The Case of the Dirty Dentist

English: Putting toothpaste on a toothbrush. T...

English: Putting toothpaste on a toothbrush. The toothpaste is Crest Pro-Health Clean Cinnamon, 0.454% stannous fluoride, 0.16% w/v fluoride ion. Deutsch: Zahnpasta auf eine Zahnbürste auftragen. Русский: Выдавливание зубной пасты из тюбика на зубную щётку (Photo credit: Wikipedia)

Most of us wouldn’t think twice before checking that our silverware is clean at a restaurant.  But, when we sit in the dentist’s chair nervously eying the tray of gleaming stainless-steel instruments laid out beside us, we don’t pick them up and make sure they’re clean. We rely on our dental professionals to sterilize anything going into our mouth. That reliance may be a mistake.

Last week the Board of Dentistry performed a surprise inspection of oral surgeon Dr. Scott Harrington‘s Oklahoma office and found numerous problems with sterilization of instruments. The good doctor’s response when questioned?

“Dr. Harrington referred to his staff regarding all sterilization and drug procedures in his office,” the complaint read. “He advised, ‘They take care of that. I don’t.'” His attitude seems to be that not infecting his patients with blood-borne diseases is someone else’s job.

Other issues that came to light during the inspection included the doctors reuse of needles, disregard of expiration dates (one bottle of morphine expired in 1993) and his use of unlicensed assistants to perform tasks only a licensed dentist should perform, such as giving IV sedation.

Now over 7000 patients will undergo  testing to see if they contracted hepatitis or HIV due to the oral surgeon’s noncompliance with basic infection control practices.  In the meantime, don’t be fooled into thinking this is an isolated problem caused by one errant doctor.  On March 22, 2013 the Rhode Island Board of Dentistry temporarily shut a practice down after finding debris on multiple instruments in ‘sterile’ packages in exam rooms. No word on whether that dentist took responsibility for his office practice.

But, speaking of responsibility, how much responsibility do patients have to protect themselves from healthcare acquired infections? People have been trained not to touch someone else’s blood unless they wear gloves. People are encouraged to use barrier devices, such as condoms, during sex to prevent STD’s. Should our public health officials start a campaign to encourage patients to protect themselves during invasive procedures such as dental procedures, colonoscopies, and injections? If so, how can that be accomplished?

Recent articles have suggested patients ask dentists to prove they’re following guidelines in the care and maintenance of sterilization machines.  They’ve also advised patients to request to inspect the instruments prior to being removed from their sterile packages.  Other tips are to watch the dentist’s glove use, look at the overall office cleanliness, and quiz the dentist and staff as to how they handle reusable instruments. All excellent points, but it also requires a level of doctor-patient transparency and discussion that’s not usually seen. More importantly, how is your dentist going to react to his judgement and cleanliness being questioned?

In my work in the healthcare field, even the idea of a patient (or another healthcare team member) questioning whether someone has washed their hands before patient contact is a source of controversy. In a Swiss study, 76% of patients felt uncomfortable asking a nurse if she’d washed her hands and 77% felt uncomfortable asking a physician the same question. If patients don’t feel comfortable asking a simple question like that, do we really expect them to ask complicated, technical questions about sterilization procedures? Asking for clean instruments should be as easy as asking for a new knife or fork at a restaurant when the one on the table is dirty, but it isn’t.

English: South China Sea (May 16, 2006) - Hosp...

English: South China Sea (May 16, 2006) – Hospital Corpsman Steffon Corna sets up dental tools for a tooth extraction in the Dental Department aboard the Nimitz-class aircraft carrier USS Abraham Lincoln (CVN 72). Lincoln and embarked Carrier Air Wing Two (CVW-2) are currently underway in the Western Pacific operating area. U.S. Navy photo by Photographer’s Mate Airman Apprentice Brandon C. Wilson (RELEASED) (Photo credit: Wikipedia)

Will I stop going to my dentist? No. Will I ask to inspect the instruments for debris before my next procedure or cleaning. Yes. Hopefully he’ll understand, but if he doesn’t, I’ll tell him I’m holding him to the same standards I’d hold a restaurant to. I’m sure he doesn’t like eating off dirty forks any more than I do.

