TETRA PHOBIA

TETRA PHOBIA
Dr. Gangadhar Sahoo

In surgery, surgeons are more afraid of foreign bodies  than the bleeding or tissue damage during surgery. Bleeding can be stopped, damaged tissues can be repaired but the foreign bodies like instruments, needles, gauze packs and tetras are sometimes left in the abdominal cavity subconsciously. Therefore these items are counted and written on the black board and after surgery the used items and non used items are counted to find out if some items are missing or not . However meticulous one may be, mistakes do happen. Because to err is human. Leaving a foreign body is not a small issue. Not only it is a surgical issue where the patient suffers but the team leader is responsible for this irregularity and it is a medcolegal issue where the negligent team leader usually the operating surgeon is likely to be punished . As per the CPA(Consumer Protection Act) he has to bear not only the expenses incurred for her treatment but for her loss of wages and mental trauma.

In this anecdote I am citing a few interesting incidents, I have encountred during my clinical practice.

After a busy OT day I had come back home at about 2pm , taken my lunch and was relaxing, going through the English newspaper when the calling bell rang. I thought some patients might have come. This is the time when patients from far off areas come for consultation. When I opened the door I was surprised to see two of my girl PG students were standing with one umbrella, half drenched and trembling.

I asked them to come in ,gave a towel to wipe out the water and offered them hot coffee to make them comfortable . After they were settled, I asked them what was the problem. Why they were so much stressed? One of them told that they had completed the post operative round and all patients were doing well. The last patient that they were closing the abdomen, when I left the OT had some problem. Then both of them stood still looking at each other but dumb. I thought some thing serious had happened. I controlled my self and asked, "Any serious problem with that patient? "

"No ,Sir! Most probably we had left one tetra inside her abdomen."

"Are you sure ?"I asked.

"Yes Sir ." was their reply.

In the evening round I called all the OT staff including the staff sister who was assisting me in the OT. I asked the OT sister if there was any missing tetra.Her bold reply was NO . I asked the in charge OT sister if the total number of tetras used that day were physically intact. Her reply was in affirmative. But the PG students were stubborn on their stand that they had left a tetra in the abdomen. I was totally confused. What to do ? Whom to believe?

If by chance the postgraduate assistants were correct and I didn't intervene, then I had to shoulder the responsibility. That would be too late . In this whirlwind I took the decision to reopen the abdomen and see .I can't wait beyond 24 hours. The patient and her family are my disciples, very simple. What I say, they believe like the verse of the Vedas . I counseled them telling the fact that during surgery we had left an instrument by mistake in the patient's abdomen. "If it's not removed now, it will induce sepsis later and it will be risky for us to remove and for the patient to treat. So I have decided to reopen now. It will be done under anaesthesia. All expenditures will be borne by the hospital. Your hospital stay will not be prolonged."

 The patient and relatives were convinced. They said, "You are our Bhagaban . Whatever you do will be a blessing for us. " We immediately took the patient to the OT. The anaesthesiologist cooperated. We opened  the stitches ,searched the abdomen and found nothing. This was THE  PHANTOM TETRA.

SECOND EPISODE :

A senior lady doctor in the rank of Chief District Medical Officer aged about 45 years consulted me for a huge fibroid which requires surgery. She was admitted to a nursing home. All investigations for surgery and anaesthesia were done and everything came out to be normal. One unit blood transfusion was arranged for emergency purpose.

The operation was uneventful. Before closing the abdomen the sister found that there was one tetra missing. I along with my team searched through out the abdominal cavity starting from the under surface of the diaphragm to the pelvis. But no trace of tetra was found. The sister was very firm that she was short of one tetra .She did not allow the operating team to leave the OT until the tetra is recovered. The washing area was searched but in vain. The drying area was searched but with same result. On that day a new sweeper was posted in OT. He observed every body was stressed, sweats dropping from the forehead, shoulders drooping. Desperation and anger was visible through the mask. He politely asked the head staff sister to know what was the matter. The head sister holding a tetra in her hand asked him if he had seen such a thing. He ran to the washing area came with a dirty wet tetra.

