Bongi recently had a post about an experience getting stuck by a needle while operating on an HIV positive patient. It reminded me of a time during my residency I had forgotten.
I was a second year resident on the transplant service and it was out of control busy. My program had just added a new liver transplant surgeon who had quadrupled the surgical volume in the 6 months he had been at Rush. Unfortunately, our program still hadn't changed the resident distribution to account for the extra work so there was just a PGY-1, a PGY-2, and a PGY-3 taking care of over thirty patients. We absolutely got killed but it was fun because, as junior residents, we did a lot of operating. Not many second year residents in American surgery programs get to first assist on a liver transplant and put all the stitches in on a portal vein anastomosis.
I was post call and there were seemingly a thousand AV fistula cases to do before I could go home. I'd been up all night during the call doing a kidney transplant. The third year was stuck in a liver case and the intern was running around like a headless chicken trying to take care of the patients in the ICU and on the floors. It was around four o'clock in the afternoon when I introduced myself to the last AV fistula case.
Initially, I thought I'd entered the wrong room. The patient was on an oxygen mask and he was curled like a wounded calf on the bed. He appeared to weigh somewhere between 60 and 67 pounds. He looked at me with these dead black eyes. He wouldn't talk, just nodded his assent to my queries. His skin hung like an ill-fitting rubber mask from his protruding facial bones. He was a skeleton, thinly clad in papery, translucent skin. I reviewed his chart. He was HIV positive. His last CD4 count was less than 50. He was on five different medications. The note from his ID doc indicated that he had a "highly resistant strain" of HIV. And he had renal failure. He needed a fistula.
As a second year resident, I didn't question anything. Somebody had decided he needed a fistula. So be it. I wheeled him back to the OR. Of course now, looking back, the whole scenario is absurd. An AV fistula takes months to mature. You can't even consider using them right away. What were we thinking? This man needed dialysis access? He needed a bed at hospice.
In those days, the attending would scrub in briefly, make sure the anastomosis was lined up properly, and then we were on our own. The case actually went quite well. There was a nice thrill in the venous limb when I released the clamps and I proceeded with the closure. As the attending was leaving, he asked me a couple questions about patients on the floor. I wasn't paying close attention, my eyes off the operative field when I felt a sharp prick on my index finger. Looking down, my heart sank; the creamy white of the glove was rapidly staining red from the inside. I ripped the glove off and blood was pouring from a deep wound. It hurt like hell. I felt it to the bone. I started dumping betadine on it, then wrapped it in gauze. The attending sent me down to employee health.
When you sustain a needle stick injury, you get plugged into the "system". You get your blood drawn. You meet with the nurse practitioner. An incident report is filed. You basically spend three hours in employee health. Then I met with the ID specialist. This was the same guy, coincidentally, who took care of my patient. He shook his head, reading the chart. Of all the people to get stuck by, he said. That night he started me on three different HIV drugs. Nothing beats gagging down three horse pills four times a day. Back at employee health, I met with a counselor. She was very nice and gentle and everything, but she made me feel like I was already infected. I was given literature on "dealing with HIV". I was encouraged to attend local HIV support group meetings. Lots of pamphlets. Thanks, but no thanks, I told her.
Once I finally got home, I was in shock. I hadn't slept in 36 hours and my finger still throbbed and I had fifteen jawbreaker-sized pills to swallow. I felt like my life had suddenly veered into a brick wall. I had just gotten engaged. I was going to be a surgeon. I was living in Chicago. I wanted a family and a nice life and to be a good father to a couple of rugrats. And now everything seemed to be in jeopardy.
In retrospect, my fears were exaggerated. The risk of HIV transmission after getting stuck by a hollow bore needle is 0.3%. I was hurt by a suture needle, which further reduces the chance of transmission. Furthermore, there has never been a documented case of a surgeon acquiring HIV from a needle or scalpel. But at that time, I was a basket case. The rapid HIV test wasn't available then, so I had to wait the full four months to assess for possible seroconversion. Intially, the days crawled by painfully. I couldn't stop thinking about it. About three weeks after the incident I developed a horrible cold. Granted, it was winter in Chicago and everyone was getting it and I hadn't been sleeping or eating well, but I wondered; is this the prodromal HIV flu? I refused to acknowledge the possibility. It was the only way to get through the days.
After I got my blood drawn four months later, I didn't call the lab for the results for two weeks. I figured if it was positive they would have contacted me. But I was also terrified. I didn't want the burden of knowledge. I wasn't ready.
Finally, I got off early one day post call while on trauma. I went to some sleazy bar and gunned down a couple of beers. Courage restored, I went to employee health and requested the results. When they told me it was negative I felt lighter than air. This invisible, oppressive burden I'd been hauling around for months had finally been lifted. I could breathe again. My reprieve had come through. I made a lot of promises to myself that day. How I would be the most dedicated and empathetic surgeon on earth. How I was going to be the best husband to my wife. How I was going to make the most of time, wringing every last drop of utility and meaning and enrichment from my remaining waking days. Philosophy and kindness and charity and all that rigamarole. It would start that afternoon and last the rest of my life.
After a couple weeks, I forgot my vows. It didn't take long. I started getting pissed off again at stupid inconveniences. I wasted time watching sports and surfing the internet. Once again, I was consumed with the minutiae of my narrow, regimented life. The years rolled by and I forgot about the whole episode.
Reading Bongi's post brought it all back. And strangely enough, a small part of me sort of misses that time. There was something powerfully existential and substantive about it all. Rarely do we visit those dark places of the soul where our ultimate weaknesses are exposed. Rarely do we acknowledge our ineluctable mortality. It's too much. It throws us off our fragile equilibrium. There's too much to do in the here and now. But the time will come for all of us. The day of reckoning is unavoidable. Whether it's lump in the breast or a heart attack at age 47 or a sudden stroke or a car that runs a red light. Eventually, there's a needle stick that gets us all. And I think it hurts, initially, no matter how old you are when it happens.