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Why did this have to happen?!? ARGHHGHG

Discussion in 'Clinical Rotations' started by ocean11, Apr 27, 2007.

  1. ocean11

    ocean11 Senior Member
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    Man I feel like such an idiot! worse... I made the mistake of sticking myself with a needle today. We were doing a central line on an 80 y/o guy with end stage renal disease and CHF as well as DM etc etc... and I accidently stuck myself when tying up/suturing the line to secure it in place. At least the needle wasn't a hollow bore... but still, that was so unnecessary.

    Anyhow, make a long story short, I went to employee health, they did a rapid HIV test on this guy, came out negative. Now they are doing the more confirmatory HIV/Hep C/Hep B tests on him and I got my blood drawn to, to get my 'baseline'

    F*&^ don't let this happen to you!

    be warned!!

    Ocean11
     
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  3. w a n g

    w a n g blarg
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    ouch. hope everything is okay. how did the superiors react? concern? no reprimanding i hope
     
  4. SLUser11

    SLUser11 CRS
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    Supposedly central lines are the number one situation in which accidental needle sticks occur in residents. I read that in a med journal a long time ago, but I'll post a source if I can find it. Of course, for nurses/phlebotomists/whatever, there are more frequent offenders than the keith needle.

    The main reasons people stick themselves with the keith needle is that they don't know how much force it will take to go through the skin (and provide counter-traction with their fingers), or they forget to reverse the needle when going through the ring on the catheter.

    Of course, accidents just happen, and I'm not assuming you did the procedure incorrectly. I just thought that it was an interesting stat....

    FYI if you're going into a procedural specialty, be prepared to stick yourself from time to time and feel like a [email protected] about it. It happens.
     
  5. Tired

    Tired Fading away
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    I don't understand why they have that damn thing in there anyway. Put a goddamn suture needle and driver in the there. Why is that so hard?
     
  6. ocean11

    ocean11 Senior Member
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    I totally agree with you, the funny thing is I actually asked for a driver and suture needle and the resident laughed at me and was like 'use this' you don't need one!!! guess what?!?!? I stuck myself!!!!!

    For the other poster, my resident left while I was suturing up and when it happened I was in a state of shock for like 5 minutes... although ofcourse I finished the job. After 10 minutes I called my senior resident and told her to order the HIV/Hep c panel... she also told me to go to the ER --> which sent me to employee health (which are great at my hospital and orgonized all my tests and the patient's tests + did the rapid HIV on him).

    I stupidly, was actually considering, to not report the stick, for fear of reprimand or a bad evaluation, but figured my health is more important. I'm lucky that my senior resident is so cool and so are the two interns. Although the one who was with me and left, was a little offended that I didn't tell him about the stick right away (he found out later on in the day from the senior resident). Anyhow, I reported the stick because I didn't want to take a risk with my health, ie: if he was HIV+ I would be taking the prophylaxis.... and am glad that at least next week I'll know the score, bad or good news.... I'm going to either avoid doing central lines LOL or improving my technique!!
     
  7. SLUser11

    SLUser11 CRS
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    While I know nothing of the dynamics of your surgical team, it sounds like you had poor supervision, and this needle stick is partially the fault of your supervising resident.

    You asked for a needle driver and curved needle, thus acknowledging you've never used the straight needle before (and likely never sewn in a central line before), and then the resident told you to use the keith, and didn't show you how to use it safely and correctly, and then left the room. There's a lot more to central lines then cannulating the vein, and he should have supervised you start to finish.

    Thats 1. dangerous for you, and 2. dangerous for the patient. What if you tagged the catheter with the needle?

    Anyway, I couldn't find the old article I was looking for, although in the process I found several editorials in anesthesia journals calling for the abandonment of the keith needle altogether....
     
  8. Bertelman

    Bertelman Maverick!
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    This being hindsight, I believe your best course of action typically is to immediately remove gloves and proceed to the nearest scrub sink to wash the bejeezus out of your hands. Obviously, you would have had to contact your resident to complete the suturing.

    I got stuck with an open-bore on a confirmed Hep C patient. Knew it as soon as it happened. Luckily, I was wearing gloves. Freaked out, did some research to find out that the few studies that had been done showed between 2-5% chance of transmission in a gloved hand with a hollow-bore. Sure, 5% is still WAY too much, but I never seroconverted. It's been nearly a decade now.

