ARTS & FARCES internet

A few days ago, one of the best dialysis technicians I’ve ever seen got a really nasty needlestick from a contaminated needle (not mine). She has more experience than anyone except two of the nurses, so this was not a beginner’s mistake.

I learned that most dialysis centers do not screen their patients or staff for Hepatitis C, but do screen for Hepatitis A and Hepatitis B. Hepatitis C is more contagious than HIV, is transmitted mainly by IV-drug use, can remain dormant for many years, is difficult to treat, and often leads to conditions for which the only treatment is a liver transplant.

The reason why dialysis centers, including those in inner cities with a high population of IV-drug using patients? It’s too expensive. The company that owns the dialysis center I use, DaVita, Inc., reported first-quarter profits this year of US$34.6 million and second quarter profits of US$70 million. But a US$60 Hepatitis C Check screening test is too expensive. Never mind that DaVita has its own lab with internal costs significantly lower than the price you and I would pay.

I've been very proactive with my care. Many ESRD patients I've seen aren't. Needlesticks (with new, uncontaminated needles) are a common occurrence. It just can't be avoided because the needles are everywhere and emergency situations arise frequently. In addition, there's usually potentially contaminated blood everywhere as patients' wounds break open post dialysis, and other accidents happen. Consider at any given time, roughly 20 people are undergoing an invasive medical procedure in each dialysis center.

Open wounds -- these are 15-gauge needles we're talking about that leave huge gaping holes when removed -- anticoagulants in every needle, potentially contaminated blood, and many transfer agents do not make a good mix.

Consider this scenario. One of the more common emergency occurrences is that one of the dialysis needles works loose. Blood is being removed from the body, filtered, and replaced at the rate of up to 650mL/min. If the arterial needle works loose and isn't immediately caught, it doesn't take long for the patient to bleed out. Is the staff, upon seeing a gusher of an open blood vessel and a needle spewing blood like a garden hose going to take the time to get clean gloves before slapping a gauze sponge on the open vessel?

Or consider this more common scenario. Nurse Nancy sticks herself with a sterile needle that has been heparinized ( heparin is an anticoagulant used in dialysis to reduce blood clotting) and she's bleeding profusely. No harm, no foul, at least as far as infection goes, right? Well, maybe not. Ten years ago Nurse Nancy was an IV-drug user and contracted Hepatitis C by sharing needles, but she doesn't know it because the disease can remain dormant for a long time and her employer is too cheap to pay for a screening test. Nurse Nancy has to get me on the machine and is running late. She doesn't wait for her needlestick to fully quit bleeding and it's oozing around the gauze. She doesn't put a glove on because it won't fit over the gauze. I'm having a bad day and don't catch it. She has problems sticking my access, removes the needle, grabs a gauze sponge, and applies pressure to my open wound to stop the bleeding. The gauze sponge slips and her Hepatitis C infected blood comes in contact with my open wound. Bingo, what are the chances of my contracting Hepatitis C?

According to Canadian data, the risk of infection after a needlestick varies by pathogen:

I don't much like those odds.

Kip Sullivan, a Twin Cities-based single-payer healthcare system advocate, [disclaimer: I'm working with a healthcare task force, of which Kip Sullivan is a member; more on Kip and the task force in future articles] identifies three ways in which managed care providers maintain their profits at the expense of patient care and medical staff well-being:

1. Financial incentives
2. Utilization review
3. Rising workloads

Rising workloads likely result in lower quality patient care and more catastrophic mistakes. And we don't need extensive studies to know that.

While I'm not ready to say that someone who tests positive for HIV or Hepatitis C should be precluded from working in a dialysis center, I'd at least like to be informed. After all, patients and staff are all screened for Hepatitis A and B which are much less contagious.