The following interview was recorded in December 1994 for distribution to orthopedic surgeons across America. The participants were Dr. Bruce Orisek and Dr. Stanley Monteith, both of Santa Cruz, California. Dr. Orisek is in full-time orthopedic practice, while Dr. Monteith is a recently retired orthopedist who has authored the book:, AIDS: The Unnecessary Epidemic, and publishes HIV-Watch, a newsletter covering hard-to-get facts concerning the HIV epidemic. Dr. Monteith has lectured both nationally and internationally on the AIDS epidemic.
(Dr. Orisek): Are orthopedic surgeons in danger of acquiring HIV infection from operating on HIV-infected patients?
(Dr. Monteith): Certainly. Orthopedists are always getting stuck with needles, wires, or sharp spicules of bone, and HIV disease is known to be spread by piercing the skin with an HIV-infected needle, or simply by HIV-infected blood coming into contact with intact skin. This was clearly demonstrated by the CDC in the MMWR of May 22, 1987, where the CDC described three nurses who got HIV-infected blood onto their skin or mucus membranes and contracted HIV disease. In addition, it is well known that Hepatitis B can be spread from infected patients to surgeons, and HIV disease is spread in exactly the same manner as Hepatitis B.
(Dr. Orisek): But the Centers For Disease Control, on page 15 of their June 1994 HIV/AIDS Surveillance Report, noted that there is only one instance recorded in America where one surgeon might possibly have contracted HIV disease occupationally, and that case is not definitely confirmed.
(Dr. Monteith): Tragically, orthopedists are going to have to learn that they can't trust some of the data coming from the CDC in recent years...if they are going to survive in the age of AIDS. I first became aware of the fact that certain CDC employees were intentionally issuing false and misleading information when I visited the CDC in Atlanta, Georgia, in April l989... I spent an hour with one of the CDC's chief statisticians. When I mentioned to him my concern over the MMWR report of March 27, 1987, revealing that 57% of prostitutes in Newark, New Jersey had tested positive for HIV disease, the CDC official emphatically denied that any such report existed... to the point where I began to doubt my own memory, and sanity. Indeed, I had to recheck the MMWR report on my return home to make sure that I wasn't imagining things. It then became painfully obvious that the statistician at the CDC had intentionally misled me. As time has gone by, and I've studied CDC reports and press releases, it has become increasingly apparent that some of the employees at the CDC have a political agenda and are releasing faulty information, intent upon misleading physicians and the public as to the nature and extent of this epidemic. Let me give you just one flagrant example of their pattern of disinformation. As you know, AIDS is simply the end-stage of HIV disease. In homosexuals, AIDS develops, on average, about 10 years after initial infection. The latency period is even longer in hemophiliacs, and their latency period is probably closer to 15 years. So what does the CDC report to the public? They regularly release AIDS statistics which tell us what happened in the epidemic 10 to 15 years ago, not what is happening in the epidemic today. Yet the pattern of CDC reporting suggests that AIDS statistics actually reflect the course of the HIV epidemic in America. CDC officials have never told the public that AIDS statistics are only of historical interest and give no information as to the current progression of the epidemic in our land. Of course the reason that national HIV statistics are never reported is that the Gay and AIDS lobbies have blocked reportability of HIV disease in most of our states where the epidemic is concentrated. Thus the CDC has no idea how far the epidemic has really spread, or who is infected. If anyone were to suggest that syphilis or gonorrhea be treated in a manner similar to the way we treat HIV disease they would be branded as incompetent, yet CDC officials have gone right along with the agenda expounded by the Gay and AIDS lobbies and have consistently failed to tell the public that they are unable to monitor or control this epidemic because of political pressure from special interest groups. I could give you dozens of similar examples, but that discussion is beyond the scope of today's talk. Let me simply repeat that orthopedists must learn to distrust government reports if they hope to survive in the age of AIDS.
(Dr. Orisek): How can you document the fact that the CDC is not telling physicians the truth about the incidence of HIV disease and AIDS in surgeons?
(Dr. Monteith): In the MMWR of August 21, 1987(on page 48), the CDC reported that of the 32,395 AIDS cases in America to that date, there were 1,875 infected health care workers identified, among which there were 33 health care workers who had been thoroughly worked up and found to have no identifiable risk factors. Among those 33 health care workers, there were three surgeons with AIDS. Amazingly, over seven years later, with almost 450,000 cases of AIDS and HIV disease reported, the CDC now announces that they know of only 1 surgeon who may possibly have become infected as a result of occupational exposure. The three surgeons reported in 1987 have simply been forgotten. Don't you find that somewhat disturbing?
