The unkindest cut of all

A new book highlights the need to prevent transmission of viral infections between medical staffers and patients – but the Health Ministry has not given the subject much attention.

By JUDY SIEGEL-ITZKOVICH
DR. MARK S. DAVIS (photo credit: Courtesy)
DR. MARK S. DAVIS
(photo credit: Courtesy)
Patients submit themselves to operations, the most invasive type of medical care, in the hope of getting better. Their surgeons wouldn’t dream of hurting their patients or being hurt by them.
But around the world, surgical patients are getting infected with hepatitis B or C or with HIV/AIDS – or their doctors are infected by them, often meaning the end of their careers.
No one knows how often this tragedy occurs, but what is clear is that prevention is far preferable to giving victims costly drugs or leaving them to suffer because of the lack of treatment.
Dr. Mark S. Davis, who spent 30 years performing obstetrical/gynecological surgery in the US before developing a tremor that forced him to reinvent himself as a hospital safety expert, has written a 133-page book with detailed advice on preventing “sharps” injuries.
Now a operating room safety consultant working out of Longboat Key, Florida, Davis has advised hundreds of hospitals, surgery centers and the medical device industry in the US and Japan how to promote operating room safety.
Irresponsible: What Surgeons Won’t Tell You And How to Protect Yourself begins with documented incidents: Between 1987 and 1989, a Florida dentist infected with AIDS transmitted the HIV infection to five of his patients. In 1999, a French orthopedic surgeon infected his patient with HIV during a hip replacement.
In 2003, a Spanish obstetrician infected with AIDS gave a woman HIV during a cesarean section. Between 1991 and 2005, worldwide, eleven surgeons infected with hepatitis C transmitted their infections to 38 patients.
Between 1991 and 2005 worldwide, 12 surgeons with hepatitis B, for which there are preventive vaccinations but no cure, transmitted their infections to 91 patients. More recently, Davis wrote, there have been reports of multiple patients exposed to hepatitis C during colonoscopy due to improper sterilization of equipment.
No one knows how often events like this actually occur because there is not a reliable system for tracking and reporting new cases of HIV/AIDS, hepatitis C and hepatitis B, he added. “In addition, instances of infection transmission may escape public scrutiny when malpractice lawsuits against surgeons and hospitals are settled out of court with binding confidentiality agreements; in exchange for monetary compensation, patients are prohibited from revealing how they became infected.”
Sharp needles, scalpels and other instruments can cause “sharps injuries,” leading to deadly viral infections through patient exposure to doctors’ blood and doctor exposure to patients’ blood. According to David and other safety experts, most of these surgical incidents are preventable if surgeons and nurses take appropriate precautions. “The problem is, many of them don’t.”
“Before safety devices that could prevent sharps injuries became available, I was, like many surgical healthcare workers, a frequent victim of injuries caused by suture needles, scalpels and other sharp instruments,” he recalled. I escaped becoming infected with HIV or hepatitis C initially by dumb luck; later by formulating an overall plan to prevent sharps injuries. I’ve met surgeons whose luck ran out when they became infected with hepatitis C as a result of sharps injuries. Tragically, some of them later transmitted their infection to surgical patients.
“In addition to surgeons, I’ve talked to OR nurses, scrub technologists and others who have fallen victim to infection with HIV and hepatitis C while assisting with surgical procedures. My interest in safety became a passion and I had to share that knowledge...I can assure you that this threat is real. Numerous patient safety experts have told me that this book had to be written to protect both the general public and hundreds of thousands of healthcare workers.”
Medical errors of all types – from giving the wrong medication to operating on the wrong limb – cause as many as 100,000 deaths annually in the US alone. A study published in the Journal of Patient Safety estimates that the true number of deaths associated with preventable harm to patients is a horrendous 400,000 per year.
According to the US Center for Disease Control in Georgia, surgeons and their assistants are injured about 1,000 times a day by suture needles, scalpel blades and other sharp objects.
It is not a minority of individuals who undergo surgery, writes Davis. A recent study by the American College of Surgeons stated that the average American will have 9.2 surgical procedures in a lifetime.
Surgical patients are not automatically tested for HIV or infectious hepatitis either in the US or in Israel. When there has been a sharps injury, the hospital either conducts tests or assesses the risk by noting whether the patient was a homosexual, intravenous drug user, prostitute or other high-risk individual.
If anti-viral drugs are taken quickly to protect the surgeon against HIV, the disease can be prevented, but if the risk is considered low, the surgeon may not do this. Universal precautions dictate that the blood of all patients be considered as potentially infected.
