Cathleen Terhune Alty
The March 1996 Dialogue asked readers three questions about percutaneous injuries involving sharps: What happened, how did you react, and did job-related stress occur as a result? Some of the responses to the survey are as follows:
-"It happened while unscrewing the needle cartridge after recapping. The cap popped off the needle and then `ouch!` I was employed through a temporary agency. The dentist really liked my work and continued to ask the agency for my return to fill in until he found a permanent hygienist. Then I had a needle stick. I went to him and told him. He became very cold. I asked if I was supposed to fill out any forms. He told his receptionist, and she gave me what she had. The dentist did not sign or acknowledge the forms. I was never asked back. He said I was a temporary and he had no responsibility. I was concerned. How did I cope, and still cope? I pray...
"... [Dentists] squeeze in more patients to squeeze out extra dollars. I always run behind because I take all the precautions to protect the patient. I thought it was me but I observed other hygienists who run ahead or are on time during their day. What I found was very disturbing. They take shortcuts to make it on time.
"They don`t change all the plastic wraps. They use the same gloves they cleaned up the room with to set up for the new patient. During the procedures, they reach into drawers with contaminated gloves. They soak X-ray bite blocks for a few minutes - rinse them off and use them again with the next patient - usually because the dentist doesn`t want to spend the extra dollars to have enough. A lot of dentists don`t want you to sterilize the prophy angles because they won`t last as long. I see hygienists bring their dirty, contaminated instruments (bagged or not) to the autoclave or chemiclave, open the sterilizer and handle the sterilized bags with the same gloves.
"Remember, we are not good hygienists if we run behind. I don`t go to the dentist myself or send my family. Someone should conduct a study to time how long it takes a hygienist to do everything. A lot of hygienists will shortcut with the prophy to stay on time - when you think about it, that might be the safest place to bend."
-"I was injured by a scaler while cleaning up a tray setup. My finger bled despite wearing vinyl gloves. I immediately told my employer who had me wash with an antibacterial soap. He asked me if I wanted to be seen by my physician. I declined. He did not report the incident to OSHA. I rechecked the patient`s health history. When I saw the patient in six months, I told him about my exposure and asked if he developed any serious illnesses, especially AIDS or hepatitis. I try to work slower."
-"[A] needle stick injury occurred while dismantling an anesthetic syringe. Disbelief [was my reaction]. I`ve been working in dental hygiene for 25 years, and this was the first incident I ever had. I did report it immediately. I don`t really know if the incident was reported to OSHA. Fortunately, I knew the patient fairly well, so I didn`t feel that there was much need for concern. If this had not been the case, I would have been (and still would be) constantly worried. I surely will never yank on a jammed needle ever again!"
-"[I was injured] while hand scrubbing a curette after a dental prophylaxis. Fear, pain, and anxiety [was my reaction]. [In regards to first aid,] I did not know it at the time, but I now know I should encourage bleeding. I reported it to my employer who was non-compliant and did not report it to OSHA. I went for HIV testing. Thank God I was negative. I was counseled before the testing. I was a nervous wreck waiting for the results. I do not scrub instruments anymore."
New York hygienist
-"I was reaching for an instrument from the bracket tray, and the instruments were `tangled.` As I picked one up, a sickle scaler punctured my thumb. I became upset because the puncture was deep and there was a lot of bleeding. The inside of my glove was full of blood. I know there was blood on the scaler. I reported it to my employer who just shrugged it off. I was concerned even though there was no indication of health problems on medical history. I worried about the incident for days and then the worry subsided - although I do think about it occasionally."
New Jersey hygienist
-"[I] punctured the skin while in the process of getting ready to clean instruments. [It] happened while on active duty with U.S. Navy. Reported injury immediately to dentist and clinic supervisor. Injury report was filed, and I was sent for blood test - gamma gobulin shot. Patient was called back also for testing. Medical history reviewed. [I was] not concerned, just aggravated that it happened, was in a rush. I now take more time and precaution when handling instruments."
New York hygienist
-"I was injured by a dirty, sharp Cavitron tip. I was temping as a dental hygienist and was unfamiliar with the room setup. I turned quickly to reach for something and got stabbed in the palm of my left hand (I am right handed). I became very upset and worried about contracting HIV, hepatitis, etc. I reported the accident to my employer, who made light of it and told me not to worry about it. I insisted on being tested and having a report filed. He did agree, but still felt I was overreacting. He said he knew the patient and felt he was `clean.` I was scared to death about contracting a disease. The stress I felt was overwhelming! I received counseling from my MD and only felt better when my baseline and three-months blood test came back negative. I still have a six-months test left to go. I am very cautious now - not that I wasn`t before. But now I pay a lot of attention to where the sharps are positioned in my workspace."
