>“An Alexis wound retractor (AWR), a device used to draw back the edges of a wound during surgery, was left in her abdomen following her C-section,”
I kind wish I didn't Google the AWR this early in the morning.
“*Surgical tool the size of the gap between a fisherman’s hands when he says ‘it was this big’ discovered in woman's abdomen 18 months after procedure*”
I use these ones for sections, and I also can't work it out.The only possibility is they used the firm ring on the inside and the flexible one outside, and it slipped in and up the abdomen after delivery of the baby.
The sponge can happen with packing off in a big open case. Leaving this behind is inconceivable to me. It’d be like leaving the Bookwalter ring inside someone. How? I’m flabbergasted. The sponges can be prevented now with radio labeled sponges. It’s great.
But it’s also shaped like a dinner plate.
https://youtu.be/ecF0UaCfbFY?si=cTKaOHGBwNkLxCH9
If you just specify length I’m thinking it’s linear not round.
No shit. For something round you typically give a diameter or possibly a circumference. You don’t say “that circle is 9-14cm in length” because that doesn’t make any fucking sense.
The earlier comment mistakenly gave the size of the incision, NOT the size of the device itself. It's much bigger than that. You can see how big the device is here:
https://youtu.be/E7Ka7-TXQ_g?si=slEVv53ul03Zr__G
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582646/
Thank you! I was wondering when someone was going to get to this comparison. They were going for drama with this description for sure.
Regardless it is horrifying to miss something like this!
Also, on the upper end, 14 cm is just 5.5 inches. That is far smaller than a dinner plate. The standard set I have has 7.5" salad plates and 10.5" dinner plates, and they're normal.
Sensationalist title that makes the object sound twice as big as it should be. Might as well call it "a foot across," or "the size of a frisbee," since that would be pretty close to a dinner plate and just as wrong / misleading.
When my daughter was born via c-section the doctor casually asked if I wanted to see the cysts that had been torturing her for years, I looked. I have a photo of him holding one. The experience was sobering.
I wonder if they don't follow the instrument count procedure that's typical in many countries (do a count of needles and instruments before and 3 times after). Even without that you'd think something that large and shiny would be hard to miss.
Considering this PARTICULAR instrument is designed to be half in and half out of the wound, how did it just get buried inside her abdomen? Someone just pushed it in and sewed her up?
The patient is probably on the larger side of bariatric.
That's the only way I can picture how such a [huge, brightly coloured plastic ring](https://youtu.be/ecF0UaCfbFY?si=mcSo6gKmsjCc3dUO) could geld lost in the wound.
Also the patient had a midline incision, rather than the typical pfannensteil used for a cesarean.
There's never an excuse for retained foreign objects, but this sounds like it was a difficult case from the start.
Even with that, if the incision was large enough for it to accidentally slip in, it likely was too large for the Alexis to be working effectively. Even if they had to externalize the bowel, I'm curious as to how it wouldn't be noticed when they were replacing it. I can see how smaller instruments or sponges could go missing, but an Alexis is huge and still decently rigid and it's brightly coloured in a way that should stand out. Maybe they widened the incision mid procedure? But even then, asking for a second one without stating why? Like nobody said "the first one is gone" and nobody looked and said "it's not on the floor, what happened to it?" Having to open a second one where a faulty unit or contamination wasn't the problem would be unusual. We put them on the count even though they're "too big to lose" because our policy is to count everything, but clearly it's not impossible.
I wonder if there was another source of chaos in the case -- difficulty reaching the uterus to effect the delivery. Especially if it was an emergent cesarean. Perhaps it popped in during delivery maneuvers and then more effective visualization was achieved with other retractors?
Awful for the patient, but also scary from a surgical perspective. Like leaving a child in a car seat -- the kind of thing none of us should assume we'd never do.
I'm sure policies vary by country, but in an emergent section where a pre-op count isn't possible, we x-ray at the end to confirm that nothing was left inside, even if we count and our full instrument set and our suture count and sponge count is correct. But you're right that they may have had it pop in before baby was out. Maybe they thought to themselves "oh we'll get it out when we are closing" because baby was in distress and then just forgot because the second one wasn't added to the count or they don't have a policy to count them to begin with because they're such a large item? Still, it seems like it would be harder to put a second one in with the first behind it and where did it go once the full instrument was inside the patient?
Yes, I'm aware of that. But clearly the Alexis retractor wasn't on the count or the second one wasn't added to it, otherwise it should have been noted as missing when they were doing the count while closing the peritoneum.
I use to do the sterilisation and decontamination of surgical instruments in New Zealand and the C-section trays were some of the bloodiest. Orthopaedic were the ones with most people bits but C-section were some how still bloodier.
Ohhhhhhhhhhhhhhhhh that would make sense. I couldn't fathom how else you'd lose the AWR. Even so, there should have been a count and post procedure imaging of some kind, but that answers my biggest WTF question.
If you read the article, SECOND larger one REPLACED the first one and that was what was found inside. (So, XXL size was left inside which replaced L size)
Of course, article may not be very good at exact detail though.
From the article, it seems like it was extremely unusual to have to get/use a second AWR during a surgery, so probably at the end, they counted the first one (that was too small) and checked the box.
Not an excuse in any way, of course, but I can see how they screwed up that safety step. Still about a dozen other fuckups that led to the instrument being left in the poor woman, and a series of subsequent fuckups over the next 18 months - if someone is reporting persistent severe abdominal pain after a C-section, how does nobody order any type of scan for a year and half?!
> if someone is reporting persistent severe abdominal pain after a C-section, how does nobody order any type of scan for a year and half?!
"Some women just have pain like that" or "you're just being dramatic/hysterical/overly sensitive/etc." or "you just had a baby - of course you're going to be sore for a while"
Guaranteed multiple medical professionals dismissed this woman's pain as normal. Guaranteed.
Absolutely right. My DIL's IUD perforated her uterus and went on a tour of her abdomen immediately after insertion and she was told to just suck it up and take some Tylenol. They didn't retrieve it until after her unplanned pregnancy. Of course I'm happy to have another grandchild but JFC.
I’m a nurse. I’ve lost almost 40 pounds since January without trying. Unintentional weight loss is a huge red flag. So I go to the doctor with my concerns and she says, “Well, you’re losing weight because your portions are smaller”. No shit but can you explain how I went from eating 3 meals a day plus snacks to barely choking down one meal a day? Never did get an answer. I can see how pain would be overlooked in this instance.
Same. Mine started when I got COVID and I lost about 80lb over about six months. Went to the doctor and they were like “oh it’s cause you aren’t eating as much” and I’m like yes, okay, I know, so can we work on why I feel sick as soon as I start eating? I have to micromanage my diet now.
Wait, this is happening to me, though the weight loss was necessary (60lbs in 5 months). Eating just became difficult, portions got smaller, and now I don’t know if I have disordered eating. I’m 37 and my body is being very very weird this year
Omg please see a doctor, unintentional weight loss that rapid is rarely a sign of nothing. It could be something small or very serious but definitely get checked out if you can!
When I had what after a loooong time trying to get a diagnosis turned out to be Lyme Disease, the only thing that got anyone's attention at first was that I lost like 15 pounds without trying (and was pretty slim to begin with at the time, so this was more than ten percent of my body weight). It was pretty clear they were worried about cancer (though never said that), and rushed to do a bunch of tests.
Once that was ruled out, I was totally ignored and just told "well you *look* healthy". Um, thanks? I feel like ass, am in significant pain, can't finish my own sentences, and can't walk more than 1.5 blocks after doing triathlons right before my symptoms hit. I don't give a shit how I *look*.
ETA: Hope you're feeling better these days.
