http://www.guardian.co.uk/worldlatest/story/0,1280,-5073534,00.html

Surgical Tools Washed With Hydraulic Fluid

Tuesday June 14, 2005 3:01 PM

AP Photo NCSD601

By ESTES THOMPSON

Associated Press Writer

RALEIGH, N.C. (AP) - Doctors at two North Carolina hospitals
unwittingly used surgical instruments that were cleaned with hydraulic
fluid instead of detergent, a mistake that affected nearly 4,000
patients.

Toward the end of last year, elevator workers at Duke Health Raleigh
Hospital and Durham Regional Hospital drained hydraulic fluid into
empty soap containers and capped them without changing the labels.

Not long afterward, medical staff complained that some of their
surgical tools felt slick. But it was not until January that the
patients affected learned that for two months their surgeons had
unknowingly used instruments washed in the fluid. The instruments also
had been run through a steam bath for sterilization.

Duke University Health System assured patients that the mix-up created
little chance of medical problems. The hospital said it monitored
infection rates and found no increase for the time the hydraulic fluid
was used.

But a federal agency determined both hospitals had endangered patients.

Since the problem became public, at least one patient has sued the
elevator company, complaining of severe infection, temporary loss of
kidney functions and other ailments.

This week, a Raleigh lawyer began running television ads recruiting
patients exposed to the fluid. About 15 or 20 former patients
complaining of aching joints and infections have contacted him.

``What we really want is a response from Duke to prove their assertions
that there was very little risk to the patients,'' attorney Thomas
Henson said. ``I mean, patients are hanging out there with problems and
Duke won't give an answer to us.''

Both hospitals have created plans to prevent such problems in the
future, said a spokeswoman for Duke University Health System, which
owns the two hospitals. The system also includes Duke University
Hospital, widely considered one of the nation's top medical facilities.

Carol Svec, 46, had surgery at Duke Health Raleigh on Nov. 15 for a
torn rotator cuff. Before her operation, she did research to find the
best surgeon close to her home in Raleigh. But she said her recovery
has been slow, and she wonders whether the hydraulic fluid might be a
factor.

``Maybe this is how I would have recovered under normal circumstances,
but we don't know,'' she said Monday.

``We put our faith in Duke, and in one way, they failed us,'' she
added. ``It seems to me that a good company with a good reputation
should be bending over backwards for us.''

Opinions on the potential harm from the fluid varied. A report by the
federal Centers for Medicare and Medicaid Services said the hospitals'
errors put patients in ``immediate jeopardy.''

But state investigators - while citing the hospitals and the elevator
company for mistakes that created the confusion, including poor
communication and improper labeling of chemicals - did not consider the
problem serious, said spokeswoman Heather Crews of the state Labor
Department.

At least one medical expert questioned how the error could happen and
how it was allowed to persist through 3,800 operations performed in
November and December.

``It should be pretty easy to see when you start to wash something that
detergent is different from hydraulic fluid,'' said Dr. Michael Grodin,
director of medical ethics at the Boston University School of Medicine.
He said the two fluids normally have different colors and textures.

There is little data on how hydraulic fluids - made of many kinds of
chemicals that are used in cars, industrial machinery and airplanes -
affect humans. In studies, rabbits that inhaled the fluid had trouble
breathing and other animals experienced nervous-system tremors and well
as diarrhea and breathing problems.

``It's pretty toxic stuff,'' Grodin said.

Duke has struggled with patient safety issues since February 2003, when
a surgeon accidentally transplanted a heart and lungs of the wrong
blood type into 17-year-old Jessica Santillan. She received a second
transplant but soon died.

A federal inspection prompted by Santillan's death found toxic
chemicals stored next to food and other problems. Later that year, two
infants were burned in separate incidents in the hospital's neonatal
intensive care unit.

After the problems were revealed, Duke officials pledged major changes
to the hospital's patient-safety programs to avoid a potential loss of
more than $300 million in Medicare and Medicaid reimbursements.

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TC