She is an elegant, composed blond woman in her mid-50s, slim, fashionably dressed. This morning, she’s sitting in a modest stucco house in the high desert. The meeting place is not her home; she won’t reveal where she lives. That’s because Dr. Lorraine Day, the former chief of orthopedic surgery at San Francisco General Hospital, is at the center of some of the most emotionally charged issues of the AIDS epidemic: the rights and risks of patient and physician in the face of the virus called HIV. These are, quite literally, matters of life and death.
Day didn’t become controversial by chance: Her style is incontrovertibly confrontational. “If she lived in Dallas,” says Dr. Richard Fine, chief of staff at San Francisco General, “she would have been a Kennedy-conspiracy theorist.” But Day pursued a different theory: In 1983, she was among the first to ask whether surgeons were putting themselves at risk of contagion when operating on HIV-infected patients. Four years later, Day spoke out for mandatory HIV testing of all hospital patients, and, finally, she donned a full-body “space suit” while operating on patients classified as high-risk for the disease. The image suggested that she was treating her patients as pariahs.
Day endured a firestorm of criticism. Gay activists argued that her actions could lead to discrimination against homosexual patients. AIDS experts acknowledged that doctors and nurses were at risk and recommended precautions, but Day’s space suit definitely was not among their suggestions. And her bosses at San Francisco General remained adamantly behind the law that prevented mandatory testing. Even today, they make no secret of the fact that they consider Day and her positions “disruptive,” at the least.
Two years after putting on the surgical space suit, Day resigned her position at San Francisco General. Now she lives in the desert, no longer practicing medicine, but still, via a book she is writing and a newsletter she edits, alerting surgeons to what she sees as the hazards of this century’s most lethal virus. She is also helping to develop equipment, from syringes to gloves, that will make treatment of HIV-infected patients safer. Ironically, now that she has left the profession, research and events seem to add support regularly to some--if not all--of her positions.
Early on, Day worried about “swimming in blood” in the operating room. Just last month, an editorial in the Journal of the American Medical Assn., based on a federal study, emphasized that workers in operating rooms are “unequivocally” in frequent dangerous contact with blood--which “must be regarded as a toxic substance.” The Centers for Disease Control now count among their AIDS statistics 40 health-care workers determined to have contracted HIV on the job. Another 60 HIV-positive health-care workers are thought likely to have gotten the virus on the job.
When Day called for patient testing, she suggested that physicians, too, should be tested and forced to disclose whether they were HIV-positive, for the protection of their patients. In recent months, three patients have been shown to have contracted the virus from their dentist. (Current government estimates indicate that about 6,000 health-care workers have AIDS.)
But Day has by no means won over her critics. When she donned her space suit, complete with air filters, Day was concerned about the possibility of aerosolized blood--tiny droplets of blood in the air created by the use of power tools during surgery--as an AIDS transmission route. Infectious-disease researchers discount this theory, and others she has suggested (such as the notion that AIDS can be transmitted by coughing, sneezing or even breathing) as just that--pure theory. A federal study on aerosolization and AIDS is now in progress.
And Lorraine Day remains controversial. Dr. Julie Gerberding, the infectious-disease expert at San Francisco General and a co-author of the recent JAMA editorial, refuses to even comment on her one-time colleague. “We’ve been scalded by Lorraine too many times,” she says. Mark Wang, a spokesman for the gay-activist group ACT-UP in San Francisco, gets easily exercised over Day. “I would call her a liar to her face,” he says. “She is an AIDS-phobe, a loose cannon. She gets people panicking about every gay person they see.” And Dr. Fine says succinctly, “She’s dangerous because everything she says has a kernel of truth . . . but she makes exaggerated leaps of faith from that one kernel.”
In short, Day is something of a modern-day prophet without honor--in part because of her controversial message and in part because of her own prickly personality.
“I FINISHED MY RESIDENCY IN 1974,” DAY SAYS ON A blustery Southern California morning, “and since trauma was my main interest, I stayed at San Francisco General.” It was an apt choice: San Francisco General handles many of the car accidents, drug overdoses, stabbings and shootings that occur in the city. Day worked her way up to chief of orthopedic surgery in 1985.
