The needle and the damage done: circumspection

needle

Scrolling through my timeline on Twitter the other day, I saw that a junior doctor had suffered a ‘blood splash’, presumably in the face. This is when a patient’s blood is sprayed or flicked into your mouth or eyes…carrying with it the risk of infection from a blood borne virus such as hepatitis C or HIV (medical staff are immunised to hepatitis B). It made me think back on a similar experience as a junior doctor…a needle stick injury from a patient infected with hepatitis C. I’ll describe what happened in a minute, not because I enjoy telling unpleasant personal stories, but because I think the impact that these ‘avoidable but let’s face it they’re going to happen now again’ accidents have on doctors and nurses should be understood and emphasised. When I looked into the subject I discovered that research had been published on the subject this year, the results of which I will go on to summarise. It seems that the psychological impact of these accidents can be very grave indeed.

*

As soon as I felt the deep sting of the needle as it entered my finger I knew what it meant – potential disaster. I was cutting a space between the ribs of a patient on intensive care, making room for the insertion of a large chest drain. The tissues were tough, and I had to tear at the fibres with my fingers deep under the skin. But the patient was not sedated, and she was feeling it despite the local anaesthetic injection I had administered beforehand. So I did something stupid. I kept one finger in the cut, so as not to lose the track I had struggled to form, and with my other hand I carefully inserted the anaesthetic needle alongside it. In this way I hoped to numb the deeper tissues. I jabbed my own fingertip – ouch…a shock, but not really painful. It was the knowledge that hepatitis C viruses in my patient’s blood could now be running up the veins of my arm and into my bloodstream that caused me to freeze in fear. I withdrew my finger, looked down at my hand, tore off the glove, and squeezed the fingertip until droplets came out. The nurse who had been helping me recognised what had happened, but had nothing to say. I walked over to a sink, washed the blood off, wrapped a waterproof dressing around the tiny wound and went back to the patient. She still needed a chest drain after all. Soon the job was done, and the rest of the nightshift passed without incident. But throughout the small hours I could think only of myself: were there any viruses in the needle? How many would it take to cause a permanent infection? Would I need anti-viral treatment, would it work, could I continue to be a doctor while receiving the famously toxic combination of interferon and ribavirin? Might it fail, would I develop cirrhosis, would I end up in this very hospital, waiting for a transplant? Oh God.

I was distracted by anxiety for weeks, not to a disabling degree…not so as anyone would notice. At six weeks I had a blood test to see if there were detectable levels of virus in me. A week later I attended the occupational health department to get the result. The nurse had not read a Hep C result before, it seemed to me. She looked quizzically at the small piece of paper in front of her, and tilted her head slightly.

‘Err…you have…err…Hepatitis C.’

I nearly fainted. I looked at the report closely, upside-down, and lunged forward,

‘Let me see that!’

I turned the report round and saw that she had misread a < for a >. I had < 50 virus particles per millilitreof blood, not > 50! I was negative! She accepted my interpretation, and was embarrassed. I left the room and walked back to my ward. My skin was cold and wet. I felt fifteen years older.

There were antibody tests at three and six months, and they were negative too. I was not infected. In fact, looking back, knowing more now about the absolute risks, and the cleaning action that plastic gloves perform as a needle passes through them, it was never very likely. But the experience changed me.

*

Professor Ben Green and Emily Griffiths (University of Chester) recently published a paper called ‘Psychiatric consequences of needle stick injury‘ in Occupational Medicine. They administered a depression questionnaire to 17 needle stick injury (NSI) recipients who had been badly affected enough to be referred to a psychiatric clinic. None were actually infected. They compared these results with 125 non-NSI recipients who had been referred for other forms of psychological trauma. The authors hypothesised that NSI caused shorter or less intense periods of psychological morbidity. Their findings included a description that I recognised immediately,

Four of the cases (24%) described an initial period of up to 2 days of acute anxiety, disbelief, tremor and profound sleeplessness consistent with an acute stress reaction.’

Within the (admittedly highly selected) group of 17,

‘Thirteen (76%)…had a diagnosis of adjustment disorder (AD). Four (24%) met the guidelines for post traumatic stress disorder according to ICD-10 diagnoses.’

Other observations included,

‘NSI patients with AD repeatedly said that although accident and emergency staff or occupational health staff had reassured them that the chances of seroconversion were small they focused on the fact that there was still a ‘possibility’ of seroconversion and thus did not feel reassured.

They concluded, among other things, that

‘psychiatric disorders in NSI patients were similar to other trauma-related psychiatric illness in severity, but while they last for 9 months on average, this was not as long as other psychiatric trauma patients. Psychiatric illness following NSIs had major impacts on work attendance, family relationships and sexual health.’

*

These individuals were at the worse end of the spectrum, and the conclusions reached in this paper do not apply to all NSI recipients. I wonder if there is a more subtle effect on those who do not end up being seen by a psychiatrist – a heightened, and more general, sense of self-preservation. My own experience brought it home to me that while my career would involve seeing hundreds or thousands of patients who might carry serious or incurable infections, there was only one of me. I resolved to do everything I could to protect myself…not to a paranoid degree, but by applying a greater sense of caution. So, instead of plunging into the next cardiac arrest situation without a care for the bodily fluids that were leaking onto the patient’s chest or bed, I held back until my gloves were safely on. I know that’s what you’re supposed to do anyway, but in real life people don’t. They rush to save the patient. When I saw a woman collapse during a night out in Soho I ran up to her, checked for a pulse, but did not contemplate performing mouth-to-mouth resuscitation without a mask. I felt selfish, but I could not face the prospect of waiting for more blood test results. (Mouth to mouth is out of fashion now anyway – and fortunately, she was breathing.) Beyond the arena of infection, I became less inclined to make sacrifices that might affect my health or put me at risk of making mistakes; swapping into crazy sequences of night and day shifts as a favour for colleagues, covering extra clinics when dog-tired…sensible behaviour, in no way abnormal, but a change. The damage done.

The Needle and the Damage Done is a song by Neil Young (Harvest, 1972)

cover to tweet

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