This Date in UCSF History: Wake Up Call

Originally published in Synapse on April 30, 1992.

Being a medical student or a health professional of any kind involves certain inherent occupational hazards. The end result may be a motor vehicle accident stemming from lack of sleep; getting cancer after year of exposure to numerous toxic, mutagenic, and frequently carcinogenic drugs (which are paradoxically used to treat cancer); having a spontaneous abortion that is related to the amount of time one has spent in an operating room.

Contacting an infectious disease has always been a common occupational hazard in the health professions. In the early part of the twentieth century, tuberculosis and syphilis were rampant and it was not uncommon for a health professional to convert from a negative skin test to a positive skin test for tuberculosis, only to later have outright tuberculosis disease. 

Even today, tuberculosis is on the rise, and constitutes a potential risk to healthcare workers. In the 1970s and ’80s, Hepatitis represented a difficult-to-prevent disease which has significant morbidity and mortality. Other infectious diseases that the healthcare worker is susceptible to include scabies, viral respiratory infections, conjunctivitis, and, of course, HIV infection.

To prevent healthcare workers from contracting these diseases a whole host of guidelines has been designed, ranging from Hepatitis B immunization to annual PPD (skin) testing for tuberculosis. In the 1980s and ‘90s, “universal precautions” has been the in-vogue method of preventing disease transmission. Health workers are urged to use some combination of gloves, masks, gowns, and protective eyewear when likely to come into contact with “body fluids.” 

Still, even with precautions, the healthcare worker is at risk for contracting diseases that are either quite serious or incurable. This sentiment never quite hit home until one Friday night while I was working in ihe emergency room at Mount Zion Hospital. All day long there had been a continuous ebb and flow of patients in the emergency room. 

Some walked in, some were pushed in sitting in wheelchairs, and others were rolled in on gurneys. Some of the patients were sent home, but many were sick enough to be admitted. One woman, a somewhat obese 50-year-old married woman whom I’ll call P.E., came into the emergency room complaining of a five-day history of pain on the left side of her chest. 

Her pain was gnawing and continuous with occasional episodes of sharp non-radiating pain and she had been coughing up blood-tinged sputum for a couple of days. We ordered a chest x-ray, an electrocardiogram, and a room air oxygen saturation. 

The chest x-ray was normal, her electrocardiogram showed sinus tachycardia (basically a normal rhythm with a fast rate), and the oxygen saturation was slightly lower than normal. We began to entertain the idea that she may have had a pulmonary embolism. That prompted the next test, an arterial blood gas, or an ABG in medical lingo. 

I had done many ABGs in the last two years and finally felt comfortable doing them. In fact, I had just done one on another patient in the emergency room — a perfect stick, right into the artery. I gathered the necessary materials, put on some gloves, felt for the patient’s radial artery in her wrist, and proceeded to obtain the blood sample without any problem. 

When I had enough blood, I withdrew the syringe and needle from P.E.’s arm and held pressure over her artery. I expelled a small amount of air from the needle, removed the needle from the syringe and capped the syringe. I placed the needle alongside the other materials I had used, including some gauze and an iodine pad and alcohol wipe. 

The sharps box (a container for disposing of sharp equipment such as hypodermic needles and scalpels) was on the other side of the room, so I decided to take the sample to the front desk at the ER, have them place it on ice, and then clean up. 

Normally, I would have gotten the ice before drawing the blood so that I could immediately chill it, but they didn’t seem to do it that way in the ER, so I didn’t either. I came back to the room, and proceeded to clean up, forgetting about the needle that was lying among the other things that needed to be disposed of. 

As I grasped the materials I felt an unusual sensation in my left index finger. Oh my God... there was a needle sticking a good quarter of an inch into my index finger. Panic. Terror. Fear. Instantly

I thought, “I’ll just forget about it.” 

But in the next second I thought, “I can’t do that I’m going to call the needlestick hotline.” 

My heart was racing, and I was having thoughts of doom. 

