Saturday, October 25, 2008

Facing Fears of Contaminated Blood

Yesterday morning, I did my second point/counterpoint. This debate was about how to counsel a woman who was BRCA-positive and had an extensive family history of breast and ovarian cancer. I was charged with arguing the pro-surgery viewpoint to prophylactically remove her ovaries and breasts. The opposing position was to monitor and screen her regularly. Since we don't have any way to biochemically or radiologically detect ovarian cancer until it is probably too late, screening women at high risk for ovarian cancer is really an untenable position. After the debate was over, I told the facilitator that the debate should really be about whether to use prophylactic surgical management versus medical management with an anti-estrogenic drug like raloxifene. At least that would be a real debate, because screening is known to be ineffective for preventing ovarian cancer, while prophylactic surgery is known to work in most cases. For those reasons, I thought only screening her for ovarian cancer was tantamount to malpractice. He agreed that the debate was too one-sided, so I think future students will have a medical versus surgical management debate instead.

In the afternoon, we had a POD session on innovations. It was awful. First, we got a one hour talk about the CCF Innovations office and how they would work with us if we had something we wanted to patent or whatever. I'm thinking, all I want to do is survive the next week of IM! Then, we had to break into small groups to work on projects. Our biomedical engineer facilitator gave us a problem and told us to innovate, as if you could order people to come up with creative ideas on the spot like that. The project was on designing a better artificial knee implant. I had been up late the night before preparing for P/CP and had a night of call ahead of me, so I wasn't in the mood for this nonsense. When the guy asked if I had any suggestions, I said no. Then he asked if I had any engineering background, and I said no. After that, he pretty much just ignored me, which was fine by me. I even managed to doze off a little. When it was over, I went to the cafeteria for dinner and then caught up with my team.

Last night wasn't too bad for a call night. I spent most of it with the intern, who, like I already said, is awesome. He let me do a bunch of procedures. First, we had to get an ABG (arterial blood gas) on one patient, so he asked me if I wanted to draw it. Well, I hadn't ever drawn one before, but I said I wanted to, and he walked me through it. Fortunately, things went well and I only had to stick the patient twice. Unfortunately, getting an ABG drawn is extremely painful for the patient. I don't know why drawing blood from an artery hurts so much worse than getting it from a vein, but it does. This patient was semi-comatose, but he could definitely withdraw to pain! I have no idea if he could hear me when I apologized for hurting him, but I hope so.

The intern and I took the ABG down to the lab ourselves instead of sending it through the pneumatic tube so that we could be sure it got done right away. However, we wound up neglecting to fill out some form that needed to go into the bag with the blood samples. So a few minutes after we left, the lab paged us, told the intern they couldn't run those samples, and asked us to bring over new ones with all the proper labels and paperwork. That was aggravating, because obtaining the blood for an ABG is very unpleasant for the patient, and the samples did have labels on the actual tubes of blood. But the lab was firm, insisting that the labels on the tubes had gotten smeared or could get smeared or would get smeared. Anyway, to make a long story short, I got the opportunity to draw a second ABG, and this time I hit it on the first try. But I felt really bad about having to do it at all, and we didn't tell the patient why we needed a second sample. Of course, I'm assuming he was even aware of what we were saying.

Later, we went to try to start an IV on a patient that the nurse hadn't been able to stick. I don't understand why the intern on call is expected to do sticks that the nurses can't get, when the nurses have way more experience starting IVs than the interns do. But we got called, so we went to try. The patient was really dehydrated and obese, which were major contributors to his being a hard stick. The intern tried first a few times but couldn't get it. Then he asked if I wanted to try, so I did. The patient was calmly lying in his bed and didn't jerk at all when I pierced his vein. I got a little flush of blood, but the needle came out again. After one more cautious attempt, I gave up. The patient's IV would just have to wait until a phlebotomist showed up in the morning. Normally I'm not the kind of person who has unsteady hands while performing procedures, but last night I did. Plus, I probably didn't try as vigorously as I could have, because that patient was known to be HIV+.

This was the first HIV+ patient I had ever knowingly encountered, and I was thinking later about how mindful I was about his HIV status the whole time I was poking around in his arm. Being stuck by an HIV-contaminated needle is every health care worker's nightmare. When the intern first asked me to try starting the IV, I had a fleeting thought of refusing. There would have been no repercussions if I had refused. I am only a medical student, and there was no inherent expectation that I would try to start that IV. But I tried anyway, even though I was afraid. I tried even though the entire time, the thought that this patient's blood contained the HIV virus was in my conscious awareness. But I managed not to be overwhelmed by that fear even though I was so aware of it.

As a preclinical med student, you tell yourself that your fear of contracting HIV would never interfere with your sense of duty to help patients. But somehow, the situation is a lot more ambiguous when you're poking an HIV+ person with a hollow needle, and the only thing preventing his blood from contacting your bare skin is a thin, latex-free glove.


John said...

Just curious but does your hospital do/teach ultrasound guided peripheral IV placement? Either by MD or by nursing staff?

CCLCM Student said...

Sorry, I have no idea. They don't teach it to third year medical students, at any rate.

KyleNx said...

"screening is known to be ineffective for preventing ovarian cancer"

Aye, this is true.
However, the act of screening it self, that screening which is known, how are we to know that it is sufficient for detecting ovarian cancer in the first place?
How do we know that we cannot detected with a different screening technology which has not yet been developed?

Do ovarian cancer types truly display no unique chemical identifiers that we could trace in the blood?
And do they truly have no unique receptor sites which we could target with functionalized nano particle that would allow easy detection?

CCLCM Student said...

In response to your first question, I would argue there is no doubt that our current methods of screening for ovarian cancer are ineffective. That's why I thought it was a loaded debate. Screening high risk women is no better than doing nothing at all.

In response to your second question, of course we have no way of knowing that an effective method to screen for ovarian cancer won't be developed in the future. But unfortunately, no such test exists at the present time. It's tough to have a debate about using a test that as yet is nonexistent!

Regarding your third question, I have no idea. I'm not an ovarian cancer biologist.

Regarding your fourth question, now you're totally out of my league. I know nothing about receptors for ovarian cancer cells, let alone nanoparticles that can bind to them.

Based on all of these strange and yet leading questions, I assume that you are involved with some kind of research to try to develop nanoparticles that can be used as a screening test for ovarian cancer. If so, I wish you all the luck, because it's sorely needed.