Indexing Title: OLEYSON’s Medical Anecdotal Report [05-08]

MAR Title:  Patience is a virtue

 Date of Medical Observation: September, 2004

Narration:

It was another grueling Sunday duty when I was doing an explor laparotomy on a 21-year-old male who sustained a stab wound on the epigastric area left with omental evisceration around 3:00 am.  According to him, he got stabbed by an unknown assailant in a jeepney hold-up incident when on his way home.  After seeing the eviscerated omentum we immediately rushed the patient to the operating room to look for intra-abdominal injuries sustained by the penetrating sharp object.

Intra-operative findings were multiple jejunal perforations and gastric perforation. I did a primary repair on both injuries. It took me two and a half hours to explor and repair on all the injuries. I told the anaesthesiologist that I am already closing the abdomen and ask him the condition of the patient. He responded “Stable vital sign’s sir.”

Before I decided to close the abdomen, I turned to my circulating nurse, and asked her to do the initial count on the sponge, instrument and needles used during the operation. To my surprise, the sponge count was incomplete and one sterile gauze was missing.  My initial response was to explor again because as per routine I am not allowed to finish my work with an incomplete count.  Tension was building-up inside the operating room and it’s becoming unbearable.

 I prayed for guidance and clarity of mind despite the pressure and fatigued I felt during those hours. I found strength in Him and continued again in exploring the abdomen. Still no sterile gauze was found. I applied and re-applied the retractors and visualizing the whole abdominal cavity but to no avail. I became anxious on the situation so I asked my circulating nurse to look under the OR table and even in the trash can for the missing gauze.

It took us another two hours just to search for the gauze but still it was missing. When all hopes are fading and daylight covers the whole operating room. I am already exhausted, and desperate.  I called my service consultant and informed him of what happened. I asked permission to close the abdomen with an incomplete gauze count.

My consultant did not agree at first, but when I explained that it took me almost two hours searching.  He finally agreed on my decision to close because the patient’s bowels are beginning to turn edematous making it difficult for closure.  Furthermore, patient exhibited signs of hypotension and hypothermia.   Added time might complicate the operation and risk of post-operative infection was already high.

To double check that everything will be alright, I asked again my circulating nurse together with her nurse supervisor and with the new shift of nurses to help find the missing gauze.  I did my final exploration and finally got hold of my needle holder with Vicryl 0 suture.  I was ready to close the abdomen, when my circulating nurse surprisingly found the last gauze hidden on the underside of the lap sheets which completed the sponge count.

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

Surgeons must be tough to withstand the pressure of everyday cases, especially complicated ones.  Patience plays an important factor too. Errors in judgment cannot be corrected by simple sin of omission.  These means disregarding the sponge count and do the closure because of the threat that poses on the life of the patient.

As the primary physician I must prioritized the life of the patient rather than the morbidity of leaving the missing sponge. However, on the other side of the coin the presence of an incomplete count of sponges brings about medico-legal suit or malpractice. As much as possible it must be avoided in a surgeon’s case. Like a double edge blade. Being the “captain of the ship”, I do understand that I am responsible for every error my team and I commit considering the complications that may arise post-operatively.

I did all the searching under time pressure and asked for the assistance of others to help find the missing gauze until exhaustion stopped me from doing so. Finally asked for the help and decision making from my consultant. 

I can strongly prove that in all pressure involved patience is the great solution so I religiously applied it in this case.  Thank God the last sponge was found.