Needle Sticks and Scapel Injuries

I've been stuck by a sharp object twice in my medical career. The first time, I was doing a lumbar puncture, aka spinal tap, on a 3 week old neonate for a complete septic workup. I had everything prepped and had the long spinal needle in my right thumb and middle finger. As I was turning to ask the assistant something, I poked myself at the tip of the index finger. Fortunately, the needle was clean and I had not even began the procedure. I washed up immediately and was not concerned about infection or tetany (I had my tetanus shot 2 years ago)

Recently, I was about to place a chest tube on a patient.

I prepped the skin and injected generous amounts of lidocaine into the tissue. I made a small incision with my scalpel above T4 level along the anterior axillary line and placed the bloody scapel on the sterile drape over the mayo stand.

I turned to grab the Kelly's and instead stabbed myself with the scalpel on my right thumb through the latex glove. Blood oozed immediately into the glove and yet I felt no pain.

My attending told me, "Sam, wash your hands like you've never washed them before." Luckily, the surgical residents were right next to me and took over the procedure. We didn't know too much about this patient, so it was frightening to consider that I could become infected with HIV, Hep B, Hep C, or other bugs.

Although, I've taken care of several staff with needle exposures, I'd never personally really felt the fear of the unknown. A rapid HIV test was ordered on the patient, along with Hep B and Hep C testing. The wait felt like it took forever and I was offered a triple combination of HIV antiviral medications. Should I take them? I pondered as I looked over the CDC recommendations:

As you can see above, I am in the "Source HIV status unknown" and "More severe injury type." CDC does not generally recommend taking PEP. However, I opted to take one dose now, as its most effective in the first 1-2hrs, plus I got some Zofran ODT to prevent nausea/vomiting.

Overall, everything turned out OK for me (pending studies). I gained several insights about needle sticks during this encounter:

1) Although the risk is very low, it's mind-boggling freaky to be faced with the diseases that can change your life.

2) During procedures and traumas, it's particularly important to SLOW down and be aware of each and every sharp object on the table.

3) Percutaneous injuries are very common in the hospital. Even with all the safety mechanisms, more automatic methods need to be created to prevent them.

For example, in the central line kits, there is Styrofoam piece designed to temporarily place needles into.

My suggestion: Please place one in the chest tube kit!

Seven Lessons Learned from Ambulance Ride Alongs

I am on EMS this month as part of my residency training. This includes time with police, firefighters, 911 operators, and ambulance crews. Today, you will gain from my experiences with hanging out with an AMR ambulance team.

1. Be nice to the EMTs/Paramedics. They determine who comes to your ER. Typically, patients can request which hospital to go to. However, if a patient is clueless about where they want to go, the ambulance crew will decide for them. Otherwise, they will bring all indigent vomiting/diarrhea patients to you.

2. Listen to EMS providers. Sometimes the ride to the hospital takes a while, and there is a paramedic in the back talking to the patient for a solid 15-30 minutes. They ask a lot of questions and can give you a significant amount of history.

3. Teach an EMT/Paramedic something each time you meet one. A lot of these guys/gals are eager to learn. Because they are truly the "front-line" they can help you with diagnosing critical situations.

4. Give free food. It's tough being out on the road. EMS providers don't get as many perks as police officers or firefighters, but definitely deserve props for the work they do in the community. In my opinion, they are truly unrecognized heroes.

5. Help them access a place to sit for paperwork. Documentation is a necessary evil in the practice of medicine. It's much easier to sit in a non-moving site to finish up charting on paper and computer.

6. Give them feedback. If you see an EMS provider and recall a patient they brought in previously, tell them about what happened during the ER stay. A lot of paramedics and EMTs remain in the dark about the ultimate outcome of the patient they bring in.

7. Don't sweat IV access. It's challenging to get an IV on patients, and even more difficult in the back of a vehicle bouncing along the roads. If they don't get an IV, please give them a little slack.

Overall, we have to respect them. Listen and teach. They have a lot of information to give and are willing to learn.

Easy Ocular Application of Fluoroscein

Below is a Blog Post in Tricks of the Trade that I helped write. Thanks Dr. Lin!

Trick of the Trade: Easy ocular application of fluoroscein

Gently instilling a fluorescein drop into a patient's eye requires that the patient keep his/her eye still. What do you do for a patient who can't quite stay still enough, such as an infant? This is an innovative trick of the trade, written by Dr. Sam Ko (Loma Linda EM resident) and Kimberly Chan (Loma Linda medical student).

A 14-month old male is brought into the Emergency Department by his mother because he is rubbing his eye and inconsolably crying. You suspect a corneal abrasion or foreign body and decide to quickly evaluate his cornea using the fluorescein stain. Using the method below, you’ll be able to perform the exam with little discomfort to the patient.