“Trauma is a very bloody business,” says Day. “It’s not like taking out a gall bladder. In elective surgery, the patient has one thing wrong, and you can tie off the bleeders. But if someone’s leg is run over by a truck, it’s a terrible crush, and you can’t even find the bleeders to tie.”
The element of trauma only added to an environment that was more like an abattoir than an operating room. “Orthopedic surgeons use very sharp instruments,” Day says. “We create huge sprays of blood with our power tools. We are the carpenters of surgery.” She would finish an operation drenched in blood. Day didn’t mind--until, in early 1983, she began to hear about AIDS and its transmission via blood.
She knew that many of her patients--like the patient population as a whole at San Francisco General--were at risk for AIDS. “I went to our infectious-disease people,” she recalls, “and said, ‘This seems dangerous. We’ve got blood all over the place. And we get stuck all the time--with wire, nails, saws, needles, hammers.’ ”
Day says she was reassured by Gerberding and others at San Francisco General that AIDS transmission was unlikely in doctor-patient situations, and that traditional precautions--strictly observed--were sufficient. In fact, says Fine, the hospital instituted educational programs to help its staff “relearn” proper precautions. “We told the staff to treat every exposure to blood as a toxic,” Fine says, “and we were the first to do it.”
By 1985, she was receiving calls from other orthopedic surgeons around the country who were operating on high-risk patients; they wanted to know what precautions to take. She went by the book. “I’d tell them,” Day says, “our people say it’s fine. We’re swimming in blood and we don’t worry.”
In 1986, however, the experts had something new to study. The Centers for Disease Control’s Morbidity and Mortality Weekly Report--a newsletter that tracks infectious diseases in the United States--for the first time included nurses who tested HIV-positive after experiencing needle sticks.
Day heard about the report through the medical grapevine, and again approached San Francisco General’s infectious-disease experts. According to Day, the news was downplayed. Gerberding had looked at the data; some of those nurses, Day remembers being told, might also have engaged in high-risk behaviors such as promiscuity or drug use.
Day’s life turned upside down on Oct. 2, 1987. At a routine weekly staff meeting at San Francisco General, an administrator announced that a staff nurse had had a single needle stick and had subsequently tested positive for HIV infection. “You can imagine the look on my face,” says Day. “I’d been told by people I trusted that this couldn’t happen. My whole life was passing in front of me--all the times I’d been stuck. They called the nurse’s case seroconversion . It sounded like she got religion, not a death sentence.”
Fine acknowledges that the so-called Nurse Jane Doe case was a cataclysmic event at San Francisco General. “It shook the institution,” he says. But he also says that the incident was an extreme case: “The needle stick was very deep and the nurse received a large inoculum of blood from a very sick patient.”
The next morning Day said she wanted to be tested for HIV, as did the residents who trained under her at the trauma center. “I was concerned for my troops,” she says. Day’s staff drew one another’s blood, and the results were all negative. At the same time, she decided to ask all non-emergency orthopedics patients to be tested--for their protection and the protection of the staff. It was a controversial decision. AIDS testing was a political hot potato. There were fears that tests could be used to discriminate against gays, to deny them insurance benefits or jobs, to “out” them. By law in California, taking the test was absolutely voluntary, and the results were confidential. If Day wanted a patient tested, she would have to get his or her written consent.
All of Day’s patients agreed to the test, with one notable exception. The patient, a man with a broken ankle and a candidate for elective surgery, refused to sign the consent form. “Fine,” she told him, “you’ve got a fracture, and it’s in alignment. You’re in a long-leg cast, and that’s the way you’ll be treated. If it goes out of alignment, we’ll have to operate.” (Orthopedic surgeons confirm that this is standard practice.)
The patient healed, but he also went to the San Francisco Chronicle, which in October, 1987, reported on a “major flap” over Day’s testing policy. In it, the man implied that Day had refused to operate on him because he said no to the test.
Day denied violating hospital policy and defended her decision. Hospital chief of staff Dr. Michael Federle said the policy was legal if unusual--no other department was routinely asking all patients to test.
