by Robert Schnell
The 54 year old male came to the hospital for an elective laparoscopic cholecystectomy. You know, gall bladder removal. Go in early morning, gall bladder out before noon, home before 5 PM, out bowling with friends that evening. A “walk in the park” procedure!
The patient goes to surgery. It takes 75 minutes, recovery room another 90 minutes, then post op surgery floor for observation.
Post op orders are written by the surgeon. Unknown to the surgeon the patient’s internal medicine doc, Dr. Moodswing, comes in and adds his two cents. He writes post op orders for anticoagulants. The order is sent to pharmacy and processed. A Medicine Administration Report (MAR) is generated and sent to the floor.
Meanwhile, the busy floor nurse with three other patients takes the new post-op “chole” admission after an “abbreviated” report from the recovery room nurse. No one really knows much history or anything else, for that matter, on this patient. He came from home that morning for the procedure. No post operative nurse has ever laid eyes on him let alone seen a history or done a physical assessment.
According to the new MAR, Lovenox (a power anticoagulant) is ordered. Subcutaneously. 140 milligrams. That’s odd. Normally you don’t give anticoagulants for 24 hours after any surgery but Moodswing ordered it. It’s given.
An hour later the patient has a heart rate of 140 and no blood pressure. He’s put on a Dopamine drip. He’s tachypnic, breathing at a rate of 35-40 breaths a minute and acidotic (pH 7.25) by blood gas determination. He is rushed to the ICU. The surgeon arrives seconds later while Dr. Moodswing is now at home enjoying a glass of wine, as is his habit.
The surgeon orders a unit of packed blood cells “STAT”.
Guess what? No pre-op type and screen or crossmatch was done. (A lap chole is a “walk in the park“, who needs emergency standby blood?!?) It will take at least an hour to type, screen, crossmatch and get the blood available and that is if you don’t detect antibodies (cross your fingers).
The patient needs the blood now! More fuel to the chaotic fire; the surgeon informs us the patient got Lovenox prior to the procedure. What??? That important tidbit of information was never passed along. He also received another 140 milligrams subcutaneously less than an hour ago, courtesy of Moodswing’s post op order.
This case is turning into a comedy of errors with no one laughing. Don’t these docs talk to each other? Does the right hand have any idea what the left hand is doing?
Two units of uncrossmatched blood are transfused. Dr. Moodswing keeps calling and interrupting while the nurses assist the surgeon placing lines. He shows up later only to get in the way. The patient crashes. Moodswing calls for anesthesia to intubate all the while badmouthing everyone from the unit clerk, charge nurse, to the blood bank. (He should have stayed home and finished that bottle of wine. Maybe he did! Would explain a lot!)
The patient later returned to surgery eventually needing 12 units of packed red blood cells, 6 units of fresh frozen plasma, and platelets. He ended up being hospitalized for 10 days (mostly in the ICU). He suffered a small heart attack from the hypovolemia caused by hemorrhaging but recovered and was eventually discharged home. No bowling with friends for awhile though.
Moral of the story: With any “walk in the park“, as everyone knows, there can be unforeseen events.