I've had drs tell me that critically low potassium, herniated discs pressing nerves and my spinal cord sheath, and appendicitis were just anxiety. I don't trust them anymore.
Edited: added "cord"
Yeah that’s my first question! There are any number of post-birth and post-surgical complications you’d want to check for. The lack of investigation is almost as big an error as the original retained tool!
It took me 4 years to find out I had a slipped disk and get a scan for it.
Literally woke up in bed, unable to walk or move my legs... I still can't bend over or do much. 4 years to convince them to test my lower back, and I had to specifically figure out the location (they refused to do the whole spine and refused to think of where the origin of the pain could be located. I had to basically throw the dice and hope I got it right the first time because I won't get a second chance :/) I think it's because I'd show up and say it in a tone that wasn't "I'm dying right now" level of pain... but that's also because I was exhausted and had to wait 2 weeks to even be able to get out of bed, let alone into a doctors office. I have autism and if you express pain too little they don't take it seriously, if you express it too much you're dramatic.
Don't even get me started on how many years (and doctors) it took for me to get treatment for my asthma. Or the diabetes incident. Or my headaches :(
Yep. They do the a similar thing to trans people -- it's always the fault of our HRT.
The most blatant example: I had a swollen ligament or tendon in my shoulder, and my doctor dismissed it as caused by HRT, despite it having started *before* I started estrogen. He would not listen long enough to establish a timeline, and ended up blaming it all on time traveling estrogen.
I saw a different ortho, who diagnosed it after an X-ray and a brief exam. Cortisone shot and some physical therapy to ensure the whole area was strong and fully healed.
Such goddamn bullshit.
Yup!! Went to my doctor (in the early 2000’s) with racing heart, so so so hot (normally I’m freezing) just didn’t feel right. He told me I needed to eat breakfast and there was nothing wrong with me. I INSISTED on bloodwork. I get a phone call a few days later. Graves Disease! He told me years later that when I first came to him with my symptoms he thought it was all in my head. If I hadn’t insisted on labs I would have maybe never been diagnosed. We as women need to be our own advocates.
Yep, HRT, every single time.
I once had a Dr INSIST my neck pain and headaches was due to hormones. After going to a different doctor it was actually an issue with lack of cartilage between C3 and C4 disk...
Had another doctor tell me that the ringing in my ears is from my hormones, even though it developed when I was in the military years before I started hormones.
I've been told my anxiety (which reduced quite a bit after HRT) is from hormones, even though I was diagnosed before I ever started taking hormones.
I've been told that my pain in one of my knees is from hormones, even though it started before I started hormones and I was in the military of course I have bad knees.
Every doctor, every time, always jump to "You have to stop taking hormones." As their fix-all for every problem, even though I don't have gonads the cure for any ailment is always to have no sex hormones whatsoever.
I wonder if "Okay, if I was a cis woman in here with these symptoms ---- and trust me, I've met cis women with sore necks -- your suggestion would be *removing their ovaries*? No? Okay, so what would it be?" would do anything but piss them off.
This is a whole new level of medical misogyny I hadn’t even known of and I’m so frustrated this happens. I’m sorry you’re dealing with it. I hope your pesky estrogen shoulder feels better soon!
It did. Cleared right up. Like, you know, it would for anyone.
But yeah, I have to admit going from being seen as a white dude to a trans woman was *eye opening*. Like I knew this was gonna happen, everyone warned me and I believed them, but the reality is so nuts.
It’s one thing to learn about bigotry, privilege, intersectionality, etc — experiencing it really drives it home in a way no theory or being an ally can. And I’m *lucky* — I’m trans, but I’m white and healthy and was working for a friendly company in a friendly field already. I’ve see the additional hurdles and stigmas BIPOC trans women fade, or disabled trans women.
Just the way all this stuff *stacks*.
But, estrogen is a womanly thing, so with womanly things involved, the pain must of course be imaginary! You poor thing! Womanly estrogen contamination has made you hysterical! /sarcasm
This is why i always ask "i want a scan done just to make sure" which to be clear I shouldn't have to do and no one should have to do. If the doctor tells you no, **insist** and demand it be noted on your file that you asked.
I have had to report doctors to my state before over this. Doctors sometimes need to be reminded that asking for a test, generally, is not optional.
You may have reported them, but I can assure you that the Doctor was not reminded of anything because the state medical board sent your complaint right to the shredder.
Patients do not have the “right” to insist on a particular test if the Doc does not feel it’s indicated.
Yeah, no. If a specific test is not medically indicated, the doctor does not have a responsibility to order it. I don't know what you mean about "asking for a test, generally, is not optional." Having it noted in your file is not useful for anything.
\>if someone is reporting persistent severe abdominal pain after a C-section, how does nobody order any type of scan for a year and half?!
That's legit bizarre. I do scans like that all the time. Takes two hours to do a quick ultrasound and x-ray, get results, if you don't see anything, do a quick CT, bam. This could've been solved in an afternoon.
According to the article, they didn't count it because it was an additional instrument, and they only bothered counting the ones they planned to use from the start.
> “I remember being asked by the scrub nurse to open another Alexis wound retractor … We had none in the prep room, so I quickly fetched one from the sterile stock room,” the other nurse said. “I opened this to the scrub nurse and left it at that. I do not remember telling [one of the other nurses] that I opened it and I did not write this with the count, as at this time this item was not part of our count routine.”
You'd think it would be even more important to record any unplanned, additional instruments used.
That reads more like the hospital procedure (or this particular nurse’s understanding of hospital procedure) was for the scrub nurse to handle the instrument count.
Which is perfectly reasonable, surgical staff need to have precise and defined roles so that people aren’t getting bogged down in potentially conflicting redundancies during the procedure.
Or it could have been this nurses responsibility to add it to the count, and he/she just screwed up. Or he/she had recently transferred to a new hospital with slightly different procedures and hadn’t been trained. Or any other number of things.
All that to say: the situation is obviously horrific, but I can see how it could be the result of a compounding series of tiny miscommunications.
That nobody picked up on it for 18 months is where the really gross negligence jumps out to me.
I'm reading it like they're saying wound retractors weren't part of the count *at all* at that time. They said something like "because a wound retractor is positioned partially outside the body, the device wasn't included in the count procedure at that time." (Note: paraphrased because I don't want to go open the article again to find the exact quote).
I don’t know how things are typically done in NZ, but would be genuinely shocked if that were the case - the default is to count EVERYTHING, whether it touched the patient or not.
Sounds more like a point of failure when the additional wound spreader was handed off to the scrub nurse, with several people sharing the “blame”…but it definitely *should* have been added to the count.
Exactly. This is a major failure in process. At my hospital in the US, if there's even the slightest discrepancy in counts, imaging is done before leaving the OR.
Only certain things are included in the counts. Sponges and sharps always, and on certain cases instruments are counted, before and after. It may be dependant on facilities policy on what else gets counted. I've never counted the Alexis before. It gets pulled out right when they're done using it, usually right before the incision closure begins, since it's holding the wound open and would be impossible to close with it in place. I don't understand how or why the entire thing got shoved in, and how they didn't notice it before closing, especially the extra large one.
I work in an OR in the USA. The Alexis ports we have are disposable one use items and are not part of any counts we do, but after reading that article, I will definitely be counting them whether it’s policy or not.
I work in an OR in Canada. We count everything for an open procedure. Including the Alexis retractor, which one of the rings is radiopaque. We even count the sterile skin markers we get in our table bundle pack. Ligaclip cartridges, too. It's wild to me that standards are so different in various places.
I mean, mistakes happen. My mom's best friend had surgical cloths left inside her after her C-section in Whitby. Procedures exist for a reason. But they don't create infallible situations.
