Indexing Title:

JGGuerra’s Medical Anecdotal Report (05-02)

MAR Tilte: "Unaccounted Sponge"

Date of Observation: February 2005

Narration:

It was a humid Sunday morning in February when I got up from bed to prepare for another day in the hospital. Like any other duty day, I anticipated it to be an ordinary day; morning rounds, manning the emergency room as well as performing emergency operations. There was no indication that it would be different from any other day.

At around 1pm, I was called upon by my senior to operate on a 16 year-old-male diagnosed with Acute Appendicitis. Routinely, I did my preoperative assessment and physical examination.

In few minutes time, me, my surgical intern and clerk were doing the operation. Step by step, I described the operative technique, pathophysiology of Appendicitis, treatment and follow up plan to my assistants. The operation went on smoothly. Before I started to close the peritoneum, I asked my clerk as well as my circulating nurse to do the sponge count. After a while, they confirmed that sponges were complete. I proceeded with the closure. Half way on the peritoneum, half jokingly, I asked the nurse, " complete sponge count b talaga?" the nurse responded with a smile, "syempre doktor, gusto mo ulitin ko ulet eh!?" she started counting the sponges again and to my surprise, she replied in shock, "kulang po ng isang sponge." What??? I searched my operative field and to my dismay, I found nothing. I instructed the nurse to check under the operative drapes and table, and still there was no trace of the missing sponge. After repeated counting by the nurses, one sponge was unaccounted for! Tension was building up in me and I have to say, its becoming unbearable. After coming from a ‘point blank" I regain my composure, I decided to check the abdomen, I slightly loosen the suture and started palpating for the sponge. After few minutes of exploration, I got hold of the sponge. As I was trying to recall, after the first sponge count, it was my habit to put a sponge under the peritoneum while closing it to prevent injury to the bowel.

At long last, my operation has ended.. I told myself It will not happen again.. I hope…

Insights: ( Discovery, Stimulus, Reinforcements / (Physical, Psychosocial, Ethical)

Unlike any other professions, the practice of medicine, particularly surgery, has no room for errors of judgement or decision making. The fragility of human life is such that it leaves very little room for miscalculations. One miscalculated move might lead to a complicated case, medicolegal case or ultimately dead patient.

As to my case, I was so lucky that early in my practice, I was exposed and reminded to be more cautious in my operations. I suggest that, as much as possible avoid putting sponges under the peritoneum while closing it. Secondly, always remind the circulating nurse to have the sponges, needles and instruments counted prior to abdominal closure and as well as prior to unscrubbing. Thirdly, lets get back to the practice of using 16x16 inches sponges, instead of 8x 16 inches for abdomila surgery.