S01E05 The 35-Year-Old Feeding Tube: A Hidden Medical Error

TRANSCRIPT S01E05 The 35-Year-Old Feeding Tube: A Hidden Medical Error

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The Med Disaster Podcast, Season One, Episode Five, The 35-Year-Old Feeding Tube, a Hidden Medical Error.

I'm Dr. Sam Rhee, and in today's episode we have a patient who had to live with unexplained pain for 35 years. Only to discover it was caused by something left inside her from a surgery decades ago.

This is the reality one Wisconsin woman faced a medical error from 1989 that wouldn't reveal itself until 2024. Today, we delve into Deborah Lowe's story, a tragic cascade of medical events, a hidden foreign object, and the quest for answers and accountability.

It's a story of unimaginable loss, resilience, and lessons for both healthcare professionals and patients.

Our story begins in Milwaukee, Wisconsin in [00:01:00] 1989. Deborah Lowe was 25 years old and pregnant with twins when a medical nightmare unfolded. Severe complications forced an emergency C-section at Mount Sinai Medical Center, now called Aurora Sinai Medical Center. Tragically, both of her premature twins did not survive the ordeal.

As if losing her babies weren't enough, Deborah suffered a life-threatening postpartum hemorrhage, massive internal bleeding after delivery, which required an emergency total hysterectomy, removal of her uterus. In one traumatic day, she not only lost her newborn children, but also the ability to have children in the future.

Deborah's condition was so critical that after the surgery, she was placed on life support in the intensive care unit. She spent two months in a coma hovering between life and death. To keep her alive, doctors had inserted a feeding [00:02:00] tube, a medical device that delivers nutrition when a patient cannot eat normally. In the chaos of saving her life, tubes were everywhere, as Deborah later recalled the feeding tube, typically a flexible plastic tube threaded through the nose or mouth into the stomach was meant to sustain her until she recovered.

But unbeknownst to anyone at the time, this tube would become the central character in a medical error that went unnoticed for decades. When Deborah finally emerged from her coma and left the hospital, she carried profound emotional and physical scars. She was a young mother who went home without her babies, and she was a 25-year-old woman who was told she could never have children again.

She was the survivor of multiple surgeries whose body had been through unimaginable trauma. She gradually healed from the immediate physical injuries, but [00:03:00] some wounds, both emotional and physical, would linger much longer than anyone realized.

Decades of Pain and Mystery

In the years following 1989, Deborah tried to rebuild her life. However, she was plagued by chronic health problems that doctors struggled to explain. She experienced persistent abdominal pain, bloating, and gastrointestinal troubles that came and went without a clear cause.

Her stomach would swell up painfully and she often felt unwell. She also suffered symptoms like migraines and shortness of breath that made daily activities difficult. Since 1989, I couldn't do things, Deborah said, describing how the constant health issues limited her life.

Over the decades, Deborah sought answers from multiple doctors. She underwent many tests and procedures in hopes of pinpointing the source of her pain. In fact, medical records show she [00:04:00] even had diagnostic colonoscopies, which are scopes to examine the large intestine in 2013 and again in 2023. But despite these efforts, the results were always inconclusive. No obvious abnormality was found inside the colon, and no doctor could give a definitive explanation for her agony. It was a medical mystery. Some might have assumed her pain was due to the extensive scar tissue from her surgeries or other complications from her difficult childbirth.

And frustratingly for 35 years. Debra lived with debilitating pain and no answers. She tried to carry on with life as best she could, coping day by day, all the while something was wrong inside her, something no one had ever suspected.

Deep in her abdominal cavity, a piece of that lifesaving feeding tube from 1989 had been left behind. It was silently causing trouble, a foreign [00:05:00] object where it didn't belong. Over time, this tube fragment became embedded in her abdomen. It likely triggered chronic inflammation and scar tissue, or adhesions, that bound up her internal organs.

These adhesions can tether organs together and can cause pain or digestive problems. In Deborah's case. Court documents later alleged that the retained feeding tube was the likely source of her decades long abdominal pain and gastrointestinal issues, and had likely contributed to extensive intraabdominal adhesions, which eventually required additional surgery. For so many years, Deborah's suffering had a very real but hidden physical cause.

