CPSO Blood Borne pathogen policy

[quickdraw_mcgraw]

Something to consider in considering a specialty, from a surgeon in practice.

Every year you must prove you do not have HIV or Hep C to the College of Physicians and surgeons on Ontario.  If you test positive, you may no longer operate.

You may live the clean life of a Buddist monk, but if you get something splashed in your eye, or a needle stick from a patient with Hep C, you will no longer really be able to practice surgery.

The Hepatologists figure there a a whole host of baby boomers out there infected with Hep C, thank you sexual revolution.

Add this to the calculus of considering your future specialty, it would suck to have to change specialties, and be infected, in the middle of residency.

Wish you luck in your career endeavors.

Dr. McGraw

[Lactic Folly]

How commonly does this happen?

[PilotMD]

Come on......

There are many reasons not to become a surgeon - this one should be positioned right at the bottom of the list.

What next - don't drive because you have an increased chance of dying in a car accident if you drive versus if you don't? Don't fly because your chances of dying from a plane crash increase if you fly versus if you don't? 

Yes - a surgeon can loose his/her privileges if he/she contracts a blood borne illness. The statistically likelihood of this is extremely low. Couple that with PEP for HIV and the cure rates for HIV C, and I think you have very little to worry about. There are a million  'what if's' that could impact on your ability to do surgery.... what if you loose a limb/an eye etc in a terrible accident? What if you develop severe arthritis or a neurological condition that impacts on your ability to operate? What if you get cancer and die right after residency (seen that)? Should we all be worrying about this as well prior to a decision?

There are many future events waiting for us that are beyond our control - why worry about them? Instead, focus on the things you do have control over - like double gloving in surgery (many don't), wearing eye protection (many don't), tying without holding instruments especially when there is a fu$king needle present (many don't). Just like you wear a seatbelt while driving and choose an airline with an excellent safety record, there are things you can do to mitigate risks in your surgical practice. 

Choosing not to do surgery because you are afraid of what MIGHT happen while in practice is a poor decision at best. There are numerous other factors that will significantly impact on a successful and enjoyable career that should be weighed in your decision - in my opinion, this is not one of them.

2 cents from a surgeon in practice

[rmorelan]

On 4/13/2018 at 3:45 PM, quickdraw_mcgraw said:

Something to consider in considering a specialty, from a surgeon in practice.

Every year you must prove you do not have HIV or Hep C to the College of Physicians and surgeons on Ontario.  If you test positive, you may no longer operate.

You may live the clean life of a Buddist monk, but if you get something splashed in your eye, or a needle stick from a patient with Hep C, you will no longer really be able to practice surgery.

The Hepatologists figure there a a whole host of baby boomers out there infected with Hep C, thank you sexual revolution.

Add this to the calculus of considering your future specialty, it would suck to have to change specialties, and be infected, in the middle of residency.

Wish you luck in your career endeavors.

Dr. McGraw

Not to sound boring but that is exactly why disability insurance exists with same profession rider. There are a million health related reasons we might not be able to continue in our chosen fields. 

Also not to dismiss the consequence in the remote chance that it happens of course (and it can happen in my branches of medicine, not just surgery - there are procedures in a lot of branches of medicine after all and may of them would be impacted by stuff like this) - but the odds of it happening really are small (although being someone that has been stabbed already some of those post exposure medications kind of suck).

I say take precautions, always follow procedures designed to protect you, and don't let fear rule the day

[medigeek]

On 4/13/2018 at 3:45 PM, quickdraw_mcgraw said:

Something to consider in considering a specialty, from a surgeon in practice.

Every year you must prove you do not have HIV or Hep C to the College of Physicians and surgeons on Ontario.  If you test positive, you may no longer operate.

You may live the clean life of a Buddist monk, but if you get something splashed in your eye, or a needle stick from a patient with Hep C, you will no longer really be able to practice surgery.

The Hepatologists figure there a a whole host of baby boomers out there infected with Hep C, thank you sexual revolution.

Add this to the calculus of considering your future specialty, it would suck to have to change specialties, and be infected, in the middle of residency.

Wish you luck in your career endeavors.

Dr. McGraw

Do they really make residents in every specialty get tested every year? Like is this a confirmed fact?

[ploughboy]

7 hours ago, medigeek said:

Do they really make residents in every specialty get tested every year? Like is this a confirmed fact?

http://www.cpso.on.ca/Policies-Publications/Policy/Blood-Borne-Viruses

[rmorelan]

2 hours ago, ploughboy said:

http://www.cpso.on.ca/Policies-Publications/Policy/Blood-Borne-Viruses

I mean it makes sense after all I think - public safety issue.

[ellorie]

13 hours ago, medigeek said:

Do they really make residents in every specialty get tested every year? Like is this a confirmed fact?

Only residents who may perform exposure prone procedures (so anybody rotating through emerg/ob/gyn/surgery/a few others, even if that's not your primary specialty).

