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The Tick in the Box


When I first started with surveillance, I felt an inordinate amount of pressure to never miss an SSI. As a result, I have binder after binder with notes of wound reviews and thousands of patient labels as testament that not only did I see the wound, but that I also reviewed the relevant medical notes. I rarely took more than four days off at a time, and most (if not all) of my conversations at work contained the word ‘wound’. I also inadvertently qualified as a hobbyist (‘Sticker Collector’).

I viewed each surgical wound though PHE-tinted glasses, and, I can admit now, all those years ago that that maybe, just maybe I was a bit too prescriptive in my approach. Take the criterion Swelling. I ticked ‘swelling’ each and every median sternotomy and scribbled in the word“proximal”. The sternal notch has swelling for weeks after surgery and it is the one area patients tend to point out as well. It is swollen after sugery. But the swelling it isn't part of the infective process. So many ticks…so little common sense.

But you get the idea, I was nothing if not genuine. So much so, that many years ago, when an SpR waved his arms to keep me back from a patient’s bed space and said ‘You don’t need to review this patient. We have placed a VAC but it’s just precautionary,’ I believed him. A few days later, the same SpR caught up with me with an update (this next bit is verbatim:) ‘You don’t need to bother seeing the patient with the VAC. There is pus, well probably it’s not pus. It’s not an SSI, don’t worry’- I believed him. And when the micro results came back positive for all sorts of bugs, he reassured me these were most certainly just multiple results with contaminants. And I believed him. There was a return to theatre or two for this patient, but the SpR was so reassuring – the returns for debridement were all 'just precautionary'. And I believed him. He was so smiley.

I can still remember the shock on reviewing this SpR’s the discharge letter for this patient which plainly referred to the ‘sternal wound infection’.

An SSI, hidden in plain sight.

The one time I had stepped away from the PHE protocol.

The one time I didn’t tick pus, managed dehiscence, culture positive – the veritable Bingo of the SSI card. Not exactly the school of hard knocks, I grant you. But I did learn, surveillance is 50% common sense and 50% PHE protocol. I want to say it is 0% smiles, but that isn’t true. I got that SSI confirmed. And that made me smile​.​

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