“DOCTOR, YOU KNOW this patient is HIV-positive.”
As I watched a spot of blood pooling beneath my surgical glove, the scrub nurse's words hit me like a ton of bricks.
I'd been called into the OR to assist one of my colleagues, a surgeon who'd requested my help after he'd entered the patient's bladder inadvertently during a hernia repair. I scrubbed in and took a look—the bladder was almost completely separated from its neck. A small tumor was visible just inside the bladder, on the left. I snipped off the tumor with fine scissors, fulgurated its base, and proceeded to help the surgeon sew the bladder back together with some resorbable sutures. We were finishing the repair when I moved some peritoneum away with my hand and accidentally stuck the back of my left middle finger with the suture needle.
Disbelief, then fear
The first thing you think of in this situation is that it didn't happen; however, clearly there was blood beneath my glove, so I'd been exposed. The surgeon completed the repair and I took my glove off. I immediately washed my hand with soap and water followed by betadine and alcohol,1 and reality began to set in, along with incredulity. In the past, I'd performed several vasectomies on HIV-positive patients, and I always made sure that everyone involved in those procedures knew about the patient's HIV status before starting the surgery. In this case, the surgical team, perhaps distracted by the unexpected complication, had forgotten to pass along to me that crucial bit of information. I couldn't help but think that my brief second of carelessness might have been prevented had I known about the patient's HIV status. I think most of us in this situation tend to fear the worst: How would being HIV-positive affect my marriage, my career, my health? How could this have happened?
The protocol for dealing with needle-stick injuries is fairly standardized, and both the patient and I had HIV bloodwork drawn. The ED staff was very sympathetic, but I had the feeling that my visit there was just a formality.
“The risk of acquiring HIV from a needlestick injury is low, but not zero,” the triage nurse told me. “You can elect to start post-exposure prophylaxis (PEP) within 72 hours of the incident; the sooner the better.”1
I looked over the half-page list he'd given me of the potential adverse reactions to antiretroviral therapy. I'd studied these once for a test, but they meant a lot more now that I was faced with taking them myself.
“I-I'm not sure,” I stammered. “I guess I'll just take my chances.”
“OK. Just sign here to decline, and someone from Employee Health will call you in the morning.” Initially I felt relieved that the whole thing was in the past now, for better or for worse.
Fortunately for me, however, that next-day call came from an NP in our hospital's occupational health department. She asked me to come to her office to discuss “the situation,” as she called it. Once again, I was presented with the laundry list of potential adverse reactions to antiretroviral therapy. The way she described the rationale for PEP was just perfect—that it wasn't a guarantee, but that it would greatly reduce my chances of becoming HIV-positive.
“I don't think I can deal with these adverse reactions,” I said to her.
She excused herself for a few minutes, then returned with one of my infectious disease colleagues. She'd asked him to drop whatever he was doing and talk with me. He explained that PEP is the standard of care in this situation, and the adverse reactions are usually manageable. “You're still within 24 hours of the exposure, a treatable window,” he said. “All it takes is one virus particle to infect you.”
I reconsidered and decided to do it. He smiled and left the room. He prescribed a three-drug antiretroviral regimen of tenofovir-emtricitabine plus raltegravir. Within the next 2 hours, the NP had obtained the medications for me and given me her cell number in case I had any questions or problems. Later, she called me at home to make sure I'd started taking the medications.
Several days went by. At first, PEP was a piece of cake. The NP called me with the patient's test results: His Western blot was positive, but his viral load wasn't too high—a hopeful sign. Everything seemed rosy until a week later, when the drugs started affecting my gastrointestinal tract. I decided to take the NP up on her offer of antiemetics so I could at least look at food. The month of PEP finally passed, and I didn't miss a dose. My wife and I were also careful to abstain from sexual contact as directed by CDC guidelines.2
After 6 months, my serologies remained negative. The source patient recovered nicely; his first postop cystoscopy showed no recurrence of his bladder tumor and he was doing well.
This unfortunate experience taught me a lot. Thankfully, I happened to benefit from the actions of an incredible NP who truly cared. For this I'll be forever grateful.
1. Bartlett JG, Weber DJ. Management of healthcare personnel exposed to HIV. UpToDate. 2015. http://www.uptodate.com
2. Centers for Disease Control and Prevention. Updated U.S. public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. Morb Mortal Wkly Rep
. 2001;50(RR11); 1–42.