by Cina, Joshua A. Perper, Stephen J. ; Cina, Joshua A. Perper, Stephen J.
Transmission of infections from patient to patient most commonly occurs via unwashed hands. In essence, the soiled physician plays the role of the rat passing on the Plague. Prior to the adoption of aseptic techniques (and the use of rubber gloves) thousands of women died of puerperal fever, an infection passed between women following delivery via the bloody, dirty hands of the obstetrician. Similarly, many soldiers wounded during the Civil War died of infections spread throughout hospital tents by the very people who were trying to save them. Visitors to the injured men also frequently fell ill. Once the basic habit of hand washing became engrained in the mind of the physician, iatrogenic infections (those caused by doctors) dropped off dramatically. In modern times, doctors are rarely the source of serious outbreaks in hospitals. Even so, they still are quite capable of transmitting diseases to their patients (even in the absence of inappropriate physical relationships).
A recent study which sampled neckties worn by 42 doctors at the New York Hospital Medical Center of Queens found that half of them were inhabited by dangerous bacteria capable of causing pneumonia and life-threatening infections including Staphylococcus aureus (“staph infections”), MRSA (methicillin-resistant Staphylococcus aureus), Klebsiella pneumoniae and Pseudomonas aeruginosa.
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infections through their clothing and contaminated scrubs. The frightening, antibiotic-resistant bacterium MRSA, a bug that thrives in the hospital setting, may walk out of the hospital and into the gym or kitchen or movie theater along with its host making new acquaintances along the way. Another study showed that if a hospital worker was in the same room with a patient having a MRSA infection, bacteria contaminated their clothes 70% of the time even if the employee had no physical contact with the patient. That’s scary.
Given the frequent interaction of hospital employees with numerous sick people there is a high likelihood that an employee will be carrying around some sort of bacteria. Some countries in Europe have attempted to prevent the spread of infection both within the hospital and in the community by having health care workers wear a set of “hospital” clothes in the facility and their own clothes outside of the hospital.
The “hospital” clothes and shoes are provided by the hospital itself, a very nice perk not enjoyed in the United States. Of course, this implies that the hospital administration is the arbiter of fashion (which may be not so bad in France). Most American hospitals also have policies requiring their staff to change out of their scrubs and into their street clothes before leaving the facility. Unfortunately, this policy is not well monitored and enforced and in most localities one may encounter doctors or nurses wearing their scrubs around town. For some reason, these walking Petri dishes seem to frequent supermarkets – how lucky for us!
Doctors harboring infections may unknowingly or knowingly transmit them to their patients. Nobody knows how many medical professionals harbor blood-borne pathogens such as Hepatitis B and C and the Human Immunodeficiency Virus (HIV). Over 23,000 healthcare workers, including 1,792 physicians, 5,378 nurses, and 476 paramedics have contracted AIDS. Out of these at least 57 infections (and possibly 139 more) were acquired from an exposure at work. Generally, HIV-positive staff members are allowed to practice freely as long as they follow standard infection-control techniques and have informed their patients that they are carriers of the virus. Some restrictions may be placed on doctors, dentists, nurses and technicians who perform invasive procedures with sharp instruments since these activities carry the greatest risk of exposure to contaminated blood. Although several civil liberties groups have opposed mandated physician disclosure of infection, current regulations force surgeons and other types of doctors infected with HIV
or Hepatitis to inform patients of their condition prior to performing any invasive procedure.
The Sad Story of Kimberly Bergalis
The first well-publicized incident of HIV transmission from a doctor to a patient involved Kimberly Bergalis, a 22 year-old Floridian who allegedly was infected by her dentist, Dr. David Acer. Her case stirred an intense and bitter national debate over AIDS testing. Kimberly, the eldest of three daughters, was born in 1968 in Pennsylvania and moved to Florida in 1978. In 1985, Kimberly enrolled at the The Sad Story of Kimberly Bergalis
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University of Florida majoring in business. While attending college, she had two
“significant” boyfriends.
In December 1987, Bergalis had two wisdom teeth removed by Dr. Acer, her dentist. Unbeknownst to her, he had been diagnosed with AIDS in the fall of 1987; he later died of the disease in 1990. When she came home on a vacation from college in March 1989, her mother, a nurse, noticed that her daughter appeared seriously ill. Ten months later Kimberly was diagnosed with AIDS. When she became aware of her diagnosis and related it to Dr. Acer’s dental extractions she sued the dentist for reckless malpractice. She also began a campaign to enact legislation aimed at preventing AIDS-infected medical personnel from providing unhindered medical care. To settle her lawsuit, Miss Bergalis collected $1 million from Dr. Acer’s estate and an undisclosed sum from his insurance company. She continued unabated on her, “You’ve Ruined My Life” crusade. Kimberly told reporters and Florida health officials in 1990 that she was a virgin who had never taken IV drugs or received a blood transfusion. Despite state-of-the art treatments, AIDS soon transformed her into a shadow of her former self. Nevertheless, she struggled on and even testified before a Congressional Committee in support of her proposed legislation. Before the committee, Bergalis softly stated from her wheelchair: “AIDS is a terrible disease that we must take seriously. I did not do anything wrong, yet I am being made to suffer like this. My life has been taken away. Please enact legislation so that no other patient or healthcare provider will have to go through the Hell that I have.”