 

 

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When Your Employer Won’t Take No For an Answer

English: This is CDC Clinic Chief Nurse Lee An...

English: This is CDC Clinic Chief Nurse Lee Ann Jean-Louis extracting Influenza Virus Vaccine, Fluzone® from a 5 ml. vial. (Photo credit: Wikipedia) You go, girl!

The recent firing of 8 healthcare workers who refused to get a flu vaccination at Goshen Hospital in Indiana is not surprising. As influenza season kicks into hyper-drive, hospitals unleash the latest public relations strategy in making patients believe they are safer – mandatory flu vaccination for healthcare workers. The reasoning is that hospital inpatients are already vulnerable to infection and preventing healthcare workers from infecting them, because the healthcare worker has immunity due to the flu vaccine,  will save lives.  This mindset has a few flaws.

First, the flu vaccine is not 100% effective. That’s not to say I don’t get one myself, but, as the Centers for Disease Control (CDC) website points out:

“The effectiveness of influenza vaccines varies from season to season, and depends upon a number of factors. One factor is how well the vaccine strains match the viruses that actually circulate during the season. In addition, vaccine effectiveness is affected by the recipient’s age, immunocompetence, and previous exposure to influenza viruses.”

No 100% guarantee there.  In fact the CDC notes,  “Recent RCTs (Randomized Control Trials) of inactivated influenza vaccine among adults under 65 years of age have estimated 50-70% efficacy during seasons in which the vaccines’ influenza A strains were well-matched to circulating influenza A viruses,” “a study of Dutch community dwelling people aged 60 years of age and older reported a vaccine efficacy of 58%” and “study among 92 healthy adults aged 18–41 years, the efficacy of inactivated and live attenuated influenza vaccines in preventing laboratory-confirmed influenza was 71% and 85%, respectively.”

With the average age of registered nurses at 46 and doctors at 51, I’d guess the vaccination effectiveness is in the 50-70% range. Oh, and did I mention if you’re going to get immunity,  it can take up to 2 weeks after the shot to get immunity?

Even if it did confer immunity to 100% of the healthcare workers who received it, they are not the only carriers of influenza. Since the infected are able to infect others one day BEFORE getting symptoms and up to seven days AFTER getting sick, think of all of the other traffic in a hospital including visitors, admitted patients, and vendors. Are they all vaccinated against flu? Who knows. Can hospitals require them to receive vaccination? I’m guessing the answer is no. This means in a perfect world, with every healthcare worker not only immunized but also immune, there would still be potential flu carriers wandering the halls every single day. Since the flu can be spread to others up to six feet away, a vendor or visitor at the nurses station can infect a patient who is walking nearby for physical therapy. Unless hospitals go into lock-down at the start of flu season, a strategy of mandatory vaccination leaves plenty of room for infection.

Forcing people to get immunized for flu or lose their job is easy. In my book, proving that it is the best and most effective option to save patient lives is a little bit harder. Having worked in a number of healthcare institutions, I know most healthcare workers work sick for a number of reasons including managers who penalize them and co-workers who resent working short-handed. I also know that hand hygiene, considered the baseline measure to prevent the spread of disease, is nowhere near 100% in organizations. Instead of picking the low hanging fruit of vaccination, organizations should look toward preventing all healthcare acquired infections. I’d love to see someone fired for not washing their hands.

