White Coat Syndrome

White Coat Syndrome is the most common of diseases that afflict scientists of the medical field, particularly the medical practitioners. This illness is characterized by the onset of sudden, unexplainable urges to keep the white outer garment adorning their bodies on at all times, as well as the uncontrolled tendency to wear these garments to wholly unsuitable places such as cafeterias, parking lots and – in more serious cases – restrooms. The incubation period for this disease varies among individuals, the more impressionable ones being a great deal more susceptible than those from the traditional school of microbiology, who may at times demonstrate almost complete resistance to infection. Once infected however, chances of recovery are very slim, and those who do are saved only through months of rigorous rehabilitation by constant, stern indoctrination and example administered by a select number of immune, dedicated volunteers.

Sounds familiar, but can’t put your finger on it? Keep your eyes wide open the next time you visit the hospital, and you may yet see this phenomenon occur before your very eyes.

We are, of course, referring to the spanking clean white laboratory coats that denote the status of medical scientist or researcher. Scientists and doctors throughout the world have, for a long time, worn white coats as a badge of profession – indeed, we have come to identify sophisticated instruments and stethoscopes and medicines with these people. It’s a tradition thing. Cartoon mad scientists who boast oversized white jackets and Einstein-esque wild bush hairdos mix bubbling solutions together while cackling, declaring their intentions to take over the world with their latest – and not surprisingly – evil inventions. Photographs in science books show researchers in impossibly crisp laboratory coats bending over microscopes, amazed at the new mutant microbes they have discovered. Television doctors and surgeons, rushing from ward to emergency room to pharmacies, glide gracefully down corridors, boasting impeccably creaseless white coats. In the real world, the white coats are perhaps a little less white, a little more disheveled, the people less melodramatic, but these coats are worn nevertheless.

So what is wrong with the picture?

First of all, we must ask ourselves this question – what exactly is the function of a laboratory coat in the medical context?

The obvious answer is: protection.

A laboratory coat is about the only thing that separates a medical doctor or a scientist from the environment. It is a barrier, a shield, an insulation layer. It keeps the wearer clean from agents that might otherwise dirty his clothing, such as staining dyes, or chemicals that might harm him, such as acids and toxic substances. It makes sure that the wearer is not unnecessarily exposed to infectious agents such as blood and body fluids from patients suffering from contagious diseases, or cultures of highly pathogenic bacteria.

Yet, in the same manner that it protects a doctor or researcher from a potentially hazardous environment, it also protects the environment from him. In laboratories where DNA contamination is a serious threat to workflow (1), scientists wear long-sleeved laboratory coats and gloves to minimize the risk of their own DNA mixing with that of which they are studying. Wearing these coats, too, reduces the chances of sterile culture media (for cultivating selected bacteria) being contaminated by whatever microorganisms the researchers may be harbouring. And just as importantly in the hospital, it reduces the risk of patients with weakened immune systems becoming exposed to potentially dangerous bacteria that, under normal circumstances, cohabit peacefully with humans but, given the right conditions (compromised immune systems, or the presence of another disease in the patient), will infect them and cause serious harm.

Let’s get this right: lab coat prevents doctor/scientist from becoming contaminated by environment; lab coat prevents doctor/scientist from contaminating environment.

Given these points then, we would surmise that a laboratory coat would be most appropriately worn in: (1) wards with sick or injured people (particularly those oozing bodily fluids), (2) clinics or outpatient treatment centres (where doctors have to treat cuts and wounds), and (3) of course, laboratories, since all of these are high-risk areas. Nowhere is it indicated or implied that a doctor/scientist is at risk of infection or contamination at cafeterias, bathrooms, lounges or carparks.

Wearing a laboratory coat to an inappropriate place is not only as awkward as wearing a loud Hawaiian shirt and baggies to a formal reception, it is a health hazard. Remember that the lab coat is meant to protect the wearer from exposure to infectious or dangerous agents. This means that it is the lab coat that becomes soiled with chemicals/DNA/microorganisms, and not the person inside. What, then, happens when a person wearing a contaminated lab coat walks around and mingles with common people outside of his laboratory or ward?

Here is a good story dating back to 1847, just before the Golden Age of Microbiology. A Hungarian-born doctor named Ignaz Semmelweis observed the horrifying mortality rate of puerperal (childbed) fever among mothers who gave birth in one maternity ward of the Viennese General Hospital in Austria (2), which was a ghastly 10-30%, as compared to the 3% mortality rate of those who delivered in a second ward. He noticed that deliveries in the first ward were made by medical students who had come straight from dissecting cadavers, and that women who came to the hospital after delivering rarely contracted this disease. The obvious struck him: the students must have been carrying some kind of poison from the dissecting room into the maternity ward that caused the women to become ill. Consequently he insisted the students rinse their hands in lightly chlorinated water before helping with the deliveries, and the death rate dropped drastically to 1%.

(Back then, doctors were already wearing white coats, but it was to protect themselves from becoming dirtied with the blood or pus or other undesirable body fluids from patients. The only time doctors cleaned their hands – often on their coats – was when their hands became stained with the said fluids.)

