TB

We were never great people for planning for the future in this country, then again that opening statement may not be fully true, we’re probably a great little nation at the highest level for  commissioning consultants to draw up grandiose plans which once completed, printed and bound are left on well stacked shelves to gather dust alongside their predecessors.  We make the plans all right, but we rarely follow through on them, or if we do by the time they become operational for the most part they have been, bisected, dissected, emasculated, disembowelled and so altered that they become ill conceived, vagrant orphans,  unloved, unwanted, unclaimed but damned by all.  Still however these bastardised projects generally manage come to their blighted fruition at multiples of the projected cost.   One area  however that seems to have evaded any form of planning bastardised or not is infectious disease control and prevention, an area in which we are infinitely worse off now than we were, say twenty years  or so ago, a time when the threats were nowhere as great as today. I well remember when I started into general practice and indeed for a good many years afterwards that it was a complete no-no for a doctor to send a child with gastro-enteritis needing hospitalisation to a children’s hospital. The reasoning was quite simple and straightforward, the hospital authorities were intent on keeping their hospitals gastro free.  In those days children with gastro-enteritis were admitted to Cherry Orchard directly, all that was needed was one simple, quick phone call. No call waiting, no instructions to press 1 for two, 2 for that 3 for the other.  No unsolicited Mozart or Sibelius.

One simple phone call is all it took.  Alas since Jan 03 Cherry Orchard has ceased to cater for non HIV related infectious diseases and hence the child with severe gastro is routinely referred to A/E where over the course of a seven or eight hours the little mite has ample opportunity to pass his germs on to those not already inflicted by same.  Gastro-enteritis of course is not confined to children but affects all ages and the same criticisms can be levied at the lack of designated isolation facilities for the treatment of severe adult cases as can be made for their absence in the case of children. Is it any wonder that  we frequently hear of hospital wards being closed due to  the winter vomiting virus,  summer vomiting virus, whatever? MRSA, big perpetual topic, big perpetual problem.  What isolation facilities are there available for the proper treatment of same in our hospitals currently? I have had plenty of opportunity to observe at first hand the almost total absence of isolation facilities for the curtailment of the spread of same in several hospitals over the past years few years. And two areas of danger in particular stand out. A) A/E. There appears to be no vetting of patients in A/E to ensure that MRSA infected patients are not lying cheek by jowl alongside

MRSA free patients and bearing in mind that stays of patients in A/E routinely top ten, twelve hours this gives ample time for the old staph to seek out fresh pastures.  B) Visitors

to an MRSA infected patients nonchalantly, blissfully, in total ignorance  afterwards, drop in to see friends and neighbours in  different wards and indeed on different floors afterwards, thus ensuring free and widespread dispersal of the bug.  And why wouldn’t they when no one of authority hammers home advice to the contrary.  Proper policing should in fact make this practice not only unlikely but indeed impossible.     With the explosive growth of air travel to and from increasingly exotic destinations that has taken place both generally in the world at large and in particular  to and from  this country in recent times it is probably only a matter of when rather than if,  that we will be hit  by  a serious outbreak  of  an  infectious disease.   It may well be SARS, Bird Flu, non-bird flu, or some other exotic disease brought back to our shores by our increasingly intrepid travellers.  My guess however is that the outbreak snapping at our heels will be an old villain, smartened up, repackaged and launched afresh with renewed vigour and venom.  And despite all the warnings of its impending arrival it is a villain for which we appear to be totally unprepared for. NCB stockbrokers in their recent gaze into the crystal ball have forecast inward migration in this country to average 53,000 in the coming five years, before tapering off to 25,000 by the year 2020, by which date they predict that 20% of the population will be non-nationals.

Many of these immigrants will be from former Soviet states particularly the Baltic states, Estonia, Latvia, Lithuania where multi drug- resistant TB is fairly widespread. This is a disease with up to a 50% mortality rate.  What plans have we made to tackle such a problem?  Do we screen immigrants? No.  Should we screen immigrants??  What facilities have we for treating cases of multi drug-resistant TB in isolation. We have only one such bed in Dublin and this also has to be available for Bird flu, SARS or any other exotic visitor to our shores.  And what happens if someone with either known or unknown multi drug resistant TB requires urgent treatment for a concurrent illness. Like everyone else he or she will queue in  an overcrowded A/E department for the mandatory 10-12 hours giving him plenty of time to pass the hardy tubercle around, perhaps accepting in return a bit of MRSA,  Rota virus or whatever else is in the air that day.   And of course this only serves to highlight one of the true but oft neglected criticisms of our A/E departments. They are dangerous places.  If you weren’t really sick before entering, you probably would be before leaving.  By definition A/Es are full of sick people with a myriad of complaints and diseases not at that stage fully evaluated.  Hence the motto should be, suspect the worst, leave no stone unturned, and don’t put other patients and or relatives at risk.  If our A/ES were anything else but A/Es they’d be closed down long ago. Restaurants wouldn’t get away with that sort of overcrowding and dangerous work practices.