Dr. Justin Maxhimer tried to be careful as he drew blood from an obese patient lying in a hospital bed. The man was HIV-positive, and Maxhimer, a surgical resident at Johns Hopkins Hospital, didn't want to stick a nurse or himself with the contaminated needle.
But as he removed the hollow needle from the vein, the man's belly shifted and bumped Maxhimer's hand. "The needle poked my free hand and drew blood," the 31-year-old doctor recalled.
Known as needle sticks, these injuries are occupational hazards at hospitals and medical clinics. U.S. health care workers suffer up to 800,000 needle jabs each year, with nurses regarded as particularly vulnerable because they draw blood and give shots so often.
Now a study by Johns Hopkins researchers suggests that needle sticks are far more common among early- career surgeons than previously thought and could put them at risk for disease.
In fact, while nearly all surgical residents accidentally jab themselves with needles, fewer than half the injuries are reported and treated appropriately, the study found.
The results of the survey, involving nearly 700 surgical residents at 17 U.S. medical centers, including Johns Hopkins Hospital, were published today in The New England Journal of Medicine.
Even when working with patients infected with blood-borne pathogens such as HIV and hepatitis B or C, surgical residents often skip treatment for needle sticks, the study found.
The authors blame an operating room culture that discourages doctors from reporting needle sticks despite medical advances that make it critical to seek help immediately after such injuries. That institutionalized stoicism, they warned, puts doctors in danger.
Between 1985 and 1999, the Centers for Disease Control and Prevention documented 55 cases of health care workers contracting HIV at work, and most of those infections came from a needle.
1 in 300 chance
The National Institute for Occupational Safety and Health estimates that 1 of 300 health care workers who get a needle stick while working with an HIV-positive patient will contract the virus. When treating patients with hepatitis C, a potentially fatal liver disease, two of every 100 sticks lead to an infection.
Although the risk of contracting a disease through a needle stick is low, the Hopkins researchers note that it would be virtually nonexistent if doctors reported the injuries and sought treatment right away.
"With current drugs, HIV is almost 100 percent preventable if treated early enough," said Dr. Martin Makary, a Hopkins general surgeon and lead author of the study. "We also have good early treatment drugs for hepatitis. But we are finding the majority of people aren't reporting their injuries. It seems as if that's the accepted way to handle needle sticks."
Makary said the survey results confirmed his suspicion that needle sticks among surgeons are more common than previous estimates suggested.
The survey found that nearly 99 percent of surgical residents have had a needle stick and that they suffer two sticks per year on average. That means "they occur at much higher rates in the operating room," Makary said, "than in the rest of the hospital, where most of the data is collected."
What first clued Makary in to the prevalence of the injuries was the number of doctors taking drugs to prevent HIV. "I talked to a lot of doctors who are nauseous because they are taking the anti-retroviral drugs," he said. "It suggested a high rate of [HIV] transmission from needle sticks that isn't being recognized."
Surgical residents are prone to needle sticks and often work with high-risk patients. Because they are rookies, they are often assigned simple surgical procedures, such as tissue biopsies and draining infected areas.
These surgeries - often referred to as "intern cases" - are common in patients with HIV or hepatitis, Makary said.
Residents are also often ordered to stitch up patients at the end of an operation, a procedure in which finger pricks are common.
To avoid jabbing themselves, Makary suggests doctors use "sharpless" technologies, such as skin glues and staples, particularly if their patient has a blood-borne disease.
He also encourages attending physicians - established doctors who serve as mentors for residents and medical students - to set a good example by reporting injuries and insisting that their subordinates do the same.
He cautioned against ignoring needle sticks when patients appear disease-free. "There are silent carriers," he said. "More than a quarter of people with HIV are unaware they have it."
Dr. Craig D. Thorne, the medical director of employee health and safety at the University of Maryland Medical Center, said regular training is important for getting workers to report needle sticks.
"In my experience, people are sometimes fearful of reporting," he said. "Institutions need to let them know that testing is confidential, free and convenient."
Both UM and Hopkins have established 24-hour telephone hot lines for workers to report needle sticks, and OSHA requires institutions to keep a log of the injuries.
Maxhimer, the Hopkins resident, said needle sticks are unavoidable in the operating room, particular when working on trauma patients. "Needles and knives are flying everywhere," he said.
Residents work long shifts in stressful conditions, he said, and might be reluctant to take time out of their hectic schedules to deal with a needle injury. "Some people say it's not worth the hassle," he said.
There's also the issue of operating room machismo - surgeons' reluctance to swallow their pride and admit they slipped up.
Makary says reporting might be stigmatized in the operating room, whose occupants value technical prowess.
Ill but reassured
That didn't stop Maxhimer from seeking help in March, when he was stuck while taking blood from the HIV-positive patient.
He reported the injury and started a month-long course of anti-HIV drugs that day. "It was the most miserable month of my life," he said, because the medicines made him feel ill. "That's what I would imagine it is like to have morning sickness all the time."
He initially worried that taking the HIV drugs might interfere with his wedding, which is planned for September. "At first, I didn't know how long I would have to take them," he said.
However, the drugs also provided some reassurance while he waited for his HIV test results, which he expects back today. "It's stressful," he said of the experience. "Everything goes through your mind at first."