When it comes to covid-19, numerous column inches have repeated the mantra: “stay apart and flatten the curve.” Recently, a new hymn has emerged: “enough already; open things up”. Like you, I am unsure what to advise and what to expect. For now, most of us strive for monkish separation while praying that this won’t last. I simply want to inform this debate by outlining the literal and figurative costs associated with “splendid isolation.” If not for healthcare professionals, then consider our patients. This is because, through the fog of my visor, some look scared and alone.
Pre-covid studies showed that patients on isolation precautions (IPS) were more likely to experience adverse events, report lower satisfaction, and pen more formal complaints. Despite everybody’s efforts, isolated patients probably get less attention from nurses: approximately 50% less room entries, 50% less time spent in their rooms, and 50% less physical contact. Before doctors get too pious, we fare equally badly when it comes to laying on (literal) hands. In short, good-intentions can compound social isolation with literal isolation. Sometimes, Safety (with a big S) can be dangerous.
Isolation precautions might also increase the patient’s psychological vulnerability when they crave reassurance and human touch. Isolation might even make patients feel they are “unclean” or even “undeserving of attention.” Isolated patients appear to have higher rates of depression and delirium, plus greater use of antipsychotics and physical restraints. The threat of quarantine could deter patients from seeking help, as outlined in medicine’s euphemistic new term: “non covid, covid-related deaths.” These are the patients who stay away from the hospital until, for example, their stroke or heart attack is past the point of no return. Are we surprised?
We expend finite resources whenever we screen and isolate, and let’s face it, we weren’t resource-flush before all this began. We also burn through precious masks that may already be in nail-bitingly limited supply. There is also what is known in admin-speak as “labour-time”. This is time spent donning and doffing protective gear, which could be invested elsewhere. There is the cost of employing infection control practitioners. There are the cost of follow-up and the cost of testing and testing and testing. There is also the costs from the inability to co-locate isolated and non-isolated patients. There are costs because of delayed discharge and preventable ICU-days. And on, and on…
Recent clinical shifts have taught me that, when it comes to covid-19, no “isolate/don’t isolate algorithm” is a match for the realpolitik of frontline care. I know I am not supposed to put my head in my hands, but I can’t help it because somebody somewhere seems to find a reason to isolate each and every patient. Once “on precautions” they are rarely removed for at least a day, and sometimes not even when the test comes back negative: let me further explain.
Even in the absence of signs (those things that healthcare workers measure i.e. fever, x-ray changes) or symptoms (those things that patients report i.e. shortness of breath or cough) you are likely to hear the following well-intentioned refrain: “but you can’t always trust the test: isolate him.” In those not yet tested, I also hear “but he could be an asymptomatic spreader: isolate him.” There’s also “I can’t trust his answers because he’s confused/intoxicated/unreliable: isolate him,” and even “it’s in the community: isolate him.” To some this will sound fine: you can’t be too careful, after all. But like everything in medicine, there are pros and there are cons. Just like everything in life, complexity can rarely be distilled into an unsinkable one-page algorithm.
A wonderful caring colleague reminded me that Anne Frank managed 761 days of isolation. This was as he despaired that his fellow citizens have already returned to the pavements, paths, and bike lanes. Secretly, I have found myself channeling the 1800’s Scottish Philosopher Thomas Carlyle who argued that “isolation is the sum total of wretchedness”. Regardless, my guess is that self-imposed isolation has been tough on everyone. I bet we now all understand why solitary confinement is the worst thing you can do to a prisoner.
Covid-19 is teaching us that human connection is like oxygen. We now understand the difference between solitude (aka one week of blissful Netflix) and loneliness (aka one month of nothing but Netflix). If so then we should understand that, for inpatients, there is a huge difference between a broken bone that lays you in bed for a day, and a virus that imprisons you for weeks. Just take a moment and imagine what it’s like to be sick, starved of visitors, and unable to recognize masked healthcare workers as fellow humans eager to help.
Perhaps you can identify when I say that I relish a firm handshake, delight in seeing the sparkle in another’s eyes, and love a rib-busting hug. Moreover, after 20 years working as an ICU doctor, the science is often workaday but the thrill of connection remains. The term “splendid isolation” originated in the 1900s with politicians warning about the risks of getting too close. The analogy seems on point for covid, but so does the eventual historical lesson. In other words, for better or worse, “splendid isolation” did not last. Those in power eventually accepted what the public always knew: being close is what makes life splendid, or at least a little less wretched. As we struggle with this mighty question, let me reassure you of one thing: your doctors and nurses care deeply, even if you can’t see that in our faces because of all this clunky gear.
Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Competing interests: None declared.