The Needlestick at 4:15 pm

First 15 minutes - the wound:

1. Wash immediately with soap and running water and let it bleed freely under the tap. Do not squeeze, milk or suck the wound, and do not scrub with a hard brush - these push contaminated blood deeper into tissue.
2. Apply an antiseptic (70% alcohol or povidone-iodine) after washing and cover with a waterproof plaster.
3. Note the exact time of exposure. This becomes the reference point for every prophylaxis decision.

First hour - the report:

1. Inform the nurse-in-charge or the most senior person present, in writing, in an incident register. Concealing it is the single worst option: prophylaxis has a time window that cannot be reopened later. A student cannot be penalised for reporting a sharps injury; an institution that discourages reporting is the one at fault.

Decision-making on prophylaxis:

• HIV: the source patient must be assessed and, with informed consent and confidentiality, tested. The source is currently unknown, so this is a risk assessment, not a guess. PEP should be started as soon as possible - ideally within 2 hours, and no later than 72 hours - and continued for 28 days with a three-drug regimen (e.g. tenofovir + lamivudine + dolutegravir) prescribed by a doctor, not by the student. Baseline HIV testing of the student is done at the start.
• Hepatitis B: if the student's vaccination record shows a completed course with documented protective antibody, no further action beyond a booster decision by the doctor. If she is unvaccinated or her status is unknown, hepatitis B immunoglobulin plus the first vaccine dose should be given, ideally within 24 hours.
• Tetanus: check immunisation status and give a booster if due.
• Follow-up: repeat testing at 6 weeks, 3 months and 6 months, and document each visit.

Critique - every step is unsafe:

• Washing in a basin of tap water does not disinfect anything. It leaves blood and tissue on the instruments, and a basin concentrates bioburden that is then transferred to the next instrument.
• Boiling in an open pan for 5–10 minutes is not sterilisation. Boiling at 100 degrees Celsius kills most vegetative bacteria and viruses but does not kill bacterial spores, which is exactly what matters for tetanus and gas gangrene. Open pans also lose temperature when instruments are added.
• Drying on a cloth towel re-contaminates the instrument with lint and skin flora and leaves it damp - the ideal condition for bacterial regrowth.
• Storage in an open drawer exposes sterile items to dust and hands. There are no indicators and no biological monitoring, so nobody knows whether the process ever worked.

Correct sequence:

1. At point of use: do not recap needles; discard sharps straight into a puncture-proof sharps container. Soiled instruments are kept moist (covered with a damp cloth or soaked in detergent) so blood does not dry on.
2. Decontaminate and clean: soak in detergent and water, brush hinges and lumens under water, rinse. Cleaning is the step that removes the bioburden that protects microbes from heat.
3. Sterilise by autoclave: 121 degrees Celsius at 15 psi for 15–20 minutes, or 134 degrees Celsius for 3–4 minutes for wrapped instruments. Where no autoclave exists, a pressure cooker is far safer than an open pan. Hot air oven (160 degrees Celsius for 2 hours) for metal and glass; 2% glutaraldehyde for heat-sensitive items.
4. Dry in a dust-free area, not with a shared towel.
5. Store in a closed, labelled cupboard; use packs in order of sterilisation date.
6. Monitor every cycle with mechanical gauges and chemical indicator strips, and with periodic biological spore testing.

This is also the honest answer to the student's exposure: recapping is a practice that should be abolished, not a habit to be adapted to.

What to document:

• In the incident register: date, exact time of injury, what procedure was being performed, the device involved, depth of injury, whether gloves were worn, and the immediate first aid given.
• Source patient details: name, hospital number, reason for admission, and the consent and result of any HIV, hepatitis B or hepatitis C testing. This information is strictly confidential and is held only by the treating doctor and the person managing the exposure.
• The student's own record: vaccination history, baseline blood sample, date and time prophylaxis started, the drug regimen and duration, and the schedule of follow-up tests.
• The action taken on the ward: sharps container replaced, recapping practice flagged, staff instruction given.

Why it matters:

1. Clinical safety - prophylaxis has a 72-hour outer limit and an ideal 2-hour window. A written time of exposure protects the student from missing it.
2. Continuity - the follow-up testing schedule spans six months, far longer than any single posting. Without a record, the student will be tested at random or not at all.
3. Accountability and compensation - if seroconversion occurs, the documented report establishes that the exposure happened at work.
4. System improvement - the same register reveals that the home has no sharps policy and no PEP kit, which is a management failure, not a student failure.

Keeping quiet to protect an attachment is a false economy: it trades a career for a fortnight's convenience.