October 13, 2011

getting stuck

today I was first assist on a below-the-knee amputation on an older man with diabetes.  It's a pretty brutal operation - as in, they actually use an actual bone saw, a very large knife and it's less possible than I thought it would be to precisely cut off the muscle in someone's leg.
But somehow I do have the stomach for surgery -  so even though at moments it seemed like a halloween trick gone awry,  I was able to focus on how fascinating it was to identify and technically interesting it was to  isolate the three major neurovascular bundles in the leg (sort of like tubes containing nerves and the blood vessels that supply them).

the attending sutured the muscle/fascia layer because that is the critical layer for holding the operation together
but then he let me suture half of the skin line.
I've just started feeling more confident in my suturing and yesterday I got to suture a lot, 
so I was feeling almost confident

until I stuck my own finger with the needle.

this is not an uncommon thing in medicine
in fact, the first thing that happened was that the scrub tech, the circulating nurse, and my attending all empathized with me and told me how many times they had been stuck

then they told me to take off my gloves and gown and go wash my hand with bleach
I was escorted from the OR to another building in the hospital to start the "needle stick protocol".
this consisted of me walking into the employee health center and being immediately ushered into a small room (they were expecting me because the OR had already called them), filling out a report about what happened, hearing what would happen from there on out:

1. The patient would be told that one of the health care workers in his surgery had been exposed to his blood, would he consent to be tested for HIV, HepC, and HepB please?  (he said yes) Would he please fill out a survey outlining his risk factors? (his wife did, he was still waking up from anesthesia)
2. I would fill out these incident reports.  One would be filed with employee health and one I would take to my supervisor.  Because I'm a med student and don't have a medical health record number, I would also have to create one of those.
3. I would have to have five tubes of blood drawn from the lab downstairs, now.
4. the nurse on call tonight would call me back with the results of the patient's STAT HIV test.
5. they would call me tomorrow with the results of his other tests and by Monday with the results of my tests
6. if I had any questions, I could call them.  If the tests were negative there was nothing else to do. If they were positive - well, there are more tests.
So I did.

I am really really lucky.
Less than two hours later, they called me with his previous lab results (all negative), and his risk factors ( blood transfusions in the hospital only - very unlikely to contain HepC or HIV), and later this afternoon called me with the results of his STAT HIV test - negative.
The nurse on the phone told me that I could breathe a big sigh of relief -
but that she'd still call me with all the rest of the test results.

Talking on the phone with the manfriend, he sounded almost more worried than I was, realizing for the first time that if we are both going to be doctors we are going to be at greater risk of contracting some pretty serious diseases.  And maybe more importantly, how will we organize our careers around this - will we try not treat people with more easily contractable incurable illnesses like HIV/AIDS? (hopefully we will treat them just the same as anyone else)  Will we wear more layers of gloves?  Will we be better about getting vaccines?  Get serum tests for transmissible diseases every year?  Or maybe just try hard not to think about it too much and carry on with what we've decided are our respective callings?

This article caught my eye because it explains some of the very scary things that can happen to med students, and yet is still very inspiring.  I'm reading Abraham Verghese's In My Own Country right now, which is about his own experience treating the first patients with HIV and it's making me think a lot about the balance between protecting yourself and providing good medical care.

"But we also agreed that what made the difference in life was not how well you succeeded;  it was how well you failed, how many times you picked yourself up
and put yourself back in the fray."
- Dr. Dietrich 
who contracted HepC from a needle stick as a third year medical student, 
see the article above


  1. Do patients have to disclose if they are HIV positive pre surgery?

  2. Great question! As far as I've seen, we do not routinely test patients for HIV before surgery. Typically, the laboratory tests most patients get before surgery are mostly to see if they have an infection (white blood cells), if they have anemia (red blood cells), if they have coagulation problems (tests called a PT/INR and a PTT), and what their blood type is (in case they need blood).

    Surgery is supposed to be done in a protected environment and a lot of effort and research goes into how to make this happen - everyone is gowned & gloved and the operating area is very clearly defined to try to provide barriers so that the patient doesn't get any diseases from the people working in the OR and vice versa. But as you can see in this blogpost, sometimes the barriers are broken.