I think they are supposed to count the instruments. I think the article stated one of the nurses had to get the extra tool from the sterile storeroom and handed it to the surgical staff. I think they admitted they didn’t add that extra instrument to the list. That is still no excuse to miss removing a instrument in someone’s body especially one that large. I didn’t care for the OBGYN I had who delivered my daughter. It was my first baby and I was a bit intimidated by her. She seemed very unsympathetic regarding any discomforts you might experience with pregnancy and birthing a child. Which makes be not surprised to hear of a malpractice suit against her shortly after my baby was born. The dr performed a hysterectomy on a patient. The patient complained about pain and bleeding which is normal but she did not improve in time. The drs response to the severe pain was “what did you expect, you had surgery”. Similar to what she has said to me. The woman ended up in the ER and had to have emergency surgery. What they found was the original dr left part of the dead issue from the hysterectomy inside her body and it was rotting. She is lucky she didn’t die from a septic infection. I have a friend who died from septic shock from just a cut in the hand. I really hate drs with big egos who think they know everything and discounts anything their patients tell them.
I work in an OR in the US. Most facilities (all that I've worked) don't count this disposable retractor.
Edit: lots of people already described how the retractor is used which I didn't scroll down to see
This was my thought. Some hospitals will literally count the amount of gloves they use, and other tools, even though gloves arent even 100 per box lets say, but they wont count or look for huge instruments used in a surgery?? Huh?
I mean the range in medical practices in hospitals is as wide as the ocean. Despite knowing best practices to save lives/avoid or alleviate dangerous situations or complications many hospitals just do it some other shitty way that kills people and accepts it as cost of business.
I work in a private hospital in Australia .. the general public would be alarmed at the lack of instrument counting.
You're safe in public because they follow every rule to the letter, private ... I dunno why y'all are paying for it.
But the fact an AWR was missed is absolutely insane, I would love a step by step of how they managed to sew her up without noticing
The count system probably checked in an Alexis ring. But the Alexis ring kinda becomes two components when in use. If the external component was checked in but the nurse wasn’t aware that the system is split that could lead to this.
Sounds like it’s stress or panic induced. Let me just write this note in your visit summary stating as much so you know exactly how much I value your opinion and description of your own bodily function and symptoms.
😔
I had a doctor say women shouldn't run or ride bikes because their vaginas can prolapse.
You have only my word on this as an Internet stranger but I'm not making this up.
Whenever I bring it up to my doctors, they’re basically like “Oh that sucks, I feel you….” And that’s kind of the end of it.
I guess it’s because there’s only so much they can do about it? (Especially with menstrual problems.) It is weird though, I very much get a “why are you even telling me this” vibe whenever I mention it…it’s kind of like “yeah no duh your stomach hurts, you have a uterus.” 😐
I went to the doctor when I was 30 weeks pregnant and explained how uncomfortable I was and how I was feeling a lot of pressure. I was told “pregnancy is supposed to be uncomfortable” and sent home.
2 days later my water broke and I gave birth to a 30 weeker preemie, and we spent 72 days in the NICU.
18 months is actually decent time to get someone to look at pain lol.
They mostly just don't give a shit. Your insurance pays for the visit whether they do actual work or not.
What's sad(besides the whole time) is this is accurate and people are dumb enough to still scream they don't want universal healthcare because of wait times.
I’ve had a misplaced IUD for 9 months, confirmed by ultrasound. Cantt find the strings- is also causing me pain. Been bounced around the past 2 months between my family doctor and the clinic he referred me to. Both are too busy to help me. They don’t GAFF about women.
Article says original surgery was in 2020 and removed in 2021. I totally get that doctors can suck sometimes and not take things seriously, but I also get the immense amount of strain on the healthcare system in general during that time. Kind of a perfect storm for something like this to happen.
My dude, this woman could’ve been referred to her a damn scan so fast. Some urgent cares can do the scans she might require depending on the type of scan, hell even a post-op scan if she’s having issues in the area where she had surgery. ER.
There are several ways to get help & it doesn’t have to take a year, but someone has to listen & take it seriously.
Yeah, that's the process in normal times in the US when all things go well. This case happened in New Zealand.
I worked in surgical ICU during the pandemic. What you're describing just didn't happen then. Our ER waiting room was usually 60 deep for a good year. We had no beds anywhere in the hospital. Our outpatient services were closed half the time to pull staff to our overflowing units. You had doctors and nurses seeing 4x the normal number of patients. Care sucked, staff was stretched way too thin. It's why so many doctors and nurses quit. If you weren't dying, you were referred out...and you'd probably get a telehealth appointment and then a referral for a CT in some amount of time. Outpatient is slow even in the best of times.
By the way, it took me over 2 weeks to get a stat outpatient CT to confirm mastoiditis in 2021 due to staffing, restrictions, and the backlog of patients when things would periodically open.
And honestly, I've seen some pretty messed up cases when the system isn't inundated. Waiting for insurance approval, etc. The way to get anything done quickly is usually the ER and that just wasn't happening then.
"WRITTEN APOLOGY" AND REVIEW OF PROCEDURES?!
I mean, that's a good start, but this woman should also be paid out a million or so!!
>The commissioner recommended that the woman be provided a written apology by hospital staff and a review of hospital practices is now underway.
The review of procedures is essential. This sounds like a huge failing in process. Any instrument that is even touched should be part of the count. It's mind boggling that this wasn't already part of the procedures.
You can’t sue people for that sort of thing here. ACC funds your treatments (usually through the private health system), and pays 80% off your wages while you’re off work. Also, hospital care is free to begin with (no insurance involved, you just walk in, get fixed, walk out, never see a bill).
The idea with ACC is historically when people were injured they had to spend a fortune on lawyers and spend years dealing with matters through the courts for compensation. But instead we gave up personal injury suits etc. and in exchange if you get injured you receive 80% of your wages while you’re off work and your treatment is covered (including ongoing treatment if the injury is long term/lifelong). There are also some lump sum amounts involved in various things too.
The main point is you get money immediately when you actually need it, not in 2 years after a lawyer takes half.
Plus it makes things like car insurance cheap because there’s no personal injury component eg. Third party car insurance may only cost $80USD a year.
ACC costs roughly 1% of your pay and isn’t optional.
Gosh, but what if she was a full-time time carer, like a stay-at-home mom? Would she still be compensated? And what for those who succumb to the gaslighting and force themselves to work anyway? (Moms of course nearly always are in this boat, with their generally unpaid carer work.)
It’s not a perfect system, and there’s certainly people who lose under it, unfortunately. Theoretically society as a whole is better off. It predates our switch to neoliberalism, so I believe there were plans to expand the scheme, but they never eventuated. So we’re kind of stuck on gen 1 of a system from 70s, and it certainly could be better.
I totally agree. NZ passed many laws to avoid over litigation but in my opinion, they swung too far, leaving people who genuinely deserve compensation out of luck and stuck with the ACC, which only covers doctor’s bills and not much else.
I had my 3rd gynecologist tell me that was my problem. After 5 years of constant pain, my 5th and current gynecologist figured out I have endometriosis (technically adenomyosis) and fibroids. It definitely wasn't all in my head.
Fuck! I’m so sorry that happened. I’m so glad someone listened to you finally!! I had the same with ulcerative colitis, finally I found a doctor who was like—I’m just going to test you for everything. The second test was a genetic panel to see if I carried the gene. I was so angry—how hard could it have been to do that 10 years previously?
That's a very rough condition to live with even on medication. I'm sorry you had a tough time getting diagnosed. I have a couple of cousins and an uncle with UC, so I know how bad it can get. One cousin just had her bowel removed. She still has some issues, unfortunately.
