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Filthy surgical instruments: a threat in America's operating rooms (2014) (publicintegrity.org)
155 points by adenverd 48 days ago | hide | past | web | favorite | 121 comments

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.

I was an SPD tech and Surgical Tech for a while and while I no longer have skin in the game it's still something that concerns me.

In our hospital anything that came from a Rep, sterilized or not, HAD to be reprocessed as of it were used because there is no way to verify conditions between transport; humidity, height from floor/ceiling, biological incubation and results. On top of that sometimes Reps would only have a single tray but the doc would schedule 4 back to back caeses needing that set. Who gets the blame when it's not ready in time? Not anesthesia for putting the pt under too soon, not the doc for their inability to contact spd prior to scheduling cases, not the nurse for failure to check with the scrub, no it's the SPD staff.

Things like yankhauer and Poole suctions are impossible to clean; many packs come with disposable ones now. Hell, the vast majority of surgical equipment is disposable but hospitals are in the making money business and reuse is much cheaper. Many clinics in our hospital were unaware of how to reprocess their items and would turn in soiled items that sat all weekend covered in blood without any enzymatic cleaner; not to mention half their items were single use but are being treated as multi-use.

Man, I'm glad I moved to being an assist and even happier I left the surgical field in general.

> 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.

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

I’m definitely not qualified to answer this question. I speculate that a surgical infection is serious because the infection involves pathogens growing deep inside tissue that isn’t normally exposed to infection. Thus your immune system is ill equipped to fend it off.

If someone comes into hospital trusting the opinion of their doctors that this procedure is going to result in an improvement in their quality of life, and then instead of returning home better they have extended complications, it is just awful. I’m not sure how else to explain it - but consider if your mother/father/partner went to theatre for an elective joint replacement and then instead of being back at it in a couple of months, better than ever, was still in hospital undergoing rescue surgeries and strong antibiotics

In order to help you, a surgeon has to cut you and damage you. There's a huge amount of trust you have to place in the surgeon, the staff, the hospital, the equipment manufacturers, etc. Even if it all goes well, it can take weeks to years to fully recover from a major surgery. I know people who likely have PTSD from getting a good outcome. I cannot imagine if it went sideways. How would you trust that hospital, or any hospital?

Antibiotic resistant bacteria?

So what's the plan on prions? If an autoclave doesn't kill it it must be near immortal.

All instruments used on prion pts must be destroyed dead stop. They don't even get reprocessed/cleaned. Place in a bio bag and send them off.

A few years ago there was an issue with this in Germany

Nuke it with lye. Nothing survives lye, even nonliving germs like prions.

Problem with lye is it may cause pitting in metallic surfaces which is a problem because it gives bioburden something to grab hold to, thus harder to clean. Not only that but some sets contain a mix of metals and lye can cause those coatings to be removed.

Please excuse me if this is an uninformed question, but could this potentially be a use case for robotic/remote controlled surgery? It seems like getting a clean room set up where no humans outside of the patient are present could at least prevent operator in terms of contamination.

Of course, my fear is that the contamination comes more from everything that's not the patient or the surgeon as it pertains to the surgery -- nurses, cleaning staff, etc. Every actor and entity in that chain needs to ensure sterility, so the screws would have to be sealed until opened, the cleaning staff would have to use these kinds of space suits (or clean remotely) and likewise for the nurses. Unless or until this all becomes possible, the whole system is not going to be set up for sterility.

Surgeries don’t take place in clean rooms. The patients themselves are not clean. The contamination in these cases is coming from previous patients. So, unless you can make a self cleaning and self sterilizing robot, a human will be involved in turning instruments over for the next surgery.

>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.

I can imagine how an open joint surgery has a high infection risk for the patient. But how does it also impose a risk for the surgeon?

All the interventions described seem to be designed for the purpose of keeping what the surgeon breaths out from getting into the wound.

The risk to the surgeon is the same in all other surgeries - ie. cutting yourself etc, although in Ortho theatres there can be good splashes which can throw fluid up over your head. You should always wear a face mask that has a visor or separate goggles in surgery to avoid splashed but the pulse lavage used in Ortho washouts has the potential to really spray fluids about.

Bad results could impact their income?

Joint surgeries are some of the highest risk for infection.

Can you expand on why that is? Do we know why joint surgeries are so problematic?

