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Stuck in the Middle

Middle managment

Peter J. Waldman, Vermont, 28 Jul 2009 2:37 PM EST

Competing interests: None declared

I woud definitely treat the intensivist with PEP, would absolutely consider testing the source patient without consent, and I would also ask the girfriend for permission. In addition, once the patient is obtunded, hospital administration could provide implied consent, since the diagnosis of HIV would be crucial for the patient as well as the physician.

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HIV

Joalie Davie, New Mexico, 28 Jul 2009 2:33 PM EST

Competing interests: None declared

I assume that the patient will not be available for a follow up HIV test as well so even if the patient is negative at the time that will have to be in consideration with the history and the true risk of recent exposure and possible infection of the patient with HIV.

One option is that the test be done and the patient will have to be informed that he doesn't have to be informed of the results of the tests and that the test will not reflect in his record but it will reflect in the physician records.

I would only recommend this option if the result of the HIV test done once will make difference in the management, then I would recommend to do the HIV test on the patient's blood but not inform the patient of the outcome of the test and inform the physician.

If the patient still refuses, then I would base prophylaxis on the past and current risk factors for this patient and blood tests other than HIV testing which might suggest a diagnosis of HIV/ AIDS. Of course I would let the physicain involved decide the ultimate course of treatment/prophylaxis.

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Stuck in the Middle

NSKE NSKE, 28 Jul 2009 1:29 PM EST

Competing interests: None declared

Without a doubt if it was me - obtain baseline test for HIV both HIV antibody and vL. Then immediately begin HAART. After a month repeat the baseline labs.

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HIV refusal / internist needlestick

Mariah Haley, ICU Nurse, 28 Jul 2009 12:49 PM EST

Competing interests: None declared

Patients shouldn't be the ONLY people with rights in this situation!

Yes, they have the right to refuse to consent to have their blood tested -- fine, then test the blood and don't tell them the results if they don't want to know. BUT...the internist needs to know whether he/she has been infected with HIV b/c this will change the rest of his/her life!

Tell the patient -- you have the right to refuse consent, but your blood will be drawn & tested so that the other person (who also has rights) needs to know about his/her treatment options. If you don't want to know the results of the testing, that's fine, but if something comes back positive, we will have to do some further investigation in case other ppl are infected as well.

Healthcare workers put up with a lot of things and NOT getting to know whether you are possibly HIV positive is something that needs to be taken care of. Sorry the patient refused -- he has that right -- but I also have the right to know what I've possibly been infected with.

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treatment of accidental needle stick in healthcare provider.

GB Howell, Outpatient clinic, 28 Jul 2009 12:41 PM EST

Competing interests: None declared

I would test and I would treat.

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Intensivist Needle Stick from ?able pt.

Ruth H. Strauss MD, 28 Jul 2009 12:22 PM EST

Competing interests: None declared

To be honest, I would ask the girlfriend, and if she said "no" I would probably either have 2 physicians sign it was an emergency or call the Risk Management Department or consult a lawyer, but at all costs, OBTAIN the result--the doctor is the one who is trying to perform life- saving treatment for the patient and there is no rational reason to deny him of his own life-saving information. I would imagine even in a court of law, that the decision to do this would be upheld.

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cerd

carlos e. rojas, 28 Jul 2009 12:21 PM EST

Competing interests: None declared

The same principle of law, that you may breech information about pt condition, in case of life threatening event involving either the patient or others, should apply and the HIV testing should be done. As far as PEP, I will treat him in standard fashion, considering a high risk patient.

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stuck in the middle

Herschel V. Murdaugh, retired, 28 Jul 2009 12:15 PM EST

Competing interests: None declared

My first responsibility is to the patient, then the physician stuck with the needle. Clinical experience suggests that the patient who refuses an HIV test believes he or she may have HIV. For the well being of the patient I would assume the diagnosis and do the first thing to guide therapy - get a viral load. I would treat both the patient and the physician as guided by the viral load.

