When John Harrison, a 63-year-old sales manager had rotator cuff surgery to repair his right shoulder, he thought that he was simply going to undergo a routine procedure. However, little did he know that he would soon be fighting for his life.
After his surgery, his surgical scar reddened, turned feverish to the touch and oozed a yellowish liquid. His wife rushed him back to the hospital to get it checked out. Once surgeons had opened the wound, they found a massive infection had destroyed part of his shoulder bone and rotator cuff and loosened screws and other medical devices that were implanted as part of the procedure.
For the next several months, Harrison required regular medical care to treat the infectionand could not go to work or dress himself. He had to have seven follow-up surgeries. His health was so poor that he regularly came close to dying. Miraculously, he eventually recovered, but never regained full movement in his shoulder.
Investigation of the Infection
As Harrison was one of seven joint surgery patients who developed similar infections, the hospital along with the Centers for Disease Control conducted an investigation. The investigation narrowed the source to the infection to two probable sources: an arthoscopic shaver used to shave away bone during surgery, and an inflow/outflow cannula used to suction and irrigate the surgical area.
Using a small video camera, the investigators examined the inside of the devices and found alarming results. The arthoscopic shaver and the cannula still had human tissue and bone within the devices after they had been cleaned. After a further investigation, it was discovered that the hospital had not cleaned the cannula with a brush according to the manufacturer’s recommendations, but had simply run tap water through it.
What the investigators found with the shaver was even more alarming-it had been cleaned according to instructions provided by the manufacturer and was still dirty. The investigation concluded that the hospital infections were likely caused by the dirty medical instruments or the liquids that passed through them.
A Recurring Problem
Harrison’s case is not novel. Unclean instruments regularly show up in hospitals and outpatient facilities. Experts say that as medical instruments have become smaller and more elaborate, they have become harder to clean. Joe Lewelling, vice-president at the Advancement of Medical Instrumentation said, “cleaning was once a basic factory job. Now it is very complex. It takes a lot of steps…”
The FDA reviewed the safety of arthoscopic shavers in 2009, but despite findings that experts have commented on as “gross” and “scary,” it has done nothing to solve the problem, saying that action is unnecessary because only one percent of arthoscopic procedures results in an adverse event. However, experts say that hospitals discourage their staff from reporting all but the most egregious adverse events, so the actual percentage is likely much higher.
Source: “Filthy surgical instruments: The hidden threat in America’s operating rooms,”Iwatchnews.org, 2/22/12.
