Alvin Heller, MD, chief of plastic and reconstructive surgery at a U.S. academic medical center, remembers the moment in the OR that he believes he became infected with hepatitis C. "We were working on a patient with elevated liver enzymes who had tested negative for hepatitis B and was thought to have non-A non-B hepatitis [later identified as hepatitis C]. During the procedure, I sustained a deep injury from a large (3.5-inch) retention suture needle and was probably infected as a result. But no test for hepatitis C was available then."

This wasn't the first time this had happened; from the time he started his residency in 1979, Dr. Heller (not his real name) says he was "regularly soaked in blood from the waist down and stabbed with instruments. You just changed the instrument and got back to work. There was little protection."

The hepatitis patient incident was no different - as before, Dr. Heller simply got back to work. It took about a year for the first symptoms to manifest themselves. He became very ill and was unable to work. His liver enzymes were high, but because he tested negative for mononucleosis and hepatitis B, and because there was still no test available for hepatitis C, his condition was not diagnosed. The symptoms abated after a month, and he remained in good health until he finished his residency and went into private practice.

By 1992, he was ill again. By this time, a marker for hepatitis C had been discovered, and an HCV antibody and a PCR test revealed that this respected surgeon, husband and father of four children had indeed been infected.

An all-too-common story
There is little doubt that Dr. Heller became infected in the OR. He had no risk factors for HCV other than a history of occupational blood exposures; he never had surgery requiring a blood transfusion, did not have tattoos and had never taken intravenous drugs. Unfortunately, stories like his are not uncommon. From 1993 to 2000, nearly one-fourth of percutaneous injuries (PIs) occurred in operating and recovery rooms, according to data from the EPINet Sharps Injury Surveillance Network, coordinated by the International Healthcare Worker Safety Center at the University of Virginia (83 hospitals contributed data). Sharp-tip suture needles, such as the one Dr. Heller was using, are the leading cause of PIs in the OR, accounting for 40 percent in the EPINet data; reusable scalpel blades account for 15 percent. In all hospital settings, suture needles were second only to disposable syringes as a source of PIs.

An ongoing struggle
Over the next several years, Dr. Heller struggled to maintain his practice as he dealt with his worsening symptoms of HVC, including severe fatigue, sweating, nausea, diarrhea and loss of appetite. His doctor suggested treatment with interferon, at that time considered experimental; he took it for three months while continuing to practice. At the end of treatment, his liver enzymes were normal, but six months later he was ill again. Another liver biopsy a year later showed some fibrosis, and he had a second course of interferon. Wanting to keep his condition a secret, Dr. Heller decided to leave his practice for three months to undergo treatment in another part of the country. But after he left, word got out that he had hepatitis C.

When he returned, his colleagues told him they didn't feel comfortable referring patients to him; they were worried about liability. A hospital committee met to consider the issue of informed consent and concluded that he needed to tell patients of his serostatus. Dr. Heller complied, but quickly lost patients, and by 1995, he was forced to close his practice. He started thinking seriously of changing specialties, or leaving medicine altogether.

Within a month, however, he was invited to join the surgery department of a nearby university in a teaching-only role. Today, Dr. Heller supervises upper-level residents in plastic surgery, diagramming operations beforehand and giving them direction with a laser pointer during procedures. He is always double-gloved. Occasionally, he scrubs in and uses a blunt hemostat to direct the residents in the surgical site, but they perform all cutting and suturing.

Preventable accidents
Despite increased education about bloodborne pathogens and sharps injuries in recent years, Dr. Heller believes that most ORs still have a long way to go to comply with OSHA needle-safety regulations and protecting OR workers from occupational exposures. Since he began teaching, he has been injured twice by residents handling sharp devices under his direction. One involved a needle-tip Bovie coagulator, the other a retractor rake used to pull aside a piece of tissue. Both of these injuries were unnecessary, because blunt alternatives are available for both of these devices.

Sharp-tip suture needles, the leading cause of PIs in surgical settings and the probable vehicle for Dr. Heller's infection, need not be used in many, if not most, cases. Blunt-tip suture needles - sharp enough to pierce internal tissue, but not sharp enough, under normal circumstances, to pierce skin - can be substituted for suturing muscle and fascia (for cutaneous closures, staples and tissue adhesives or adhesive strips can often be used). One study found that substituting blunt-tip suture needles for sharp-tip ones wherever clinically feasible could potentially reduce the number of sharps injuries in ORs by as much as one-third.1

Using unnecessarily sharp devices in ORs endangers not only surgeons but all other personnel handling the devices. In EPINet data from 1993 to 2000, 30 percent of injured workers (for all settings other than the OR) said that they were not the original user of the device causing their injury. In data for the OR, however, that percentage was nearly double - 58 percent. EPINet data also show that 58 percent of OR injuries were sustained by nurses, surgery attendants and technicians, while 30 percent were sustained by physicians. In response to the question, "When did the injury occur?," 27 percent of injured OR workers indicated "between steps of multi-step procedure." For all other settings, excluding the OR, that fraction was 6 percent. These data underscore that many PIs occur during passing, when personnel other than surgeons are handling sharp devices.

A tough lesson learned
Today, Dr. Heller's life is very different from the one he enjoyed 10 years ago. In addition to losing his surgical practice, he continues to have active symptoms of HCV. The irony, he says, is that "my illness could have been so easily prevented. It is all a question of awareness." But he acknowledges that getting surgeons to take the problem of exposure prevention seriously has been difficult: "We are heading in the right direction of being more aware and better protected - but we still need to go much, much further."

Reference
1. Jagger J, Bentley M, Tereskerz PM. Patterns and prevention of blood exposures in operating room personnel: a multi-center study. AORN Journal. 1998;67(5):979-96.