Infectious disease hazard of transvaginal ultrasound
A friend asked that I serve as her patient advocate during a transvaginal ultrasound—incidentally, something that can easily be done without breaching propriety. We've often discussed how medical and dental healthcare providers frequently expose patients to infectious disease hazards because of inadequate education, nonchalance, or being too rushed to do their jobs properly. Consequently, she was concerned about the infectious disease risk of her procedure. As a physician avidly interested in mitigating this risk via education and technical advances, and as someone who has previously written about germ transfer, I was eager to see if this Top 100 hospital took all possible infectious disease precautions.
The short answer? No, not even close.
The long answer? The ultrasound technician committed so many errors that I almost wondered if she were educated before the advent of the germ theory of disease.
Mistakes #1 and 2: She touched several obviously nonsterile surfaces (cabinet door, cabinet top, ultrasound machine, etc.) and then, without washing her hands, clumsily plopped the condom-like probe cover (that fits over the ultrasound probe) onto the keyboard of the ultrasound machine, which was bound to be filthy.
Mistake #3: She pulled a nonsterile glove from a previously opened box (of 100) in such a way that she touched the outside of the gloves she withdrew, and likely others, thereby contaminating their external surfaces with germs picked up by previously touching obviously nonsterile surfaces.
Mistake #3: She used nonsterile technique to squeeze out lubricant from a multi-use tube (not a single-use packet), smearing it on the probe cover in a nonsterile way almost certain to spread germs onto the surface of the probe cover, which would soon be in my friend's vagina—had I not spoken up.
So I did, asking, “Shouldn't you wash your hands first?” I explained how she'd touched myriad nonsterile surfaces in ways bound to contaminate the vaginal probe cover.
She didn't seem very pleased with that suggestion, so she began making excuses. I didn't buy any of them. Even if she'd washed her hands immediately before calling us back from the waiting room, she'd touched so many nonsterile surfaces that her hands and the probe cover were now inevitably contaminated.
Mistake #4: She washed her hands in a quick, perfunctory way that wouldn't suffice at Burger King, let alone a healthcare facility.
I wondered if she knew how to wash her hands until she erased any doubt by touching the faucet paddle with a hand (Mistake #5).
Healthcare personnel who know what they are doing don't touch faucets after washing their hands, because that inevitably deposits germs onto their hands. If we can't use an elbow or foot pedal, we have enough common sense to use paper towel. The latter isn't perfectly sterile, but it is much cleaner than faucet handles, which may be contaminated with HIV or hepatitis viruses, MRSA, and other dangerous infectious disease risks.
Watching her hands like a hawk, I noticed that the paper towel dispenser was situated low on the wall, located just over a telephone, making it difficult to pull paper towel from it without touching the phone with hands or paper towels (Mistake #6). Research has shown that phones are often heavily contaminated, so healthcare facilities who give due consideration to infectious disease hazards would never have a phone situated so precariously close to a paper towel dispenser.
Adding up all these potential sources of infection, I said that she would need to wash her hands again, and I would turn the faucet off for her. Her body language and countenance projected anger, yet she complied with my request, washing her hands again. However, she ended this second rush job (Mistake #7) by turning the faucet off with her hand (Mistake #8) after I'd already informed her of that mistake!
I declared that the faucet handle could be contaminated with pathogenic organisms such as MRSA (and countless others), which likely would have transferred to her hand from the faucet. I asked if she agreed with my assessment, and she did.
I said that her mistakes inevitably contaminated the vaginal probe cover, so I emphasized that she needed to repeat the procedural preparation, this time giving more consideration to germs. I suggested depositing the probe cover onto a sterile field, but she said she had no access to sterile field drapes, which can be purchased for less than 29 cents each. My friend recommended that the technician use gloves from a new box, so the tech left the room and retrieved one. With no access to a sterile field drape, I proposed improvising the procedure. I said that I'd wash my hands, open the box, and carefully don gloves from it, apposing the medial surfaces of my palms-up hands to simulate a reasonably clean, if not sterile, surface onto which she could deposit the probe cover. She agreed to this improvisation that minimized—not eliminated—the risk to my friend.
