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Duke Patients Share Stories Of Surgical Instrument Mixup

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RALEIGH, N.C. — Patients whose surgeons unknowingly used instruments washed in hydraulic fluid instead of detergent held their first group meeting, sharing stories of delayed recoveries and distrust of their doctors.

About 50 people attended the meeting at the Sertoma Arts Center in Raleigh Thursday night. It was organized by Carol Svec, who was among 3,800 patients to undergo surgery with instruments washed in the fluid in late 2004 at two hospitals owned by Duke University Health System.

"I still don't have full motion in my shoulder," Svec told the audience. "People have experienced everything from delayed healing, wounds that just don't heal for months, all the way to some people have been in comas."

"I continued to have pain and was not able to walk," said Lois McAlpine, who suspects her slow recovery was a result of being exposed to the hydraulic fluid-tainted tools.

Duke spokesman Jeff Molter said hospital officials were not invited to the meeting but had provided information to Svec.

Workers at Durham Regional Hospital and Duke Health Raleigh Hospital had complained about slippery instruments before it was discovered that hydraulic fluid had been inadvertently used in place of soap in washing machines that clean surgical tools. The instruments also had been run through a steam bath for sterilization.

The hydraulic fluid came from a hospital parking garage where workers had drained it into empty soap containers while working on an elevator, then packaged it on a pallet. The containers were sent back to the distributor and then reshipped to the hospitals when soap was ordered.

Duke officials asked for advice from an environmental health toxicologist at the university and other experts. They also have offered health monitoring for two years to the patients.

A social worker at Thursday's meeting advised the patients on seeking financial help from Social Security and Medicaid while a counselor discussed feelings of isolation and anger among the group.

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.


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