Tales f/t O.R. Vol.7 TRICKLE UP MALPRACTICE

Eye X

TRICKLE UP MALPRACTICE

 

It’s this simple. You arrive at a surgical care establishment.  The receptionist takes your insurance info and marks you off the schedule as “arrived” and you’re sent to a nurse that checks you in. He or She says (as she looks at the print out) so we’re working on your left eye? You say: “Yep” then she looks at you and puts an X over the left side of your forehead. (Remember it’s left from her point of view)

And you have no Idea what just happened.

The nurse that put an X on your forehead takes you into an area called “Pre-op”. This is where you are supposed to be asked a million times, which eye or limb are we working on.  Some nurses may be more concerned about what drugs you are allergic to. Some just look at the X on your forehead (especially if there are a lot of patients) and say I see you’ve been written on. “I see your X”.  So the mistake is accepted at the 2nd check point.

After you’ve stripped, put on a gown and locked your valuables in a locker, a doctor that is going to either put you to sleep during the case or keep you sedated does a rough check, looks at your armband, checks the name with the chart and asks again: “Are you allergic to any drugs”? You say: “Just Ancef that I know of.” So the doctor/anesthesiologist puts a note on the top of your chart that says ALLERGIC TO ANCEF. It’s usually on a big red label designed to catch a care provider’s attention.

Your doctor is grumpy because he can’t have his coffee until after your surgery. If he’s using a microscope, he can’t have a shaking hand.  So your doctor says to the Surgical center: “I want all of my patients on the table 10 minutes before their scheduled time.  I don’t want to wait as I have a busy office schedule.  So you get rushed into the O.R. ASAP.

Someone says: “Dr. Grumpy just pulled up. Let’s get going. The next thing you know is you’re being draped and they’re putting Iodine around the eye with the X.

This actually happened at that HMO I talked about in vol.5. I was the guy getting ready to put a drape around the eye so it would be ready when Dr. Grumpy walked in the room. But for some reason (I call it divine intervention) I STOPPED!  I said: “Read me the Operation Permit”.  This is the document signed by both the doctor and the patient in the Doctor’s office.  The room nurse said: “It says cataract removal left eye”.  The X was over the right eye and had made it past 3 check points.  It was at this point, that if we were ever operating on a part that had a counterpart, I always asked for the Op-permit to be read before I came near the patient.

OK, If God put me on this planet for 3 reasons, the 3rd was to stop that patient from having a lens put in a normal eye. Chalk one up for the Holy Spirit’s intercession.

Three is a sign.

In my final week in the Operating Room I witnessed 3 events. One event is a fluke. Two is a serious concern. Three is a sign.  That’s how I see it.

The first event was a patient that came back with belly stitches coming undone.  When I heard that I prayed: “Please don’t let it be my name on the Op-report”.  Please let this NOT be a patient I sutured up.  It wasn’t

The 2nd event was a case I was working on.  It was an ACL repair of the left knee that had been done a week before.  It was infected and needed to be opened, inspected and irrigated.  I found a sponge. Not a 4×4 inch gauze, but a thick absorbent rag. Again my prayer went out and no my name was not on that Op-report either.

THE 3rd and FINAL EVENT

The day before I quit, a patient was brought into the O.R. and his leg was put into a leg holder. Some facilities set up the first case of the day for you.  If you’re doing a right leg, they’ll put the leg holder on the right side.  The staff before didn’t have time to set up the room and the morning staff assumed the room was set up.  Because the nurse put the leg in the holder, the tech assumed it was the correct extremity.  She didn’t check for an X or ask for the Op-permit to be read.

The patient got the wrong knee operated on!

MY LAST DAY

The next day I had to assist 10 hours without a break for food. (I’m not a breakfast guy, but I did have a Vente Americano at 6:30AM. At 5PM I asked if I could get a break for some water or a PBJ.  I was called a pussy and told to keep working.  One nurse showed mercy on me and gave me a sip of Orange juice through a straw under my surgical mask. “During a case” but only because I was getting dizzy.  I told a friend who knew I had been on my feet for 12.5 hours non-stop.  A doctor who assisted on a lot of cases as well as brought his general surgery cases there: “I don’t think I’m coming in tomorrow”.

I started work on my first solo album the next week.

CHB

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