A few months ago, I was on my general surgery rotation on the colorectal service as a medical student. It was in the late afternoon that we started a case of a robotic rectopexy to repair a rectal prolapse. Our patient was a kind and warm 89-year-old woman. The operation finished without a hitch.
As we undocked the da Vinci machine, the resident and I began to suture closed the multiple robotic ports on the abdomen. Half-way done with the second port on my side, I felt a pinch on my left index finger as I was locating the suture needle with the driver. I paused briefly to check my gloves. It was only later as I unscrubbed that I saw a tiny puncture wound from the suture needle and a few bright drops of blood. By the end of the day, I walked myself to the emergency department per protocol and waited for the results of my patient’s infectious disease screening. I had checked her chart already. Hypertension. Hyperlipidemia. Cataracts. Arthritis. No IV drug abuse or promiscuous sexual activity. She was a typical 89 year old.
And so, I casually waited. You must know where this is going. This 89-year-old woman with a completely benign medical history turned up HIV-positive. I frantically searched for the sensitivity and specificity of the tests. Both were well above 99 percent. We checked and re-checked. It wasn’t a false positive. She had a viral load in the tens of thousands. I stared blankly at the floor as I gulped down the first two pills of my 4-week post-exposure prophylaxis medication.
It seems like I did all of the right things but I’ll fill you in now on the parts of the story that I hesitated and almost stumbled at. As I paused to checked my gloves for a puncture, I heard the scrub nurse say, “You didn’t stick yourself, did you? I hope not because that’s a ton of paperwork for everyone.”
So, instead of taking my gloves off immediately, I waited until the end of the case. And then, instead of going to the emergency department immediately, I waited to finish rounds with the resident. In the hours between the needlestick and emergency department, I asked myself again and again whether this was worth reporting. I thought about all the potential repercussions. What if my resident or attending adjusted my clinical evaluations? What if I was known as the student that stuck himself? I thought up scenarios in which my resident complains to her peers, “My stupid medical student stuck himself, and now, I’m swamped with paperwork.”
This all went through my head, and I would be lying if I didn’t tell you that I was a second away from driving home without going to the emergency department that evening. I almost didn’t tell anyone because no one would have known. And that’s the terrifying part. No one would have known, including me.
Needlestick injuries happen all the time. A survey of 702 surgical trainees in 17 programs from 2007 reported that 99 percent had a needlestick injury by the end of training. Yet, 51 percent of the injuries were not reported to an employee health service. It seems so straightforward to follow the protocol but it’s not until I went through it that I realized why some don’t. We cannot allow ourselves to establish a culture where a needlestick injury is a measure of incompetence or seen as an inconvenience of paperwork. Even as I shared my story, I overhead fellow students comment, “That’s why he’s going into anesthesia, right?” You are as important to creating that culture as a medical student or surgical scrub nurse as an attending or a resident is.
The field of medicine is not without risks. Who would have thought that an 89-year-old woman with a few innocuous medical conditions had uncontrolled HIV? The family of my patient was shocked and incredulous to the point that I was asked if it was possible that I had transmitted it to her. We only know what our patients’ decide to report to us, and we need to approach everyone with the same caution as we would the most contagious patient. I’ll never forget what an ER attending told me about being in a code. The most important pulse is your own. You must take care of yourself before you can take care of others.