New York hygienist
-"I was injured by a sharp instrument in February 1996. It was the first stick I have ever had. It happened during a prophylaxis on a retired military man with a history of syphilis and herpes. He told me I was `overreacting.` We had no protocol to follow, and the incident was not reported to OSHA. I was extremely concerned about contracting a disease. I have also been under a lot of stress as I`m sure I will be for the next year. I`m more upset about my employer`s reaction to the situation."
-"[I was injured while] cleaning my instruments (hand scrubbing). I was in a hurry and didn`t want to wait for the ultrasonic. It was full of instruments. [I] rinsed injury [and] washed with soap. Told employer. He did not report it, as the patient was not a high-risk individual for HIV. I was unwilling to ask patient to be tested. Employer did pay for me to be tested for HIV. My faith in God helps me to face my fears. Also, I slowed down, and I wait for the ultrasonic now."
-"[The injury occurred] during a dental procedure when a patient became extremely agitated and violent. Incident report [was] completed as soon as possible. [I] was seen by physician on-site - bloodwork, AIDS, hepatitis A&B blood tests were ordered on the patient, according to policy of facility. [Contaminated sharps] is a hazard of the job. I am more careful with combative patients.
Rhode Island hygienist
-"In June 1995, I was scaling a patient`s lower anteriors and the instrument slipped. I poked my ring finger on my right hand. I didn`t realize it went as deep as it did. But I tore off my glove, let my finger bleed, then double-gloved that hand and finished the prophy. Both the patient and myself went for blood tests and documented the results in our OSHA book. I was not worried. However, I did pray a lot and that seemed to ease my mind. I do try to watch and also keep my instruments sharp."
North Carolina hygienist
-"The metal tip of an ultrasonic scaler [became] imbedded 2mm into the palm of my hand when the bracket arm of the unit dropped into the path of my moving hand. The arm dropped to lack of servicing the unit. I was quite shocked and concerned about disease transmission. I had just completed a very bloody subgingival scaling with the ultrasonic scaler. I was working on a young, sexually active single man. I told my employer and he gave me penicillin 500mg tablets. He did not report the incident. I took myself for HIV testing on my own initiative. I repeatedly tested negative for HIV after two years. The doctor still did not get the unit repaired for "drift," so that the operator was still in danger of an accident. I left the doctor`s employment."
-"Turning during a prophylaxis procedure, [I] scratched my left arm on an uncapped Titan tip. I washed the area with antibacterial soap, but not until after the prophylaxis was completed. The accident was documented with the dental assistant. I don`t think she reported it to OSHA. Yes, I was concerned about contracting disease. I don`t cope with the stress very well. I try to be very cautious, but am aware another sharps accident could occur very easily."
-"[A] Cavitron with contaminated tip pierced calf muscle deeply when hose became kinked. Numerous punctures [have occurred] while cleaning instruments (not reported). Most punctures [are] by explorers and sickle scalers. After first shock [during kinked hose incident], [I] cleansed and bled the puncture wound. Reported incident to my employer, who sent me to physician where I received a tetanus booster. No report to OSHA: 1.) OSHA did not regulate dentistry then and 2.) not enough employees to require OSHA 200. I am more concerned about the lack of information on worker`s rights, workers` compensation, and OSHA complaints. In the [Cathleen] Alty article [March issue], it had a blame-the-victim, cost-to-employer bias."
New York hygienist
-"My [injuries] with sharps have been with the scaling instruments, mainly during bagging instruments for autoclaving. Being in a hurry, I haven`t used gloves. But since the instruments have been disinfected in the ultrasonic, I haven`t worried too much. I did stick myself with a needle, but that was a sterile needle which was set up for a procedure. I have also cut my finger while sharpening a sterile instrument (I love sharp scalers!). The protocol I follow [after an incident] is to wash immediately with soap and water, then apply an antibacterial ointment, a bandage, and a fingercot if necessary. The incident is reported on an exposure incident report and signed according to whether I will seek treatment or refuse treatment. The patient`s name is recorded, and an objective description of events is written. The report paper is kept in my employee file, and the incident is added to the sum of total office exposures. I am always concerned when I have poked myself. Luckily, I have learned from the few incidents I have had. I am more careful now compared to when I started practice. And there`s no sense worrying about it, since it has already happened. Worrying won`t help. I`ve got to live each day to the fullest. I love my job. The pleasure of providing a service for my patients and seeing their progress outweighs the fear of contracting a disease from past needlesticks."
-"[I was] injured from scalers - always when cleaning, always while rushing too. Stuck a couple times by explorer when retrieving instruments. This doesn`t happen anymore because I`m very careful. All injuries were prior to 1990s standards set by OSHA. I think I once told an employer, who seemed nonplused. I was concerned, but you can`t worry about it. I`m definitely more careful, and I never rush during cleanup. (I hate that part of my job)."