The 2024 Discovery

The truth finally surfaced in the spring of 2024. After 35 years of mysterious pain, Deborah experienced a health crisis that [00:06:00] led to yet another procedure. This time it was a surgical operation on her colon. In April of 2024 at Milwaukee's Froedter Hospital, she underwent surgery to remove what had been described as a boil or abscess on her colon. It was supposed to be a routine procedure to address a localized issue. But it turned into the moment of revelation that Deborah had been unknowingly waiting for. When Deborah woke up from this colon operation, she was met with astonishing news.

She recalls the surgeon coming to her bedside to explain what they had found. I was like, what's going on? she remembered asking. And the doctor's response left her in shock. He said, I found a feeding tube inside of you and I had to remove it. She was utterly stunned. A feeding tube inside her, after all these years? At first, she could hardly comprehend it.

The surgical team had indeed discovered a foreign [00:07:00] object lodged in her abdominal cavity during the operation. It was identified as part of a feeding tube, the same type of tube that had been placed when Deborah was in a coma back in 1989.

In other words, a portion of that tube from her life support days had never been removed and had remained inside her body for 35 years. It had become embedded in tissue, essentially hiding in plain sight inside her all this time.

For Deborah, this revelation was validating but also devastating. On one hand, she finally had an explanation for her decades of pain. The chronic pain, the swelling, the digestive distress, it wasn't all just in her head or just scars. It was due to a tangible object that never should have been there. But on the other hand, realizing that this object had been left behind was horrifying. All those years of suffering might have been preventable if only someone had caught the mistake.

[00:08:00] Deborah was overwhelmed by emotions, anger, grief, disbelief. She later said she was in shock and kept thinking, how could they do this? Who could make this mistake? It was almost too much to process.

When the retained tube was removed, Debra could finally begin to heal physically, but the damage was already done. Doctors noted that the tube had likely caused significant internal scar tissue and adhesions, which themselves required surgical intervention to repair.

Emotionally the knowledge of what had been done to her reopened the old traumatic wounds of 1989. The presence of that tube she felt, had stolen much of her life that she could have had, compounding the tragedy that began with a loss of her twins and her childbearing capability.

Aftermath: Shock, Grief and Accountability

In early 2025, Debra Lowe decided to take [00:09:00] legal action and she filed a lawsuit against the hospital and also as yet unidentified staff involved in her 1989 care. Because so many years have passed, the specific individuals responsible for the oversight remain unknown, and the suit lists several John Doe defendants who were staff at the hospital in 1989.

At the press conference announcing the lawsuit. Debra stood alongside her attorney and bravely told her story to the public. It was an emotional scene, a 60-year-old woman voice shaking, describing a nightmare that started when she was 25.

For decades, she had lived day by day in pain and confusion, and now she hoped that speaking out would help prevent anyone else from suffering a similar fate.

As Deborah's story spread through media outlets, it prompted discussions among patients and healthcare professionals alike. How could something like this happen and what factors allowed a tube to be left inside a patient and remain undetected for so long? And crucially, could [00:10:00] modern safety practices have evolved to prevent such errors?

To fully understand the significant of Deborah's case, we need to explore the broader context of retained surgical objects in medicine.

Retained Surgical Objects in Perspective

Leaving a medical object inside a patient by mistake is known in healthcare as a retained surgical item or sometimes, retained foreign object. It is one of the most disturbing types of medical errors, so much so that patient safety experts call it a never event, meaning it's an event that should never happen if proper precautions are taken.

Yet, as rare as these cases are, they still do happen. To the average person, the idea of surgeons forgetting something inside a patient might almost seem unbelievable. Operating rooms have strict protocols. Surgical teams count all sponges, tools and instruments before and after an operation specifically to ensure nothing gets left behind.

How then did a feeding tube segment [00:11:00] slip through the cracks? Understanding that requires looking at the circumstances and some known risk factors for retained items. Studies have shown that emergency surgeries carry a much higher risk of retained objects compared to planned routine operations.

One landmark study by researchers at Harvard found that errors leaving surgical sponges or instruments inside patients are much more likely to happen during emergency procedures or in operations where there is a sudden change in plan.

In fact, in that study, emergency operations were associated with a ninefold increase in the likelihood of a retained object error. This makes sense. In an emergency, the surgical team is working quickly under great stress, perhaps with unexpected complications, and without the usual preparation time. There may be multiple surgical teams working together, lots of bleeding and a life on the line.

Normal protocols can be challenged, as Dr. Atul [00:12:00] Gawande, one of the study's authors, put it. In such chaotic situations, even experienced teams can make mistakes or deviate from the checklist in the rush to save a patient's life.

