Now to the nitty gritty of counting: the instruments.
There are a few rules for when to count instruments.
The first is the beginning count.
This is the pre-incision count.
This is where it is established what instruments and soft goods have been opened for the case. Any discrepancy in this count will have reverberations in the rest of the counts.
Basically, don’t screw it up.
After the case has been opened and prepared by the scrub tech, ideally before the patient enters the room, the count can begin.
This is an auditory count where the scrub tech counts aloud, and a visual count where the instrument/soft good must be visualized by both the circulator and the scrub tech.
All the instruments on the table before the start of the case are counted during the initial count.
ALL the instruments.
Remember, any misstep here will echo through the entire case.
Everyone has heard about the misadventure of the retained surgical item. This is usually a sponge or a needle.
But the most egregious stories are the instruments left inside. You probably have heard the story of the retractor left inside a patient that was 3 inches wide and 12 inches long. Yeah, that one.
The count is one of the things that keeps the patient the safest.
What goes in, must come out.
Unless it is meant to remain there.
A simple surgery of a lipoma removal has an instrument set that is called a minor set. This is called different things in different ORs. But it is a basic instrument set, with a little bit of everything in it. The minor set in my hospital has knife handles, forceps, retractors, hemostats (basic clamp), kellies (a bigger basic clamp), allis (a tissue-holding clamp), babcocks (a tissue-holding clamp for thicker tissue), tonsils (a long clamp), needle drivers (to hold and manipulate the suture needles), different kinds of scissors (to cut tissue or suture), sponge sticks (to hold a folded up raytec), and towel clamps (to hold things together or on the drapes), and ednas (blunt towel clamps).
This totals 60 instruments that must be counted.
Now imagine a case with 4 instrument sets of 14-70 pieces (or more).
And the importance of the instrument count comes clear. Any of those instruments, if not properly counted, can end up in a human body and be left behind.
This is why the count is so important.
It is a matter of patient safety.