Saturday, May 28, 2005

Needlestick

Alan, a.k.a. Gruntdoc, my favorite ER doc blogger, has an interesting post today regarding getting a needlestick injury. As he points out, it's an occupational hazard of being a doctor, although some specialties (emergency medicine and procedure-oriented specialties like surgery) have a much higher risk than others (psychiatry, radiation oncology, non-interventionalist radiologists, for example). I can totally sympathize with his first thoughts:
The first thought that flew into my mind: "Crap! I'm better than that." Really, I was terrifically disappointed in myself, and angry I'd made the rookie mistake of not watching the needle in my hand. I handle needles for a living, and they never get me, they get the patient, as intended. That's how it's Supposed To Be.

Indeed.

Needlesticks are almost inevitable if you're a surgeon. All you can do is to try to take every precaution and keep them to a minimum. However, sooner or later, it will happen. Gruntdoc's post took me back to the worst blood exposure incident I ever suffered, one that still haunts me to this day. Fortunately, given that it was 11 years ago and I've had multiple negative hepatitis B and HIV tests since then, I know I'm no worse for it. I was the senior resident on the trauma service, and a man had come in after a fall from a balcony of about 25-30 feet. He had multiple broken ribs, severe head trauma, and a fractured pelvis. It's unclear what he was doing there or what led to the fall, but he did reek of alcohol. In any case, we had done a diagnostic peritoneal lavage to rule out intraabdominal bleeding (these days, we would have done a quick ultrasound or even spiral CT), and we were working on him, getting ready to take him for a head CT. Over about five minutes, his blood pressure fell to zero and we were unable to get a pulse. It was clear that he was going down. It was decided by the trauma attending that we would do a bedside thoracotomy. Now, for blunt trauma (as opposed to penetrating trauma like gunshot wounds or stabbings), the success rate for bedside/ER thoracotomies is very close to zero, which is why we generally don't do them anymore for blunt trauma. When a patient with extensive blunt trauma loses his vital signs, that's usually all she wrote. It's rare to be able to bring him back, no matter what you do. In retrospect, therefore, it probably wasn't the correct thing to do, as it had such an incredibly small chance of making any difference in this man's outcome. But the attending was new and wanted to "do everything." An older, more experienced attending almost certainly would have simply coded the patient for a while and, if there were no immediate response to our interventions, called the code.

So, I got ready to do the procedure with the intern, and the intern asked if he could do the incision. Fool that I was (this was not one of our more stellar interns, to say the least) or in the heat of the moment, I said yes. And so it began.

The intern made the skin incision, and then, while I was repositioning a retractor, telling him to hold on a second to let me get better exposure, he ignored me and carried the incision deeper--right across the side of my index finger.

I was stunned. I stared at the slice in my glove, the cleanly severed latex edges flapping to reveal the cleanly severed skin beneath. Blood was pooling within the finger of the glove, darkening my finger and slowly leaking out of the gash to mingle with the patient's blood already there. After a couple of seconds, I regained my composure enough to utter a few choice profanities at the clueless intern and throwing him out of the procedure. (Crap! I'm better than that. I should have kept a better eye on the intern--especially this intern. Or I never should have let him do this in the first place!) I quickly regained my composure and continued the futile procedure. When the attending saw what happened, he gloved and gowned up to take over, allowing me to run off to wash out the incision. It was pretty deep, but fortunately, as far as I could tell, not deep enough to damage any nerves or tendons. Sensation distal to the injury was intact, and there were no deficits in my ability to move my finger that might indicate an injury to a tendon. While I was doing that, our attending finally bowed before reality and called the code.

