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Ignaz Semmelweis

People keep calling for things like transparency and mandatory reporting. They call for laws to force health care professionals to report honestly. When they don't call for that, they call for restoring empathy and compassion, as though it used to be there but now is not. People who call for these things are people who don't know history. It is a conversation we have been having for at least 160 years.

Most people have heard of MRSA by now. It stands for Methicillin-resistant Staphylococcus aureus, a bacterial infection that, by using so many antibiotics, we have bred to be resistant to antibiotics. Overusing antibiotics robs future generations of the ability to benefit from them - just one of the reasons why it is important for the patient community not to be infected in the first place, especially by caregivers.

Ignaz Semmelweis is the man who first figured out something that could be done to prevent patients from being infected by their caregivers. He is so renowned for the discovery that asking someone in medicine who Semmelweis is is like asking someone born and raised in the United States who George Washington is - with the difference that they don't know two of the most important lessons to be learned from Semmelweis.

Semmelweis practiced medicine during the mid 1800s. When he first graduated from medical school he was unable to get a position as an internist, so he became an obstetrician. He was put in charge of two government-supported maternity wards. Among his duties were examining every patient everyday in preparation for the professor making his rounds. He also was in charge of all the records.

Every patient and every record

The fact that then, as now, almost no adverse events get reported accurately (see Medical Reporting) was a problem he could overcome because he saw every patient everyday himself and he saw all the records made by others. What was going on in the institutions was hard to hide from him by leaving it out of the record.

One of the things he noticed was that the first maternity clinic had a mortality rate that varied from month to month from 10% to 30%. The second had a mortality rate closer to 4%.

Young pregnant women are very interested in learning how to survive the new world they are about to enter. Among other things, they pay attention to other pregnant women. When they see 1 in 3 of their friends die in one clinic one month, but not in the other, that matters to them. They could see that the first maternity clinic was a death trap. The caregivers saw it too, but they still sent patients there. This is one of the most important things that patients should understand. Then, as now, caregivers send patients into death traps even when they know them to be death traps.

Most patients didn't die. During the worst months 70% of them survived. If you believe that the patient community is better off with your care than without it, while you are letting 30% of them die, when all you would have to do to save them is not send them to that unsafe clinic, you see the world very differently than patients see it.

The chief difference between then and now is that back then the patients were able to figure out that the death rate was not spread evenly across the two clinics. Most of the time only one clinic was a death trap. Today, patients don't know and caregivers don't know. Adverse events are erased in medicine whenever possible. Today no one has an accurate grasp of where safety is.

Semmelweis saw every patient and knew.

All of his patients were young pregnant women. There are few things on earth more compelling than a young pregnant woman. Semmelweis wrote about facing women who, when told they were being sent to the first clinic, got on their knees pleading not to be sent there. One of the unfortunate aspects of being a patient is having to find ways to motivate caregivers to care. Enough young pregnant women pleading with him finally got Semmelweis to care.

And that is why he is
so important in the history of medicine.

He began analyzing what was known. He searched for differences between the two clinics. He tried disallowing some religious practices to see if that made any difference, but regligious practices had no relevance to the outcomes.

Then a friend of his who worked in the first clinic was helping students with an autopsy when the scalpel of one of the students slipped and cut his friend. The fever killing so many young mothers in the delivery room was the same fever his friend died of in the autopsy room This was before bacteria had been discovered. So Semmelweis speculated that perhaps some cadaverous material, as he called it, was traveling on the hands of the students from the autopsy rooms to the delivery rooms.

The workers in the second clinic were midwives. In the first clinic they were students. Throughout history, until recently, the chief tool for teaching medicine was cadavers. The students in the first clinic would be studying by doing autopsies in one room when suddenly a woman went into labor in another room and they would rush to deliver her baby. Then they would return to doing the autopsy.

Without washing their hands

When examining the differences between the two clinics, the fact that students were the caregivers in one and midwives were caregivers in the other had not seemed important to him. And that the students were doing autopsies did not seem to him to be an important difference between the two clinics. But the way his friend died made him wonder. So Semmelweis tried an experiment. He ordered the students to wash their hands after leaving autopsies before delivering babies. In three months the death rate dropped to zero.

