A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension, and diabetes was found to have obstructive, multi-vessel coronary artery disease. The patient was referred for bypass surgery and mitral valve repair. He underwent successful surgery and was discharged to a rehabilitation facility where he recuperated at the expected rate.
The patient continued to attend hemodialysis and clinic visits without fail. Eight months later, he was admitted to the hospital with shaking chills and confusion and found to have an empyema (i.e., collection of pus) on the left side of his chest. He underwent thoracic surgery where the trapped lung was freed from its adhesions and a 12-cm red-rubber snare was recovered—a surgical instrument from the prior surgery. The patient recovered to his baseline level of functioning after a 10-day intensive care unit (ICU) course followed by treatment in a rehabilitation facility.
On subsequent investigation, hospital staff members were puzzled by the failure to detect the object. The patient underwent three-times weekly dialysis sessions, at least eight clinic visits with multiple physicians, and had no symptoms until his dramatic presentation many months later. He also had seven chest radiographs postoperatively in which the device was not detected.
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