The nurse wheeled Mr. M past me and paused. "Infection control told us to isolate him," she said casually. "He has VRE in his urine." And with that, she quickly whisked him into the darkened room. In short order, the familiar red sign was taped next to the door, advising all visitors that the patient within was under strict contact isolation and instructing them to see the nurse for further orders. Soon, the isolation cart, with its drawer of cheap yellow gowns and box of gloves, appeared.
From the infectious disease doctor's view, contact or respiratory isolation is an integral and important part of our daily work. Unfortunately, to the nurses and hospital staff, isolating a patient makes everyone's job a little more difficult. It becomes a large housekeeping issue, as personnel furiously juggle patients around from room to room, floor to floor. Properly following isolation protocol, whether it is gowning and gloving or putting on a mask, certainly hampers staff and physician efficiency. What nurse or doctor has not had to gown and glove several times to see the same patient, because of interruptions by stat overhead pages or important phone calls at the nurses' station?
Isolating a patient can trigger feelings of fear and uncertainty in the patients and their families. The gowns, gloves, and masks can be viewed as undignified barriers to human contact. And for a sad few, such as Mr. M, going into isolation can mark the harsh beginning of the end.
Our group had been seeing Mr. M for many years, so we knew quite a lot about him. A long time ago, he had been in the military police. Later on, he joined the local police force. He had a distinctive limp from an old leg injury he had had while an MP, but in his youth, this didn't slow him down at all, and he still cut an imposing figure. He was a fixture for years and years in the community. Everyone knew him, from business owners to the local politicians, to the neighborhood scoundrels. He was not loquacious, but was as courageous, honest, and trustworthy a man as you could find. At any local parade or event, you would always find him, watching protectively over the crowds of people. The local schoolchildren could vouch for his kindness because he was always ready to help out any child in trouble. Unfortunately, he and his wife were never able to have children themselves.
Many years later, he was diagnosed with a heart ailment. He proved to be an uncooperative patient. He wanted to be the one in charge and was not any good at playing the sick role. He had no interest in discussing his disease and had even less interest in his medicines. Eventually, he was forced to retire. After this, he started to experience a very long slow decline. He was no good at retirement. He could no longer protect the citizens in his community. And although his wife was healthy, she was getting on in years, and he could no longer care for her, either. And so he was miserable.
The years passed, and his cardiomyopathy continued to progress. He grew weaker and weaker, growing more dependent on his now elderly wife. Inevitably, his wife had increasing difficulty caring for him at home. His hospitalizations for congestive heart failure became more and more frequent, and his hospital stays were longer and longer. Some can adjust to these situations better than others. Mr. M was not one of these patients. In the hospital, he began to retreat within himself. His leg became more painful, but he refused to cooperate with the physical therapists. His hearing continued to decline, but he refused to get a hearing aid. The psychiatry consultant was unable to make much headway. It didn't help that his wife was unable to visit him as much as he would have liked. He had outlived most of his peers, and so he had fewer and fewer visitors. And it seemed very cruel to him in his time of need that he had no children, no strong son or daughter to lean on.
Finally, on one of his last admissions, the hospital screened him for VRE in the urine, as per infection control protocol, and he came up positive. I gave his wife the usual explanation for the need for contact isolation, citing the need to protect other patients from resistant organisms, and trying to keep a positive spin on things. I had given this exact same monologue dozens of times before. But although Mrs M. understood the concept, she absolutely abhorred the idea of her husband in the single room way at the end of the corridor. And I soon saw why: for once this most sociable of men was put in isolation, everything rapidly deteriorated.
His once muscular frame continued to sink in daily. His strikingly handsome features became gaunt and care-worn. His heart failure was intractable. He no longer had any interest in speaking to any of his physicians. For a very short time, we were able to get Mr. M to a rehabilitation facility, but it was only a temporary respite. Within a week, he had returned to the hospital with an MRSA bacteremia. Back he went into that dreary isolation room.
A few weeks passed, and Mr. M continued to weaken. His blood cultures were still positive for MRSA, as they had been for 2 weeks already. We had imaged his entire body looking for a focal source and failed to come up with a drainable site. Had we even found one, though, he was no longer in shape to sustain any type of operation. We had rearranged his antibiotics in an effort to clear the bacteremia, yet none of this had sterilized his blood.
I came in to round on him, gowned and gloved, as usual. There wasn't a whole lot for me to say. He wasn't going to get better this time, and he knew it, and I knew it. I grasped his hand in mine.
"Mr. M, I'm sorry that you have to be in this room by yourself. I hope you feel better, sir." I gave his hand a squeeze, then snapped a last military salute to the former MP.
He looked up at me uncertainly, looking very small and vulnerable in the darkened room.
"I can't hear you," he said, his eyes dull, not even trying. "I can't hear you."
Mr. M's isolation was complete.