Spurred on by the public uproar, the Centers for Disease Control (CDC) proposed barring infected healthcare professionals from procedures in which HIV
might be transmitted. Soon thereafter the legislation stalled and the CDC backed off following intense opposition from state and local health officials, several powerful medical societies, and advocates for AIDS patients. Opponents of the proposed regulations effectively argued that the Florida case remained an anomaly, that thousands of patients of other doctors with the HIV infection were tested and found uninfected, and that new rules were not needed. The CDC did conclude, however, that Bergalis as well as five other unrelated patients had contracted the same strain of the HIV from Acer; DNA sequencing showed that there was a high correlation between the subtype of the virus carried by the dentist and his patients.
A study conducted by the CDC estimated that out of more than 190,000 cases of AIDS reviewed only 13–128 patients may have acquired the disease from healthcare workers. Acer’s five patients were the only people confirmed to have been infected by this route.
In a posthumous letter addressed to Florida health officials made public by her parents, Kimberly wrote:
“Do I blame myself? I sure don’t. I never used IV drugs, never slept with anyone and never had a blood transfusion. I blame Dr. Acer and every single one of you bastards. Anyone who knew Dr. Acer was infected and had full-blown AIDS and stood by not doing a damn thing about it. You are all just as guilty as he was. You’ve ruined my life and my family’s.
If laws are not formed to provide protection, then my suffering and death was in vain.” She ended by saying: “I’m dying, guys. Goodbye.”
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When Kimberly’s case was diagnosed, Dr. Acer told health investigators that he did not believe he had infected
anyone. But he finally notified his patients anyway, informing them of his illness just before he died on September 3, 1990. Experts still question how the infections occurred. The most common theories hold that Dr. Acer bled from a cut finger into an open surgical incision; or, he used instruments on patients that had accidentally punctured his skin; or, that he used dental drills that had not been sterilized after working on another infected patient. While his co-workers and patients gave conflicting statements regarding the cleanliness of his techniques, proponents on the side of Dr. Acer questioned the veracity of Kimberly Bergalis. Regardless of how the disease was spread in this case, it has resulted in the bad-tasting rubber gloves and masks now used by dentists and dental hygienists throughout the country. And there has not been another documented transmission between a dentist and patient since that time.
Blood Money
In June 2008, ABC News reported a corrupt trade in human blood that resulted in the infection of 119 babies and toddlers with the HIV in Kazakhstan, a former Soviet Republic. Most of the children were from poor families living in remote countryside areas. The youngsters were given blood transfusions by local doctors for a variety of fictitious ailments for which they were charged exorbitant fees. No parental consent was obtained and none of the children were ill (until they received the blood). Prosecutors alleged that the profits from the transfusions were split between the doctors and the local blood bank – which had collected blood from all comers in unsterile conditions. Only after ten children had died and the outbreak had become an international scandal were 21 doctors, nurses and officials arrested.
Sixteen were found guilty of criminal medical negligence and sentenced to prison over the outbreak. The night before the verdict was announced the crime claimed one more victim – a 2 year-old boy.
Honesty is the Best Medical Policy
Physicians concealing or lying about their contagious status may face criminal conviction for reckless negligence and fraud. Dr. Umesh Gaud was an Indian-born surgeon practicing in East London who had been infected with the Hepatitis B virus while finishing his training. Between 1990 and 1993 he worked at both the London Chest Hospital and the Royal London Hospital as a cardiothoracic surgeon.
He obtained these prestigious positions after falsifying his job history and claiming to have been vaccinated against Hepatitis B. When the hospitals asked him to provide a blood sample for pre-employment screening, he substituted blood taken from an immunized patient. After an outbreak of hepatitis among the patients at one of The Last Word
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the hospitals, another blood sample was requested and, again, he submitted a sample taken from a non-infected patient.
His deception was discovered in August 1993, when blood was taken from him under the eyes of several witnesses after another outbreak of hepatitis. At least 19
of his patients contracted the disease – he had exposed hundreds more. It is unclear if Dr. Gaud’s recklessness will cost anyone their life-only time will tell. Hepatitis can be a chronic, innocuous disease or it can progress to fulminant liver failure, cirrhosis, and death. When he was convicted for “causing a public nuisance” (how British can you get?) the judge branded the physician’s behavior as deceitful and deplorable, adding: “What you did was a terrible thing for a doctor to do.” As Dr.
Gaud began his 1-year prison sentence, the British Department of Health required all surgeons to be immunized against Hepatitis B.
The Last Word
Doctors don’t appear to be killing their patients intentionally by infecting them.
