EMS Question about HIV

[nockamura]

I was curious to know if an EMS worker is exposed (needle stick, etc) can he/she demand that the patient be subject for testing of all known communicable diseases including HIV? My EMT instructor said that an EMT that is exposed can request any test except that for HIV, but my professor says that we can request it if we're exposed. Does anyone know what the law regarding this says exactly, specifically in California?

---

Members don't see this ad.

 

[Daedalus]

Well here's a document that addresses this issue in Los Angeles County:
http://www.dhs.co.la.ca.us/ems/manuals/policies/836.pdf
I'm not sure how close to CA law is on the matter, but I assume it's similar if not identical.

Generally, if it is known that the patient is HIV positive, the physician can tell the exposed EMT whether or not the patient consents. If it is not known if the patient is HIV positive, he or she can refuse to be tested, but any blood sample obtained prior to the exposure can be tested without consent. It seems a little shady to me that if a physician determines that there has been a significant exposure, a patient can still refuse testing.

 

[FoughtFyr]

I was curious to know if an EMS worker is exposed (needle stick, etc) can he/she demand that the patient be subject for testing of all known communicable diseases including HIV? My EMT instructor said that an EMT that is exposed can request any test except that for HIV, but my professor says that we can request it if we're exposed. Does anyone know what the law regarding this says exactly, specifically in California?

You should understand that according to a large clinical trial, the odds of contracting HIV via a needle stick injury are, at best, 0.3%. The level is only reached when stuck by a needle from an active, very ill, AIDS patient. Asymptomatic patients have only a negligible risk of transmitting HIV in this fashion.

See:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9366579

- H

 

[nockamura]

You should understand that according to a large clinical trial, the odds of contracting HIV via a needle stick injury are, at best, 0.3%. The level is only reached when stuck by a needle from an active, very ill, AIDS patient. Asymptomatic patients have only a negligible risk of transmitting HIV in this fashion.

See:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9366579

- H

Yeah, I know that the odds are very low, but I was just trying to pin down the law concerning HIV testing for healthcare workers.

 

[bemused]

Everybody gets so worked up about HIV. Not that I'd want to get it, but it really is an insignificant risk, like FF states above. What you need to worry about is Hepatitis B. The chances of getting HIV from a needlestick are 0.3% but "the risk of developing clinical hepatitis if the blood was both hepatitis B surface antigen (HBsAg)- and HBeAg-positive was 22%--31%; the risk of developing serologic evidence of HBV infection was 37%--62%."

Current CDC guidelines for exposures

It seems a little shady to me that if a physician determines that there has been a significant exposure, a patient can still refuse testing.

It's not so shady if you consider the patient's rights. If you are exposed to a patient's blood, through no fault of the patient, and if there is no blood available to be tested, isn't it unfair to demand that the person be subjected to a blood draw against their wishes? Plus, it is possible for body substances to be infectious prior to there being measurable serological evidence of infection.

Remember, OSHA requires that your employer make available to you HBV vaccines and boosters. If you do have an exposure, your employer is required to provide the most currently-recommended prophylaxic treatments. If you report an exposure to your designated officer, you WILL be protected.

 

[12R34Y]

I'd say i worry about hep C the most. because everyone has it (so it seems). hepB also very bad and more easily transmitted.

having said that....i don't actually worry about it much at all.

later

 

[Oats]

I agree. I worry more about Hep C, TB, meningitis, etc. Our RN is wonderful when it comes to exposures and such. She's actually called us in before to inform us about a recent exposure that we weren't aware of at the time of the initial call. So, I know if and when the time comes, she'll do what it takes to take care of us.

 

[bemused]

I'd say i worry about hep C the most. because everyone has it (so it seems). hepB also very bad and more easily transmitted.

having said that....i don't actually worry about it much at all.

later

Actually....

"HCV is not transmitted efficiently through occupational exposures to blood. The average incidence of anti-HCV seroconversion after accidental percutaneous exposure from an HCV-positive source is 1.8% (range: 0%--7%) (73--76), with one study indicating that transmission occurred only from hollow-bore needles compared with other sharps (75). Transmission rarely occurs from mucous membrane exposures to blood, and no transmission in HCP has been documented from intact or nonintact skin exposures to blood (77,78). Data are limited on survival of HCV in the environment. In contrast to HBV, the epidemiologic data for HCV suggest that environmental contamination with blood containing HCV is not a significant risk for transmission in the health-care setting (79,80), ... The risk for transmission from exposure to fluids or tissues other than HCV-infected blood also has not been quantified but is expected to be low. "

Having quoted that chunk from the CDC, I realize that I, too, really don't worry about it much at all, either!

