23 July 2011

Person to person

I got a patient’s blood on me the other day.

(not unusual)

A patient’s blood splashed in my face the other day.


A patient’s blood spattered over my face, little drops over my neck, cheeks, forehead, and one on the inside of my lip. That I felt – one. None in my eyes.

A patient’s blood spattered on me and her eyes were closed and she was concentrating so hard on her breathing that she didn’t notice I stopped, stopped the procedure. I stopped for a minute, maybe two, at most. More like 90 seconds.


I stopped touching her when her blood spattered over my face.

There was a second year medical student in the room – she saw. I motioned her over to me. She grabbed a paper towel and started dabbing at my face, my neck. I gestured, half whispering, half mouthing the words without moving my lip – here. My mouth. Finally, she slipped the paper towel between my lips and the one blood spot, the one, might have been wiped off and gone. “Go check in the bathroom later,” she said. I was almost finished, so I finished the procedure, had the patient sit up and made sure she was okay, then I left the room. Walked, walked to the bathroom, rinsed my mouth, saw a few other spatters. Tiny, tiny red spots. I might not have noticed right away if I hadn’t known – someone who wasn’t right next to me might not have noticed. The debate then, was whether to tell anyone.
It wasn’t a needlestick.

And blood to skin…yes, mucous membrane, that one spot on my lip, but it’s not like I was bleeding, too, and had a cut there. None to my eyes. The risks of transmission of anything…
thinking, thinking, thinking. Nothing. Nothing that wasn’t curable and easy. And probably nothing.

I did. Tell. I told the charge nurse, she told me to call needlestick (“exposure”, it was. I had an exposure. I was exposed to a patient…). After a series of call-backs, call-back-laters, and why-are-you-calling-this-number-and-not-that-other-ones, I described what had happened.
I’m a med student and I’m interested in infectious diseases. I’ve studied/worked in HIV for almost 7 years. I know the risks, I know them, but I wanted to check I wasn’t being cavalier.
The woman on the line said the only thing she could have worried about being transmitted would be heptatitis B – but I’m not only vaccinated but immune, as proven for school. Anything else… HIV, hepatitis C being the major worries – was next to impossible. Next to, since nothing is.
We discussed testing the patient – she was coming back the next day, anyway, and we had no labs for her.
If it won’t change your clinical management, don’t do it.

We learn that. It’s rational.

Were she positive, would I go on PEP? (post-exposure prophylaxis for HIV, a month worth of antiretrovirals, making you retchingly, wretchedly tired and sick). No.
For Hep C, there’s nothing to be done anyway.
And anything else – well. Both close to zero possibility and curable.
(End Infection control and disease transmission lesson for the day) .

Universal precautions? Not applied universally. No one wears a mask for this.

We love to use the word “discomfort.” “This shouldn’t hurt, but it might be a little uncomfortable.” “Pressure… lots of pressure.” “Is that pain or pressure?”

(Discomfort: acutely feeling each drop, real (real) and maybe imagined, each spatter-point. Hyper-aware. Discomfort: the mask over my face, eyes, that alien-like barrier from the patient, frustrated with breathing, sometimes, and not fogging up the eyes).

What I used to consider a sort of torture instrument (tenaculum), I’ve used to manipulate with ease – and as much force as I can muster. It’s a clamp you put on the cervix to straighten out the uterus, essentially. In some techniques, you inject lidocaine first; in others, you don’t. Is the tenaculum-discomfort worse than the lidocaine injection-discomfort – should you just get it over with? With these procedures, it’s injection first, tenaculum second, and then two more injections for the paracervical block.

The tenaculum is there to help straighten out the uterus by pulling on the cervix, which makes it easier/safer to manipulate anything in there, instruments, etc. And if the patient isn’t flinching, I’m pulling. It’s my counter-traction. And I’m pulling hard.

If the patient isn’t flinching or saying anything to me or tensing her legs – she’s not feeling it. True? Yes, or at least, I’m not causing any additional discomfort. There are varying theories on this – do the block first and tenaculum second? Or just the tenaculum? Ie, pain of injection, anxiety of longer procedure, versus just pain of tenaculum and over more quickly?

The patient, the patient’s blood, the blood on me.

For this procedure (consider: tenaculum. This was a pelvic procedure, involving the cervix. It was frank blood, fresh bleeding, from something that I had caused – normal, normal, when any instruments touch it. It’s friable (delicate, in brief).
In Spanish, “cervix” is boca de la matriz. Mouth of the (mater, mother). In English, the opening of the cervix is the os. Latin for “mouth.” We could call it “mouth of the womb.”
Bright red bleeding per os, this was. Fresh from vessels I had micro-lacerated, in space, to me.

No one wears a mask for this. But there was blood pooling in the vault, in the fornices…
(in the next, or the next-next, I will describe what I was doing, why I was doing it, and what I’ve been doing this month. For now, the patient, and her blood).

On my ob/gyn rotation, third year, a patient’s blood spattered at me – but I was wearing glasses. I only knew later, taking them off, seeing the dried flecks on the glass. It was unusual for me to wear them. It was the first time there had been blood.

Another time (there are many times), a patient’s blood dripped onto my skirt. I was wearing red that day, luckily – and I don’t say this just for staining purposes, but because that way the patient didn’t do. I didn’t want her to – I never do with this. There’s no reason for them to feel badly about it. They apologize enough for having bodies and for reacting to things within and outside their bodies.

No apologies for what those bodies might do, might interact with me. I don’t tell them. Unless it’s a question of real disease transmission – a needle stick or way I really could have contracted something – they don’t need to. There’s no purpose – there’s no therapeutic purpose in them knowing. As long as they don’t see, I don’t say.

Patients apologize for the state of their bodies, for what they look like while sick (or well), for what they're wearing, for what they say in pain – in-between bouts of complaining (we say everything they say is complaining, and everything they say “no” to is denying) and yelling and sleeping and getting pain meds and getting off of pain meds and feeling better. I’ve had apologies after pain meds wear on, after patients feel they’ve been listened to, the next day, in clinic a few weeks later…
The patients who mutter under their breath, apologizing for the language they feel slips out uncontrollably while I’m doing some procedure that is quite uncomfortable – no apologies, I say, say or yell whatever you want. Call me whatever you want, I promise I’ve heard it before – and I won’t be offended. (True and true).

They apologize enough for having bodies.


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