Wall Street Journal - February 26, 2008
Benjamin Brewer, M.D.

Our small town shut down for the evening. I was thankful because I don't get many calls after hours when it snows heavily. People stay put and the whole prairie landscape seems serene and beautiful.

It's not always that way, though. A vicious winter storm last year knocked out power to the hospital when I had two women in labor. A backup generator failed, keeping half the hospital in the dark. Then a water pipe in the neighborhood burst and the hospital was without water for the better part of a day.

This big storm was looking more benign. I had no one in the hospital and no babies due for a month. After a 12-hour day topped off by 20-mile drive home on a rural two-lane road in the snow, I was ready to relax and go to bed.

Then my pager went off. A woman with no local doctor had come 15 miles by ambulance to the hospital a few blocks from my house. She was HIV-positive, in labor and just over three weeks early. She needed a C-section and a medicine called AZT to cut the risk that her baby would contract HIV during birth. The baby would need AZT, too, and special handling at birth. I'd never knowingly performed surgery on an HIV patient and never dealt with an HIV-exposed baby either. I'd done house calls and clinic visits for patients with HIV and AIDS in my training, but that was 10 years ago.

I drove a few blocks to the hospital because it was still easier than walking through the snow. When I got to the labor unit, I pulled a thick spiral notebook containing the HIV-treatment protocols off the shelf. Thankfully, we had the medicine in stock even though we'd never had a use for it before. We were able to obtain just a few records on the woman because it was after hours and she had seen three different doctors before me. I called the three physicians who had taken care of her, but no one would accept her in transfer due to the risks of travel in the storm.

It seemed like a convenient reason for them to bow out. She'd made it 15 miles to my place in an ambulance already. But when the patient is risky, the snow suddenly seems a whole lot deeper to the guys at the bigger hospitals. One doc stopped seeing her halfway way through the pregnancy for failing to follow his instructions. He sent her to a specialist in high-risk pregnancy. She had one visit. She ended up with another obstetrician after no one else would take her. She also saw a specialist in infectious disease at some point, but had been taking her HIV medications for less than a week. I went ahead because she and I had no other choice. I drank some orange juice so I wouldn't fumble from low blood sugar. It has the added benefit of almost washing away the taste of fear.

It was pretty nerve-racking doing surgery due to the risk of a needle-stick. I was tired, it was close to midnight and I had already been up for 18 hours. Not an ideal scenario to be operating on anyone, really.

Everyone who operates has been stuck. It happens. The risk of catching HIV from a needle stick is supposedly low, but I don't think like that while operating. I work as though I only have one chance because I don't have faith in statistics when the consequences are so serious.

I've been stuck before in surgery. The suture needles are very sharp, and you barely feel the stick. Just a bit of blood under the glove is often the only outward sign. I've stuck myself when I've been tired or hungry or unlucky. I've been stuck when someone else was handling the instruments. I put on an extra pair of gloves for added protection. I operated very deliberately -- at half my usual pace -- touching the needle only with surgical instruments and never losing site of the needle tip.

Her surgery was successful and she had a little boy. He has an 80% chance of avoiding HIV infection but it's too soon to tell for sure. I brushed off my car and made my way home in the swirling snow.

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