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Intensivist with needle-stick

Vickie L Becker, 28 Jul 2009 12:07 PM EST

Competing interests: None declared

I would test the patient and give the intensivist PEP, according the most recent guidelines: Hep B- HBig + vaccinate; HIV- 2 or 3 HIV drugs (azt/3tc) +/- protease inhibitor

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about Stuck in the Middle

Daniela G Nikolova, Clinic of infectious diseases-Varna,Bulgaria, Europe, 28 Jul 2009 12:05 PM EST

Competing interests: None declared

On all questions my answers are- yes. PEP will be 3-component therapy-for example- Combivir and Viramune or Kivexa and Kaletra I think it is good- the intesivist have to chek his HBsAg,anti HCV, as the same for patient, because as a drug ab/user may be he is with VBH or VCH

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Manage the intensivist

V Sanders, 28 Jul 2009 11:52 AM EST

Competing interests: None declared

Follow post-exposure guidelines for unknown source. Do not test the patient against his will. Provide postexposure prophylaxis. Intitial lab test for HIV, Hepatic Function Panel, Hep B, and HCV. Repeat labs in 6 wks, 12 wks, and 6 months. Hep B series if not already given. Counseling if needed.

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HIV Exposure risk

Deepak Bhagwandas,MD.PT, 28 Jul 2009 11:35 AM EST

Competing interests: None declared

Start antiretrovirals ppx

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Stuck in the middle

Benjamin D. Gordon, M.D., retired, 28 Jul 2009 11:12 AM EST

Competing interests: None declared

A patient whose mental status is "waxing and waning" and who has evidence of cocaine and opiate use is not in a competent mental state. His refusal cannot be considered with the same legitimacy as someone "alert, coherent and cooperative". To put the physician at significant risk in this situation belies common sense. The objective of having laws at all is an attempt to achieve "justice". Sometimes law does not achieve this and the use of judgement is required. When this patient was obtunded, HIV testing should be done. This does NOT harm the patient in any way and proper information can then guide appropriate management - of both patient and physician. If the patient is positive, when he has regained a rational mental state, he should be told and receive what is indicated. If he is negative, he does not need to be told. Bottom line: either way, NO HARM IS DONE.

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stuck in the middle

ROBERT A MAXWELL, 28 Jul 2009 11:04 AM EST

Competing interests: None declared

1. Ask him again, even though he is intubated, and inform him that the physician suffered needlestick, for permission. Also do STS, HepB&C 2. Ask his girlfriend for permission to test her for HIV 3. Ask her for permission to test him. 4. Save a sample of his blood in the frezzer. If he should die, then I would have it tested for HIV. 5. Test MD for HIV; repeat in 6 wks

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HIV Test

Dr, Cornelius Reinhard Weerts, Germany, 28 Jul 2009 10:43 AM EST

Competing interests: None declared

Undergo an HIV Test twice -in different times - on your own cost.

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HIV testing

Paul H King, 28 Jul 2009 10:03 AM EST

Competing interests: None declared

test the subject....period..no discussion required

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Stuck in the Middle

Jean Yared, 28 Jul 2009 9:49 AM EST

Competing interests: None declared

I would start by testing the intensivist for ELISA HIV at D0 (and every 6 weeks up to 6 months), if negative I will proceed to HIV RNA PCR. Anyway, I will also start him prophilactically on 2 NRTI's +/- 1 PI for up to 4 weeks.

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Patient Testing for HIV

Lawrence E. Plaskett, 28 Jul 2009 9:38 AM EST

Competing interests: None declared

In view of the circumstances under which he was admitted, I would evaluate his HIV status. Additionally, I would inform him of the results whether negative or positive. (However, since his condition had deteriorated significantly, the need for providing this information to him, could be delayed pending improvement in his general health including his 'mental status'.)

I would consider close followup (delayed treatment) of the physician until the patient's HIV status was determined.

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Stuck in the Middle

Humberto Olivencia, 28 Jul 2009 9:35 AM EST

Competing interests: None declared

In my hospital we have a consent that is firmed by most of the patients when they are hospitalize ( not firmed in emergencies) were the patient agree in testing in the above circumstances. Done to protect the physicians. The patient can decide if he wants to know ect.

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"informed consent"

Mel Breite, 28 Jul 2009 8:38 AM EST

Competing interests: None declared

our beloved patient is having all kinds of things done without real "informed consent" to possibly save his life. We can add HIV testing to possibly save the doctor's life or make it easier.. Then find a jury that would convict the doctor or the hospital.

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needlestick patient refuses HIV test

Ste..a J. Fitzgibbons, IPC, 28 Jul 2009 8:09 AM EST

Competing interests: None declared

Hospitals all over the world have policies for this, what's the big puzzle? The patient's blood is sent for testing that includes HIV and sometimes other tests; the patient is not given the HIV result but the stickee is, and antiretroviral treatment started if appropriate. It would certainly be ethical to re-offer testing at some later time to the patient. You can't have a perfect solution, but you can prevent or slow the development of HIV in the intensivist. Again, what's so new about this situation??