Sidebar, initially they classified psychiatry as performing EPPs because of the supposed risk of being bitten by patients.  The psychiatry PDs got together and expressed that this is unnecessarily stigmatizing of our patients and not really in line with clinical reality, so now we are no longer an EPP specialty

[medigeek]

4 hours ago, rmorelan said:

I mean it makes sense after all I think - public safety issue.

The odds of transmission of HIV in this context is ~0.3% unless the physician recently got it (high viral load). The likelihood of a physician having HIV is <0.1%. Then of course there has to be some form of accident which is quite unlikely on the physician's part. 

So when we compile these numbers, seems kind of a silly thing to constantly test for. Especially since accidents prompt PEP use. 

[GrouchoMarx]

From my studying for the boards, I have learned that there has never been a case of HIV transmission from a physician to a patient, ever, at least in North America. 

This policy is a CPSO PR stunt.

[rmorelan]

43 minutes ago, medigeek said:

The odds of transmission of HIV in this context is ~0.3% unless the physician recently got it (high viral load). The likelihood of a physician having HIV is <0.1%. Then of course there has to be some form of accident which is quite unlikely on the physician's part. 

So when we compile these numbers, seems kind of a silly thing to constantly test for. Especially since accidents prompt PEP use. 

Valid points - what is the down side of testing? the cost is minimal, the risks are very small but not zero, and it reassuring to the public at least. The act of constantly being tested may be  one the reasons rates are so low.

It is an annoying test for sure - so it the TB test you have to do every year. As a side note I gain a small speck of understanding about anti vaccination logic after being told for the 6th time to get a TB test including right now even though I will be in the hospital for about 3 weeks after the results come back.  

[medigeek]

4 hours ago, rmorelan said:

Valid points - what is the down side of testing? the cost is minimal, the risks are very small but not zero, and it reassuring to the public at least. The act of constantly being tested may be  one the reasons rates are so low.

It is an annoying test for sure - so it the TB test you have to do every year. As a side note I gain a small speck of understanding about anti vaccination logic after being told for the 6th time to get a TB test including right now even though I will be in the hospital for about 3 weeks after the results come back.  

Well I mean we've taken an approach of doing less and less tests (both in Canada & USA) for patients, so I always find the extra (relatively) useless tests for health care workers interesting. As you pointed out, TB being the worst of them all. But ultimately it's a hassle that has minimal upside. If there was a exposure, everyone gets tested and gets PEP if needed anyway. 

Thing with the TB test is... we're handing out a hepatotoxic drug to people who may not (and likely don't) have TB to begin with. Prime example being those who had the BCG vaccine and have a positive PPD. Like at least do the Quantiferon.. lol... pretty insane when you think about it. The infectious disease guys constantly preach this too but everyone else loves the crappy PPD protocol for some reason. 

[quickdraw_mcgraw]

On 4/15/2018 at 8:21 AM, ploughboy said:

http://www.cpso.on.ca/Policies-Publications/Policy/Blood-Borne-Viruses

Yes, surgical specialties, they just made a list of the specialties that are high risk.

[quickdraw_mcgraw]

On 4/15/2018 at 10:53 AM, rmorelan said:

I mean it makes sense after all I think - public safety issue.

Exactly, so I just mention it so that you might use it as further information in choosing a specialty.  The high risk in infecting a patient, as I best understand are surgeons and assistants in OBGYN, GEN. ORTHO.  Not sure about the others.

[quickdraw_mcgraw]

On 4/15/2018 at 3:23 PM, medigeek said:

The odds of transmission of HIV in this context is ~0.3% unless the physician recently got it (high viral load). The likelihood of a physician having HIV is <0.1%. Then of course there has to be some form of accident which is quite unlikely on the physician's part. 

So when we compile these numbers, seems kind of a silly thing to constantly test for. Especially since accidents prompt PEP use. 

But one positive test ends your right to practice in Ontario, and it happens.  And we don't know the true prevalence in the baby boom population.  One positive test, I cannot do the only thing I know how to do...

[quickdraw_mcgraw]

On 4/15/2018 at 3:34 PM, GrouchoMarx said:

From my studying for the boards, I have learned that there has never been a case of HIV transmission from a physician to a patient, ever, at least in North America. 

This policy is a CPSO PR stunt.

Totally right.  And it can really f-ck up your career.  You are at risk of catching it, but at zero risk of giving it to the patient.  Meanwhile you are not allowed to practice.

[quickdraw_mcgraw]

On 4/15/2018 at 4:13 PM, rmorelan said:

Valid points - what is the down side of testing? the cost is minimal, the risks are very small but not zero, and it reassuring to the public at least. The act of constantly being tested may be  one the reasons rates are so low.

It is an annoying test for sure - so it the TB test you have to do every year. As a side note I gain a small speck of understanding about anti vaccination logic after being told for the 6th time to get a TB test including right now even though I will be in the hospital for about 3 weeks after the results come back.  

