Resident and Student Voice
My Needlestick
- RONA SCHWARTZ, M.D., Second-Year Family Practice Resident
- Georgetown University/Providence Hospital Family Practice Residency
- Washington, D.C.
It was the end of a long day.
I was an acting intern in my fourth year of medical school at a community hospital. I was post-call, and it was late in the afternoon. On rounds that morning we'd discussed the work-up for fever of unknown origin in Mr. J, a patient with end-stage acquired immunodeficiency syndrome (AIDS). The attending physician suggested that we obtain fungal blood cultures, so I made a mental note to draw them myself before leaving for the day.
As a medical student, I only followed a handful of patients. This gave me time to get to know Mr. J, a young bespectacled man with a short, thin frame. I learned that he had tried to turn his life around. He had quit abusing drugs and alcohol and was committed to trying yet another complicated drug regimen.
I entered Mr. J's room with the culture bottles, syringes and needles. I was tired and needed a shower. I was thinking about going home, not about drawing blood. Using sterile technique, I obtained blood from his antecubital veins without difficulty. I only needed to transfer the blood from the syringe into the wide-topped culture bottle. In transferring the blood, my hand slipped. I felt something sharp at the base of my finger. A rush of fear moved through my body. I saw a hole in my glove but no blood. I quickly finished filling the bottle and disposed of the needle as thoughts flooded my head. I left the room and headed straight for the sink at the nurses' station.
I pulled off my glove. Blood! I was bleeding! I had stuck myself! I washed and scrubbed the site and squeezed on my hand until tiny droplets of blood dripped from my finger. My thoughts were racing. Was the virus in my blood? The fear was overwhelming. I couldn't believe this! What if I had injected myself with AIDS? I was dizzy and my skin felt warm. It was as if I could feel the blood circulating in my veins. What had I done? It was a pretty large needle attached to a syringe filled with the blood of a man dying of AIDS.
Dying. . . . This man was sick. His last CD4 count was less than 10. Keep scrubbing. What should I do? I held back tears. I looked at my hand and saw a small mark the size of a pinpoint where the needle had pierced. I wasn't bleeding anymore, but I kept squeezing my hand. Although my head was spinning, fear kept me from passing out. Keep scrubbing.
Who do I tell?
What was I thinking? Why did my hand slip? Why did I stay to draw his blood? Be calm. Keep scrubbing. I did not want to tell the nurses or the senior resident because I was too embarrassed. I imagined the look and reaction that I would get if I told someone. I could feel my eyes fill with tears. Be calm. I stopped scrubbing. Again I looked at the spot on my hand. How deep had it gone? I knew other people who had needlesticks but not from a patient with AIDS! Keep scrubbing. Be calm. Hold back the tears.
I then went to the office of a faculty member I felt close with and began sobbing. These tears gave me no relief. This was only the start of many more tears to come. My attitude toward Mr. J changed, and I had trouble seeing him for the rest of the month on rounds. I was angry at him for getting AIDS and being in the hospital. It was easier to blame him than to blame myself.
This happened in the fall of 1996, just a few months after the Centers for Disease Control and Prevention (CDC) came out with an update on recommendations (shown in the accompanying figure) for chemoprophylaxis after occupational exposure to human immunodeficiency virus (HIV). At that time, the average risk of HIV infection from any percutaneous exposure to HIV-infected blood was three in 1,000. The report indicated that the risk was higher if the exposure involved any of the following situations: (1) a deep injury to the health care worker (which I think I had), (2) the needle had visible blood (it must have in my case), (3) it was a device that had previously been in the source's vein or artery or (4) the source patient died of AIDS within 60 days (I was too scared to ever find out).
Management of Health Care Workers Exposed to HIV STEP 3: Determine the PEP recommendation EC
HIV SC
PEP recommendations
1 1 PEP may not be warranted. Exposure type does not pose a known risk for HIV transmission. Whether the risk for drug toxicity outweighs the benefit of PEP should be decided by the exposed health care worker and treating clinician. 1 2 Consider basic regimen.†† Exposure type poses a negligible risk for HIV transmission. A high HIV titer in the source may justify consideration of PEP. Whether the risk for drug toxicity outweighs the benefit of PEP should be decided by the exposed health care worker and treating clinician. 2 1 Recommend basic regimen. Most HIV exposures are in this category; no increased risk for HIV transmission has been observed but use of PEP is appropriate. 2 2 Recommend expanded regimen.‡‡ Exposure type represents an increased risk of HIV transmission. 3 1 or 2 Recommend expanded regimen. Exposure type represents an increased risk of HIV transmission. Unknown If the source or, in the case of an unknown source, the setting where the exposure occurred suggests a possible risk for HIV exposure and the EC is 2 or 3, consider PEP basic regimen.
