Nov 3, 2005
Dear Dr. Frascino,
I am a med student who completed an OB/GYN rotation approximately 8 months ago. During a laparascopic ectopic pregnancy resection, my resident pulled out the suction/irrigation with the CO2 supply still on. As a result, I was splashed with blood. At the time, I was fully gowned with a protective face shield. However, as I'm sure you are aware, this set-up does not protect your neck from blood exposure. I am not sure if my skin came in contact with blood or not. After the procedure, I checked my neck, but I did not see any visible blood. This was 20 minutes later, however. 5 weeks later, I had an episode of very painful sores on the posterior border of my tongue. I have had these in the past, although not as severe as I experienced with this episode. Also, I had what looked to be a painless exuduate on my tonsils. No other symptoms. Approximately 2.5 months after the possible exposure, I developed a pneumonia, which my Dad subsequently contracted. 3 weeks later, I again noted these painless exudates on my tonsils. Finally (I apologize for the length of the letter), for the last two months I have had chronic abdominal pain, flatulence, gaseous distention, alternating constipation/mushy stools. This was preceded by 1 week of acute watery diarrhea with fatigue, which 2 of my family members also experienced. They have not, however, had the chronic symptoms like I have had. I realize this could be IBS, but I am more concerned that I have Giardia, which I have read is more common in HIV+ individuals. I also worry that this could be HIV enteropathy. I should have included this earlier, but I do not know the HIV status of the girl; however, I do consider her high risk--18 y/o with pregnancy, prior suicide attempt, low income, etc. I know I should just get tested, but I am so scared I just don't know what to do. I was top of my class--no lie--before this happened. I have continued to do well in medical school, but it is getting to the point where I just want to give up. I can't even think about residency right now. My question for you: do I have reason to be so worried?
Response from Dr. Frascino
Do you have reason to be so worried? Yes, I believe you do. But not for the reasons you think. I believe you have cause for concern about your future plans to become a physician if you yourself are having such difficulties in confronting a medical situation. Competent, compassionate physicians cannot have their judgment clouded by fear. Clearly you know what needs to be done. Yet you are paralyzed into inaction by excessive (and unwarranted, I might add) fear. Top of your class or not, if this is your visceral response to medical crises, you may need to reconsider your career plans.
As a medical student now on the wards, you should be well versed in what to do if you sustain an occupational exposure to blood or potentially infectious bodily fluids. An incident report should be filed and you should have an immediate evaluation to asses your actual degree of risk, need for testing, management and follow-up. I recommend you review the "Updated U.S. Public Health Service Guidelines for Management of Occupational Exposure to HBV, HCV and HIV and Recommendations for Post-Exposure Prophylaxis" that were published in the MMWR (June 29, 2001/50(RR11); 1-42). They can be downloaded at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011al.htm.
That said, I will now address your primary concern. Your risk of HIV transmission from this type of occupational exposure is nonexistent. HIV cannot permeate intact skin. If you and your resident had reported this incident at the time it happened, as I'm sure the protocol in your training program recommends, you would have been advised of this fact by the physician evaluating your situation. You also would have saved yourself eight months of unnecessary worry. Even though it is well after the fact, I would still encourage you to report the incident to "occupational health" or your program director. They will provide you with additional reassurance (and a copy of the policy and procedures for occupational exposures no doubt!). If you remain worried, they may even recommend an HIV test merely to set your mind at ease.
Finally, I should also caution you regarding self diagnosis ". . . Giardia . . . HIV enteropathy . . ." etc. the old adage goes: "The physician who attempt to diagnose and treat himself has a fool for a patient and an idiot for a doctor."
The good news is that HIV is not your problem. The not-so-good news is that you have much to learn before becoming an effective physician. I suggest you take the lessons learned from this experience to heart.
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