To all residents
Reminder from Andrea Durkin
EMPLOYEE OCCUPATIONAL EXPOSURE TO HIV
(What to do in a nutshell!)
1. STOP WHAT YOU ARE DOING! Ask a colleague or Senior House Officer to
take over for you! Immediately wash exposed the area thoroughly with soap
and water. Splashes to the mucous membrane areas (eyes, mouth) should be
flushed vigorously with water. Needle sticks sites should be cleaned with
Betadine solution. YOU HAVE ONE HOUR TO GET YOUR STAT DOSE OF ANTI-HIV MEDS
FOR IT TO BE MOST EFFECTIVE!
2. GET TO THE EMPLOYEE HEALTH CLINIC (M-F, 8:30 am – 4:30 pm) or THE
EMERGENCY DEPARTMENT (if after hours, on holidays or weekends.) They will
administer the STAT dose of antiretroviral agents. Depending on exposure
risk you will be offered a prescription for Post Exposure Prophylaxis (PEP).
Bring this prescription immediately to St. Barnabas Hospital Pharmacy so that
it may be filled. It will not hurt to take the STAT dose and then decide
later whether you need to continue with further treatment. The Employee
Health Service or Emergency Department will help you assess the situation
with Infectious Disease consultation.
3. HIV TESTING OF THE SOURCE PATIENT.
a. If the incident occurs Monday to Friday, between 8:30AM and 4:30PM,
then PAGE THE HIV COUNSELOR at 1-877-502-3656. State that you had
an “occupational exposure” and need HIV counseling and testing for a
patient. Have the source patient’s name, medical record number and location
available. HIV Services also recommends you leave the patient’s information
on the “HIV Test Request Line” at extension 4646. HIV Services considers
this a STAT request and will provide counseling ASAP that day (M-F, 8:30AM-
4:30PM) and results within 48-72 hours.
b. IF THE INCIDENT OCCURS AFTER 4:30PM, OR ON A HOLIDAY OR WEEKEND -
NOTIFY YOUR SUPERVISOR AND THE SENIOR HOUSE OFFICER. The senior house
officer will counsel and test the source patient. ED source patients will be
tested by an ED physician. Testing kits will be available in the main
hospital laboratory on the 3rd Floor.
4. YOU MUST GO TO EMPLOYEE HEALTH THE FOLLOWING BUSINESS DAY (MONDAY-
FRIDAY). Employee Health will follow up on the source patient’s HIV status
with HIV Services. They will also follow up your lab results, renew your
medications, help you manage side effects (if any) and give you appropriate
follow-up care in conjunction with Infectious Disease. Employee Health
Services will oversee that all the appropriate tests and procedures are
carried out properly and rapidly. Your confidentiality will be maintained.
5. COMPLETE AN INCIDENT REPORT AS SOON AS POSSIBLE AND BRING IT WITH YOU TO
EMPLOYEE HEALTH.
[see also NEJM articles from Feb 27, 2003 and
http://www.ccjm.org/pdffiles/Alvarado-Ramy503.pdf]
http://www.annals.org/issues/v138n9/pdf/200305060-00016.pdf (below)
ON BEING A DOCTOR
"Stuck"
Christine Seibert, MD
Pages 765–766
Ann Intern Med. 2003;138:765–766.
I felt a brief prick on the pad of my right third finger. I did not say or do
anything to alert the resident with whom I was working, but instead continued
until the lumbar puncture on our patient with end-stage AIDS was finished.
Then I stared at my glove before taking it off, putting it in a bag and then
in my pocket so I could scrutinize it later, without arousing suspicion. I
examined my finger and there was no puncture, no gash, and no blood. While I
meticulously scrubbed my hands, I debated whether or not to call Employee
Health. It was 11:45 p.m. and I was tired. I had a desperate urge to go home,
kiss my kids, long asleep, and climb into bed with my husband. I did not want
to make a big deal out of this in the middle of the night.
After my drive home, I walked in the house and scrubbed my hands again. Then
I doused them with bleach for good measure, not remembering whether or not
this was helpful. I crept into my daughters' rooms to complete our nightly
parental ritual of checking on each of them before going to bed. I do not
know how long I stood and stared at them, wondering whether our lives would
ever be the same again.
I awoke the next morning with a deep dread. From home, I called a friend who
is an infectious disease consultant, luckily on service that month. I related
my story to him, and he sprang into action, swiftly arranging for me to be
seen first thing that morning in Employee Health to get a dose of zidovudine
and lamivudine. He first admonished me for not calling him sooner. But he
must have sensed the mounting panic in my voice and kindly reassured me that
I did not do irrevocable harm with my delay. Later he met me for lunch, armed
with what seemed like the world's literature on needlestick injuries in
health care workers. Gently, he recited the statistics and reported that my
risk for seroconversion was 3 in 1000. He was encouraged. I had been hoping
for 1 in a million.
