Surgeon Declines Safety
Advice
LI doctor with
hepatitis C still opening, closing chests
By Roni Rabin
STAFF WRITER
March 30, 2003 A prominent Manhasset
heart surgeon who infected patients with blood-borne hepatitis C
continues to open and close patients' chest cavities, hospital
officials said, despite being advised the procedures place patients
at risk.
Heart surgeons are most likely to sustain injuries or puncture their
gloves at the very beginning of the operation, when they cut through
the breastbone, or at the conclusion, when they use wire to sew the
sternum back together. But a North Shore University
Hospital-Manhasset spokesman said other surgeons are not available
to step in and assist Dr. Michael Hall at the start and end of
surgery, and that Hall, who has hepatitis C, prefers to complete the
procedure himself.
State officials have said Hall almost certainly infected three and
possibly more patients with the illness during previous surgeries.
Hospital spokesman Terry Lynam emphasized that no new infections are
known to have occurred since Hall implemented new precautions -
including wearing double layers of latex gloves - to prevent needle
sticks and cuts that could transmit the virus.
"Dr. Hall's patients, all of whom consent in writing to have him as
their surgeon with full knowledge of his health status, insist, or
at least prefer, that he be present and perform as much of the
procedure as possible," Lynam said. "The hospital does not have a
large enough surgical staff to have someone step in and do the
closing. It's not Mass. General."
Hall did not return phone calls.
Hall, one of the top-ranked cardiac surgeons in the state, has
continued to operate since state officials disclosed the cluster of
infections last year, but he is required to inform patients of his
condition and to warn them of a slight risk of hepatitis C infection
during surgery. The virus can cause long-term liver damage,
cirrhosis and cancer.
State health investigators were never able to figure out exactly how
the virus was transmitted to patients from the surgeon, but the
infections presumably occurred when Hall stuck or nicked himself and
bled into an open surgical wound.
Several published studies of other heart surgeons who transmitted
hepatitis C to patients said the transmissions most probably
occurred during the sternal closure. And a 1988 study in the medical
journal The Lancet said 40 percent of cardiac surgeons punctured
their gloves during the sternal closure, compared to 12 percent
during the actual procedure.
Closing the sternum after surgery typically involves threading wires
through holes in the breastbone and then tying them. The wires can
apparently slice through latex gloves.
The state health department initially advised the surgeon to modify
his technique and either defer the closure to a colleague or
assistant or adopt an alternative method of closing the chest, using
clamps, which are less likely to injure the surgeon.
But the state reversed its recommendation after a nationally
respected cardiac surgeon hired by North Shore evaluated his
surgical technique, saying it was "exemplary," and that it carried
"a very low risk" of viral transmission.
"The operative conduct . . . reflects efficient and appropriate
technical maneuvers" that "minimize the likelihood of sharp object
penetration of the surgeon" that could lead to transmission, said
the Aug. 15, 2002, report by Duke University Medical Center
professor of surgery Dr. Robert H. Jones. Jones serves on the New
York State Cardiac Advisory Committee, which has ranked Hall as one
of the state's top heart surgeons in recent years.
Jones' report, however, includes a recommendation that Hall consider
deferring the opening and closing of the chest to a colleague.
"This would remove the risk of blood-borne infection from [Hall] to
the patient during the sternal opening and closing . . . when needle
punctures of personnel are most common," Jones wrote.
A year earlier, in August 2001, Dr. Barbara Wallace, who heads the
state's bureau of communicable disease control, had made the same
recommendation in a letter to North Shore's infection control
director, Dr. Bruce Farber. In it, she wrote that Hall should modify
his surgery by "deferring the closure . . . to another member of the
surgical team" or "using clamps rather than wire to close the chest
cavity."
That same August, Stan F. Kondracki, the state's regional
epidemiology program manager, wrote an e-mail to Miriam Alter, at
the U.S. Centers for Disease Control and Prevention, and said that
in light of the recent discovery of the surgeon's infection, "We are
developing interim control measures such as . . . having someone
else open and close the chest cavity." In parentheses, it added
"surgeon feels most likely time for puncture through the glove is
when surgical wires are used for closure."
State epidemiologists who observed Hall operate on the same day as
Jones' visit, last Aug. 14, also raised the subject, under the
heading of "areas for improvement." Dr. Stephanie Noviello and
Rachel Stricof said Hall occasionally left suture needles dangling
and tied sutures with needles attached, and noted that he placed his
fingers near the exit point of the needle when wiring the sternum.
"He forced the sternal wire needles off and then tied the wires off
himself, which may pose an increased risk of exposure," according to
their reports, obtained under the Freedom of Information Act.
In a recent telephone interview, Jones said his suggestions were
mere recommendations and that it would be inappropriate for him to
tell another surgeon how to "run his team."
He said it was common practice for cardiac surgeons at academic
medical centers to ask an assistant surgeon or surgeon in training
to open and close the patient, and that he rarely opens and closes
his own patients, usually deferring to a doctor in training.
But, Jones said, Hall did not want to do so.
"He likes to stay with the patient until the very end, and that's
fine," Jones said. "He thinks the disadvantage of letting someone
else do it outweighs the advantage of eliminating any very, very
remote chance that he's going to injure himself.
"Everything in medicine is a risk-benefit ratio," Jones said.
"That's the surgeon's call."
Several months after Jones' visit, North Shore's senior vice
president for quality management, Yosef D. Dlugacz, appealed to the
state to condone Hall's closing of his patients, citing Jones'
report and Hall's low rate of post-operative complications with the
closure.
State officials agreed.
"Our epidemiologists made recommendations with the caveat that a
cardiac surgeon would review them," state health spokeswoman
Kristine Smith said. "We believe the patient is at less risk if
[Hall] does the closure . . . due to his low sternal wound
complication rate."
Smith said state officials believe Hall is taking appropriate
precautions, including using blunt needles to penetrate through the
sternum during the closing, and announcing sharp instruments in the
operating room.
"We feel they are following the necessary procedures," Smith said.
She added, "The informed consent is obviously the most essential
change."
Copyright © 2003,
Newsday, Inc.
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Surgeon Declines Safety Advice LI doctor with
hepatitis C still ...
File
Format: PDF/Adobe Acrobat -
... condition and to warn them of a slight risk
of hepatitis C infection during ...
were never able to figure out exactly how the virus
was transmitted to patients
www.uhmc.sunysb.edu/prevmed/mns/mcs/2/
Physicians_operating_hepC_Newsday.pdf -
2/8/2003 2 Docs Spurn Hepatitis C Test...Draft report
cites St. Francis surgeons-Two heart surgeons
refused to be tested for hepatitis C, despite a request by state
officials investigating the source of the disease in one of
their patients... cardiothoracic/vascular surgery at the Roslyn
hospital, Dr. Paul S. Damus, nor his assistant surgeon agreed to be
tested...St. Francis Hospita...also called The Heart Center
