Working in the Harborview emergency room is a unique experience. Medical students have the unique opportunity to be 'doctor' for a large number of patients. Yes, we have supervision... but if a case is straight-forward, we are permitted, correction, expected to manage the patients' care from start to finish. Students also see a large number of complex cases. Typical large hospitals may see 4 or 5 traumas roll through the door in a day. Regional trauma centers like Harborview commonly receive 50 medivac, airlift or medic arrivals each day. Medical students only manage the most simple of these cases, and even then, it's under the close eye of two residents and an attending physician.
It was in one of these cases that I incurred my first dirty needle stick.
Before this time, I'd never actually stuck myself with a needle. Five hundred rodent thoracotomies and a year in medical school, and never once had I punctured my skin with a suture or injection needle. My clean streak ended in the Harborview ER.
We received a morning transfer from a hospital in Montana. The announcement had come in over intercom that an intubated young man with a gunshot wound to the face was in transit. Only the basics are conveyed in these announcements, the dispatch only relays information critical to receiving the patient and supporting him. Often, GSWs (as they are referred to on the patient board) come with no warning. Rooms are already equipped to handle victims' emergent needs. By the time that "Airlift is through the door" was announced, I was in the room ready to help with the case.
My extensive (for a medical student) experience with delicate surgeries comes in handy in the trauma bays. I am happy to suture head and hand lacerations for the busy residents, and I take pride in my skillful artistry. (Although, I am careful not to tell patients where I got all of my experience.) By some miracle, the large gage bullet missed the jugular vein and carotid artery. It had destroyed most of the right half of the jaw and torn open the neck below where the angle of the jaw had been. Without major vessel damage, it was clear that some temporary repair would be performed before the patient went to the operating room; I made sure I was in the right place to help. By the time the ear nose and throat (ENT) surgeon came down to the ER, I had washed the wound with five liters of warm sterile saline. The surgeon was a young resident. At the time, I made no notice - owing to my extra-medical education, most of the residents are younger than I am. But this guy might fly in the face of a previous argument I made in the debate over whether it's more dangerous to get sick in July than any other month.
In the hierarchy of medicine, there is one way to make suggestions to superiors that helps get around the delicacy of status. It's the "would you like me to" question. Medical students and residents should always pay attention to the friendly nurse who asks, "would you like me to send this blood for lactate and enzymes, too?" or the physician's assistant who asks "would you like me to sign an order for labetasol? I've had good success turning this into a nice approach to suggest we do something with minimal toe steppage. In this case, I asked:
- Would you like me to make a sterile field around the wound?
- What size gloves do you wear?
- What do you think about clamping this small artery? and
- Would you like me to move the sharps off your field?
At my hospital, one employee per day experiences a needle stick. It is so common among health care providers that there are highly standardized approaches to dealing with the experience. The first steps occur in the ER. Fortunately for me, I was already there and everyone I came in contact with worked in an efficient manner. Along with the compassionate first year surgery resident who later that day asked if I wanted to talk about my experience, or the attending who checked in by email several days later, the efficiency of the process counter-balance my building worry with a sense of support. None of them knew that my wife was on vacation out of the country and that I might not have anyone at home to talk about this with. They were just there.
So what is the risk of needle stick injuries in contracting blood-borne diseases? My reading suggests the average risk for HIV transmission after percutaneous exposure to infected blood is low - about 3 per 1,000 injuries. And that is with exposure to infected blood. The other killers to worry about are the hepatitis B and C injuries, and they have much greater transmission rates. Transmission in needle sticks with exposure to the hepatitis B virus is 30% and could be as high as 10% for the hepatitis C virus. Like all health care workers, I am immunized against Hep B. There are a host of other diseases transmissible by blood (see this nice Canadian site for more info), but I was most worried about Hep C and HIV. There are no cures or vaccines for these diseases, but there are decent treatments for them. In particular, immediate use of anti-retroviral drugs have good evidence of reducing transmission from needle sticks. But did I want to take them? This returns me to the specifics of my situation. Much of medicine is paying attention to the history; this case's history is obscured because the patient was intubated and communicating via hand squeezes, and that his family was still en route.
The patient was a young man from rural Montana. Epidemiologically, that cuts his risk of having HIV or Hep C. But why was he shot? The story at the time was that he was snooping around a hermit's shack at 2:00 in the morning. My hunch was that illegal behavior was involved. Fair or not, at the time, this element increased my perceived risk of his being seropositive. In my head, I quickly came to the conclusion that my chances of catching one of the big three were very small, but not non-existent. I made the quick decision to take a dose of Truvada.
Whenever there is a dirty needle stick, the potential donor's and the stuck person's blood are sent for testing. This information is used both to treat or reassure the stuck employee and to establish a record of serotype. Usually the patient who's blood contaminated the needle must give consent for the tests, but in the case of an unaccompanied unresponsive patient, this makes matters more difficult. So my blood was sent, and eventually his was. (By the way, this information is divorced from the patient's or my medical record, for both confidentiality and billing purposes.) When the rapid antibody-based HIV test returned negative, I was comforted, but not quite enough to stop taking the anti-retrovirals. Anyone who's taken or given an HIV test should know about the "window period." This is the time it takes for the immune system to seroconvert: it's the interval between infection and a measurable level of antibodies in the blood. For HIV, this is about 6 weeks, but many still use 3 months as a fallback number. The antibody test can therefore only tell you the HIV status of a person three months ago. There's another, more expensive test that measures the virus rather than the human antibody to the virus. It uses genetic amplification to look for viral genetic markers. This can both reveal virus before antibodies are formed and tell physicians how much virus is in the blood (and therefore, more about the patient's symptoms and disease progression). I decided to request this test. After all, if this young man recently took to exploring hermits' shacks, what's to say he hasn't experimented with new drugs or sexual practices?
This argument was barely enough to convince the employee health director to proceed with the genetic test on the patient's blood and required me to take two more days of the one-a-day emtricitabine/tenofovir combo drug. After several conversations opening with my telling her my mother's maiden name, I learned that my serologies and the patient's were all consistent with no infections or infectivity. By then the stress of this experience had faded into just another experience in the Harborview ER. I'll probably be stuck again, and next time, probably won't seek the viral PCR test. But will I take the anti-retroviral immediately after the exposure? You betcha! With no side effects and once a day treatment, the only reservation is cost. I don't know how much one Truvada pill costs because my hospital paid for it. By the time the next stick occurs, the state of diagnosis and prophylaxis for HIV and Hep C may have changed. Perhaps there will even be vaccines.