Uh-oh, help/reassurance needed!

Re: Uh-oh, help/reassurance needed!

Bob Russell — Mon, 28 Feb 2011 14:02:56 GMT

We had a massive box of pre-packed swabs (X-ray marked) and were sure the wholesaler had invoiced them incorrectly. They turned out to be very cheap so we use them all the time for routine procedures. We do have lap swabs if necessary but I would think I would notice one of those left in an abdomen.

I still count to five when I open the pack!

Always be honest. Good clients will cope and good and bad ones will create a heck of a lot more fuss in the long run if they feel they have been misled!

Re: Uh-oh, help/reassurance needed!

Richard Fox — Mon, 28 Feb 2011 11:40:11 GMT

Yup - also had an oozing bitch after a spay - kept her in overnight and said to the owner she had lost quite a bit of blood and that she was best to stay in - the next day was more comfy and PCV stabilised - I think honesty is usually the best policy :) You think the worst but it usually never get close - just use it as a learning tool and count you swabs if you think it is best?

Re: Uh-oh, help/reassurance needed!

Kate Richardson — Mon, 28 Feb 2011 10:58:07 GMT

We use pre packed swabs that come in packs of 5. Not sure how much more expensive they are? We have ones with and without radiographic markers.

Several years ago when I was working in Australia, I had to spay a GSD with pyo. All went fine, but 2 years later (which given the previous practice had diagnosed her with lung cancer a year prior to the pyo so the owners were delighted with her longevity -xrays looked completely normal for an older dog IMO) anyway she had recurrent cystitis signs so eventually we xrayed her to look for uroliths and were quite surprised/shocked/concerned to see a large pair of forceps lying in her ventral abdomen! They were approx 8-9" long!!!! Ex lapped and removed, completely covered over with omentum, uneventful recovery! Fortunately the dog belonged to the vet nurse's parents in law, who were very understanding, but thought we were great as we had removed the gloom of death from lung cancer from their dog! Dog showed no signs of 'cystitis' after that! Amazing what the body will deal with. Lucky she was such a large dog I guess! My boss wanted to clean the forceps off and re-use them!!! They found their way into the bin........

Hope your dog is doing ok, am sure she will be fine, my thoughts were more wound related problems, not peritonitis. Hopefully that has been proved to be the case by now and she is doing fine

Re: Uh-oh, help/reassurance needed!

Glen McIntosh — Sun, 27 Feb 2011 23:38:33 GMT

[quote user="Gerry Henry"] I now count all swabs in front of the theatre nurse, before and at the end of every procedure.[/quote]

Only last night I counted 21 swabs before going in on a pyometra - should have only been 20.

Re: Uh-oh, help/reassurance needed!

Gillian Mostyn — Sun, 27 Feb 2011 20:36:43 GMT

[quote user="phipps"]False economy. They are not that much more expensive (one or two pounds at most) in the scheme of the whole surgery, so I have no qualms in reaching for the laparotomy swabs (not sponges) and no qualms about charging the client for it. [/quote]

One or two pounds on every routine op IS significant.

[quote user="phipps"]Obviously not for routine spays of course.[/quote]

My mistake - I thought we were talking about what you use in routine bitch spays.............. obviously in a haemorrhaging bitch post spay cost becomes somewhat irrelevant.

Re: Uh-oh, help/reassurance needed!

Utlendigur — Sat, 26 Feb 2011 23:07:43 GMT

[quote user="Gerry Henry"]

I now count all swabs in front of the theatre nurse, before and at the end of every procedure.

[/quote]

Ditto. I started doing it when I counted the swabs after a bitch spay one day and found 11 instead of 10. Came in useful one day when I counted the swabs prior to starting another bitch spay and found 9 instead of 10 in the kit. I can imagine the fruitless, increasingly panicky rummaging round the abdomen if I hadn't, followed by sleepless nights.

Re: Uh-oh, help/reassurance needed!

Gerry Henry — Sat, 26 Feb 2011 22:41:35 GMT

I left a swab in an abdomen for the first time after almost 30yrs last year! Worse, it was picked up by a neighbouring practice. Our double check failsafe failed; the paper audit said everything that went in came out but the radiograph begged to differ. In our case we always use marked swabs so an X ray will instantly confirm or dispel your worst fears. If you're still in doubt, own up and go back in. I now count all swabs in front of the theatre nurse, before and at the end of every procedure.

Re: Uh-oh, help/reassurance needed!

Evelyn Barbour-Hill — Sat, 26 Feb 2011 21:18:11 GMT

Lor, we've all had sleepless nights worrying, only to find everything fine.

