This research article is intended to be a source of information for those medical professionals who are concerned with health and safety at work and to provide information about the causes of injury and diseases at work so that we may design and implement suitable measures towards prevention.
We, doctors spend the prime time of our lives in our clinics, wards, laboratories and operation theaters. Our occupation exposes us to cuts, stabs, scratches and stings stemming from the use of syringes and scalpels & toxic effects of prolonged exposure to disinfectants, anesthetic gases and other chemicals. We may suffer from burns from hot surfaces, electrical shock from faulty or improperly grounded electrical equipment and exposure to x-rays and radiations from radioisotope sources. We suffer from skin irritation and dermatoses due to frequent use of soaps and detergents. Our ears, nose and throat get irritated because of exposure to airborne aerosols. Allergy to latex gloves and other latex containing medical devices may take place. The demands of our profession make us neglect our families. But, in return to the dedication to our job many of us become victims of the harmful effect of the work environment. We are liable to suffer from crippling deadly infections, physical and chemical injuries, psychosocial damage, workplace violence and litigation.
Sincere and efficient doctors these days are feeling anxious and depressed, are sleeping badly and getting aches and pains during periods of great work pressure. Even interest in sex with their life partners may be more or less evaporated. Symptoms like pain in the neck, backache, headache and palpitations are typical manifestations of their occupational stress. Feeling of heavy responsibility towards patients causes perpetual psychological pressure especially when patients don’t recover quickly. Burnouts and strained family relations take place due to overtime work and being surrounded by very sick, badly traumatized or violent patients.
Workplace assaults against doctors and medical facilities are becoming common. Incidents like beating, stabbing, rape or murder of health workers and breaking or burning of health infrastructure are often published in the press. Anger and frustration of the attendants of the patient due to the financial loss and untimely demise of a near & dear needs to be directed towards the culprit disease but the treating doctor becomes an easy scapegoat to vent their frustrations.
Doctors are exposed to about 300 biological agents, viruses, bacteria, parasites, fungi, moulds and organic dusts in our work environments. HIV causing AIDS, hepatitis-B, hepatitis-C and tuberculosis infections are now major occupational hazards for us. The risk of acquiring HIV, HBV or HCV infection by exposure to blood of the patient or by needle pricks from an infected patient is very low but could nevertheless have grave consequences. Estimated risk of HIV infection to health care workers through percutaneous {needle stick injury/cuts} or mucous membrane exposure is 0.5%. Transmission has been reported to have occurred through skin contamination. The risk of infection is more if the wound inflicted on the body of the doctor is deep, if there is blood on the tool, if the injuring needle had been lying in a vessel, if the needle is hollow, if the patient dies within 6o days of injury to the medical staff and if there is massive conjunctival spill. Infectious materials include semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pericardial fluid, peritoneal fluid, amniotic fluid, any body fluid mixed with blood and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. Unfixed tissue or organs also carry the risk of infection.
TThere is 1.8% incidence of clinical infection to the medical personnel following needle stick injury from HCV positive source. 1 to 2% of health workers at the moment are suffering from hepatitis C. In the coming 10 years there is going to be an explosion of hepatitis C related complications. It is estimated that there will be 60% increase in end stage cirrhosis, 94% increase in hepatocellular carcinoma, 279% increase in hepatic decompansation, 528% increase in the need for liver transplant and the liver death rate will rise by 223%.
Medical personnel are at risk due to tuberculosis patients approaching them for treatment. Number of patients with open tuberculosis and those having multi-drug-resistant tuberculosis is rising corresponding to the rise in AIDS. Many outbreaks of tuberculosis have been reported in health facilities. Three tire measures to control the source of infection by isolation and barrier nursing; decontamination of the contaminated environment by filtering the air and use of proper disinfectants for hands and instruments and personal protection by routine use of masks by the medical staff may help.
Babesiosis, Brucellosis, Leptospirosis, Arab-o-virus, Relapsing fever, Syphilis, Malaria, Creutzfeldt-Jakob disease and Viral hemorrhagic fever are other deadly blood borne pathogens are occupational health hazards for doctors.
A study which included 8645 doctors from all specialties, nurses, laboratory technicians and cleaners from teaching hospitals in Taiwan was carried out in 1999 and the conclusion drawn was —“Needle stick injuries in health care workers may be quite common, thereby making the risks of contacting blood-borne infectious diseases very high”. The reported incidences of needle stick injuries over the 12 month period preceding the survey was 1.30/person and of injuries from other sharp objects 1.21/person. In more than half {54.8%} of the needle stick injuries, the needles had been used in patients, 8.2% of whom were known to have hepatitis B or C, syphilis, or HIV infection…………………..Guo YL et all. “Needle stick and sharp injuries among health care workers in Taiwan”. Epidemiol Infect 1999; 122(2):259-65.
