Nurse Rebekah: Imagine if aliens landed in a hospital and were trying to figure out what our clothing meant. It might seem as if the people wearing the pajamas had all the power and did all the work, while the people wearing suits didn’t do much but stare at some weird light box on a table, intermittently picking up a strange white cylindrical object with a green pattern on it and brown liquid. It would be interesting to see what the aliens might say about our outfits.

But we can forgo the fantasies of alien visitors and consider what our patients think when they come to the hospital. Remember, a hospital is alien territory to them! So what do they think about our outfits, hand-washing habits and presentation? If we keep our appearances professional, neat and stylish, we’re sure to project the competence that we possess.

Dr. Brady: Absolutely! Patients pay attention to these things, especially when they don’t have visitors to occupy them. While we’re busily running around trying to keep up with all of our work, our patients are bored, wondering when their test results will be back, when we’ll return and when they can leave or eat (or both!). They often have nothing better to do than watch us and what we do right or wrong. They notice how we dress.

Even more potentially embarrassing, they notice what we say. Don’t think they aren’t listening. They are, but that’s a whole other topic.

You heard it in nursing school and you’ve heard it again here: Dress neatly and professionally. Tie your hair back. Trim your nails. Wash your hands. Fashion is fleeting, but professional behavior and attire will always make a good impression.

[main image: Wendy Hope | Stockbyte | Getty Images]

Nurse Rebekah: Our last stop on this adventure through hospital wardrobe is hair. I have a decent amount of hair, it’s long and if I’m motivated enough, I can make it look real puuuurrrrty. But not at work!!! Tie it back, ladies! This goes for physicians, too! I’ve seen both sexes guilty of hair sins: long, beautiful hair flowing down over their shoulders and right into a sterile field, foley catheter or a seeping-oozing-disgusting wound.

Think of that old high school cheer…tie it back, tie it back, waaaaaaaaaaaaaay back. I’m just waiting for a mutant MRSA strain that makes your hair fall out in giant abscesses. People tie their hair back when patients have lice. Why? Because you can see lice. You can’t see the smarmy microbes, but they are there, right? We learned that in microbiology. Remember the door handle swabs?

Dr. Brady: Personally, I’m more interested in the touching-your-face issue. Most communicable diseases are transferred by touching your eyes, mouth or nose with unclean hands and fingers. I’m paranoid about touching my face unless I’ve just washed my hands. I consider my hands to be a disease-ridden zone, except for immediately after sanitization. The last place I want those hands to be is anywhere near my face or my food. Yet I see people all day long rubbing their eyes, picking their nose and touching their lips. I want to yell, “Don’t! Do you know where those hands have been?”

Fortunately, there is a balancing force: the secretaries who wipe down everything in a 10-foot radius with sanitizing surface wipes as soon as they get to work. I love to watch that. Fortunately, my ED is pretty clean. I even see the cleaning crew regularly spray the curtains with disinfectant. I don’t think they do that everywhere, but they should. Can you imagine what would grow if we plated those on bacterial culture?

In part IV of The Perils of Beauty, Dr. Brady and Nurse Rebekah discuss the ways our clothing enhances—or undermines—our professional image. Read Parts I through III here.

We’d love to hear your advice about avoiding germs at work. Do you wear a ponytail? Cover yourself in a coating of Purell? Wash your hands both before and after using the restroom?

[main image: Somos/Veer | Getty Images]

Although the white lab coat is an ingrained part of the healthcare culture, it may carry more than pocket references and PDAs.

Nurse Rebekah: There was an article in the New York Times recently that discussed the possibility of the American Medical Association banning white coats for doctors—not because of the hypertensive possibilities of the “white coat syndrome,” but because of the risk of germ transmission. Since white coats aren’t taken home and laundered every day, these coats carry lots of really gross germs.

The AMA is also considering adopting a “naked below the elbows” policy to prevent the transmission of microbes by dangling sleeves. The majority of the bloggers out there, however, seem to disagree with this proposal. The heart of their argument? The white coat bolsters the physician’s “authority” and protects the physician’s “clothes.” C’mon, ladies and gents, get over yourselves. This is about the patient, not your security blanket.

