HIV + Surgeon

[malick1]

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Interesting read , what are your toughs ?

Dr. Kelly paced nervously outside her colleague’s door. All during surgery, her mind had been traveling back to the employee health clinic she had visited earlier in the week. Three months prior, she had suffered a needlestick injury while operating on a young boy who was receiving a liver transplant. At first she shrugged it off. She knew the boy was HIV-positive, but she didn’t think seroconversion could happen to her. Occupational health gave her post-exposure prophylaxis, and she thought she would be ok. She felt as if the walls were closing in when she was informed that she had in fact become HIV-positive.

LEARNING OBJECTIVEUnderstand the ethical analysis applied in determining what information surgery patients should have about their surgeons’ experience and health.
Dr. Kelly knocked on Dr. Chin’s door. She and Dr. Chin had pushed each other through med school and surgery residency, and were now faculty at an academic medical center—Dr. Kelly in pediatric transplant surgery. She trusted Dr. Chin and respected her medical opinion. Dr. Kelly entered and, after exchanging the requisite pleasantries and hospital gossip, she dove straight in.

“Do you remember that needlestick injury I had a few months ago? Well I got my HIV test results back, and I’m positive.”

“What are you going to do now?” Dr. Chin asked crisply, bedside manner not her strong suit.

“Well, I have the name of one of the ID docs here who specializes in HIV. I need to set up an appointment. I guess I will start on antiretrovirals depending on my CD4 counts.”

“No I mean about your career; you won’t be able to operate anymore. Have you told the chief yet? Maybe you could be switched to full-time research faculty.”

Continue reading http://virtualmentor.ama-assn.org/2009/12/ccas1-0912.html

 

[Pacna]

Should a patient with HIV not be allowed to have surgery, even though the risk is low that they'll infect healthcare workers?

 

[malick1]

Should a patient with HIV not be allowed to have surgery, even though the risk is low that they'll infect healthcare workers?

Good answering a question with a question, which I have to Ask did you read the Article ? you want to check the commentary ! This is an important conversation! no right or wrong answers ( except for sarcastic questions 🙂 )

 

[deleted480308]

Handle sharp objects inside my abdominal cavity when stabbing yourself is how you got HIV? Nope...go do a psych/rad/pathology residency

 

[freemontie]

Should a patient with HIV not be allowed to have surgery, even though the risk is low that they'll infect healthcare workers?

One is a child who will die if they can't (pediatric transplant) the other is an adult who will have to do another job if they can't. Not really the same.

I still vote yes, though.

 

[Gurby]

Handle sharp objects inside my abdominal cavity when stabbing yourself is how you got HIV? Nope...go do a psych/rad/pathology residency

Appears to be extremely common among surgical residents (and I assume therefore also practicing surgeons), unfortunately:

By their final year of training, 99% of residents had had a needlestick injury; for 53%, the injury had involved a high-risk patient

http://www.nejm.org/doi/full/10.1056/NEJMoa070378

 

[PreMed015]

What are your opinions on the use of Truvada PrEP in the healthcare field? I take it for my sexual health, but I always jokingly tell my friends that it would be useful once I become a doctor. Recent studies have shown it to be close to 100% effective if one dose is taken within ~24 hours prior to exposure.

The alternative, PEP, is only about 75% effective if taken within 72 hours post-infection, everyday, for 28 days.

...I don't know, I like the odds of PrEP a lot more. I know there would be a major issue with medication adherence among physicians, though.

 

[malick1]

What are your opinions on the use of Truvada PrEP in the healthcare field? I take it for my sexual health, but I always jokingly tell my friends that it would be useful once I become a doctor. Recent studies have shown it to be close to 100% effective if one dose is taken within ~24 hours prior to exposure.

The alternative, PEP, is only about 75% effective if taken within 72 hours post-infection, everyday, for 28 days.

...I don't know, I like the odds of PrEP a lot more. I know there would be a major issue with medication adherence among physicians, though.

PreP with Truvada have side effects that are not ideal for someone who is at minimal risk of infection, and is not a feasible solution for healthcare workers and close to 100% is not 100% even for those who have a prophylactic prescription are urge to use condoms and other safe sex mechanism. This because you could be infected with a strain that has already develop resistance to the drug combination in truvada. that being said there is a new study with a different drug that if successful it will be a better option!

 

[deleted407021]

Appears to be extremely common among surgical residents (and I assume therefore also practicing surgeons), unfortunately:



http://www.nejm.org/doi/full/10.1056/NEJMoa070378

😱

I would be going to work in plate armor.

 

[Mad Jack]

😱

I would be going to work in plate armor.

Get ready to throw it on, cause pretty much no inpatient specialty is safe outside of maybe psych.

 

[mehc012]

This one hurt.

...what is that?

Also, to the Q at hand: absolutely.

 

[Dr Van Helsing]

Appears to be extremely common among surgical residents (and I assume therefore also practicing surgeons), unfortunately:



http://www.nejm.org/doi/full/10.1056/NEJMoa070378

Terrifying

 

[Dr Van Helsing]

I got poked when my attending was impatient at the end of the case and he let go of the hook as soon as he got it out of the skin without detaching it at the other end, so it snapped back from the elasticity...and right into my finger. It was kind of like getting stabbed with a fishhook.

