I am writing this to highlight what a minor slip or oversight can negate a well executed job.I had a friend and Colleague,Dr.R.Pancholi,a Consultant Pediatrician, when I was working in Telco(now known as Tata Motors) Hospital in Jamshedpur.He had brought his father for endoscopic surgery of his Prostate Enlargement-known in medical parlance as T.U.R.P.(Trans Urethral Resection Prostate)by our urologist,Dr.Pritwish Kumar Dhar M.S.F.R.C.S.
Well he had this operation on the appointed day but postoperatively,we were concerned since his urinary catheter afteran initially draining clear urine started getting reddish until it became tomato red.D.Dhar was expecting the drainage to clear up by the irrigation thru' the three way catheter.Despite giving 2 blood transfusions,his BP was behaving erratically and it was getting late at night,we insisted he should be taken up again for a fresh look.This was ultimately done and by endoscopy the bleeding point was coagulated and the blood clots washed away till return was clear.
The drama started after this in the Recovery Room where the Urinary Catheter was not draining a single drop of urine.Was this Acute Renal Shutdown which may occur due to undue stress of 2nd anaesthesia and intervention in a 76 yr.old?The tension in the air was palpable.I decided to check the connection of the catheter with the Urobag.Lo and Behold!! Know what I found?-the Urobag with its connector male portion is covered with a cap for sterility purpose was connected to the draining female portion of the Foley's catheter was connected with its cap on.I removed the cap and connected again and urine started draining like a river in flood.A minor slip which if missed could have led to much bigger intervention with disastrous result.It is said-take care of the smaller things,the bigger things will look after themselves.
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