 

[12R34Y]

well, 1.8% for HCV transmission is FIVE times HIGHER than HIV transmission. thus my point... i worry more about something both more easily transmitted AND more prevalent.

but........to reiterate again. I really don't worry about it.

later

 

[FoughtFyr]

YES! EMS types finally discussing serious stuff with STUDIES!!!
Keep it up! This is what defines us as a profession! We need to keep demonstrating that we read the medical literature out there that effects us. We need to produce studies on issues that concern us. "This one time at band camp..." doesn't cut it for PROFESSIONALS!

Gosh, I'm really having a good day now. Thanks!





Pickin' my knuckles up off the floor,

- H

 

[DSM]

Everybody gets so worked up about HIV. Not that I'd want to get it, but it really is an insignificant risk, like FF states above. What you need to worry about is Hepatitis B. The chances of getting HIV from a needlestick are 0.3% but "the risk of developing clinical hepatitis if the blood was both hepatitis B surface antigen (HBsAg)- and HBeAg-positive was 22%--31%; the risk of developing serologic evidence of HBV infection was 37%--62%."

Current CDC guidelines for exposures



It's not so shady if you consider the patient's rights. If you are exposed to a patient's blood, through no fault of the patient, and if there is no blood available to be tested, isn't it unfair to demand that the person be subjected to a blood draw against their wishes? Plus, it is possible for body substances to be infectious prior to there being measurable serological evidence of infection.

Remember, OSHA requires that your employer make available to you HBV vaccines and boosters. If you do have an exposure, your employer is required to provide the most currently-recommended prophylaxic treatments. If you report an exposure to your designated officer, you WILL be protected.

Have you ever been exposed? I have twice. There is small comfort in the prophylactic treatment. I want to KNOW the status of the patient. Yes, I agree with having patient's rights but I agree more with the healthcare worker who was exposed. What is one more blood test? I think there should be a mandatory test if requested by an exposed healthcare worker. Did you know that Workman's Comp will not pay unless there is documentation of an infected exposure? We had a medic who contracted hepatitis from a blood exposure to his eyes. He knew where he got the infection but had no proof. Workman's Comp never did pay him for time missed. You have to think of yourself and the possible exposure to your family first.

 

[bemused]

well, 1.8% for HCV transmission is FIVE times HIGHER than HIV transmission. thus my point... i worry more about something both more easily transmitted AND more prevalent.

Well, 37-62% for HBV conversion is, at minimum, TWENTY times HIGHER than HCV transmission. HBV isn't as prevalent as HCV (~80k vs. ~300K) but considering the patient populations for each, we are fairly likely to be exposed to both.

 

[bemused]

YES! EMS types finally discussing serious stuff with STUDIES!!!
Keep it up! This is what defines us as a profession! We need to keep demonstrating that we read the medical literature out there that effects us. We need to produce studies on issues that concern us. "This one time at band camp..." doesn't cut it for PROFESSIONALS!

Gosh, I'm really having a good day now. Thanks!





Pickin' my knuckles up off the floor,

- H

EBM rules!

 

[bemused]

Have you ever been exposed?

Actually, I have been exposed. So while it is my opinion that the patient has a right to refuse, it is an opinion based on my experiences.

What is one more blood test?

Not all patients that we get exposures from require blood draws. Mine was on a brittle diabetic who hypoglycemic at the time, but normoglycemic when we arrived at the hospital and refused to be seen. My partner had an exposure on a pt with an arm lac that was only sutured and given a tetanus. What would you suggest in those situations?

There is small comfort in the prophylactic treatment. I want to KNOW the status of the patient.

There is small comfort in prophylaxis - when it is available - but you still don't KNOW the patient's status even if they do get tested. You could be exposed prior to serologic evidence of infection showing in the patient's blood. There are also different ways to test for infectious disease, and I don't know if, in these cases, the most definitive tests are required. A negative HIV ELISA really doesn't mean much, if I am concerned.

Did you know that Workman's Comp will not pay unless there is documentation of an infected exposure? We had a medic who contracted hepatitis from a blood exposure to his eyes. He knew where he got the infection but had no proof. Workman's Comp never did pay him for time missed.

No, I didn't know that about Worker's Comp, and that really sucks for your coworker. I would hate for that to happen to me or any of my coworkers.

You have to think of yourself and the possible exposure to your family first.

Respectfully, I disagree. I knew that pathogen exposure was a risk inherent in this business when I signed up. If the risk is too great for an individual to bear, then I think that individual should look for another line of work.

