Lately we’ve been having some object lessons on the theme that just because you’ve closed the skin in the OR, the patient is not out of the woods.

The other day we had a patient give a few good coughs as the anesthesiologist started to wake them up. Shortly afterwards the surgery resident (not me) noticed a fair amount of swelling at the operative site. A few moments of consideration led him to conclude that this was probably not just normal fatty tissue. He called the attending back in (this is where I entered, seeing the attending heading back, and figuring if he was that interested, it was worth me seeing too), and the wound was opened up to disclose a large amount of fresh blood. After clearing their way in, they found a bleeding artery, which would have led to serious problems if the patient had gotten out of the OR or up to the floor with it.

Then there’s the story from neurosurgery making the rounds: a young woman involved in an ATV accident was brought into the ER with altered mental status, and developed a blown pupil (dilated, no contraction with light). CT showed a subdural on that side, so she was rushed to the OR. After the subdural hematoma had been evacuated, the skin was closed over the site. A junior neurosurgery resident then came in to take over for the senior who had done the case, just to get the patient back to the ICU so the senior resident could take care of some other issues. The junior flipped through the patient’s history, and then decided to take a look at the blown pupil for himself. His next remark was, “Which pupil did you say was blown?” This led to the realization that both pupils were now dilated and unresponsive. The patient was rushed to the CT scan, which revealed an epidural hematoma on the opposite side of the head. By the time they got her back to the OR, the patient was bradying down (Cushing’s triad, in response to increasing pressure on the brain: as the brainstem is forced down into the foramen magnum, you see bradycardia, hypertension, and irregular breathing). Her life was saved by the fact that the neurosurgeons were just in time to get the epidural hematoma out. Which was due to the attentiveness and inquisitiveness of the junior resident.

My takeaway lesson: I need to be more particular about investigating these details, particularly in postop patients. In vascular patients, I usually do check all the pulses just out of curiosity, whether postop or on new admissions. But just because you’re handed a postoperative patient, with the assumption that they’re all fixed, doesn’t mean that everything is necessarily ok. No time to relax till the patient is stable in the recovery room, and not quite even then. Verify all pertinent findings, and relevant negative findings, for yourself. For example, when getting signout on a patient in the ER, that their abdominal exam is benign – take the time to go down, say hello, and check for yourself before you let them be discharged or sent to the floor for simple observation.

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