(Dr. Orisek): But the American Academy of Orthopedic Surgeons did a study where they tested over 3400 orthopedic surgeons and found only two surgeons who were HIV positive, and both of them had risk factors. There was one other orthopedist who had three or four indeterminate HIV tests, but HIV disease was never definitely confirmed. Doesn't that suggest a very low incidence of HIV disease among orthopedic surgeons?
(Dr. Monteith): First of all, you must know the details of that study. The testing program was carried out at an Academy meeting in March 1991, and was to be largely financed by the Academy. The Academy invested almost $100,000 in preparation for the study, yet the CDC did everything they could to prevent it. Not until just a few days before the Academy meeting did the CDC finally drop their opposition to the study. We are told that only 2 orthopedic surgeons were found to be HIV positive, and both of them had risk factors which supposedly explained their infections. Did you ever read what those risk factors were?
(Dr. Orisek): No, I don't remember specifically reading about them.
(Dr. Monteith): That's because even the CDC didn't know which risk factors were involved. Orthopedists participating in that study were requested to fill out a questionnaire asking if they had any one of a series of risk factors, but the orthopedists were not asked to identify which risk group they fell under. The questionnaire asked if they had had a blood transfusion between 1978 and 1985, or received clotting factor, engaged in male-to-male sex, or used IV drugs after 1977. Then they were asked if they had been born in Haiti, central or eastern Africa, or if they had had sexual relations with anyone fitting into one of the above-listed risk groups since 1977. The term "risk factor" can be very misleading. If your wife had a blood transfusion after 1977, you would automatically be put into a risk group. If you have had sex with someone who might have had sex with an IV drug user, or your wife was born in central Africa, you would automatically be placed into a so-called risk group. The CDC doesn't have to test your sex partner to see if he or she is infected. Once a person is declared to be in a "risk group," that is assumed to explain how they contracted the disease, without any scientific basis for the conclusion. Putting people into risk groups without checking their sexual contacts is one of the techniques used by CDC officials to mislead physicians and the public as to the true extent and nature of this epidemic. Did you know that both the HIV-infected physicians had operated on patients with HIV risk factors, and one had operated on patients known to be HIV infected or with AIDS? Did you know that both surgeons admitted to percutaneous injuries during the previous year? This is all covered in the MMWR of May 17, 1991. Furthermore, have you ever read about the survey of the orthopedists who declined testing at the Academy meeting?
(Dr. Orisek) No!
(Dr. Monteith): Two of the orthopedists contacted said that they declined testing because they already knew that they were HIV infected. According to Dr. Lorraine Day, who had access to the CDC's records of the survey, both orthopedists indicated that they had acquired their disease occupationally.
(Dr. Orisek):I never heard that before.
(Dr. Monteith): There is a great deal that most orthopedists have never heard. First of all, HIV disease is not reportable in the majority of our States where the epidemic is centered, and spreading most rapidly. Why doesn't the CDC admit that fact when telling us that there is only possibly one surgeon who might have become infected during surgery? Why don't they admit that they have no idea how much disease there is among health care personnel? Why doesn't the CDC recommend routine HIV testing of health care workers to determine the true incidence of disease? I'll tell you why. I personally believe that certain CDC officials don't want physicians and other health care personnel to know the extent of their danger because if surgeons and nurses knew the truth, many might leave the profession and the American health care delivery system would begin to implode. I believe that certain people within government agencies have intentionally chosen to lie to orthopedists and other health care workers about the incidence of occupational disease.
(Dr. Orisek): Aren't there any figures that we can rely on to give us true estimates as to the incidence of HIV disease among orthopedists?
(Dr. Monteith): Dr. Lorraine Day has, for many years, been the leading spokesperson in America advocating a responsible medical approach to the HIV epidemic. For this reason, physicians from across America have contacted her with information about their infection and the infection of others. She has compiled the names of 19 occupationally infected surgeons of whom 9 are orthopedic surgeons. There were also maxillo-facial surgeons, ENT surgeons, and plastic surgeons. In addition, I personally know of another surgeon, Dr. Ed Rozar, a cardiac surgeon from Wisconsin, who was infected as a result of his occupation. Thus we can say without question that the CDC is intentionally deceiving and misleading surgeons as to the extent of their risk.
(Dr. Orisek): What should orthopedists do ?
