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zoom RSS 感染への恐怖と戦う/米国医療事情

<<   作成日時 : 2009/05/22 20:56   >>

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感染への恐怖と戦う
 「患者の治療は特権であり天職である。誰も契約を強制されない」
 4年前にDr. Kent A. SepkowitzとDr. Leon Eisenberg が医療労働者の労働死についての研究が公表された。米国では年間100万人あたり17-57人が死亡している。
 平均よりは高いが警察官や消防士より低い。漁師や建築業、飛行士、軍人に比べればずっと低い。逆に弁護士やウエイターは最も安全な仕事である。
 しかし、約900万人が従事しており、全体の死者は年間300人以上となり、最も多い職業の一つである。
 しかし、こうした比較にはすべて欠陥がある。医療労働者に関する年間死亡率の見積もりは、良くても過小評価に過ぎない。全ての従事者に存在する高い現実のリスクにもかかわらず、仕事に伴う損傷や感染による死亡率は不明である。警察官や消防士などの危険な職業と違い、仕事で受けた感染や傷害からくる死亡を追跡する全国的な登録システムが全く存在しない。
 2人の研究は、B型肝炎、C型肝炎、H.I.V.、結核という4つの感染症からの死亡から推計された最も良い数値である。
 正確な数値がなければ、危険な状態のままで労働者を保護するより良い方法を考え出すことは不可能である。
 歴史家Gerald M. Oppenheimerがエイズ患者を治療する医師について詳しく書いているが、誰もどう病気がうつり感染するかを理解していなかったという。医師達は信念のために危険を冒したという。
 医療労働者の仕事に関連した死亡の全国的登録システムは、並はずれた決定をする際の認識やサポートに貢献するだろう。勤務するときにかわす協定の一部とすべきである。
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夜間シフト勤務の代償/発ガン性
http://kurie.at.webry.info/200803/article_36.html
医師と睡眠剥奪
http://kurie.at.webry.info/200803/article_37.html
急増する医師の過労死と違法「当直」/今年6人が過労死認定
http://kurie.at.webry.info/200712/article_23.html
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Fear of Contagion
http://www.nytimes.com/2009/05/21/health/21chen.html
By PAULINE W. CHEN, M.D.
Published: May 21, 2009

画像Early on in my internship, a senior doctor pulled me aside after hearing a couple of other interns grouse with me about our workload. “Caring for patients is a privilege, a calling,” he said. “Remember, no one forced you to sign your contract.”

For years those words came to mind whenever I cared for patients who had lethal, and potentially contagious, infections, patients like Jean (not her real name), who was in her 50s when I met her. She had contracted hepatitis C from receiving a vaccination with a contaminated needle years before, and the symptoms of her end-stage liver failure had become increasingly difficult to tolerate over the last year. She itched constantly from jaundice; her memory had deteriorated; and she had had episodes of life-threatening bleeding that had landed her in the intensive care unit on two separate occasions. According to the nurses, Jean had walked into the hospital on the night she was to receive a liver transplant, bubbling over about the new start on life she would have with the new organ.

Despite Jean’s optimism, she ended up suffering from a series of devastating postoperative complications and infections. By the time I came onto her surgical team as one of the interns, she had spent three months in the hospital.

One morning soon after I began taking care of her, one of the nurses noticed that Jean had become short of breath. A chest X-ray showed fluid in her lungs, fluid that I could drain to help her breathe. The drainage procedure wouldn’t take long once the needle was in her chest; but because everything would be done using sterile technique, once the procedure started, I could not leave Jean’s side or touch anything other than the instruments I was using.

My beeper went off the moment I slipped on the sterile gloves. I tried to ignore it, forging ahead with the procedure. I disinfected Jean’s skin, laid down sterile drapes and began numbing her skin with a syringe filled with anesthetic solution.

Over and over again, my beeper went off. And I continued ignoring it until the fifth page, when I began to worry that there might be an emergency elsewhere in the hospital. I wriggled my hips against Jean’s nightstand, trying to dislodge the beeper from my waist without touching it or contaminating the sterile field. I shouted for help, but no one answered my calls.