I can't resist adding my two penn'orth about precautions. My rule is that no swab ever goes into the abdomen without something attached to it: if not your hand, then some artery forceps, a string, anything. It helps with peace of mind.

Re: Uh-oh, help/reassurance needed!

Mark Hedberg — Sat, 26 Feb 2011 21:02:43 GMT

[quote user="An On MRCVS"]

We were careful to ensure no swabs were put in the abdomen without being removed, but when we counted them before stitching up, we were one down from the number that we should have had if all the swab packs had their full quota - they often don't at our hospital alas.

Both my colleague and I were satisfied no swabs had been left in when I sutured her up again.

Now I am starting to think of worst case scenarios, such as - did we leave a swab in?? Has anyone had any experience of this? when would signs appear if a swab was left in? how much pyrexia is expected after such a big surgery and blood transfusion?

Please be nice, this is really stressful and the dog is lovely.

[/quote]

How's doggy?

It might all turn out to be just a mild postop infection (going in twice is certainly stressful, and you might not need a swab to get that one naughty bacteria in the wrong place, especially if you're rooting around looking for the uterine stump.). Alternatively postop pain and bruising from the second op could cause panting and increased temp even without infection. (There's a lovely book on Analgesia and Pain

Best way to keep this stress free next time, in my opinion, is to see if you can find out about the swab packs. If they are often not at quota, it definitely needs looking into, but that's an organization issue, not a medical issue. Accurate swab counts are important; do you have a manager you can mention this to? It should be strongly stated from above that the swab packs have accurate and consistent count. (At least, we do where I work currently and it's not exactly a taxing job - all we're asking the prep staff to do is count the swabs they put in the pack before sterilization and make sure it's 4 in our kits, or 6, or 8, or whatever number happens to suit your workplace. Not a long job, takes a few moments.)

(If you're worried about this reflecting on you, it's fine to wait until dog recovers fully. Then mention how stressful it was to you to have an incorrect swab count, mentioning that both you and your colleague were satisfied none were left in cavity.)

Re: Uh-oh, help/reassurance needed!

Glen McIntosh — Sat, 26 Feb 2011 13:25:07 GMT

[quote user="Gillian Mostyn"]It's a lot cheaper to use counted 10x10 swabs with a radiodense marker! You should only need to use lap sponges if the abdo is doing a good impression of a swimming pool....[/quote]

False economy. They are not that much more expensive (one or two pounds at most) in the scheme of the whole surgery, so I have no qualms in reaching for the laparotomy swabs (not sponges) and no qualms about charging the client for it. Obviously not for routine spays of course.

If the abdomen is doing a good impression of a swimming pool then you should be reaching for the suction apparatus.

Re: Uh-oh, help/reassurance needed!

Gillian Mostyn — Sat, 26 Feb 2011 12:51:08 GMT

[quote user="phipps"]And where ever possible I use 30cm x 30cm laparotomy swabs if I am putting any swabs inside the abdomen[/quote]

It's a lot cheaper to use counted 10x10 swabs with a radiodense marker! You should only need to use lap sponges if the abdo is doing a good impression of a swimming pool....

Re: Uh-oh, help/reassurance needed!

Glen McIntosh — Sat, 26 Feb 2011 11:50:15 GMT

I've had panic attacks of this nature a couple of times. To this day I do not know for certain if I had left a swab in the abdomen in those cases, but having obsessed about it for several days after the event I came to the conclusion that it was very unlikely that I had.

One things for sure, after those couple of episodes I now make an effort to count swabs before starting surgery and counting swabs before I start closing up. And where ever possible I use 30cm x 30cm laparotomy swabs if I am putting any swabs inside the abdomen. I reckon it would be harder to leave those behind.

You are entitled to be stressed and upset about this, but don't dwell on it for too long. Most of us have had similar fears, and I suspect that, as is probable in your case, that we haven't actually left a swab behind. And it would help to remember that even if you did leave the swab behind and the very worst possible outcome that you can imagine occurs, it will seem bad at the time but you will survive and you will come away from the experience wiser and a better vet. We all have our battle scars.

Re: Uh-oh, help/reassurance needed!

Hannah Wynne Richards — Sat, 26 Feb 2011 11:22:30 GMT

I second everything Bob has said-and good luck-you obviously care which means you are the right type to be a veterinary surgeon

Wynne

Re: Uh-oh, help/reassurance needed!

Bob Russell — Sat, 26 Feb 2011 11:16:45 GMT

I referred a spaniel to one of our soft tissue specialist because I could not find the cause of her illness. I did say to the owner that I was suspicious that there was a soft FB but I could not find it even with contrast radiographs.