Dr. Brady: This is a good point. There are lots of downsides to the white coat for physicians as well as patients. However, there are benefits as well. In fact, the majority of patients prefer a doctor who is dressed in a white coat, at least when they’re taking a questionnaire and given a number of drawings of physicians in different attire from which to choose. I’m sure, however, that if you told the same questionnaire-takers that the physicians in white coats were five or ten or however times more likely to spread germs to their patients, there would be a big change in the answers given.

Some doctors already eschew the white coat as it is. Personally, I like it, though more to protect me from germs—and for the pockets. I would be fine with changing my habits, though, as long as Rebekah doesn’t send the fashion police after me when I wear cargo pants to work.

What do you think? Is it high time to apply evidence-based medicine to the clothes we wear? Dr. Brady and Nurse Rebekah will continue their discussion of disease transmission in part III of The Perils of Beauty—and remind nurses that scrubs should be practical and professional.

In this edition of “He Said/She Said,” Dr. Brady Pregerson and Nurse Rebekah Child talk about The Perils of Beauty in healthcare fashion and function.

Nurse Rebekah: So this month’s edition of “He Said/She Said” is all about fashion…kind of.

I remember reading an article once that discussed the length and weight of doctors’ white coats. The longer and lighter your coat was (fewer books in the pockets = lighter coat), the higher up on the physician food chain you were. Many police officers sustain workers-comp injuries from their gun belts; the belts are so heavy, it throws their backs out.

I wonder if the same couldn’t be argued for medical students and first-year residents. Unfortunately, they aren’t allowed to take sick days to figure out if all the reference texts weighing down their coats are the cause of their sciatica. I still can’t figure out why they haven’t put all those books on a PDA application by now [editor's note: there are some very helpful iPhone apps]. Maybe the books are just old-school security blankets. As for the attending’s empty pockets, some hypothesize that their wizened experience means they have all these facts memorized by now; others would say they have mastered the art of delegation.

Dr. Brady: I’m no fashion prince—just ask my wife—but I do try to don acceptable, if not respectable, attire. I gave up scrub pants a long time ago so I could wear something with more pockets.

Now I mostly use scrub pants for rock climbing at the indoor gym; they’re perfect because they’re light and cover my knees, which otherwise sometimes get scraped. I used to wear a scrub top, but gave that up when my director kept noticing that I was “untucked.” Let me tell you, when you’re 6’4”  it’s hard to keep your shirt tucked in at work; shirts just aren’t long enough.

I still haven’t taken to wearing a tie at work. There’s a fomite that never gets washed. Plus, I don’t want a homicidal schizophrenic to be able to grab onto a slipknot around my neck.

Although pocket books and other medical references might not be considered part of a doctor’s “fashion statement” by many, Rebekah has a good point. The lack of additional white-coat real estate is actually one of the first things you notice in someone whose pockets are brimming over. Many doctors (and nurses) opt for PDAs or iPhones to store information they want on hand, but I’m still a fan of some of the better pocket texts. All you need are one or two, and paper is still lighter, cheaper and less breakable than the alternative. The series from ERPocketBooks.com is one of my favorites.

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Think about it: Is your work attire streamlined and practical? Lots of pockets are great, but are you carrying around anything you don’t need? In Part II of “The Perils of Beauty,” Nurse Rebekah and Dr. Brady talk about what else might be hitching a ride on your clothes, and in Part III, they discuss what happens when germs end up in your hair, on your hands, and all over your face..

[main image: altrendo images | Stockbyte Collection | Getty Images]

Dr. Brady: It’s often frustrating for me when I’m caring for a patient whose parents haven’t had her vaccinated. I want to give those parents a piece of my mind, but I now realize that unless they ask me for my opinion, it’s probably a waste of time—actually, a waste of time that I really don’t even have. I’m just too dang busy when I’m at work.