After recounting the details of my exposure again, he recommended 30 days of
prophylactic drug therapy. Grateful for any ammunition to ward off HIV, I
agreed that I could take any concoction for a month if it would stack the
deck in my favor. Before deciding which drugs to take, my friend suggested
that I meet with another expert in this area. Though I was leery of telling
anyone else, I allowed my friend to make the arrangements.
The expert paged me that evening. I met him at his HIV clinic, feeling self-
conscious immediately upon walking through the door. In one of the exam
rooms, I told my story again. Though his work in the hospital was not done
and it was already 6 p.m., the expert was patient, thorough, and sympathetic.
I will always be grateful that I shared my secret with him. He decided on a
three-drug combination of zidovudine, lamivudine, and nelfinavir, one of the
newer protease inhibitors. I would feel like I had the flu and would have a
significant chance of diarrhea. He gave me pointers on how to prevent the
diarrhea by eating Metamucil bars along with twice-daily calcium. He
tactfully reviewed how to protect my husband and family. I added condoms to
my mental grocery list.
I left the clinic with my prescriptions and strategized how and where I would
fill them with the least wagging of tongues. The pharmacy where my husband
works was out, as was my neighborhood pharmacy. I decided on the seemingly
anonymous hospital pharmacy. When I brought my prescriptions to the window,
the pharmacist looked at my white coat, then at the prescriptions again and
asked, "Are these for you?" I replied affirmatively, causing her to quickly
avert eye contact and awkwardly busy herself. After the prescriptions were
filled, I was nervous when I saw a familiar face at the pick-up window. The
pharmacist and I exchanged pleasantries, and he admirably hid most of his
surprise at the drugs I was getting. I felt compelled to explain my story to
him so he would not judge me as I felt the other pharmacist had done. He
wished me luck in a pitying sort of way. I nearly ran back to my office.
There was still one more task before heading home. I had to have baseline
labs drawn. Knowing how vulnerable a computerized record can be, I asked the
Employee Health nurse to allow me to have my labs drawn under an alias. I
shed my not-so-anonymous white coat in my office and reluctantly walked
toward the lab with my requisition. I got questioning looks from the check-in
person, as well as from my tactless phlebotomist, who asked me why I was
getting my blood drawn with an alias. I explained that I was an employee and
I wanted to keep my medical care private. That produced the same aversion of
gaze I experienced earlier at the pharmacy counter.
Finally at home, my girls gave me their customary welcome mauling and then
ran into the backyard to finish some sandbox creations. As soon as I made eye
contact with my husband, I burst into tears. He tried to comfort me, but I
would have none of it. The events of the day and my own imaginings of the
worst possible conclusions to this incident squashed my usual optimism.
That night, when putting my daughters to bed, I hugged them tighter and
longer than usual, crying silently as I lay down with each of them that
evening. I imagined how HIV would affect my family. I calculated how old they
would be when I would begin to suffer the ravages of the disease. Would I
embarrass them? Would I be a burden? Would they forget how vital and
energetic I used to be? As tears streamed down my face in the darkness while
I hugged my youngest, I was immediately taken aback. What was the
concentration of HIV in human tears? I quickly let her go, jumped out of bed,
and ran out of the room to wash my hands and face.
The first week after my needlestick was the hardest. Already worn out from
nearly a month of being the ward attending, I began to feel increasingly achy
and sluggish. My eyelids seemed to gain 20 pounds as I uncharacteristically
fought to keep them open at every conference or meeting. I became
hypervigilant about touching my family. One evening after I absentmindedly
licked my fingers before rubbing some debris off of my daughter's cheek, I
became nauseated with dread after realizing my mistake. This new obsessive
antiseptic approach was going to be hard on our family of lackadaisical hand
washers, who seemed to share a lot of body fluid, not to mention the
occasional toothbrush.
Over the next few weeks, I played more and worked less, coming home much
earlier than usual. I noticed the blooming zinnias in my backyard and started
cutting them for arrangements. My husband and I began taking long walks after
dinner. I joined my daughters' tea parties and swung with them on their swing
set. I read few, if any journals, instead focusing my efforts on novels I
always wanted to read. I did not exercise as much, partly from exhaustion and
partly because it did not seem to matter. I became impatient with patients
who came in with "trivial" concerns. Time was wasting, after all.
The next milestone was my first follow-up HIV test. I was not bothered as
much about the inquisitive looks at the lab this time. After a month of the
three-drug regimen, I was spent. How did people take those toxins month after
month? I hoped I was not going to find out. For several days after my test, I
got a sick feeling in my chest every time I was paged to a number I did not
immediately recognize, sure I was going to get bad news. About a week later,
a letter from the hospital came for me at home. Though I was fairly sure that
positive results would not be sent in the mail, I made my husband open the
envelope. I finally exhaled after finding out I had dodged the bullet that
time.
During the next few months, I searched my soul and reprioritized my life. I
became a better mom and wife, a more empathetic doctor, and a more caring
friend. Like Sleeping Beauty, my life changed with the prick of a finger. I
was now holding out for the fairy tale ending.
Author and Article Information
From University of Wisconsin Health-East Clinic; Madison, WI 53718.