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Nature heals

Martín G. Murman, 28 Jul 2009 7:59 AM EST

Competing interests: None declared

Primum non nocere

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Stuck in the middle

Maria Mohammed Satti, 28 Jul 2009 7:44 AM EST

Competing interests: None declared

I will test the patient without his consent & will not give him the results either way they are. He either knows he is positive or does not want to know.

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Non-consented test for the patient.

Krispin Hajkowicz, Australia, 28 Jul 2009 12:43 AM EST

Competing interests: None declared

I would perform a non-consented HIV test on the patient for his own wellbeing in an emergency. A positive or negative result would significantly change the management of the patient.

I would offer with a strong positive recommendation to the intensivist to take tenofivir/FTC as soon as possible, either for 30 days or until the result of HIV serology is negative on the patient. I would cease the PEP if the HIV test is negative.

I would give the patient results of a positive or negative test when he recovers.

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Testing the patient

Harvey A. Elder, San Bernardino Co. P.H.D. Early Intervention Clinic, 27 Jul 2009 11:47 PM EST

Competing interests: None declared

I would have drawn the blood for the test before receiving the patient's permission. If refused, I would identify the intensivist as the one stuck by a needle from this person. That way, the patient's results are not available to the patient but the intensivist has the requisite info.

I would question the patient as to high risk drug and sex activities after I drew the blood. This would be part of my discussion with the patient.

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needle stick

howard zhang, UMMC, 27 Jul 2009 10:10 PM EST

Competing interests: None declared

I would prophylactically treat the physician, and test the patient for HIV even though he refused. I think the consent is not required in this situation. The patient will not be informed with the result because he does not seem to want to find it out.

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Stuck in the Middle

Bettina Bernstein, 28 Jul 2009 4:34 PM EST

Competing interests: None declared

postexposure prophylaxis if the intensivist was not allergic HIV test on the blood already drawn as the test result is important for management of the patient and the intensivist the results on basis of an urgent emergency need then get a court order if the test is positive to obtain informed consent to treat

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HIV

James S. Long, 28 Jul 2009 4:49 PM EST

Competing interests: None declared

Start PEP on the intensivist, test for HIV, even without consent, and inform him of the results after he recovers.

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Stuck in the Middle

Samuel S Zagarella, Australia, 28 Jul 2009 7:45 PM EST

Competing interests: None declared

Doctors have rights too. The intensivist has an obligation to save this patient AND an obligation to their own health as well. Testing should be done while the patient is confused and the intensivist receive appropriate treatment. The law is not correct for every situation and if tested , I hope sanity would prevail in this case.

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Stuck in the Middle

SUDHIR REGMI, KMCTH,Kathmandu,NEPAL, 29 Jul 2009 12:21 AM EST

Competing interests: None declared

Certainly, the first step from my side would be post-exposure prophylaxis for the intensivist. In view of patient's toxicology screening,he falls into high risk group.So, better would be to take written consent from his girlfriend.If not possible, do HIV screening and donot provide reports to the patient concerned. Here, issue of testing for HBV and HCV also should be considered.

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Stuck in the Middle

Tania Acevedo, Danbury Hospital, 29 Jul 2009 5:00 PM EST

Competing interests: None declared

Treat the intensivist, with prophylaxis and test the patient. There 2 human lives that can be seriously affected by this result.

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Implied Consent

KS Kahlon, Community Hospital, San Diego, California, 29 Jul 2009 7:58 PM EST

Competing interests: None declared

At our institution, patients who are able or a legal surrogate sign a form at the time of hospital presentation consenting to necessary medical treatment: blood draws, radiography, IV fluids, antibiotics, etc. My understanding is that this includes consent for HIV, HBV, and HCV testing in the event of serious exposure involving hospital personnel. In this case, since the patient is already being given life-sustaining treatment in a hospital, consent for HIV, HBV, and HCV testing in this situation is implied.

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testing with no consent

José Manuel Ferreira, 31 Jul 2009 7:17 PM EST

Competing interests: None declared

in portugal the patient would be testede because in our understanding the patient admited to hospital is in the ritgh for the best treatment and this only can be provided if all the test necessary can be done! legally the patient as the rigth to be informed but there is no history of no complaint of that subject in our country! The patients often are gratefull to the phisician who finally made the rigth diagnosis!

