Residential Space A creative outlet during residency, turned ongoing virtual soap box

My first needle stick as a physician  2

Posted on July 1st, 2006. About Ramblings.

In the world of medicine, when a patient needs IV access, but has no accessible peripheral veins (for whatever reason – IV drug abuse x many years, chronic health problems requiring many hospitalizations, etc), we often opt to place a central venous catheter, or a “central line.” My favorite place to insert these catheters is into the internal jugular vein, but they can also be placed in the femoral or subclavian veins. In December, while working in the Medical Intensive Care Unit, I was placing a central line on one of my colleague’s patients. The whole procedure went smoothly, no surprises – until I used the scalpel to cut the tail of a suture, the scalpel slipped in my bloody glove, and stabbed me through the glove.

Ahhh, despite being careful, it was inevitable – my first needle stick (or in this case, scalpel stick) as a physician. Within two minutes my gloves were off and I was washing the wound thoroughly. I discussed what had happened with my critical care fellow on duty, who sent me to the emergency room to document the stick. I was seen in the ER within thirty minutes, and upon arrival I informed the nurse practitioner that saw me of the patient’s name and medical ID number so that he could be approached about hepatitis B, C, and HIV testing. At the time, given the expense and intense side effects of antiretroviral therapy for HIV, and given the 0.3% chance of transmission during such an incident, I opted not to begin taking the medication. After all, it is incredibly rare that in such a case a patient in our system would turn out to be HIV positive where HIV status was previously unknown…

…until the following morning when the Employee Health nurse practitioner paged me to inform me that the patient was refusing to be tested for HIV. WHAT?!?! My response was something of this nature. His blood could used for testing for hepatitis B and C, but a Washington’s law regarding HIV confidentiality specifies that a person must give consent for an HIV test, regardless of circumstances. The patient was assured by the hospital reps handling this that the results would remain confidential, and that the purpose of this test was only to decide whether his doctor (me) would need to take prophylactic medication. He still refused. At this point, I began the medication out of fear that this man was HIV positive. Throughout the day, the progression of events involved the appropriate representatives attempting to change his mind, and it was explained to me that the hospital may have to receive a court order for the blood sample on hold in the lab in order to run an HIV antibody test on it. It finally went to a high enough level to where the patient, realizing he was left with little choice, gave in. A rapid test revealed him to be HIV positive, as well as hepatitis B and C positive.

The week that followed was horrible. I was out of work for two days, one of which I spent the entire day vomiting from the medication. The Employee Health nurse practitioner prescribed a wonderful anti-nausea drug called ondansetron (trade name is zofran) that alleviated this issue. I also had baseline testing for these viruses, all of which were negative. I did make it through the required four weeks of medication, which not many people do given the side effects. My blood was tested at six weeks and three months and remained negative for everything. I am pleased to announce that I just received the results from my blood work at six months, and I am free and clear – all is well. 8)

I swore when this incident first occurred that, when all turned out okay, I would blog about it. I would also begin writing to my representative and senators in the state government, demanding to know why this man’s rights outweighed mine. I was taking care of him, providing him a service, and to think he had the right to refuse a blood test when I was injured in the process of caring for him is unacceptable. I recognize the stigma that is associated with HIV infection, even today in 2006, but after this experience, I strongly believe that health care providers also need to be protected. The medications are hard to take – side effects include not only nausea, but anemia, drug-induced hepatitis, and other (albeit rarer) complications that can be even more severe. Physicians and nurses have the right to know if they have been exposed to HIV so that they can weigh whether it is worth the risk to their health to take prophylactic medications. If a patient is HIV negative, then they spare themselves the risks from the drugs.

I grow frustrated that society expects doctors to be there for everyone, but society is unwilling to protect them. I think there are many out there that still see doctors as people with yachts, lucrative salaries, and charmed lives. They don’t see the near-80 hours weekly I spend in the hospital during certain months or the tough call schedules – or the fact that when my health is put at risk in caring for a patient, I don’t even have the right to know what diseases I have been exposed to in the process.

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