After the procedure, she opened a container of cleansing wipes and began swabbing the ultrasound keyboard, likely cognizant of the infectious disease risk posed by placing the probe cover on the keyboard, as she'd done earlier. Looking at the many keys on the keyboard, I said that she couldn't thoroughly clean it even if she spent an hour doing that. She agreed, and then swabbed the vaginal probe and its handpiece, but in a way I knew did not begin to sterilize it. She was undoubtedly giving a better show of cleaning after I'd repeatedly noted mistakes she made, but even this cleaning procedure was woefully inadequate. The CDC emphasized the need for thorough cleaning by stating:
Vaginal probes are used in sonographic scanning. A vaginal probe and all endocavitary probes without a probe cover are semicritical devices because they have direct contact with mucous membranes (e.g., vagina, rectum, pharynx). While use of the probe cover could be considered as changing the category, this guideline proposes use of a new condom/probe cover for the probe for each patient, and because condoms/probe covers can fail195, 197-199, the probe also should be high-level disinfected. The relevance of this recommendation is reinforced with the findings that sterile transvaginal ultrasound probe covers have a very high rate of perforations even before use (0%, 25%, and 65% perforations from three suppliers).199 One study found, after oocyte retrieval use, a very high rate of perforations in used endovaginal probe covers from two suppliers (75% and 81%)199, other studies demonstrated a lower rate of perforations after use of condoms (2.0% and 0.9%)197, 200. Condoms have been found superior to commercially available probe covers for covering the ultrasound probe (1.7% for condoms versus 8.3% leakage for probe covers)201. These studies underscore the need for routine probe disinfection between examinations. Although most ultrasound manufacturers recommend use of 2% glutaraldehyde for high-level disinfection of contaminated transvaginal transducers, the [use of] this agent has been questioned202 because it might shorten the life of the transducer and might have toxic effects on the gametes and embryos203. An alternative procedure for disinfecting the vaginal transducer involves the mechanical removal of the gel from the transducer, cleaning the transducer in soap and water, wiping the transducer with 70% alcohol or soaking it for 2 minutes in 500 ppm chlorine, and rinsing with tap water and air drying204.
Considering the alarming rate of leakage for probe covers, it isn't surprising that the CDC recommended extensive cleaning and high-level disinfection. The CDC states, “High-level disinfection traditionally is defined as complete elimination of all microorganisms in or on an instrument,” adding that “meticulous cleaning must precede any high-level disinfection or sterilization process.”
Although the technician called the probe cover a condom, its very narrow diameter strongly suggested it was a probe cover, not a condom. As the CDC noted above, condoms have a much lower rate of leakage.
Notably, the cursory cleaning procedure I witnessed did not begin to meet the CDC guidelines. Even if it had, the technician's mistakes inevitably contaminated the vaginal probe cover. Furthermore, she did not even attempt to clean or sterilize the other surfaces she touched before touching the outside of the gloves she used to place the first probe cover.
If this technician were better educated in infection control procedures, and if the hospital cared enough about patients to spend less than 29 cents for a sterile field drape, the risk to my friend and countless other women could have been eliminated. However, the technician seemed annoyed and antagonistic. My friend stated, “She wasn't really listening to you, because she didn't do all of what you asked, such as not touching the faucet after washing her hands.”
While this technician unquestionably committed errors, the hospital is responsible for the overall inadequacy of the procedure by not giving her adequate training, supervision, equipment, and time to comply with CDC recommendations.
Besides addressing the technical gaps in her training, the hospital needs to help this employee and others gain more empathy toward patients. Healthcare providers who put themselves in the shoes of their patients would not behave as this technician did. Researchers have shown that a simple but uncommonly used step can rapidly kindle empathy, which helps healthcare providers deliver better care and insulates them from burnout.
Apparently trying to excuse her errors, the technician repeatedly asserted this was a nonsterile procedure. First, it could have been an acceptably sterile procedure, if the hospital were more circumspect of infectious disease risks. My friend, a nurse, said the technician turned what should have been a clean procedure into a dirty procedure.
Second, no prudent person would touch all of the surfaces she did and then touch someone's eyes, nose, or mouth, so one would need rocks in his or her head to think it is acceptable to risk introducing germs from obviously nonsterile surfaces into the vagina. Some of those surfaces likely weren't only not clean, they were likely contaminated directly or indirectly from prior patients.
Where there's smoke, there's fire
This supposedly Top 100 hospital has an overly carefree attitude about germs. I went there to have blood drawn for a lab test, and was alarmed to see their phlebotomist make several mistakes during such a simple procedure. They also permit employees to wear uniforms outside the hospital, which inevitably transfers drug-resistant superbugs into the community. Betsy McCaughey, former lieutenant governor of New York state, a fellow at the Hudson Institute and chair of the Committee to Reduce Infection Deaths, discussed this problem in a Wall Street Journal article: Hospital Scrubs Are a Germy, Deadly Mess.
The Chris Hansen moment
I wish I had hidden camera footage to show you the horrified look on the ultrasound technician's face when I told her I was a doctor. I know what she was thinking: that I was just another man tagging along to hold the little woman's hand. The tech likely thought she could be as cavalier about germs as she was and the clueless man would be none the wiser. She undoubtedly knew what she was doing in terms of obtaining the ultrasound images, but she had amazing gaps in her knowledge that all healthcare personnel should possess.
The first principle of medicine is Primum non nocere, a Latin phrase that means First, do no harm. In other words, whatever we do trying to help patients, we shouldn't harm them in the process. Exposing patients to germs that could infect and possibly kill them is reckless harm. It's inexcusable, unprofessional, and frankly disgusting.
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- Two out of Three Medical Students Do Not Know When to Wash Their Hands
- Washing With Contaminated Soap Increases Bacteria On Hands, Research Finds
- Low Hospital Staff Levels Increase Infection Rates