Day’s actions may have been defensible, but in the political climate at the time, they were anathema. “You have a physician essentially breaking ranks,” the story quoted a “high-ranking hospital source.” “The hospital has some of the world’s experts formulating infectious control procedures. It doesn’t serve anyone well to have a single chief of service going off on her own.” (“My colleagues all ran and hid,” says Day. “They had about as much guts as the man in the moon.”) And the gay press in San Francisco attacked Day fiercely. Perhaps the kindest epithet hurled was homophobe.
The controversy attracted the attention of ABC’s “Nightline,” which devoted a segment to the issue of health-care-worker risks on Nov. 24, 1987. By the time the “Nightline” crew visited San Francisco General, Day’s public position had broadened--all hospital patients should be tested, period--and San Francisco General’s official response had become less tolerant. James Walker, “Nightline’s” reporter, was told he would have to interview Day outside the hospital building. Says Day: “I was the only one with my hair blowing in the wind. Everybody was talking about rights and discrimination, but what the hell was going on here?”
Day claims to be baffled that her stance should surprise anyone: “There’s no other blood test in the world we can’t give a patient without consent. Ethically, a doctor should have the right to test any patient for anything. What if I operated on your mother and didn’t know she had diabetes? It’s the same with HIV: It’s my duty to ask questions--for the patients’ benefit.”
Day’s argument makes some sense: An HIV-positive patient, who may have a suppressed immune system, needs to be treated with more care in case of opportunistic infections. And, of course, knowing a patient is HIV-positive allows health workers to take extra precautions to protect themselves. The ideal solution, according to Ruthanne Marcus, with the CDC Hospital Infections Program, is that every patient should be treated as if HIV-infected. But patient care at financially stressed public hospitals such as San Francisco General tends to be rationed out by need, and medical personnel are unlikely to be 100% vigilant 100% of the time.
IT’S EASY TO SEE WHY LORRAINE DAY AROUSED CONTROVERSY. SHE can be as poised as a talk-show hostess, but she is also self-righteous and often strident. The polish fades when she gets upset by a question, and her voice rises to a harsh edge. There is a trace of paranoia in her language--them versus me: “They don’t keep the same people in the front lines of battle for six years--they get rotated off, and no one thinks they’re cowards. Sometimes I’m besmirched because people say I’ve deserted my duty. But why not get out while I’m still negative?” Day does not suffer fools gladly or pull any verbal punches. Example: “Some of my colleagues are yellow-bellies, frankly, because they won’t say publicly what they say privately.”
In fact, her reputation for homophobia may derive less from her views about testing and medical precautions than on her reckless quotability: “I always thought the gay bathhouses were reprehensible, long before AIDS,” she says. “I was taking care of fisting injuries, intestinal ruptures, liver and spleen ruptures. We had a whole museum of foreign bodies we’d taken out of rectums. We saw patients who had thousands of sexual partners. This was not an alternative lifestyle-- give me a break! “
So did the gay community bring the plague upon themselves? “I can tell you that’s not a moral question. If you smoke and get lung cancer, it’s not because God gave you cancer as a punishment. There are rules of nature; if you set yourself on fire, you burn up. When you abuse your body, as gay men did in the bathhouses, you can’t stay healthy. Syphilis, gonorrhea, drug abuse, intestinal parasites, hepatitis--they were sick as hell already. Put AIDS virus into that milieu, and you’re going to have a holocaust. God doesn’t have to punish anybody; they do themselves in.”
Day’s uncompromising nature, and her strong sense of cause and effect, may derive from her upbringing. Born in Illinois, she was raised in Southern California. Her father was a Seventh Day Adventist minister with a firm hand. At age 9, she remembers, she dusted the house and awaited his inspection. “That’s not good enough,” he said. She dusted again, and again, and again, “and by the fifth time, I was in tears. He told me, ‘You do it right the first time, and you don’t shirk.’ ” Day approves of her father’s strong hand but in one regard diverged from his ministerial ways: For decades, she has been an agnostic.
Day worked as a floor model to help pay her USC undergraduate bills. Then she worked as a dental hygienist and supported her first husband through law school. But she wasn’t satisfied: “I decided I wanted to do something that would make a difference,” Day says. She entered the UC San Francisco Medical School at 28 and was one of the oldest residents during her tenure at San Francisco General Hospital. She was already outspoken: When interns and residents threatened to strike over working conditions, she stood up at a hospital meeting and argued, against virtually all her peers, that abandoning patients would be wrong.
