Why are foreign bodies foreign?

Unfortunately, like most other doctors, I have retrieved my share of foreign bodies. I obviously appreciate that there are some people who get a thrill out of putting objects inside themselves (and for some others, that thrill extends to having it removed). But as a person who abstains from wearing a watch, ring, necklace, bracelet, getting pierced, tattooed or otherwise mutilated in any way, I just cannot understand or empathise.

The very first foreign body I unfortunately had to remove was as an intern - a deodorant roll-on (cap still intact). Unfortunately the soft plastic and the smooth contours of these objects make them nigh on impossible to grab with a sigmoidoscope and forceps. Thankfully, just as the surgical registrar was about to book theatre for the laparotomy, I managed to grab it with my fingers (under a fair amount of midazolam sedation) and extract the nasty object. My lessons from that incident?

1. It is amazing how far up a gloved hand can go.
2. It is possible to endure a plane flight and two taxi rides with a very full rectum.
3. You don't want to know how it got there.

I still wonder about whether I was the subject of some practical joke the second time. A young 20-year old girl presented complaining that she (or her partner) had lost a condom. Perhaps the lawsuit is still coming, but even after a thorough examination, x-rays and consulting with our friendly gynaecologist I found nothing. In retrospect perhaps I should have just told her to believe the ultrasound.

Since then there have been numerous other rectal foreign bodies of various shop-bought, home-made, and (in one case) almost-flat-battery types. There have been the cotton-bud tips in the ear, the fish hooks in the bladder, and the spoon found after 3 months in a skin fold, bits of unchewed steak in the oesophagus (aren't I glad I learnt to do a rigid scope) , and various foreign bodies in diabetic feet. My favourites have been the apple-stem lodged sideways which removed easily after a flash of inspiration (cut it in half!) and, as an iatrogenic complication, the coronary guidewire tied in a knot inside the aorta. Basically you name an orifice (including those created by doctors) and something bad can get up there.

So here are my top ten tips for dealing with foreign bodies:

1. Glass is visible on x-ray. It is amazing how revealing a plain x-ray is. Now we have the luxury of CT scans, but if you are ever unsure - just get an x-ray. And failing that an ultrasound.
2. Unless a rectal foreign body presents as an assault, it is never the first time.
3. You don't really want to know how or why. Just how to get it out.
4. The patient never wants it back.
5. Never poke a sharp object up to retrieve a blunt one, unless you can see exactly what you are doing and are prepared to deal with the consequences. Plaster of Paris can come in handy.
6. For rectal foreign bodies, before you do the laparotomy (or colotomy), try some bimanual palpation under GA. Often a gentle suprapubic push and two intrarectal fingers will guide it around the sacral prominence.
7. Just because it came out, don't assume it (or you) did no damage. Keep the patient for observation and/or do a scope.
8. Prison inmates like to swallow things, usually to get out of the boredom of prison for a few hours. Usually they look impressive on X-ray (e.g. razor blades, screws) but are often harmlessly wrapped in sticky-tape.
9. If swallowed, occasionally it is easier to let it work its way out on its own.
10. Sometimes there is nothing there (e.g. fish bones). If you can't find or prove it, it probably won't do any harm anyway.

Surgical Principles of Bongi

This is a series of entertaining and very true posts from Bongi over at Other Things Amanzi:

1. to swear does in fact help.
   
2. fear nothing but fear itself.
   
3. all bleeding stops.
   
4. enjoy.
   
5. it is in fact always the surgeon's fault.
   
6. take a moment.
   
7. break the tension, don't add to it.
   
8. we do it to impress the chicks.

Clearly Bongi is more successful at impressing chicks because when I did what he did they all went off for debriefing and counselling.

First Day Tips for Surgical Interns

Every registrar or consultant has a talk that they give to new interns joining their team. It is about establishing heirarchy, rules, standard operating procedure, and team-building.

My talk generally incorporates a few important principles:

1. Your job is to make my job easier. Just don't do anything illegal, unethical, or dangerous in order to do so.
   
2. The consultants may mark your assessment form, but I tell them which boxes to tick.
   
3. If I ask you a question about a patient, don't lie. If you don't know the answer, tell me that you don't know the answer.
   
4. If I ask you to do something, I expect it done by the end of the day. If it isn't done, tell me why and when it will be done.
   
