Hep C

[ESU_MD]

Is anyone else going into/ already in surgery afraid of getting Hep C? I mean, its one disease that will quickly end your career and shorten your life too. I think I'd rather get HIV than Hep C.

Especially early on in your career before you really learn how to handle instruments gracefully I can imagine its not that hard to get stuck with something sharp. Or even then there are always scrub techs that drop instruments or medical students who will have sharps in their hands. The surgical residents I worked with said they get stuck "all the time"

Life is full of risks and I guess its just something I have to deal with, but I was wondering if any if my colleagues are also worried about this and their thoughts.
Or am i just a scaredy cat?

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[womansurg]

Originally posted by ESU_MD
I think I'd rather get HIV than Hep C.

Noooooooo... The majority of hep C infections are silent. Only a small number go on to cause cirrhosis and hepatic failure.

Most of the surgeons I work with (myself included) have become pretty nonchalant about body fluid exposures. I'd say I get an exposure about once overy six months to a year - needle stick, blood spray in trauma bay, hole in your glove at the end of a case when you have some abrasion on your skin....

When I've been exposed, I send the patient's blood off for testing. They hospital likes to draw your blood as well and send it for baseline testing, since they'd like to prove your infection preceded that exposure - that way they might save on disability/workman's compensation. It's very emotionally stressful to undergo HIV/hep C testing, so I have skipped this part a couple of times. If the patient comes back negative on rapid screen (which they always have) then you're done. If they are positive for HIV then you start prophylactic antiviral meds - or you can elect to take the antivirals pending more definitive testing, but the meds make you pretty sick. I'm not sure how it's handled if they came back hep C positive - not sure if a prophylaxis exists.

Although I'm sure it's been recorded, I've never heard of or known a surgeon (in the current environment of universal precautions) who contracted a blood borne disease from a patient, despite the fact that we are repetitively exposed in the course of our work. Even if a patient tests positive, the chances that a needle stick will cause you to seroconvert is very small - and most patients aren't infected to begin with.

Universal precautions for all appropriate situations - that is what dramatically reduces your risks.

 

[surg]

You should be concerned. Recently the bulletin of the American College of Surgeons detailed the story of one surgeon who did contract Hepatitis. Don't have the cite on me, but it was in the last year. I'm sure it is easily found.

What can you do?
1) Universal precautions. Put on gloves to handle patients if there is any chance of exposure. Wear glasses with side shields or masks with face shields in the OR and in the trauma bay. Cover up exposed cuts (tegraderm is a wonder for this). Double glove.

2) Watch your sharps. Insist on careful handling of sharps around you. Don't recap needles or scalpels (stabbed myself once doing a PEG tube this way because I was stupid)

3) Remember that it is your health. Don't let others convince you that you are being dumb for ignoring either #1 or #2. The chances are small, but NOT zero.

 

[neutropeniaboy]

Originally posted by womansurg

When I've been exposed, I send the patient's blood off for testing.

I'm assume you consent that patient for HIV testing...

Other than that, can't say I agree with your cavalier attitude, however. I'd like to say my career ended from contractures secondary to Gameboy, not Hep C/HIV.

 

[womansurg]

Originally posted by neutropeniaboy
I'm assume you consent that patient for HIV testing...

Other than that, can't say I agree with your cavalier attitude, however.

Actually you don't have to have the patient's consent anymore. To be more precise, they are not able to refuse to provide blood for testing in situations of health care worker exposure; their consent for medical treatment involves consent for testing if indicated. At least that's the way this hospital system handles it.

I'm not sure what my you mean by 'cavalier attitude'. Just stating the facts about the types, frequency, and the manner of handling of exposures in my five years as a surgeon. You watch 'Trauma - life in the ER' and half of the surgeons are in the OR without eyewear - something I would never, ever do. I double glove on every case, which many surgeons still don't, despite strong evidence that it cuts the risk of viral transmission from a needle stick many times over. I use universal precautions for all patient contact.