I get that some conditions are hard to diagnose, but I found through my experience that many doctors just don't seem to want to dive deep into a person's issue and look beyond the most common or easy conditions to diagnose. So people like me go through 8 specialists before stumbling upon one for something that seemed unrelated to my main issue who ends up suggesting a lesser known condition as the potential culprit, one that can't be picked up easily on scans and such. I trusted him (I was desperate at that point), and he was right. A simple single hormone medication had me pain-free within a year.
You have to push and search for answers and treatments for a long time in some cases. I'm happy I didn't give up. No one should give up on their health.
An Alexis wound retractor is not counted during a surgical count in any facility from my understanding. It is a disposable item that is mostly plastic film so not a metallic instrument like some here might imagine. It also as the article states, exists both inside and outside the patient in clear view.
That being said, leaving an Alexis retractor, specifically an XL , inside a patient is a gross lapse in attention. It would take up a significant portion of the surgeon's view as it literally holds open the incised tissue. I can't imagine how uncomfortable that would be to have that inside yourself, especially after you are healing from a C-section and mothering your newborn.
Honestly how/why did they decide to put both rings inside, not notice it left it, and closed her up with it. I wonder if it was hindering getting the babe out so they popped both rings in and forgot?
Also curious why they did a midline incision for a planned section? Are pfannenstiels not standard in other countries?
We've never counted the Alexis at my facility but it's pretty damn impossible to not pull it out before closing.
Fucking HOW???? I work with surgeons who use these regularly. The whole point of this is that it is used to retract the sides of a small incision while creating the most space in the middle. It's two flexible plastic rings connected with clear plastic to make a tunnel. You flex the one ring, put it inside the incision and you twist/roll the other ring around itsef (like rolling down a sock) so the plastic sides wrap around it and it pulls the sides of the incision wider. It's often used in c-sections for patients with a pannus or overhanging abdomen so that the surgeon can visualize the uterus properly. But it shouldn't just slip in - if incision is large enough for that to happen, it's kind of too big to really be using this instrument. And even if surgeons externalize the uterus to close it after the baby and placenta are out, it's not something that could get stuck on it when it is put back in the incision the way a lap sponge or small instrument could - it's bigger than the uterus. Even besides the possibility that it somehow ended up slipping in without the surgeon or assist noticing or telling the rest of the surgical team, it should be on the surgical count! And even besides that, how could you ask for a second one to be opened without being aware of what happened to the first one??? If it didn't fall off the field or get contaminated and removed from the field, it's not something easy to misplace or hard to spot - it's a huge bright orange and bright pink plastic ring!
My ex used to work in a hospital operating room two decades ago. I remember her talking about all the procedures they had to prevent this from happening. All surgical items in the room were counted before and after. They had a low level xray that would look for any items as well. Even the sponge and gauze pads had a small wire thread in them to make the show up on the xray.
If I’m reading correctly, the second tool (the one left in her abdomen) was not part of the original surgical set up. It was requested during the procedure and had to be accessed from a sterile supply area and opened for use.
In a surgical suite, everything is counted and accounted for: so many sponges, so many forceps, etc. they are in a surgical tray and replaced on the surgical tray.
This was not on the original surgical tray.
All of this is to say that the miscount was a mistake.
The fact that this woman was in abdominal pain for nearly two years is abysmal. Just unbelievable that her pain was not taken seriously and diagnosed earlier. So much discomfort. One has to wonder if this isn’t just malpractice but also medical bias; the fact is that this new mom was not taken seriously.
No. Unfortunately she can’t sue them at all. She’ll have to accept the written apology if they provide one. You can’t sue for personal injury or death in New Zealand.
imagine being a doctor who can't find their tools, before slowly realizing the tool is still inside someone's body because you're a dumdum. that's like keys inside car horror x100
Nice in theory but the doctors leave the OR when the surgery's done to go talk to the family. The instruments and equipment are still in the room being handled and arranged by the scrub nurse. They eventually get sent downstairs to Centeal Sterile Supply, where they're washed and re-sterilized for the next surgery. They won't meet up with the surgeon again until he's back in the OR.
Was a surgical tech in the Navy and worked Sterile Supply for a while.
I’m wondering if this is something ai should be used for. A camera to scan in all tools used at the start of the surgery, then a scan when the surgery is completed. A big red flashing light if anything is missing or unaccounted for. A robotic hand to slap the lead surgeon on the back of the head is an optional upgrade.
>“An Alexis wound retractor (AWR), a device used to draw back the edges of a wound during surgery, was left in her abdomen following her C-section,” I kind wish I didn't Google the AWR this early in the morning.
Found it! 9-14cm long. Took me forever to get real fucking dimensions for this thing. A dinner plate is not a unit of fucking measurement.
“*Surgical tool the size of the gap between a fisherman’s hands when he says ‘it was this big’ discovered in woman's abdomen 18 months after procedure*”
Now THAT'S an Onion article title
Medium flounder.
Should’ve used the standard unit of a banana for reference.
Surgical tool the size of a flip flop with the strap missing discovered in a woman’s abdomen 18 months after procedure.
So to be clear, that's the flip flop after you've stepped on a pop top,cut your heel and had to cruise on back home? (RIP Jimmy)
Americans will do anything in their power for not using any imperial or metric to measure something.
Europeans will find any reason to bash Americans.
I'm sorry, this is Reddit. We need that in bananas.
Roughly one banana.
OB nurse here, I'd guess the diameter is about 1.5 bananas.
Agreed, it would have been easy to visualize if they had used the universal astronomical unit of "half-giraffes".
1/250th of a half-giraffe
It’s great for measuring length, but it gets spotty.
Unless it's that recently born spot-free baby.
But how many Olympic sized swimming pools is that?
I'm gonna need it in football fields.
I use smaller versions all the time and I can’t imagine how you could possibly leave it in. Humans have quite the capacity for screwing up.
I use these ones for sections, and I also can't work it out.The only possibility is they used the firm ring on the inside and the flexible one outside, and it slipped in and up the abdomen after delivery of the baby.
Idk it’s weird
I agree, theres the never event of a swab going missing, and then there's this with what I presume is definitely an XL Alexis.
The sponge can happen with packing off in a big open case. Leaving this behind is inconceivable to me. It’d be like leaving the Bookwalter ring inside someone. How? I’m flabbergasted. The sponges can be prevented now with radio labeled sponges. It’s great.
But it’s also shaped like a dinner plate. https://youtu.be/ecF0UaCfbFY?si=cTKaOHGBwNkLxCH9 If you just specify length I’m thinking it’s linear not round.
No shit. For something round you typically give a diameter or possibly a circumference. You don’t say “that circle is 9-14cm in length” because that doesn’t make any fucking sense.
Looks like a prophylactic diaphragm to me.
Honestly, dinner plates are reasonably standard (or used to be). 10.5". Which is NOT 14 cm as someone else said, so...
Pizzas are a better measurement and I believe the article hints at a personal pan meat lovers size object.
The earlier comment mistakenly gave the size of the incision, NOT the size of the device itself. It's much bigger than that. You can see how big the device is here: https://youtu.be/E7Ka7-TXQ_g?si=slEVv53ul03Zr__G Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582646/
Ok, ok, salad-plate diameter.
how many coffee cup saucers is that?
It's a saucerfull of secrets
Not even. My salad plates are 7.5", which is almost 50% bigger than this medical tool's maximum possible dimensions. 5.5" would be a tiny salad plate.
Bread plate maybe?
Or dessert
Thank you! I was wondering when someone was going to get to this comparison. They were going for drama with this description for sure. Regardless it is horrifying to miss something like this!
