My Gyno Screwed Up - How Worried Should I Be?
August 24, 2019 12:32 PM Subscribe
Went for my annual PAP Smear today. Because my cervix is so tightly closed, my doctor has to insert a very thin metal dilator in order to obtain a good sample. Several hours after the procedure, she called to let me know that the instrument she used to dilate my cervix had been inadequately sterilized. How worried should I be that I've been exposed to a communicable disease or infection?
The doctor's office was short-staffed today and she was having trouble finding the right-sized dilator. We thought we'd have to reschedule as a result. But, at the last minute she located the instrument, unwrapped it from the sealed plastic, and we went forward with the procedure.
When she called, it was to inform me that the metal dilator she thought had gone through all the steps of the three-step sterilization procedure, had actually only gone through the first two. As she explained it, there are three steps to the process, the first two involving placing the instrument in two separate sterilizing baths and the last sealing it in plastic and placing it in an autoclave which heats it. She discovered after using the instrument that it hadn't been autoclaved after having been sealed in plastic.
The "good" news, if you can characterize it that way, is that she feels there is very little risk to me given that the first two steps had been followed. She also checked with the doctor who had used the instrument most recently with another patient. According to the other doctor, her patient is not HIV or HPV positive. I didn't think to ask about Hepatitis but I will.
So, I know you are not my doctor but, if you are someone with knowledge of medical equipment sterilization and risks, how freaked out would you be by this breach of protocol? What should I be worried about? Right now, I'm most focused on having been exposed to a serious communicable disease. I'll deal with the question of whether or not to find a new doctor later.
The doctor's office was short-staffed today and she was having trouble finding the right-sized dilator. We thought we'd have to reschedule as a result. But, at the last minute she located the instrument, unwrapped it from the sealed plastic, and we went forward with the procedure.
When she called, it was to inform me that the metal dilator she thought had gone through all the steps of the three-step sterilization procedure, had actually only gone through the first two. As she explained it, there are three steps to the process, the first two involving placing the instrument in two separate sterilizing baths and the last sealing it in plastic and placing it in an autoclave which heats it. She discovered after using the instrument that it hadn't been autoclaved after having been sealed in plastic.
The "good" news, if you can characterize it that way, is that she feels there is very little risk to me given that the first two steps had been followed. She also checked with the doctor who had used the instrument most recently with another patient. According to the other doctor, her patient is not HIV or HPV positive. I didn't think to ask about Hepatitis but I will.
So, I know you are not my doctor but, if you are someone with knowledge of medical equipment sterilization and risks, how freaked out would you be by this breach of protocol? What should I be worried about? Right now, I'm most focused on having been exposed to a serious communicable disease. I'll deal with the question of whether or not to find a new doctor later.
I'll deal with the question of whether or not to find a new doctor later.
Accidents happen, even in the best of circumstances. You want a doctor who calls you when they realize something like this.
posted by NotMyselfRightNow at 12:43 PM on August 24, 2019 [169 favorites]
Accidents happen, even in the best of circumstances. You want a doctor who calls you when they realize something like this.
posted by NotMyselfRightNow at 12:43 PM on August 24, 2019 [169 favorites]
I'm not a physician, this is not medical advice, etc. I am someone who regularly sterilizes things in a laboratory context and adheres to sterile practice for certain parts of my work. I'd like to reassure you that you're almost certainly fine based on my understanding; please disregard if this kind of general explanation is not helpful to you.
As I've been taught it, sterile practices are more akin to ritual than to science, and whether something is considered sterile has more to do with whether those rituals have been properly followed than with whether there is a real risk of infection. This is by design: the purpose of sterile practice is to strongly err on the side of caution, so much so that when you're following the procedures properly, you don't even really need to think about things in any detail, and you can be confident that there's no significant risk of infection. Breaking of sterility doesn't mean that there now is in fact a significant risk of infection; really it just means that now you have to think about whether there's a risk of infection. In general you don't want doctors having to spend effort thinking about the risks associated with each action they take, so the function of sterile practice is to reduce everything to a relatively simple "sterile/not sterile" dichotomy.
