Surgeon Suture Needle He Pc

A Publication for the Prevention of Occupational Transmission of Bloodborne Pathogens

VOL. 5, NO. 6 2001

ADVANCES IN EXPOSURE PREVENTION

Published by theInternationalHealth Care WorkerSafety Centerat the University of Virginia

Center website:www.healthsystem.virginia.edu/internet/epinet

AEP interviewed a surgeon infected withhepatitis C, presumably from an occupa-tional exposure; although Dr. Jones(not his real name) wished to remainanonymous for this article, his willingnessto come forward and speak to us was un-usual. His experience sheds light on thepersonal and professional realities con-fronting an infected health care worker,and the factors that determined his pro-fessional future.

Dr. Jones is chief of plastic and recon-structive surgery at an academic medicalcenter; he is mar-ried and the fa-ther of four chil-dren.

AEP: In whatyear did youstart performingsurgery?Dr. Jones: Dur-ing my residency,starting in 1979. Iwent through fiveyears of residencytraining, thenstarted my ownpractice in 1984.AEP: Its histori-cally significantbecause measuresto prevent occu-

pational exposures were implementedgradually during the late 1980s and early1990s, and a test for hepatitis C wasntavailable until 1989.Dr. Jones: Its hard to imagine, but back in1979-80, at the beginning of my residency, Iremember coming out of the operating roomliterally soaked in blood, from the waistdownpants, underwear, socks, shoes. AndId sit down and have a cup of coffee in myblood-soaked clothes, and then Id go backin to fight again. I remember going intosomeones chest in the emergency room withjust sterile glovesno gown or goggles

A Surgeon,a Suture Needle

and Hepatitis C

Operating room personnel sustain more percutaneous injuries than any otherhealth care workers.

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5 05 05 05 05 0 ADVANCES IN EXPOSURE PREVENTIONVOL. 5, NO. 6, 2001

A Surgeon, A Suture Needle and Hepatitis C

because he had been shot in the heartand had gone into cardiac arrest. Andwhen you did put on sterile gloves,it was to protect patients from you,not the other way around. You werebathed in blood regularly, gotstabbed with instruments. It was nobig deal. You just changed the instru-ment and got back to work. Therewas little protection.AEP: So you didnt have a docu-mented exposure that you could cor-relate to your HCV infection?Dr. Jones: Thats right; it was rareto report exposures back then. But Isuspect that my infection occurredsometime during my residency.There was one particular patient Illalways remember. I was using a largeretention needle, and really got har-pooned. These are very large sutureneedles, maybe 3-1/2 inches long,that are used for big closures that aresubject to a lot of stress. I remembergetting cut really badly, and the pa-tient having non-A non-B hepatitis.As I look back, that could have beenthe event that led to my hepatitis Cinfection. But that was before a testfor hepatitis C was available.AEP: How did you find out the pa-tient had non-A non-B hepatitis?Dr. Jones: In the course of treatingthe patient we discovered she hadelevated liver enzymes, and every-one was worried that she had hepa-titis B. We tested her for that, butshe was negative. We concludedthat she had some form of hepati-tis, but not A or B.

I remember getting very sick in1981, during my residency. I was outof commission for about a month,and my liver enzymes were elevated.At one point they thought I hadmononucleosis, but I tested negativefor it, and was also negative for hepa-titis B. Then, after about a month, Irecovered and went back to work.AEP: Did you have any other risk fac-

tors for hepatitis C, outside of work?Dr. Jones: I never had surgery re-quiring a blood transfusion. I hada septum fixed and wisdom teethremoved, and that was it for sur-gery. I did not have any tatoos, hadnever been on drugs. I had no otherrisk factors.AEP: Do you recollect how muchtime elapsed between the exposureevent you described and yourfirst illness?Dr. Jones: It was about a year. I hadhorribly elevated liver enzymes, butI did not have jaundice. After thatillness, I finished my residency andwent into private practice. I did notgive it any more thought until tenyears later, when I got very sick

againthat was 1992. Again theythought I might have mono; theychecked my liver enzymes, whichwere about twice the normal level.At that point a marker for hepatitisC had finally been discovered, andthat was when I tested positive forHCV. A liver biopsy was performed,and it showed moderate inflamma-tion with signs of chronic, persistentHCV infection.

