Case Review: Mystery Stick

Attack One responds to a report of a “person ill” at a large industrial park at the far edge of its district. Heavy traffic makes it difficult to reach the call location in the late afternoon, but the crew finally arrives and makes its way through the factory complex to the restroom area where the patient is supposed to be. However, workers there report the patient has been moved to another office, and after searching two more offices, the Attack One crew finally finds the young man. Fortunately, the first responders had located him more quickly through a different access to the factory. They are working to finish their assessment when the Attack One crew arrives.

The man complains of weakness and has been vomiting for most of the day. He’s told the first responders he’s been ill for some time, but has been evasive about what the illness is. The patient is noticeably pale and speaks quietly. There are no signs of respiratory distress, he does not have a fever, and his vital signs otherwise appear stable. His blood sugar on fingerstick testing is 80. His mucus membranes look pale and dry.

“Sir, we understand you are feeling bad,” the Attack One paramedic tells him. “You appear to be dehydrated from vomiting, and if you are still nauseated, we should give you some intravenous fluids and medicine to reduce it. We will transport you to the hospital closest to us.” The medic notes the patient still seems uncomfortable and evasive.

“Would you please start my IV line in the ambulance?” the man requests. “Be happy to,” the paramedic replies. The crew loads up the patient and moves him into the ambulance. He vomits one more time while being moved.

“You need to protect yourself with gloves,” the patient tells the paramedic when she starts to set up the intravenous line. “I have some kind of infection I haven’t been able to afford the treatment for, and it is contagious to others.”

The paramedic stops and asks the patient to explain as fully as possible. After a series of questions, the patient reveals he has hepatitis C and had been undergoing treatment he’d now discontinued. He has been very fatigued and losing weight, and has missed some work because of his illness. He does not want his bosses or coworkers to know he’s ill, so he has avoided any discussion in their presence. He is afraid his illness will cause everyone to be afraid of him, and he will be fired.

The paramedic takes the usual precautions, starts the IV line, gives the patient a bolus of fluids and some antinausea medication, and transports him to the emergency department. He arrives there stable. The crew gives its report to the responsible nurse and physician and is doing its patient care documentation when a call comes from dispatch. The crew is asked to return to the incident scene and meet one of its department supervisors—and not to complete and close out the care report until that meeting is complete.

They return to the scene and are told over the radio to meet the supervisor in one of the offices where they’d been with the patient. There they find a woman who says she’s one of the man’s bosses. She was helping him when the first responders arrived. They had taken the man’s vital signs and used their glucose meter to check his blood sugar. They’d left some material on the desk in that office, and after the patient was gone, the woman had gone in to clean up. She’d stuck herself on the end of the lancet, enough to make her own finger bleed. She immediately cleaned the area with warm water and soap and applied some alcohol-based solution.

“I can tell this young man has some kind of medical problem,” she tells the crew, “and I want to know if I was exposed to something. I have completely cleaned the wound, and I have always been healthy. Can I get checked and treated for whatever that young man has?”

The Attack One crew leader apologizes immediately, offers to check her wound and asks to see the lancet. Her wound is clean, bandaged and not bleeding. Her vital signs are taken and normal, and the paramedic asks the other crew members to prepare a patient care report. She uses gloved hands to open the dressing material and examine the involved lancet. She recognizes that it is not the type Attack One’s department has used for years, and not the retractable design that has been a standard in the service for the last half decade. Somehow it must have been in the first responders’ equipment, and they used it to do the fingerstick blood sugar.

“Ma’am, once again we are very sorry this happened,” the medic tells the woman. “We treat patients’ medical information with great respect for privacy, so we’re not able to release any information about the young man’s condition. However, we would like to transport you to the hospital where we took him, and we’ll explain to the physician there what happened and let them decide if any testing or treatment is needed. Would that be OK with you?”

“That will be fine,” the patient replies.

The supervisor offers some further guidance: “The device you were stuck with is called a lancet, and we use a form of that device that does not leave it with an exposed sharp end. Somehow the first crew that arrived did not use our device. We will follow up immediately on that to make sure that no more of those are in the system anywhere. We will prepare an immediate report, and you will receive a follow-up phone call from our chief to check on you and to confirm that what has happened will not happen to anyone else.”

The Attack One crew accompanies the patient to the hospital and shares the incident history with the emergency nurse and physician. The ED staff offers to examine the woman, talk with the original young man to see how he wants to share any information, and get any necessary consultation. The woman will receive any available information on her exposure and be provided necessary follow-up.

