Sunday, January 15, 2006

Before we begin operating, would you like these instruments to be washed in elevator juice or hospital equipment-washing stuff?

Just to prove I'm still alive.

So I'm minding my own affairs, reading the online version of the Raleigh News & Observer.

I came across this article about Duke University Health System. It caught my eye because my good friend Amanda is an RN at Duke. The article had nothing to do with her or her ward, but I thought I would read up about the goings on over there.

Turns out, they fucked up really bad, and have come forward to apologize for it. In a nutshell, what happened is that some maintenence folks were draining hydraulic fluid out of some elevators as part of routine elevator maintenence stuff. The fluid was drained into some empty detergent barrels, and were presumably set aside for disposal. Somehow, this fluid was recirculated as "cleaning agent", and lots of surgical tools were "sterilized" using said elevator juice. Some 3,800 patients at two hospitals were operated upon using the tainted equipment.

They've come forward to apologize, and apparently they are protected from litigation. North Carolina has recently joined many other states in enacting a mea culpa law that states that as long as they admit fault, AND apologize, people cannot come out of the woodwork to sue. If they have legitimate health issue stemming from this aggregious act of negligence, then they can sue. I can understand the logic, which is to prevent silly litigation. However, there has to be some provision for a case like this.

This part of the article actually made me laugh:
One study confirmed that instruments were clean of viruses, bacteria or fungi in spite of the hydraulic fluid on them, easing concerns about infections. A second study, which Duke commissioned from RTI International in Research Triangle Park, analyzed the chemical composition of the used hydraulic fluid and determined how much was left on instruments. RTI reported that about 1/2000th of a drop of fluid coated the instruments -- an amount so small that Duke has argued it was harmless.

James A. Bond, a toxicologist and editor of the journal Chemico-Biological Interactions, reviewed RTI's full report and said the amount of fluid on the instruments is important because risk depends on the dose. The smaller the amount of fluid, Bond said, the smaller the risk to patients.

But he notes that, despite RTI's findings, there is no way to know exactly how much hydraulic fluid came off into patients' bodies. Further, if fluid did come off, there's no way to know how much each patient absorbed.

Here's my whole thing. Agent 007 doesn't think that anyone should be alarmed. "Oh, c'mon. It's just a few drops. You'll get over it". I'm not as qualified to comment on the toxicoligy of it, but I would loudly scream that any amount at all, whether it's one drop or one gallon or 1/2000th of a drop, is WAY too much hydrolic fluid to wash surgical equipment with. He seems to be taking the "It's not that bad" route instead of the "Wow! That's really fucked up" route.



Reid said...

That's hilarious that James A. Bond makes sure to put in his middle initial. Why doesn't he just go by "Jimmy" or something? And I wonder how many times he's introduced himself only to have people say, "Yeah, right." Most of the time, I'd imagine.

Amanda - who is sometimes embarrassed by her employer said...

Yeah... ummm... it's kind of interesting. We get "briefed" on this every once in a while on our employee intranet, and well... let's just say they don't exactly take responsibility when it comes to fessing up to their own employees. They don't want ANYONE walking around Duke thinking we ever screw anything up. Oh god... I could go on forever, but I'll probably get investigated and fired.

Bill Purdy said...

You'll love this: my son was born at Duke Health Raleigh Community Hospital last November 5, by caesarian section. About a month later, we read on the front page of the N&O the hospital used hydraulic fluid instead of detergent for almost two months, beginning in late October.

THEN, we get a letter from Duke Health admitting the mistake, but assuring us there is absolutely no risk of infection.

My wife, Beth, has had no abnormal side effects from the surgery. She complains the scar is more numb than she would have expected, but cannot identify any other negative health consequences that may have arisen from the surgery. And, of course, my son is fine.

Still... this sort of fuckup might not affect its victims for a long time. Regardless of physical effects that may occur, 3,000+ patients are suffering from significantly increased anxiety and fear because of this mistake. An apology doesn't help much when you're that much more afraid of cancer and other long-term health issues because of something careless they did. For two whole months. Despite physician's constant complaints the instruments were "slipperier than usual."

My wife's OB-GYN and his practice have since left Duke Health for Rex Community and, I am afraid, so will we.

And, in case you're wondering, our lawyer does not believe Duke Health is protected from litigation in this case.