-"[I was injured while] sharpening during preventive maintenance appointment in a perio practice - wearing latex glove [on] non-dominant hand. Didn`t report injury to employer. Felt minimal risk as patient was married. I was worried but rationalized risk as miniscule. Also, how deep must cut/puncture be. Need we be concerned with cuts/punctures that don`t draw blood on the injured party? Six months later, had HIV test, which was negative. Routinely pay for HIV test once a year which has always been negative. Still sharpen during care, [but] now try to keep it to a minimum and try to keep fingers out of the way while holding stone. I try to sharpen before using instruments after they`ve been sterilized."
Editor`s Note: The responses above were based on a survey that also asked readers how long they have been a practicing hygienist. Since many of the dentists and employers involved were apparently negligent in their response to the injuries, we paused when we came across comments from a veteran of many years experience. We felt it might become a matter of only a few hygienists in a particular state with as much experience. In order to ensure anonymity, we did not disclose work experience information above. In general, though, the readers responding include four with more than 20 years experience, nine with 10 to 20 years, and four with under 10 years. We feel this point is relevant since "rookie mistakes" are not an issue here.
The author`s response...
As the author of the article about percutaneous injuries (March 1996 issue), I want to say that I sincerely appreciate the comments of those who responded to the dialogue questionnaire that followed the article. But after reading them, I am so deeply concerned. It appears that we as hygienists are deceiving ourselves, and we are laying our very lives on the line because of percutaneous injuries from contaminated sharps.
Now it may be hard for some hygienists to accept but we are responsible for our own safety! Most of us aren`t poked by an instrument someone else is holding; we are doing it to ourselves. Hurrying. Not looking or paying enough attention. Poor timing. Trying to be helpful. We have got to stop being so cavalier, so tough and cool, such good girls who don`t have a clue as to what to do when we get a percutaneous injury.
I`m all for prayer and I believe in its power. But too many of you are getting poked and praying that it will all be OK.
This is serious stuff; we get an injury and run to the dentist and expect that he will tell us what to do. I haven`t been in physical dental hygiene practice for awhile, but I know what 80 to 90 percent of dentists are going to say. He`s going to blow you off. "Don`t worry. That patient is clean," or "You`re overreacting." According to the OSHA standard, this is breaking the law. The employer is suposed to encourage you to get treatment. It is the employee`s right, not the dentist`s, to decide to be tested. He has no legal right to impose his own personal assessment of the situation. Instead, he is charged by the law to follow the procedure OSHA so clearly spells out.
OSHA says you must document exposure incidents. You can refuse treatment or refuse just HIV testing. But you get to choose. It`s your life. Very few dentists will compromise their bottom line for the health and mental well-being of their hygienist. God bless the few that will. To most dentists, any RDH can do the job and nearly any of us will do. Just keep quiet, don`t talk back, or cause trouble. If you do, you`re out of there. It has been this way for years and it probably won`t change!
What has to change is us. Don`t expect Daddy Dentist to give you good advice. Getting yourself and the source patient tested is going to cost him money, and he isn`t going to like it. You may have your follow-up care performed during working hours, and he isn`t going to want you to be out of the office. But it`s the law.
What happens if you are stuck with a contaminated sharp and you develop disease. Let`s look at worse case scenarios and say you are one of the few 0.3 percent who somehow do seroconvert and become HIV positive. How will you be able to work if you develop full blown AIDS? Who will pay for your treatment? How will your family survive without you? How much of your life will you miss because you didn`t take advantage of your rights of reporting the incident, getting tested, and having the entire thing documented?
Workers comp won`t pay because there is no documentation. The dentist isn`t going to pay; there`s no documentation that the accident ever even occurred.
So here`s the bottom line. If you are stuck with a contaminated anything, tell your employer. Don`t ask him what to do. Tell him you`ve been stuck, document it, and then get follow-up care if you choose to. You go to your physician, tell him what happened.
Get it all documented. Get tested. Get counseling to help you deal with the trauma. If, God forbid, you develop disease from the injury, at least you`ll have the benefit of workers` compensation to help you. Yes, it`s worrisome, scary, and a hassle but it is your only recourse.
And maybe, just maybe, you`ll be a little more careful, take a little more time, so it doesn`t happen again.
Don`t allow the dentist to have the "superior" knowledge of the OSHA standard. You were able to read all that horrible oral microbiology and tooth morphology stuff in dental hygiene school. You are certainly smart enough to read the OSHA standard and understand what it is saying. He may not even have read it himself or understand it but you can.
It is your right, but you can`t argue the point if you don`t know for sure. READ the thing and know what to do. Don`t be a victim.
Get smart. Only you can take care of it ... only you can keep yourself safe.