Should Gloves Be Worn When Giving Allergy Shots?

A common question patients ask is whether nurses and or other medical staff be wearing gloves when giving allergy shots (or other forms of immunization).
According to the CDC:

"Gloves are not required when administering vaccinations, unless persons administering vaccinations are likely to come into contact with potentially infectious body fluids or have open lesions on their hands." [link]

As such, the practice of wearing gloves is left up to the discretion of the person administering the shot.

Test Video


Some offices/hospitals may have a policy in place that makes it mandatory, but technically it is not required.

Of course, many individuals will point out a conflicting policy based on "Universal Precautions" which can potentially be interpreted as mandatory use of barrier protection (like gloves) whenever there is the possibility of bloodborne pathogen transference (which some may interpret as risk is always present).

However, if one actually reads the Universal Precautions put out by the CDC as it relates to blood drawing (considered higher risk than immunizations),

"In universal precautions, all blood is assumed to be potentially infective for bloodborne pathogens, but in certain settings (e.g., volunteer blood-donation centers) the prevalence of infection with some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some institutions have relaxed recommendations for using gloves for phlebotomy procedures by skilled phlebotomists in settings where the prevalence of bloodborne pathogens is known to be very low. Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health-care workers who wish to use them for phlebotomy." [link]

Not quite the "mandatory" use of gloves some people stipulate when quoting Universal Precautions policy.


References:
General Recommendations on Immunization. CDC 2/8/02

Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings. CDC 6/24/88

Wrong Site Surgery Performed by ENT

In 2010, an ENT performed a tongue tie release on a 5 years old child who was supposed to undergo a tongue lesion biopsy (apparently 1cm in size over the central dorsal tongue). Tongue tie release was NOT consented for nor discussed with the parents who expected a tongue biopsy to be performed instead. In the investigative report performed by the Department of Public Health:

"When the surgeon was asked whether he examined the patient in the preop area prior to the surgery, he stated, "Usually, I don't examine anybody. I sometimes visit... In this case, there was no time to do a pre-operative visit. From now on, I need to see the patient prior to the surgery." [link]

According to the record, time-out WAS performed. Consent WAS in the chart for a tongue lesion biopsy. Records indicated that all mandated check-lists and time-outs were performed.

So what happened?

1) Surgeon Error: Let's face it... the surgeon made a mistake. Ultimately, it is his responsibility to ensure that the procedure goes smoothly which by definition means doing the correct procedure.

Seeing patients before surgery probably would have prevented this error. Not seeing the patient prior to surgery is not good practice.

Even if a surgeon employs a nurse practitioner or a physician assistant to see patients for him in the office or in the hospital, before any surgery, he personally should examine and discuss the upcoming surgery with all patients.

As an aside, at least once per week, I have patients calling who desire to schedule surgery without wanting to see me first for a consultation appointment. There are many reasons why I mandate that a patient MUST first be personally seen by me in the office PRIOR to any surgery scheduling. Preventing this scenario is one good reason why.

2) Nursing Error??? If the nurses knew what procedure was supposed to be done (according to the report, they did)... they should have spoken up! If they were too afraid to speak up, they should have contacted management to speak up for them... or ask the anesthesiologist to say something.

After all, patient welfare supersedes all else. Having wrong site surgery is the exact opposite.

However, to be fair in this particular situation, I do not believe the nurses knew what the surgeon was doing. Why???

The procedure was being done inside the mouth and a small child's mouth at that... honestly, nobody except the surgeon and possibly the anesthesiologist can really see what the surgeon is doing. The instruments used for tongue tie release is very similar to what would be used for tongue lesion biopsy.

3) Time-Out and Check-List Error: In a typical day, there are so many time-outs and check-lists being performed that it starts to get muted into background noise. It's just like the alarms and blinking lights that I imagine an instrument panel of a sophisticated machine would be for somebody who stares at it all day, everyday. You hear/see it... but than you don't hear/see it.

What people notice are sounds that are unusual for a given situation.

For example, cars make all sorts of noises when being turned on and moving somewhere. However, most people don't actually "hear" the sounds being produced by the car because of our lack of attention to it, because it is repetitive and continuous.

However, if one day, the engine starts knocking, that certainly gets a driver's attention and remembered.

Time-outs and check-lists suffer from inattention... even if performed.

They are a wonderful tool, but utterly undependable for long-term use.

So what would work given it must be done per regulations??? My suggestion would be to mix it up to prevent it from becoming "background" noise.

Have the time-out performed by different members of the surgical staff on every case rather than the same person. Ring a bell before doing time-out one time. On another time, have everyone dance a short jig before doing it. Whatever is done, do NOT make it repetitive which otherwise risks being inadvertently ignored.

The key is to make it different and notable each and every time in order to focus attention and prevent the task from becoming muted into the background.