"Where did you get it ?"

He very politely replied, " The OT sister asked me to clean the bowl which contained blood stained dirty water. I took the bowl, cleaned it and brought full of hot water. I found this piece of dirty cloth and threw it in the drain. I don't know that you all are so much worried because of me . Please excuse me."

Then came a sigh of relief . DECEPTIVE TETRA, THANK YOU.

THIRD EPISODE:

A middle aged woman was admitted into my ward in a low condition. She had undergone peripartum hysterectomy for ruptured uterus three months back in our hospital. The discharge ticket showed that with much difficulty total abdominal hysterectomy was done. Three units of blood transfusion was administered during operation. There was oozing from different sites which was controlled by pressure packing. At last a corrugated rubber drainage was given both for drainage and to diagnose fresh bleeding. After 10 days the patient was discharged with routine advice and check up after one month. Since she was okay and poor she didn't come for check up. In the mean time she had fever, vomiting, distension of abdomen and no passage of urine or feaces . The neighbors of the patient helped her to  bring to the hospital in that low condition.

At the time of admission she was in a state of shock with cold calmy skin,feeble rapid pulse and low blood pressure. Abdomen was distended with massive free fluid in the peritoneal cavity.

Drainage site showed the rubber drainage intact with dribbling of foul-smelling purrulent discharge. Ryle's tube was given and an indwelling catheter was inserted into the bladder. She was anuric. I started the treatment in the line of shock and sent necessary investigations.After some time the condition of the patient improved slightly. Then I instructed our staff sister to prepare trolley for dressing of the drainage wound site and if required to remove the drain. I cleaned the site .When I pulled the drain a little bit , I saw plenty of purrulent foul-smelling dark fluid rushed out through the wound site. So I removed the corrugated rubber drainage to allow the drainage of itraperitonial fluid.

At that point of time I marked the tip of the tail of the tetra peeping through the drainage opening.

Under local xylocain anaesthesia I extended the opening and pulled the tail of the tetra and the whole tetra came out easily. I thanked God and His plan. Because the surgeon had left the drain and the drain opening was intact the tail of the tetra had come near the opening with the current of the intra peritoneal fluid. Had it not been that, the retained tetra could have created havoc in the abdomen. By that time the patient might have been in the Heaven not in the hospital. Then I kept the wide opening open for drainage. With utmost care and confidentiality I preserved the tetra. Really it was a miracle ,one of the most famous miracles I had seen in my long clinical career. I named this tetra as Divine Tetra.

These three episodes tought us many things.

• During surgery any foreign body should not be taken lightly. Each and every OT staff should be aware of it.
• Over diagnosis is better than a missing diagnosis.
• A left drainage whether intentional or not ,saved the  life. It was God's plan.
• DEAL SUCH SITUATIONS WITH UTMOST CONFIDENTIALITY. NEVER TRY TO TAKE A CREDIT .

HAVE FAITH IN GOD.

Prof Gangadhar Sahoo is a well-known Gynaecologist. He is a columnist and an astute Academician. He was the Professor and HOD of O&G Department of VSS MEDICAL COLLEGE, Burla.He is at present occupying the prestigious post of DEAN, IMS & SUM HOSPITAL, BHUBANESWAR and the National Vice President of ISOPARB (INDIAN SOCIETY OF PERINATOLOGY AND REPRODUCTIVE BIOLOGY). He has been awarded the BEST TEACHER AWARD of VSS MEDICAL COLLEGE,BURLA in 2013. He has contributed CHAPTERS in 13 books and more than 100 Scientific Articles in State, National and International Journals of high repute. He is a National Faculty in National Level and delivered more than 200 Lectures in Scientific Conventions.He was adjudged the BEST NATIONAL SPEAKER in ISOPARB NATIONAL CONVENTION in 2016.