Description of Event or Problem · 1
THE PT CODED SHORTLY AFTER A FLEXIBLE HYSTEROSCOPE (CYSTOSCOPE) WAS USED TO EXAMINE HER UTERUS. THE PROVISIONAL DIAGNOSIS AT AUTOPSY IS GAS EMBOLISM. THE DR. IN PREPARING FOR THE HYSTEROSCOPY (PT WAS PREPPED, THE PHYSICIAN WAS IN THE ROOM, GOWNED AND GLOVED) NOTED THAT THERE WAS NO HYSTEROSCOPE IN THE TRAY. THE CIRCULATING NURSE DETERMINED THAT THE RIGID SCOPE WAS IN CSR AND HAD NOT BEEN STERILIZED. THE PHYSICIAN WAS OFFERED AND ACCEPTED THE FLEXIBLE SCOPE.THE PHYSICIAN DECIDED TO USE THE HAND INSUFFLATOR (DOUBLE BLOWER) TO EXAMINE THE UTERUS. THE PHYSICIAN USED THE RICHARD WOLF CYSTOSCOPE/HYSTEROSCOPE TO PERFORM A HYSTEROSCOPY WITH THE "DOUBLE BLOWER" (HAND INSUFFLATOR) ATTACHED TO THE IRRIGATION COCK. HIS PURPOSE HE SAID WAS TO APPLY ENOUGH AIR TO KEEP THE LENS CLEAR.THE PHYSICIAN WAS USING TWO HANDS TO MANIPULATE THE SCOPE SO HE GAVE THE HAND INSUFFLATOR TO THE SCRUB NURSE AND TOLD THE SCRUB NURSE TO APPLY A SMALL AMOUNT OF PRESSURE. THE SCRUB NURSE SAYS SHE TOLD THE PHYSICIAN THAT SHE HAD NOT USEDE INSTRUMENT BEFORE. HE HANDED HER THE BULB (IT LOOKS LIKE THE BULB FROM A BP CUFF). HE TOLD HER TO PUMP THE BULB SO THAT THE BLADDER STAYS INFLATED. WHEN SHE TOLD HIM THAT WHEN SHE RELEASED THE BULB THE BLADDER GOES DOWN, HEETOLD HER TO KEEP THE BLADDER INFLATED. SHE PUMPED, RELEASED, PUMPED, RELEASED (WHEN THE BLADDER FILLED UP SHE WOULD RELEASE AND THEN WHEN THE BLADDER WAS FLATT SHE WOULD PUMP AGAIN) (DEMONSTRATED TO REPORTER). THE PHYSICIAN REPORTED THAT THE WHOLE PROCEDURE TOOK ABOUT THREE MINUTES AND THE NURSE ALSO SAID THAT IT TOOK A SIMILAR SHORT PERIOD OF TIME. ONCE THEY WERE FINISHED THEY PROCEEDED TO THE ABDOMEN FOR THE LAPAROSCOPY, THE INCISION WAS MADE AND AT THAT TIME THE ANESTHETIST POINTED OUT THAT THE PT APPEARED TO BE IN ELECTROMECHANICAL DISSOCIATION AND A CODE WAS CALLED. I WAS TOLD BY PHYSICIAN IN ATTENDANCE AT THE CODE THAT WHEN CENTRAL LINES WERE PLACED AIR WAS ASPIRATED.PORTABLE CHEST X-RAY TAKEN DURING THE CODE WAS READ AS HAVING GAS IN THE PORTAL VENOUS SYSTEM AND AN UNUSUAL LUCENT OVER THE LEFT HEART SHADOW SUGGESTIVE PRESSENCE OF INTRAVENTRICULAR GAS. CT SCANS TAKEN FOUR HRS POST DEATH DEMONSTRATE GAS IN THE RIGHT VENTRICLE OF THE HEART AND GAS THROUGHOUT THE PORTAL VENOUS ORGANS. ALSO SOME SUBCUTANEOUS EMPHYSEMA OVER THE NECK AND ESPECIALLY OVER THE LEFT GROIN WHERE CENTRAL LINES ARE ENTERING THE LLIAC VESSELS. NO EVIDENCE OF GAS IN THE BRAIN.MY INVESTIGATION FOUND THAT THE HAND INSUFFLATOR (DOUBLE BLOWER) IS USED TO CHECK THE INSTRUMENT FOR LEAKS. IN INVESTIGATION OF LITERATURE BY THE CHIEF OF SERVICE SHE COULD FIND NO LITERATURE THAT RECOMMENDED THE USE OF AIR WITH THIS DEVICE. THE DEVICE THAT IS NORMALLY USED WITH THE HYSTEROSCOPE USES FLUID OR C0/2 FOR INSUFFLATION.