 

[FoughtFyr]

Did you know that Workman's Comp will not pay unless there is documentation of an infected exposure? We had a medic who contracted hepatitis from a blood exposure to his eyes. He knew where he got the infection but had no proof. Workman's Comp never did pay him for time missed. You have to think of yourself and the possible exposure to your family first.

Actually not true. Workingman's comp will not pay if you suddenly show up and say "now I've got Hepatitis, I'm sure it was from that one guy." But if you report the exposure when it occurs, draw baseline labs to prove that you do not have Hepatitis at that time, and monitor your course over time, they have to pay - in every state. Outside of that, state rules to vary greatly. For instance, Philadelphia got federal aid to cover their workingman's comp when some ~15% of their fire department was suddenly diagnosed with Hep C. They "paid out" on all of them - even though no specific exposure could be proven. Lastly, I agree with Bemused, there are inherant risks to this job. You have to acknowledge that going in. What is it the medic in your story could've done, other than not be on the call, that would have changed the outcome?

Since we've now started EBM

Here is the OSHA Bloodborne pathogen standard:
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051

"Post-exposure Evaluation and Follow-up. Following a report of an exposure incident, the employer shall make immediately available to the exposed employee a confidential medical evaluation and follow-up, including at least the following elements:
1910.1030(f)(3)(i)
Documentation of the route(s) of exposure, and the circumstances under which the exposure incident occurred;
..1910.1030(f)(3)(ii)
1910.1030(f)(3)(ii)
Identification and documentation of the source individual, unless the employer can establish that identification is infeasible or prohibited by state or local law;
1910.1030(f)(3)(ii)(A)
The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, the employer shall establish that legally required consent cannot be obtained. When the source individual's consent is not required by law, the source individual's blood, if available, shall be tested and the results documented.
1910.1030(f)(3)(ii)(B)
When the source individual is already known to be infected with HBV or HIV, testing for the source individual's known HBV or HIV status need not be repeated.
1910.1030(f)(3)(ii)(C)
Results of the source individual's testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.
1910.1030(f)(3)(iii)
Collection and testing of blood for HBV and HIV serological status;
1910.1030(f)(3)(iii)(A)
The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained.
..1910.1030(f)(3)(iii)(B)
1910.1030(f)(3)(iii)(B)
If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.
1910.1030(f)(3)(iv)
Post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service;
1910.1030(f)(3)(v)
Counseling; and
1910.1030(f)(3)(vi)
Evaluation of reported illnesses."

Clarification letters can be found at:
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=22804

And regulatory overview at:
http://www.osha.gov/SLTC/bloodbornepathogens/index.html

And yes, I've ben exposed. In fact, when I took my first EMT-A class, rubber gloves were still optional! In my career I've had 4 needlesticks and two splash exposures. I followed procedures after each, and because one had recieved the Hep B vaccination, misread by the lab for active Hep B, I once got a two week vacation on the City's dime.

- H

 

[nockamura]

Thanks for the discussion guys, but I just wanted to clarify something a professor said in a lecture (that EMS can force an HIV test if exposed). I understand that my chances of contracting HIV (or for that matter, other blood-borne diseases) is minimal. So it looks like EMS workers cannot test for HIV unless the patient consents. Or is it that if blood has already been drawn we can test without consent?

 

[FoughtFyr]

Thanks for the discussion guys, but I just wanted to clarify something a professor said in a lecture (that EMS can force an HIV test if exposed). I understand that my chances of contracting HIV (or for that matter, other blood-borne diseases) is minimal. So it looks like EMS workers cannot test for HIV unless the patient consents. Or is it that if blood has already been drawn we can test without consent?

In many states, and I do not know of a comprehensive list, consent is not needed to test blood that is already drawn. Almost nowhere can you draw the blood against a patient's wishes. Off the record, let the ED personnel know if an exposure occured. In my experience it lowers the threshold for running blood tests on the patient (i.e., CBC, lytes), thus obtaining a "testable" sample.

- H

 

[DSM]

Actually not true. Workingman's comp will not pay if you suddenly show up and say "now I've got Hepatitis, I'm sure it was from that one guy." But if you report the exposure when it occurs, draw baseline labs to prove that you do not have Hepatitis at that time, and monitor your course over time, they have to pay - in every state. Outside of that, state rules to vary greatly. For instance, Philadelphia got federal aid to cover their workingman's comp when some ~15% of their fire department was suddenly diagnosed with Hep C. They "paid out" on all of them - even though no specific exposure could be proven. Lastly, I agree with Bemused, there are inherant risks to this job. You have to acknowledge that going in. What is it the medic in your story could've done, other than not be on the call, that would have changed the outcome?