5. Don't leave messages for me. If I am busy doing something, come and talk to me. If that means getting changed and coming into theatre, then do so.
   
6. Decisions may be made on the ward round, but reasoning is discussed in the operating theatre. If you want to know why, come to theatre and listen.
   
7. I expect an update at least once during the day and once at the end of the day. Don't go home without letting me know.
   
8. Never be afraid to call me at any time - work, home or mobile. I would much rather know about an ill patient than a dead one.

Apart from laying down the ground rules, I expect interns to learn along the way. There are many things that you have to work out for yourself, or are merely applications of common sense. Here are some tips:

1. Know What You Need To Know. Keep on hand a list of common phone numbers, pager numbers, and hospital stationery. Memorise the important ones. Know who your patients are and where they are at all times.
   
2. Don't Shit Where You Eat. Nurses, Ward Clerks and Registrars that you need to make referrals to can make your life hell. Other interns will sometimes cover for you if you are busy. Keep them on your side. Sleeping with hospital staff (or patients) is a potential disaster area. Don't try it unless you are willing to cop the ensuing flak.
   
3. Prioritise, Prioritise, Prioritise. Every ward round generates work. Usually a lot of it at once. Decide what is important, do what must be done immediately, and plan out your day so that the other tasks get done in a timely manner.
   
4. Work Smarter, Not Harder. There are lots of time-saving ways to made your work efficient. Do things in batches. Keep pads of pre-filled pathology slips. Check results on all your patients together, not just one now and one later. Fill out Discharge Summaries ahead of time.
   
5. Predict and Pre-empt. All units work on a timetable. Know the timetable, and what tasks need to be done before important events like unit meetings, ward rounds, and operating sessions. Repetition abounds. Start to recognise patterns in your registrar and consultant's behaviour in regards to certain patients, conditions, presentations etc. Predict what will need to be done and make preparations beforehand.

A great deal of being an intern is learning to work within a team, being responsible for and to your patients, and getting yourself organised. These are skills that take time to develop - but they will come.

Tips for Medical Students: Scrubbing in Theatre

Milk & Two Sugars from Tea at Ten recently made a post about being uncomfortable when scrubbed in theatre. I gave her some suggestions in the comments, and she suggested that I post my tips to my own blog, so here goes.

Ten Things to Make Scrubbing Up Easier

1. Make sure you have a piss before you start. Or get a pair of those NASA astronaut undies.
   
   
2. Do calf pumps and change your stance regularly, or else you will get venous stasis and pass out more easily.
   
   
3. Whenever you can, rest your hands and or forearms on the operating table. Preferably not the patient, as they can get pressure areas from you leaning on them for too long. Don't wave your hands around (especially over the wound) unless you want to get stuck with a needle. And remember to maintain sterility.
   
   
4. Always let the surgeon know when you are uncomfortable. They will understand. Better a moment to change position than a medical student unconscious on the floor (or in the wound).
   
   
5. Try to engage in banter (where appropriate). You are not the only person who is bored and can't see much - the primary surgeon is the only one who is actually doing something interesting. Mind you, as soon as you have something to do, like a wound to sew up - you will wake up immediately. Also don't feel that you have to talk medicine all the time. It may be hard to believe, but even surgeons have outside interests, and sometimes we are actually interested in you as a person, not just a student.
   
   
6. Tie your mask a little loosely, and tape the top edge to your nose. That way it won't ride up and you can breathe air in from around the edges of the mask when necessary. Make sure you have eye protection - find some goggles if you don't like the full-face masks. Often hospitals will stock very cheap disposable ones, or buy one between several of you.
   
   
7. Don't stick your head in the light. The surgeon loses their lightsource, and you get very, very hot. And then your head explodes, which makes a big mess.
   
   
8. Don't inhale diathermy fumes on a full stomach and don't wave the laparoscope around (both in the patient or outside). The smell of vomit tends to hang around the scrub sink for a few hours, and there is nothing like a laparoscope shining in your eye to make you go blind for a few minutes.
   
   
9. Check out what step sizes are available beforehand - it is more important that you are at a comfortable height than whether you have the best view. You don't want a sore neck, back or shoulders for the rest of your life.
   