I definitely feel that one of my main roles as a doctor is to be a health educator, and I always do my best to fill that role. However, it’s often too hectic to spend as much time teaching as I would like. So I choose my battles, and when there is an issue I feel strongly about, but know that my audience may not be that receptive, I sneak in a quick and/or subliminal comment or piece of advice. For a young smoker, I may do no counseling at all, but rather simply ask after listening to his lungs, “Do you smoke?” in a way that scares him into thinking I can actually hear lung cells dying. For the parents of the unvaccinated, where the spin and possible conspiracy theories are all so potentially confusing, I may say something that simplifies it and breaks it down into plain English: “I have kids, too. I made sure they were vaccinated.” That is the most powerful seed I can plant.

Nurse Rebekah: I don’t have kids yet, but I make sure my dogs get vaccinated! And I’m fairly sure that I would love my kids—most of the time—even more than I love my dogs.

People tend to believe that bad things will never happen to them. Until they do. And then hindsight is 20/20, right? Your health is your choice—just don’t come crying to me in the ER when you’re having full-blown spasms from tetanus or body aches and rigor from the flu. I won’t say, “I told you so,” but you’ll know and I’ll know that you should have gotten your vaccines.

I love the debate that’s going on right now about vaccines. Whatever your viewpoint, it’s healthy for science and for healthcare in general to have a vigorous debate about vaccination. Debates move science forward. I’m hoping this debate moves forward to that common cold vaccine—one I will definitely get in line for! Or a cellulite vaccine…or a gray hair vaccine…or….

Today, more than ever before, patients come to us with their own thoughts, ideas and opinions about medical interventions. So talk to your patients. See where they stand on vaccination. Really listen to what they have to say. And then figure out where to go from there.

[main image: Ian Hooton | Science Photo Library | Getty Images]

Dr. Brady: If it weren’t for vaccines, I think I would have already died of measles, tetanus or rabies; suffered permanent damage from H. flu, rubella or polio; or been incredibly sick from typhoid, yellow fever or mumps. Infections are a major cause of death worldwide. According to the World Health Organization, they account for six of the top ten causes of death in low-income countries. In high-income countries, where vaccination tends to be widespread, infection accounts for only one of the top ten causes of death.

It’s not that I’m looking forward to any of the alternatives—heart disease, stroke and cancer topping the list—but I’m happy to avoid any and all ailments that I can. Measles—there’s a vac for that. Polio—there’s a vac for that. Swine flu? There’s a vac for that, too. I wish there were a vaccine for everything, but for now, I’ll take what they’re giving. I know that a vaccination, like everything else in medicine, and everything else in life, has a risk. There are no certainties. But there are calculable odds, and that’s a good enough strategy for me.

Nurse Rebekah: Poor Dr. Salk. All that work to invent the polio vaccine and people are walking around just snubbing their noses at vaccines in general. I don’t know about you, but I don’t think my iPhone would get great reception in an iron lung. Vaccinate away, please! Kids today don’t even have to suffer through the chicken pox. I kind of think that’s a little unfair, though…itchy pox never hurt anyone (ha ha); they built character and gave Calamine lotion a guaranteed demographic.

Imagine, though, if there were a vaccine for the common cold…think of all those companies that would be out of business! Wait a second, talk about a conspiracy! What if the cure for the common cold is out there, but scientists are holding out on us for financial reasons? Nah, what am I talking about? They would still make money from all the people who refuse to get vaccinated.

How do you handle a patient who refuses vaccination? In part 4 of The Great Vaccination Debate, Dr. Brady and Nurse Rebekah weigh in on this tough issue.

Dr. Brady: Before you chart something that may be critical, consider conspiring with the rest of your team. I’m not saying you should lie. You are obligated to tell the truth, but you get to decide how you will tell the truth. If you and the doctor think your patient with a URI and chest pain may actually have a pulmonary embolism, chart “pleuritic chest pain” and the CT scan is justified—and if there is a complication from the contrast, everyone is vindicated.

If, like most people with a URI and chest pain, she really has just a painful cough, chart “painful cough” instead of “pleuritic chest pain” and send her home. If three months later she really does have a blood clot and you all land in court, the consistent, harmonious charting will likely get the case dropped.