I was having a hard time prac-ticing. I would do a couple of casesthen would have to go home. I wassweating all the time and lost weight;I was nauseous, had constant diar-rhea and no appetite. Thats when mydoctor offered me treatment withinterferon. He said it was grueling,

Are blunt suture needles, stapling devices, adhesivestrips or tissue adhesives used whenever clinically fea-sible in order to reduce the use of sharp suture needles?

Are scalpel blades with safety features used, such asround-tipped scalpel blades and retracting-blade andshielded-blade scalpels?

Are alternative cutting methods used when appropriate,such as blunt electrocautery devices and laser devices?

Is manual tissue retraction avoided by using mechanicalretraction devices?

Has all equipment that is unnecessarily sharp beeneliminated?(Example: towel clips have been identified as a cause ofinjury in the operating room, yet blunt towel clips are avail-able that do not cause injury and are adequate for secur-ing surgical towels and drapes. Other examples of devicesthat do not always need to have sharp points include sur-gical scissors, surgical wire, and pick-ups.)

Is double gloving employed in the surgical setting? Do circulating nurses, as well as personnel close to the

surgical site, wear eye protection such as goggles orfaceshields that have a seal above the eyes to preventfluid from running down into the eyes?

Safety Checklist for the OR

5 15 15 15 15 1ADVANCES IN EXPOSURE PREVENTIONVol. 5, No. 6, 2001

The disability company said to me,Having hepatitis C is not sufficientreason to claim disability anymore.Because, according to the CDC, havinghepatitis C should not put restrictions onyour practice.

But in courts of law, issues ofinformed consent are settled in favor ofpatient-plaintiffs. When it comes to gettinghospital privileges, neither courts norhospital administrators are going by theCDC position regarding HCV-infectedphysiciansbut disability carriers are.They are saying an HCV-infectedphysician should be able to practicewithout restriction.

That leaves infected surgeonsbetween a rock and a hard place: Shouldthey inform patients of their serostatus, asthe AMA advises, and risk losing theirpracticeand their disabilityor practicewithout restriction, but risk being sued bypatients for lack of informed consent?

-Dr. Jones, HCV-infected surgeon

Between a rock and ahard place:

but thought I should go ahead and tryit. I took it for three months while Iwas still practicing. After the treat-ment, my liver enzymes were backto normal.

About six months later I got illagain. This time, the tests showed thatmy liver enzymes were normal, but Iwas feeling terrible. So I reduced mywork schedule and took it easy for awhile. After about a year, I felt fine,but my liver enzymes had gone backup! It made no sense. I had anotherliver biopsy and it showed a little fi-brosis this time, so they wanted to putme back on interferon. I was told Iprobably would not be able to prac-tice this time, while I was taking thedrugs; so I left my private practice forabout three months and went to an-other part of the country. I was tiredof people asking questions, wonder-ing if I had AIDS or liver cancer orsome other disease. I did not want toreveal that I had hepatitis C. But even-tually it got out after I left.AEP: How did that happen?Dr. Jones: I was getting my ownmedicine from the hospital, andpeople started to talkOh, Dr.Jones is ill. By the time I got back,everyone knew I had hepatitis C.When you are a physician and youare gone for three months, rumorsstart to flypeople automaticallyassume you are a drug abuser, an al-coholic, or deathly ill.

When I got back, I was still oninterferon and was going to try topractice three days a week, on the dayswhen I wasnt taking it. But my col-leagues told me, Look, we dont feelcomfortable referring patients to youbecause you have hepatitis C, and wecould get sued for that, because weknowingly sent our patients to you.They said if I told my patients that Ihad HCV, they would feel comfort-able referring people. Well, I triedthat a few times, and it just did not

work. As soon as patients find outyou have hepatitis C, they suddenlychange their minds about having sur-gery.

At that timearound 1992-93I had two lawsuits filed against me.One was for a scar from anabdominoplasty op-eration I performed. Inthe course of the liti-gation, the patientslawyer found out I hadhepatitis C and addeda claim for emotionaldistress, saying that Idid not properly in-form my patient aboutmy condition and thatshe was now deathlyafraid she might havebeen infected. Soon af-ter, another patientsued me for a siliconebreast implant. The pa-tient claimed the im-plant rupturedthiswas during the sili-cone wars. Andagain, attached to thatsuit was a claim forlack of informed con-sent about my hepati-tis C. One of the law-suits cited a case inwhich a surgeon whowas a recovered alco-holic and a member ofAA was successfullysued in court, on thebasis that the patienthad a right to know thatthe surgeon was a recovered alco-holic. The decision was upheld by thestate supreme court.