I got a phone call and was devastated to be told that the surgeon had found a swab inside. She had been spayed here several years before! In my defence I was a little comforted when she told me that her theatre nurse (who used to be a nurse here) remembered the surgery was carried out by a locum when I was at WSAVA in Bangkok at the time. The locum was extremely experienced so disasters don't just happen to the inexperienced.

We learnt from the experience (VDS, VDS, VDS!) and the swabs we use all have markers in them. We do strict checks when we open packs and again before closure. It helps me sleep knowing that another member of staff has seen that both ovaries are completely removed, there is not bleeding before closing and the correct number of swabs are present on the tray.

Remember you are human and fallible and make mistakes (and are allowed to make them). It is much easier to lose a swab outside the body than in it. So hopefully the panic will prove unnecessary.

The fact you are so upset about it suggests you are the type of vet I would prefer to entrust my animals to. The vet that does not care is the one to avoid. Whatever has happened it will sort itself out in the end!

Re: Uh-oh, help/reassurance needed!

Rob Reid — Sat, 26 Feb 2011 10:58:07 GMT

[quote user="Rob Davis"]Some years ago I palpated a tennnis ball sized mass in the caudal abdomen of an Airedale at a routine vaccination check. I removed the mass (was enveloped in omentum) and sent it for histopathology. The report suggested it was likely to be a reaction around a surgical swab.[/quote]

I had a similar situation in a previous job - the dog had been speyed at a rescue shelter which was likely where the guilty swab had been left in. Walled itself off nicely from anything important, just a minor attachment to the small intestine which blunt dissected away with ease.

OP - Don't worry about having to open a spey up again. We've all been there, your heart goes through the floor but complications happen to everyone, even the best surgeons in the world.

If the dog is doing well it is unlikely to be anything nasty, but I would echo the advice of others and be checking white cell counts before I go back in with the scalpel. And just be honest with the owner, most clients are amazingly understanding (and indeed appreciative) when they realise that all you are concerned about is the welfare of their pet.

Re: Uh-oh, help/reassurance needed!

Rob Davis — Sat, 26 Feb 2011 09:43:53 GMT

[quote user="An On MRCVS"]did we leave a swab in?? Has anyone had any experience of this?[/quote]

Some years ago I palpated a tennnis ball sized mass in the caudal abdomen of an Airedale at a routine vaccination check. I removed the mass (was enveloped in omentum) and sent it for histopathology. The report suggested it was likely to be a reaction around a surgical swab. The only time the dog had had any surgery was when she was spayed 5 years previously. I decided that the best policy was to be completely honest with the owner (she had be spayed at our practice by a locum). I could not have wished for this to happen to a better owner. She was a retired human theatre nurse, and told me she had seen much worse things left behind in people! She recovered well (and had not shown any ill-effects previously), the practice obviously covered the cost of the surgery, and the client was if anything and even better advocate for the practice afterwards as she appreciated the honest approach.

Surgical nightmares are fortunately infrequent, but they do happen to all of us. Many of us unfortunately have an in-built propensity for over-worrying about our patients and our treatments, and this is not healthy. Following this event I am always meticulous about counting swabs in and out as even though it wasn't me who left the swab in the first place, I am paranoid about doing it myself.

I hope that she recovers well, but whatever happens, don't beat yourself up!

Re: Uh-oh, help/reassurance needed!

Ruta — Sat, 26 Feb 2011 09:29:44 GMT

Hello,

Yes, it is really stresful situation, and I hope you doing well after all. Once I had done cat spay, it was first operation by my own. She was pregnant, and it was more stresful, because I noticed that just when opened the abdomen. Operation was fine, but when I finished it, I noticed that filament was without needle. I was scared until death and thought I left it in abdomen. At last I saw it on the floor. I really don't know how this happened.

So, could it be the same to you? Are you sure that swab, which you think left in abdomen is not laying in operation theatre bin?

Take care!

Ruta

Re: Uh-oh, help/reassurance needed!

Mark Hedberg — Sat, 26 Feb 2011 07:45:33 GMT

Some patients just don't behave themselves. Sometimes the premed (acp or dom, can be either) can send the bp crashing through the floor. Happened last month to my boss of 30 years experience, and now it's happened to you. Deep breath, don't panic. Go get a hug from somebody, it's healthier than booze and more fun. If the pyrexia hangs around another week, grab a hematology to check infection and explain to the owner your deep concern for their (and indeed every) patient you touch. Communication is vital here. If they are on your side it's be fine.