One more example: If a mom says her child is lethargic, but the child looks fine, chart “less playful” rather than “lethargic.” That’s what the mom means. She doesn’t mean “I can’t keep my child awake,” which is the medical definition of lethargy.

Again, you shouldn’t lie, but if you spend a little time conspiring or collaborating with the doctor and explaining things to your patient, you might accomplish many things that would make both your mother and President Obama proud: less unnecessary testing, lower medical costs, more realistic patient expectations, few medicolegal lawsuits and hopefully happier, healthier and more trusting patients. Perhaps if we are breathing in harmony, work could even become more harmonious.

Nurse Rebekah: Harmonious! Sounds like yoga to me! Relaxing and very zen-like. However, when it comes to charting and documentation, I just try to be as objective as possible. For instance: “Patient complains of severe nausea and is currently eating chips in triage.” That uses the patient’s own words but paints a pretty clear (and objective) picture of what is really going on.

Try at all costs to take the bias out of your charting. If your chart looks biased, a lawyer can always say to a jury, “Look, Nurse Child wrote that this patient stank and was rude. She didn’t even like this patient, so how could she have taken good care of him?” That will make you look like Nurse Ratched and like the comedian I mentioned in Part III—”Heeeeere’s your check.”

Instead, you can always chart: “Patient stood up on gurney and urinated into sink while calling staff ‘ugly, stupid, dirty gigolos.’” The patient just painted his own picture as a real jerk, and also, as the comedian says, “Heeeeere’s your sign.”

Healthy work environments and healthy communication styles go hand in hand. In the super technology-laden world that we live and work in today, we can take care of many, many patients, all at the same time. This can come at the expense of face time with our colleagues. So strike a downward-dog pose, breathe and collaborate. Maybe even light a candle to relax as you conspire away.

Got it? Conspiring with your colleagues is a good thing. So choose your words carefully, communicate your concerns and expect an increasingly harmonious environment.

In part 2 of The Great Vaccination Debate, Dr. Brady Pregerson and Nurse Rebekah Child analyze some common objections to vaccination.

Dr. Brady: My brother probably won’t get vaccinated or have his one-year-old vaccinated, either. I don’t think his child has had any vaccines at all. I feel terrible about it. But I got tired of arguing with someone I love over the health of my only nephew (so far). My brother is smart, but he’s a lawyer, not a doctor. He also doesn’t trust the system. He’s a believer in conspiracies—not the type we wrote about last month, but the type where the harmonious cooperation involved is meant to take advantage of others. All the science in the world either goes in one ear and out the other, or just polarizes him further toward his outpost.

Sure, people are making money off vaccines, but they make it off antibiotics and x-rays and cars and food, for that matter. I try to convince my brother, but it seems there’s no use arguing. It’s just a waste of time. I give up—I say uncle. I don’t want to alienate him. I want to be approachable when he does have medical questions. But am I really doing the right thing or just taking the easy way out?

Nurse Rebekah: Ah yes, the age-old “herd immunity” mind-set. If you live in a tiny town in Missouri, herd immunity—relying on everyone else to get their vaccines so you or your children don’t stand a chance of getting the disease—might work for you. However, if you live in a big city, especially one with lots of immigrants, beware! Herd immunity is not for you! Living in Los Angeles, I couldn’t and wouldn’t rely on herd immunity because the herd is full of nasty, preventable, communicable diseases. I remember one of my first pediatric deaths was a 13-year-old who died from Influenza A. I don’t know if he had his flu shot that year or not, but I cringe to this day thinking his death may have been preventable.

As a health professional, how do you help your patients separate the fact from fiction? How do you help them realistically assess the chances of disease vs. the likelihood of a serious side effect? In part 3 of The Great Vaccination Debate, Dr. Brady and Nurse Rebekah discuss the benefits of vaccination.

[image: Tetra Images | Getty Images]

Dr. Brady: What should have been done for our patient with the TIA in Part II of our Charting Conspiracy series? In terms of care, communication and charting, everything would have gone much better if all the providers had been acting in harmony.