It is harder for infection fighting cells to get into the joint space compared to other tissues

lack of or reduced blood supply

You just made me happier that I declined the surgery for my separated shoulder.

Same here. I've been living with a partially torn labrum for a long time now and seems like outside the occasional flare up with pain that I can just treat with some ibuprofen, I am functionally fine. I am going to avoid going under the knife as much as I can.

You can probably fix it better with stem cells than surgery anyways. I’ve heard you can get treated out of pocket by Dr. Roddy McGee for a few grand.

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?

> 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.

> 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.

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.

Steris sterilizers (think sort of dishwasher-type devices with a highly specialized detergent) can do this, I believe. I'm pretty sure there's still room for error with devices that are complicated enough that they might not be completely cleaned by the flow of the cleaning chemical, which is a problem with almost any cleaning method you use on that kind of equipment.

Plasma probably. Again metal only.

High energy ultra violett light? Yes, it destroys plastics- and only reaches surface layers. But if you get it to the evaporation stage and keep it up long enough - cleansed is cleansed.

Management, or maybe the manufacturer. Ultimately the manufacturer is responsible for providing tools that are fit for purpose, and one of the parts of that is being able to reliably sterilize them for repeat use.

Because people consider other people much less important than their new car. Hence, more chaos and less quality control because "it only happens to poor people and others, right? Right?"

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

Not really. Persistent problems are management’s fault. Individual errors are made by individuals.

There's no such thing as an "individual error" - every individual is operating within a management structure. Every error has the chance to be prevented before the fact or mitigated after the fact by proper quality management. Even if that individual is a lazy idiot who shouldn't be trusted with pointy scissors, whose fault is it for hiring him?

All errors exist on a spectrum of foreseeability and severity. Is it foreseeable that someone might miss a spot when cleaning? Yes, clearly, even if they're exceptionally diligent and well trained. The odds of them making that error diminish with training, skill and care, but they never reach zero. How severe are the likely consequences of that error? In this case, someone could die of sepsis.

You can't just shrug and say "the guy who was supposed to clean the device didn't do it properly, it's not our fault". Why did that error happen? What could management have done to reduce the probability of that error? How could that error have been detected before a patient was put at risk? From reading the story, I think it's abundantly clear that many opportunities to reduce risk are being missed due to poor management of the process.

You’re saying that management can influence events and that’s true. But management can minimize risk to more than acceptable levels and the individual can still screw up due to their own folly. This really feels like a dumb argument, that your mistakes must be the result of higher order systems.

Are you willing to extend the 'no such thing as individual error' philosophy to management as well?

Managers also exist inside a structure, one which they may not have created themselves, or where they lack power to make unilateral changes. Managers also often work inside highly competitive environments (e.g. capitalism) where much deviation from the current norm can be disastrous for both the organization and themselves.

At some point, any practical moral philosophy needs to direct some individual to change their actions. Morality without responsibility is powerless.

> Are you willing to extend the 'no such thing as individual error' philosophy to management as well?

Ultimately it's the CEO's responsibility to lead a culture of safety. If the current norm is causing death and illness, it's their moral duty to push back against it.

Ok but the question isn’t about a norm of death and illness, it’s about a single one off individual error

Even with an individual error, the system/office/company put the individual in the position to make the mistake, and then didn't provide adequate accommodation or procedure to prevent the mistake.

Not every individual mistake can reasonably be averted with changes to the system, but it's vitally important that we at least ask the question of how the system failed. Otherwise we're virtually guaranteed to wind up with a pile of "unrelated incidents" that might have been prevented at little to no cost.

Pay $8.50 an hour, expect work worth $8.50 an hour.

Management should have no reason to expect high standards at those prices.

So... can management acknowledge individual errors if they’re paid highly?


But when someone is earning $8.50 an hour, and the manager overseeing them earns $100 an hour, I know who is responsible for the work.

Ok but you’re kind of just throwing numbers into the mix here to justify your position. What if the manager makes $12.50 an hour? Or $10?

The notion that people with low wages can’t be held accountable for errors EVER is... not reasonable

> What if the manager makes $12.50 an hour? Or $10?

Well, who manages that guy? Even if literally everyone but the CEO barely earns a living wage, and you end up with results like those, I still know who is to blame.

Just go up the chain until you find someone who is paid enough to shoulder responsibility, even if it means you have to go all the way up to upper management.