The Attack One crew finishes its work with the woman, provides her with the name of their chief and leaves her the names and contact information for individuals in the department she can contact with any problems.

Hospital Course

Both patients are treated and released from the emergency department after being tested for hepatitis and any other liver problems. The young man has been infected with hepatitis C, but it is not at an infectious stage, and the risk to the woman is almost zero. He is started on treatment for the chronic form of hep C and referred to a clinic where he can receive it at a reasonable cost. No other infection problems are identified.

He allows the information on his disease to be released to his colleague who had been stuck with the dirty lancet. She is tested for hepatitis and found to have no problems. She receives a follow-up set of blood tests several months later, and her results are again negative.

An investigation of the incident by the department finds that the first-responder unit was using older-model lancets that were not retractable. That unit was from a group employed by the company where the call took place, and was not part of Attack One’s EMS department. Attack One’s chief offers to have his department’s infection-control staff inspect all the first responders’ gear and remove all older and dangerous equipment. A memo is also prepared for all first-responder units functioning in the jurisdiction to make sure no others are using systems that aren’t needleless. Finally, the department’s staff reviews all stocks and supplies of equipment on all apparatus in all stations and in the supply areas to make sure all older needle and lancet systems are gone. All personnel are reminded to clean up all equipment used in patient care before leaving the scene, and to use sharps containers or bags to eliminate secondary exposures.

Case Discussion

Hepatitis C is caused by the hepatitis C virus (HCV). Infection with the virus leads to inflammation and swelling of the liver. In the past it was referred to as hepatitis non-A, non-B. People who may be at risk for hepatitis C are those exposed to blood from others who have the infection, including persons who have regular contact with blood products (like EMS providers); patients who received blood transfusions (particularly before 1992, when better testing became available); patients on dialysis; those receiving tattoos; and those who inject street drugs or share dirty needles. Around 1.5% of the U.S. population is infected with HCV.

Hepatitis C has acute and chronic forms, and a significant number of people who are infected with the virus develop chronic hepatitis C. Most people who are recently infected with hepatitis C do not have symptoms. But acute infection can cause the same symptoms that occur with hepatitis A or B, including abdominal pain, nausea, vomiting, loss of appetite, fatigue and dark-colored urine. Around 10% will develop jaundice, which resolves on its own. Patients with long-term infections frequently complain of fatigue, and have abnormal liver tests and low white counts. If the virus is present in the blood, the patient will remain infectious to others.

Blood testing is done to diagnose hepatitis C and test for liver damage. For healthcare workers exposed to the virus, testing is usually done shortly after the exposure and then again several months later.

Treatment of hepatitis C is evolving and usually includes both oral medicines and weekly injections. The goals of HCV treatment are to remove the virus from the blood and reduce the long-term risks of cirrhosis and liver cancer. The medications have a number of side effects, which resemble those of the infection itself.

As with all bloodborne diseases, the key is prevention. This is particularly important for EMS workers. There have been some hepatitis C outbreaks in fire/EMS personnel that mirrored community epidemics and caused those workers to have long-term problems. There is currently no vaccine for hepatitis C, but research is ongoing.

Customer Service Opportunity

EMS providers have responsibilities to other individuals around the scenes of emergencies to prevent secondary injuries and other problems. An important issue is prevention of exposure to infectious materials. In airborne illnesses, it is appropriate to cover the face of the ill patient with a simple mask to prevent the patient from coughing and spreading an illness (as with a patient with meningitis or tuberculosis). Bloodborne illnesses are spread in bodily fluids, so careful cleaning or absorption of those materials can reduce spread, as well as avoiding dirty needles. Some patient management, particularly in critical care situations, causes more contaminated material to be generated, like bloody instruments, used endotracheal tubes or intubation instruments, emesis containers and suction devices. When possible, all those materials should be bagged up and disposed of properly.

There are a few other situations where EMS providers will have a responsibility to prevent harm to others. One is identifying an environment where dangerous exposure is likely, such as an incident where carbon monoxide is present in a building. EMS providers are responsible to notify protection agencies if they find the life of a dependent person is at risk (e.g., child or elder abuse or neglect).

Bibliography

Rosen HR. Clinical practice. Chronic hepatitis C infection. N Engl J Med 364(25): 2,429-38, Jun 23, 2011.
City of Philadelphia v. Workers’ Compensation Appeal Board (Kriebel). No. 49, EAP 2010. Argued March 9 to October 19, 2011.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton and an EMS World editorial advisory board member. Contact him at jaugustine@emp.com.

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