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|Title: ||Clinical Ethics Committee Case 17: A paramedic sustains a bite while attending a callout. The assailant refuses testing for HIV or Hepatitis C: what should we do?|
|Authors: ||Newson, A.J.|
|Issue Date: ||2012|
|Publisher: ||Royal Society of Medicine Press Ltd|
|Citation: ||Newson, A.J. (2012) “Clinical Ethics Committee Case 17: A paramedic sustains a bite while attending a callout. The assailant refuses testing for HIV or Hepatitis C: what should we do?” Clinical Ethics, 7(1): 1-6. doi: 10.1258/ce.2012.012m02.|
|Abstract: ||Helen works as a paramedic for an NHS Ambulance Trust that serves a medium-sized city. She attends a
huge variety of incidents in the course of her work; including those arise from excessive consumption of
On Saturday night, Helen was on duty when a call came in to attend a brawl involving approximately 10
young men near the city centre. Members of the public had reported the men drinking heavily in a local
bar before being ejected from the premises. Police were already in attendance and there were reports of
injuries requiring onsite assessment with a view to hospital admission. On arrival at the site of the brawl,
Helen and her colleague began to assist those that had sustained injuries.
While assisting a man with a deep cut to his face, Helen was approached by another man, Joe, who had
previously been fighting with the man Helen was treating. Joe shouted at Helen to “stop helping that
thug – he doesn’t deserve it.” Helen replied calmly that her role was to treat those who needed her help.
Joe then lunged at Helen, grabbing her and pulling her to her feet. In the process, a gap between her
glove and her uniform sleeve became exposed, and Joe bit Helen on her wrist, drawing blood. Joe had
previously been punched in the mouth and so was bleeding around this area. At this point the police
(who had meanwhile been trying to contain the brawl) intervened and arrested Joe. Helen’s colleague
called for another ambulance as Helen now also required treatment herself.
At the time of this assault, Helen was 10 weeks pregnant. Although the bite itself did require stitches,
Helen did not have to be admitted to hospital for treatment. Her wound was also sore and bruised. An
accident and emergency duty doctor mentioned to Helen that she might want to think about any
occupational exposure to disease that might have occurred and whether she might like to think about
Post-Exposure Prophylaxis (PEP: taking drugs that are around 80% effective at preventing infection
also mentioned that expert on-call advice was available if she wanted it. Tired and sore, Helen said she
just needed to get home to sleep and would think about it the next morning.
Early the next morning, Helen returned to the accident and emergency department. Visibly distressed,
she talked with a different doctor about the fact that she was pregnant and was concerned about
infections resulting from the bite she had sustained, in particular HIV and hepatitis C. Helen explained
that she “wouldn’t be able to live with herself” if she had contracted either of these conditions and then
passed them on to her baby, especially as there were things that could be done during pregnancy and
birth to prevent transmission. However she also knew that the options for PEP were reduced due to her
being pregnant and that PEP would likely have unpleasant side effects and toxicity.
The doctor discussed with Helen that if she did decide to go ahead with PEP she would need to do so
soon: PEP should ideally be initiated as soon as possible after exposure and no later than 48-72 hours
afterwards. She also explained that PEP should not usually be delayed while waiting for information on
the source individual. Helen would then need to take these drugs for 28 days. The doctor also explained
to Helen that the chances of HIV infection being transmitted in this way were around 3 in 1,000 or 0.3%.
Helen was initially reassured by this information. However she then stated: “Actually, I just want this to be over with; I don’t want it hanging over me for the rest of my pregnancy. I also don’t want to take PEP
when I don’t have to. Can’t we just test the guy that bit me?” The registrar explained that consent would
be necessary for this test to go ahead; Helen asked her to look into it.
An hour or so later, the registrar returned. She had talked with a police officer at the site where Joe was
being held pending being charged. Joe had been approached regarding testing for HIV and hepatitis C
but he had refused consent, saying that apart from his drunken loss of judgement on Saturday night, he
was a “solid bloke who didn’t need to be tested for anything.”
“Great,” said Helen. “So where does that leave me? Are my rights worth less than those of the guy who
bit me?” The doctor frankly admitted that she wasn’t sure and offered to contact the Clinical Ethics
We are approaching the Clinical Ethics Committee with the following questions in mind:
1. Assuming that we can’t have Joe tested against his will, is this fair on Helen, particularly given
that she is pregnant? What about her psychological distress?
2. Would it ever be appropriate to test a competent patient for HIV or Hepatitis C without consent?
If not, does this mean that healthcare workers’ rights are subordinate to those who refuse
3. What if this dilemma were the opposite, for example, if a health professional refused consent to
test after possibly infectious contact with a patient?
4. Are there any other ways we could find out this information about Joe?
5. Are there any other ways we can resolve this problem that we haven’t thought about?
6. Should Helen be able to continue to work in the meantime? If so, should any extra provisions be
made or precautions be taken?|
|Description: ||case study|
|Type of Work: ||Article|
|Type of Publication: ||Post-print|
|Appears in Collections:||Research Papers and Publications. Sydney Health Ethics|
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