    Don't ever be embarrassed by something like this. If you are working in a unit , OR, etc., you will be surrounded by people who have been stuck. If your resident has not yet had the pleasure, he'she will at some point in their career.
     
  9. ocean11

    ocean11 Senior Member
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    thanks for your kind replies people :)

    Yeah you're right, I should have washed my hands, but didn't know that this was the protocol... the employee office told me afterwards... they said you scrub hard with betadine after this happens. Ofcourse I was in a patient's room and NOT the OR so there was no betadine available BUT I should have washed with water and soap. I suppose I was just so shocked that I didn't even think about it... I just kept thinking does he have HIV, Hep C?!? am I going to die?!?! and how stupid I was...... anyhow, I really hope his results come back negative.... and in a way perhaps this whole incident was ment to be a lesson, or what NOT to do and what TO do incase this ever happens again (hopefully not!) and perhaps another reminder of how lucky I should feel about being healthy (lets hope I'm still healthy!!) and alive and not to take life for granted.
     
  10. SLUser11

    SLUser11 CRS
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    Somewhat even more chilling than the circumstances of your needle stick is that you continued to work on the patient after being contaminated.

    You should have had standard training on all of this before you ever stepped foot on the wards, but I can understand how fear and panic after a stick can alter your judgment.

    This is why it's even worse that you were unsupervised. I also was trained in a "see one, do one, teach one" mentality, but this is exactly why that concept is flawed.

    Honestly, I wouldn't be surprised if your resident gets written up for this. Of course, I hope that you don't personally see that it happens, since we have to stick together as a team, and it sounds like he was going out of his way to expose you to some procedures (of course, instead he just exposed you to HIV). I just hope that he learned his lesson.
     
  11. Winged Scapula

    Winged Scapula Cougariffic!
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    As others have noted, most anyone in a field which does procedures involving sharp objects has been stuck before. Sometimes its not even your fault - I got stuck by an attending while we were both sewing abdominal wounds closed.

    However, SLUser1 is right:

    1) don't blame yourself; you should have been more closely supervised or at the very least had someone else gloved and available to help. Most IC departments actually require it...I can recall an ID fellow "training" us on the new central line kits (which included gowns, hats, full body drape, etc.) and talking about the "assistant". Even the attendings laughed, knowing that most of the time the residents were doing the lines unassisted, without even the patient's nurse in the room.

    2) even outside of the OR, you should have Betadine readily available. There is no reason that even a floor nurse can't go get some for you to scrub vigorously with - its on the shelves in the supply closet, in the Pyxis, etc. Even on MEDICINE floors.

    3) do NOT ever think about not reporting it if you are stuck again. Should you, God forbid, test positive for Hep C or HIV, you may be denied any work related benefits or the ability to claim workman's comp. Besides, YOU need to know if you are positive - for YOU, your family and of course, your future patients.

    4) finally, if you are fearful of reporting a mistake for fear of a reprimand or a bad evaluation, your RESIDENT should be the one embarassed. You are there to learn and mistakes happen. Part of a resident's job is to teach - albeit to give you some independence, but if your resident team reprimands you or punishes HIS/HER faulty teaching with bad student evals, that resident needs to be written up.
     
  12. Tired

    Tired Fading away
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    It seems unlikely to me that betadine vs soap/water would make any difference here. Also, the recommendation to "scrub vigorously" seems more likely to promote infection than decrease it (ala - shaving the skin before surgical procedures). Finger wounds are so vascular, and the vasodilation after acute injury occurs in seconds, so what possible difference would "scrubbing vigously" with a known cytotoxic agent make? Sounds like one more medical myth.
     
  13. Syranope2

    Syranope2 Senior Member
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    Ohhh, poor ocean11. I stuck myself suturing closed a drain hole on the floor on my third day of surgery. Unfortunately, I was on transplant surgery at the time and the guy's indication for a liver transplant was, you guessed it, Hep C. I almost passed out. When you hear that there's a 2% chance of becoming infected it sounds really small until you're actually stuck and it's you who has the 2% chance. Then it's far too high a percentage for comfort. Fortuantely, student health takes care of things like this all the time. They are very good at what they do and will make sure that you get all the proper follow-up care.

    I felt so stupid after sticking myself, especially because I want to be a surgeon and felt incompetent, and I was afraid to tell my resident, who wasn't in the room at the time. But you suck it up and you do it. Just remember that people get stuck ALL THE TIME, even attendings who have been doing this forever. At our third year orientation the student health rep told us they take care of ~400 needlesticks every year. So don't feel stupid. Make sure to tell the right people, get the right tests, and take care of your own health.

