Tech in Surgery Prep / Unit 23 TSC 571 review, 2 to 3 minutes
A Burn Under the Pad
The idea
A worked example, constructed for this course, follows the discovery of a skin injury at a dispersive pad site and the steps that would have prevented it.
In practice
After a long abdominal case, the circulating nurse removes the dispersive pad from the patient's thigh and sees a red, blistered area along one edge. The team reviews what happened. The pad was placed on the outer thigh, but the patient's thigh was hairy at that spot and the pad had not been checked for full contact after positioning. During the case, the patient's leg was repositioned to improve access, and one edge of the pad lifted. Midway through, the surgeon asked twice for a higher power setting, saying the pencil seemed weak. The circulating nurse turned the power up. Nobody connected the requests to the pad. The unit's contact alarm sounded once and stopped after the circulator pressed on the pad. Afterward, the injury is documented, the surgeon is told, the patient is assessed and treated, and an incident report is filed. The review identifies four missed chances: the hairy skin at the pad site, the unchecked contact after repositioning, the repeated requests for more power, and the alarm that was silenced rather than investigated.
Where people slip
Every one of the four warning signs was taught in this unit, and each was noticed by someone. What failed was connecting them. A scrub person who hears the surgeon ask for more power should think of the pad, and say so: checking the pad takes a minute; a burn takes weeks to heal. The same is true of the alarm: it exists to stop the case for a moment, and pressing on the pad to quiet it treated the symptom while the cause remained.
Your place on the trail
Every lesson rests on earlier ones and opens later ones. Tap any to jump.
Builds on
Unlocks
- Nothing yet depends on this.
Something wrong in this lesson? Flag it · Sources for Tech in Surgery Prep