Day’s character may also have been toughened by her trauma tenure at San Francisco General. “I took care of a hooker who was set afire by her pimp, and she died a horrible death over two days. At the same time I was taking care of the pimp, because he burned his hands while he was holding her down.” She also treated a perpetrator of the Golden Dragon massacre in San Francisco’s Chinatown; he’d been shot in the hand and asked that it be repaired so he could shoot a gun again. “I did,” she says simply, “the very best I could.”
IN EARLY 1988, DAY READ A PROVOCATIVE ARTICLE IN the Journal of the American Medical Assn. It suggested that the use of lasers to burn off venereal warts could produce a plume of infectious smoke; physicians should use respirators to keep virus out of their lungs. “I thought,” Day says, “we’re breathing these huge sprays of aerosolized blood in our operating rooms every day.” Surgical-room attendants all wear masks, but, as Day puts it, virus goes through them like BBs through a tennis net.
She wrote to administrators at San Francisco General, conveying her concerns and asking that her elective-surgery patients--but not emergency-surgery patients--be tested and that the hospital investigate the dangers of aerosolized blood. Elliot Rapaport, associate dean at San Francisco General, responded quickly: The notion of virus being transmitted through blood in the air was speculation, he said. The hospital’s policy would remain the same: Mandatory testing for any reason was illegal.
Day continued to make waves. One weekend, she was treating an HIV-infected patient who had a sore on his heel so large and deep that when she examined it her fingers reached all the way under his footpad to the toes. He had a temperature of 106 degrees. He could have died of septic shock. The indicated procedure was to cut away the tissue, then clean out the wound with pulsing water. But when the water hits the wound, blood and water splash back at the surgeon.
An option on the equipment was a plastic umbrella to intercept the spray. San Francisco General had none in stock, so Day told a nurse to get some from another hospital. The nurse returned with five. “ ‘Five,’ I said. ‘I may have 25 patients this weekend who need them.’ She told me to use them on just the worst patients. And I told her that the law doesn’t let me know who the worst patients are.”
“Pretty soon you start to think, ‘Who the hell cares about my life?’ ” Day says. “If I test positive for HIV and can no longer operate, I get $896 a month in worker’s compensation. The odds on getting HIV from a needle stick are 1 in 250. What if I sold you a light switch that would only electrocute you once every 250 times you touched it--maybe the first time, maybe the last? Or would you tell your son that it’s OK to play Russian roulette because there are a lot of chambers in the gun?”
Day took a radical step. She began to wear full-body protection, complete with elaborate air filters. Her new attire was quickly dubbed a space suit by the press. It did resemble a space suit, although it was hardly new to medicine. The suit had been designed 14 years earlier in England for use when surgeons were performing total knee and hip replacements. The point then was the patient’s protection--cutting down the bacterial count in the operating room. “No one complained about it for 14 years,” says Day. “Then when I started to use it, I became a wild woman walking around town in her space suit.”
The suit provided two advantages in Day’s view: additional protection against needle sticks and splatter but also defense from aerosolized blood. Day’s justifications were simple: “Suppose I had a little spray bottle of HIV-positive blood, and I let you wear a surgical mask, and I just sprayed it around you while we were talking. Well, you’d run for cover, right? Or, you’re building me a bookcase, but you have to submerge all the lumber in a big vat of HIV-positive blood, before you can start using your power tools; you’d probably say, ‘Wait a minute.’ ”
Her critics kept talking about proof. “I can’t say that the AIDS virus is not transmitted by an aerosol,” Dr. Laurens White, former president of the California Medical Assn., told the San Francisco Chronicle. “It’s tough to prove a negative. But I don’t know of any evidence that it is, and she doesn’t. But she’s scaring the socks off people.” Experts cautioned against leaping to conclusions: If it were easy to catch AIDS, they said, many more physicians would have it. White told the Chronicle, “It’s amazing how hard it is to transmit the disease by accident.”