    Thankfully, I've tested negative for HepC for 8 months. I'm pretty much in the clear.
     
  14. Winged Scapula

    Winged Scapula Cougariffic!
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    I was simply responding to the OP's claim that he didn't wash his hands because there wasn't any Betadine available. I disagree with what seems to be your assertion that washing after an injury is a "medical myth".

    I wasn't recommending that he "scrub vigorously" with the brush side of a scrub brush (again just using the OP's words) but washing vigorously (betadine or not) doesn't promote infection - the reason shaving does is from micro-cuts/tears in the skin - but rather can actually reduce dissemination/infection rates.
     
  15. Bertelman

    Bertelman Maverick!
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    I also doubt this is a medical myth. Quick 5 second Google yielded the following...

    http://gateway.nlm.nih.gov/MeetingAbstracts/102263516.html
     
  16. Wednesday

    Wednesday Senior Member
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    Why are you guys SUTURING when there is no resident in the room! These residents are seriously missing the point of teaching (and supervising) students.
     
  17. Tired

    Tired Fading away
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    Seriously? Okay, in the event I ever stick myself, I'll be sure to immediately tie off the affected limb and infiltrate the wound with betadine. But wait, I'd better do it within two minutes after injury:


    Fokin et al. Protection of a Surgeon from Dangerous Needlesticks. Ann Thorac Surg. 2004 Nov;78(5):1882

    "Our experimental findings indicated that after subcutaneous introduction (the depth at which needle sticks usually occur), it takes the simulated viruses about 6 minutes to appear in major lymph channels but less than a third of this to enter the main blood circulation. The lymph, however, will carry 1000 times more viral-sized particles, but with much less speed than blood."


    Of course, my point was, does cleansing the area with betadine improve outcomes, versus using soap and water? Betadine, after all, is a cytotoxic agent, so if soap and water is just as good, using betadine would be pointless (or as I put it, a "medical myth").


    FERREIRO, ROXANA B. MD; SEPKOWITZ, KENT A. MD. Management of Needlestick Injuries. Clin Obstet Gynecol. 2001 Jun;44(2):276-88

    "After a cutaneous injury, the local exposure site should be cleaned with soap and water. Exposed mucous membranes should be flushed with water. Antiseptic preparations are not known to be more effective, but they are not contraindicated. The use of caustic agents such as bleach is not recommended."


    I find nothing in the literature suggesting Betadine is better. Unless, of course, you can tourniquet really really quick, and happen to have a syringe full of betadine available at the bedside to infiltrate the injury.
     
  18. SocialistMD

    SocialistMD Resident Objectivist
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    Not that this is a plug for Cook, but they put curved needles and drivers in their kits now (along with 3 saline flushes) rather than the keith needles. Our SICU/CTICUs changed over about a year ago and it is great; you really appreciate it when you are trying to put in a line on the floor/MICU/CCU, where they still have the old Arrow kits.
     
  19. ocean11

    ocean11 Senior Member
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    WOW! that is so scary! I feel for you dude! anyhow, I'm really glad to hear you're neg after 8 months! I'm sure you're in the clear... still though, scary coming back to the office for those tests again and again. It's the waiting period, when they draw your blood thats so tough! For me its going to be tues/ or wednesday.... and its hard... this weekend hasn't been the easiest for me, but I'm handling it well! keeping myself busy, seeing friends, going out, just can't think about this needle stick or my stupidity or the fact that I might be sick arghghghghgghghghghgh........ ok need to relax

    thanks for the support people! it is SO much appreciated :)

    sending out some love to all of you!:love:

    Ocean11

    PS: I'm a she not a he to the poster above
     
  20. Bertelman

    Bertelman Maverick!
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    For starters, I expected you could have gleaned appropriate info from the article without adhering to the total picture. Yes, it was an animal study. Yes, they tied off with a tourniquet. I understand. That's why my post was prefaced with "Quick 5-second Google search". It was not meant to be the seminal paper for this discussion. I'm glad you located more relevant articles.

    Second, I misinterpreted your argument. Nonetheless, a significant percentage of needlesticks occur in critical environments such as OR, etc. Anyone who spends time in these environments knows, from experience, exactly where betadine lives. It's not like I'd have to put in a request to bring it up from central receiving.