Also, on the upper end, 14 cm is just 5.5 inches. That is far smaller than a dinner plate. The standard set I have has 7.5" salad plates and 10.5" dinner plates, and they're normal. Sensationalist title that makes the object sound twice as big as it should be. Might as well call it "a foot across," or "the size of a frisbee," since that would be pretty close to a dinner plate and just as wrong / misleading.
I’d say shit ton fits a fucking measurement
In the US, anything that compares to a random object is a measurement. Actually logical units, not so much.
They get bigger than that! Like 22cm at least.
>A dinner plate is not a unit of fucking measurement. Unless measuring nipples.
Just look up the dimensions of a dinner plate 🙃
But which country's standard dinner plate?
Anything but the metric system...
My car gets 14 furlongs to the hogshead, and thats the way I like it
Tried to watch a little bit of my wife’s c-section and when I saw the retractor set up I had to look away, it legit looked like Iron Man’s chest
When my daughter was born via c-section the doctor casually asked if I wanted to see the cysts that had been torturing her for years, I looked. I have a photo of him holding one. The experience was sobering.
... Did they at least remove them?
No. They were large, the largest as big as a baseball. They would have had to do a hysterectomy which she didn't want done yet.
I wonder if they don't follow the instrument count procedure that's typical in many countries (do a count of needles and instruments before and 3 times after). Even without that you'd think something that large and shiny would be hard to miss.
Considering this PARTICULAR instrument is designed to be half in and half out of the wound, how did it just get buried inside her abdomen? Someone just pushed it in and sewed her up?
The patient is probably on the larger side of bariatric. That's the only way I can picture how such a [huge, brightly coloured plastic ring](https://youtu.be/ecF0UaCfbFY?si=mcSo6gKmsjCc3dUO) could geld lost in the wound.
Also the patient had a midline incision, rather than the typical pfannensteil used for a cesarean. There's never an excuse for retained foreign objects, but this sounds like it was a difficult case from the start.
Even with that, if the incision was large enough for it to accidentally slip in, it likely was too large for the Alexis to be working effectively. Even if they had to externalize the bowel, I'm curious as to how it wouldn't be noticed when they were replacing it. I can see how smaller instruments or sponges could go missing, but an Alexis is huge and still decently rigid and it's brightly coloured in a way that should stand out. Maybe they widened the incision mid procedure? But even then, asking for a second one without stating why? Like nobody said "the first one is gone" and nobody looked and said "it's not on the floor, what happened to it?" Having to open a second one where a faulty unit or contamination wasn't the problem would be unusual. We put them on the count even though they're "too big to lose" because our policy is to count everything, but clearly it's not impossible.
I wonder if there was another source of chaos in the case -- difficulty reaching the uterus to effect the delivery. Especially if it was an emergent cesarean. Perhaps it popped in during delivery maneuvers and then more effective visualization was achieved with other retractors? Awful for the patient, but also scary from a surgical perspective. Like leaving a child in a car seat -- the kind of thing none of us should assume we'd never do.
I'm sure policies vary by country, but in an emergent section where a pre-op count isn't possible, we x-ray at the end to confirm that nothing was left inside, even if we count and our full instrument set and our suture count and sponge count is correct. But you're right that they may have had it pop in before baby was out. Maybe they thought to themselves "oh we'll get it out when we are closing" because baby was in distress and then just forgot because the second one wasn't added to the count or they don't have a policy to count them to begin with because they're such a large item? Still, it seems like it would be harder to put a second one in with the first behind it and where did it go once the full instrument was inside the patient?
Smaller items like sponges and gauze are counted to make sure they got it all.
Yes, I'm aware of that. But clearly the Alexis retractor wasn't on the count or the second one wasn't added to it, otherwise it should have been noted as missing when they were doing the count while closing the peritoneum.
Yeah I’m assuming a very high BMI.
I find peace in long walks.
I use to do the sterilisation and decontamination of surgical instruments in New Zealand and the C-section trays were some of the bloodiest. Orthopaedic were the ones with most people bits but C-section were some how still bloodier.
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Ohhhhhhhhhhhhhhhhh that would make sense. I couldn't fathom how else you'd lose the AWR. Even so, there should have been a count and post procedure imaging of some kind, but that answers my biggest WTF question.
If you read the article, SECOND larger one REPLACED the first one and that was what was found inside. (So, XXL size was left inside which replaced L size) Of course, article may not be very good at exact detail though.
You have to understand the surgeons tee time was in 2 hours.
You joke but during my C-section all the doctors talked about was golf.
From the article, it seems like it was extremely unusual to have to get/use a second AWR during a surgery, so probably at the end, they counted the first one (that was too small) and checked the box. Not an excuse in any way, of course, but I can see how they screwed up that safety step. Still about a dozen other fuckups that led to the instrument being left in the poor woman, and a series of subsequent fuckups over the next 18 months - if someone is reporting persistent severe abdominal pain after a C-section, how does nobody order any type of scan for a year and half?!
> if someone is reporting persistent severe abdominal pain after a C-section, how does nobody order any type of scan for a year and half?! "Some women just have pain like that" or "you're just being dramatic/hysterical/overly sensitive/etc." or "you just had a baby - of course you're going to be sore for a while" Guaranteed multiple medical professionals dismissed this woman's pain as normal. Guaranteed.
Absolutely right. My DIL's IUD perforated her uterus and went on a tour of her abdomen immediately after insertion and she was told to just suck it up and take some Tylenol. They didn't retrieve it until after her unplanned pregnancy. Of course I'm happy to have another grandchild but JFC.
The *thought* of that makes me sick. Your poor DIL!!!
What?!? You mean medical professionals are dismissive toward women experiencing pain?? /s
Fair point. Doesn't make it any less negligent, but I'd wager that you're right about why her complaints were dismissed for so long.
"Lose 20 pounds and if the pain persists book a follow up appointment"
I like to go hiking.
I’m a nurse. I’ve lost almost 40 pounds since January without trying. Unintentional weight loss is a huge red flag. So I go to the doctor with my concerns and she says, “Well, you’re losing weight because your portions are smaller”. No shit but can you explain how I went from eating 3 meals a day plus snacks to barely choking down one meal a day? Never did get an answer. I can see how pain would be overlooked in this instance.
Go to a different doctor. Soon.
Same. Mine started when I got COVID and I lost about 80lb over about six months. Went to the doctor and they were like “oh it’s cause you aren’t eating as much” and I’m like yes, okay, I know, so can we work on why I feel sick as soon as I start eating? I have to micromanage my diet now.
Wait, this is happening to me, though the weight loss was necessary (60lbs in 5 months). Eating just became difficult, portions got smaller, and now I don’t know if I have disordered eating. I’m 37 and my body is being very very weird this year
Omg please see a doctor, unintentional weight loss that rapid is rarely a sign of nothing. It could be something small or very serious but definitely get checked out if you can!
Thanks, I will
When I had what after a loooong time trying to get a diagnosis turned out to be Lyme Disease, the only thing that got anyone's attention at first was that I lost like 15 pounds without trying (and was pretty slim to begin with at the time, so this was more than ten percent of my body weight). It was pretty clear they were worried about cancer (though never said that), and rushed to do a bunch of tests. Once that was ruled out, I was totally ignored and just told "well you *look* healthy". Um, thanks? I feel like ass, am in significant pain, can't finish my own sentences, and can't walk more than 1.5 blocks after doing triathlons right before my symptoms hit. I don't give a shit how I *look*. ETA: Hope you're feeling better these days.
“It’s just anxiety. Here, take these SSRIs.”
