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What If.....

The Emergency Department can be a very hazardous place to work. Over the course of one year I have seen random acts of violence, and have had friends exposed to various bodily fluids. I have seen a meal tray thrown at a nurse and unruly patients take swings at ER personnel, in fact one of my fellow residents was attacked and bitten by a patient in the hallway of a San Francisco hospital. Although physical threats are a reality, a more common threat to healthcare workers are from monsters smaller than 1 micron: Tuberculosis, Hepatitis A, B, C, and HIV. The Emergency Department can indeed be a very dangerous place to work-I personally experienced this fact 2 months ago.
Mr. R, was a 35 year-old who came into the Emergency Department one evening because he was having an extremely difficult time breathing. He was diagnosed with a horrific pneumonia. He could not speak more than 3 words at a time, he was covered in sweat, and his blood pressure was very low-he really needed our help. We placed a tube into his lungs to help him breath, and I took charge of inserting a large catheter into his Jugular Vein in order to rapidly administer fluid into his blood stream. This is a procedure that most Emergency Department Residents become very comfortable with after a year of working in the ER-but as I have learned, one must NEVER let his or her guard down when performing an invasive procedure. After I had inserted the catheter into his neck, I began anchoring it to his skin so that it would stay in place. In order to do this we use what looks like a sewing needle attached to a length of suture. The room was very hectic as we worked to save our patient.
In one instant, amidst the chaos, while standing at the head of the bed, and suturing the catheter in place I looked away to grab a scalpel-the needle pierced my glove and stuck into my index finger. These procedures can be very bloody-all I remember seeing was my blood covered hand, a blood covered needle. I immediately took my glove off, and saw what I had feared: blood oozing from a small puncture wound on the side of my finger.
After stabilizing the patient, I thoroughly irrigated my wound under water for 5 minutes. My mind was racing....what if Mr. R has HIV, or Hepatitis? Why does a seemingly young healthy 35 year old have such a terrible pneumonia? Is he immunocompromised, meaning is there a disease which we do not know about, such as HIV/AIDS which is shutting down his immune system? I tried to calm myself by thinking, "There is no way he has anything...", but the “what if’s” kept creeping in. Suddenly his world, his life, collided with mine.
Mr. R passed away 2 hours later in the intensive care unit from sepsis-or an overwhelming infection causing a dramatic loss of blood pressure, and respiratory failure. Per our hospital's protocol I was evaluated in the Emergency Department in order to determine my risk of exposure to Hepatitis, or HIV, diseases commonly transmitted through blood exposure. The whole scenario evolved so quickly. We simply had no answers: what was his lifestyle, did he use IV drugs, did he have Hepatitis or HIV? We needed to talk with the family to obtain their permission to run the necessary tests.
One of our Infectious Disease specialists talked with the family, and told them of the situation-they graciously agreed to allow us to check Mr. R for Hepatitis A, B, C, HIV, and a "Viral Load" which would quantify for us how much HIV Virus was in his system if indeed he had HIV. We also checked a CD4 count which is a rough estimate as to how well Mr. R's immune system was working (CD4 counts drop in the various stages of HIV infection). We worked with the Morgue to obtain the necessary blood work. Meanwhile, a family member informed us that Mr. R was homosexual. Although he was regularly tested for HIV with consistently negative results, my odds of being exposed to HIV were now much higher.
When dealing with exposures, and particularly needle-stick exposures, there are several key factors that come into play to determine if one needs to take prophylactic medication to prevent infection: 1) What is the probability that the patient has an infectious disease: what are their risk factors for Hepatitis and HIV, for example, IV drug use, a history of multiple blood transfusions, or sexual activities, and 2) What type of needle was the worker punctured with: was it hollow or solid, was it covered with blood, did it pass through gloves first? These are all factors which are additive and determine one's risk. Reassuringly, I was using a solid needle, although it was covered with blood, it did pass through a gloved hand first- all factors which lower the rate of transmission.
Based on the risk of exposure from this patient, I elected to start anti-retroviral therapy-or therapy to kill the HIV virus if it was circulating in my blood stream. I really sympathize with anyone who needs to take this medication-for any reason. After 2 days I became nauseous, and had horrible muscle aches-I felt hungry all of the time, yet I always wanted to vomit. I tried to stick it out for the full course, or at least until we had some answers.
Fortunately Mr. R did not have Hepatitis A, B or C. Unfortunately having to acquire an HIV test after he passed was not so easy-the sample of blood we obtained was unable to be tested....we will never know if he had HIV. We did discover that he passed from a common bacteria which causes pneumonia. I took the medicine for 2 weeks, I could not do it any longer because of the side effects. I will need to be regularly tested for HIV over the next year. Although I would not wish anyone to go through this experience-it really was eye opening.
An estimated 700,000 healthcare workers receive puncture wounds from needles every year. Studies have shown that the risk of transmission of HIV after receiving a needle stick from a person known to be infected with HIV is 0.3%. Conversely, the risk of contracting Hepatitis B or C, a much more likely virus to contract in a similar scenario, is upwards of 30% (if not vaccinated-all healthcare workers are required to have an up to date Hepatitis B Vaccination). Reflecting on my experience, I learned that one must always remain incredibly vigilant while working in the Emergency Department; the risk of exposure in real. I also learned that knowing the facts about exposures helps to quiet the “what if’s” in your head: sometimes the thing we fear the most is the least likely to happen to us.
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.