For neurosurgery, when operating on a patient with suspected prion disease, the surgery will be done with disposable instruments as much as possible. This may mean however that the surgeon will have to use a hand drill, instead of a power drill.

For the other cases without prions, normal sterilization works. And you don’t want to throw away all your equipment after each surgery. A neurosurgical power drill can cost around $20,000 - $40,000

Presumably picked up by someone’s insurance plan, or a “not my problem” situation for the attending surgeon.

Sub-sanitized instruments should not be a possibility given our current understanding of infections and their root causes.

In my case, I’d rather have one less test to confirm something, if it means I get to have my surgical implements experience one more run through the UV sterilizer or the autoclave before they are used on me. Better yet, why not use a whole new set of virgin tools following a time-proven blueprint?

They don't have to be designed with motors and such accessible to contamination.

I had surgery to remove impacted wisdom teeth around 10 years ago. I recall the surgeon telling me at the time that he used new instruments every time because of the risk of prion diseases.

Don't blame the techs when device manufacturers make theirs too complicated to reasonably clean and provide unclear instructions, and when their management pay them barely above minimum wage and pressure them to work as quickly as possible.

For such life-and-death critical jobs involving routine and mundane steps, we would be wise to employ a memory aid system. One good example is the way Japanese rail-workers wear white gloves and point at things [1] as they complete their routine checks.

[1] https://www.atlasobscura.com/articles/pointing-and-calling-j...

I also remember since a long time knowing that the surgical tools themselves were disposable (the price for a little bit of steel is nothing compared to the value of the operation for example), perhaps they mean the tool holders or more complicated instruments that hold the tools?

Most surgical instruments are absolutely not disposable. I don't think you can realistically represent yourself how much increase in healthcare costs that would imply. We are talking billions.

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.

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.

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.

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/...).

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.

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.

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

According to The Checklist Manifesto, antibiotics should routinely be administered just before surgery for this reason and has shown large reduction in mortality rates

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.

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

Using dirty tools isn't a new thing either

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.

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.

The issue is trust/verification during transport. Were temp/humidity kept in check? What was the biological lot number? Model of the machine that read the biological? Temp sterilization/dry time?

Granted you could have a database and hospital customers could retrieve that information from there but what happens when they can't?

There are definitely places where the SPD process could be improved but outsourcing isn't a very handsome one.

On the question of sterilizing prion-contaminated surgical instruments:


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).

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.

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.

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.

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.

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

Antibiotics does nothing against viruses.

Or prions, or toxins (i.e botulinum)

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.

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.

It is sarcasm

Nah man, I think he picked up on it.

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.

They are not: https://www.healthcaredive.com/news/hospital-operating-margi...

> A new Navigant study analyzed for-profit and nonprofit provider networks and found that the average operating margin declined by almost 39% over the same time span, from 4.15% in 2015 to 2.56% in 2017.

Contrary to your assumption, hospitals are about as profitable as grocery stores. It would be useful to introspect about that a bit, because I imagine many people have similar misconceptions. What was your assumption that hospitals are “extraordinary profit centers” based on? Do you think peoples’ attitudes toward hospitals might change if they knew the real facts? Does the truth change your attitude about who should go to jail?

Be careful with these numbers. As far as I know they operate more like a lot of non-profits around DC. Big money for insiders and leadership, but no profit at the end of the year.

For-profit hospitals have shareholders who should ramp down on such waste, but they don’t appear to have appreciably higher profit margins.

The keyword is “should”. But they don’t. I know somebody who did research into the ownership structure of hospitals in an area and where the money goes and you can’t compare this to normal companies. It’s a highly corrupt insider system that makes a lot of money from local governments and patients.


In situations where large sums of money are vanishing on a continuing basis, Hanlon's razor ("don't attribute to malice what can be explained by incompetence") must reversed.

They have to pay the staff that chases down delinquent patients for fraudulent charges, too, you know.

Is this irony or not? After all everyone knows that it's the hospitals that send the fraudulent bills. Right now: ER visit, didn't have insurance details on me. Hospital sends full-fare bill. I send insurance details via certified mail because it happened before. Hospital sends full-fare bill. It's always like that. They do this to prey on the elderly and disorganized.

I've wondered how much time and money Americans spend on rectifying billing problems between health care providers and their insurance. I imagine(with only anecdotal evidence) it might be greater than the amount of time and money Americans spend on needlessly complex tax filings.