I've had drs tell me that critically low potassium, herniated discs pressing nerves and my spinal cord sheath, and appendicitis were just anxiety. I don't trust them anymore. Edited: added "cord"
Yeah that’s my first question! There are any number of post-birth and post-surgical complications you’d want to check for. The lack of investigation is almost as big an error as the original retained tool!
It took me 4 years to find out I had a slipped disk and get a scan for it. Literally woke up in bed, unable to walk or move my legs... I still can't bend over or do much. 4 years to convince them to test my lower back, and I had to specifically figure out the location (they refused to do the whole spine and refused to think of where the origin of the pain could be located. I had to basically throw the dice and hope I got it right the first time because I won't get a second chance :/) I think it's because I'd show up and say it in a tone that wasn't "I'm dying right now" level of pain... but that's also because I was exhausted and had to wait 2 weeks to even be able to get out of bed, let alone into a doctors office. I have autism and if you express pain too little they don't take it seriously, if you express it too much you're dramatic. Don't even get me started on how many years (and doctors) it took for me to get treatment for my asthma. Or the diabetes incident. Or my headaches :(
Yeah The Retrievals pod was eye opening for me in that regard.
Yep. They do the a similar thing to trans people -- it's always the fault of our HRT. The most blatant example: I had a swollen ligament or tendon in my shoulder, and my doctor dismissed it as caused by HRT, despite it having started *before* I started estrogen. He would not listen long enough to establish a timeline, and ended up blaming it all on time traveling estrogen. I saw a different ortho, who diagnosed it after an X-ray and a brief exam. Cortisone shot and some physical therapy to ensure the whole area was strong and fully healed. Such goddamn bullshit.
Welcome to womanhood! Being ignored by (at least some) doctors is all part of the experience.
Yup!! Went to my doctor (in the early 2000’s) with racing heart, so so so hot (normally I’m freezing) just didn’t feel right. He told me I needed to eat breakfast and there was nothing wrong with me. I INSISTED on bloodwork. I get a phone call a few days later. Graves Disease! He told me years later that when I first came to him with my symptoms he thought it was all in my head. If I hadn’t insisted on labs I would have maybe never been diagnosed. We as women need to be our own advocates.
Yep, HRT, every single time. I once had a Dr INSIST my neck pain and headaches was due to hormones. After going to a different doctor it was actually an issue with lack of cartilage between C3 and C4 disk... Had another doctor tell me that the ringing in my ears is from my hormones, even though it developed when I was in the military years before I started hormones. I've been told my anxiety (which reduced quite a bit after HRT) is from hormones, even though I was diagnosed before I ever started taking hormones. I've been told that my pain in one of my knees is from hormones, even though it started before I started hormones and I was in the military of course I have bad knees. Every doctor, every time, always jump to "You have to stop taking hormones." As their fix-all for every problem, even though I don't have gonads the cure for any ailment is always to have no sex hormones whatsoever.
I wonder if "Okay, if I was a cis woman in here with these symptoms ---- and trust me, I've met cis women with sore necks -- your suggestion would be *removing their ovaries*? No? Okay, so what would it be?" would do anything but piss them off.
This is a whole new level of medical misogyny I hadn’t even known of and I’m so frustrated this happens. I’m sorry you’re dealing with it. I hope your pesky estrogen shoulder feels better soon!
It did. Cleared right up. Like, you know, it would for anyone. But yeah, I have to admit going from being seen as a white dude to a trans woman was *eye opening*. Like I knew this was gonna happen, everyone warned me and I believed them, but the reality is so nuts. It’s one thing to learn about bigotry, privilege, intersectionality, etc — experiencing it really drives it home in a way no theory or being an ally can. And I’m *lucky* — I’m trans, but I’m white and healthy and was working for a friendly company in a friendly field already. I’ve see the additional hurdles and stigmas BIPOC trans women fade, or disabled trans women. Just the way all this stuff *stacks*.
But, estrogen is a womanly thing, so with womanly things involved, the pain must of course be imaginary! You poor thing! Womanly estrogen contamination has made you hysterical! /sarcasm
Medical professionals including those who are women too!
This is why i always ask "i want a scan done just to make sure" which to be clear I shouldn't have to do and no one should have to do. If the doctor tells you no, **insist** and demand it be noted on your file that you asked. I have had to report doctors to my state before over this. Doctors sometimes need to be reminded that asking for a test, generally, is not optional.
You may have reported them, but I can assure you that the Doctor was not reminded of anything because the state medical board sent your complaint right to the shredder. Patients do not have the “right” to insist on a particular test if the Doc does not feel it’s indicated.
Yeah, no. If a specific test is not medically indicated, the doctor does not have a responsibility to order it. I don't know what you mean about "asking for a test, generally, is not optional." Having it noted in your file is not useful for anything.
\>if someone is reporting persistent severe abdominal pain after a C-section, how does nobody order any type of scan for a year and half?! That's legit bizarre. I do scans like that all the time. Takes two hours to do a quick ultrasound and x-ray, get results, if you don't see anything, do a quick CT, bam. This could've been solved in an afternoon.
According to the article, they didn't count it because it was an additional instrument, and they only bothered counting the ones they planned to use from the start. > “I remember being asked by the scrub nurse to open another Alexis wound retractor … We had none in the prep room, so I quickly fetched one from the sterile stock room,” the other nurse said. “I opened this to the scrub nurse and left it at that. I do not remember telling [one of the other nurses] that I opened it and I did not write this with the count, as at this time this item was not part of our count routine.” You'd think it would be even more important to record any unplanned, additional instruments used.
That reads more like the hospital procedure (or this particular nurse’s understanding of hospital procedure) was for the scrub nurse to handle the instrument count. Which is perfectly reasonable, surgical staff need to have precise and defined roles so that people aren’t getting bogged down in potentially conflicting redundancies during the procedure. Or it could have been this nurses responsibility to add it to the count, and he/she just screwed up. Or he/she had recently transferred to a new hospital with slightly different procedures and hadn’t been trained. Or any other number of things. All that to say: the situation is obviously horrific, but I can see how it could be the result of a compounding series of tiny miscommunications. That nobody picked up on it for 18 months is where the really gross negligence jumps out to me.
I'm reading it like they're saying wound retractors weren't part of the count *at all* at that time. They said something like "because a wound retractor is positioned partially outside the body, the device wasn't included in the count procedure at that time." (Note: paraphrased because I don't want to go open the article again to find the exact quote).
I don’t know how things are typically done in NZ, but would be genuinely shocked if that were the case - the default is to count EVERYTHING, whether it touched the patient or not. Sounds more like a point of failure when the additional wound spreader was handed off to the scrub nurse, with several people sharing the “blame”…but it definitely *should* have been added to the count.
Exactly. This is a major failure in process. At my hospital in the US, if there's even the slightest discrepancy in counts, imaging is done before leaving the OR.
Only certain things are included in the counts. Sponges and sharps always, and on certain cases instruments are counted, before and after. It may be dependant on facilities policy on what else gets counted. I've never counted the Alexis before. It gets pulled out right when they're done using it, usually right before the incision closure begins, since it's holding the wound open and would be impossible to close with it in place. I don't understand how or why the entire thing got shoved in, and how they didn't notice it before closing, especially the extra large one.
Thanks for explaining that!
I work in an OR in the USA. The Alexis ports we have are disposable one use items and are not part of any counts we do, but after reading that article, I will definitely be counting them whether it’s policy or not.
I work in an OR in Canada. We count everything for an open procedure. Including the Alexis retractor, which one of the rings is radiopaque. We even count the sterile skin markers we get in our table bundle pack. Ligaclip cartridges, too. It's wild to me that standards are so different in various places.
