Re: CJD Question. A Logical Defence?
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Sorry about the delay in replying but I've been a little busy recently and
have therefore not accessed HISTONET. I am not sure that I can logically
justify our protocol forbidding FS on known infective specimens. But I am
certain I can do it "long windedly", so I'll apologise now for the length of
I fully accept your comments on the long incubation times associated with CJD
and other diseases (particularly pertinent in the UK following the "Mad Cow"
debacle) and we do have robust protocols to deal with decontamination of the
cryostat on a routine basis which certainly take account of most infective
agents (CJD is the bugbear). However, I think it is a question of balance as
far as risk is concerned. The best risk assessment is "if you can avoid doing
something which is dangerous, then do so".
If I know a specimen comes from an infective patient I would prefer not to
perform a technique which is inherently
'dangerous', no matter how well prepared we are to deal with the risks and
subsequent decontamination procedures. As for the "law suit" from a patient,
I am certain that I have a good defence in law, if I can show that I have
assessed the risk and decided not to perform the FS on the basis of that risk
assessment in relation to the known infectivity of the tissue. Indeed I have
a statutory duty to do so (Health And Safety At Work Act 1974 and associated
regulations 1992). The only duty I owe to the patient is a Common Law duty of
care (in negligence at that). In English law the Statutory duty is preferred
above the Common Law duty. I presume its the same in other Parliamentary and
Common Law jurisdictions.
Of course if we opted not to do an FS, we would obviously offer other
(cytological) investigations in an attempt to provide the surgeon with an
answer, as well as our normal response for an FS requst on any known
viral/microbiological infective agent, which is: fix the tissue in hot
formalin for 15 minutes and then prepare an FS, followed by rigorous
decontamination procedures. (When we accept a frozen we do ask about
infection risk). I fully understand that we all want to the best for the
patient, but my colleagues and I are not paid to risk our health and become
patients ourselves. We are paid for our technical expertise. I hope this
doesn't sound harsh, but it is true.
As for your suggestion (tongue in cheek I suspect!) that we throw way the
cryostat, I would be quite happy to do so. Not performing FS's reduces the
risks associated with Histological analysis. In our DGH setting, dealing with
malignant disease there are better and safer procedures to diagnose disease
in a patient. Surely no surgeon could justify doing an FS in a breast case
rather than a needle biopsy? Perhaps the only valid reason for performing an
FS (in our setting) is to examine excision limits?
I accept that other Units perform frozens for diagnostic procedures other
than Ca, they will have to risk assess according to their own needs.
When I started doing frozens in the '70's the infection risks were 'low', we
only worried about getting HepB (and there was a cure for that), never wore
gloves and sprayed CO2 around with gay abandon. Since that time we have had
an upsurge in lethal infective diseases, we wear gloves, we don't spray the
tissue with anything that might create an aerosol. In short, we have reduced t
he risks. However, should we still be performing a difficult, dangerous
technique in an era of antibiotic failure and "new", untreatable diseases?
This is surely the crux of the matter. We know it is high risk. We know that
there has been an increase in lethal infective conditions. Hopefully we have
all adopted more stringent protocols to reduce the risk. In the 21st Century,
can I justify the extra risk of performing an FS on a known infective
specimen no matter how well prepared I am? I don't think so.
With all the respect due to a fellow professional, I think that we have
excellent infection control procedures, better perhaps than yours - we don't
do FS on known infective material. Short of not doing FS at all you can't get
much more stringent than that!
Again, sorry about the lack of brevity!
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