You're getting downvoted to hell, but I heartily approve of your cynicism.

You think it’s expensive now? Just think how expensive it would be to “properly” clean all the reusable tools.

“In 2010, there were 2.1 million arthroscopic procedures of the knee performed and yet total adverse events from all causes was 1 percent.”

That’s all causes, not even 1 percent caused by contamination specifically, and does not tell us anything about how severe the AE was.

So yes by all means we should be testing cleaning instructions in real-world conditions and make sure instructions are clear and clearly followed.

But articles like this are part of the reason that hospital stay costs $10,000 in the first place.

Yep. And $25,000 for 1 hour of a surgery room. And $20,000 for 1 hour of a recovery room. Practically poverty levels.

You wonder how veterinatians manage. A few years ago, the cat had to go in for dental treatment. Chronic gingivitis, known problem in the feline, removal of teeth is indicated. Several hours of surgery under general anesthesia, two or three people are involved. Bill comes to 700 dollars. How far do 700 dollars get you in the hospital? The handshake with the anesthesiologist is already more expensive!

Veterinarians manage because they are far less specialized than docs for humans. Also, there is less demand for potentially lifesaving but financially ruining treatments.

I wonder the same with dentists too. I had two wisdom teeth removed and it costed just as much as my sister getting a doctor to remove a cotton ball from her ear (while waiting in line).

One involved surgery and anesthesia. The other involved a pair of tweezers. Same price.

You are paying for a bunch of other people who used their ER but didn't pay, while the gov still forces the hospital to treat them.

Most people have no idea how much big houses and sports cars cost either. A while ago my girlfriend paid $30000 facility fee for a 5 hour stay. Plus several $10000 more for surgeon, anesthesiology and others. Who could live on that?

Add: Some people here don't seem to understand sarcasm.

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.

This is a fantastic idea and is the same principle behind NASA's policy of tossing a pseudorandomly selected aerospace engineer's child into the space shuttle before each liftoff to improve reliability.

Before rockets, people thought cannon would enable space travel (think Jules Vernes). And in medieval times, to prevent corruption by unscrupulous cannon builders from building impressive but unreliable cannons (which tended to explode, just like rockets), the cannon builder had to sit on the cannon for the demonstration firing.

The GP's proposal, while a bit over the top, would actually at least change the coffee talk between doctors from flaunting their last acquisitions (boats, cars, ...) back to medicine... if it would ever be put into practice. Suddenly they would conjure myriads of verification systems to ensure for example that their employer or stock manager wasn't secretly recycling disposables and having them repackaged...

Edit: spelling correction, thank you

I can think of lots of systems that would theoretically have a minor positive effect at great ethical and human cost. That is not helpful!

Also, the way you're talking about seems super dismissive of these people, so it seems a lot more like a fancy way of saying you don't like or value doctors than a useful discussion.

Also, you seem to know a lot about cannons but not how the word is spelled.

my prejudice is not so much against doctors, but more against surgeons, FYI

It's good to admit that, thanks! I do think it's probably easier to come up with solutions in this space checking that bias more carefully.

There seems to be some argument about how common this is for auto racing, but a similar scheme is the foundation of horse racing. Most thoroughbred races in USA (but essentially none of the ones you see on network TV) are "claiming" races. Any particular claiming race has a particular claiming price, e.g. $10,000. Before the race is run, any licensed trainer with sufficient money in his account for the deposit may claim any horse in the race. If the horse starts the race, it belongs to that trainer (or some other owner whom she or he represents) at the end of the race. That's true no matter how the horse performs or even if it survives the race.

This complicated scheme is used in order to ensure relatively balanced fields, which is important for wagering. If favorites are too heavily favored, then no one will bet. So, you can enter a horse worth $25k in a $10k claiming race, and you'll have a great chance of winning, but you'll also have a great chance of selling your horse for much less than it's worth.

The concept of "skin in the game" is fine, but I'm not sure this cascading infection scheme is the way to go. For one thing, physicians are rarely in charge of cleaning equipment. They have other expertise.

What happens if multiple people claim the same horse?

The racing office performs a "shake", which is pouring numbered beads out of a bottle, to randomly choose one.

I think that you're talking about the Lemons races.