Did you have a "pregnancy scare" moment when you were stuck the first time?

Did your attending apologize?

Great visual..

 

[Dr Van Helsing]

The first time was during med school, so that one was pretty terrifying. It was also the high risk one of course. Pretty harrowing couple of days while it was all getting sorted out.

The two since then have just been minor nuisances that didn't really worry me. Although I remember the exact circumstances of all three, so I suppose that says something.

The lonestar one was on like the lowest risk patient I could imagine (although I know there is no such thing as a no-risk patient). That one I was honestly just pissed because it really did hurt like a mother*****. The attending apologized yes, and felt really bad. It was just one of those things that happens.

Wow. Just wow.
Well good thing you're OK..

 

[bioman1275]

Good answering a question with a question, which I have to Ask did you read the Article ? you want to check the commentary ! This is an important conversation! no right or wrong answers ( except for sarcastic questions 🙂 )

Ethically, the HIV +worker should not be allowed to operate. That person is putting her patent at un needed risk (aside from surgical risks). IF the patient was informed then proceed with caution, if not the patient should be informed and given the option to choose as it is adding unneeded long term risk factors.

 

[Holmwood]

Would this discussion also apply to sleep deprived surgeons and epileptic surgeons? : /

 

[Winged Scapula]

It's a Lonestar self-retaining retractor. You put the ring around the wound and attach the little hooks (which are on an elastic string) to the skin edges:

.

Why didn't you include a picture of what the lone star is commonly used for? LOL

 

[MrChance2]

I've never seriously thought about this issue but Dr. Chin is pretty tactless for dumping the quitting surgery thing on her immediately after learning she has HIV and confiding in him.

 

[ridethecliche]

I'm guessing it's used for buttholes?

 

[ridethecliche]

I mean. They could have called it the lone chocolate starfish.

 

[malick1]

Would this discussion also apply to sleep deprived surgeons and epileptic surgeons? : /

No , Sleep deprivation while it can affect the situation it is arbitrary since it can mean different levels of function for different people, Epilepsy should a whole new thread of its own, as it is a completely no- contagious pathology, and it might or might not posses the same risk based on treatment options !

 

[NotAProgDirector]

No , Sleep deprivation while it can affect the situation it is arbitrary since it can mean different levels of function for different people, Epilepsy should a whole new thread of its own, as it is a completely no- contagious pathology, and it might or might not posses the same risk based on treatment options !

Sleep Deprivation and Epilepsy are just as "arbitrary" as being HIV positive. If a patient is HIV positive, on treatment, and has an undetectable viral load, the risk of patient infection is likely zero even with an exposure. On the other hand, if your surgeon has been up for 24 hours, I expect the risk is much more than zero. Even with epilepsy, the risk of another seizure is real even with treatment.

There have been very few cases of healthcare worker -> patient transmission of HIV, summarized here: http://www.aidsmap.com/Four-cases-of-transmission/page/1324553/ Note that in most of these cases, the healthcare worker wasn't aware they were HIV positive, and most seem to have had severe, uncontrolled disease.

The honest truth is that HCV+ healthcare workers are likely a much bigger risk. HIV just has more stigma associated with it.

From a practical standpoint, the problem is what to do when an HIV positive surgeon whose viral load is undetectable has a needlestick during an operation. The likelihood of transmission is vanishingly low. But does the surgeon need to disclose to the patient, and should the patient get tested?

 

[mehc012]

Sleep Deprivation and Epilepsy are just as "arbitrary" as being HIV positive. If a patient is HIV positive, on treatment, and has an undetectable viral load, the risk of patient infection is likely zero even with an exposure. On the other hand, if your surgeon has been up for 24 hours, I expect the risk is much more than zero. Even with epilepsy, the risk of another seizure is real even with treatment.

There have been very few cases of healthcare worker -> patient transmission of HIV, summarized here: http://www.aidsmap.com/Four-cases-of-transmission/page/1324553/ Note that in most of these cases, the healthcare worker wasn't aware they were HIV positive, and most seem to have had severe, uncontrolled disease.

The honest truth is that HCV+ healthcare workers are likely a much bigger risk. HIV just has more stigma associated with it.

From a practical standpoint, the problem is what to do when an HIV positive surgeon whose viral load is undetectable has a needlestick during an operation. The likelihood of transmission is vanishingly low. But does the surgeon need to disclose to the patient, and should the patient get tested?

👍
I would hope that in any exposure situation, the same standards are applied. I feel that the same protocol for patient->provider exposures should be implemented for provider->patient exposures...aka risks explained, prophylaxis offered, blood tests, compulsory blood testing performed on the source for situations meeting certain criteria (though if recent tests/vaccination records exist, some screens may not be required), results discussed with further risk analysis, followup tests, etc.

Both from an ethical and a practical, evidence-based standpoint, it seems obvious that HIV or even hepC status alone should not dictate whether you can continue with your chosen career. If anything down this line of reasoning were to be pursued, it seems that viral load should be considered.