Because of all this uproar, one ofthe hospitals where I had surgicalprivileges formed a committee to dis-cuss the issue of my hepatitis C andinformed consent. Their final recom-mendation was that I inform my pa-tients about my HCV status. I was onfriendly terms with the people at thishospital; they were providing my in-

terferon free of charge, because thedrug was considered experimental atthe time and insurance didnt cover it.At that time, it cost between $400-$600 a month. I was on and off it foreight yearsI kept failing treatment,with continued symptoms and ele-

vated liver enzymes.The lawsuits, which were on-

going for about six years, were even-tually dropped. The patient whobrought the silicone breast implantsuit ended up suing the manufacturerof the implant instead. As far as Iknow, neither of the patients devel-oped hepatitis C. But, of course, I stillhad to pay the attorneys fees.

At that point I really had to re-consider my career path. No patients



wanted to see me, I had been suedtwice, my colleagues did not want torefer patients to me, the hospitalwhere I worked required me to tell mypatients that I had hepatitis C. Whatshould I do?

But I struggled on for the nextcouple of years, trying to maintain mypractice. Thingsjust becameworse andworse, how-ever, and by1995 I could notafford to stay inpractice be-cause of lack ofpatients, and be-cause I was ill.So I finally gaveup. You can onlyfight the systemso much.

Within amonth of thetime I closedmy plastic sur-gery practice, Iwas called bythe chairman ofthe surgery de-partment at a nearby state university.He understood my situation and invitedme to join the faculty, strictly in ateaching role. I would oversee and in-struct the residents under me, and theywould perform the actual surgery. Iprovided the knowledge, the re-sources, and the direction.

For me, it was a great opportu-nity: it meant I could still be involvedin medicine in some capacity, and usemy experience to teach others. I defi-nitely wanted to give it a try. So, inMarch of 1995, I joined the faculty atthe university. It turned out to be agreat situation. I would go to the op-erating room with the upper-levelresidents under my supervision, anddiagram on the chalkboard the opera-

tion they were going to perform. Iwould tell them what to do, and theywould do it. During the operation Ihad a laser pen and a pointer to aid ingiving them directions. OccasionallyI would scrub in, and would push andpull, using a blunt hemostat, to showthem where to go, but they did all thecutting and sewing. I was double-gloved, of course, which helped easemy own fear of infecting patients.

The hospital was very comfortablewith this arrangement. It did nothave an explicit policy about in-fected surgeons, and I did not signany written statement. It was agentlemens agreement. I was verygrateful to have a job, and they werehappy to have me, so it turned outto be a great partnership.

So that has been my life for thelast six years. I rarely wield a knife,unless there is an urgent need to do so.AEP: Sounds like a great example ofthe medical community taking careof its own.Dr. Jones: Absolutely.AEP: Another alternative for someonein your position might be conductingtraining for endoscopic procedures, since

the training is performed on animals.Dr. Jones: Yes, that would be a pos-sibility. Another is something calledZeus, a computerized virtual-reality surgery program where youoperate with hand-held devices inanother room using the computer,and the actual surgery is done by arobot. There are usually scrub techsor residents in the room with the pa-tient who place the instruments to

get the robotgoing, and thesurgical staff isin the otherroom operating.AEP: Thatsounds like anew horizonfor you.Dr. Jones: It isabout ten yearsaway from be-ing perfected.So for now, Iteach others.My biggestfear in the op-erating room isgetting stuckby one of theresidents, whoare relativelynew to surgery.

Of course, I only have one type ofhepatitis C, and there are several vari-ants of it. I have been stuck by resi-dents a couple of timesone timewith a needle-tip Bovie coagulator.The device was plugged in when Igot stuck, so I got an electrical shockat the same time. I assume any patho-gens would have been killed by theelectricity, so Im not worried aboutanother infection. I was also stuckwith a rake, a retractor with sharplittle claws on it. A resident was us-ing it to pull a piece of tissue out ofthe way; it went through the tissueand stuck my finger.AEP: Of course, with sharps expo-sures we always want to know whatthe device was and whether it needed


Figure 1. Potentially PreventableSuture Needle Injuries

6 hospitals, 15 months,suture needle injuries=197

used toused tosuturesuturemuscle ormuscle orfasciafasciaused toused to

suturesutureskin orskin orotherothertissuetissue

100%preventable

with the use ofblunt suture

needlesmany arepreventable by

substitutingalternativemethods ofskin closure

59%

41%

From: Jagger J, Bentley M, Tereskerz P. A study of patterns and preventionof blood exposures in OR personnel. AORN Journal 1998;67(5):979-996.