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stuck in the middle

E Kunka, 1 Aug 2009 1:11 PM EST

Competing interests: None declared

I would start PEP for the Doctor and then go ahead to collect blood for an HIV testing from the patient. I feel that since there is another persons life at stake, his right to health should not be undermined. I would give him 2 NRTIs +1NNTI

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What I would do, Stuck in the Middle

Elsa J. Aguilera, VA Boston Healthcare System, 31 Jul 2009 12:02 PM EST

Competing interests: None declared

1) After taking blood from the intensivist for HIV, HBsAg, HCV treat him on emergency basis

2) Ask the girlfriend for a blood test to r/o HIV, HBsAG and HCV as a way of knowing what is going on with the patient and herself. She is living with a drug addict and the possibility of being infected is significant

3) If the girlfriend does not consent to the above, GO ahead with testing the patient. After all, the intensivist 's life is changed for the worse

4) Give to the patient the blood results (negative or positive) for treatment and for the avoidance of virus/es transmission if results are positive (or education/advice if negative)

3) As soon as possible consult with both the Hospital Ethics committee and the hospital lawyer (Of course after 1 and 2 are done)

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postexposure prophylaxis

khaled hamad, afh oman, 3 Aug 2009 3:42 PM EST

Competing interests: None declared

after reviewing the hx and the circumstance of the injury and taking in consederation that the pat. was found in the street with positive toxicolody this places him in risk group for hiv. the other thing to cosider that the victem case used a hollow-bore needle increase the risk further. also the injury seems to be somehow deep which increase the risk further and this occured though the gloves which dcrease the risk since the pt. condition is deteriorating. it looks that his immune status is depressed and asuming that he is hiv posetive that means he has advance disease. and sice he is refusing hiv testing while he is awake this cant be done and his gairlfrind cant give consent on his behalf and cd4 count testing want be helpful in this situation it is not aconfermatory test for hiv.

putin all together i think this is high risk expusure so i will starte postexpusure prophylaxis after testing the victem for hiv HBsAg.

and follow him up and try to get more information about the sourse pat. or to get help for the low aouthority to take consent and if it is negative i ll stop the prophylaxis.

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Dilema Do or Dont

Rabia Akbar Vali, Central Private Hospital, 6 Aug 2009 11:42 AM EST

Competing interests: None declared

the patient is admitted in a confused state and preferably i will take the consent of his girl friend and if she refuses i will opt for post exposure prophylaxis with combivir and viramune for the intensivist after drawing blood on D0 and every 6wks thereon..

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Have Patient Pre-sign before receiving any treatment

Rochelle Y. Odell, Disabled W/CRPS, but worked at USC University Hospital in Los Angeles before becoming disabled., 8 Aug 2009 2:25 AM EST

Competing interests: None declared

Being a former Critical Care Tech at a community hospital in Georgia, I received a needle stick. Fortunately, it was further up in the IV line because the RN had not secured the needle in the added IV Line and when turning the patient, it became loose and stuck me.There was no exchange of bodily fluids.

When working as an ICU Nurse Tech, we had a patient with full blown AIDS who's wife didn't believe he was dying from HIV-AIDS and no amount of showing her the test results as he had the disease for some time could convice her or her chldren. One of our ICU RN'a just hapened to be in our Urgent Care Office one evening when I came in for a pain flare up, as she had received a blood stick from this patient. I knew she was started on the drug cocktails given to medicaI professionals, but didn't see her after about a month and often wondered if she had developed HIV.

I believe all patients being treated in an Emergency Department setting or as an in Patient , should sign a form to be tested for HIV, so that the staff is protected. Particularly if the patient is scheduled for surgery, when the risk to the Surgical Team is at it's greatest.

I was working at a hospital in Las Vegas for three months as a Cardiac Monitor Tech waiting for an opening at USC, and all potential employees were not given the option of taking an HIV Test, it was a requirement for employment.

It makes no sense to me. Patients who have TB have to be reported to the CDC as well as any patients who develop STD's, yet a blood disease that kills the patient at some point in time, does not have to be reported. What's wrong wth this picture?

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stuck in the middle

Doanh Lu, Vietnam, 11 Aug 2009 1:35 AM EST

Competing interests: None declared

The responses from the experts clearly showed that they have never had a needle stick from a high-risk patient, nor taken a PEP regimen with its attendant constant nausea and fatigue, nor suffered through many months of uncertainty, over and over, as intensivists and surgeons are apt to stick themselves more than once. Until these experts have exposed themselves to such risks daily, their rather one-sided opinions border on being hypocritical. Doctors, who work hard to save these patients, have the right to protect themselves, as well. Furthermore, at least in developed countries, HIV disease has become a chronic disease and managed much like diabetes and CAD. It's not a fearsome disease it once was. Why all the hush-hush around testing for it? Why not considered HIV just another chronic disease? The time has come for ethicists and lawmakers to change their views on the requirement for HIV consent. In my opinion and experience as a HIV doctor, not knowing one's HIV status is more harmful than knowing it.

