
Filthy surgical instruments: a threat in America's operating rooms (2014) - adenverd
https://publicintegrity.org/health/filthy-surgical-instruments-the-hidden-threat-in-americas-operating-rooms/
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throwaway911411
A few observations from the article from a surgeon’s perspective . First of
all, I agree with the article that sterilizing modern equipment is more
difficult. Back when you just had steel equipment, you could just throw them
in an autoclave and be sure that they were sterile (with the exception of
prion diseases). As the article mentions, a lot of equipment can’t take that
kind of treatment and or has areas that are had to access such as long
channels.

In additions, not all surgeries are created equal with respect to infection
risk. Joint surgeries are some of the highest risk for infection. In fact,
when doing open joint surgery, orthopedic surgeons will wear what looks like a
space suit with helmet and air supply and work under a giant air suction
device to keep the would from being contaminated. Add to that, that they were
putting in foreign materials in the form of screws, and you have a recipe for
disaster if there is the tiniest bit of contamination. As I have told my
patients and medical students, a surgical infection is a life altering event.
There is a good chance that you will never be the same after experiencing it.

I think this type of thing will be a bigger issue as we move forward. Surgical
equipment is getting more intricate and more expensive. Everybody is pushing
to cut costs. Having less equipment for a hospital is less capital costs, but
more times that it needs to be properly cleaned, and every time you clean is
an opportunity to screw up.

I think the ultimate answer might be taking the responsibility of sterilizing
complex surgical equipment from the hospital to the manufacturer. Basically,
the hospital would use the equipment once and send it back for reprocessing
back to the manufacturer. For a lot of these surgeries, the manufacturer
representatives are there at the hospital for surgeries requiring single use
stuff likes screws, rods, artificial joints, etc so this would just add to the
stuff they are bringing to the hospital anyway. It would be much easier for
the FDA is o monitor and regulate a few reprocessing centers instead of every
hospital. Simple equipment that you can just throw in an autoclave, can still
be done by the hospital. Doing this would also force the manufacturers to
think more about ease of cleaning since they would be the ones responsible
directly for it.

Just my 2 cents.

~~~
nickles
> As I have told my patients and medical students, a surgical infection is a
> life altering event. There is a good chance that you will never be the same
> after experiencing it.

What is it that makes such an infection is so impactful? Is there physical
damage that persists, psychological trauma due to the experience, or some
other factor?

Edit: Read the comments prior to reading the article.

> When Harrison awoke from that surgery, he imagined his nightmare was over.
> But in reality, it had just begun. Since then, what began as a simple
> operation has turned into a lengthy struggle that left him for months at a
> time dependent on hired nurses, unable to dress himself, take a shower, or
> work, and afraid for his life.

~~~
rscho
3 months in the ICU with an open abdomen (for example) is likely to cause all
kinds of lifelong impact.

------
copperx
It's unsettling to learn that a life-saving surgery can compromised by a tech
who didn't spend a few extra minutes cleaning the tools properly.

I had read that surgeons were moving into using disposable instruments because
of the possibility of prion contamination (prions can't be destroyed by an
autoclave). But maybe that was only for neurosurgery?

~~~
jdietrich
_> It's unsettling to learn that a life-saving surgery can compromised by a
tech who didn't spend a few extra minutes cleaning the tools properly._

Why are the devices so difficult to clean? Why are processes in sterile
processing units so chaotic? Why aren't decontamination errors being picked up
by quality control?

It's never the fault of the guy on $8.50 an hour. The buck stops with
management; the buck always stops with management.

~~~
chrisseaton
> Why are the devices so difficult to clean?

How would _you_ clean prions off surgical devices? This isn't a case of
workers not bothering to use soap, you know.

~~~
tomxor
prions are currently a problem for basically any equipment, but they are rare,
and they are not this problem - this is an issue of basic sanitation of
modern, intricate and difficult to sanitize devices causing bacterial
infections.

------
DoreenMichele
I think it was a book called "The Hot Zone" that talked about ebola and
similar diseases. It also said the village elders in rural Africa stopped the
spread, not the well-educated, monied foreigners from more developed
countries.

They barricaded the roads and only let locals come in.

They told their people "Don't go to the white man's hospital." because you
would go to the hospital for a fixable problem, like a broken leg, and die of
ebola contracted at the hospital.

They quarantined the sick. You couldn't leave your hut. They would leave food
on your doorstep to provide care. If three days food accumulated, they burned
the hut down without verifying if you were dead or alive.

Antibiotic resistant infections and the like are partly a product of our
modern mentality that tech can fix anything. Often, it can't. Old fashioned
procedures still have their uses and we don't rely upon them enough.