In the case of a surgeon with an infectious disease, he may not know himself or inform the patient if his skin is punctured and the blood mixes.
Six weeks after being infected, Davis writes, the surgeon can develop flu-like symptoms that he or she ignores, but which could mean HIV. Six months later, while operating on a different patient, if the surgeon suffers a cut with a blood-coated scalpel and the bleeding hand touches the patient’s incision, the patient can be exposing to HIV infection. If infected, the patient could further pass it on via sexual relations.
THE BEST way to prevent this scenario, writes Davis, is to use safe, blunt-tipped suture needles, which are effective in sewing up internal tissues, but not the skin. Although their prices are only a little bit more than sharp-tipped needles, only 5% to 10% of American surgeons use them. The figure in Israel may be much lower. In addition, there are shielded safety scalpels with a cover when not actually being used in cutting. These too are not widely used in either country, according to experts.
A third measure is for doctors, nurses and others not to pass sharp implements directly from one hand to another. Instead, they should become trained to use a neutral zone such as a place on the operating table, first putting the implement down for the other person to pick up.
A fourth technique to not replace the caps on needles, but leave them uncapped, to prevent surgeons from being pricked with “dirty” needles, while a fifth would be a safety checklist that all personnel in the operating room go through as each patient is rolled in.
The author also recommends that operating room personnel wear glasses and other equipment to protect their eyes from being splashed and infected. Although wearing them may be cumbersome, they offer important protection. He also suggest that they wear two pairs of latex surgical gloves, one on top of the other, even though these only reduce – but do not eliminate – the risk and may make some tasks during surgery clumsy.
Sharps accidents, Davis writes, could occur in other situations beyond surgery, such as hemodialysis, invasive dental treatments and colonoscopies, if the equipment is badly sterilized and reused.
“I firmly believe that all surgeons want to protect their patients, and that no surgeon would want to injure their teammates or themselves...So, given that the majority of surgical sharps injuries can be prevented, why don’t all surgeons follow these simple precautions?” Davis asks. “It would be unfair to generalize, because obviously not all surgeons are alike… Surgeons were trained to give orders, not take them. Many of my surgical colleagues don’t take advice well. They believe that their own way of doing things – the way they were trained – is the only way.
“Sharps safety is not taught in medical schools or surgical training programs… People find it difficult to adapt to change, and surgeons are no exception. I believe surgeons are especially resistant to change… As surgical residents, we were traditionally taught to use dangerous sharp instruments and this becomes a deeply embedded habit. In addition, some surgeons feel omnipotent, living in denial of their own risk of infection with HIV and hepatitis C, and deluded by the mistaken belief that sharps injuries are ‘just part of the job.’ “The additional cost of safety scalpels is not a valid excuse to reject them. The cost of a sharps injury, or worse yet, an acquired HIV or HCV infection, makes safety scalpels cost-effective.”
In Israeli public hospitals, there is little or no choice of surgeons, unlike in the US, which is mostly private. Still, Davis recommends that before undergoing surgery, patients ask surgeons if they use blunt-tipped suture needles, a neutral zone for passing sharps, double gloves, protective eyewear and safety scalpels.
The Jerusalem Post sent a copy of Davis’s book to the Health Ministry. Asked for comment, the ministry replied that it had not read it and was not aware of it. The ministry said that it does not require sharps accidents to be reported, and that it does not have accurate statistics on such incidents. In addition, it said, Dr. Anat Aka-Zohar, who was recently appointed to head its “quality and safety department,” had not looked into sharps injuries, nor could it give figures on how many patients or medical personnel had been infected with HIV, hepatitis B or hepatitis C.
Prof. Yoel Donchin, a longtime anesthesiologist at Hadassah University Medical Center who now teaches safety at the Hebrew University Medical Faculty during his retirement, declared that “there are containers in all hospitals to collect sharp objects, but many just throw them into garbage bags where cleaning workers who take out the garbage could be pricked. The only thing that will work is creating a safety culture in all hospitals, here and around the world. Staffers continue to use what is comfortable. The ministry has issued a directive against recapping, but it is not always observed. If a nurse sees a surgeon who recaps, she should tell him not to do it. Too many in operating rooms say: ‘It won’t happen to me.’ From time to time, I have been pricked myself. I suggested needle-less taking of blood by pumping it, but it is not widely used.”
Creating a feeling of teamwork in the operating room can make each person feel responsible for the other and induce them to be more safety minded, he suggested.
But Donchin does not think that sharps incidents are very common here, particularly as laparoscopic (keyhole) surgery without open tissues, and clips rather than skin sutures are becoming increasingly common.
Still, he concedes, every case of a preventable infection is a tragedy.