Re: Uh-oh, help/reassurance needed!

An On MRCVS — Fri, 25 Feb 2011 21:42:00 GMT

The owner thinks she is doing really well, is bright, eating well, no vomiting, possibly urinating more (am worried about this too, her BP did go quite low when we opened her up, despite blood, colloid boluses and crystalloids intraop). I often find animals have pyrexia post surgery, so much so that I only take temperatures at post op checks or routines if I think there is a problem as they are nearly always in the 39's. Am seriously hoping that the PUPD is not real and that her temperature is nothing to worry about! I am definately worrying more than the owner, but I suppose I am more aware of the potential complications!!!

Re: Uh-oh, help/reassurance needed!

Julie Innes — Fri, 25 Feb 2011 21:33:46 GMT

Well, I've never (to my knowledge!) left a swab in something....but I have lain awake half the night worrying about ops I've done that day/ week, and know how horrible it is!! It's really unlikely that you left a swab in, so try not to worry (easier said than done, I know!)

Wine is a good idea! I'm sure you will be monitoring the dog over the next few days, so see how it goes and act accordingly. As far as the pyrexia is concerned, is the bitch eating? bright? I've found some dogs seem to have a persistent pyrexia in my surgery, even at routine boosters,(is this like white coat syndrome in humans?) so I always look at the dog as a whole, rather than focus on the reading on the thermometer.

Hope it all turns out well (sure it will!)

Re: Uh-oh, help/reassurance needed!

An On MRCVS — Fri, 25 Feb 2011 21:23:43 GMT

Thanks everyone, you and the wine have calmed me a bit!

Re: Uh-oh, help/reassurance needed!

Mark Holmes — Fri, 25 Feb 2011 21:09:46 GMT

I find swabs the veterinary equivalent of leaving the iron on when you go out. You can worry about it too much. I have left one or two in. You don't think you might have - you know you have. Thankfully the brain itch has always started before the dog has been recovered and the swab retrieved very quickly. If two of you had good hunt around and are both happy no swab was left, then no swab was left. It will be the transfusion.

Re: Uh-oh, help/reassurance needed!

Amanda Nicholls — Fri, 25 Feb 2011 21:03:02 GMT

[quote user="An On MRCVS"]

I am hoping that someone can lay my mind a little at rest about a potential disaster - it's becoming a catastrophe in my mind at the moment anyway.

[/quote]

Please try not to worry yourself too much, this job is stressful enough without creating extra worry about what ifs after every procedure we do. I expect you are feeling a bit paranoid after the awful experience you have been through and I think as you were careful with the swabs in the abdomen, chances are you did remove them all.

I expect we've all been there with bitch spays bleeding post op. Mine was a Great Dane and I really beat myself up over it until several years later I worked in an OOH clinic and realised these things happen even to the best vets! And regarding swabs being left behind - i referred a case to a vet school for surgery, a year later it came to light that a swab had been left behind. It was in the thorax and presented as a discharging sinus, I don't recall ever seeing one in the abdomen so I can't say what you should look out for, only that I think it is so unlikely, I don't think you should open the dog up again while her abdomen is comfortable.

Have a nice big glass of wine tonight and relax!

Re: Uh-oh, help/reassurance needed!

sarah mason — Fri, 25 Feb 2011 21:00:25 GMT

I had a dog present with acute onset vomiting, projectile diarrhoea on a weekend who had a history of eating FBs. Abdominal x-ray showed a swab in the cranial abdomen which was then removed uneventfully-had been left in at an ex-lap to remove a sock a few months previously.

If not improved I would explain to the owner that you are worried something could be amis and a quick xray would be best to rule out anything suspicious-it will certainly put your mind at ease if you don't see one. At least you have the radiolucent ones!

Re: Uh-oh, help/reassurance needed!

Catherine Williams — Fri, 25 Feb 2011 20:37:04 GMT

The only case I've encountered of a swab left in a dog was a spay that bled, no immediate signs, some months later there was just a vague malaise + on abdo palp felt a lump that we suspected was a mass on the end of the spleen. No ultrasound available so ex-lapped + found a swab with a lot of localised reaction, did fine once removed. Fortunately dog belonged to receptionist, I tried not to enjoy the fact that the operating vet responsible was the one who always gave me grief for being too slow and careful on my bitch spays at the time (I was a relatively new graduate back then)

There were no reported problems immediately post-op with that dog + really very little sign when she did have difficulty and I know she made a complete recovery. I've also had a few pyrexias post transfusion. I'd agree, treat the fever, give her some time, wouldn't be jumping back in there just yet