Deborah Lowe's 1989 surgery fits this high risk profile. It began as an obstetric emergency, an C-section for a troubled twin pregnancy and escalated to a fight for her life when she hemorrhaged and needed an unplanned hysterectomy.

It's exactly the kind of scenario where the focus was understandably on stopping the bleeding and keeping her alive and where normal routines might have broken down. We don't know the specific breakdown that led to the feeding tube being left, whether a communication mixup, a distracted provider or simply human error amid the crisis.

It's possible that when Deborah was rushed to the ICU, the tube was accidentally cut or disconnected and a piece remained inside. What we do [00:13:00] know is that the feeding tube should have been removed when she was recovering, yet it wasn't.

Retained objects are most commonly things like surgical sponges, which are gauze pads to soak up blood and small surgical instruments. In fact, sponges account for the majority of these incidents, analyses have found roughly 69% of retained object cases involve sponges. And about 31% involve surgical instruments like clamps or needles.

These items are small. They can blend into blood or tissue, and if a manual count is off or miscommunicated, a sponge can easily get lost in a body cavity. Less commonly, other devices or fragments of devices can be left behind, for example, broken pieces of tools or catheters and tubes. Deborah's case involves a tube, which is a rarer type of retained object, but not unheard of.

Medical literature notes, incidents of lost guide wires, [00:14:00] catheter pieces, and other tubing left inside vessels or cavities when things go awry. And these are all classified as retained foreign objects and all pose serious risks to patients.

What kind of harm can a forgotten object inside a patient cause? Quite a lot unfortunately. If you leave something like a sponge or a piece of tube inside the body, it can lead to infection since it's a foreign material, harboring bacteria. It can cause chronic inflammation and scar tissue as happened to Deborah. That in turn can lead to organ dysfunction or obstruction.

Patients may experience pain, bloating, or bleeding that won't resolve until the object is removed. In severe cases, a retained object can even be life-threatening, causing sepsis, a body-wide infection, or damage to vital organs. The Pennsylvania Patient Safety Authority, which tracks such events, found [00:15:00] reports of retained items causing issues like internal bleeding or organ injury requiring further surgery.

Patients often suffer not just physically, but emotionally as well. It's a breach of trust at a fundamental level, and many patients feel anger, betrayal, or develop anxiety or post-traumatic stress disorder related to the experience.

It is important to put retained surgical object incidents in perspective. They are rare, given how many surgeries occur daily. Analysts estimate roughly one to two retained items occur per 100,000 surgical procedures. Another review cited an incidence of about one in 10,000 surgeries. Either way, this amounts to a tiny fraction of all operations.

However, when it does happen, it's considered a serious, preventable error. Hospitals are not allowed to shrug off such mistakes. They must report them, analyze how they happened, [00:16:00] and implement changes to prevent recurrence. Since 2008, the US Centers for Medicare and Medicaid Services have stopped reimbursing hospitals for the additional costs of care, resulting from a retained object error.

Preventing Retained Surgical items: Then and Now

Given what we know, could Deborah's ordeal have been prevented? And what has changed in the years to make patients safer from this kind of error?

Let's consider the practices in 1989. At the time, operating rooms did have protocols for counting instruments and sponges. However, the systems were not as advanced as in some of today's methods. In a high pressure emergency situation, the surgical count might have been interrupted or deemed secondary to the life-saving efforts.

If multiple teams were involved, obstetric surgeons for the C-section, then perhaps general or trauma surgeons for the hysterectomy and bleeding control, handoffs and communications could have faltered. The feeding staff might have been [00:17:00] placed by the intensive care staff rather than the surgical team, creating another point where accountability could blur. Who was responsible for removing it?

Ideally, there should have been a checklist upon transfer out of the ICU to ensure all lines and tubes were removed when not needed, but it appears in Deborah's case that tube was never documented or even noticed after she recovered.

Let's fast forward to today. Over the past few decades, the medical community has tackled the problem of retained surgical items. Guidelines and safety practices have been developed in the intervening times in hospitals around the country.

There are detailed guidelines on preventing retained surgical items, which stress things such as multiple independent counts of all sponges, needles and tools, using standardized count sheets and whiteboards in the OR, and not closing a surgical incision until counts are verified correct.

They emphasize minimizing distractions in the operating room and [00:18:00] improving teamwork and communication, especially during shift changes or when multiple surgical teams are involved.

A common refrain in the operating room for all surgeons before a patient is closed is, are we missing anything? Is the count correct? It is a hard stop moment where everyone double checks.