(Dr. Monteith): Orthopedists should do what is medically and morally correct. Physicians are members of a noble and righteous profession. There has always been an element of risk in caring for those with infectious diseases. When I went through medical school, tuberculosis was endemic, and almost every medical school class lost at least one of its members to tubercular infection. Yet we all took that risk when we entered medical school because becoming a doctor was the finest, most idealistic of all professions. Fortunately, HIV disease is much harder to contract than tuberculosis, and if you know your patient is infected you can protect yourself and your staff quite effectively. The real danger lies in not knowing your patient's HIV status.
(Dr. Orisek): What do you suggest?
(Dr. Monteith): First, orthopedists need to determine which of their patients are infected. Even in a region with a relatively low incidence of HIV disease, all patients being admitted to hospitals should be routinely tested if they haven't been tested within a year. In 1993 the CDC recommended routine HIV testing of all patients between the ages of 15 and 54 if there was any incidence of HIV disease in the community. They based their recommendation on the sentinel hospital study published in the New England Journal of Medicine, August 13, 1992, which showed a 4.7% HIV infection rate in patients in the 20 hospitals studied. I personally believe that orthopedists should test all their patients - even in low prevalence regions. Physicians should never try to second guess their patients. If you test only patients you suspect of having risk factors you are accusing your patients of possible misconduct, either sexual misconduct or drug use. Furthermore, in large-scale studies it was found that if you limited testing to only those who have risk factors you would miss two-thirds of those who were infected. When I was in full-time orthopedic practice I routinely tested all my patients going into the hospital, explaining to them that testing was part of my routine hospital admission policy. I told them that they had the right to decline, but that the testing was being done for their protection as well as for the protection of my staff. Almost universally, patients thanked me for my concern and many expressed the sentiment that they had always wanted to be tested but had been reluctant to ask. Why is it so important to know if someone is infected? First, so that you can modify your surgical technique and equipment to protect yourself and your operating room staff, secondly so that the patient knows that he or she is infected and can avoid infecting others, thirdly so that patients can be placed under good medical treatment which will prolong their lives, and fourth, so that you can use extra antibiotics and take special precautions to avoid surgical infections. If a patient is HIV positive and is having elective surgery, you should certainly check the T4 helper lymphocyte count prior to surgery to make sure that the patient will be able to muster an effective immune response. If the T4 count is significantly diminished, the patient should be placed under good medical control before proceeding with surgery.
(Dr. Orisek): How should we modify our surgical technique?
(Dr. Monteith): Orthopedists must take special precautions. These precautions are outlined in the Academy publication entitled "Recommendations For the Prevention of Human Immunodeficiency Virus (HIV) Transmission in the Practice of Orthopedic Surgery" which is available from the Academy. To summarize their suggestions, surgeons should wear special impervious gloves beneath or over their rubber gloves to prevent nicking of their skin or tearing of their gloves with secondary blood contact. Second, they must modify their surgical technique. Universal precautions recommended by the CDC are totally inadequate for orthopedic surgery. They must avoid passing scalpels by hand . Use of a kidney basin for passing sharps is recommended. They must never palm a needle. They should plan to use individual sutures in the deeper layers and staples on the skin which will limit the possibility of getting stuck or sticking their assistants. They should wear special impervious gowns and knee-high shoe covers. They should use an air filtering apparatus such as a Stackhouse unit or similar filtration units because bovie or laser smoke may allow transmission of the virus. The face shield on an air filtration unit will also prevent splashing blood onto your skin. Furthermore, patients who are HIV infected are more prone to infection than non-infected patients with similar injuries, and use of a filtered air system will protect the patient as well as the surgical team. In a recent study published in Orthopedic Review, in August 1994, covering open tibial fractures, the authors found that almost all their HIV-positive patients developed secondary infections while the HIV-negative patients did not. In addition, because the CDC has advocated routine HIV testing of hospital admissions, if you fail to test your patients and one of your patients and their sexual partner should be found to be HIV positive at a later date, you could be sued for failure to protect their sexual partner and be found negligent. Colonel Redfield, one of America's outstanding AIDS researchers, from Walter Reed Hospital, has repeatedly stated that" Knowing is always better than not knowing", and I would add that knowledge is always better than ignorance. The life that you save by doing routine HIV testing could be the sexual partner of your HIV-infected patient, or your nurse's life, or your surgical assistant's life, or your own life, or the life of your wife. American physicians have delayed far too long in approaching the HIV epidemic as the plague that it is. I hope and pray that orthopedic surgeons may one day lead all of American medicine into addressing this epidemic in the same manner that physicians have addressed epidemics in decades past, by identifying those who are infected and preventing them from infecting others, before more health care workers and surgeons become infected - unnecessarily.