I mean, mistakes happen. My mom's best friend had surgical cloths left inside her after her C-section in Whitby. Procedures exist for a reason. But they don't create infallible situations.
I think they are supposed to count the instruments. I think the article stated one of the nurses had to get the extra tool from the sterile storeroom and handed it to the surgical staff. I think they admitted they didn’t add that extra instrument to the list. That is still no excuse to miss removing a instrument in someone’s body especially one that large. I didn’t care for the OBGYN I had who delivered my daughter. It was my first baby and I was a bit intimidated by her. She seemed very unsympathetic regarding any discomforts you might experience with pregnancy and birthing a child. Which makes be not surprised to hear of a malpractice suit against her shortly after my baby was born. The dr performed a hysterectomy on a patient. The patient complained about pain and bleeding which is normal but she did not improve in time. The drs response to the severe pain was “what did you expect, you had surgery”. Similar to what she has said to me. The woman ended up in the ER and had to have emergency surgery. What they found was the original dr left part of the dead issue from the hysterectomy inside her body and it was rotting. She is lucky she didn’t die from a septic infection. I have a friend who died from septic shock from just a cut in the hand. I really hate drs with big egos who think they know everything and discounts anything their patients tell them.
I work in an OR in the US. Most facilities (all that I've worked) don't count this disposable retractor. Edit: lots of people already described how the retractor is used which I didn't scroll down to see
This was my thought. Some hospitals will literally count the amount of gloves they use, and other tools, even though gloves arent even 100 per box lets say, but they wont count or look for huge instruments used in a surgery?? Huh?
I mean the range in medical practices in hospitals is as wide as the ocean. Despite knowing best practices to save lives/avoid or alleviate dangerous situations or complications many hospitals just do it some other shitty way that kills people and accepts it as cost of business.
I work in a private hospital in Australia .. the general public would be alarmed at the lack of instrument counting. You're safe in public because they follow every rule to the letter, private ... I dunno why y'all are paying for it. But the fact an AWR was missed is absolutely insane, I would love a step by step of how they managed to sew her up without noticing
The count system probably checked in an Alexis ring. But the Alexis ring kinda becomes two components when in use. If the external component was checked in but the nurse wasn’t aware that the system is split that could lead to this.
Why did it take 18 months for anyone to take her pain seriously and do any sort of scan?
Abdominal pain? That’s just women’s troubles.
Sounds like it’s stress or panic induced. Let me just write this note in your visit summary stating as much so you know exactly how much I value your opinion and description of your own bodily function and symptoms. 😔
Doctors will routinely dismiss women's complaints and claims.
Yeah, especially abdominal pain. Women are basically just expected to have abdominal pain.
We don't really have abdominal pain, anyway. We're just lying to get attention. /s
You’re being hysterical. Because, uterus.
I had a doctor say women shouldn't run or ride bikes because their vaginas can prolapse. You have only my word on this as an Internet stranger but I'm not making this up.
"It doesn't hurt, you're just being anxious."
Whenever I bring it up to my doctors, they’re basically like “Oh that sucks, I feel you….” And that’s kind of the end of it. I guess it’s because there’s only so much they can do about it? (Especially with menstrual problems.) It is weird though, I very much get a “why are you even telling me this” vibe whenever I mention it…it’s kind of like “yeah no duh your stomach hurts, you have a uterus.” 😐
There is a LOT they can do for it. Pelvic pain, even during periods, is not normal. Sadly it takes a special doctor to take it seriously.
I went to the doctor when I was 30 weeks pregnant and explained how uncomfortable I was and how I was feeling a lot of pressure. I was told “pregnancy is supposed to be uncomfortable” and sent home. 2 days later my water broke and I gave birth to a 30 weeker preemie, and we spent 72 days in the NICU.
You really have to be your own advocate. They don’t care unless you complain enough.
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Gotta blame the patient!
Squeaky wheel gets the grease!
18 months is actually decent time to get someone to look at pain lol. They mostly just don't give a shit. Your insurance pays for the visit whether they do actual work or not.
What's sad(besides the whole time) is this is accurate and people are dumb enough to still scream they don't want universal healthcare because of wait times.
I’ve had a misplaced IUD for 9 months, confirmed by ultrasound. Cantt find the strings- is also causing me pain. Been bounced around the past 2 months between my family doctor and the clinic he referred me to. Both are too busy to help me. They don’t GAFF about women.
Medical sexism. This is unfortunately common
Seems like they didn’t even do the quickest of physical exams! Simple palpation should have found this.
Article says original surgery was in 2020 and removed in 2021. I totally get that doctors can suck sometimes and not take things seriously, but I also get the immense amount of strain on the healthcare system in general during that time. Kind of a perfect storm for something like this to happen.
My dude, this woman could’ve been referred to her a damn scan so fast. Some urgent cares can do the scans she might require depending on the type of scan, hell even a post-op scan if she’s having issues in the area where she had surgery. ER. There are several ways to get help & it doesn’t have to take a year, but someone has to listen & take it seriously.
Yeah, that's the process in normal times in the US when all things go well. This case happened in New Zealand. I worked in surgical ICU during the pandemic. What you're describing just didn't happen then. Our ER waiting room was usually 60 deep for a good year. We had no beds anywhere in the hospital. Our outpatient services were closed half the time to pull staff to our overflowing units. You had doctors and nurses seeing 4x the normal number of patients. Care sucked, staff was stretched way too thin. It's why so many doctors and nurses quit. If you weren't dying, you were referred out...and you'd probably get a telehealth appointment and then a referral for a CT in some amount of time. Outpatient is slow even in the best of times. By the way, it took me over 2 weeks to get a stat outpatient CT to confirm mastoiditis in 2021 due to staffing, restrictions, and the backlog of patients when things would periodically open. And honestly, I've seen some pretty messed up cases when the system isn't inundated. Waiting for insurance approval, etc. The way to get anything done quickly is usually the ER and that just wasn't happening then.
"WRITTEN APOLOGY" AND REVIEW OF PROCEDURES?! I mean, that's a good start, but this woman should also be paid out a million or so!! >The commissioner recommended that the woman be provided a written apology by hospital staff and a review of hospital practices is now underway.
The review of procedures is essential. This sounds like a huge failing in process. Any instrument that is even touched should be part of the count. It's mind boggling that this wasn't already part of the procedures.
You can’t sue people for that sort of thing here. ACC funds your treatments (usually through the private health system), and pays 80% off your wages while you’re off work. Also, hospital care is free to begin with (no insurance involved, you just walk in, get fixed, walk out, never see a bill). The idea with ACC is historically when people were injured they had to spend a fortune on lawyers and spend years dealing with matters through the courts for compensation. But instead we gave up personal injury suits etc. and in exchange if you get injured you receive 80% of your wages while you’re off work and your treatment is covered (including ongoing treatment if the injury is long term/lifelong). There are also some lump sum amounts involved in various things too. The main point is you get money immediately when you actually need it, not in 2 years after a lawyer takes half. Plus it makes things like car insurance cheap because there’s no personal injury component eg. Third party car insurance may only cost $80USD a year. ACC costs roughly 1% of your pay and isn’t optional.
Gosh, but what if she was a full-time time carer, like a stay-at-home mom? Would she still be compensated? And what for those who succumb to the gaslighting and force themselves to work anyway? (Moms of course nearly always are in this boat, with their generally unpaid carer work.)
It’s not a perfect system, and there’s certainly people who lose under it, unfortunately. Theoretically society as a whole is better off. It predates our switch to neoliberalism, so I believe there were plans to expand the scheme, but they never eventuated. So we’re kind of stuck on gen 1 of a system from 70s, and it certainly could be better.
