From today's NYTimes August 12, 2005 Duke Patients Discuss Dirty Surgical Tools By THE ASSOCIATED PRESS Filed at 12:51 a.m. ET RALEIGH, N.C. (AP) -- Patients whose surgeons unknowingly used instruments washed in hydraulic fluid instead of detergent held their first group meeting Monday, sharing stories of delayed recoveries and distrust of their doctors. About 50 people attended the meeting, organized by a freelance medical writer 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. 'What's happened to us has never happened to anyone before in the history of medicine,' said meeting organizer Carol Svec, who said she has not recovered from shoulder surgery. 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. Shirley McCaden, who had back surgery at the Durham hospital, said she has suffered rashes and pain and that her hair also fell out since the operation. Her attorney has been unable to get information that she thought would be in her medical records, including what she told doctors about her postoperative problems, McCaden said. 'It's like I've been totally ignored,' she said. 'Where do you go if you feel like your medical records have been tampered with?' 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.