“I could die from this... What if this patient is HIV positive?” 

I immediately told the ER doctor what had happened. He calmed me down, had me sit down and gave me some juice to drink.

We then paged the needlestick hotline. They called back in about five minutes, which seemed like 10 years. All sorts of ideas raced through my mind. I was in a state of oblivion. 

What would I do if I seroconverted? Why didn’t UCSF have disability insurance for medical students? 

Thank God I just took out a $50,000 HIV indemnity policy in case I ever converted. When the phone rang it was a doctor from the occupational health department. He asked what happened and when I told him about P.E. and how I had stuck myself, he said it was a low-risk stick, given her history. 

We would ask the patient if she would consent to an HI V test and a blood test for hepatitis B and C. We would also draw my blood and test it for antibodies to Hepatitis B (I had been vaccinated in my first year of medical school, at my own expense, before having any exposure to patients in a real clinical setting) and for HIV.

The patient consented, but the samples would not be processed until Monday, three days later. And the results would not be available until Tuesday.

“Low risk... low risk... low risk” I told myself. But when you are stuck with a needle, low risk docs not mean no risk, it means high risk. I had been married for only one month, and now this. Why? Why? I had never stuck myself. I prided myself on my safety. 

But I had changed my procedure for doing ABGs. Did it matter? There would always be some risk. Why now? I realized that the test results of the patient would not be back until the day of the Medical Boards (a horror story in itself).

When I had my blood drawn by a nurse practitioner who works with the needlestick hotline, I was terrified. Would I be HIV+? I had never been tested. But I had not led a high risk life — never had a transfusion, never used IV drugs, never had sex with a prostitute or another man, did not sleep around, almost always had used a condom. 

My results would be back on Wednesday, day two of National Board Examination. Great.

I did find out some interesting facts from the needlestick hotline. I was the 128th person to have a body-fluid exposure in 1992 at UCSF or Mount Zion. (SFGH and the VA have their own system). 

No one has ever converted in the two and a half years that the needlestick hotline has been operating at UCSF/Mount Zion. The hotline averages 10-12 calls per week. 

Since its inception, of all the patients who have been tested when a healthcare worker had a body-fluid exposure, only two turned out to be HIV+ and unaware of it. (Even more surprising, these two patients never called to get the results of their blood tests.) 

One in three third-year medical students have an exposure during that first clinical year. It is estimated that far more exposures occur than are reported. Why? Denial.

There will always be a risk of needlesticks, even when we are careful. Thus, no matter how many precautions we take, the risk is never zero. I now believe that the most important part of patient care is my care first. 

After all, if a healthcare worker converts, they will not be able to provide patient care, so in reality protecting ourselves is protecting our patients. 

Second, if you are doing a procedure that you feel is logistically awkward, do not do it. 

My accident probably could have been avoided if a co-worker had been present to either take the blood sample, hold pressure on the patient’s artery, or dispose of the needle. 

Third, always think about how you are going to dispose of a sharp instrument and make sure it is the first thing you do after a procedure. 

Fourth, as a medical student, make sure you have adequate supervision when doing something you’ve never done before or have only done a few times before; and try to do it on a patient who is a low risk for HIV rather than on someone who is known HIV+. 

Fifth, UCSF should require all healthcare students to show proof of immunity to Hepatitis B, or prior infection, before allowing students to work with patients. And finally, while prevention is the best medicine, it is not enough.

I urge every healthcare student to petition His or her dean and the school administration about instituting disability insurance for every student. We must have a policy to protect us in the event of seroconverting and for other disabling illnesses. With the medical environment what it is today, to have anything less is ludicrous. 

Finally, as a student, seize the opportunity to take out extra medical insurance, disability insurance, or an HIV indemnity. The American Medical Association offers each of these policies. 

The peace of mind is more than worth the one or two hundred dollars that it costs.

Happy ending: both P.E.s blood tests and mine were negative and P.E. did not have a P.E. (pulmonary embolism).