Clean Needle Technique, Social Safety, and the Benefits of Being a Safety Nerd

When it comes to safety, there’s a big difference between advocating for yourself individually versus cooperatively creating safety in an organization. Most people have only ever experienced the former, so the latter represents a growth curve. It can feel unfamiliar and uncomfortable to recognize the difference between what makes you feel safe in the moment versus what contributes to more safety (not perfect safety, just more) for everyone, patients and punks alike.

Consider this exchange, overheard at WCA:

New Punk: If someone says they have an infectious bloodborne pathogen like Hep B, does one note that, somewhere evident in the patient’s chart, so punks are aware?

Old Punk: Just put it in your regular chart notes for that visit. And you should treat every patient like they have Hep B.

New punk: Yeah, I do and I did. But I have also gotten a slight needle stick before. And were I to see a clear note on disease status in a chart after a stick, I might be more likely to pursue follow up care.

Me, initially: NOOOOOOOOOO

Me, later: ooh, what a good opportunity to unpack the difference between individuals lobbying for individual safety vs. everyone working to cooperatively create more safety across the organization!

The idea behind Clean Needle Technique is that an acupuncturist needs to approach every patient as if they had all possible bloodborne diseases. This is important for your individual safety as a punk, as Old Punk noted, because you can’t depend on patients to 1) know their status or 2) tell you. But approaching every patient in the exact same way is also crucial to the social safety of the clinic -- and the bigger the clinic, the more people involved, the more concerning the potential consequences become for not treating every patient in the same way.

A punk flagging a patient’s chart based on what the person says about their bloodborne disease status might assuage some anxiety for that individual punk in the moment, but it’s not actually good safety practice. It’s introducing a variable (“this chart has a special note”) where there shouldn’t be any variables. Good safety practice requires consistency.

As I may have mentioned a few hundred times by now, I got introduced to safety culture by queer safer sex educators during the AIDS pandemic. Some of them were HIV positive and had bad experiences with healthcare providers, including doctors and nurses who ostentatiously avoided touching them or put on gloves just to take their blood pressure. That kind of discrimination fed into other kinds of discrimination that persist today; people with HIV still can lose their housing or employment if someone decides they’re dangerous. This is illegal, of course, but it happens. It’s one of the problems that the Americans with Disabilities Act, or the ADA, is meant to address.

Punks can’t interact with patients differently because they have a bloodborne illness (or they suspect they might have a bloodborne illness). Flagging their chart with a special note is an example of interacting with them differently. It creates stigma. It says, be careful, this particular person might be hazardous to the punks’ health. Even if that wasn’t the intention, that’s the effect. If it’s not an actual violation of the ADA, it’s at least in opposition to its spirit.

Risk management is our responsibility as punks. We can’t offload it onto the patients, not even in subtle ways, like relying on someone’s self-reported status in order to make a decision about how to respond to a needlestick. To punk successfully in a high volume clinic, you need to have (or work to develop) a positive attitude about risk management. You need to actually embrace it as part of your job -- including the risk management of needlesticks. Part of having that positive attitude is being willing to pay thoughtful attention to the details of the risk itself. It really helps to be a safety nerd! It’s way better to nerd out about risk than to react to it -- especially by slapping a “hazardous” label on to the patient.

As far as we can tell, the risk of transmitting bloodborne pathogens via an accidental needlestick with a single use, solid core, filiform acupuncture needle is vanishingly small. A POCA Tech student from Cohort 3 (who was also a nurse) nerded out on this topic and did a literature search as part of her Capstone project, looking for evidence of bloodborne pathogen transmission with single use acupuncture needles. She couldn’t find any reports anywhere. (If anyone out there knows differently, please, please email us with the details).

If a needlestick happens, the risk management questions you need to ask yourself as a punk include: was it deep? How deep? Was there blood on the needle? Did the needlestick draw blood? Was I able to wash the affected area immediately? OSHA guidelines say all needlesticks should be followed up with a visit to the ER, which I think is an unfortunate consequence of not making a distinction between hollow core hypodermics and tiny, solid core, filiform needles. But the guidelines do reflect the principle that a needlestick is a needlestick regardless of which patient the needle was in before you got stuck.

Punks need to decide how they respond to needlesticks in their practice, period. The more patients you treat, the more opportunities you have to make a mistake and stick yourself. (It’s just math!) But all of your patients need to be approached as equally likely to have a bloodborne illness and so, equally risky. (Who knew Clean Needle Technique was so inherently democratic?)

For me one of the silver linings of COVID was more public discussion of risk management related to infection. Just because there’s some virus, even live virus, on a surface, doesn’t mean that virus is readily transmissible to a human. There are a lot of other factors involved. How much viral material is actually present? How well can it get past the immune system’s defenses? It makes sense that it would be difficult to infect a person with a bloodborne pathogen transmitted via a solid core filiform needle, because how much infectious material can that needle actually hold on its tiny surface area, let alone convey into the bloodstream?

Punks make their own informed decisions, of course, about seeking follow-up care for a needlestick. How could it not affect the social safety in the clinic, though, for punks to think, “a needlestick that I get from treating THAT patient would make me go to the ER, but not a needlestick that I get from treating any of the six other people sitting in the room with them”? Be honest, are you equally happy to see the patient whose treatment might send you to the ER? What about all the other punks who treat them? What are the odds that nobody will behave differently toward the patient with a special note on their chart?

Talking about safety issues is always better than not talking about them. I’m glad New Punk reached out to Old Punk as opposed to just putting a note at the top of the patient’s chart saying “careful, this person has a bloodborne illness”. And it might seem like overkill to respond to such a short conversation with a whole blog post, but this is such a good example of how an individual focusing narrowly on what makes them feel safe is extremely different from approaching safety collectively, creatively, and with critical thinking. WCA’s cooperative safety culture is foundational to our ability to be genuinely welcoming to everyone who walks through our doors.