Brooke Army MEDCEN curtails surgeries: dirty instruments

[Monty Python]

Very disturbing if accurately reported. This will probably put a new burr under Joint Commission's saddle for high reliability.

Army hospital curtails surgeries due to dirty instruments

SAN ANTONIO — Commanders at the Army health system's flagship Brooke Army Medical Center have shut more than half of the San Antonio hospital's 28 operating rooms and curtailed elective surgeries because of a shortage of properly sterilized instruments.

The San Antonio Express-News reports (Discovery of unsterile tools forces BAMC to close operating rooms, reduce surgeries ) the hospital famous for treating victims in its burn ward found 73 cases of improperly sterilized instruments last month, including 16 where organic material like bone or skin fragments or blood was left on surgical tools.

The hospital isn't saying if the dirty instruments have led to infections. One commander, Col. Douglas Soderdahl, who also is a physician, says the numbers can be "interpreted in different ways" but says there are "no concerning spikes or things going in the wrong direction" in the hospital's medical care.

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[Homunculus]

more mandatory training for everyone even though this was likely a central supply issue in 3.... 2..... 1....

--your friendly neighborhood is that a bone chip on my endoscope? caveman

 

[HighPriest]

Ive had this happen to my four or five times, always at an MTF. The problem is that they rotate people through CMS so none of them actually learn how to do their jobs, and there's zero accountability because everyone knows that they don't know how to do their jobs. Same reason I'll get a foot-long instrument in an ear set. Because the pack lost said forcep, so they put in a forcep. Doesn't matter if it was designed to take a car door off in a pinch, but the set is for microsurgery.
Luckily, to my knowledge we have always caught frank bioburden before the case started, which only means a 45 minute delay while we have the guy down at CMS accuse us of planting the filth and then pretend not to know what set we're asking for.

 

[dr zaius]

Ive had this happen to my four or five times, always at an MTF. The problem is that they rotate people through CMS so none of them actually learn how to do their jobs, and there's zero accountability because everyone knows that they don't know how to do their jobs. Same reason I'll get a foot-long instrument in an ear set. Because the pack lost said forcep, so they put in a forcep. Doesn't matter if it was designed to take a car door off in a pinch, but the set is for microsurgery.
Luckily, to my knowledge we have always caught frank bioburden before the case started, which only means a 45 minute delay while we have the guy down at CMS accuse us of planting the filth and then pretend not to know what set we're asking for.

This is so true. No matter how many times you try to change the preference cards it never ends up correct. Ever.

They rotate people through sterile processing faster than anywhere else here. There is no institutional memory. Frequently you get broken instruments. The number of trays that get opened for a standard case is mind boggling.

 

[YayPudding]

saint mattis of quantico pls square this away

amen

 

[Ziehl-Neelsen]

saint mattis of quantico pls square this away

amen

Be careful what you wish for. General Mattis nearly got milmed embroiled in one of the biggest medical frauds of the new millennium.

Trump’s pick for defense secretary went to the mat for the troubled blood-testing company Theranos

 

[Homunculus]

Be careful what you wish for. General Mattis nearly got milmed embroiled in one of the biggest medical frauds of the new millennium.

Trump’s pick for defense secretary went to the mat for the troubled blood-testing company Theranos

LTC Shoemaker deserves an award for preventing a potential disaster. an O5 standing up to a what, O-10? that takes some balls. I'm somewhat surprised there wasn't some attempt to remove or replace LTC Shoemaker with another person. maybe he was air force? they abbreviated his rank Lt. Col. which the air force loves to do... may have been what saved him. either way, glad to see scientific principles prevail.

--your friendly neighborhood maybe I can be a lobbyist when I get out caveman

 

[Helpful Troll]

LTC Shoemaker deserves an award for preventing a potential disaster. an O5 standing up to a what, O-10? that takes some balls. I'm somewhat surprised there wasn't some attempt to remove or replace LTC Shoemaker with another person. maybe he was air force? they abbreviated his rank Lt. Col. which the air force loves to do... may have been what saved him. either way, glad to see scientific principles prevail.

--your friendly neighborhood maybe I can be a lobbyist when I get out caveman

This is likely the right Shoemaker - He retired from the Army in June 2013, likely precipitated by this issue. I don't know if it's what he wanted but... 'They can always hurt you more.' was ignored for 'Do the right thing, always.'

USAMRMC: News: Lt. Col. David Shoemaker retires after 20 years of military service

 

[Homunculus]

This is likely the right Shoemaker - He retired from the Army in June 2013, likely precipitated by this issue. I don't know if it's what he wanted but... 'They can always hurt you more.' was ignored for 'Do the right thing, always.'

USAMRMC: News: Lt. Col. David Shoemaker retires after 20 years of military service

"He is such a man of principals that he was not afraid to inform Gen. Mattis, the Commander, United States Central Command, in person that a FDA un-cleared medical device could not be used in theater, and was successful."

the fact this is seen as such an accomplishment (it is) should tell you something.

""I will be taking advantage of the post-9/11 GI bill and attending the Landing School in Maine from September 2013 to June 2014," said Shoemaker. "I am enrolled in the Marine Systems program and will be getting my hands dirty learning how to repair marine diesel engines, electronics, refrigeration, fiberglass, etc. After that, my wife and I will be sailing on our own 40' sailboat 'Nonstop.'"

Shoemaker plans to cruise the East Coast for a couple years and then cross the Atlantic and visit Ireland and Europe."

I love this man.

--your friendly neighborhood diamond in the rough caveman

 

[Gastrapathy]

I love this man.

--your friendly neighborhood diamond in the rough caveman

Dude

 

[Homunculus]

Dude

gotta admit it's a pretty badass retirement. tells mattis to suck it, retires as an O5 and spends his days sailing the ocean and seeing the world. the only improvement would be if "boats and hoes" were his sailboat's name.

--your friendly neighborhood maybe man crush would be a better term caveman