Instead, Goshen Hospital fires 8 out of 1300 people who refuse vaccination. It makes me wonder about the 1292 workers who didn’t get the vaccination, but were allowed to keep their job. Maybe the excuse was they don’t provide direct patient care. Maybe the hospital couldn’t take the financial hit of losing certain positions, such as doctors, surgeons, and top administrators.  Firing front line staff, such as nurses, therapists, housekeepers and food service workers,  has always been easier than the politics of firing the rainmakers of healthcare.

Perhaps this is just the first salvo organizations will fire in the crusade to show their commitment to patient safety. Imagine a hospital website proclaiming, “100% flu vaccination rate” instead of “71% rate of compliance with washing hands between patients.”  The illusion of safety provided by mandatory immunization shouldn’t be confused with the reality of 1.7 million hospital-acquired infections and 99,000 associated deaths each year.

For now, firing a few employees for show will have to do. I know I feel safer.

Fired red stamp

Fired red stamp (Photo credit: Wikipedia)

Dealers Gotta Protect Their Turf

English: Vicodin tablets Italiano: Pillole di ...

English: Vicodin tablets Italiano: Pillole di Vicodin. (Photo credit: Wikipedia)

In New Hampshire, more people die of prescription drug overdoses than car accidents. CDC statistics report that prescription drugs are involved in 75% of all drug-related deaths in the United States. In 2011, the Centers for Disease Control estimated 14,800 deaths related to opioids (opioids or opiates defined as morphine, heroin, oxycodone, codeine, methadone, hydrocodone and hydromorphone.)  Note that with the exception of heroin, all drugs of abuse are available from your friendly healthcare provider.

Whether drug sales are illegal enterprises selling vials on the corner or a transaction that takes place in an exam room, it’s all about numbers and turf. Getting people hooked and keeping them coming back are the keys to a thriving business. For people with insurance, getting narcotics (opiates) from their local doctor or Emergency Room is easier and less expensive than going to the corner drug dealer, particularly since drug dealers don’t settle for a co-pay. Just as dealers rename their products to generate interest,  Big Pharma continues to feed the appetite of addicts with new medications and new formulations of old medications.

Narcotic painkillers have been combined with over the counter meds because of  the belief that the two medications together provide better pain relief than either of the medications taken alone. Unfortunately when people take two Vicodin (hydrocodone and acetaminophen) every 4 hours for pain round the clock (12 pills daily), they run the risk of liver damage because of the amount of acetaminophen bundled in the pill.  The makers of Tylenol (brand name acetaminophen) are so concerned about acetaminophen overdoses that they have decreased the recommended maximum daily dose from 8 pills daily (4000 mg)  to 6 pills daily (3000 mg). This change forces the makers of Vicodin to lower their recommended maximum dose to stay within the new guidelines and will result in Vicodin users having their daily dose decreased.  Sad that in the face of increasing numbers of overdose deaths due to prescription narcotics and the increasing number of prescription drug addicts,  the push to change labeling is due to the potential for a Tylenol overdose resulting in liver damage, rather than concern about overdose or addiction.

Of course the makers of Vicodin don’t want to see their business cut in half. They want to keep on selling the same number or more pills every year. Faced with the very real possibility that providers will decide to switch patients on Vicodin to a drug without any pesky daily maximums, the makers attempted the business affirming move of  trying to get approval for a pure hydrocodone pill. Luckily the FDA panel on pain relief voted against it.

The panelists agreed the higher dose of hydrocodone would be an effective pain reliever, but they felt uneasy providing another formulation of a drug in a class that is already widely abused. According to the Drug Enforcement Agency (DEA), hydrocodone is on the top of the list of most abused drugs in the United States. Sounds like a no-brainer.

Hopefully the FDA will agree with the panel and prevent a new dangerous drug from flooding America’s streets, school yards, and homes. In the war on drugs, our government has gone after the dealers of meth, pot, heroin, and crack. Somehow the legal dealers, Big Pharma, are allowed to thrive while they destroy lives.

opioid prescriptionsDo some people need narcotic painkillers to control their pain? Of course.  In the face of increasing narcotic use, do we need to add more potential drugs of abuse to the marketplace? I think not.  Big Pharma seems to be doing pretty well with what they have.

chart courtesy of the National Institute on Drug Abuse.

