How safe is safe enough?

Hospitals are rather strange places to work. The rationale, after all, of purposely concentrating into close quarters the sick, the frail, and the contagious is elusive at times. Further compounding the situation is the introduction of healthcare workers into the mix, usually at the ratio of approximately five or six full-time employees for every hospital bed. In no other circumstance, except perhaps daycare or nursery schools, does a healthy person deliberately walk into an environment where billions of pathogens routinely are coughed and sneezed and excreted into the atmosphere. Yet the risk of healthcare work is a seldom-discussed aspect of the job. Some might feel that such concern might be borne of wimpiness or, worse yet, is a form of indecent selfishness. After all, do workers have the right to suggest that their own health is of greater concern than that of the sick patient before them? Is fascination with this concern the ultimate selfish, self-centered act of a generation wellknown for things selfish and self-centered? Are we dealing with just another baby-boom, “yes but what about me?” sort of whining? A generation aggrieved by yet another slight? Well, no. The hazards of health care are real, are plentiful, and are ever-changing. This is indeed a serious business; as the list of potentially transmissible agents grows, for many, preventions or treatments are sorely lacking. Nor is the problem an abstract or remote one. Many of us have watched a colleague grow extremely ill from an occupationally acquired infection: a beloved medical attending during my house staff training years later developed fatal occupationally acquired multidrug-resistant tuberculosis during the New York City epidemic. More recently, a clinical trials nurse I had worked with for years died of fulminant hepatoma, 20 years after developing occupational hepatitis B while learning to draw blood in nursing school. At the less dramatic end, each of us has dragged and moaned and hacked and sniffled from something we have caught from a patient. A mitigating concern runs through all formal reviews and assessments of healthcare-worker risk. As the recent adventures in tuberculosis control have shown, genuine concern about worker safety quickly can take on a regulatory life of its own, complete with particle-measurement experts, mask-thickness experts, and an alarming amount of administrative frenzy. Who would have dreamed, 10 years ago, that we would—each of us—be sniffing puffs of aerosolized saccharine under a Ku Klux Klan sort of white hood, all in hopes of equipping us to dodge the dreaded tubercle bacillus better? So, examinations of this issue are entered with not a small amount of knee-knocking fear. The converse aspect of the relationship has been discussed more publicly: namely, the risk to patients of being cared for by (for example) a Mycobacterium tuberculosis-, human immunodeficiency virus-, or hepatitis B-infected healthcare worker. A recent decision by the French to restrict from the operating room all HIV-infected surgeons may presage the start of a renewed debate about this most complicated issue, a delicate balancing act between the individual rights of the worker versus the need to minimize patient risk. The superb guidelines prepared by Elizabeth Bolyard and colleagues at the Centers for Disease Control and Prevention (CDC) authoritatively update both aspects of the problem, while giving practical recommendations for managing the thorniest of problems.1 As such, it builds on the earlier landmark article by Walter W. Williams.2 Careful guidance is given for prevention and management of over 25 diseases or conditions, supported by no less than 549 references. Areas range from common situations such as