Don't forget, a false positive, while figuring it out, is all over your EMR, under your name.  And you cannot practice during that time.  And HCV is the bigger concern, the CPSO panel has not accepted HCV infection can be cured yet, it might take a few years.

[quickdraw_mcgraw]

On 4/15/2018 at 9:03 PM, medigeek said:

Well I mean we've taken an approach of doing less and less tests (both in Canada & USA) for patients, so I always find the extra (relatively) useless tests for health care workers interesting. As you pointed out, TB being the worst of them all. But ultimately it's a hassle that has minimal upside. If there was a exposure, everyone gets tested and gets PEP if needed anyway. 

Thing with the TB test is... we're handing out a hepatotoxic drug to people who may not (and likely don't) have TB to begin with. Prime example being those who had the BCG vaccine and have a positive PPD. Like at least do the Quantiferon.. lol... pretty insane when you think about it. The infectious disease guys constantly preach this too but everyone else loves the crappy PPD protocol for some reason. 

Most surgeons, including myself, prick themselves in the OR once or twice a year, higher for residents.  We don't routinely test for HIV or HCV preop, especially in emergency cases.  It is not a controlled environment.  You can tell me, but my understanding is that the prevalence of the two, HCV and HIV are increasing, and no one really knows what the risk is, the 1/300 number is a guess, I haven't found the original source.

[quickdraw_mcgraw]

And you guys forget the eye splash, happens very often, even with good PPE.

[crysally]

On 4/15/2018 at 9:03 PM, medigeek said:

Well I mean we've taken an approach of doing less and less tests (both in Canada & USA) for patients, so I always find the extra (relatively) useless tests for health care workers interesting. As you pointed out, TB being the worst of them all. But ultimately it's a hassle that has minimal upside. If there was a exposure, everyone gets tested and gets PEP if needed anyway. 

Thing with the TB test is... we're handing out a hepatotoxic drug to people who may not (and likely don't) have TB to begin with. Prime example being those who had the BCG vaccine and have a positive PPD. Like at least do the Quantiferon.. lol... pretty insane when you think about it. The infectious disease guys constantly preach this too but everyone else loves the crappy PPD protocol for some reason.  

4

As someone who recently did a Quantiferon for another false positive PPD, my number is 0 AFTER getting the BCG. Any idea what I can do if I think might be allergic to the PPD?

[quickdraw_mcgraw]

7 minutes ago, crysally said:

As someone who recently did a Quantiferon for another false positive PPD, MY number is 0 AFTER getting the BCG. Any idea what I can do if I think might be allergic to the PPD?

Of course the extra health care worker testing is odd, literally against the policy "Choosing wisely"

[ellorie]

48 minutes ago, crysally said:

As someone who recently did a Quantiferon for another false positive PPD, my number is 0 AFTER getting the BCG. Any idea what I can do if I think might be allergic to the PPD?

Yeah I have the same issue. Negative Quantiferon but occasionally major skin reaction. Sensitive skin. 

As far as I can tell, my options are pay out of pocket for quantiferon or get CXR every year. 

Luckily I get a lot of redness but variable induration so I just get PPD every year and most experienced nurses read it negative. Only got into trouble one year with a less experienced nurse. 

[sangria]

28 minutes ago, ellorie said:

Yeah I have the same issue. Negative Quantiferon but occasionally major skin reaction. Sensitive skin. 

As far as I can tell, my options are pay out of pocket for quantiferon or get CXR every year. 

Luckily I get a lot of redness but variable induration so I just get PPD every year and most experienced nurses read it negative. Only got into trouble one year with a less experienced nurse. 

Do you have to get quantiferon done every year just like you would for PPD?

[ellorie]

2 hours ago, sangria said:

Do you have to get quantiferon done every year just like you would for PPD?

If you were using quantiferon exclusively, probably yes.

I just get PPD because sometimes my skin doesn't react.  But if it gets read as positive, I'll go to quantiferon.

[medigeek]

On 4/18/2018 at 4:33 PM, quickdraw_mcgraw said:

Most surgeons, including myself, prick themselves in the OR once or twice a year, higher for residents.  We don't routinely test for HIV or HCV preop, especially in emergency cases.  It is not a controlled environment.  You can tell me, but my understanding is that the prevalence of the two, HCV and HIV are increasing, and no one really knows what the risk is, the 1/300 number is a guess, I haven't found the original source.

You don't test post-op after a legit exposure occurs? 

The 0.3% easily fluctuates based on many factors. What's the viral load? If the patient got it recently, it'll be sky high. If they're on haart, it'll be very low. If they have it and don't know, it'll be in the middle somewhere. Plus many other factors just as quantity of blood exposure, depth of injury etc. Same concepts apply to sexual transmission which is on average <0.1% for vaginal intercourse but as high as 1 in 5 for insertive anal intercourse if the person just got the infection.