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I will test the patient,for his benefit

Rabia Akbar Vali, Central Private Hospital,Sharjah,U.A.E., 11 Aug 2009 2:19 AM EST

Competing interests: None declared

both the patient and the treating doctor are important and both need to be taken care of and as the pt is not fully cognitive i would test him and at the same time start the pep and inform the patient re the result whatever reported and act accordingly once the pt is in full cognisance.

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Needle stick from high risk source

Peter T Comfort, Overberg Hospice, South Africa., 11 Aug 2009 5:50 AM EST

Competing interests: None declared

If HIV +ve, the patient endangers medical staff, their families,their own future health and all those whom they may come in intimate contact with. Whether to HIV test this patient or not is not to be approached from an individual perspective when there is a serious possibility of community health risk.

I would test the patient immediately and without his consent, just as I would carry out the other emergency procedures without his consent. Regrettably,the intensivist will need to follow the usual needle stick protocols, on the assumption that the patient has the HIV/HBV/HBC viruses. If the patient tests +ve for any of these, then I would inform him of the results and of his obligation to protect others from himself, as well as strongly advising him to undergo appropriate treatment. As regards any illegality/unethical practice in my action, I would be happy to face any court, and any jury, knowing that my actions have saved more lives than 1 here, and that should I have failed to act as I had, the consequences would have been far more serious.Whatever the Court then does to me is unimportant.

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Needle Stick

Melissa Hawthorn, Clinical Research, 11 Aug 2009 8:14 AM EST

Competing interests: None declared

Is that lawyer high? Since when do the rights of one always trump the rights of another? By this I mean: since when do the rights of the medical community always come in as rock-bottom last? And to try the "ethically inappropriate" garbage? Trying to make your opponent feel guilty and unworthy is a defense of the last resort. A person's freedom and rights extend unrestricted only until they bump up against another's. So tell me, Ms. Esq. and the rest of you "ethical" experts, why does someone who, in all likelihood knows he is infected and that is why he refused testing in the first place, always "win"? A doctor can go to court and get the court to agree to a treatment to save a patient's life even if the patient resists... after all, that would be loss of mental capacity and gives the court the right to overrule the stated wishes of the patient But he can't go to court and get a blood test ordered from an obviously mentally-incapacitated patient who could conceivably endanger many others in the course of his irrational life? By all means, let us take all humanity out of the law.... and all reason as well. Has the human race actually devolved to this point? All that matters is the absolute literal words of the law? I doubt Thomas Jefferson, et al ever intended this when they set up the government.

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Post-exposure prophylaxis

Suleiman ibrahim Kuranga, University of ilorin teaching Hospital, ilorin, 11 Aug 2009 9:44 AM EST

Competing interests: None declared

From the history given, there is no need the intervist insist on the patient doing the test againt his will, but he should rather report the case to the managemet or the hospital authority and start the PEP therapy with truvada preferrably because of its less untoward side effects.

Dr Kuranga I Suleiman (FWACP), Ilorin, Nigeria.

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Ethics

Deborah May, 11 Aug 2009 9:54 AM EST

Competing interests: None declared

So breaking the law whenever it is deemed to be in the best interest of the physician is an acceptable practice, according to many posts. Sorry, "common sense" and personal vulnerability do not trump the law.

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Put yourself in the intensivist shoes

Thabisa Sibanda MBchB, PG diploma in Clinical trials, 11 Aug 2009 10:16 AM EST

Competing interests: None declared

Firstly it is unethical to test this patient. Surrogate markers are equally unethical and also unhelpful. Unfortunately this situation is critical for the intensivist as he has two options both of them very risky.

Option 1. Blindly take PEP and hope that there will be no adverse events. At the same time remain psychological traumatised when it is possible that there is no need to panic after all.

Option 2. Presume that either the patient is negative or that he (the intensivist) is one of the 99.7% lucky one who will not seroconvert. Check his status at 3,6,9,12 amidst a lot of panic attacks. This I will call TRUST in divine power.

If I was in the shoes of this guy i would do the following;

1. Draw blood from this patient and do a rapid test (from my on kit). Keep this information confidential from the patient, girlfriend and even my colleagues.

