He was 450 pounds and was coming in with a series of problems that hopefully would have been taken care of by gastric bypass surgery using a scope. Most of these patients are already sick and gastric bypass is their last option for a healthier life.
During the surgery, we had complications with forming the stomach pouch that would allow this patient to restrict food intake. The stomach was transected but the tissue was too heavy and thick. The staples did not form and there was fear that the pouch would not close. If that was the case, everything this patient would have eaten would have gone into the sterile abdominal cavity causing serious infection and possible death.
The surgeons decided to put more staple lines in and take a larger portion, thus closing the pouch. But after a while, it was difficult to tell where we were at. The stapler began to make some funny noises. I'd heard them before and knew it was because they were either, cutting over an instrument or going too fast and that they were taking too much tissue into the stapler for it cut properly. The cartridges were bent when they came out. I suggested using a larger stapler to ensure a better closure. They did not. We soon found out that the spleen had been sliced and the bleeding was difficult to stop. I've seen this before and told the nurse to get the "open" instruments; I thought they were going to convert from a scope to an open belly case. They did not. They just kept cutting away.
Out of concern, I asked a few days later what happened to him. I was told he passed away from complications due to surgery. The day after his gastric bypass, they brought him back to the OR to remove his bleeding spleen and was sent back to the floor to recover. He did not make it through the night.
I knew things went wrong. I knew I made the appropriate suggestions but I have very little authority in the OR. I knew we should have converted to an open case. I knew the doctor was rushing along (as he always does). I also knew that he was not going to take my advice. Rightfully so, why should he? This was HIS patient and HIS surgery and no one was going to tell him what to do. But I saw the signs and, if it were my patient and my license, I would have opened him up and taken care of things differently. But, it was not and I am under the direction of the surgeon, working under the RN's license. (these are things I would like to see changed so that those in my position would have more a "voice" in the OR).
Who was at fault? Did we do something wrong? I am now locked in a moral and ethical battle with my conscience. I will be writing an anonymous incident report (although, how anonymous can it be? there were only 7 of us in the room). I could lose my job but things like this should not happen.
ninibud92 posted on Jan 26, 2007
| views: 362
Comments
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MissMimi said on Jan 26, 2007....
You did what you could do, ninibud. You said yourself that the doctor wouldn't take your opinion into account. The buck stops with him. I applaud you for making an incident report. I think you're doing the right thing.
I think this also points up the fact that bariatric surgery is major surgery, there are definite risks, and shouldn't be undertaken lightly. This was a tragic incident, but it wasn't your fault.
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ninibud92 said on Jan 26, 2007....
Bariatric surgery is a HUGE risk! When people speak of it as a major weight loss plan, I tell them what has happened to others and what I have seen. People die from this and it is very dangerous.
Thanks MissMimi
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secretlife said on Jan 26, 2007....
if you know something is wrong...then i personally think that you owe it to the next patient and the next and the next to report the incident in some manner.
how would you like your mother or brother or child to get that doctor?
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ninibud92 said on Jan 26, 2007....
exactly, secret. which is why I will be writing that incident report. It is the quickest way I know how to bring attention to the matter with the administration.
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MissMimi said on Jan 26, 2007....
ninibud, do you have any experience with the lap band procedure? -
ninibud92 said on Jan 26, 2007....
I assist with the lapband procedures 4 times a week. -
mom said on Jan 26, 2007....
It is stated that Gastric Bypass Surgery is quite dangerous. People have them done anyway. It is a risk that they are willing to take. From what I have always been told is that you don't tell a doctor what to do. You said what you felt was right and he ignored you. It may have saved that mans life. You'll never know.You have a right to nail this doctor. I applaud your courage. Don't you think you feel guilty whenever a patient dies even if it is not your fault?Keep us posted on how this goes. -
Jenna said on Jan 27, 2007....
Wow...this is a tough one ninibud. I applaud your courage too. You do need to make the report. This is a very sad post. This someone....he was someone's son....someone's friend. I am sorry he is gone and sorry that a doc did not take his time. I hope you do not lose your job over this. Keep us posted on what happens. And good luck to you! You are so brave....in so many ways! -
secretlife said on Jan 27, 2007....
ninibud: this is precisely the reason I could never do what you do. I don't think i could bear to see what you see and know what you know......and i think seeing it over and over would harden me so badly that I wouldn't recognize myself.
you are much braver than i am.
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gingersoul said on Jan 27, 2007....
Nini....i am not a surgeon, i am not a nurse, i am just a patient that has been under surgery more than once and more likely will be there again. Dont we all soon or later?
I just hope to find in that room more people like you and no one like that merciless, rushins, too busy with other kind of surgeon.
You did what you could do in your position.
And the fact you are willing to risk your job to purse the right and to avoid other patients such avoidable death give you tremendous honor.
You see things i would never be able to witness......not only the sterylized, practical cut and open but the pain of these patients and their families...
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MsStar39 said on Jan 27, 2007....
I think it's commendable that you are willing to do something by reporting this. -
ninibud92 said on Jan 27, 2007....
It is my responsibility to protect these patients. -
silverwhisper said on Jan 28, 2007....
nini, i'm so sorry to hear that. does your hospital do a M&M survey after each patient fatality, or engage in some other form of formal inquiry?
ed -
ninibud92 said on Jan 28, 2007....
yes, the PA's have a monthly M&M meeting and discuss what has happened. Unfortunately, techs are not able to attend. But I can still give my record of events. -
silverwhisper said on Jan 29, 2007....
that seems like that's as much as you can do. i'm glad you're doing it.
ed
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