For example, in the operating rooms I work in, surgeons wear sterile gloves and gowns that go to about knee-length, and they hold their hands above their waists. If you're sterile and you drop your hands below your waist, you've just broken sterility and you need to reglove, even if you know you didn't touch anything. This is because there are generally lots of non-sterile things below waist height, and if you allowed your hands to drop below waist height it means you were inattentive for a moment, so you can't be absolutely certain that you didn't brush something non-sterile.
So sterility in a medical context is a high bar, by design. Any break from your standard practices is a loss of sterility. In reality, there are many practices that would be classified as "high-level disinfection" rather than "sterile" for which there is still no appreciable risk of infection. These include soaking equipment in a chemical such as gluteraldehyde for some time, which is what I would guess is one of the sterilizing baths your doctor described. In fact, under FDA guidelines these kinds of chemical baths can be considered full sterilization depending on the chemical, concentration, and soak time; I had to look this up recently for work.
My guess is that in certain contexts, any one of the three steps your doctor uses for sterilizing instruments would be considered at least high level disinfection if not full sterilization. However, because their standard procedure is to use all three, presumably to be extra cautious, they have in a sense defined sterility to require all three, meaning that since the final step of autoclaving was omitted here, they needed to notify you. But in fact, the whole point of their multi-step sterilization procedure is to prepare against exactly this sort of case; even though the instrument was not autoclaved, it still went through two separate methods of sterilization (or at least high-level disinfection depending on the chemicals used), and you should be safe.
As for whether you should find a new doctor, that is definitely up to you, but mistakes do happen in any doctor's office, more often than most care to admit. It sounds like her practice is using procedures that are well-designed to defend against those kinds of mistakes, which is exactly what you want as a patient. If you're otherwise happy with the doctor, I personally wouldn't seek a new doctor over this one incident.
posted by biogeo at 6:07 PM on August 24, 2019 [78 favorites]
As I've been taught it, sterile practices are more akin to ritual than to science, and whether something is considered sterile has more to do with whether those rituals have been properly followed than with whether there is a real risk of infection. This is by design: the purpose of sterile practice is to strongly err on the side of caution, so much so that when you're following the procedures properly, you don't even really need to think about things in any detail, and you can be confident that there's no significant risk of infection. Breaking of sterility doesn't mean that there now is in fact a significant risk of infection; really it just means that now you have to think about whether there's a risk of infection. In general you don't want doctors having to spend effort thinking about the risks associated with each action they take, so the function of sterile practice is to reduce everything to a relatively simple "sterile/not sterile" dichotomy.
For example, in the operating rooms I work in, surgeons wear sterile gloves and gowns that go to about knee-length, and they hold their hands above their waists. If you're sterile and you drop your hands below your waist, you've just broken sterility and you need to reglove, even if you know you didn't touch anything. This is because there are generally lots of non-sterile things below waist height, and if you allowed your hands to drop below waist height it means you were inattentive for a moment, so you can't be absolutely certain that you didn't brush something non-sterile.
So sterility in a medical context is a high bar, by design. Any break from your standard practices is a loss of sterility. In reality, there are many practices that would be classified as "high-level disinfection" rather than "sterile" for which there is still no appreciable risk of infection. These include soaking equipment in a chemical such as gluteraldehyde for some time, which is what I would guess is one of the sterilizing baths your doctor described. In fact, under FDA guidelines these kinds of chemical baths can be considered full sterilization depending on the chemical, concentration, and soak time; I had to look this up recently for work.
