Stick me baby one more time

Unfortunately I have sustained my second needlestick injury in 12 months. This time, I was jabbed by one of my registrars. She managed to impale our scrub nurse as well in the same operation.

I cannot blame her for the event. We are new to each other, and still getting used to operating together. She is left-handed, and I am not. There is a clash on the operating table where we both like to put our hands. Goggles and visors reduce visibility but protect us from splashes. Double gloving reduces infection risk but reduces sensitivity in operating. Guarding the needle requires handling it an extra time with one's fingers.

Every protective manouevre we undertake compromises our ability to operate. If we are going to work with body fluids and sharp objects there will be a risk of exposure. We have to accept that fact of life, and draw an arbitrary line in the sand between our safety and our patients' wellbeing.

Those two blokes who got stuck in the mineshaft in Tasmania knew that they were at risk. What made that risk acceptable to them?

In any case, what irks me is not that it happened. Rather, it was the Infection Control Nurse^* who came over with her forms and wanted to debrief us on all factors contributing to the needlestick injury. "What could we have done to avoid this event?" I could have said any number of things, like:

• not done the operation and let the patient suffer
  
• use blunt needles that would have botched the whole operation
  
• not worn visors, improved visibility and risk a splash injury
  
• refuse to work with left-handed female registrars

It was clear that none of these were acceptable, or would get me out of her vice-like grip so that I could go and finish the rest of my operating list. So what did I say? "I could have put my hand somewhere else." It was lame, but it filled in the space on the form so I could get away.

Even better was her parting comment. "Why should we risk our lives for our patients?" The fact is, every health worker risks their lives every day for all of their patients. I negotiate insane drivers to get to work every day. I risk being mugged walking from the car park to the hospital. I run the risk of being strangled by a delirious post-op patient every day. And I risk contracting an infectious disease every time I operate. I would love some way to eliminate all of these risks without inconveniencing me or my patients. Unfortunately, the only way this will happen is if I quit and stay home all day. I'm still considering that one.

^*The Infection Control Nurse is a highly trained nurse practitioner / specialist clinical nurse consultant who has a plethora of duties, such as chastising people for needlestick injuries, chastising people for not washing their hands or using alcohol rubs, chastising people for standing in a room with a patient with "black colonies" (i.e. might have a remote chance of possibly having highly non-pathogenic VRE), and handing out jelly babies after torturing you with your annual influenza vaccination.

Breaking Bad News

Yesterday I had the unfortunate task of informing a patient's family that he had passed away suddenly. He had died of (what I presume) was a ruptured abdominal aortic aneurysm (or AAA). This is where, over many years, the main artery carrying blood from the heart dilates and swells, getting weaker over time. In most people this is a very slow process, but for some people it can happen over a few short years, especially if they have high blood pressure, high cholesterol, and smoke. It can continue to dilate like a balloon until it bursts, at which point the patient has a 1 in 2 chance of making it to hospital alive, and a 1 in 4 chance of surviving surgery. Most patients have no idea that they have this problem, especially if they rarely see a doctor.

In any case, my patient had been previously well, but suddenly complained of back pain, collapsed, and had a cardiac arrest at home (a bad sign). He was transported to hospital by an ambulance crew and his rhythm restored, but things were not good. By the time he reached the operating theatre he had died and his belly was so full of blood it looked like a giant watermelon. All of this happened over the course of 2 hours, and there was hardly any time for the family to understand what was happening.

It is tragic enough breaking bad news to anybody, whether it be cancer or any other serious illness, the need to perform any operation to save life or limb, or a death. It is even worse when there is no time or opportunity for the patient or family members to realise that bad news might be coming.

Sadly I have to do this on a regular basis, and perhaps I have not learnt how to do it with grace, but rarely is there a meeting where at least one family member is not crying or asking "How could this have happened?". I have come to accept that no matter how empathic or caring I am, it is always distressing. I have learnt to carry on with my job after breaking the news (there is always paperwork), but make sure that a nurse or somebody else remains with the family to talk things over further and make sure nobody passes out.

So, my (limited) tips for breaking bad news:

1. Always sit down. Do this whether you are breaking bad news or not. It is a good habit for you, and encourages the family member to sit down. It also avoids many fainting episodes.
2. Introduce yourself, then ask the family what they know. This lets the family talk first so you can get a gauge to how they will respond. Often they know what you are going to say.
3. Get to the point. Family members know when you are beating about the bush, and it only gets worse if you put it off. That doesn't mean make it the first thing you say, just be tactful.
4. Always have tissues handy. Nobody ever says no to tissues.
5. Maintain eye contact until you have finished what you are saying. Staring at the wall or floor are bad no matter who you are talking to. It makes you look insincere.
6. Don't try to say too much. They will not remember. It is silly to blabber on while people are crying. Blah blah blah, blah blah blah blah ...
7. Don't get drawn into discussions about "What if?". Theories are theories, and given the selective memory of family members in grief, your conjectures may come back to haunt you. Usually in the Coroner's Court. This is especially true if you have strong opinions about what happened. You are probably upset too (and sometimes wrong).
8. Always check if they have any questions, and offer to discuss and explain what happened at a later stage if they wish. This avoids many complaints.
9. Tell them what will happen next. They do not want to make difficult decisions straight away, but they will want to know if the Coroner or Police will be involved, if an autopsy will be requested, when the body will be removed and to where.
10. If they wish to see the body warn them of what they will see, especially if there are any tubes, wounds or deformities.
11. Always make sure that somebody else is there with you to make sure you are not talking gibberish.