5 35 35 35 35 3ADVANCES IN EXPOSURE PREVENTIONVol. 5, No. 6, 2001

to be sharp, particularly in the sur-gical setting. If Im not mistaken, inboth those situations, with the Bovieand the rake, a sharp-edged devicewas not necessary.Dr. Jones: Thats correctthere areblunt Bovies and blunt retractors. Ithink the sharp versions should beremoved from the operating room al-together. There are many unnecessar-ily sharp instruments that endangerhealth care workers that ought to beremoved from the OR.AEP: The number-one sharp deviceto get out of the OR is the sharp su-ture needlethere are very few caseswhere this device is really necessary.Blunt suture needles can be substi-tuted for the suturing of less-dense in-ternal tissues; for cutaneous closures,you can use staples or tissue adhe-sives or adhesive strips. [Editors note:See Figure 1, page 56.]Dr. Jones: You are talking to a plas-tic surgeon now, and if I told you Iwas going to close your eyelids withstaples I think you might get a littleupset.AEP: Im sure you have to be selec-tive about the use of staples. Whatabout tissue adhesives, what is youropinion of them?Dr. Jones: I use them frequently, butyou cant use them around the eyes,and you cant use them around themouth or inside the nostrils.AEP: It would be useful to de-velop an inventory of surgicalprocedures, with a list of all thesharp items that can be eliminatedfrom those procedures.Dr. Jones: Absolutely. I would havesharp towel clips removed from ev-ery operating room in the countryright now. Those are ridiculouswho needs them?

My objective now is to stop thetransmission of these diseases tohealth care personnel. I have to tellyou that being infected with hepati-

tis C has ruined my life. My life as Iknew it, with all the training I un-derwent to be a plastic surgeon, isover. The crazy thing is that it couldhave been prevented so easily. It isall a question of awareness. Today,everybody is aware of the risk of in-

fection. We are heading in the rightdirection of being more aware andbetter protectedbut we still needto go much further.AEP: Getting the attention of sur-geons on this issue has been verydifficult.Dr. Jones: Well, they need to real-ize the potential consequences of aninfection. Your life is ruined, andthe financial consequences are dev-astating. After I got sick, I was ableto get disability, but I never gotworkers compensation because I


never filed a claim. I didnt knowexactly when I got infected, becausethere was no test for hepatitis C, andI was in training at the hospitalwhere I had that major exposureI did not want to rock the boat.And, of course, now it is too late.But at least I had the disability.

Recently, though, my disabilityhas been cut off. I am paid for myteaching, but it is very little com-pared to my former income. It isenough for food and shelter, but cer-tainly not enough to put my fourkids through college or lead thelifestyle that I trained and struggledso hard to have.AEP: What happened with yourdisability?Dr. Jones: The disability companysaid to me, Having hepatitis C isnot sufficient reason to claim dis-ability anymore. Because, accordingto the CDC, having hepatitis Cshould not put restrictions on yourpractice.AEP: That is an unintended use ofthe CDC position.Dr. Jones: Its frightening. Accord-ing to my disability company, whichis one of the major carriers in thecountry, having hepatitis C or HIVis not a reason to restrict your prac-tice. That is a point of view that willscare any surgeon in private prac-tice. If the carrier ends up being suc-cessful in denying me disability onthis basisobviously I am going tohave to go to court with themyou are going to have more in-fected surgeons hiding in thecloset than ever before. You know,if I had kept my mouth shut, Icould have kept practicing.

Regarding the issue of in-formed consent, I think that if some-one is physically able to work andis totally asymptomatic, they shouldbe able to practice. But I also thinkthat patients need to be informed oftheir surgeons sero-status, based onethical and legal considerations.Surgeons should do everything in

My life as I knewit, with all the

training I underwentto be a plastic

surgeon, is over.The crazy thing isthat it could havebeen prevented

so easily...We are heading in

the right direction ofbeing more aware

and betterprotectedbut we

still need to gomuch further.