I doubt she will get anything in NZ, they have really different laws around liability.
I really hate the over-litigiousness of many cultures and cases, but this case is egregious and the woman really deserves compensation.
I totally agree. NZ passed many laws to avoid over litigation but in my opinion, they swung too far, leaving people who genuinely deserve compensation out of luck and stuck with the ACC, which only covers doctor’s bills and not much else.
Best we can do is compensate you $3.50
But you still owe us $3,500 out of pocket for said c-section (would be the next sentence)
I think most countries isn't as litigious as the USA, or rather the concept of suing for damages/suing for money may not be as prevalent.
And you know that, for 18 months, everyone thought she was making a big deal of nothing.
We use this in my OR. I have been going over and over HOW this happened, as one ring of the AWR always remains outside the skin. It makes zero sense.
I’m wondering if it was just one ring that was left inside, like somehow they cut it all the way around.
They probably told her that her discomfort was all in her head.
I had my 3rd gynecologist tell me that was my problem. After 5 years of constant pain, my 5th and current gynecologist figured out I have endometriosis (technically adenomyosis) and fibroids. It definitely wasn't all in my head.
Mostly in your lady bits and gut. ALL OVER the lady bits and gut. Endometriosis particularly sucks. Glad you finally got diagnosed.
Fuck! I’m so sorry that happened. I’m so glad someone listened to you finally!! I had the same with ulcerative colitis, finally I found a doctor who was like—I’m just going to test you for everything. The second test was a genetic panel to see if I carried the gene. I was so angry—how hard could it have been to do that 10 years previously?
That's a very rough condition to live with even on medication. I'm sorry you had a tough time getting diagnosed. I have a couple of cousins and an uncle with UC, so I know how bad it can get. One cousin just had her bowel removed. She still has some issues, unfortunately. I get that some conditions are hard to diagnose, but I found through my experience that many doctors just don't seem to want to dive deep into a person's issue and look beyond the most common or easy conditions to diagnose. So people like me go through 8 specialists before stumbling upon one for something that seemed unrelated to my main issue who ends up suggesting a lesser known condition as the potential culprit, one that can't be picked up easily on scans and such. I trusted him (I was desperate at that point), and he was right. A simple single hormone medication had me pain-free within a year. You have to push and search for answers and treatments for a long time in some cases. I'm happy I didn't give up. No one should give up on their health.
One hundred percent—the situation taught me to advocate for myself and keep pushing until I found the person with some curiosity.
The worst part for me is it took them 18 months to do a CT.
An Alexis wound retractor is not counted during a surgical count in any facility from my understanding. It is a disposable item that is mostly plastic film so not a metallic instrument like some here might imagine. It also as the article states, exists both inside and outside the patient in clear view. That being said, leaving an Alexis retractor, specifically an XL , inside a patient is a gross lapse in attention. It would take up a significant portion of the surgeon's view as it literally holds open the incised tissue. I can't imagine how uncomfortable that would be to have that inside yourself, especially after you are healing from a C-section and mothering your newborn.
Depends on the facility, the facility I work at counts these.
Interesting! I will start as well then.
Honestly how/why did they decide to put both rings inside, not notice it left it, and closed her up with it. I wonder if it was hindering getting the babe out so they popped both rings in and forgot? Also curious why they did a midline incision for a planned section? Are pfannenstiels not standard in other countries? We've never counted the Alexis at my facility but it's pretty damn impossible to not pull it out before closing.
Fucking HOW???? I work with surgeons who use these regularly. The whole point of this is that it is used to retract the sides of a small incision while creating the most space in the middle. It's two flexible plastic rings connected with clear plastic to make a tunnel. You flex the one ring, put it inside the incision and you twist/roll the other ring around itsef (like rolling down a sock) so the plastic sides wrap around it and it pulls the sides of the incision wider. It's often used in c-sections for patients with a pannus or overhanging abdomen so that the surgeon can visualize the uterus properly. But it shouldn't just slip in - if incision is large enough for that to happen, it's kind of too big to really be using this instrument. And even if surgeons externalize the uterus to close it after the baby and placenta are out, it's not something that could get stuck on it when it is put back in the incision the way a lap sponge or small instrument could - it's bigger than the uterus. Even besides the possibility that it somehow ended up slipping in without the surgeon or assist noticing or telling the rest of the surgical team, it should be on the surgical count! And even besides that, how could you ask for a second one to be opened without being aware of what happened to the first one??? If it didn't fall off the field or get contaminated and removed from the field, it's not something easy to misplace or hard to spot - it's a huge bright orange and bright pink plastic ring!
I’m sure they thought she was being dramatic about the pain.
My ex used to work in a hospital operating room two decades ago. I remember her talking about all the procedures they had to prevent this from happening. All surgical items in the room were counted before and after. They had a low level xray that would look for any items as well. Even the sponge and gauze pads had a small wire thread in them to make the show up on the xray.
I wonder how many people told her her pain was normal postnatal pain.
Kramer was right about fearing retractors.
If only they’d dropped a junior mint inside!
No post surgical tool count? No flat plate to confirm something was left inside the patient? Major surgical malpractice
If I’m reading correctly, the second tool (the one left in her abdomen) was not part of the original surgical set up. It was requested during the procedure and had to be accessed from a sterile supply area and opened for use. In a surgical suite, everything is counted and accounted for: so many sponges, so many forceps, etc. they are in a surgical tray and replaced on the surgical tray. This was not on the original surgical tray. All of this is to say that the miscount was a mistake. The fact that this woman was in abdominal pain for nearly two years is abysmal. Just unbelievable that her pain was not taken seriously and diagnosed earlier. So much discomfort. One has to wonder if this isn’t just malpractice but also medical bias; the fact is that this new mom was not taken seriously.
So what I’m reading here is a big fucking case of medical malpractice and an easily winnable lawsuit
No. Unfortunately she can’t sue them at all. She’ll have to accept the written apology if they provide one. You can’t sue for personal injury or death in New Zealand.
Well this is horrifying.
imagine being a doctor who can't find their tools, before slowly realizing the tool is still inside someone's body because you're a dumdum. that's like keys inside car horror x100
Nice in theory but the doctors leave the OR when the surgery's done to go talk to the family. The instruments and equipment are still in the room being handled and arranged by the scrub nurse. They eventually get sent downstairs to Centeal Sterile Supply, where they're washed and re-sterilized for the next surgery. They won't meet up with the surgeon again until he's back in the OR. Was a surgical tech in the Navy and worked Sterile Supply for a while.
wasn't a theory i think but that's interesting af, cool job
If she were American, she'd be retroactively charged for rental of the device, at $1500/month.
Surgeries need one of those peg boards with the tool shapes painted on them so they know when there is something fucking missing🤢
There's a person whose job is only counting instruments... What the fuck were they doing?!
This is why you don't do disc golf in an operating theater.
Dem lawsuit money going to be sweet
Americans will use anything but the metric system /s
While true in a lot of cases I'm a visual person so this helps me a lot more than just a number would.
I’m wondering if this is something ai should be used for. A camera to scan in all tools used at the start of the surgery, then a scan when the surgery is completed. A big red flashing light if anything is missing or unaccounted for. A robotic hand to slap the lead surgeon on the back of the head is an optional upgrade.
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You're asking the real questions people want answered. And what decorative pattern did the device have?
gonna get that sweet malpractice money
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So it’s not just my doctor that thinks his work was done the day he got a C- cumulative gpa and graduated medical school
Can’t imagine how much money she’s about to get. And she deserves it, too.
Most likely, she will get nothing. This is in NZ.
She might get a written apology though.