It was a day just like any other during my general surgery rotation. The attending I was working with had a full day of cases in the OR. The first operation was an inguinal hernia repair and it proceeded without a hitch. The second case was a laparoscopic cholecystectomy, which also proceeded as planned. After the third patient was rolled back to the OR, transferred to the table, anesthetized, and draped, the attending (already scrubbed and gowned) reached up to adjust the overhead lights. It was then that he realized one of the two lights already had a sterile green handle cover, yet there were still two handle covers on the mayo stand that had not yet been put on the the light handles. “Why are there 3 handle covers in this room? There should only be 2,” he remarked. “Is this handle cover from the last case?”… Continue reading →

As I watched Lewis Blackman’s story unfold before my eyes on the screen at the front of the room, I found myself becoming angry. How could this 15 year old boy be dying? He entered the hospital for a minimally invasive procedure and I’m sure the last thought on his and his family’s minds was that he would never step outside again. As I watched his heart rate increase, and his abdominal pain worsen, and then his blood pressure drop until it was no longer detectable, I was screaming on the inside, “why has no one scanned his abdomen?! He is bleeding into his abdomen!” I did not know why he would be bleeding into his abdomen when he had surgery on his chest wall (I didn’t know ketorolac can cause GI bleeds), but the developing clinical picture seemed to fit that diagnosis.

When one physician writes a statement in… Continue reading →