Semmelweis reported this amazing discovery, that washing hands saved lives, but did other physicians start doing that? No. In fact they rebelled. They harassed him.

Semmelweis began writing open and increasingly angry letters to prominent European obstetricians, at times denouncing them as irresponsible murderers. His outrage at their refusal to protect the lives of patients simply by washing their hands so outraged him that his behavior began to appear to his contemporaries, and even his wife, as his having lost his mind. In 1865, nearly twenty years after his breakthrough, he was committed to an asylum. Only two weeks after being committed he died of septicaemia, possibly from wounds caused by being beaten by the guards.

Two years later Louis Pasteur proved that microorganisms exist. And he proved that they cause disease. And he proved that it was possible to protect patients from those diseases.

Even with that information, in the 160 years since Semmelweis and Pasteur we have not managed to get treatment providers adequately to protect patients from them. We continue to have the same conversation Semmelweis had - how do you get treatment providers to wash their hands enough. And do the other things necessary to protect patients. But we haven't managed to succeed even with handwashing (see micromanage).

Today we know how to reduce infection rates in hospitals to zero, but it isn't done. In interviews treatment providers say that, for one thing, it would take too much time.

Safety takes too much time

Semmelweis was able to get the students in the dangerous clinic to do it because they were students. They had to do what he said. Doctors don't have to do what anybody says. And the well being of doctors, and nurses, is improved by letting patients get infected. This is because other patients cannot not find out who and where patients are being killed by treatment providers for whom protecting them takes too much time. To be truly informed, patients must be able to learn that so they can choose to go some where else. When that becomes possible, treatment providers will find enough time.

Until then, life is easier and more money is made by infecting patients.

So Super Bugs Evolve

One new bacterium now resistant to many antibiotics is Clostridium difficile, a germ that causes deadly intestinal infections in hospital patients. It can spread through the air. It sends out spores that land on surfaces where it is picked up by hands. Those hands spread it.

Normally other bacteria that live in our intestines keep that one from being a problem, but the broad spectrum antibiotics given to hospital patients wipe out the protective bacteria already in the intestines of patients and allow Clostridium difficile to flourish and broadcast more spores into the air. The spores are resistant to disinfectants and can survive in open areas for months.

C diff

Anyone with diarrhea could be spreading it. Catching it can produce fever, nausea, abdominal pain, severe diarrhea and sometimes colitis. The best way to prevent its spread? Washing hands. Because hospital personnel do not disinfect their hands enough, antibiotics have had to be used so many times to save patients from it that it has become resistant to those antibiotics.

If the patient community could learn where the biggest problems with this infection were, they could avoid those places. If patients avoided those places, providers would find the time to clean up the problem because their own well being would depend on it.

Passing another rule requiring better behavior has not increased hand washing enough in 160 years. Appointing another watchdog or implementing another best practices policy has not either. Patients really need to be able to see the facts of what and where such problems are in order to make intelligent cost-benefit analyses themselves. An informed patient community can make its well being important enough to the well being of care givers to cause them to clean up their acts.

Chalk Outline - A Symbol for Patient SafetyCare givers don't care where the death traps are as much as they care about protecting their own well being. If they did, they would know. And they don't. The only reason Semmelweis cared is that his patients knew where the dangers were because they were in a unique situation that enabled them to figure it out for themselves. That's the position patients need to be in again today. Otherwise it will continue to be in the interest of medicine to infect patients.

According to the Centers for Disease Control, 99,000 patients die from infections acquired in hospitals (where only a quarter of care takes place and only a quarter of infections are caught in medicine) each year. A number many times larger than that are disabled by the infections, but do not die from them. When the means to prevent those infections is known and available, but is calculated to take too much time, it is difficult to label those infections as errors. That is why the symbol for patient safety should be a chalk outline (and why we should stop pretending that "errors" is an accurate term to use for all problems harming patients - see the word "error" in medicine).

If the symbol is not a chalk outline, it should be a graphic representation of concerned people having the same conversation for 160 years without figuring out that it is the wrong conversation to have. If it weren't, things would have improved. It is time to change the conversation.

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