There are far better ways to do that. In most cases, infections are spread by practitioners who are cutting corners, putting their financial well-being ahead of the welfare of their patients, or jettisoning common sense. It should go without saying that syringes should not be reused and dialysis filters need to be rinsed between patients. Nobody will get the Nobel Prize for figuring out that blood and harvested organs intended to be used for transplantation should be checked for infections prior to giving them to sick people. You don’t need Sherlock Holmes to deduce that you should wear gloves and wash your hands after delivering a baby (having done this we recommend washing them a few times). But, to be fair, we should acknowledge that in some settings the possibility of transmitting infection cannot be completely avoided. Consider that doctors use sharp objects to cut bad things out of people from hard-to-reach places in their bodies and that these instruments can cut both surgeons and patients. When this happens blood may be exchanged between the two of them. If the blood is infected, then someone can get sick due to sheer bad luck. We have focused on patients getting infected from their doctors but, in fact, many more caregivers are infected from their patients than vice versa. We will address this in our sequel, When Patients Kill. Just kidding. Well, maybe.
Chapter 20
Fictitious Physicians: Where Has Marcus
Welby Gone?
Medicine is my lawful wife and literature my mistress; when I
get tired of one, I spend the night with the other.
– Anton Chekhov
Medicine and the fine arts have been intertwined for centuries and more than a few physicians have had great success as writers. Drs. Anton Chekhov and Arthur Conan Doyle weren’t too bad. Dr. William Carlos Williams wrote some pretty good poetry. More recently, Drs. Robin Cook and Michael Crichton have brought to life stories such as Coma and Jurassic Park, respectively. And let’s not forget that Crichton also gave us the hit television series “ER”, the show that catapulted George Clooney (“Dr. Doug Ross”), Anthony Edwards (“Dr. Mark Greene”) and Noah Wyle (“Dr. John Carter”) to superstardom (well, at least Clooney became a superstar). Clearly some doctors can write. Going back over the past couple of centuries, however, one finds that doctors are just as likely to be characters flowing out of a plume, pen, or printer as they are to be authors. So why do they make such compelling fictional figures?
The answer may lie in that everyone is familiar with doctors. You may or may not have had the pleasure of utilizing the skills of an attorney. Maybe you have not yet had the opportunity to share intense, personal moments with your friendly, local electrical engineer. But chances are you have seen a physician at some point in your life and you have been left with an impression. In broad terms, doctors belonging to the “Greatest Generation” were held in high-esteem and widely accepted as pillars of the community. Since fiction mirrors reality, is it any wonder that the fictitious physicians of the 1960s and early 1970s such as Marcus Welby, Ben Casey, and James Kildare were essentially flawless? Can you imagine if these doctors suffered from Alzheimer disease, a drug addiction, or displayed homosexual tendencies? Things like that just weren’t talked about several decades ago although they surely existed. The fact is that doctors were essentially deified on the screen just as they were idolized in reality for the most part. It would seem that doctors were put on a higher pedestal in the past than they are now; somehow, physicians have become all too human.
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Off the Pedestal
Of course, not all fictitious doctors were perfect prior to the advent of modern fiction. Traditionally when doctors in fictional settings were good they were very, very good and when they were bad they were horrid. This is not so in the modern depiction of physicians. Many doctors are now portrayed like other people, a mixture of good and bad. The medical series House, M.D. exemplifies this phenomenon.
The lead character, Dr. Greg House, is a brilliant, Hopkins-trained diagnostician.
He also walks with a cane, abuses his trainees and fellow staff members, insults patients, and ignores most accepted treatment protocols in lieu of his own intuition.
Oh, and he is addicted to Vicodin™ (hydrocodone) and is not above stealin
g prescriptions from dead patients. Suffice it to say that if he truly existed, Dr. House would not have a long career given the current litigious state of medical practice.
Nonetheless, this character is popular with the masses because he gives people something they need – a doctor with imperfections. Doctors are not gods. Anyone who watches the news or reads the newspaper or has access to the Internet or purchases a popular novel about doctors that kill knows that physicians make mistakes.
Modern medicine is amazing in the scope of diseases that can be cured and doctors still cure many patients (and occasionally earn our eternal gratitude). But some of these same doctors use drugs, get sued, drive drunk, harass nurses, have sex with patients, get divorced, contract AIDS, go to jail, die young, screw up personal relationships, and lie, cheat, and steal. People don’t look to doctors to be the shining example of altruistic purity that they were in the past – they want and need doctors to be like the rest of us. And that is what modern films and television gives them.
The very word “Doctor” adds legitimacy and power to any film, television series, or book that chooses to use it or abuse it. Consider Dr. Zhivago, Dr. Strangelove, Dr. Who, Dr. No, Dr. Demento, and Dr. Caligari. Would these titles have the same impact if they were Councilman Zhivago, Strangelove the Handyman, Rabbi Who, Father No, Mr. Demento, or Judge Caligari? As long as people have contact with physicians, doctors will be featured in fiction as they have been for hundreds of years. We could write a whole book on all of the doctors who have been portrayed in literature or on the screen. The exploits of soap opera physicians alone could fill several hundred pages (this is not a promo for a sequel). But in keeping with the theme of this present work, we are going to focus on physicians in fiction who have displayed characteristics similar to those of the murderous physicians found in these chapters.