~~~
a_t48
The solution for stopping infectious diseases is to let anyone who contracts
one die? You're not completely wrong, but I'll take my odds with modern
medicine.

~~~
DoreenMichele
That's a wildly uncharitable interpretation of both my comment and the active
efforts of village elders to stop the spread of an extremely deadly infection
that had no known effective treatment at the time.

------
fencepost
Note that the article is from 2012, with some level of update in 2014.

It would be interesting to see whether these findings led to any improvements,
although there's a good chance that many of the same individual pieces of
equipment are still in use. In also curious whether some of the changes in
Medicare reimbursement rates for return visits made any difference since they
were targeted specifically at unplanned returns and complications (Modifier
78, [https://www.emblemhealth.com/Providers/Claims-
Corner/Coding/...](https://www.emblemhealth.com/Providers/Claims-
Corner/Coding/Global-Surgery-Reimbursement-Policy-Concerning-an-Unplanned-
Return-to-the-Operating-Room)).

~~~
totallynotcool
Many shavers can be ran through a washer now which is great, but until they
can be submerged in an ultrasonic cleaner these issues will remain. I'm a huge
proponent for sterile handpieces and disposable inserts; doesn't really work
in this case as the 'blade' for the shaver is disposable.

------
empath75
I imagine that routine use of antibiotics after surgery is covering up for a
lot of this and is also contributing to antibiotic resistant bacteria showing
up in hospitals with greater and greater frequency.

~~~
copperx
I don't think giving antibiotics after surgery as a rule is a modern
invention.

~~~
brianpgordon
Are you saying that after-surgery antibiotics can't be a cause of antibiotic
resistance because we've been giving antibiotics for a long time? It takes on
the order of decades for antibiotic resistance to be selected for enough that
it becomes a problem. And the first antibiotic wasn't even discovered yet a
hundred years ago.

~~~
copperx
Even if post-surgery antibiotics were the prime contributor to antibiotic
resistance, arguing against the practice is disingenuous because there is no
viable alternative.

------
andrewl
This is an important article.

I read several years ago about manufacturers sterilizing medical tools with
radiation before they left the factory. I could imagine that the setup for
doing that is too complex and dangerous for a regular hospital to run, but
could it be offered as an outside service? Tools that can't undergo
autoclaving could be sent out for irradiation after every surgery.

But this is very much _not_ my area, so there are probably a hundred things
wrong with my suggestion that I'm too uneducated to see.

~~~
ChuckNorris89
Good point. Couldn't Gamma radiation kill what heat alone won't?

Edit: Did some research, Gamma radiation can't kill prions. That's one though
SOAB.

------
jes
On the question of sterilizing prion-contaminated surgical instruments:

[https://consteril.com/prion-sterilization-
guide/](https://consteril.com/prion-sterilization-guide/)

~~~
goblin89
I’m half-expecting any sterilization guide dealing with prions to be an empty
page with huge “Dispose of and ensure it’s never ever used again”.

The article by Consolidated Sterilizer Systems does reference an Oxford
Journal’s opinion that there is _no_ method of prion decontamination or
sterilization that has proven 100% effective.

Interesting fact: Consolidated Sterilizer Systems is in the business of
selling autoclaves, and at the end of the article there’s their lead
collection form.

It’d be very unfortunate if future shows that financial interests of
conventional sterilization equipment makers played a part in delaying the
establishment of effective prion contamination management practices (which may
or may not involve disposable instruments—being not an expert myself, I can
only speculate).

------
tomohawk
Trust but verify. Without independent verification, this is exactly the type
of result that is expected.

If the manufacturers are not out in the field inspecting the devices and how
they operate, how will they improve their designs in beneficial ways?

If the government regulators are not doing spot inspections of the equipment,
how do they know they haven't made a mistake in approving something, or that a
hospital has not trained people properly, or whatever?

If you're a patient, faced with these failures on the part of the regulators,
the hospitals, and the manufacturers, what do you do? The whole system has
failed here.

------
buckminster
I'm surprised the patient went weeks without getting treatment for an
obviously serious infection. When a friend had her knee replaced she received
detailed instructions on recognising infections, including taking her own
temperature twice a day, so it could be treated before it had any time to
develop.

------
ijiiijji1
Candida auris is so persistent autoclaving, hydrogen peroxide and bleach
aren't effective... hospitals have had to resort to binning equipment and
removing wall tiles. Imagine the hospitals / ORs that are are less fastidious,
and in the US, hospitals aren't required to release statistics on preventable
infections and deaths.

------
orionblastar
There is software that handles that issue. I wrote some in 2002 that uses bar
codes and tracking to see what instruments need cleaning. We invented a lot of
the tech involved with it into a Windows 98 Javalin touch screen. I migrated
the database from Excel to Access and SQL Server to speed things up. Other
companies had similar products but not GUI at the time.

------
hairytrog
Considering the amount of antibiotics used, doctors could probably use tools
fished out a dumpster.

