My Injury, Your Blood

I have a colleague who teaches about uncertainty in medicine by showing his students a series of optical illusions. In one is a picture that, depending on the gestalt the viewer "sees," appears to be either an elaborate vase or the profiles of two old women staring at one another. Well, gestalt shift applies to moral issues in medicine, too. Recently, I had such an experience. A practice I'd "seen" dozens and dozens of times before suddenly appeared differently.

The gestalt shift took place at our Occupational Medicine clinic, where my patient was a surgical resident fresh from the operating room.

"Triple A's are a piece of work," he said. "Messy. Sometimes you can't even see what you're doing."

I looked at the cut on the pad of his left index finger, a puncture wound that had somehow stretched into a small laceration. If it had happened with a sewing needle at home, a Band-Aid would have done the trick. However, forty-five minutes earlier my patient had been helping his chief repair an abdominal aortic aneurysm—his patient was a 60-year-old hypertensive man with widespread vascular disease. At the clinic we were embarking on our hospital's standard protocol for follow-up of needlestick and other sharps injuries. Our concern was the possibility of a bloodborne pathogen.

I asked about the source patient. Did he have hepatitis B, or C, or HIV? Had he a history of blood transfusion? What about risk factors for sexually transmitted disease? As I started down the list, the resident said, "No sweat. We've already drawn the hep titers and an extra tube. When he wakes up, we'll just ask him about running the HIV."

New York has special requirements for HIV testing. These include pre-and post-test counseling, as well as the patient's informed consent prior to drawing the blood. These requirements remain the same whether testing is indicated for the individual's own medical care, or being performed as a result of a needlestick accident. In the latter case, if the source patient cannot or will not agree to testing, we generally have to proceed without knowing his or her HIV status.

This law strikes many physicians as strange. To them, phlebotomy, performed without a formal consent procedure, is so much a part of everyday practice that making an exception for HIV is jarring. They consider it a legal peculiarity. In the "normal" state of affairs we presume consent for blood work because the patient comes to us for help. Another basis for the presumption is the standard admission consent form, which covers blood work along with other low-risk procedures. From a legal perspective, the distinction between battery and legitimate health care turns on this presumption of consent. However, in practice physicians are likely to forget these ethical and legal justifications and refer only to the risk, generally so small that it disappears from the equation. While the laboratory ensures compliance with the law by refusing to do an HIV test without the appropriate signed consent form, clinicians sometimes see no problem with drawing the blood in advance and requesting consent later.

Like many health care professionals who experience fingerstick injuries, my patient displayed a mixture of detachment and anxiety. On the one hand, he realized that his risk of infection was low, even if the source patient actually had a bloodborne disease, which seemed unlikely. The resident had completed his hepatitis B vaccine series, so hepatitis B posed very little danger, and given this type of surgical accident, the transmissibility of hepatitis C and HIV is only about 3 percent and 0.3 percent, respectively—not very impressive numbers. Yet beneath his nonchalance I detected an anxiety that often comes from knowing too much about medical uncertainty. Residents are well aware that something can always go wrong. While the risk of infection may be low, it exists. Physicians spend much of their time taking care of people suffering from statistically improbable diseases. As I listened to the young man's anxious thinking-out-loud about whether he should begin prophylactic anti-retroviral...