Whip that tube, which tube?  

We had a patient who had a Whipple’s Operation on the ward, who had two intrabdominal drain tubes – one left and one right. The left drain tube had started to dry up and it was time to be removed. We documented and asked the nurse looking after him to remove the left drain tube. The Upper GI/ hepatobiliary ward, of course was busy that day, and the nurse had a lot on their mind. They got his left and right confused with the patient’s left and right, and pulled out the wrong drain tube. The drain he pulled out was draining a pancreatic leak. The patient became unstable and bled and had a MET call shortly after. Luckily we were still in hours, and we managed to arrange an urgent percutaneous drain insertion in radiology. The patient ended up staying longer than expected and had multiple operations and total parenteral nutrition.

From that day on, the unit adopted policy that if a patient had multiple drain tubes then the doctors (Registrar or Fellow) would need to label the correct drain tube to be removed with the patient’s bradma label. When I do this I write the words “Pull me”.


Yank and Suck

When I was working in Sunshine, there was a rare occasion where a pre-adolescent child had abdominal surgery. On the weekend, this child was ready for discharge, and their drain was ready to be removed, as decided on the morning ward round. Once again, for some reason the ward was busy; and the drain wasn’t removed until the afternoon. When it came out, I believe the nurse was not familiar with the suction on the drain and had left it on. A tongue of omental fat was dragged out along with it. It laid licking this child’s abdomen. I was called, and we took him promptly to theatre to reduce and close.


Lessons learnt

  1. Never remove drains late in the day

  2. When removing drains, ensure suction is turned off

  3. If multiple drains, make sure the person removing it has a very clear fool-proof way of identifying the correct drain for removal.

Dr. Chris Ip