Jane, You Ignorant Slut, A Vaccine Doesn’t Cause Promiscuity

Sexually transmitted disease

Sexually transmitted disease (Photo credit: Wikipedia)

What if an immunization existed that made young girls become sexually active? Sounds like a horror story that I might write one day. Realistically, though, no pharmaceutical company would be interested in developing a vaccine that made young girls sexually active. Vaccines are developed to prevent disease, not to promote unwanted behaviors.

In June 2006 a vaccine for HPV (Human Papilloma Virus) was licensed. The vaccine information statement provided by the CDC has this to say about HPV:

Genital human papillomavirus (HPV) is the most common sexually transmitted virus in the United States. About 20 million Americans are currently infected, and about 6 million more get infected each year. HPV is usually spread through sexual contact.”

Sounds like a disease one would wish to avoid.

“Most HPV infections don’t cause any symptoms, and go away on their own. But HPV can cause cervical cancer in women. Cervical cancer is the 2nd leading cause of cancer deaths among women around the world. In the United States, about 12,000 women get cervical cancer every year and about 4,000 are expected to die from it.”

Cervical cancer bad, right? Minimizing the chances of getting it would be good. I mean, children are vaccinated against diseases like hepatitis B, polio, and flu. Protecting them from a virus that causes cancer should be a no-brainer.

So why did so many parents opt out of HPV vaccination when it was first introduced? And why did so many states battle to make sure it wasn’t required?

Maybe because HPV is a sexually transmitted disease aka STD and you can’t catch STD’s if you are abstinent. Abstinence education believes that “the only 100% effective protection from the physical, emotional, mental, and social consequences of sexual activity is to save all forms of sexual activity for marriage” (source: http://www.ampartnership.org/) If children are abstinent, they have no risk factors for HPV and don’t need the vaccine. Further inflaming the abstinence educators was the recommendation that HPV vaccine be given to girls age 11 and up. Obviously giving them a vaccine to prevent STD’s at that age would send a tacit message that they were expected to have sex.

Really. Like if you get a Hepatitis A vaccine you’d lick watermelons bathed in raw sewage because you’d be protected against a disease spread by infected bowel movements. Or if you have a tetanus vaccine you’d start jumping on rusty, dirt covered nails because you wouldn’t be worried about a disease spread through cuts or wounds. If the above were true, clearly immunization against HPV would encourage young girls to have casual sex with multiple partners.

In reality, giving the vaccine to children before they are sexually active gives the best bang for the buck. The vaccine only works against HPV types the person has not been exposed to.

Sexual contact = potential HPV exposure = less effective vaccine.

Simple. Give it to people who haven’t had sex and, if they wish to remain abstinent until marriage, they’ll be protected then. You know, in case their spouse carries the HPV virus.

Unfortunately logic didn’t stop the outcry that allowing a child to have the vaccine gave approval for the recipient to have sexual activity and lulled the (now) sexually active child into believing they were impervious to STD’s.  Parents, legislators, and religious leaders all loudly railed against this vaccine.

Recently a three year study published in Pediatrics journal concluded that girls who received the HPV vaccine showed no increase in pregnancy rates, STD rates, or contraceptive use when compared to girls who didn’t receive the HPV vaccine. In other words, vaccination did not turn the girls into sluts. Instead it protected them from infections with HPV types 16 and 18, the cause of  approximately 70 percent of cervical and anal cancers.

And, as the years go by and research continues, there should come a time where  there is a clear difference in cervical cancer rates between those vaccinated with, and those who didn’t get, the HPV vaccine.  When that time comes, I think it will be damn hard to explain to your child that you didn’t protect them against a deadly disease because you misinterpreted cancer prevention as an assault on your child’s virtue.