~~~
teddyh
Antibiotics does nothing against viruses.

~~~
eukaryote31
Or prions, or toxins (i.e botulinum)

------
crimsonalucard
Makes sense that hospitals would do this in the United States. It's a cost
problem. Simply put, hospitals do not have the financial resources to fully
clean their tools.

Last year I was in the hospital for 1 day and it cost me $10,000. What a
travesty. How can doctors ever properly wash surgical tools with that paltry
amount of money? Doctors and hospitals deserve better.

~~~
joe_the_user
Hospitals are extraordinary profit centers for their owners - vast amounts of
money go through them. If they can't clean their surgical instruments, the
situation is morally and, uh, literally, criminal. Whoever is ultimately
responsible for such situations - managers, not underlings - should be in
jail.

~~~
corndoge
It is sarcasm

~~~
crimsonalucard
Nah man, I think he picked up on it.

~~~
joe_the_user
I didn't, I was reading quickly but whatever. I'm on HN as a site where
content rather than whether you get the jibe is important.

------
msandford
When you want to race automobiles but you aren't an F1 driver there are
leagues that will accommodate you. But not everyone is equally rich. How do
you ensure that it's driving skill that determines the winner, rather than who
is willing to spend more money on a better car? You make a rule that says
there are no rules about how much a car can cost, but that anyone can buy the
winner's car at the end of a race for $X.

I can't help but think that a similar law might not be helpful. Make doctors
and hospital administrators randomly subjected to these devices in a mostly-
not-invasive procedure where sterile water is flown over the devices and then
onto a finger-prick.

In both cases making people have true skin-in-the-game is the solution to the
problem.

~~~
the_pwner224
That would have potentially serious _permanent_ and irreversible consequences.
It's much different from losing $200k by having to sell your car at the end of
the race. And there are various factors that affect the sterility of the
instruments, some of which are out of the doctors' control.

It is not OK to give a doctor HIV just because the maintenance people didn't
service the machine correctly, causing it to output clean-looking but infected
instruments.

~~~
msandford
But it's OK to do that to a patient because "reasons"? Why are the doctors
more important than the patients? The harm to patients is serious, permanent
and irreversible too. Your argument doesn't seem to make sense to me.

~~~
a_t48
The argument is that it's not okay to do in either case, I believe. There's a
risk in either case, but the possible exposure to patients is necessary (they
need a possibly life saving procedure), whereas the risk to doctors is not
necessary (they don't need to be cut open). You'd have to prove that
increasing the risk of doctor infection would lead to a lower rate of patient
infection. That seems unlikely, just from the fact that the doctor himself
could be a vector for infecting a patient. You're also endangering anyone else
the doctor comes in contact with in their personal life.

~~~
msandford
> You'd have to prove that increasing the risk of doctor infection would lead
> to a lower rate of patient infection.

The point isn't to infect doctors. The point is to make them (potentially)
subject to the tools they're about to use as a way to ensure that they are
sufficiently involved in designing and overseeing the systems that ultimately
move the needle on patient outcomes.

When things are done sufficiently well these kinds of steps aren't necessary.
We don't make the engineering team that designs a bridge walk/drive across it
first because bridges have an exceedingly low failure rate and the failures
that do happen aren't infant mortality (you designed it wrong) they're old
(you maintained it wrong).