Surveillance on health care workers in UK, who have been exposed to blood born viruses has been carried out since 1984. by the end of June 2000, the Communicable Disease Surveillance Center had received 827 reports of exposures to material from patients with antibody to HIV, hepatitis C or hepatitis B. 242 of the health care workers were exposed to HIV. Out of the total of 82 infected 337 were nurses and 262 were doctors; these two groups remain the most frequently exposed…………“CDR Weekly, Communicable Disease Report”. Volume 10, Number 33.
Medical instruments and even heavy equipment like gas cylinders often fall upon the legs and toes of the doctors dealing with the patient in tense and emergency situations. Doctors suffer from musculoskeletal problems and back pains resulting from handling of heavy patients. They slip, trip and fall on wet floors of their clinics or operation theaters while they are mentally occupied to save the lives. Chronic poisoning can take place because of long term exposure to medications, sterilizing fluids, detergents and antiseptics.
Safety lies in a safe and healthy environment where hazards are eliminated or minimized through a system of engineering controls, personal protective equipment, education and regular work site surveillance. All employees are responsible for working in a manner that ensures a safe and healthy environment. Joint rounds with all concerned employees should be conducted every week for risk assessment and hazard surveillance. Work injuries and illnesses of all employees should be monitored, evaluated, reviewed, trends identified and corrective actions be taken as needed.
The following “universal precautions” are advised: Universal precautions mean taking precautions with everybody. We do not have to make assumptions about the possibility of risk from a particular person. In spite of our relations with the patient, dignified life style of the patient, his apparent behavior or health we have to maintain high index of suspicion and take full precautions with everyone.
- Always wear gloves when handling blood and other body fluids or unfixed tissue. Use barriers like goggles, face shield, gum-shoes and waterproof gowns in routine.
- Medical staff should look for the presence of cough in patients approaching health facilities for excluding the possibility of tuberculosis and should make the patient bear a mask, immediately.
- All medical and para-medical staff should be immunized against hepatitis B. HBV vaccine has proved highly effective. In USA it is mandatory for an institute to start immunization of the non-immunized employee for hepatitis B within 3 days of joining the service. We must always remember that no immunization exists to prevent hepatitis C or hepatitis B and vigilance alone can keep us free from these viruses colonizing our bodies. Occupational safety and health organization{OSHA} in USA has streamlined the procedures to help medical fraternity. It is mandatory to report exposure to blood by splash or otherwise from 1.1.2002. under “Needle-stick Safety and Prevention Act” passed by the senate.
- To avoid needle-stick injury never bend, recap or break with hands contaminate needles or sharps.
- In the event of percutaneous exposure, bleeding from the wound should be encouraged by pressing around the site of the injury under a running water tap (take care not to press immediately on the injury site). If mucocutaneous exposure occurs rinse or wash the area with detergent or a chlorine solution {1%solution of sodium hypochlorite}. If there is splash in the eyes, irrigate thoroughly for 15 minutes, by watch.
- Cuts or abrasions on your body should always be covered with a water proof tape.
- Sharp needles or scalpel should not be passed from hand to hand i.e. by hand of the assistant to the hand of the doctor and vice versa these should rather be placed in a container from where these should be picked up and returned. Sharps should be disposed off immediately after use in a puncture proof container. In case of risky patients prick resistant gloves can be used.
- Treatment with anti-HIV drugs {post exposure prophylaxis—PEP} be stated immediately after a confirmed exposure has occurred, in order to reduce the risk of infection.
- Every person working in our health facilities should receive training to report all violent incidents, including threats and verbal abuse. They should be able to identify and respond to potential workplace security hazards by diffusing hostile situations. Entry to the work place should be guarded. Special care should be taken to keep the place well illuminated in the evenings and at night. There should be a single entry and exit door. At night when the staff is reduced and patient’s attendants are likely to be under the effect of liquor, special vigilance is warranted. Only one attendant should be allowed to accompany the patient in the doctor’s clinic. As a matter of rule there should not be more than two chairs in the clinic of the doctor. Carrying any types of arms into medical facilities should be prohibited. Procedures for summoning assistance in case of an emergency situation should be chalked out in advance.
“Those who will not take care of their health now, will have to take care of their illness later”.
Dr. Narotam Dewan, MS, Consultant Laparoscopic & General Surgeon, Dewan Hospital, Ludhiana. Formerly– *Resident surgeon, GOMCO Patiala; *Sr. resident surgeon, CMCH, Ludhiana.; *Consultant surgeon, SJH, New Delhi & Central Hospital, Al-Khoms, Libya; and *Sr. Lecturer, DMCH, Ludhiana.
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