You count everything in and everything out, twice, out loud, with a second person. The counts match. There is still a thing on my tray at the end that is not on the list.
I have scrubbed for nineteen years, mostly general and vascular, at two hospitals.
The count is the thing I want to explain before anything else, because everybody thinks they know what it is and they do not.
Before the patient is opened, the scrub nurse and the circulating nurse count everything on the trolley. Every instrument, by name and number. Every swab, in fives, held up and separated so both people see them. Every needle, every blade.
It is said out loud. Both people see each item. It goes on the whiteboard.
You count again before the surgeon closes the cavity, and again as the skin closes, and if the numbers do not match then nothing else happens in that theatre until they do. Not the closing, not the next case. You count again. You look in the drapes, in the kick bucket, on the floor. If you still cannot find it, the patient goes for an x-ray before they leave the table.
That is not an exaggeration or a story. That is the procedure and it is followed, everywhere, every time, because the alternative is a swab left inside somebody and a career and a life ruined.
My counts have always matched.
Here is the thing that is wrong, and it took me four years to be able to say it in a sentence.
The count matches. And when the case is finished and the trolley is being broken down, there is an instrument on my tray that I did not count in, and that is not on the tray list.
It is not missing from anywhere. Nothing is short. The count out equals the count in, every time, and the thing is extra.
It is the same instrument every time.
It is a pair of artery forceps, curved, about seven inches, a very ordinary pattern that any theatre in the country has forty of.
They are old. Not dirty and not damaged, but old in the way you can see: the finish is different from the current stock, and the box lock has that slightly heavier look that instruments had before about 1980.
There is no set number on them.
That is the part that matters more than anything else I can tell you. Every instrument in a modern theatre is etched with a tray identifier so it can be tracked through decontamination: a code, a number, sometimes a datamatrix square. It is how a tray is proved complete before it is sealed.
These have nothing. The shank where the etch goes is blank and unmarked and always has been.
I have handed them to sterile services eleven times.
The first time I put them in the tray and sent them through with everything else, which is what you do with a stray instrument, and I raised it as a discrepancy on the form, and the form came back saying instrument not identified, returned to circulation.
After that I started handing them over in person to whoever was on the desk, with a note.
Three times they have been taken away and quarantined, which is the correct action, and I have followed it up, and on each occasion there is no record of an instrument being received without an identifier on that date.
Once, in 2017, a technician I know well took them off me and put them in the quarantine box while I watched, and closed the lid, and I went back an hour later and asked to see the box.
He opened it. There were two other things in it, neither of them mine.
They came back to my tray in the next case. Not that week. That case.
I have tried the obvious things and I want them on the record.
I have started counting instruments a second time before I count them at all, on my own, before the circulating nurse arrives, which is not the procedure and which I have done perhaps two hundred times. They are never there at the start.
I have worked with eleven different circulating nurses and it happens with all of them, and no, none of them have ever seen them on the initial count either, and yes, I have asked, carefully, and twice not carefully enough.
I have moved hospitals. It followed me. That is the sentence I have not said out loud to anybody in nineteen years and I have just typed it and I am going to leave it there.
The last thing, and this is why I have written this down now rather than in any of the previous nineteen years.
In the June I had a case that went wrong. Not through anybody's fault; some do. A bleed we could not find, and a long twenty minutes, and the consultant asking for things faster than I have ever handed them.
At one point he put his hand out without saying anything, which he does, and I put a pair of curved artery forceps into it.
I did not take them off my tray. My hand went to the tray and there was a pair in it and I gave them to him and he clipped a vessel I could not see and the field went quiet and the patient is alive and went home eight days later.
At the end I counted, and the count matched, and on the tray there was one extra pair of curved artery forceps with no etch on the shank.
I have not decided what I think about that.
What I have decided is that I am not going to hand them in again. They go into the tray, they go through decontamination with everything else, and if they come back they come back.
Because for nineteen years I have been treating them as a fault in a system that has never once been short of anything, and I am fifty-one, and I would rather be the nurse who has a pair of forceps she cannot account for than the one who is short.