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Dr. Bob Please Evaluate Occupational Exposure
May 20, 2007

Hi Dr. Bob. I don't know if you remember me, but Im the female HCW who always signed as "Your Friend Me."

I know you get thousands of e-mails per day. I would really appreciate it if you would evaluate what happened to me. It might even help others who have had a similar type of exposure even if the environment is different. Admittedly I have had some occasional tendencies towards OCD, so I don't know whether this is one of those times. I hope it is. In fact, I hope I'm stark raving mad.

I sustained maybe a little less than a half inch horizontal paper cut on the back of my little finger, not on the knuckle but close to it, on a Monday evening maybe around 7:30 pm at the latest. It might have bled a little, but not for too long. I was on call Tuesday during which I had to keep washing my hands and changing gloves. I didnt have a bandaid on it because quite frankly I had forgotten about the cut. Early that Wednesday morning, maybe 6:00 am I was helping with a trauma patient who was bleeding and had HIV/AIDS. He was not on any antiretroviral medications so his viral load was presumably high. I removed my gloves to change to another pair and felt fluid hit the finger where the paper cut was. It was either pure blood or blood mixed with a little saline. It might have stayed on about 20 to 30 seconds before I was able to get to where I could wipe it off with an alcohol pad. I don't recall major burning with the alcohol, but I can't say that it definitely didn't burn especially since I was concentrating on the patient. So the cut was about 34 hours old. I don't remember when I was able to get to the sink to wash my hands since I was trying to help save the patient. I was wearing one of those blue O.R. gowns. They are completely non-absorbent so that fluid can just run down off of them. The blood or bloody saline probably ran off the gown and onto my finger when I was trying to change gloves.

1) Should my skin have been closed enough by 34 hours to be considered "intact"?

I contacted the ID physician who evaluates occupational exposures in a sort of informal off-the-record consultation, because she knew my previous history with HIV fears. I spoke with her on that Friday still within the time period to have taken PEP. She assured me that she really didn't see any significant exposure in my case and that by 34 hours the cut would be closed enough to not allow HIV to get inside.

2) Dr. Bob, do you agree with the ID doctor's assessment? Im hoping she was right. The problem is that usually as soon as person A identifies that person B has OCD tendencies, person A no longer listens to what person B is actually saying about an exposure. Person A just assumes its more of the same irrational fears. I sincerely hope this is an irrational fear.

3) Is there any worry about reopening the cut by flexing the joint back and forth and frequent hand-washing before the exposure?

4) I know that youre not a dermatologist, but how soon does a paper cut generally close (meaning enough so that HIV cannot go in)?

5) Should the alcohol in a regular hospital alcohol pad (70% isopropyl) have been able to kill/inactivate the HIV virus?

6) Would a mentally normal person not worry about an exposure like this, or maybe not even remember the cut 34 hours later? I spoke to a couple of other colleagues about this and they say that the cut would have been closed from HIV long before that time and Im fine, but I cant help but wonder if they would say the same if it happened to them.

7) Was the ID doctor correct or just dismissing it as more OCD and telling me what I wanted to hear.

8) Do you have any data on the HCW's that were infected by blood on non-intact skin? Were the wounds bleeding? On some websites they say that if the wound is bleeding out, nothing can be going in. So does that mean that since my cut was not bleeding at the time, that whatever went in, stayed in including HIV?

Dr. Bob please help! I'm really freaking out about this. Im not eating or sleeping well.

I know that when men write in to another certain website that they are scared because they "fingered" a possibly positive woman during her period while they had a cut on their finger, they are generally told that there was no risk. But somehow blood on a cut in a healthcare environment seems to be seen differently.

I have taken some comfort in your answer to the question below. This was the closest I could find relating to my situation although I think my cut did bleed a little in the beginning (not sure). The person below seems to have been sure that her cut never bled.

Quote [Paper cuts and HIV (from a soon-to-be liberal) Aug 7, 2003

Can HIV be transmitted via a paper cut (the non-bleeding variety)? Say, if HIV-infected blood came into contact with said paper cut? Bob, I'm a republican who will be willing to make the political switch if you answer this (also, I love you THIS much! You're converting me!). Much love to you and yours.

Annie

Response from Dr. Frascino

Hi Annie!

No, a non-bleeding paper cut should not be of any concern. They actually close up fairly quickly. HIV would only be a worry if there were significant blood-to-blood contact.

Now if we can arrange for that political switch, we could change you from "Annie Get Your Gun" to the other type of Annie. You know, the kind who sings, "The sun will come out tomorrow. Betch' your bottom dollar that tomorrow, there'll be sun . . . . "

Well I'm wishing you many sunny and healthy days ahead.

Dr. Bob] End Quote

9) Would your assessment be the same for me? Can I rest and put this behind me?

10) Was I a fool for not insisting on PEP?

11) The exposure occurred on 4/25. My period started on 5/9 and is still continuing to this day. If I have become infected with HIV, could it affect my period this soon?

On 5/14, I had diarrhea but have not noticed a fever so far. (I check every morning.) I try to be so careful, no matter who I'm working on. I just can't believe this happened to me. I've been trying not to reach hysteria level here. Please forgive me for being so long-winded.

Thanks so much in advance for your time and for your heart of gold. "Your Crying Friend Me"

Response from Dr. Frascino

Hello "Your Crying Friend Me,"

I must admit when I see an 11-part question that goes on for pages and pages, I'm a bit reluctant to respond, because these types of questions generally get posted by folks who are complete anxious wrecks and it's difficult to address so many hypothetical "what ifs" completely. Also, when I do answer questions like this, almost invariably the questioner immediately writes back with additional questions or wants further clarification on some minute point.

First off, considering your somewhat repetitive multipart question and the fact you have sent it to me every day for weeks and weeks, perhaps you should consider intensifying the "occasional tendencies toward OCD" diagnosis!

One general comment first: you should not be in this dilemma! As a health care worker you should know that all potential occupational exposures need to be reported, documented and formally evaluated. All medical facilities have policies and procedures in place to do this. If you had followed those policies and procedures, you wouldn't be trying to second guess whether an "informal off-the-record consultation" was valid or not. If a qualified physician evaluated your 34-hour-old paper cut at the time of the incident, he could have answered your questions much more accurately than I. That said, I'll try to briefly respond to your 11 questions:

1. Most likely yes; however, since I did not actually evaluate the cut at the time, I cannot give a definitive answer.

2. I have no reason to doubt the ID doctor's assessment.

3. Probably not, but again you are asking me to evaluate something I did not examine.

4. Be reasonable! This would vary depending on the depth and severity of the cut.

5. Yes.

6. I believe your worries are indeed excessive.

7. Again, I have no way of knowing.

8. I suggest you download the updated guidelines from the CDC on occupational exposure to HIV and use of PEP. You can find them on the CDC's Web site and they were published in MMWR. http://aidsinfo.nih.gov/contentfiles/HealthCareOccupExpoGL.pdf

That your wound was not "bleeding out" doesn't mean that it's necessarily "sucking in" either!

9. Yes. I would suggest you do just that!

10. No, however, you were unwise in not following the established guidelines for reporting and evaluating a possible occupational exposure.

11. No.

My final piece of advice is that you report and document this incident, even though it's after the fact. That way there will be a record of what transpired and if the evaluating on-the-record physician feels no testing is warranted, that will be documented as well. Alternatively, he may decide to give you a rapid test at the three-month mark just to calm your worries. One final piece of advice, I believe your "occasional tendencies toward OCD" need attention. Counseling could help you confront and conquer these irrational fears and anxiety-provoking behaviors.

Good luck!

Dr. Bob



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