On New Year's Eve, 2011, Syndi Miske lay in a Creighton University Medical Center hospital bed, suffering through severe hot flashes, night sweats and a persistent ache in her abdomen.
Miske says her doctor told her the pain was a common side effect of the six-hour elective surgery she had undergone the previous day — a surgery to remove tissue and cysts and make it more likely that Miske could get pregnant.
But that pain likely wasn't caused by routine, postoperative soreness, a lawsuit alleges. The pain also wasn't caused by what doctors later thought was a large ovarian cyst — a mistaken belief that eventually prompted other doctors to wrongly diagnose Miske with ovarian cancer, remove her uterus and end her chances of giving birth.
Instead, the lawsuit alleges, the pain came from something doctors discovered during her 2013 hysterectomy: a surgical glove that Creighton doctors or nurses had left in her body during the December 2011 surgery. A glove, filled with clear fluid and tied at the end, that had been inside her body for nearly two years.
I read the story of Miske's pain — and subsequent $1.75 million lawsuit against Creighton — in this newspaper last week. What horrible luck, I thought. What a horrific, one-of-a-kind accident.
But then I did a little research. The shocking truth: Surgical items like sponges, equipment and gloves are left inside patients hundreds and maybe thousands of times each year.
Medical officials dryly refer to these cases as “retained surgical items.” They are often classified as “never events” — events that experts say should never happen inside a U.S. hospital. Yet these never events keep happening.
“We have to realize that we keep making the same mistakes over and over. We have to do better,” says Dr. Verna Gibbs, a professor of surgery at the University of California in San Francisco and an expert on retained surgical items. “We are trained professionals. This isn't a day care.”
No one knows for sure how often a sponge or other item is mistakenly left inside a patient during a surgery. We don't know for sure because there is no federal requirement that hospitals track retained surgical items, even though a Congress-funded study urged mandatory reporting of these mistakes more than a decade ago.
Gibbs, extrapolating from California numbers, estimates that a surgical item is left inside 500 U.S. patients annually. A government health care agency, analyzing hospital billing records, has pegged the number at 3,000.
And a USA Today report, harnessing research studies that assume many cases go unreported, concludes that this happens as many as 6,000 times each year. If true, that means that a surgical item is left inside a patient's body, on average, more than 16 times each day.
We tend only to notice when a high-profile lawsuit, like the Miske case, grabs our attention.
None of the defendants in the Miske lawsuit, which include Omaha's Pope Paul VI Institute, Creighton and three doctors, have commented on the case. Miske, through her attorney, also has declined interview requests.
Experts disagree on the numbers, but they agree on this: The most common items accidentally left inside a patient are the cotton sponges used to soak up blood during surgery.
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The offending sponge is often discovered soon while the patient is still hospitalized, Gibbs told me — a discovery that triggers another painful surgery.
But it's far worse and more painful if the sponge isn't discovered for weeks, months or years. Then patients may suffer unexplained pain and develop infections. In extremely rare cases, some people are killed by the items mistakenly left inside their bodies.
And here's the frustrating part: We can and should be able to remove these cases of lost sponges and other surgical equipment almost entirely from the American medical system.
Currently, surgery personnel often account for sponges and other items by trying to count them by hand — an approach that can lead to mistakes.
But the Mayo Clinic and others are using technology such as marking sponges with a bar code that can be scanned before and after surgery, or fitting them with a tiny radio-frequency tag that can be detected before closing an incision.
Mayo uses the bar-code method and hasn't lost a sponge in four years, according to the USA Today report.
The Indiana University Health System uses special sponges with the radio-frequency tags. IU Health once averaged a lost sponge each month. Now it hasn't lost a sponge in five years, a hospital administrator told USA Today.
Only around 1 out of every 100 hospitals use this technology, despite the fact that the various sponge-tracking devices cost around $10 per operation. No Omaha-area hospitals use this technology, officials at the Nebraska Medical Center, Methodist Health System and Alegent Creighton Health confirmed this week.
Gibbs says that even without technological changes, there are ways that hospitals and medical personnel can do a better job of preventing surgical equipment from being left in patients.
Hospitals need to mandate accounting practices on every single item used in an operating room, she says. These practices need to be the same for doctors, nurses and radiologists no matter the type of surgery or which surgeon is presiding.
This may seem like the ultimate no-brainer, Gibbs says, but far too often the counting practices she observes in hospitals vary widely day to day and room to room.
Far too often, she says, medical equipment is accounted for by different surgery personnel in different spots in the operating room at different times. And far too often, she says, medical personnel use this scatter-shot approach because it's simply the way they have always counted.
But longtime practices sometimes need to change.
She offered a comparison: Decades ago, people used to buckle their seat belts on long trips but not when they went down the street to the mall. Then studies showed that most deadly accidents tended to happen on short trips. And then car companies, prompted by the government, installed devices which annoyingly ding at us until we buckle up.
“When you get in your car now, you fasten your seat belt and you do it every time, right?” she says.
Here's hoping that, sometime soon, all our hospitals hear the dinging from cases like the sad story of Syndi Miske.