The truth of "women's intra-abdominal death left behind by gauze after induced labor" sounds the alarm bell!2019-01-13 09:03:10 191 ℃
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Juan Mei came and sat down like a gust of wind: "Zhao Ge, Zhao Ge, the events that were questioned by the major official media the other day,'Women died in the abdomen left behind by the gauze after induced labor'."
Official investigation report has been issued, which belongs to the first class A medical accident. 57347
Zhaoge sighed: "Well, as a gynecologist and obstetrician, I am still very concerned about this kind of news. We should be good at summarizing the mistakes made by others and avoid repeating them in our future work.
The loss of a living life, the blow to relatives and friends, and the impact on medical care are far-reaching, and time can not heal all the wounds.
I am a Virgo. I am good at finding clues from details. I wrote an article a few days ago and put forward some of my own analysis. At present, it is accurate. The report reveals some previously unknown secrets and clarifies some doubts. Where did the gauze come from?
Investigation report indicates that the gauze in intestinal tract of the deceased was left over from the cesarean section in Hongshi Hospital of Panzhihua on June 6, 2018. The deceased had been cremated, but the gauze remained in the hands of their families. It is impossible for any hospital to buy gauze and needles one by one, in batches.
Hand over the gauze to the relevant departments. Compared with the existing finished products in the hospital, the origin is clear at a glance, which is also the reason why the hospitals concerned make prompt reparations. < p > < p > < strong > 2. How did the gauze stay in the abdominal cavity?
Investigation report indicated that during the process of replacing operation packages, the relevant system of operating room management was not strictly implemented.
Can imagine the scene at that time: Originally decided to do a cesarean section fetal extraction, the heart rate, blood pressure dropped several times during the operation, the hospital doctors involved in the rescue while seeking help from the superior hospital.
In the process of waiting for expert help, the doctor on stage used several gauze to defecate the intestine. The consultation expert found placenta implantation and decided to perform `hysterectomy'. The operation methods were different, and the operation kit needed to be replaced.
In the operating room, the anesthesia machine is alarming, the surgeon is shouting, some people running around are taking blood, some are taking medicine... It's easy to make mistakes in a hurry.
The patient's condition is critical. The hospital has contacted the ICU of the superior hospital to do the next rescue. The gauze logarithm of the instrument in the bag of hysterectomy ignores the situation of the previous bag. Fortunately, the investigation was conducted seriously and fairly, and the surgeon who went on stage to cut the uterus was not held accountable. He left the stick on the nurses in the operating room and the surgeons who performed the operation. < br >< p > < strong > 3. Why does gauze enter the small intestine?
If the intestinal cavity is lost during the operation, the doctors on the stage will consult the gynecologist and obstetrician at the same time, and the gastrointestinal surgeon will consult. Anyway, a Bodhisattva has been aroused. Why not invite more than a few, sharing the risks? It is even more impossible for patients to swallow by themselves after operation. Abdominal pain is more than 140 days after operation. If swallowed immediately after operation, either it is stuck in the stomach or pulled out early.
If swallowed at the last moment, the patient will not see the doctor repeatedly, and it is not easy to find the gauze of the operation hospital more than 140 days ago, and the family members will not persevere in seeking the truth. The problem of
has troubled me too, but soon I came to the conclusion that the gauze is in the abdominal cavity. Because of the break in the intestinal tract, the gauze slowly enters the intestinal cavity during intestinal peristalsis. It can only be said that the human organs are very wonderful.
Many doctors will question this statement, but in fact there are relevant case reports: a 30 cm*30 cm gauze, from a 2 cm defect in the intestinal cavity into the intestinal tube.
4. Why hasn't gauze been found before?
The abdominal pain of the patients was 146 days after operation. No gauze was found in 6 hospital examinations before and after 3 hospitals. The main problem was that the gauze had no development strip.