Finally, when my pager went off for the sixth time, I pulled off my left glove and reached down, groping for the beeper hanging on my right hip while walking toward the door to find a phone.

I felt a sharp sting. Looking down, I saw a small scarlet drop emerging from the tip of my left index finger. I had stabbed my finger against the needle I had just used to anesthetize Jean’s skin, a needle I still held in my right hand.

I stared at the tiny red bloom on my fingertip. And for a moment, I felt the floor beneath my feet give way, pulling everything ― Jean, my heart, my work, my life ― down with it. I stood there paralyzed, staring at the puncture wound on my fingertip and unable to stop the movie playing in my mind’s eye, a movie of a future like Jean’s. Jean would never leave the hospital and, a few months later, would die in the I.C.U., succumbing to a final, massive infection.

Over the years, I have been stuck, cut, coughed on, scratched and splashed several more times. Each time, I feel the floor and my life fall away. I have never contracted a life-threatening infectious disease; but sometimes I catch myself wondering if it’s only a matter of time. During the SARS epidemic a few years back, for example, health care workers were disproportionately affected; certain hospitals in affected areas reported that over half their workers contracted the disease.

And then every day there is news that swine flu may still reach pandemic proportions.

When I think about the possibility of becoming infected with a potentially deadly disease during the course of my work ― when I allow myself to think about it ― I struggle to reconcile my beliefs about a doctor’s responsibilities and my fears about my own safety.

But, always, I arrive at the same conclusion. Like that senior doctor, I believe it’s a privilege, a calling, to take care of patients. And I believe that in deciding to practice medicine, I have consented to an unspoken contract with the public, one that requires that I take care of those who are sick.

Lately, however, I have also begun to think that there is another side to that contract. Maybe there are obligations that the general public has to its health care workers.

Four years ago, Dr. Kent A. Sepkowitz from Memorial Sloan-Kettering Cancer Center in New York and Dr. Leon Eisenberg from Harvard Medical School published a study on occupational deaths among health care workers. They estimated that anywhere from 17 to 57 deaths per million workers occur annually in the United States as a result of occupational exposures. When placed in the context of other occupations, this calculated death rate was more than the national average, less than that of policemen and firefighters, and much less than that of the most dangerous occupations like fishing, construction, flying and being a part of the military. (Lawyers and waiters, interestingly enough, came at the bottom of the entire list with some of the safest jobs.)

But with some nine million people working in the health care industry, health care workers end up with one of the highest numbers of total deaths, upwards of more than 300 per year.

There is a flaw, however, in all of these comparisons. And it is that the estimated annual death rate for health care workers is, well, just that ― a calculated guess that is an underestimate at best. Despite the very real risk that exists for all health care workers, the actual number of deaths from occupational injuries or infections is unknown. Unlike policemen and firefighters and other high-risk occupations, health care workers have no national registry to track deaths caused by infections or injuries acquired on the job. As Drs. Sepkowitz and Eisenberg are quick to point out, the figure they use is based on their best educated guess regarding occupational deaths from only four infectious diseases: hepatitis B, hepatitis C, H.I.V. and tuberculosis.

In a recent e-mail, Dr. Sepkowitz confirmed that four years after the publication of their paper, we still do not know what the actual occupational death rate is for health care workers. No federal or national organizations have stepped up to the plate and taken on the task of tracking these deaths. Without those numbers, without a clear idea of just how many people are affected, there is no way any of us can come up with better ways to protect those workers who put themselves at risk to care for others.

I recently spoke to Gerald M. Oppenheimer, a historian who has written extensively about the doctors who chose to care for AIDS patients just as the disease was emerging in the 1980s. It was a frightening period; no one understood how the illness was transmitted or infected.

“We are so used to seeing heroes as different, as people who are larger than life and who prepare all their lives for this event. But it’s not that at all,” Dr. Oppenheimer said. “[These doctors] were ordinary people who were responding to something that appeared to be very dangerous. And they were willing to take that risk because of their beliefs.”

Supporting a national registry of occupational deaths in health care workers would go a long way toward recognizing and supporting some of the extraordinary decisions of ordinary individuals. And that registry, I believe, should be part of the agreement between health care workers and those they serve.

Join the discussion on the Well blog.

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