I have to say that I am as careful as anyone I have ever worked with and more careful than many, but exposures happen in this discipline. The reality is that patient to physician transmission is EXCEEDINGLY low. Being fearful and paranoid is not the same as being careful.

 

[surg]

WS- just a point of information, the need for consent varies from state to state and also varies based on the nature of the visit and the consent statement used for the encounter. For instance at my medical school the rules were, you may test them without further consent if they are an inpatient or being admitted, but otherwise you had to get specific consent. Also the HIV test had to be followed up with a specific separate consent with counseling as to the impact of the test.

I agree with you that exposures are inevitable in surgery. I've had my fair share, and I consider myself quite careful. The risk is extremely low as you said, and although intellectually I know that, it still upsets me a little every time it happens (at least until the test results on the patient comes back! So far so good!)

 

[neutropeniaboy]

Originally posted by womansurg
Actually you don't have to have the patient's consent anymore. To be more precise, they are not able to refuse to provide blood for testing in situations of health care worker exposure; their consent for medical treatment involves consent for testing if indicated. At least that's the way this hospital system handles it.

Well, I don't know where you work, but where I train, not consenting a patient for HIV testing or even CD4 interrogation is a violation of patient privacy and prosecutable.

I'm not sure what my you mean by 'cavalier attitude'.

Just commenting on your "nonchalant" attitude. I repeat myself: can't say I agree.

 

[womansurg]

Originally posted by neutropeniaboy
Just commenting on your "nonchalant" attitude. I repeat myself: can't say I agree.

Aahhh...semantics. Perception vs. reality .

So the fact remains that I am exquisitely careful in my prevention of exposures. When one inevitably occurs (yes, exposures are inevitable in surgery...you're fooling yourself to think otherwise) I, like my colleagues, am nonchalant in coping with it (nonchalant -"giving the appearance of unconcern.." Websters dictionary). This apparently is bothersome to you. I presume you would feel more comfortable if I instead gave the appearance of becoming anxious and frightened?

Now this would stand in counterdistinction to having a cavalier - your word - approach to the prevention of exposures (cavalier - "disdainful, haughty"), which could arueably result in a higher incidence of exposures. Such is not the case. O, but why bother with reality when finger pointing is so much more fun?

I can never assure a prospective surgery candidate that s/he will not be exposed. I can, however, reasonably discuss the frequency, handling and actual risks of exposures when they occur, as well as measures to lower risks.

The reality is that I worry more about ending up in the Trauma bay from my drive into work every morning than I do about becoming HIV or hepC positive from a patient exposure - that would be based on data supporting the liklihood of either of those two occurring. That doesn't mean I get a tremor in my voice when I talk about driving. Instead I snap on my seatbelt, and I put on my eyewear, and I double glove, and I handle sharps responsibly - and I go about my day. Sorry my lack of palpable fear bothers you.

 

[womansurg]

Originally posted by neutropeniaboy
Well, I don't know where you work, but where I train, not consenting a patient for HIV testing or even CD4 interrogation is a violation of patient privacy and prosecutable.

I guess I'd be talking to the hospital administration about that, or even my state legislature.

So, the pregnant RN who gets sprayed with arterial blood in the trauma bay from a sucking chest wound in an IV drug abuser has no recourse when the patient refuses to undergo testing? She would be forced to undergo emperic antiviral therapy, I presume. That would be inadequate protection of the rights of health care workers, in my opinion.

 

[jason952]

At my institution, the rules are like what womansurg said, blood is drawn without consent, which is the way things should be. At the VA system, Blood can be drawn without consent also for hep testing, but AIDS may or may not require consent, I've heard both ways, but I think I would draw that lab myself or find some reason for a draw. In this case, CYA is literal.

I really feel bad for the other employees at the hospital (janitor esp.) who may get injuries from randomly misplaced sharps and have no idea whether or not they were even used on high risk pt's. That would suck,

Jason

 

[Airborne]

Interesting thread, and directly relevant to all fields of medicine - surgical or otherwise.

If one looks at the actual probability of seroconversion, they are approximately 30% for HBC, 3% for HCV and 0.3% for HIV (The rule of three's for those of you studying for Step I). As my PhD was in hepatology, I'll use HCV as an example.

