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Man's Chest Tattoo Could Have Led To A Serious Medical Mishap


The patient after surgery. The "play" symbol tattoo resembling an arrow can be seen on his chest, and the medical team's addition of a true arrow is on his arm. Edlin and Kanagasabay/BMJ Case Reports, 2018

Many medical providers love to point out that tattoos can have some unpleasant unintended consequences for one’s health. Typically, the situations wherein body art goes wrong leave the doctors frustrated and the inked-up patient sheepishly regretful.  

A London man nearly upset this balance, however, when a play symbol tattoo on his chest – resembling an arrow pointed to his left side – momentarily flummoxed the St George’s Hospital surgical team prepping him for a procedure on his right side, according to a case study published in BMJ Case Reports and written by two cardiovascular department physicians.


The unnamed 23-year-old patient had been scheduled to undergo surgery to treat a recurrent right pneumothorax (also known as a collapsed lung), and following protocol, the team came by beforehand to obtain official consent and mark the planned incision site with a special pen.

Hoping to avoid any potential confusion, they came up with a quick and simple solution: They drew a bigger arrow on his right arm pointing toward the errant air bubble that had formed between the lung and the chest wall.

“Although the patient’s tattoo gave rise to quite a stir in the anaesthetic room and operating theatre, it reminded the entire team of the importance of correct site marking, the five perioperative communication steps and adhering to the WHO Surgical Safety checklist,” the authors wrote.

CT scan of the chest showing a pneumothorax on the person's left side (right side on the image). A chest tube is in place (small black mark on the right side of the image), the air-filled pleural cavity (black), and ribs (white) can be seen. The heart is the object in the center. Wikimedia Commons

It may seem shocking to those outside the medical field, but procedures performed on the wrong body side or site are not that uncommon.


A 2006 study concluded that between 1,300 and 2,700 wrong-site events likely occur each year in the United States. Exact numbers are unavailable, but clinics and hospitals in the UK and beyond are just as susceptible to these mistakes, which stem from a lack of proper case documentation, poor staff communication, and/or failing to look at existing records.

In response to the troubling number of regrettable – and very preventable – incidents, the World Health Organization (WHO) launched the aforementioned checklist initiative in 2009.

Thankfully for the patient, the minimally invasive operations to vent the air pocket, called a bulla, and remove the damaged part of the membrane enveloping the lungs where the air had escaped were successful and uneventful.

"My parents always told me my tattoos would serve as a lesson one day, I don’t think they pictured this,” the patient stated.


“Glad I could provide a source of bemusement and hopefully education."

Last year, Florida doctors were put in a truly confusing situation when a dying man bearing an oddly specific piece of body art – a chest tattoo reading "Do Not Resuscitate" – was brought into a Miami hospital. Turns out the man had also put this instruction in legally binding writing, so his request was honored.


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