-Dr. Jones


their power to make their surgicalpractice as safe as possible, by us-ing protective equipment such asmesh gloves and blunt sutureneedles. And infected surgeonsshould avoid performing exposure-prone procedures.AEP: Your experience was that onceyou informed your patients,you did not have any morepatients.Dr. Jones: That is true, andit is a difficult decision tomake. But I feel it is still thepatients right to know. Ithink most of the time youare going to find people likeme saying, I better makesure I never expose a patientto this illness. Of course,one option is to switch spe-cialties to something like fam-ily medicine or radiology. Or,if I wanted to continue prac-ticing plastic surgery, I couldlimit myself to teaching andto procedures like laser resur-facing, laser photocoagula-tion, childrens port winestains, chemical peels, andmicrodermabrasions.AEP: Is there a need to in-form patients who havethese kind of procedures ofyour HCV status?Dr. Jones: I dont think so if the pro-cedures are non-invasive. Of course,there are some aspects of this issueon which I have not reached a con-clusion. For instance, if I were a gen-eral surgeon and I had hepatitis C, Iwould just restrict my practice to non-exposure-prone procedures. But if Iwere a heart or orthopedic surgeonwith HCV, I would probably just quit,because most of their procedures areexposure-prone.AEP: Have you thought about switch-ing specialties?Dr. Jones: Oh yes. Ive thought

A Surgeon, A Suture Needleand Hepatitis C

about going into psychiatry or radi-ology. But Ive kind of carved out aniche for myself in a totally differ-ent avenue of plastic surgery. I runa very large clinic where I directwound therapy and treatment. Itdoesnt involve my doing any sur-gery at alljust seeing patients andtaking care of wounds, particularlydiabetics. Thats where most of myresearch is now. It is very reward-

ing; if a diabetic is able to keep aleg, he or she is extremely grateful.AEP: Are you still on the interferon?Dr. Jones: No, I have been off theinterferon for about a year and a halfnow. I have hepatitis C fatigue at-tacks, where one day I am doinggreat, and then the next day I am to-tally wiped out and cannot move. Itfeels like the flu and lasts from 24to 48 hours. I get them about onceor twice a monththey are welldocumented in the literature onhepatitis C. I also get night sweatsand myalgia. But my prognosis isgood; Ive been infected for prob-

Why don't surgeons report?As an occupational health nurse, I know that

blood exposures are under-reported, particularly fromthe OR. Recently our surgeons appear to be evenmore reluctant to report blood exposures and havebaseline testing performed. OR nurses helped meunderstand this when they invited me to speak tothem about hepatitis C. Stories are circulating in theOR that a well-known surgeon withdrew from hispractice due to HCV infection. Fear of inability topractice surgery, related to HCV, may contribute toeven greater resistance among surgeons to reporttheir exposures.

All of this made me think about what I could do,since HCV is treatable. I must ensure confidentialtesting results, educate health care workers aboutprogress in treating HCV, and utilize this as anopportunity to actively involve surgeons in exposureprevention efforts.

- Occupational health nurse, Seattle, Washington

ably 20 years, and I have no evidenceof cirrhosis. Ill probably continue tolive like this, hopefully for a normallifespan. My biggest fear, of course,is liver cancer. I may be in sustainedremission right now, because I donthave any detectable virusbut thatdoes not mean anything in terms ofwhether youre still infectious. No-body can tell you whether you arecured or not.

AEP: What kind of ef-fect has your illnesshad on your family?Dr. Jones: Everybodyworks nowmy kids are20, 18, 16 and 11. Every-body has a job, includingthe 11-year-old. It wasquite a change in lifestylefor themfrom havingeverything to suddenlyhaving very little security.AEP: Do you have anypolicy recommendations?Dr. Jones: I do not un-derstand why we donthave a national policyon the issue of HCV-infected surgeons andinvasive procedures. Ithink surgeons have aright to know if theirpatient is infected, and Ithink patients have aright to know if theirphysician is infected. At

my hospital, of the two surgeonsbesides myself who are occupa-tionally infected with hepatitis C,one has limited herself to teach-ing and the other is doing what Ido, having the residents performthe surgeries. So there are threesurgeons who are all adhering tothe same self-imposed restric-tions, because we do not want togive the disease to anyone else. Ifyou have this disease and youhave been through the hell, youwould not want to pass it along toanyone else, not even your worstenemymuch less a patient.

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Surgeon Suture Needle He Pc