   
10. If you are not too keen on getting your hands inside the patient, then sometimes the best vantage point comes from not being scrubbed. Crossing the blood-brain barrier can sometimes give an excellent view. As long as you can see, there is no need to scrub - you can just join in at the end when there is a wound to suture.

Getting Blotto with Otto

At the risk of turning my blog into a "Dear Abby" column for disaffected medicos, I am replying to Anonymous who writes:

Dear Sheepish,

A question for you: I asked my HMO3 today why he thinks women are more likely to develop a femoral hernia. He said that it is because the process of childbirth weakens the posterior wall of the femoral canal. I asked him to tell me an examination feature that would distinguish an incarcerated femoral hernia from a tender groin lymph node. He said that a patient with an incarcerated femoral hernia would have signs of a bowel obstruction and that a hernia is reducible.

I am not on call tonight.

My question is: How many alcoholic beverages should I consume tonight?

Unfortunately for you, Anonymous, however many drinks you have tonight, your poor HMO will still be there on Monday, oblivious to his ignorance and not having learnt a thing. You, however, will be hung over and barely functioning, and very much the worse for wear for your alcohol-fuelled binge.

If you plan on pursuing your surgical career, you need to decide on one of two paths.

1. Work out how much you can drink on a regular basis without anyone knowing the difference. This may take a fair bit of trial and error.
2. Realise that one-in-two or one-in-one on-call, will make frequent Toga Parties or Bond Nights a near impossibility, so perhaps it is time to give up or cut down now.

Personally, I have made it a point that I don't drink when I'm on-call, and at other times I'm limited to one drink at night with dinner. If I'm on holiday, then no restrictions apply. In reality, though, not being in the habit of drinking regularly I often just go without. There is not much point opening a bottle of wine when I know I'll be unlikely to finish it before it goes off - but that is just me.

I don't think that I am any more authoritative on this issue than anyone else - is it OK to drink when you are on call? Given that sleep deprivation for 24 hours is said to be as bad as having a blood alcohol level of 0.05, perhaps it's OK to have a few drinks if you get plenty of sleep? Stories abound about surgeons who operate while inebriated. Is an impaired surgeon better than no surgeon at all? Is an incompetent surgeon better than no surgeon at all? The Bundaberg experience would say no, and so would my MDO.

Perhaps next time, you should ask your HMO3 if he knows what a torsion of the testicle feels like. Or intermittent claudication of the arm. If not, you can always provide a demonstration.

It's Official: Senseless Killing Saves Lives

Apologies for the hiatus since the last post. I have just been through a period of great change, and more is yet to come. In the meantime, I couldn't let this one go. In the latest issue of the Archives of Surgery is this article suggesting that video games enhance performance on laparoscopic trainers.

I guess that means that all those hours spent playing Ghost Recon, Rainbow Six, and The Sims are paying off? (I must say, however, that having worked long hours and not having much of a social life for the last decade I have learnt a great deal about how other people live, or at least how Americans think that other people live, based on The Sims).

Now you know why I've been so quiet for the last few months... I've been brushing up my hand-eye co-ordination skills into the wee hours of the night. I'm still trying to work out whether buying an XBOX 360 or a PS3 would be tax-deductible.

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.

Can't you take a hint?

Betty was 95. She lived in a nursing home. She was delirious and bedbound. She had diabetes, emphysema, untreatable ischaemic heart disease, and a recent stroke. And now she had a fever and a gangrenous leg.

She was going to die, sooner or later.

"She's a fighter" her son said. "Before she became delirious, she told me that she'd rather lose her leg than die."

I didn't say what I was thinking - "This is not a life. You are just torturing her. She is going to die anyway."

Instead I say: "I appreciate what you are saying, but you must understand that amputating her leg has a very high chance of killing her, both immediately and in the near future. And even if she were to survive that operation her quality of life would only be worse, not better. She would definitely never walk again."

"We know that, doc, but we'd rather she die under an anaesthetic than like this. We know that's what she'd want. She doesn't walk as it is."

Perhaps I am weak, but I cannot flat out refuse to do it. I don't know for certain that she will die. She might pull through. Her chances are poor, but they are not zero.

Two days later she is awake and talking to her family. She thanks me for doing the amputation, and goes back to her nursing home. A week later I hear that she has had a "heart attack" and has passed away.

