When 63-year-old John Harrison had surgery to repair his rotator cuff in 2009, he thought he would have a better quality of life and be good as new in six weeks. Instead, two weeks after the surgery, his scar turned bright red, felt hot to the touch, and a thick fluid oozed from his wound. After his wife frantically called the hospital, they were told to immediately make the seven-hour drive back to Houston to be checked. His doctor had to perform emergency surgery that evening and found an infection had eaten away part of his shoulder bone and rotator cuff, the metal screws and hardware became loose and sutures came undone. His surgeons cleaned out the infected shoulder, installed two drains and prescribed antibiotics to kill the infection. Instead of improving his range of motion in his shoulder, he was now fighting for his life.
Harrison was one of at least seven joint surgery patients at Methodist Hospital in Houston who had acquired serious infections during a two-week period. This outbreak forced Methodist to close operating rooms and call on the Centers for Disease Control and Prevention (CDC) to investigate. The CDC found two probable sources – deep inside a hand-held arthroscopic shaver, used to shave away bone and tissue during surgery and inside a long, metal tube called an inflow/outflow cannula, used to irrigate and suction the surgical site. During the investigation, surgical tools were inspected with a tiny video camera revealing human tissue and bone stuck in both devices. The camera also found a bristle from a cleaning brush left in an arthroscopic shaver. Further investigation found that the hospital followed cleaning instructions provided by Stryker, the manufacturer of the arthroscopic shavers used on all the infected patients. The instruments were properly cleaned, but were still dirty. A former investigator at the Centers for Disease Control and Prevention Epidemic Intelligence Service blames the Methodist infections on those dirty devices. This is the probably the only explanation Harrison will get for why he had to undergo seven follow-up surgeries and still cannot raise his arm when he awakes in the morning. Harrison filed a lawsuit against Stryker and Methodist. Early this year, Harrison settled for an undisclosed amount with Methodist. His case against Stryker has been moved to federal court.
Sadly, Harrison’s case was not isolated. In 2009, the Department of Veterans Affairs admitted that 10,737 veterans in Florida, Tennessee and Georgia were given colonoscopies and endoscopies between 2002 and 2009 with endoscopies that were not properly sterilized. Many of these patients later tested positive for HIV, hepatitis C, or hepatitis B. Many lawsuits filed against the VA are currently working their way through the courts and many more are expected to follow. In 2008, an outbreak of hepatitis C that sickened six people in an outpatient surgical center in Las Vegas was due to improper cleaning of endoscopes, as well as the reusing of biopsy forceps, which were intended for a single use. Following that incident, a Center for Medicare and Medicaid Services (CMS) pilot program inspected 1,500 outpatient surgery centers and cited 28 percent for infection control deficiencies related to equipment cleaning and sterilization.
Years ago, surgical tools were made of steel and glass, so sterilizing them was easy; just put them through a shot of steam. Today, doctors use high-tech flexible endoscopes and surgical robotics, which become clogged with debris unable to visualize with the naked eye.
A risk management clinical engineer at the University of Michigan Health System videotaped the insides of 350 surgery-ready suction tips and found that every single one of the tips contained blood, bone, tissue, and in some cases, rust. Even after his team tried to clean the tips, all but seven were still dirty. A design flaw was to blame.
It is said that another reason for poorly cleaned surgical tools is that hospital employees who are hired to clean surgical instruments are underpaid and overworked, rushing to have the tools ready for the next surgery. The cleaning process is usually done in hot, humid basements and in large hospitals, with about 40,000 surgical tools have to be cleaned daily. The dirty devices can sit around for days before someone gets around to cleaning them, and by then, human waste has been baked on them.
It is sad to learn that New Jersey is the only state in our country that requires cleaning technicians to be certified. Imagine that our dog groomers, tattoo artists, and nail technicians need to be certified to work, but hospital sterilization workers undergo no training and need no certification. So many deaths occur annually from filthy, unsterilized surgical tools and most of the time, these patients die in vain. Very few of these cases have been documented, as they are difficult to prove. I have heard of surgeons leaving their tools inside of a patient, but maybe what the real problem was, was the fact that those tools were filthy and infected. It is frightening enough to undergo surgery, but having to worry about being sent home with a permanent, debilitating condition really makes you think twice before showing up for that procedure. In John Harrison’s case, it is fair to say that he would have been better off living with his poor range of motion than the constant pain and suffering he endures every day of his life.
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