Beyond manual counting, technology has helped in preventing these mistakes. Many hospitals have adopted surgical sponges embedded with radio frequency tags or barcodes, which can be detected by a scanning wand or mat before the patient leaves the OR. The scanner will beep and alert the team, even if the manual account was mistaken.

This extra layer might help reduce retained sponge incidents. One quality improvement study found that using radio frequency tagged sponges led to fewer retained sponges and reduced reoperations to retrieve them.

And in some cases if a surgical count is off and they can't find a missing item, the team will take an x-ray of the patient on the table, since sponges [00:19:00] have markers visible on x-ray to ensure nothing is inside the patient before finishing the surgery.

Metal instruments of course, are visible on X-rays too. And while these technologies and practices add time and cost to procedures, they may help to prevent the kind of harm. Deborah experienced.

Additionally, there's a culture change in medicine around patient safety. The Joint Commission has noted that hospitals with weak safety cultures or absent leadership involvement tend to have more of these errors. So hospitals are encouraged to foster an environment where any team member, surgeon, nurse, tech can speak up if they're unsure about a count or if something doesn't seem right.

Checklists such as the WHO Surgical Safety Checklist, implemented widely in the two thousands include items to verify all sponges and instruments are accounted for.

With all these measures, one might wonder, could a case like Deborah Lowe still exist in 2026? While the hope is that it's extremely unlikely, these retained [00:20:00] surgical objects do occur despite all of these measures.

Human errors and system failures still align in rare unfortunate ways. Even recently, over the past year, there have been reports of retained objects making headlines. For example, a recent medical journal report detailed a woman who discovered two surgical sponges left inside her abdomen six years after a C-section when she went to her doctor for persistent bloating.

Six years is far from 35, but it shows that these errors, while less common with modern precautions, have not been completely eradicated. And the goal of the medical community is to learn from each case to ensure every possible safeguard is in place.

Reflections And Takeaways

Deborah Lowe's story is painful and extraordinary, but it carries important lessons for all of us. For medical professionals, the case underscores why a meticulous attention to detail, even in the most frantic [00:21:00] emergencies is so crucial. It's a reminder that patient safety protocols exist for a reason.

Every sponge, every instrument, every tube must be accounted for, every time. When routine protocols break down under stress, that's when the risk of harm skyrockets. Deborah's ordeal also highlights the need for effective communication during handoffs, such as from surgery to the ICU.

Modern healthcare teams can take this as a somber example of what can go wrong if anyone assumes someone else must have removed that tube. Clear responsibility and checklist based handoffs might have prevented that tube from being forgotten.

The medical community must continually commit to improving systems, practicing drills, and embracing technologies. While we are not at that point, the goal should always be zero retained objects, zero preventable tragedies.

For patients and the [00:22:00] general public, the one takeaway is the importance of advocating for yourself and listening to your body. Debra knew something was wrong with her for years. She kept seeking answers, and even though it took a long time, she did not give up.

Her persistence eventually led to the discovery that validated her complaints. If you ever have persistent, unexplained pain or symptoms that doctors can't pin down, Deborah's story teaches us not to simply accept living in misery. Seek second opinions, ask for further investigations and keep pushing for answers.

It's rare that the cause will be something as dramatic as a retained surgical item, but many conditions from endometriosis to autoimmune disorders can go undiagnosed for years without patient persistence. Finally, Deborah's experience invites us all to have empathy for those harmed by medical errors.

She's not just a headline or a lawsuit. She's a [00:23:00] person who endured loss and pain for the best years of her life. The emotional impact of what she went through cannot be overstated. Victims of medical errors often suffer in silence, sometimes feeling too defeated or distrustful to speak out. Deborah chose to share her story, and in doing so, she has likely helped others, whether by motivating a surgeon to double check the count or a nurse to speak up in the OR, or a patient to insist that follow-up scan, her voice can lead to change. And as listeners, we can honor her courage by taking to heart the lessons her case provides.

This is a call to action for vigilance, honesty, and compassion in medicine. Her hope and ours is that telling her story will help ensure that no other patient has to endure a similar fate.

Thank you for listening to this episode of the Med Disaster Podcast. I'm Dr. Sam Rhee, and we would like to hear from [00:24:00] you. Please reach out on Instagram @Med.Disaster or follow us at www.med disaster.com. Until we scrub into our next episode, please stay vigilant and stay compassionate. Thank you.