To be clear -- this mechanic (forced sale of vehicle) is not common in auto-racing. Very few sanctioning bodies do this, and they're all bottom-barrel (funding wise) groups like the Lemons endurance events or derby-style cars that aren't expected to have any longevity, anyway.

Also, that mechanic has been cheated numerous times. Since the Lemons series doesn't hold the car in escrow or in any other financially or legally binding manner it's up to the seller to be polite and abide by the rules. Plenty of people haven't. They're not usually welcomed back as drivers', they just move to another team and cheat there, instead.

The real way to do what you're trying to achieve (create a fair place for those with limited budget to compete in) in automobile racing is by strict classing rules and strict scrutineering. A good example of this is SCCA Solo autocross racing. It's extraordinarily cheap to compete in, and highly competitive. This is achieved through strict rules, tons of bureaucracy, and the threat of tattle-tales in the form of competing teams or drivers.

I don't know how that moral can be related back to surgery, but I do believe the Lemons' style of fairness-by-threat-of-sale is flawed.

It's fairness by having to put your money where your mouth is. Do you attest that your car didn't cost more than $5k? OK great! Sell it for that.

Do you as an administrator attest that the instruments are clean? Perfect! We're going to use them on you.

Doctor, would you be willing to have this knife used on yourself? No? Well who better to get to the bottom of the problem than the people who can grind a hospital to a halt?

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.

So who is best positioned to know which factors are out of the doctor's control? a tax payer? or the doctor? this system would in fact quickly result in attention to these factors out of their control.

a lot of people think increased discussion means bad news

it's not because a measure increases the amount of discussion that it can't be a good measure, if it helps unearth the actual problems

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.

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.

> 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).

Seems like some folks have missed the point. The idea isn't "hey let's infect doctors because it's their fault!"

It is self-evident that enough care is not currently taken on washing instruments. Or else we wouldn't hear about these kinds of things. If instrument washing was 99.9999% effective there wouldn't be a problem needing solving.

So what kind of feedback mechanism would be strong enough to get the doctors and hospital administrators to really be interested in the absolute level of quality of the cleaning and sterilization process? I don't know for sure, but I can say that anything that ties people's own personal outcomes to those of the folks they're supervising tends to get better results.

I (obviously?) don't want doctors or administrators to get horrible diseases for fun. What I want is for them to exercise an appropriate level of oversight and care.

I went to school for Electrical Engineering and while doing so I heard stories about people that went to work for GE designing things for MRI machines. Those people then were the first ones who had to test out the machines as people before they were allowed to be used on other people. I can't help but think that this kind of a policy makes people willing to double, triple and quadruple check their work when their own lives are on the line.

Similarly by making the people who should be exercising significant oversight (but seemingly aren't) subject to the results of the processes that they have designed it's very, very likely that they will do all the things that they need to do in order to ensure that their outcomes will be what we all expect: boring. That might mean that pay has to go up, or that minimum cleaning times need to be specified or that better inspection methods need to be utilized or any one of another dozen things.

If a doctor wouldn't be willing to use an instrument on themselves that they're going to use on another person I have a hard time understanding how they are adhering to their oath of "first do no harm" and I can't help but feel that anyone managing doctors should be similarly bound.

From the article, it sounds like the surgeons are already well aware of the risk from improper cleaning, but don't care enough to push for a systemic solution, instead relying on "workarounds" when it is their own family member under the knife.

> Except when an important person or a doctor’s family member is on the table, that is. “They call and say, ‘Dr. Jones’ wife is having surgery,’”

I always thought the mechanics were competing, not the racers. Tv stations try to hype up drivers but I just find the racing really boring to watch. However, engineering a car that goes really, reallly, reallllly fast is something I get a lot of amusement from observing.

So randomly forcing teams to be separated from their cars seems almost cruel. Like, how do we even know that the buyer has the expertise to maintain it or make it go faster? What if they can't even comprehend the technology, so they just run it till it breaks and then toss it on the scrap heap?

Michael Schumacher was said to be one 1 second faster than any other driver. To beat him, you would need a new engine designed and built (about $500 million.)

Danica Patrick won a single race (Japan) in her career of 116 IndyCar races and was eventually "retired" because she couldn't win often enough.

So now we have filthy instruments and dead doctors?

Because the doctors are unable to influence the policies and procedures of the places they work? If anyone can affect change in a hospital it's the doctors.

You obviously are not working in healthcare, to say that.

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