Sultana-related Sentinel Event

The LITFL team have heard through the grape vine that Professor Inglebert Struvite Staghorn, at the bequest of the Society for the Prevention of Surgery, has been investigating an unfortunate episode currantly referred to as the ‘Sultana-related Sentinel Event’.

A bunch of eye witness reports obtained by the Inquisitorial Disciplinary Committee has revealed that the following events may or may not have actually taken place:

  • 0800: The patient is brought into the operating theatre.
  • 0801: Induction of anesthesia is commenced.
  • 0930: The anesthetist is satisfied that patient is now ready for open heart surgery to begin.
  • 0931: The anesthetist leaves the operating theatre as it is time for his morning break. Surgery continues.
  • 1101: The anesthetist returns from his morning break.
  • 1102: The anesthetist leans over the surgical drapes (aka blood-brain barrier) to assess the surgeon’s progress. As he does so, the anesthetist pulls up his surgical mask from around his neck to prevent the emission of exhalations in the vicinity of the new scrub nurse with the big blue eyes.
  • 1103: Surgery is stopped.
  • 1104: The surgeon is heard to exclaim: “What the F$%K is that?” as he grasps a small object with his forceps, that was seen to roll into the open chest wound and start bouncing up and down on the undulating epicardial surface of the heart.
  • 1105: Silence.
  • 1106: The anesthetist is heard to clear his throat and say: ” It appears to be a sultana”.

UCEM investigators are currantly working to determine whether there is any connection between the above alleged event and other eye-witness observations suggesting that:

  • the anesthetist was seen eating sultanas during his 1h 30 min morning break.
  • during this time the anesthetist had a surgical mask around his neck.

Some analysts have already wined that if the Society for the Prevention of Surgery had followed Assistant Sub-Professor Egerton Yorick Davis IV‘s advice such an event would never have happened. Davis IV, of course, is well known for championing the mandatory wearing of UCEM-approved gas masks during an operation. Other analysts have preferred to take a more sanguine perspective, stating that we should be grapeful for the research opportunities this affords. As highlighted by Professor Harry Stickler, there is now the possibility of the first n=1 trial of a sultana-encrusted mitral valve prothesis for treatment of severe mitral regurgitation. The scope for future research involving other food items, such as biscuit crumbs and bits of a ham sandwich, is enormous.

The final outcome of Professor Staghorn’s investigation, including the raisins for this unsettling occurrants, is keenly awaited. Prof Staghorn’s parting comment on the ferment was:

“One things for sure… We chianti let this happen again without ethics approval, or we’ll all be left with a sweaty, barnyard, band-aid taste in our mouths.”

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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