Description of Event or Problem · 0
PATIENT HAD ROCKET DRAIN PLACED FOR RECURRENT MALIGNANT PLEURAL EFFUSION. ROUTINE POST OP CXR DETERMINED A PORTION OF THE GUIDEWIRE WAS RETAINED. PATIENT WAS TAKEN BACK TO THE OR THE SAME DAY FOR RIGHT VATS [VIDEO-ASSISTED THORACOSCOPIC SURGERY] REMOVAL OF INTRAPLEURAL FOREIGN BODY. PATIENT WAS DISCHARGED THE FOLLOWING DAY. SURGEON STATED SHE HAS DONE MORE THAN 1000 OF THESE PROCEDURES HERSELF; IP [INTERVENTIONAL PULMONOLOGY] FELLOW WAS PERFORMING THIS PARTICULAR PROCEDURE WITH ATTENDING SURGEON SUPERVISING. THEY SWITCHED TO ROCKET CATHETERS BECAUSE THEY WILL PROVIDE THE PATIENT WITH SUPPLIES THAT INSURANCE DOES NOT COVER, ALTHOUGH NOTES THAT THEIR PROCEDURE IS SUBPAR- IT KINKS EASILY AND IS FLIMSY. SHE BELIEVES THIS EVENT WAS A COMBINATION OF TECHNIQUE ISSUE AND EQUIPMENT MALFUNCTION. THIS GUIDEWIRE IS BRAIDED/RAVELED TOGETHER, MUCH LIKE YARN. SHE BELIEVES THAT WHEN INTRODUCING THE NEEDLE, IT LIKELY SHEARED OFF/SEPARATED, LEAVING A PORTION OF THE GUIDEWIRE INSIDE THE PATIENT. WHEN THE GUIDEWIRE WAS PULLED OUT, IT WAS UNRAVELED/FRAYED, BUT STILL APPEARED TO BE THE FULL LENGTH OF THE ORIGINAL GUIDEWIRE AND ASSUMED THEY HAD REMOVED IT IN IT'S ENTIRETY. THIS PROCEDURE IS TYPICALLY DONE UNDER ULTRASOUND GUIDANCE AND POST OP XRAY IS STANDARD, NOT DONE INTRAOPERATIVELY. PER SURGEON, AFTER DISCUSSION WITH THE FELLOW THAT PERFORMED, SHE NOTED THAT SHE FELT AS THOUGH THERE WAS MORE RESISTANCE THAN NORMAL WHEN TRYING TO REMOVE THE GUIDEWIRE.