    Just to play along, though, I don't think two minutes is an unreasonable time to be able to tourniquet something as small as a finger. It's a friggin' hospital. Grab a suture line and wrap a few loops proximal to the injury. Take a 4x4 gauze, unfold and tie. Whatever.

    Myth or not, if I had a choice between betadine or soap, I'd pick betadine every time.
     
  21. MadameLULU

    MadameLULU Saucy
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    Not to sidetrack this conversation, but the policy at my school is that students shouldn't perform procedures or scrub in on any patient who is known to be HEP C + or HIV +. Does your school have a similar policy?
     
  22. Winged Scapula

    Winged Scapula Cougariffic!
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    I'm not sure if its a policy but I have heard attendings tell students not to scrub on those cases.
     
  23. Bertelman

    Bertelman Maverick!
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    That was never explicitly stated during my rotations. I recall starting IVs on Hep +.
     
  24. sofficat

    sofficat AU CVM c/o 11
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    Man, I'm glad I'm in vet med. We stick ourselves everyday, and you know what? It doesn't really matter. Once, I had needle go through my thumb... it would have punctured the other side, but a good thing my bone stopped it (thank you large, mean and crazy dalmation).:rolleyes:
     
  25. thewebthsp

    thewebthsp Shoobeedoowap
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    I helped on surgeries with HIV+ -- one student at my school (not in my class) stuck himself with a hollowbore needle from a late stage HIV+ patient -- meaning his risk was ~30% without prophylaxis and 6% with. He ended up fine. But yeah, those kind of risks aren't fun. I stuck myself from a "low risk" patient on my medicine rotation -- I think the average # is like 3 sticks per a physicians career, and higher if they go into surgery (like 10-20s)
     
  26. ocean11

    ocean11 Senior Member
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    who knows one could aquire rabies?!?? LOL.... no but seriously yeah your risk is definetly lower for somethiing nasty! unless its some weird ebola like virus --> highly unlikely in the western pet population LOL
     
  27. Tired

    Tired Fading away
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    Absolutely not at my school, though most attendings make it a point to tell us of their status, and offer to let us out of the case. I always figure it's a good chance to practice infection control, which admittedly I'm not always real good about remembering with a "routine" patient. I did a central line on an active AIDS patient last week. Scary? Yes. But no one is going to take over the case for me next year when I'm an intern, so might as well suck it up now and get some practice.
     
  28. pillowhead

    pillowhead Senior Member
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    At many large, urban, county hospitals, that would effectively prevent you from doing procedures on a very large part of the population.
     
  29. nabeya

    nabeya Senior Member
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    I wouldn't worry about it too much, especially if this guy is Hiv/Hep C/Hep B negative.

    I posted pretty much the exact same thing last July when I got poked with a Hep C needle during a C/S. Anyways, after 3 months everything turned out ok.

    I know how it feels, but you'll be ok.
     
  30. ocean11

    ocean11 Senior Member
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    Yes today I found out he's HEP C positive.... he's LFT's are normal but the Antibody hep C came back positive and so did the RNA results.... I am so depressed right now.... I just hope his HIV status is confirmed as negative tomorrow....

    does anyone here know how much time it would take me to seroconvert if I was infact positive?!? would it be 2 or 3 months? 8 months....

    man this is killing me... .when I found out I went quitly to the washroom here in the hospital and just cried..... sucks! just *(*&(*&* SUCKS arghghghghg...

    ok must think positively...

    :(
     
  31. Bertelman

    Bertelman Maverick!
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    Sorry, bud. In all honesty, though, the conversion rate is less than 5%. Probably less than 1% in your case since you were wearing gloves, and it was not a hollow-bore needle.

    I know the next few months will be filled with anxiety for you, but really, the odds are stacked far in your favor.

    As I mentioned before, I slammed a hollow-bore with hepC blood into my thumb. Luckily I was wearing gloves (I often don't), and luckily I had aspirated on the syringe before transferring.
     
  32. nabeya

    nabeya Senior Member
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    You'll have to wait about 3 months to get tested for Anti HCV antibodies to see if you're infected. But if you get a PCR test done, it can be done in 2-3 weeks and not have to wait months. Thats what I had done, it cost about $150 but it was alot better than waiting 3 months to get tested for the Anti HCV Ab test.

    :(
     
  33. ericdamiansean

    ericdamiansean High Profiler
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    Lesson learnt is just to be careful.