If the nurse and doctor shared all the relevant information, perhaps the patient would have been admitted and the stroke avoided. Even if the stroke still occurred, if everyone had worked and charted consistently, the patient may have at least felt that everything that could have been done was done and it was no one’s fault.

Or even if she did blame someone and hire a lawyer, the lawyer would have subpoenaed the chart, and after looking it over, realized that she received good care and advised her to drop the lawsuit.

Nurse Rebekah: I love conspiracies, but more like the kind that say the moon landing was fake and that the government is listening to our cell phone conversations.

I certainly don’t live in fear of lawsuits. I’ve been to court—it wasn’t fun, the food is horrible and the parking is worse—but I KNEW I gave the best nursing care I could. Even better, I KNEW I had charted pretty darn well. You know who came up with the saying “If it wasn’t charted, it wasn’t done?” Lawyers. When you do your best, you don’t worry about lawyers and judges, and you don’t feel bad about yourself or your work ethic. So chart consistently, according to your standard of practice, and avoid mistakes and self-esteem issues. Seriously, it will save you a ton of money in psychotherapy.

Take the harmonious tack a bit further by learning how to conspire with the rest of your team. Dr. Brady and Nurse Rebekah discuss the importance of choosing your words in Part IV of our Charting Conspiracy series.

Spoiler: You get to decide how you tell the truth.

Usually, we try to tease you with a little information, just enough to encourage you to read the entire article. This time, though, the message is so important that we gave it to you up front: You get to decide how to tell the truth.

And who can blame them? With a ton of scary stories linking vaccinations with autism (never mind the fact that numerous scientific studies have debunked the link), more and more Americans are refusing vaccines. In our “Great Vaccination Debate” series, Dr. Brady Pregerson and Nurse Rebekah Child share their thoughts on vaccination—and how to deal with patients who refuse immunization.

Dr. Brady: Have you had your flu shot? This year we have two: the regular seasonal influenza vaccine and the special H1N1 vaccine. I had both. The first one hurt my shoulder for more than a week; it was nothing very bad, just a mild occasional discomfort. That rarely happens to me. I don’t know if it was the ingredients or the needle placement, but I believe it was the latter because it felt painful even before the nurse started pushing the 0.5 milliliters of clear liquid through the needle.

Turns out that I probably didn’t need that one because the majority of the circulating influenza this year looks to be the novel H1N1, aka “swine flu.” A few weeks later, the swine flu vaccine became available and I took that one, too. I’m playing it safe—and it turns out that one didn’t hurt a bit. Not a side effect I could notice.

I’m a big vaccine proponent, but I have to admit I was a little scared of the H1N1 shot. I don’t know why. There was no reason to be. And the odds of a serious side effect are like a million to one. I’ll take those odds any day over a probably 25 to 30 percent chance of getting the swine flu and a 0.8 percent chance of death if you get it. But why did I ever worry? I guess it turns out no one is immune to vaccine scares, not even the choir used to hearing all the sermons of their benefit.

Nurse Rebekah: This is the first year that I’ve taken a flu shot. I personally think flu shots are a conspiracy. Every year the recommendations for who should get the flu shot gets broader and broader. I have a sneaking suspicion that those recommending the flu shot also own stock in the companies that produce those snappy little vials. But I have no proof of that, just my own theories getting the best of me.

Anyway, in eight years of nursing, I’ve never received a flu shot, and I’ve never had the flu. But never say never, right? Since I’m working full-time and attending school full-time, I felt like I really shouldn’t take any chances this year. So I buckled down and took my needle(s) like a champ.

I agree that needle placement is everything—it is a lost art. Honestly, I would rather have a first-semester nursing student give me an IM injection than a seasoned nurse. Most seasoned nurses don’t put it in the right place. My first injection was given subcutaneously and the second injection was given pretty much intra-articularly; the first by a nurse of more than 20 years and the second by a nurse of more than 40 years. Two fingers below the acromion process, people! Two fingers!!!

Yes, even healthcare professionals hesitate before agreeing to a new vaccination. But for the most part, they understand just how important vaccinations are. In part 2 of The Great Vaccination Debate, Dr. Brady and Nurse Rebekah explore some of the most common causes for vaccine refusal.