1. You will need a small vial of saline (left) and a fluorescein strip in packaging (right).


2. Open only one end of the fluorescein strip package.

3. Insert saline flush vial into the package.


4. Flush saline in and out of the packaging several times until the fluid in the bottle turns yellow.

5. Now that the saline vial contains fluorescein, use the container like an eye dropper.


Pearls to consider:

• Defects in the corneal epithelium will appear green under the light.
  
• Beware that mucus can also stain green. If you aren’t sure which is which, ask the patient to blink. The mucus will move, but the defects won’t.
  
• Remove contact lens before this exam, because they can become permanently stained (perhaps a cool Halloween trick for next year?).
• Pseudomonas easily grows in fluorescein dye, so never reuse or share dye.

Crystal Meth: Multiple Pictures are Worth a Million Words

Healthcare Cost Reduction Idea

If a person requires dialylsis for end stage renal disease and are unable to pay for it, the patient can get Medicare to fund the dialysis.

"The cost of kidney dialysis averages about $44,000 per year per patient, using 1993 figures. The average cost for the transplant patients in our study, including the transplant surgery and medical care for the first year following surgery was $89,939. After the first year, costs for the transplant patients averaged $16,043; mostly for medications to prevent rejection.

http://www.umm.edu/news/releases/kidcost.htm

I wonder if it'd be better to open up a market for kidney transplants.

Why Medical Students Stay Up During Call

Med Student: Dr. Bausch, I've got several hours more work to do tonight, and you don't. How come you're always going to sleep, and I'm always staying awake?

Roy Bausch: Simple. You're a mathemetician, right? Now, I get paid a fixed salary by the BMS, no matter how many hours I'm awake. You pay a fixed tuition to BMS, no matter how many hours you're awake. Therefore, the more I sleep, the more I earn per waking hour, and the more you stay awake, the less you pay per waking hour. Got it?

~House of God by Samuel Shem, MD

Top 20 Tips for Intern Year

1. When ordering a test or taking any action on a patient, ask your self the question, “Why am I doing this?” If it doesn’t change the patient’s outcome, reconsider your plan.

2. Evolve your communication skills to the maximum. Keep your attendings, senior residents, nurses, patients, and patient’s families up to date on the plan.

3. Ask questions when you don’t know the answer. Its okay to ask the nurse and even the actual patient, “What do you think is going on?”

4. When you’re on call overnight and sleeping in your plush intern bunk bed, and a nurse calls you about a patient with abdominal pain, chest pain, or difficulty breathing, get out of bed & go to see them ASAP.

5. If a diabetic patient comes in with nausea and vomiting with no chest pain or SOB, still consider Acute Coronary Syndrome (ACS) in your differential.

6. If someone yells at you or criticizes you, ignore the instinctual reaction of defending your position. Simply state, “Sorry. Mea culpa. It won’t happen again.” Even if it was not your fault.

7. Be nice to nurses, BUT don’t always listen to them.

8. Teach something to a medical student, nurse, PA, a junior resident at any free moment. Spend the additional 2 minutes to P.I.M.P. Doctor comes from the Latin word, doctoris, which means teacher.

9. If you say you are going to be somewhere, or promise to do something, follow through. If you can’t, let them know as soon as you realize it.

10. Be generous with pain meds. It’s better to give narcotics to fakers than to have a person in really bad pain. In trauma patients, consider fast acting fentanyl 1 mcg/kg

11. Do the things that scare you and see the patients that you find challenging. Be aware of your backups in case you suck. Feel the fear, and do it anyway.

12. Try not to hook up with co-workers, nurses, med techs, etc.

13. Exercise regularly.

14. During vacation weeks, go somewhere that requires a flight. You’ll come back much more refreshed. Also, don’t request vacations in the first week of a rotation, you might be lost when you come back.

15. When calling a consult, be sure to know the patient. Then introduce yourself by name. Verify that it is the correct service. Ask for their name. Ask how they are doing today. Begin with, “This consult is for…” and tell them the rest. End the conversation with, ‘Do you have any other questions about this consult?”

16. Try not to call bogus consults. You will recognize them after you’ve been an intern for that service.

17. If you have an infant who is crying, inconsolable, and everything else is normal, get the lidocaine eye drops. It just might be a corneal ulcer.

18. In the ED, ask the patient, “What made you decide to come in TONIGHT?” and if it’s a chronic problem, “What does your primary medical doctor think about this?”

19. If it doesn’t make sense to you, question your attendings and senior residents in a diplomatic way. They are human and make mistakes too.

20. Forgive yourself for the mistakes b/c you will absolutely make them. Just learn from each. James Allen wrote, “Circumstances don’t make a man, they reveal him”