The Weeping Lesion and the Shared Table
Dr. P has a weeping, crusted lesion on the right index finger. He covers it with a bandage but does not wear a glove because 'gloves reduce my feel.' Between patients he wipes the table with a dry paper towel and reuses the same cloth towel for the face rest. He treats a patient with an actively draining shingles rash on the lower back and then sees three other patients without changing his shirt or cleaning the table. A staff member asks about hepatitis B vaccination and bloodborne pathogen training; Dr. P says chiropractic is 'low risk' and training is not required. The clinic has no written exposure control plan. A patient later calls to say she has been diagnosed with MRSA in a skin fold that was in contact with the table.
1. Identify the infection-control breaches and describe the corrections needed.
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The clinic is not using standard precautions. A weeping lesion on a provider's hand requires a glove or, if the lesion cannot be adequately covered, restriction from direct patient contact. A bandage alone is not a barrier against blood or body fluids. Dry paper toweling is not an appropriate disinfectant; the table must be cleaned and disinfected with an EPA-registered product according to its label between patients, with special attention to the face rest. Reusing the same cloth towel for multiple patients is a cross-contamination risk. The provider should change contaminated clothing or use a barrier, perform hand hygiene before and after every patient, and use gloves when contact with blood, body fluids, or non-intact skin is reasonably anticipated. The office needs a written exposure control plan, hepatitis B vaccination offered to at-risk staff, bloodborne-pathogen training, and PPE supplies. The 'low risk' statement is not a legal excuse.
2. How should Dr. P manage the patient with draining shingles and the later MRSA call?
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For the shingles patient, Dr. P should assess whether the rash is active and draining, avoid direct contact with the lesion, use standard precautions, cover the area if possible, and defer manual treatment over the affected skin until it is no longer weeping. He should refer for medical evaluation if the presentation is unclear or severe. For the MRSA call, he should not diagnose over the phone. He should document the report, assess whether the patient's skin contact with the table created an exposure risk, arrange follow-up with the patient's medical provider, and follow current Minnesota Department of Health guidance on reportability and notification. He should review cleaning and hand-hygiene logs, notify his malpractice carrier and, if required, the Board, and avoid retaliating against the staff member who raised concerns. The key is to act on the exposure rather than reassure without evidence.
3. What public-health and Board obligations should the clinic address now?
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The clinic should bring infection control into compliance immediately: adopt a written exposure control plan, train staff annually on bloodborne pathogens, offer hepatitis B vaccination, provide and enforce glove and hand-hygiene use, obtain appropriate disinfectants, and establish a cleaning log. It should document the shingles and MRSA events, the corrective actions, and any patient notifications. If the Board's infection-control rule or OSHA requirements were violated, Dr. P should self-report as required and cooperate with any inspection. Public-health reporting depends on the current Minnesota reportable-disease list; the clinic should check that list rather than assume MRSA is or is not reportable. Staff concerns should be addressed without retaliation. Finally, Dr. P should stop treating with an uncovered weeping lesion until it is healed or properly protected.