Day, however, was undeterred. Any chance was just that: a chance. To her, the experts’ caution was a gamble with her life. “They let someone die before they change the rules,” she says. “I started to ask myself, ‘What am I doing here? I’ve done as many operations in a year as the average orthopedic surgeon does in five or 10 years. So I’ve done four or five lifetimes of work, with the worst patients under the worst conditions.’ ”
Day turned in her resignation in August, 1989, effective February, 1990. “They never threatened my job,” she says, countering rumors she has heard. “Anybody who knows me knows that I would never resign under pressure. But surgery was no longer enjoyment for me. My risk was getting too high.”
LOOKING BACK, DAY’S BASIC CONCERNS ABOUT patients, health workers and AIDS have come to seem positively mainstream. “She was ahead of the problem,” says San Francisco General’s Fine, “so credit is due.”
Current recommendations for operating-room protection call for knee-length rubber boots and a water-impermeable apron worn under the surgical gown, an extra pair of sleeves so that if one layer is soaked with blood it can be removed and replaced before the blood soaks through to the skin, two pairs of gloves and protective eye wear or face shields to protect against splatters that might hit the mucous membrane of the eye (an acknowledged transmission route).
Recent events also have spotlighted the other side of the coin: physician-to-patient AIDS transmission. In Florida last year, a dentist was found to have infected three of his patients, although epidemiologists are not sure exactly how. There are a number of possible explanations, according to the CDC: The most likely is that somehow his blood mingled with theirs. He may also have failed to properly disinfect his instruments. In the wake of the findings, the American Medical Assn. and the American Dental Assn. came close to matching Day’s testing demands: HIV-infected doctors should announce their condition to their patients or refrain from surgical practice, both associations decreed. In early April, the CDC proposed similar guidelines.
As for aerosolization, there so far has been one study that offers qualified support for Day’s worries. In the January, 1991, Journal of Medical Virology, two Stanford researchers reported testing aerosols, created by surgical tools, of HIV-contaminated blood. They demonstrated that the virus was present and viable in the aerosols, but they also concluded that the findings were insufficient to prove that aerosols created a risk in real operating rooms. A study sponsored by the government and aimed at testing that risk, is now under way in San Francisco.
The fact that medical personnel face increased risks of contracting AIDS has hit home with practitioners, and even her detractors think Day has helped get the message out. At the annual meeting of the American Academy of Orthopaedic Surgeons held in March in Anaheim, more than 3,000 surgeons voluntarily participated in an unprecedented study to determine if they had been exposed to HIV. And consider Dr. Martin Gelbard, a urologic surgeon in Burbank. During an operation on an elderly female patient, he grew tired and stabbed himself with a suture. He thought nothing more of it, until he learned the patient had tested positive for HIV. Gelbard was stunned: “It’s such an ominous goddamn thing to hear.” He tested negative, but the experience made him sympathetic to Day’s position on mandatory testing. “Requiring anybody to be tested gives up a bit of their personal liberty. But there’s precedent for that; immunization for school children, for example. Day’s concerns are reasonable, but full testing may not be the best idea.”
Even as Day’s positions gather support, she still stands accused of willfully and irresponsibly misinforming the public. She says she is telling people what the experts won’t; they say she turns suppositions and narrow research findings into broad and unsupportable conclusions.
LORRAINE DAY REMAINS A COMPLEX MIX OF MARTYR, VICTIM AND critic. In her desert retreat, she talks about the future. Recently married for the second time, she’s ambivalent about practicing medicine again. “If it gets safe enough, I’ll return. But right now, I’m doing everything I can to make things safer for doctors and nurses.”
So how is her own health? At first she bridles: “No one in the media asks gay men if they’re positive,” she snaps. “That’s the first question you ask me.” But by now, Day has been tested three times for HIV, with negative results; because of the virus’ long latency period, she will continue to have tests for another two years.
Day still fulminates about the situation. “When the government wanted to send up astronauts, they developed heat-proof tiles. They didn’t just say, ‘Take the risk.’ If in 1985 they had started to develop protective measures for health-care workers, this would be a non-problem today. They don’t send firemen into burning buildings wearing suits and ties. They have good equipment, constantly upgraded, and sometimes a fire chief will still say, ‘Don’t go into the burning building, you won’t come out.’ ”