My guess is that in certain contexts, any one of the three steps your doctor uses for sterilizing instruments would be considered at least high level disinfection if not full sterilization. However, because their standard procedure is to use all three, presumably to be extra cautious, they have in a sense defined sterility to require all three, meaning that since the final step of autoclaving was omitted here, they needed to notify you. But in fact, the whole point of their multi-step sterilization procedure is to prepare against exactly this sort of case; even though the instrument was not autoclaved, it still went through two separate methods of sterilization (or at least high-level disinfection depending on the chemicals used), and you should be safe.
As for whether you should find a new doctor, that is definitely up to you, but mistakes do happen in any doctor's office, more often than most care to admit. It sounds like her practice is using procedures that are well-designed to defend against those kinds of mistakes, which is exactly what you want as a patient. If you're otherwise happy with the doctor, I personally wouldn't seek a new doctor over this one incident.
posted by biogeo at 6:07 PM on August 24, 2019 [78 favorites]
Blogeo has given a solid explanation of the intentional overkill involved in sterilization protocols, which I hope puts your mind at ease regarding the nearly negligible risk of this break in protocol.
And your physician's office has, for its part, demonstrated an admirable level of openness in contacting you to confess the error. Believe me, I have worked with those who would instead have quickly convinced themselves that the risk to you was so low, there would be "no reason to needlessly worry the patient" and would cover up the error without a twinge of conscience.
Reporting on themselves, risking your confidence and accepting potential liability, reflects an outstanding level of professional integrity and concern for patient welfare. Errors can happen in the best environments, among the most diligent practitioners. The cream-of-the-crop distinguishes themselves by the way they handle such errors. IMHO, this practice has demonstrated that they are real pros. I'd stick with 'em.
posted by peakcomm at 6:38 PM on August 24, 2019 [43 favorites]
And your physician's office has, for its part, demonstrated an admirable level of openness in contacting you to confess the error. Believe me, I have worked with those who would instead have quickly convinced themselves that the risk to you was so low, there would be "no reason to needlessly worry the patient" and would cover up the error without a twinge of conscience.
Reporting on themselves, risking your confidence and accepting potential liability, reflects an outstanding level of professional integrity and concern for patient welfare. Errors can happen in the best environments, among the most diligent practitioners. The cream-of-the-crop distinguishes themselves by the way they handle such errors. IMHO, this practice has demonstrated that they are real pros. I'd stick with 'em.
posted by peakcomm at 6:38 PM on August 24, 2019 [43 favorites]
Maybe I'm ignorant but I've been getting pap smears for 50+ years and I've never been told they had to get into the cervix to get them. I always understood it to be a slight scraping on the outside of the cervix. I have never ever heard of having to dilate it for this, not from my sisters, my nieces, or any woman friend.
posted by mareli at 6:46 AM on August 25, 2019 [1 favorite]
posted by mareli at 6:46 AM on August 25, 2019 [1 favorite]
For some people, however, it is necessary. When we sample cells for a Pap test, we are trying to get cells from both sides of a border: the “transformation zone” between the endocervix (interior) and ectocervix (exterior), because this border is where most cervical cancers arise.
In many people, that border is easily accessible without any intervention; in some, for example, the external os (the cervical opening) is a little bit open. In some cases, however, only ectocervical tissue is visible, and therefore a small amount of dilation is necessary to access endocervical tissue and get a complete sample.
Again, this is something that points to thoroughness on this doctor’s part, not something that should be counted against them.
posted by ocherdraco at 8:34 AM on August 25, 2019 [9 favorites]
In many people, that border is easily accessible without any intervention; in some, for example, the external os (the cervical opening) is a little bit open. In some cases, however, only ectocervical tissue is visible, and therefore a small amount of dilation is necessary to access endocervical tissue and get a complete sample.
Again, this is something that points to thoroughness on this doctor’s part, not something that should be counted against them.
posted by ocherdraco at 8:34 AM on August 25, 2019 [9 favorites]
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Seriously i personally would just forget it unless told otherwise by the doctor later.
But I am so sorry that happened to you, and yes I might find a new doctor.
posted by nantucket at 12:39 PM on August 24, 2019 [10 favorites]