Source:
CA Fines 14 Hospitals for Medical Errors. Health Leaders Media 8/31/12

Reference:
California Human and Health Resources Department of Public Health Report. 5/18/11

Actor Larry Hagman Treated for Throat Cancer

In June 2011, actor Larry Hagman was diagnosed with stage 2 throat cancer. It is unclear exactly where the throat cancer was localized to (tongue, tonsil, supraglottis, hypopharynx, oropharynx, etc), but it was treated medically with radiation and chemotherapy.

Larry Hagman is a well-known actor playing oil baron J.R. Ewing in the soap opera Dallas (1980s as well as 2012) as well as Major Nelson in  the TV sitcom I Dream of Jeannie. Most impressive was the fact that he continued to act while undergoing cancer treatment for the Dallas remake.

Yesterday, Aug 29, 2012, media reported that the actor is now "cancer free."

Hogwash...

Throat cancer, especially stage 2, has the potential to come back. Though there may be no detectable signs of cancer currently, there is the possibility of cancer coming back in the future.

The risk of cancer recurrence is highest within the first 2-3 years after treatment completion, and markedly decreases after 5 years.

Typically if cancer has not come back after 5 years, the word "cure" may than be used, but even than, such patients are seen yearly for the rest of their life for cancer monitoring.

Given the high risk of cancer recurrence, patients are seen frequently for the first 2-3 years after treatment.

Every 2 months for the first year. Every 3-4 months in the 2nd year. Every 4 months in the 3rd year. Every 6 months in the 4th year. Yearly starting at 5 years after treatment.

This type of follow-up applies to all head and neck cancer.

Source:
Larry Hagman is cancer-free. SFGate 8/29/12

Larry Hagman. Wikipedia

Should Gloves Be Worn When Giving Allergy Shots?

A common question patients ask is whether nurses and or other medical staff be wearing gloves when giving allergy shots (or other forms of immunization).

According to the CDC:

"Gloves are not required when administering vaccinations, unless persons administering vaccinations are likely to come into contact with potentially infectious body fluids or have open lesions on their hands." [link]

 As such, the practice of wearing gloves is left up to the discretion of the person administering the shot.

Some offices/hospitals may have a policy in place that makes it mandatory, but technically it is not required.

Of course, many individuals will point out a conflicting policy based on "Universal Precautions" which can potentially be interpreted as mandatory use of barrier protection (like gloves) whenever there is the possibility of bloodborne pathogen transference (which some may interpret as risk is always present).

However, if one actually reads the Universal Precautions put out by the CDC as it relates to blood drawing (considered higher risk than immunizations),

"In universal precautions, all blood is assumed to be potentially infective for bloodborne pathogens, but in certain settings (e.g., volunteer blood-donation centers) the prevalence of infection with some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some institutions have relaxed recommendations for using gloves for phlebotomy procedures by skilled phlebotomists in settings where the prevalence of bloodborne pathogens is known to be very low. Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health-care workers who wish to use them for phlebotomy." [link]

Not quite the "mandatory" use of gloves some people stipulate when quoting Universal Precautions policy.


References:
General Recommendations on Immunization. CDC 2/8/02

Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings. CDC 6/24/88

Allergies May Prevent Heart Attacks???

Research has been published suggesting an inverse relationship between serum IgE and heart attacks in the US population independent of coronary risk factors.

No kidding...

This conclusion was reached based analyzing 4002 participants between 2005-2006. They also detected that of the 7 "data-driven, prespecified allergen clusters," house dust mite was the only allergen cluster for which serum IgE is associated with reduced risk for heart attack.

For those wondering, serum IgE is a rough measure of how allergic a patient is generally speaking without any specification of what the patient may be allergic to. It is obtained by bloodwork (RAST or immunoCAP).

The higher the IgE levels, the more allergic a patient is generally speaking. However, one must keep in mind that it may still be possible to be allergic even if IgE is low or vice versa.

Also, although there appears to be a relationship between IgE and heart attacks, it is doubtful it reaches clinical significance for any given patient. Rather, such conclusions may apply to a general population. This study was also retrospective and as such, it would be nice if a new study now looked at a group of allergic patients and see how many suffer heart attacks in the future.

Such un-intuitive relationships just goes to show how complex the human body is where one thing doesn't cause one problem, but rather one thing may affect multiple different aspects of human health.

Now why would IgE and/or allergies in general influence heart attack risk?

Well heart attacks are due to vascular disease (blockage of the coronary artery). Vascular disease is thought to be influenced by how much inflammation is present in the body. The more inflammation present, the higher the risk of vascular disease which in turn increases heart attack rates.

One factor thought to influence the degree of inflammation present in the body is the immune system, and allergies is one part of the immune system.

As such, allergies could be a reflection of what the immune system is doing which in turn influences the degree of inflammation present in the body which in turn affects vascular disease which plays a role in heart attacks.

Reference:
Relation between objective measures of atopy and myocardial infarction in the United States. Journal of Allergy and Clinical Immunology. In Press Aug 27, 2012.