Dishing the dirt on MRSA

Dried blood in one cubicle. Vomit in the next. Anyone who thinks we can beat MRSA with a mop and pail has clearly never been inside a hospital, says A&E veteran Dr Ed Walker

The first patient of the evening has already vomited over the trolley, and they are a nightmare to get clean. It would be nice if they could be steam-cleaned between patients, but they'd probably seize up after a while, as would the ward. And that's not acceptable - a patient waiting in the emergency department for longer than four hours sets alarm bells ringing at the Department of Health. With so much pressure to avoid four-hour "breaches", cleanliness can take a back seat.

The first patient of the evening has already vomited over the trolley, and they are a nightmare to get clean. It would be nice if they could be steam-cleaned between patients, but they'd probably seize up after a while, as would the ward. And that's not acceptable - a patient waiting in the emergency department for longer than four hours sets alarm bells ringing at the Department of Health. With so much pressure to avoid four-hour "breaches", cleanliness can take a back seat.

We move from vomit in one cubicle to diarrhoea in the next. This hopefully does not have a sinister undertone, as it seems to have resulted from loss of bowel control secondary to a large intake of alcohol rather than an infestation with clostridium, cryptosporidium or E.coli. This is just a clinical impression; I haven't sent any for culture, and don't intend to. The more immediate cause for concern is making sure that the patient doesn't choke on his own vomit.

One thing we can also be reasonably sure about is that his diarrhoea is also not due to clostridium difficile, a nasty bug that is, as its name suggests, difficult to shift. The main reason is that the patient has not been pumped full of powerful antibiotics recently, nor been in hospital. C.difficile, like MRSA, often lives in healthy people. But if you wipe out other competing bacteria with broad-spectrum antibiotics, or if your immune system is compromised due to severe illness, it will make its presence known.

Those comforting line-drawings in first aid books of the recovery position are of little help when a drunk patient with a mouthful of sick starts to fit. So it's off the resuscitation bay, dripping diarrhoea on the way. We need to put him to sleep and get a tube into his windpipe, which in a patient who is thrashing around inevitably means spilt blood. I've remembered to wear gloves, and will hopefully avoid contracting hepatitis C. Hep B and HIV are more famous viruses, but both are fragile by comparison, soon going belly-up when outside the body. Hep C on the other hand can last for days in a smudge of dried blood.

Within two hours this patient has had a CT scan of the brain and is in intensive care. The trolley is back in use, occupied by a patient too sick to notice the nearly-dry traces of faeces and blood.

Next door to him is an elderly woman who has arrived from a nursing home. She has a non-healing wound over the incision line from a recent hip replacement. The wound is leaking pus, and staff at the home have been told that swabs have grown the infamous MRSA superbug.

Unsure what to do, they try to contact the woman's GP. But like most GPs, this practice now farms out its out-of-hours service. The person they speak to says that no doctor is available for advice, and it will be three hours before one can visit. In the meantime, she suggests, staff should call an ambulance if they are concerned. That's why this woman's MRSA has been inside a vehicle that will transport another 20 people tonight.

After she has been discharged (in another ambulance), the domestic supervisor is contacted. Unlike blood, diarrhoea and vomit, we have a policy for MRSA. The trolley is given the once-over with disinfectant. The cubicle curtains are changed. Half an hour later, there's someone else in there.

It was in 1847 that someone first suggested that doctors wash their hands between patients. Ignaz Semmelweis was a leading physician at the maternity hospital in Vienna. He established that medical students were contaminating women there with material on their hands, leading to a high incidence of puerperal or child-bed fever. His ideas were rejected by the establishment.

Most people know that you can spread infection by not washing your hands. With the advent of MRSA there are posters everywhere reminding hospital staff to do it, and telling patients that: "It's OK to ask" if we have. Alcohol hand-rubs by every bed and visitor restrictions all aim to reduce the incidence of superbugs. The new Health Secretary, Patricia Hewitt, has joined the debate, claiming she is surprised that hospitals are not more like food factories, with everyone in white coats and hair nets. I would venture to suggest that she has not seen the inside of an emergency ward recently. Hair nets are of little use against the bacterial contaminants that are frequently flung in every direction.

I, like all my colleagues, wash my hands assiduously and often. I would like to say this is to protect patients, but it is more to protect myself. There are few things worse than taking a bite out of a sandwich while having a flashback of where your hands have been. If hand-washing was all it took to defeat MRSA, we'd win easily. The clue to why we won't is in the name.

Methicillin-resistant staphylococcus aureus is, like it says, resistant to methicillin. There was once a time when the slightest whiff of methicillin would kill any staph aureus in the vicinity. But with the arrival, and subsequent over-use, of antibiotics, bacteria did what they do best - mutated and became resistant. MRSA is no more virulent than any other form of the bug; it's just more difficult to treat. If you are unlucky you may get the VISA form, which has developed resistance to vancomycin, until now the mainstay of MRSA treatment.

Critics on one side suggest that the current crisis is due to the Thatcherite policy of contracting out cleaning services, ignoring the fact that it is usually the same cleaners as before. On the other side are those who claim that this Government's policies on reducing waiting lists and hitting targets are the sole cause.

If you really want to pick up a nasty infection, then a hospital, full as it is of poorly people, is the place to go. This has been the case since long before Dr Semmelweis's time. With the arrival of antibiotic resistance, you could argue that the bugs are now more dangerous. But to claim that the current situation can be cured with soap and a hair net is simplistic in the extreme.

Ed Walker is an emergency specialist working in the NHS