I was royally pissed at the intern, who in his hurry hadn't listened. (Lest you think I was being unduly hard on him, the main reason this intern was not one of our more stellar interns was his recurrent and obnoxious inability or refusal to listen and follow instructions.) I was also really furious at myself, as I should have known better than to let this clown near a knife in an emergency situation. But I was scared too. Even though the odds of getting infected from a single blood exposure incident are very small, I still couldn't help but see visions of my young life being snuffed out prematurely and in a most unpleasant fashion, all because of a stupid mistake. Making the fear level higher, the patient didn't look like the most reputable character in the world, and we later found out that he had a history of polysubstance abuse. I ended up getting a shot of gamma globulin, and sweating it out. Fortunately, much to my relief, his HIV and hepatitis B tests turned out negative (and I found out that I still had a strong antibody titer for hepatitis B from my previous vaccine, anyway). Six months later, my repeat HIV test remained negative, and, in the 11 years since then, I haven't developed hepatitis (there were no tests for hepatitis C back then).

Since then, I've had a couple of more needlestick incidents, despite my best efforts. One of them happened while I was, of all things, aspirating a breast cyst in a nice little old lady. Ironically, in my opinion, the "safety" needles that are used in our hospital now are so cumbersome that I honestly believe they make it more likely I will accidentally stick myself. Ditto the "safety scalpels" (which I've dubbed "Playskool knives"), but that may be a topic for another post. Fortunately, it's been around four or five years since I last had a needlestick incident, and I hope to extend that streak to the rest of my career.

I was going to come up with a pithy ending to the description of this incident, but Gruntdoc summed it up better than what I can come up with right now:
Mortality sucks. Mortality through stupidity would be unforgivable, for me, and I resolve to not make any more stupid mistakes.
I couldn't have said it better myself. If I could, I would have.

7 example(s) of insolence returned:


At 5/28/2005 1:07 PM, Anonymous Anonymous said...

That must have been a harrowing experience. I'm glad everything worked out in the end, and I hope the experience was jarring enough to teach that intern how to listen and follow directions.

-Ali

 

At 5/28/2005 1:40 PM, Anonymous Otterdoc said...

Orac,

I can't imagine the level of additional stress that human physicians of any sort face with the risks associated with contamination from patients.

We deal with few enough zoonotic diseases as veterinarians that it isn't a constant state of worry for me. We all strive to avoid needle sticks, of course, but when it happens there's no HIV risk, for example.

I'm glad to hear that you've been free of complications from that intern's mistake.

-Otterdoc

 

At 5/28/2005 3:59 PM, Blogger Socialist Swine said...

As an ex-lab guy, I wanted to note that needlestick injuries aren't unheard of for people doing purely research as well. There've been at least one or two incidents where I'd accidently stuck myself because a rat wiggled at inopportune moment. Now in my case there was no risk because I never had to inject infectious materials but I can imagine there are at least a few people who've poked themselves with needles full of some sort of pathogen.

 

At 6/14/2005 10:18 AM, Blogger Doctor Disgruntled said...

Orac...shouldn't you be immune to Hep B as a result of being vaccinated for it? Hep C, on the other hand...(shudder).

DD

 

At 6/14/2005 8:40 PM, Blogger Orac said...

Yes, but I hadn't had a booster in a while; I was actually surprised my antibody titer was so high.

 

At 6/24/2005 12:24 PM, Anonymous Skeptyk said...

As one of those folks who had two full series of HBV vaccines and still no evidence of antibody titre, and I work in a field with lots of sharp things, blood and spit (dental assistant), I agree with you about most of the "engineered sharps" that have been designed: they are awkward, unbalanced, unreliable and seem likely to cause more injuries. Anything that adds more steps, more handling, of contaminated sharps, is going to mean more chances of sticks. Ditto the idea that cleaning up a surgical kit and processing the instruments is supposed to be done with heavy nitrile utility gloves instead of the same well-fitted gloves as used for the procedure. Double or triple gloving with something that fits is safer than fumbling in dishwasher mitts.

 

At 7/04/2005 11:12 AM, Anonymous Anonymous said...

During my transitional internship I was the class line scrounger, since I was going into anesthesia.Toward the end of the year I got a chance to put a line in a private patient for the then astronomical sum of $50. Long story short, the patient had AIDS, I stuck myself(got the line however), and worried the next few years everytime I got my annual military HIV test.

 

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