On Controlling The Spread Of Disease, Or, The State Gives Me MRSA

It has been the practice of your friendly fake consultant to keep my personal life separate from the stories you see in this space; and where exceptions have been made it has been because I felt it necessary to tell a larger story.

The story we will begin to tell today must be offered with my own life deeply intertwined in the narrative.

Sadly, it will not just be me that will be affected by the events we will here discuss. Instead, the list of victims will include some of Washington State’s most vulnerable citizens—those developmentally disabled individuals who reside in the State’s “Residential Habilitation Centers”--and the workers who care for them…one of whom is my very own spouse.

We have within the tale all the usual suspects: a lack of safety equipment, managers who fail to do their jobs, a system that’s failing to protect either its own or those who can’t care for themselves…and now, just to give things a twist, pharmaceutical soap, little orange pills, and color-safe bleach.

Before we begin in earnest, a few words about privacy. There will be some considerable restriction as to what exactly I can say in this report due to the need to protect the privacy of both the clients and the workers involved.

In the case of the clients (residents of these facilities are not referred to as patients because they might not necessarily be suffering from disease or illness—although, as with all of us, that changes from time to time) the privacy requirements are a part of the Federal HIPPA law…and in the case of the involved workers, there are concerns regarding potential retaliation.

The best place to begin the story, I suspect, is to explain exactly what MRSA is.

MRSA is a type of staph virus (Methicillin-Resistant Staphylococcus Aureus) which, as the name implies, is resistant to some or all of today’s antibiotics.

There are several strains of the virus (USA100 and USA300 being the most common) and the universe of strains is broken down into two groups: hospital-acquired and community-acquired; they are each differently resistant to different combinations of antibiotics. The particular variety of MRSA which has infected me is from the hospital-acquired group and it is resistant to Ciprofloxacin, Clindamyacin, Erythromyacin, and Oxacillin.

About 85% of the estimated 95.000 exposures in 2005 can be traced back to the healthcare system, one way or another, and about 12% are community-acquired. “Community-acquired” MRSA exposures most commonly occur in gyms, prisons, and the military, and are primarily skin infections. Depending on where you live in the US the rate of infection in the general population might vary from roughly 20 per 100,000 to 120 per 100,000.

As you might expect, age and a compromised immune system make infection more likely.

Lucky for me, there are antibiotics that our virus (The Girlfriend and I have shared so much these many years…and now we’re sharing this) is sensitive to…which is why we’re taking Doxycycline twice a day.

The virus can enter the body through cracks in the skin, inhalation, or by the sorts of blood and fluid contacts that you might expect would spread this sort of thing from one person to another.

The virus can “colonize” itself without infecting the host or it can be in an infectious state. As a result it is possible to carry the virus for some time and become infected later, or not at all. This is common to many other forms of staph as well.

Infections can occur not only in the skin, but also in the body’s other soft tissues, or in the lungs, where it can cause pneumonia.

I’m told the “warm hairy areas” of the body are the most susceptible to colonization—face and head hair, armpits, and the crotch area in particular.

Without effective treatment, MRSA can most assuredly be fatal.

When drug therapy is successful the rate of relapse can be as low as 5%.

There are variants of the virus that are resistant to virtually all known antibiotics—and even when certain antibiotics will work there may be situations where the patient’s allergic to those antibiotics.

In those cases where drug therapy cannot be employed excision (the surgical removal of the affected tissue) and maggot therapy (yes, they sometimes use maggots for removal of affected tissue) are available options.

We’ll be returning to this topic as we go deeper into the story…but at this point we should probably take some time to discuss how the spread of disease is controlled in health-care facilities.

Readers will undoubtedly be familiar with the image of a surgeon in the operating room: the surgical mask, gown, gloves and face shields that are worn in that environment are just as important in protecting the patient from acquired infections as they are in protecting everyone else from that patient.

In settings other than the OR it is just as crucial that infection control be as close to 100% effective as possible; this is why those same protective garments are now a mandatory part of every healthcare worker’s arsenal. Those of you who are regular viewers of the “Discovery Health Channel” will probably recall seeing medical personnel “gowning up” to perform a procedure.

“Best practice” guidelines are provided by the Centers for Disease Control. Those best practices are known as “Standard Precautions”…and they’re fairly simple to explain. I’ll paraphrase:

--If you’ll be in contact with someone else’s body fluids, you should assume that person—no matter who they are—is infectious.

--For your own protection (and the protecthttp://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.htmlStandard Precautionsion of others) you’ll need gloves, gown, mask…and beyond that, a face shield for activities “that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions”.

--Although this will sound obvious, you don’t want to use the gloves, gown, mask, or face shield while moving from one person to another…instead, you need to change into new clean stuff before moving on to the next procedure.

By following these fairly obvious instructions you prevent “cross-contamination”—potentially saving the lives of yourself and all those with whom you will later make contact.

Which includes the family members back home, when the shift is over.

That’s where I come in.

The Girlfriend (of more than 26 years…hooray for us, eh?) informed me that we’ll be needing to take eyedrops for what we thought was her (relatively minor) case of conjunctivitis. We did, to no effect.

We were then prescribed Bacitracin Opthalmic ointment to resolve what had by now been diagnosed as MRSA (it requires a lab culture to confirm the diagnosis)…which meant putting this awful goo in our eyes four times daily…which did no good.

One week later we found ourselves in the office of an Infectious Disease Specialist

And now we have some…unusual…household routines.

In addition to the Doxycycline, we now use “Hibiclens” surgical soap for our washing and showering needs, as well putting Muriprocin ointment up our noses twice daily. The “ewww” factor is high, indeed on that one.

