Needlestick Injury – What to do, what to do?

There’s been some talk of an opt-out system for HIV (Human Immunodeficiency Virus) testing in Singapore.
TODAYonline: Aids stats point way to HIV tests

J., as a future healthcare professional, thinks that it is admirable the goal of protecting… healthcare professionals, though he doubts its effectiveness. It would definitely be useful in diagnosing and treatment of HIV patients, as well as for epidemiological purposes, but probably not so much in protecting healthcare workers.

J. has a healthy respect (read: fear) of needles and blood. He refuses to take shortcuts such as not gloving up or neglecting to waterproof open wounds on the hands. He makes sure that at no time is his finger at the receiving end of a needle. This [correct] behaviour was reinforced by being in a gastroenterology ward where it wasn’t uncommon to have patients with Hepatitis C or mutant Hepatitis B strains. So a patient has HIV… J. still has to take the blood, he’s still going to glove-up, and he’s still scared as hell of being poked by the needle. What’s the difference?

As a point of interest, what’s the risk of transmission from a Hep B, Hep C and HIV postive patient? Use the rule of 3s. Hep B – 30%, Hep C – 3%, HIV – 0.3%.

Anyway, since it’s both an important topic (J.’s friend was the first needlestick casualty this academic year) and a COFM question, let’s focus on what to do if, despite all measures, one pokes oneself with a needle after using that self-same needle on a patient. [DUM, DUM, DUM!]

1. Bleed and wash

   As soon as possible, get to the syringe, squeeze as much blood out from the site of needlestick injury as possible. Proceed to wash hands, in particular the needlestick injury site, with chlorhexidine solution. Do it 5 times if it makes you feel better.

   Try to avoid chopping off the arm. Circulatory physiology dictates that it would be futile, anyway.

2. Get blood for testing

   If blood’s already in the syringe, place some of the blood in a plain tube (orange top in SGH). If not, come by later and get it, or get a friend to draw the blood for you. Ask a nearby healthcare worker (preferably the nurse in charge of the patient) to send the blood off for
   Hepatitis B markers – HBsAg, Anti-HBsAb, HBV DNA, HBeAg, Anti-HBeAb, HBcAg, anti-HBcAb
   Hepatitis C markers – Anti-HCV IgG
   HIV markers – HIV DNA/RNA

3. Report and document

   Tell the sister (either nurse clinician or nurse manager) in charge of the ward and make sure that it’s properly documented. In the unfortunate circumstances that one develops Hep C/Hep B/HIV/all of the above, if properly documented the hospital will pay for all future tests and/or treatments.

4. Seek medical attention

   Within office hours, this means go to the staff clinic. After office hours, this means go to the A&E (Accident & Emergency), pay the S$70 first (get reimbursed later) and get blood drawn for testing. This usually means the viral serology panel mentioned above.

   Note that if the patient is positive (especially if patient has HIV acute seroconversion syndrome), one should get therapy as soon as possible, preferably combination therapy (for HIV) and/or immunoglobulins within 2 hours post-exposure.

5. Get back to work

   You lazy bum. Patients dying!

6. Trace patient’s blood results

   This is where everyone, religious or otherwise, starts praying for completely negative results.

7. Follow-up blood tests

   Hep B and C testing is also continued. Seroconversion usually occurs by 3 months, and almost definitely by 6 months.

   For HIV, ELISA for anti-HIV antibodies is performed at 6 weeks and then again at 3 months, by which time it is rare not to have seroconverted. If positive, a confirmatory Western Blot test for protein bands (p24, gp41, gp120/160) is performed. However, it can take up to 1 year.

   After 1 year, if tests have all been negative, one is given the all-clear.

Anyway, negative or not, this is where the shit hits the fan. Needlestick injuries are serious things, and most likely the information is going to get passed upwards until the dean of the faculty of medicine (for medical students) hears of it.

Just be safe, alright? No shortcuts.

P.S. This entry was written past midnight, 2 years after J. has done COFM. Things MIGHT be lacking. One would do well to look for the needlestick injury protocol in the respective hospitals.

Regarding J.’s friend, he had followed all safety precautions and subsequently followed standard SGH needlestick injury protocol. It was a lapse in concentration during a call. Fortunately, the patient involved was negative for all tested virology.