    In some places, there are certain "codes" or objects placed nearby patients who are Hep B/HIV + to tell the nurses or doctors to be extra careful. For example, the code used in my hospital would be a thermometer in a glass vial (it's actually so that these patients get their own thermometers and cleaning is done separately) but that tells us to be a little bit more careful. It's not discrimination though, we must protect ourselves first.
     
  34. SexPistol

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    hey guys just wondering why a glove reduces the risk by so much when it punctures the skin. also i was wondering if it mandatory for a nurse or someone to tell you the patient has HIV or Hep C, etc..before you do a procedure. Im a phlebotomist/ER tech and have sometimes not known they have it. Sometimes i think its better that i dont know anyway because it's not in the back of my head.
     
  35. Bertelman

    Bertelman Maverick!
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    Conceivably, any blood on the needle is wiped clean as it punctures the glove. Clearly this isn't as effective with a hoolow bore, hence the higher rate of transmission with these sticks v. say a suture needle.

    At hospitals I have worked at, it is frowned upon for a nurse to pull someone aside, particulalry someone not direclty involved in pt. care, e.g. a phlebotomist, to share private medical info such as transmissable disease. Some nurses pull you aside if they care, but hospital policy typically forbodes this practice, as it is probably a HIPPA violation.
     
  36. SexPistol

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    Thanks...A few instances Docs/nurses have said in a sort of pointed manner..."be careful"...I think this is a nice way to say something up without going into a patient history. Thanks for the answers
     
  37. bjackrian

    bjackrian Senior Member
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    My understanding is that HIPPA generally allows the disclosure of protected health information to people who are involved in the care of the patient which would include phlebotomists who obtain blood from the patient. 45CFR164.526 (The current standards for implementing HIPPA) states, "1) A covered entity may obtain consent of the individual to use or disclose protected health information to carry out treatment, payment, or health care operations." This consent is part of the confidentiality disclosure that all patients are given at the hospitals I've worked at.

    Anyway, I obviously don't know what happens in practice at your hospital, but I don't think there should be a HIPPA problem.
     
  38. Bertelman

    Bertelman Maverick!
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    I may have been confusing a simple verbal notification with what one hospital used to do, which was place a certain colored sticker on the chart. That's definitely a no-no these days.
     
  39. ericdamiansean

    ericdamiansean High Profiler
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    Imagine the needle going through the glove, and it wipes off some amount of blood as it passes through, thus, if you are double or triple gloving (which is done in countries like Africa), the extra layers will further reduce your chances of contracting any blood borne diseases. You can do a literature search, and the benefits of double gloving extend beyond just reducing the risks of contracting a blood borne disease when there is a needle prick. The only downside would be sensitivity.

    Don't you have biohazard stickers on the patient's notes to tell you if the patient is suspected/have HIV/Hep? We do, and it is always good to just have a look before you poke
     
  40. Tired

    Tired Fading away
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    I'm not so sure. My understanding is that if the charts are kept in a place that is not available or visible to non-health care workers, this is still acceptable. Same thing with the white boards, right? No patient names, unless it's in a back room where the general public can't see it.
     
  41. MadameLULU

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    No, I currently dso mot of my training at a large, urban county hospital and this has not prevented me from scrubbing in on a majority of cases.
     
  42. pillowhead

    pillowhead Senior Member
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    Well, at mine it still would.

    and besides, most (or at least many) hep and HIV positive patients have no idea that they're infected so unless your hospital routinely tests every patient needing a procedure for these infections, I don't see how a policy preventing students from doing procedures on hep and HIV patients would necessarily prevent all that much or add a whole lot of safety. I think if anything, it has the potential to breed complacency. That's why they're universal precautions. Just assume everyone is infected.
     
  43. dpmd

    dpmd Relaxing
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    At my school it wasn't a policy, but there were times when I was either given the choice or once or twice (in third year) I was told I wouldn't be participating in the case (I think more so because those involved didn't know me well yet and just didn't want me to end up sticking them). I was at a county hospital where I'm sure plenty of the patients had undiagnosed badness going on. I think one of our attendings not too long ago died from fulminant liver failure following exposure (I don't remember how or to what, but I think a student was involved). Maybe that made some attendings nervous about having someone inexperienced on a contaminated case.

    We should be careful on every case, but I can see wanting to take extra care in a proven contaminated case (or one where you suspect). Not really scientific, but think of it this way: you know you should use condoms to protect from disease, but how nervous would you feel having sex with someone HIV an Hep + even with that condom.
     