*--Semen or vaginal secretions; cerebrospinal, synovial, pleural, peritoneal, pericardial or amniotic fluid; or tissue.
†--Exposures to other potentially infectious material must be evaluated on a case-by-case basis. In general, these body substances are considered a low risk for transmission in health care settings. Any unprotected contact to concentrated HIV in a research laboratory or production facility is considered an occupational exposure that requires clinical evaluation to determine the need for PEP.
‡--Skin integrity is considered compromised if there is evidence of chapped skin, dermatitis, abrasion or open wound.
§--Contact with intact skin is not normally considered a risk for HIV transmission. However, if the exposure was to blood, and the circumstance suggests a higher volume exposure (e.g., an extensive area of skin was exposed or there was prolonged contact with blood), the risk for HIV transmission should be considered.
||--The combination of these severity factors (e.g., large-bore hollow needle and deep puncture) contributes to an elevated risk for transmission if the source person is HIV positive.
¶--A source is considered negative for HIV infection if there is laboratory documentation of a negative HIV antibody, HIV PCR or HIV p24 antigen test result from a specimen collected at or near the time of exposure and there is no clinical evidence of recent retroviral-like illness.
#--A source is considered infected with HIV (HIV positive) if there has been a positive laboratory result for HIV antibody, HIV PCR or HIV p24 antigen or physician-diagnosed AIDS.
**--Examples are used as surrogates to estimate the HIV titer in an exposure source for purposes of considering PEP regimens and do not reflect all clinical situations that may be observed. Although a high HIV titer (HIV SC 2) in an exposure source has been associated with an increased risk for transmission, the possibility of transmission from a source with a low HIV titer also must be considered.
††--The basic regimen is four weeks of zidovudine, 600 mg per day in two or three divided doses, and lamivudine, 150 mg twice daily.
‡‡--The expanded regimen is the basic regimen plus either indinavir, 800 mg every eight hours, or nelfinavir, 750 mg three times a day.
Reprinted from Public health service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep 1998:47(RR-7):1-33.
FIGURE 1. Determining the need for HIV postexposure prophylaxis after an occupational exposure. This algorithm is intended to guide initial decisions about postexposure prophylaxis and should be used in conjunction with other guidance provided in the published report on the management of health care workers exposed to HIV. (AIDS=acquired immunodeficiency syndrome; EC=exposure code; HIV=human immunodeficiency virus; HIV SC=HIV status code; PCR=polymerase chain reaction; PEP=postexposure prophylaxis.) That night, I had my blood drawn and received my first doses of triple therapy. By the next morning, I was plugged into my medical school's postexposure plan, and my husband and I met with the school's health care provider. My needlestick would be registered anonymously within the school.
"We see other students that this happens to," the school's nurse practitioner said, "You're not alone." I did feel alone, however, and I worried about how my marriage would be affected.
I reviewed the literature and read about the side effects of my medications. I convinced myself that if I took the pills I would not get HIV. I was afraid and did not want to tell anyone. I bought pill boxes small enough to fit in my white coat pockets so no one would know. I took the pills for four weeks, exactly as prescribed.
Then, I waited.
Even though it's been over two years, I want to keep getting my blood tested just to hear the word "negative." I feel like a survivor of something terrible, something I wish I could forget. I am angry at myself for feeling embarrassed about what happened, and I am more careful now. More importantly, I am more compassionate with those for whom fear is a reality.
This quarterly department features essays written by medical students and family practice residents. Contributing editors are Sumi Makkar, M.D., a family practice resident at the Georgetown University/Providence Hospital Family Practice Residency Program; David Hutcheson-Tipton, M.D., resident representative to the Family Practice Editorial Board; and Terrence J. Joyce, student representative to the editorial board. Submit essays for publication in AFP to Resident and Student Voice, American Family Physician, Family Med/212 Kober Cogan, Georgetown University Medical Center, 3800 Reservoir Rd., N.W., Washington, D.C. 20007.
Copyright © 1999 by the American Academy of Family Physicians.
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