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?

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 alcohol. 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 2 ). He 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 Committee. 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 testing? 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?