I Survived: A surgical screwup

I Survived: A surgical screwup

It's every veterinarian's worst nightmare: an errant sponge left inside a patient after surgery. Here's how our practice recovered.
Apr 01, 2010

I consider myself to be a pretty good surgeon. At our five-doctor small animal practice, I perform a variety of complex surgical procedures, from arthroscopy and laparoscopy to TTAs (tibial tuberosity advancements). So when my young associate called me in to assist with an emergency, I was confident.

The clients were new to our practice, and they brought in their 1.5-year-old Labrador retriever, Chloe, with acute abdominal distension and fever. An ultrasound revealed that the dog's left kidney was normal, but there was only a mottled area where the right kidney should have been. Free fluid was present in Chloe's abdomen, but she wasn't azotemic. A high white blood cell count and anemia along with elevated pancreatic enzyme levels didn't seem out of line with my top suspicion: a ruptured right kidney.

We went right into surgery and removed an enlarged, hydronephotic kidney that had virtually split in half. I wasn't able to identify a ureter on that side, plus Chloe was missing her right uterine horn, which led me to suspect a congenital abnormality with secondary hydronephrosis in this young dog. Chloe's abdomen was filled with a large amount of fluid and inflammation, so we lavaged the area aggressively. Chloe recovered uneventfully and went home the next day.

One month later, Chloe returned to the practice with the same signs: fever and abdominal distension. An abdominal radiograph stopped my associate and me in our tracks. In the right cranial abdomen was a radio-opaque marker from a lap sponge. Our hearts sank.

We wondered how we should tell the clients. My associate had been out of school for only a year and was envisioning speaking to the licensing board next. I told her, "Don't lie. Let them know we think there was a problem from the previous surgery and Chloe will need to be explored." The owners agreed and, while still reeling from the shock, we removed the sponge, along with a large amount of granulation tissue from the area where the ruptured kidney had been. The abdomen cultured negative and Chloe's recovery was again uneventful.

Not wanting to drop any more stress on my already nervous associate and because I was the head surgeon, I decided to speak with the owners. I explained the error and that we suspected it was the cause of Chloe's complications. They were obviously upset and looked at us like we were a bunch of quacks. They wanted the initial fee for the nephrectomy refunded. I kept very calm and apologetic but declined to refund the initial surgery since the sponge didn't change the fact that the initial surgery was necessary. We would, however, cover any costs associated with the sponge and its complications. I also informed them that I wouldn't skimp on care—Chloe would receive all the medications and tests she needed at our expense.

Sensing that the clients needed more explanation about how a sponge could be left behind like this, I explained that the sponges were used to block off the liver during resection and had become blood-soaked and difficult to see. But ultimately, we failed to account for it and the buck stopped with us. I made it clear that we would institute new policies to prevent this from happening again. I also told them I was doing what I'd taught my kids to do when they messed up: admit your mistake, apologize, and do anything you can to make it right. I gave the clients my personal cell phone number and told them they could call anytime with concerns. I made time and even came in on my days off if Chloe needed to be seen. When Chloe was hospitalized overnight, I came back to check on her and called the owner around bedtime with updates. Communication was key.

Chloe did great for another month, then returned yet again with the same signs. Feeling sick ourselves, we went in again and found an intense inflammatory response around the pancreas with the intestines adhered together in a tight ball. After an hour of desperately trying to free the intestine from these masses of inflammatory tissue, it became apparent that we weren't going to be successful. I called the owners and told them I couldn't save Chloe. They consented to euthanasia.