CT, ultrasound, nuclear magnetic resonance, and even gastroscopy have been done. There is no abdominal foreign body in imaging. All the data are left there. Don't say that other hospitals are poor. Who won't Zhuge Liang after the event? It seems strange to us that
the gauze without developing strip should be put on the operating table, but in clinic, we will encounter some strange things, an accident happens, and we should think of it whenever possible, so that we will not be misled by inertia thinking.
Doctors can't operate without a clear indication of laparotomy. After all, human stomach is not the hood of a car, so open it if you want to open it.
5. Is there any medical practice beyond the scope? The family members of
have doubts. Is it reasonable and legal that Li Mou, an orthopaedic surgeon, participated in the operation?
Generally speaking, every doctor will practice medicine in his own registered field. However, a large-scale rescue needs to use a lot of resources, in critical moments, cross-professional participation in rescue is not beyond the scope of occupation. < p > < p > < strong > 6. Why do we need cesarean section?
Many people do not understand why the uterus should be cut open, and then take out this unwanted baby, is not there a drug induced labor, the way out of the vagina?
The investigation report pointed out that `Cesarean section fetal extraction'had no indication of operation, and doctors who participated in preoperative discussions were mainly responsible, while Dr. Hu was secondary.
This should be the result of a group of experts organized by the local Health Planning Commission, but I reserve my personal opinion that we can not transfer the management and level of our hospital to all hospitals in the world.
is still the old saying: you can live on your own, try not to have cesarean section.
For a grass-roots hospital, there is no accurate judgment from the imaging department, no adequate supply of blood transfusion resources, no strong support from the ICU of surgery and internal medicine.
Yuan Mou, the deceased, has had a cesarean section in the past. For such a large month, he either transfers to a higher hospital or can only choose what he thinks is the safest way.
I can understand Doctor Wen's mood. She presided over the preoperative discussion. She was the chief operative knife. She was revoked the Doctor's Practice Certificate. The most painful thing is that she did not save her patients.
No tree can make a forest, and no doctor with a high level can solve all the problems, which is also the reason why many doctors dare not work alone.
At the moment of rescue, seeing the heart rate and blood pressure of the patient fall down again and again, and blood gushing out in his stomach, I think Doctor Wen is afraid, nervous, depressed and helpless. At that moment, she wished she could not die by herself. Why do I say that, because I often feel this way.
No doctor is willing to have an accident with his patient. When an accident comes, the doctor is like a lone boat in the rough sea, and the patient is on board.
either escaped from the sky or the ship was destroyed and killed.
Juanmei sighed with a sigh: "This is a real thing, it's really a problem for medical staff, and people will certainly scorn and laugh at us." Xiao Ge looked at the ceiling 45 degrees.
Zhao Ge said: "Don't complain that your income is not proportional to your work. Don't complain that the recognition and effort given by the society can't be equal. Face is earned by yourself, not by others.
Medical staff are respected or despised, not by singing praises or smearing rumors, but by every practitioner and every patient in the process of diagnosis and treatment.
Any industry, any group, has uneven levels. Only fools can measure the whole industry by a good thing or a bad thing.
We should learn from the lessons, sum up similar experience, make accountability to the personnel involved, and apologize to the family and society. These are all things we should do.
German pilot Pabbs Hain made a thorough analysis of several aviation accidents and drew a conclusion that behind every serious accident, there must be 29 minor accidents, 300 attempts and 1000 hidden dangers. The
accident never happens suddenly, but is a process from quantity to quality.
If facing abyss, such as treading thin ice, hospitals are not factories, patients are not products on the assembly line. < br >< p > Medical workers serve the living people. It is not a problem that can be solved by losing money to repair and repair a broken car.
No matter how carefully and carefully you are, you can't be too cautious; you can't be absent-minded for a moment or careless. The mistake of
is the mistake. This first-class medical accident sounded an alarm to every medical practitioner with its bloody lessons.
In awe, doctors should know the value of life.
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