The needlestick we fear the most

A hostile, struggling patient in the ER—would he test positive? Meanwhile, the author had a struggle of his own: to keep his cool and compassion.

By Phillip Silverstein, MD
Emergency Physician/Broomall, PA

It was 5 am when paramedics wheeled a fully collared and boarded man into the ER. Initially, all I could see of him were two charcoal-black eyes peeping out of blood-soaked bandages. The police told us he was an unrestrained passenger in a car wreck; his head had gone through the windshield, lacerating a branch of an artery deep in his facial muscles. The alcohol on his breath pervaded the room.

His vital signs were stable. We estimated he'd lost at least one unit of blood and was losing more, fast. "Control the bleeding," I thought. A 2-inch-wide defect extended from the bridge of his nose to a spot 1 inch behind his left ear. The lower third of his ear was hanging by a thin piece of flesh.

We hooked up a high-pressure wall suction to remove the blood gushing from the massive hole in his face. Three prominent arterioles were cut, one of them shooting blood at least three feet. "There it is," I shouted. "Suck!" We located the bleeders and oversewed them with absorbable sutures. Soon, the bleeding was controlled.

"Oh, yeah!" It's a good feeling to be challenged, to know your stuff and see such immediate results. Today had been a good day.

The sense of urgency over, I began to reconstruct my patient's face. He looked to be in his mid-20s. "Hey, where are you?" I asked as I worked. No answer. I repeated the question in Spanish. Still no answer. "Stick out your tongue." Instead, he tried to rip out his IV lines. "No," I yelled, "Don't do that!" He didn't listen; just continued trying to disconnect.

Then it happened. "Ouch!" The suture needle had punctured my sterile glove and left index finger.

At first I was calm. "Even if he's HIV-positive," I told myself, "I have only a 3-in-1,000 chance of getting infected." I kept working.

But it wasn't long before panic set in. Should I do nothing? What if I contract the disease and, worse, infect my wife? My next emotion was anger—first with the patient, then with myself for being angry with him. "Finish the job at hand," I thought, struggling to stay focused. But the patient kept pulling at his IV lines. At this point I just about lost it. "Stop it!" I screamed, suddenly wishing I could throw him out of the ER. Then I immediately felt guilty, amazed at how dispassionate I could be.

I stepped back, removed my gloves, and washed my hands. "Did you get stuck?" asked Jody, the nurse assisting me. She poured peroxide over my finger, and I soaped my hands for a full two minutes. I then re-gloved and finished sewing the patient's wound. After two hours of work, the repair looked really good, considering. But no matter how hard I tried, I couldn't block out my emotions.

I called the employee-health department to schedule the necessary blood tests. I was determined to be objective and not overreact. The patient and I both had blood drawn. It would be checked for HIV, as well as hepatitis B and C. With the single-use diagnostic system test, we'd have results in an hour. If his blood was positive for any of these, mine would be checked again at six weeks, three months, and six months. If I hadn't seroconverted by then, I wouldn't convert.

As I spoke with the nurse in charge of occupational health, I felt at peace. My character was being tested, and so far I was passing. "I'll be sleeping in the doctors' room for a while," I told her. "If the test is positive, call me; if it's negative, don't. I'll assume everything's all right."

I went to sleep feeling pretty optimistic. I convinced myself that the patient was unlikely to test positive, and even if he did, 3-in-1,000 are pretty good odds. Furthermore, I no longer felt anger toward the man. "Thank you, God." I fell into a deep asleep. It had been a good day.

At 10 am, employee heath called. "Dr. Silverstein? We've completed the quick test for HIV. The patient was positive." Positive? "Doctor, come by the office at 1. We need to talk." I was in shock. Was I dreaming? This wasn't the way the script was supposed to read.

I lay back in bed. I'd been up all night and needed some sleep before the long drive home. An intense sweat came over me, soaking my clothes. This wasn't a gym sweat; it was a sick sweat, born of profound anxiety. "Oh my God!" I thought. "Please help me go through this with class and dignity. Help me not to overreact."

I'd know in six months whether I'd contracted HIV, but I didn't want to be a basket case in the meantime. As I lay in bed, my thoughts drifted to my wife. We'd need to use condoms over the next year, just in case. How exactly would I tell her? Should I tell her at all? We were leaving on a scuba-diving trip in one week. Not the greatest news to share before a vacation.

Later, as I was getting dressed, I thought about the patient. He had to have all kinds of tests before he could be discharged, so he was probably still in the ER. My first instinct said, "Heck with him," but then I stopped myself. He doubtless knew his test result by now, so wouldn't it be a loving thing for me to encourage and console him? I headed for the ER, only to find that he had been discharged. But I was still rather proud that I'd been able to put my resentment aside. I was thrilled to be victorious over my anger, to be really learning forgiveness. Indeed, this had been a good day!

The nurse at employee health put down her phone when I walked in. She was clearly nervous. "Dr. Silverstein, I have some interesting news." Interesting? I dared not hope for a change in her report. "As you know, our rapid test showed your patient to be HIV-positive. This morning, we repeated the rapid test with four other technicians, and they all came back positive." I could feel my heart sinking into my stomach. "So then we rechecked your patient's blood with an HIV antibody test, which takes longer but is absolutely accurate, and discovered that our initial results were wrong. Doctor, we made a mistake. Your patient is HIV-negative. I'm so sorry to have frightened you."

"Are you sure?"

"Yes," she answered. "I hope you're not upset."

"Upset, how could I be upset?" I asked jubilantly. I was beside myself with joy. "Can I buy you lunch?" Her mouth dropped open.

As I drove home I thanked God for the incredible gift he had just given me. This had been a very good day!

 

Phillip Silverstein. The needlestick we fear the most. Medical Economics 2001;15:40.