-----

Jerry is 70. He came from a hostel. He was confused but relatively independent , until he developed acute appendicitis. A diagnosis made at laparotomy. He makes a good recovery, but unfortunately, a pressure sore develops on his heel. Bone is exposed, and needs debridement. Malnutrition limits what healing is present. The arterial supply is limited. He is too confused to eat. He needs nasogastric feeding, an angiogram and a small operation to clean his ulcer.

"We don't think he would appreciate it, doc." said the daughter. "He doesn't know what is going on. He won't want to risk losing his leg. We're sure he wouldn't want a tube in his nose. Why can't we let him die with dignity?"

"He is not going to die anytime soon." I say. "But this ulcer will be with him for the rest of his days unless we remove the bone and put a skin graft on it. The ulcer won't kill him but it will cause him pain."

"We think he's had enough. We'd like to speak to the palliative care nurse."

Palliative care takes him over and he is dosed up to his eyeballs with subcut morphine. A month later he is still alive. I wonder how long he will last at the hospice, and how much morphine he can handle.

-----

John was 65, living with cerebral palsy, schizophrenia, and a recently fractured humerus. Paraplegic and confused. He had recently been transferred into a nursing home where he was fully dependent. Now he had severe, sudden onset abdominal pain. There was gas under his diaphragm. There was no doubt he had a perforated viscus. Probably a duodenal ulcer. Laparotomy would be straightforward and life-saving. "I'm not going to die, doc. Just give me some pain killers and let me go home. I don't want an operation." he said.

There was no family. They had abandoned him years ago. His sister hung up the phone when rung at 2am in the morning. The GP that normally treated John was on holiday. From the little information I could gather, his quality of life was non-existent. Who do I ask? Who do I turn to? Do I have the right to decide whether to operate or palliate? In his incapacitated state does he have the right to refuse surgery?

So I passed the buck, and called the Chief Medical Officer. "What do I do?" I ask. "You are authorised under law to do as you see fit. As the clinician on duty, the hospital will support your decision." came the drab reply over the telephone.

So I wrote up the omeprazole, turned up the morphine infusion, and went back to sleep.

The pS monitor

Psst, don't tell anyone, but I am working on a secret new medical device - the pS monitor. Let me explain - imagine me as a young Trauma Surgery registrar, trembling with a combination of fear and cold (why are hospitals so cold at night?) as I get called to my first trauma in the middle of the night.

"65 year old man, previously well. Single vehicle MCA, ejected through windscreen. 4-wheel drive versus tree in an 80 k zone." As the ambulance paramedic continues talking, an extra ED nurse starts filling in her clipboard. "Patient was unconscious at the scene with GCS 5 (tick) BP 90/60 (tick) Resp Rate 20 (tick), he was diaphoretic and shut down. Intubated at the scene with difficulty."

"Why say 'diaphoretic' when you can say 'sweaty'?" I think to myself. It annoys me as much as when people say 'pussy' instead of 'purulent'. I have dreams of infected abscesses exuding cats. Call me weird if you will.

As the ambo keeps talking, I start examining the patient. He is intubated, unconscious and paralysed. I can hear breath sounds throughout the lungfields and there's no dullness on percussion. There are some clinically fractured ribs on the right. "Good," I think, "No need for a chest tube here - yet." BP 100/60, Pulse rate 100, thankfully the fluids are going in through two nice big 16G IVs.

Primary survey over, I complete my secondary survey - forehead laceration with a small right occipital haematoma, cervical spine roughly in place (and patient asleep), clavicles and upper limbs intact, rib crepitus on the right, lax, paralysed abdomen, pelvis intact, and a left femoral shaft fracture. As I describe my findings for the benefit of our ED registrar, I see the nurse in the corner of my eye going "tick, tick, tick-tick". She seems strangely quiet as I check his urethra and do a PR. I'm much happier when I feel bounding pedal pulses. Chest and Cervical Spine X-rays show some early pulmonary contusion, no haemo- or pneumothorax and aforementioned rib fractures.

The left leg goes into traction, and then off for a CT scan of his head (left parietal contre-coup contusion with a small subdural haematoma - "tick-tick"), neck (normal - but the collar stays on), and abdomen (minor hepatic laceration - "tick"). The femur gets nailed while the neurosurgeons put in an ICP monitor and the patient goes to ICU intubated with a Philadelphia collar until he wakes up.