Approximately 1-2% of Americans have HCV, and if one assumes a 3% chance of seroconversion, this approximates a 0.045 percent (or 1 in about 2200) chance of seroconversion for HCV for each needle stick. Is this career ending? I wouldn't know. But I can say that even IF you did seroconvert, the disease is FAR less malignant as we are led to believe. Indeed, there is a current believe that only if you have additional risk factors (ie alcohol) you'll progress to cirrhosis - Indeed, about 1/3 of chronic HCV carriers NEVER develop fibrosis.

In anycase, I am a firm believer in getting insurance for such career ending events - After all, your career is invested in your ability to operate and the X amount of $$$ for the insurance is a mere formality (and a small fraction of your annual income).

But of course, these are my opinions.

Airborne

 

[womansurg]

Originally posted by Airborne
But of course, these are my opinions.

As well as some good data. Thanks Airborne.

 

[neutropeniaboy]

Originally posted by jason952
At my institution, the rules are like what womansurg said, blood is drawn without consent, which is the way things should be. At the VA system, Blood can be drawn without consent also for hep testing, but AIDS may or may not require consent, I've heard both ways, but I think I would draw that lab myself or find some reason for a draw. In this case, CYA is literal.

Hmm. I don't know where anyone said blood drawing requires consent. Technically, any unwanted touching of a patient is a prosecutable offense, as it's considered assault. Blood drawing is one of those acts that follows under implied consent; however, any patient has the right to refuse blood drawing of any nature, even if it is for a CBC.

Like I said, any effort used to ascertain whether the patient has HIV, be it HIV load, CD4 count, or whatever, requires active consent. In fact, the lab at my hospital won't even process such requests unless there is patient consent documented.

 

[neutropeniaboy]

Originally posted by womansurg
I guess I'd be talking to the hospital administration about that, or even my state legislature.

So, the pregnant RN who gets sprayed with arterial blood in the trauma bay from a sucking chest wound in an IV drug abuser has no recourse when the patient refuses to undergo testing? She would be forced to undergo emperic antiviral therapy, I presume. That would be inadequate protection of the rights of health care workers, in my opinion.

Why don't you throw in the fact that she's on immunosuppression for her kidney transplant as well? Maybe that'd make it a little more dramatic.

 

[womansurg]

Yes, it is pretty inconceivable that pregnant workers would get body fluid exposures. I guess I can come up with only two cases in my own personal experiences. How silly of me to use them as examples of real life situations...

 

[Skylizard]

Originally posted by neutropeniaboy
Blood drawing is one of those acts that follows under implied consent;....any patient has the right to refuse blood drawing of any nature, even if it is for a CBC.
Like I said, any effort used to ascertain whether the patient has HIV, be it HIV load, CD4 count, or whatever, requires active consent.

Well, I will simply reply by saying it IS state and institutional dependent. My institution processes all HIV, HBV, HCV testing without consent if the order states it is for healthcare worker exposure. I have been in three hospitals in three different states and the policy has been the same. The concept of requiring consent from a patient in order to ensure a healthcare workers safety just doesn't fly in the three states I have worked in and obviously not in Iowa per what I am reading.

I will say that when we draw an exposure blood panel we are not allowed to tell the patient the result until they consent to being informed.

later

 

[neutropeniaboy]

Originally posted by Skylizard

I will say that when we draw an exposure blood panel we are not allowed to tell the patient the result until they consent to being informed.

later

Well, I have to say that that proviso is just gay. The crux of the ethical dilemma is preserving privacy, not sheltering the individual from knowing what (apparently now) everyone else knows.

Nonsensical.

 

[Skylizard]

Originally posted by neutropeniaboy
Well, I have to say that that proviso is just gay. The crux of the ethical dilemma is preserving privacy, not sheltering the individual from knowing what (apparently now) everyone else knows. Nonsensical.

First, based on guidelines and restrictions, NOT everyone should know. Drawing the lab does not make it public info.
Second, it may be nonsensical, but I do not make the rules.