Bacteria, fungi and other microscopic parasites are clingy creatures – that is to say, they are happier on a stable surface than they are floating aimlessly in the air. This is, of course, reasonable. There are very little available nutrients, and just as little water, in the air – indeed, the air is such an inhospitable environment that the only microbes that can survive for long periods in the air are those that are in dormant form (spores). To be able to grow and multiply, microorganisms – just like the rest of us macroorganisms – need to be attached to a surface or immersed in a liquid of some sort where it can get at food and water. The lab coat, being made of woven fabric, inadvertently provides these creatures with a niche, a habitat, a sanctuary on which they can happily proliferate. Bacteria, being negatively charged (3), will readily become attracted to anything bearing the opposite charge. Furthermore, being small, they easily become trapped between the threads through exposure; any passing nutrients in the air become likewise attached. Sweat from the bodies of the wearers contain positively-charged salts, and also provides them with the water of life. Spores being carried by air currents will become snagged on the lab coat fabric, and, finding conditions just right, will germinate. From the microbes’s point of view, the laboratory coat is a moving motel, haven and restaurant, all rolled into one.

But why be satisfied with the host as a diner and resort when you can use it as a mode of transport as well?

There are two classes of infections a hospitalized patient can get – one from outside of the hospital, and one from inside. The second is called nosocomial infection, and at least 5% of people who are hospitalized will contract infections of this sort. (In the Intensive Care Unit, up to 10% of the patients may acquire nosocomial infection) While the hospital is one enormous reservoir of disease to begin with, owing to the different infectious diseases that patients are hospitalized for in the first place, microbes can only travel so far on their own – even if they are carried by wind or air currents. It is the hospital staff – the doctors and the nurses – who are the main vehicles of transmission, carrying pathogenic microbes from one ward to another, spreading infectious diseases from one patient to another. Most of these people, having spent a lot of time in the hospital environment, are carriers of Methicillin-Resistant Staphylococcus aureus which, while under normal circumstances can be found as normal flora on the skin and perhaps upper respiratory tract, are deadly when they come into contact with immunocompromised patients. A physician who also lectures or does research is twice as likely to pick up drug-resistant microorganisms, and just as likely to spread them around. If different coats are not worn in the laboratory, in the morgue and in the wards, or if the coats are seldom or – gulp – never laundered, the chances of becoming a vector of infectious diseases are high. It certainly does not help if the said people have unsanitary habits, such as wiping their hands on their laboratory coats (4).

Yet while the risk of spreading infectious disease when patrolling the wards is acceptable if the coat is frequently laundered and dedicated laboratory coats are worn, spreading pathogenic microorganisms around just because some physician or researcher is too lazy to remove his/her coat before going to the bathroom or the cafeteria is simply ridiculous. Imagine – a coat that is meant to protect the surroundings from becoming contaminated by the wearer, brought into so septic a place as a restroom! What kind of microorganisms do you think you’ll pick up on a lab coat in a place where people visit to get rid of their waste? or, indeed, the microbes that you will bring into the restroom with you from the laboratory or ward? What diseases do you think you might be spreading if you were to wear so soiled a lab coat to a crowded public area? And what makes you think that the lab coat will protect you from becoming infected with the pathogens that you are carrying on it?

Being an inadvertent vehicle for transmission of infectious disease is something that cannot be avoided, and whose risk can only be lowered and not eliminated; deliberately offering yourself as a vector for pathogens by being lax in your responsibility to yourself and others, and therefore risking the well-being of innocents, is unforgivable.

In conclusion, White Coat Syndrome is a plague that must be stopped, just as anthrax and Bubonic plague and tuberculosis must be stopped dead in their tracks. Developments in medicine and medical science may progress aggressively and birth new generations of sophisticated diagnostic tools and more potent drugs and sure-fire cures; yet if the White Coat Syndrome persists, then we who are children of the 21st century are no better off than the women from Semmelweis’s time, whose doctors carried pathogens in their hands from the dissection rooms into delivery rooms.

REFERENCES

1. Molecular biologists, especially those dealing with deoxyribonucleic (DNA) and ribonucleic (RNA)-based technologies, are most afraid of DNA contamination. This is because molecular biology methods such as the Polymerase Chain Reaction, which amplifies certain targeted regions of DNA or RNA, are highly sensitive, and the presence of contaminant DNA – usually from the skin of researchers – could very well inadvertently cause misamplification of itself instead of the target sequence.

2. Brookesmith, P. 1997. Future Plagues: Biohazard, Disease and Pestilence. Universal International Pty Ltd

3. This is due to certain components of the bacterial cell wall. Gram positive bacteria cell walls are negatively charged owing to the phosphate groups in its cell wall teichoic acid. Both Gram positive and negative bacteria have strongly negative charges on their outer membranes, which helps them evade certain host defense mechanisms.

4. Speaking of unsanitary habits, here is another story, this time one that is closer to home, one that happened in the second half of the 20^th century. Physicians at a local hospital were mystified when a large number of post-operative patients contracted the same disease over a certain period of time. Running background checks, they discovered these patients were operated on by the same doctor. They decided to secretly rig a video camera inside the operation theatre and film the guy at work to see if he had anything to do with these infections. And what did they see? A surgeon in the centre of the screen bends over an unconscious patient and makes surgical incisions with his scalpel. In between procedures he straightens up, stretches – and scratches his head with one gloved hand. Would anyone care to guess how those patients got infected?