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Surgeon Declines Safety Advice
LI doctor with hepatitis C still opening, closing chests

By Roni Rabin

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.

Read More  about Dr. Hall on the message boards 338.1

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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