  44. Bertelman

    Bertelman Maverick!
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    I understand where you're coming from, but I think knowing sometimes confounds the situation. If I'm a young guy walking into a room to draw blood, but I know the Pt. is HIV+, I will be a bit more anxious. Maybe my hands will shake a little. Maybe I'll try a new system of transferring blood tubes, whatever.

    I'm sure the experienced surgeons, phlebotomists, residents, etc. have no problems dealing with known infected individuals, but when it's new to you, it may cause an anxiety that leads to greater incidence of injury.
     
  45. bjackrian

    bjackrian Senior Member
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    Not a general policy, but on our OB rotation, the course director has a policy that MS3's NOT scrub on C-Sections with HIV or HepC positive patients.
     
  46. Tired

    Tired Fading away
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    That way if someone has to get infected, it will be a med student, and not one of their precious residents! :D
     
  47. ericdamiansean

    ericdamiansean High Profiler
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    The last resident I scrubbed with for a C-section...it was an experience I would not forget. He was fast, and he was dangerous. He almost stabbed me with the scalpel and almost sutured my retractor holding fingers more than twice. These were his comments along the way:
    a) "Be careful, I have stabbed my assistants quite often"
    b) "YOU watch out where the needle goes, if your hand happens to be on the way, you WILL get pricked"

    These things keep you awake when you're scrubbing in at 4am
     
  48. bjackrian

    bjackrian Senior Member
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    whoops--that's what happens when I try to post on no sleep. That should have said NOT allow med students to scrub on those cases. Sorry.:cool:
     
  49. SexPistol

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    Can someone receive disciplinary action if they continuously stick other people? I realize needle sticks are a hazard of the workplace and will happen even if everyone is doing their jobs carefully and correctly. But if this resident isn't just trying to scare the student when is enough needle sticks enough?>
     
  50. ocean11

    ocean11 Senior Member
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    Hey everyone,

    once again thanks for all the support. I'm doing ok right now, feeling better than before, I still think about it every now and then, but am ok for the most part. Anyhow, in other news, I tested negative (my baseline) for HIV and Hep C so thats great! and he was negative for HIV, but as you know pos for Hep C so yeah... the end of this month or next month I'll get tested with the PCR test and pray that I am still negative. If I'm negative by November (6 months) I think I'm going to celebrate, honestly!!!!

    This whole experience, has led me to consider psych as a profession... heck we don't even need to know what heard or lung sounds sound like!!!! a nice easy 9-4pm job, part time during the week LOL... and VERY little chance of needle sticks (maybe from a crazy patient!!!)

    I'll update you guys on my status in a few weeks..... thanks for everything!

    Anyone have more stories to share?!?

    Ocean11
     
  51. ericdamiansean

    ericdamiansean High Profiler
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    Of course, if you're sticking someone pretty often then you should be getting an audit. The standard should be zero needle sticks, regardless of how hazardous the operation is, how fast you are that your nickname is "Flash" etc, it should always be avoided at any costs.

    I have always thought of psyh as very hazardous in comparison to the other specialties.
    a) In some parts of the world, psy patients are kept in normal wards, except that you would notice that the windows and doors are grilled, and there is a security officer stationed at the entrance. The hospital where I did my psy rotation, the psy unit is detached away from the main hospital, the patients are always kept away from the doctors/nurses. The experience is ALWAYS worse for the women, they get flashed, harrassed...even from afar..
    b) In one of the hospitals in the UK, students carry an alarm. If the patient attacks them, they hit the button on it and the guards come running. (They don't use it in other rotations)
    c) In medicine/surg/obgyn, you might get pricked with a needle. In psy, you might get stabbed (Come to think of it, it's probably better especially if the knife was not used to stab another guy with HIV/Hep, but I'm sure that you would have other things to worry about)
    d) Physical examination IS part of the whole psy exam, so you do need to know what a heart/lung sound is, and you always have to rule out medical/surgical illnesses
    e) In no other rotation, if you were to walk past the psy wing, you would automatically look up to see if anyone's going to jump off and land on you
    f) I like taking my history knowing that the patient won't suddenly lunge at me and start choking the hell out of me because "You look like the person who killed my grandmother's father's uncle's second cousin's son"

    Thus, with all these reasons, I would suggest that you consider opth or dermato:thumbup:
     

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