All clothing is now washed with color-fast bleach; and we mostly use paper towels.

All of this (except the antibiotics) for the next three months.

Hopefully it works, and the disease either is eradicated or returns to a “colonized” state.

All of this for an infection we did not have the pleasure of acquiring in Las Vegas.

So, you might be asking, if the infection control process exists, how does the infection manage to spread?

I’ve had a few conversations—and done a fair bit of reading--with the intent of finding the answer to that myself, and here’s what I’ve learned:

--Workers sometimes hang used gowns at the end of a client’s bed, go about their business, and then return later, reusing the same gown for later procedures.

--Other workers will wear the same gown for their entire shift, moving from client to client to client.

--There can be issues related to the way linens are handled and laundered that can cause the spread of infection.

--Although there are some face shields available at her facility, The Girlfriend tells me that their presence is, shall we say, sporadic—that is to say, they are not available in all of the locations where they are needed.

--There are procedures that, by their very nature, are inherently dangerous—particularly problematic are the feeding tubes which are surgically inserted directly into the client’s gastric system. These have almost universally replaced the older “nasal gastric” tubes (through the nose and into the stomach) that were often the unintentional cause of aspiration (the lungs fill with the liquid food, rather like drowning), should the tube become dislodged.

The opening in the body made to accommodate the surgically inserted tube can leak, there can be “deposits” of internal fluids on the outside of the body through the hole…and most commonly of all, the tubes can become plugged by the liquid food they are designed to transport into the body. The process of unplugging the tubes is, obviously, going to expose all and sundry to something, whether it be food or body fluids. The CDC confirms this is a huge problem.

--There is a lack of effort on the part of Infection Control management to educate and to correct these problems…and in some cases it appears that there’s a lack of awareness that these even are problems.

We will talk about this in more detail in the next part of the story, but for the moment we’ll say that since at least 2006 there have been warning signs of problems to come.

I try to keep my emotions in check when writing, as I find a dispassionate approach makes for more a clear understanding of research…not to mention an increased empathy for those about whom I write.

In this case, however, I have taken it a bit personally. You see, this is not the first potentially hazardous exposure The Girlfriend has suffered due to appallingly poor clinical practice at this facility…another subject we’ll address in considerable detail in the next installment of the story.

Since it was obvious to me that there was not going to be a change in culture imposed from the inside, I’ve decided I’m going to do it for them.

Which is why, in recent days, the emails began flowing--to the Governor, the Secretary of the State Department of Health, the Secretary of the State’s Department of Social and Health Services (the largest of Washington’s State Agencies), the Director of WISHA (the State’s OSHA equivalent), the State Attorney General (because someone’s getting a bill for my care eventually…), and the State Auditor, who is charged with investigating governmental misconduct.

(To be honest, I was a bit inaccurate in the note…I told the various parties that MRSA was the “flesh eating bacteria” disease, which was an error on my part. I blame myself, for being a bit overwrought as I wrote; and I do owe all involved an apology for the error…so Governor Gregoire, if you might see this: sorry about that—but the rest of the note is dead-on accurate.)

And that’s how we get to the part where I ask you for some help.

In the note I sent I reminded the Governor (who won in 2004 by a mere 8 votes) that not only was this affecting those vulnerable citizens who reside in the State’s facilities and the employees who are there for them--but that the problem, thanks to my infection, had now spilled into the community of…registered voters.

Not a good thing, in an election year.
But good for us, as it means we have a way to keep the Governor’s attention…focused.

So do me a favor, if you would…and drop the Governor a quick note, here at her official website, perhaps reminding her that all the State’s citizens matter when it comes to healthcare equality, or that infectious disease control is everyone’s business—even the State’s…or perhaps you might pose this question: if we can’t control MRSA, even in State facilities, how in the world are we going to control pandemic influenza in the general population when it eventually rears its ugly head?

We meet with management Monday to discuss the incident…which means part two of the story will also be a good one: we’ll talk more about past problems, we’ll asses management’s attitude today…and we’ll see if we can’t help the State find a better way going forward.

Put on your seatbelts, kids…it’s gonna be a rocky ride.

AUTHOR"S NOTE: As was mentioned by several of my new friends, MRSA is a bacterial infection, and not a viral one. My aplogy to the reader for the error.

Comments

the bigger question...

...is this just another problem in nc for vulnerable adults?

it likey is...and it's probably just as unrecognized as it is here.

"...i feel that if a person can't communicate, the very least he can do is to shut up." --tom lehrer, january 1965

One big problem I see all the time

is the delay in diagnosis with MRSA and other bad bugs.

As an X-Ray Technologist, I am not as exposed as other health care workers, but I often find that people I examine using minimal protective equipment in place, lo and behold... several days later are in complete isolation.

What changed?

Nothing.

Just the confirmation of the positive culture.

Now, don't that make you feel all secure?

that was true in our case...

...as the original "conjunctivitis" theory morphed into a confirmed mrsa case.

interestingly, tthe cdc wants those who transport suspected mrsa cases to use "contact" as well as "standard" precautions--which seems to be relatively rare.

"...i feel that if a person can't communicate, the very least he can do is to shut up." --tom lehrer, january 1965

Correction:

MRSA is not a virus. It's a bacterium. Viral illnesses have no cures; only treatments. (Haha, I didn't see your note until *after* I posted. -_-)

Other than that... the Mad Biologist has a bunch here.

Infectious disease is one of the things I find fascinating.

you are exactly correct...

...as the author's note at the end of the story suggests.

"...i feel that if a person can't communicate, the very least he can do is to shut up." --tom lehrer, january 1965