I'm left wondering what all that ticking is about - and then I realise... it is the scoring for the trauma audit. Our nurse is calculating the patient's probability of survival. And for my patient it is 27.6%. Do I care what it was? Would I have stopped, had I known his poor likelihood of survival? I don't think so. But it looks like a great business opportunity to me.

That's why I am introducing the digital Probablility of Survival (pS) monitor. This little device will use advanced voice-recognition software as the registrar describes his findings, and with some fancy wireless networking, will pick up the observations from all other monitoring equipment. Using my secret modified algorithm a much more accurate probability of survival will be calculated every 5 seconds, so that you can know exactly when to stop resuscitation.

Imagine all the unnecessary exploratory laparotomies and ICU time that could be avoided. All the CTs and MRIs and IVC filters that wouldn't be wasted. We could resuscitate people until their pS fell below the economically viable threshold for the hospital. I don't believe in the device one little bit, but at US$1000 each, 5 for each ED worldwide, imagine the money I'd make!

I can't wait until my next invention is ready... the B-S monitor.

All I need is a knife, spork and foon!

On a lighter note, one of my colleagues is known for not being fussy with his surgical instruments. As a surgical registrar, often you are subject to the vagaries of available equipment at your hospital. In many cases the instruments you want or prefer may have just been put into the steriliser (and thus unavailable for the next four hours), or in use in another theatre, or not on your scrub nurse's tray, or dropped on the floor, or just plain don't exist.

One learns to be versatile, and a pair of forceps becomes a blunt dissection tool, a retractor, and a needle holder. A pair of artery forceps (or, as those surgeons on the other side of the pond call them, "hemostats") becomes a towel clip, a retractor, a blunt dissector, a temporary replacement for dressing tape, and many other uses that only become obvious at the time.

In any case, this colleague was known for saying (when asked, "What instruments will you need?") "A knife, fork and spoon please."

Lo and behold, one day he was handed a sterilised kitchen cutlery set. The nurses were kind enough to open some real surgical instruments after they had finished laughing at their joke.

Having said that, though, a spoon actually does a pretty good job of removing thrombus from the inside of aortic aneurysms.

On the subject of spoons, this article recently came to my attention. I can only say that epidemiologists have a lot of time on their hands.

Needlesticks and Surgery

Barbados Butterfly recently posted about her needlestick injury. I hope she is feeling better. I have had three official "patient body fluid exposure incidents" during my career. They were:

1. Giving mouth to mouth at a roadside accident as a medical student, unfortunately to a fatally injured Hep-C positive patient
2. With a solid round-bodied needle during a difficult low anterior resection (no stapler)
3. At the end of last year, topping up a wound with local anaesthetic at the end of the case.

Self-safing (retractable) needles, IV cannulas are great, but in many ways they make things more difficult because they are always more difficult to manipulate (especially in difficult situations, small, fragile veins, awkwardly positioned patients) than the original. There are many times that I have lost an IV because the retractable needle was too sticky when removing it from the IV cannula (I use a single-handed IV insertion and setup technique, while the other hand steadies the vein).

By far and away, though, I think the biggest contribution to avoiding needlestick injuries are the needleless infusion systems, using IV bungs (reflux valves) and Luer locks. Unfortunately many hospitals are too cheap to stock true Luer lock syringes (that twist and lock in) and just get Luer slip syringes. In that setting spray exposure from a loose fitting syringe-to-bung is rather common.

The needle and the blade will not disappear in the foreseeable future of open surgery. Needlesticks are and will still be a fact of life. I was recently offered specific "needlestick infection insurance", and on reading through the paperwork, the payout was a lump sum on confirmation of new-onset infection:

"A benefit will not be payable if: ... a medical cure is found for Acquired Immune Deficiency Syndrome (AIDS), or the effects of the HIV virus, Hepatitis B or Hepatitis C, or in the event of a treatment being developed and approved which makes these viruses inactive and non-infectious."

Even if such treatment is hideously expensive or years away from market availability?

"... you have AIDS or any AIDS related disorder or a positive blood test... unless you are able to provide evidence, in the form of sequence analysis of the source and index virus strains, satisfactory to us that the accident involved the definitive source of the virus."

Why would I be applying for this cover if I already had HIV? What kind of product do these guys think they are offering? I think I will rely on my Income Protection Insurance, so I have thrown it in the bin.