Friday, June 17, 2005

"Slippery As Oiled Pigs"

The Washington Post followed up on the case of the hospitals that employed used elevator hydraulic fluid rather than detergent to attempt to sterilize surgical instruments. The paper reported comments by the CEO of Duke University Health System, Dr. Victor Dzau. To explain why it took so long for administrators to figure out there was something wrong with the sterilization process, he noted that normally a lubricant is applied to surgical instruments to "make sure they don't develop rust and lock up during surgery." So, "it took us a while to figure out that this was beyond the normal level of oiliness."
Futhermore, Dzau discounted the potential health risks of the exposure, "while we understand that some patients have experience symptoms following their surgeries, everything we know would suggest that no causal connection has been established between any of the these patients outcomes and instruments exposed to the fluid in the presterilization process."
Meanwhile, this case has attracted considerable media attention, most not very flattering to Duke. A local commentator wrote in the News Observer, "what galls most is not the mistake, but the post-mistake arrogance of hospital officials. Hospital regulators accused them of ignoring clear, early distress signals being sent by staff members who knew the instruments weren't supposed to be as slippery as oiled pigs and leave a yellow residue."
Unfortunately, Dzau's remarks did not convince me otherwise. Surgical instruments are made of alloys that do not corrode easily, and its implausible that more than tiny amounts of oil are normally used in their sterilization. Although I am not a surgeon, I have seen plenty of sterilized instruments, and none of them were oily. Hence, if the instruments were really as "slippery as oiled pigs," anyone familiar with the operating room context should have identified this as a big problem.
Furthermore, Dzau's comment about causality is, while probably true, not helpful. The only way to establish that exposure to operating room instruments coated with used elevator hydraulic fluid causes particular health problems would be a controlled trial that randomized some patients to such an exposure. Such a controlled trial would clearly be unethical, and I am sure no previous trial has been done. Yet in the absence of such ultimate proof, it seems reasonable to assume that it is not a good for patients to expose them to surgical instruments washed with used hydraulic fluid.
A more productive approach would require investigating why adminstrators did not identify the oily instruments as a problem sooner.


Anonymous said...

I am writing to you as a "Hydraulic Fluid Victim". I'm very pleased to see that someone has taken a little interest in our situation and at least question the integrity of Duke's protocol. As small as it may's something.

I have been extremely infected (yes, I did use the word infected) by the arrogance of this institution and by the road blocks they've placed in my way. I'm not just concerned about my future and what is going to
happen to me.......I know what it's doing and without going into the sorted details, I'm one sick lab rat. "The casual relationship" that I was "minimally" exposed to has altered mine and my family's life forever. Know one can tell me how or when this will pass or the effects
I'll have after I've been pickled by the lead, arsenic,
organophosphates, mineral oil and the other medal's that "couldn't possibly" harm me. I'm not looking to the future as I take each day as it comes and with each new day comes a different obstacle to overcome. I'm not here to have a pity party,(it's just not me) I'm wanting the
world to know that people are very ill and that all I've ever wanted is to get back to the world I came from before walking into the hospital from hell.

So, I'm just wondering why it is that if this "crap" had been spilt in an industrial accident, say for instance by a train, in a family neighborhood wouldn't the EPA and the government be cleaning up the site and making sure it didn't endanger the wildlife, drinking water or the human population? For example, In February 2005, 125,000.00 lbs of meat was recalled due to Hydraulic oil contaminating it. Now mind you, this is meat you cook, digest and not injected under the skin to fester. The FDA came down on the perpetrators and made them stop selling this enormous amount of meat. Can you imagine the lost revenue? I'm sure Duke can! So, why is it that they can get away with a monumental "mistake" of this nature and not be held accountable to someone other then the legal system? Why is it that the medical community isn't up in arms about the lack of accountability? You all as doctors wonder why us as patients distrust you......this is why!

Has anyone ever heard of the "Power of an apology"? I know Duke hasn't.

What is wrong with our society when lab animals have supporters in Washington but an institution can poison unsuspecting patients and we have no voice or defenders? We NEED HELP! SOS!

Anonymous said...

Sorry about my misspelled words and dysfunctional sentences......I think the Hydraulic Oil has wreaked havoc in my brain. :)