- H

I think you misread my post or at least misunderstood my intent. I said that Workman's comp WILL NOT pay unless there is documentation of an exposure to the illness. That is why there should be some type of mandatory testing in the case of an exposure of a health care provider. That is MY OPINION which isn't worth very much but still my opinion.

My point was that the paramedic knew where the illness came from but he had no documentation or proof so he was SOL.

 

[DSM]

Respectfully, I disagree. I knew that pathogen exposure was a risk inherent in this business when I signed up. If the risk is too great for an individual to bear, then I think that individual should look for another line of work.

I know all about the risks involved and I also know that if there is something that can make this job safer then we should do it. That is why we wear gloves now on every call when EMT's and healthworkers did not 25 years ago. When a new discovery is made on how to make out jobs safer and easier we take it. If there is a way for me to find out the HIV or Hepatitis status of a patient after I have been exposed then I believe I have a right to it. That is my humble opinion. I realize that there are dangers in this business. I did not last 16 years in EMS without that realization. I also know that even though I might do everything I can to protect myself and my partner there will be times of exposure. I believe that I should have a right to know the status of the patient.

That is all.

 

[bandaidsNhoses]

Actually, doesn't the Ryan White law deal with this type of scenario specifically???

edit: My bad! Did some research to correct myself:

http://www.thebody.com/Forums/AIDS/Workplace/Archive/Confidentiality/Q149776.html

and under OSHA LAW:
http://www.ic-ec.com/newsletter/The_Source_Sep-Oct-2003.pdf

 

[oudoc08]

While I would want to know a patient's status, I have to maintain that in this country, it is every competent individual's right to refuse any and all medical care, and that includes blood testing. It isn't your patients fault if you stick yourself with a dirty needle, and to demand of them a blood test, is an invasion of their privacy. "It's just a little blood test", you say. "It doesn't matter." It does matter. It hurts, it's invasive, and as such is not completely benign. More importantly, however, it is against their will, and that is fundamentally wrong, and is a situation where the ends most certainly do not justify the means, IMO.
The only exception would be if the patient intentionally stuck you with a contaminated sharp. Then, due to their own malice and intention, they have subjected themselves to liability, including arrest and the involuntary nature of that beast, including blood testing.

As a medical provider, you know the inherent risks. If you want to have zero risk of acquiriing a BBP, go into another field. Otherwise, be careful, and respect the wishes of your patients as you would want to be respected yourself. Besides, this is a ******ed discussion anyway. Most patients would consent to having testing if they knew of the situation, but for those who don't, I say, get your prophy's, and accept the consequences of your carelessness. (and yes, I have been stuck. It was my fault, and no one elses.)

 

[12R34Y]

Yeah, I have to agree with DSM on this one. I'm fully aware of all the dangers of the job, but that doesn't mean that I don't want to know the status of the patient who I got exposed to.

Several people have mentioned that a negative ELISA means nothing.....no it doesn't. It means they likely don't have a super duper high-viral load, rip-roaring case of HIV. that would make me much happier.

I think it is kind of along the lines of a Good Samaritan thing (i mean they have a law for that). I think it is a public health issue. You are not only affecting me, but my wife, kids, etc....

What if you are a poor candidate to take the HORRIBLE prophylaxis meds. some of those meds are really potentially bad.

I'm sure people will respond with........"patien't rights! etc.." , but oh well.

that is my opinion and you ain't gonna change it.

later

 

[bemused]

Several people have mentioned that a negative ELISA means nothing.....no it doesn't. It means they likely don't have a super duper high-viral load, rip-roaring case of HIV.

Can't disagree with that. But, let's say you get an exposure from a IVDA prostitute, and today's ELISA is negative. Are you willing to forego prophylaxis based on today's test? Are you willing to risk the health of yourself and your family, knowing that there can be a window up to 12 weeks? [assuming that you had a serious concern in the first place]

that is my opinion and you ain't gonna change it.

I can respect that, but I still cordially disagree

 

[oudoc08]

I'm sure people will respond with........"patien't rights! etc.." , but oh well.

This is America, dude. Patient's rights are exactly that.

Oh well?

 

[DSM]

The first rule of EMS is protect yourself. If you don't do that you won't be around to help other patients in the future.

I still believe I have the right to know a patients or persons health conditions if I have been exposed to their bodily fluids whether it is the patient's fault, my partner's fault or my own fault.


My opinion.