Re: Have you ever lost/left something in WAS Forceps left in a woman after section
From: R. Daniel Braun (rd.braun@gmail.com)
Wed Mar 8 10:29:26 2006
Indeed I do remember the story.
To add my own, when I was a resident, we did a crash C/S on a lady for
distress, As we are closing, the nurse says the sponge count is incorrect. A
ray-tec was missing. We took an X-ray and sure enough, there it was. We
looked every whereand couldn't find it, so we opened the uterus and still
couldn't find it. So we took another X-Ray and still there but it had moved
to the other side of the patient. Looked and Looked NO sponge. Now it is 3
PM and the scrub tech changes shift. She says, There is no sponge in the
patient, the one you are seeing on X-Ray is the lap pad that you are
covering the bowel up with when you take the picture. We removed the Lap
from over the bowel and took another X-Ray. NO Sponge on the X-Ray. Raytecs
& Lap pads have the identical radioopaque marker in them.
Due to the rush nature of the procedure, the sponges had not been counted at
the beginning of the procedure and as luck would have it that package was
missing one sponge. We spent 3 hours searching for a non-existant sponge. I
calll the incident "The Great Sponge Hunt".
There have been 3 or 4 times when the sponge count has been incorrect and
when we looked, we found the sponge.
Dan
On 3/8/06, William D. McIntosh, M.D <wmcintosh@premiermed.com> wrote:
>
> When I was junior attending, my resident called me to the labor deck
> with an interesting story. I had watched the 2nd year and the chief
> resident do a C/S an hour before, perfectly routine, no problems. After
> the case, the scrub tech called the chief into the dirty room and showed
> him a pair of bandage scissors from the case that were missing the last
> 2 cm of the wide blade. He quickly ordered an X-ray, and of course the
> film showed the tip of the blade clearly in the pelvis. He then did
> something that I am not sure I would have thought to do. He did a vag
> exam on the patient, palpating through the cervix, found the tip in the
> uterus and retrieved it. THEN, he informed me. I didn't know whether
> to chew him out for leaving me out of the loop, or give him a gold star
> for solving his own problem. Dan, you may remember this story, it was
> Jeff Nemec.
>
> William D McIntosh, MD, FACOG
> Clarksville, TN
>
> -----Original Message-----
> From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Elrod,
> Darryl G MAJ 48 MDOS/SGOBO
> Sent: Wednesday, March 08, 2006 9:46 AM
> To: Multiple recipients of list OB-GYN-L
> Subject: Have you ever lost/left something in WAS Forceps left in a
> woman after section
>
> I'm curious how many of you have ever left something (unintentionally of
> course) in a patient?
>
> My partner once picked up the needle by the tip to protect it while
> tying the first knot on his side of the fascia on a TAH, my side was
> already closed. By the last throw, I noticed the tip looked odd so I
> looked closely and sure enough the last few millimeters of the tip were
> gone. We looked and looked but never saw it. I did xray her and found
> this 2-3 mm speck just under her skin incision.
>
> Her response when I told her the news. "Well, at least when I'm edgy
> with my husband I can tell him I'm on pins and needles!"
>
> Glen
>
> //SIGNED//
>
> D. Glen Elrod, Maj., USAF, MC
>
> Obstetrician/Gynecologist
>
> Chief of Obstetrics
>
> 48 MDOS/SGOBO
>
> RAF Lakenheath, England
>
> Telephone DSN: 314-226-8130
>
> Comm: +44 (0) 1638 52 8130
>
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> -----Original Message-----
> From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Dr.
> John Provatopoulos B.Sc. M.D.C.M. F.R.S.C.
> Sent: Wednesday, March 08, 2006 3:35 PM
> To: Multiple recipients of list OB-GYN-L
> Subject: Re: Forceps left in a woman after section
>
> At Wed, 8 Mar 2006, claire wrote:
> >
> >>Thats why we have instrument counts prior to peritoneal closure
> >>and after skin closure. I'm sure you realize they are not talking
> about
> >>obstetrical forceps. Joe C
> >
> >I know, I was thinking along the lines of swabs when saturated in blood
> >may become more difficult to see (I now have an image of a pair of
> >obstetric forceps being left in, which gives an unusal image at any
> >rate) even the smallest forceps used would surely be noticable?
> >And instrument/swab counts are so basic, I couldn't imagine any country
> >not doing them
> >Claire
> >BSc student
>
> I order a flat plate of the abdomen at least once a year because the
> count said something was missing, its almost always because the count
> was wrong(usually when you change scrub/circulating nurse several times
> durring a procedure, but when in doubt get an x-ray. In a difficult
> c-section you could have dozens of sponges to count its not always as
> easy as it sounds.
>
> --
> Take care, John
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--
R. Daniel Braun
"The way to health is an aromatic bath and scented massage everyday"..
Hippocrates