2. If the guy is positive, I would tell my colleague that I have opted for a blind course of PEP.

3. If the guy is negative I would tell my colleagues that I have opted to TRUST in divine power.

The long and short of it is that I will maintain ethics by keeping this information confidential.

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Arrest 'em and test 'em

Charles E Walsh, 11 Aug 2009 10:20 AM EST

Competing interests: None declared

Charge: attempted murder, of intensivist by patient. Subpeona HIV status. Treat intensivist per results. Golf.

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hiv consent

Anne M. Pennisson,MD, gov., 11 Aug 2009 1:26 PM EST

Competing interests: None declared

Other tests could be used p24 antigen,cd4 counts but the pt should be tested for rapid HIV and vl. The physician at this point is a patient too. Offer PEP.

To not test this patient is another example of a "criminal" (the patient with illegal drugs in system" trumping the rights of the responsible citizen and patient (the physician.)

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Ethical Relativism

A W P, MD JD, 11 Aug 2009 6:43 PM EST

Competing interests: None declared

The Canons of legal ethics provide for an attorney who has not been paid by their client the leeway to "ethically" disclose to third parties confidential information that had theretofore been protected under attorney-client privilege—solely for purposes of leveraging the client into paying the owed attorney’s fee. Contrast this ethical pragmatism with the ethical standards to which some of the commenters in this thread hold healthcare providers….

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Stuck in the Middle

Emily Mawdsley, 29 Dec 2009 11:00 AM EST

Competing interests: None declared

Wouldn't we adjust the PEP regimen based on the source patient's results? For example, if the pt tests positive for HIV, I would recommend a 3-drug regimen for PEP initially (per guidelines). Additionally, most experts would give therapy targeted to the results of a genotype if the source patient was indeed positive (or the patient's most recent regimen). This negates the argument that knowing the results would not change therapy.

Additionally, the importance of knowing HIV status in caring for a critically ill patient cannot be overlooked. In this situation, the patient is undergoing many tests and therapies for which he has not explicitly consented. Why is knowing about HIV any less important or necessary to his care than knowing about diabetes, drug use, or syphilis? All of these diagnoses can cause personal distress as well but no special precautions are taken when testing for them. The physicians responsible for this patient should request emergency testing of HIV, first and foremost , because it is needed to care for the patient.

I am surprised that the lawyer and ethicist did not consider these points in their responses. I agree that the law is king, but every effort should be made to do what is right for both the patient and the exposed employee. In this case, that means testing as early as possible. Legal counsel for the hospital should be helpful in achieving these goals in a lawful way.

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patient autonomy

James H Avruch, Tufts Mwedical Center, 22 Jan 2010 8:50 AM EST

Competing interests: None declared

I'm not an intensivist and i have not had a needlestick from a high- risk patient. Some have argued that testing for HIV is no different from syphilis or TB; some have argued that consent in this instance could be implied. What about human autonomy? Perhaps if the patient had not explicitly refused HIV testing, then after he was obtunded consent could be implied, but he did specifically say that he did not want to be tested. Who knows why, and who is to say that his reasons were insufficient? True, most high-risk patients who refuse testing probably do so out of a legitimate fear that they will test positive. Which i think is the most telling point here- if you sign up to be an intensivist, then this type of situation goes with the territory, and you should be prepared at some point during your career to take an unnecessary course or two of truvada, as horrible as PEP may be. Because HIV is different than syphilis or TB, and that's the way that our society works, whether that makes strict medical sense or not. So intensivists, suck it up and deal, b/c this fellow who probably has HIV is YOUR patient and has no less autonomy than someone without a host of HIV risk factors. If you don't like it, try derm or ophthamology (both very lucrative, i'm told), because this is exactly the guy who you signed up to care for, exactly the guy who needs you the most, and just because you stuck yourself with a needle doesn't mean this individual loses his right to refuse testing. In other words, just because the patient will not take up a degree of personal responsibility does not mean that the intensivist may relinquish his personal responsibility for his actions, firstly choosing such noble and demanding work as intensive care, and secondly choosing to place a central line on a man with unknown HIV status. We always have choices, and so must this pitiable man as well.

Testing after the fact will not take the blood out of the needle. One could make cogent arguments that knowing the patient's HIV status is integral to his acute-level care and is thus a necessary test with implied consent like any other emergency procedure. All that is true, but the man specifically declined HIV testing verbally. At that point, for me, it's game over. Dutifully take your truvada and believe that karma will reward you.

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