confused, a few specks of raspberry lipstick still clinging bravely to her lower lip. During the day, propped up in a chair in the corridor, she seemed to take pleasure in the frantic comings and goings of the ward. At night, she cried inconsolably. After a few days she developed a bad case of diarrhea. The nurses moving, it seemed, more slowly than usual arranged her and her belongings on her bed and wheeled it toward an isolation room. You could hear her sobbing all the way down the hall, even after the door closed behind her. Those of us not involved in her care never saw her again, but when we passed by her room we often heard those muffled sobs until she died a few weeks later. Increasingly, modern medicine forces us to specialize in the invisible. Here we had invisible germs with an inviolable mandate, and an all too visible patient pleading with us to ignore it. It was quite a struggle to try to see the one, to try not to see the other. Dr. Abigail Zuger, who writes the monthly Books column, is an infectious-disease physician in Manhattan.