LBBERSAMIN’S MAR [15-01]:Being a Doctor, A Friend, and Family

Medical Anecdotal Report
Indexing Title: LBBERSAMIN’S MAR [15-01]
MAR Title: Being a Doctor, A Friend, and Family

Date of Medical Observation: December 2014
Tag: Understanding the role of a physician to a crisis situation of a close patient in critical condition

Category: Psychosocial– Reinforcement

NARRATION:

It was a night of merry making for me and my friends owing to the time I had away from the hospital. I was able to catch up with them enjoy the evening. During that time, I was hailed by my friend to accompany him back to their house to attend to her ailing mother who was said to have difficulty of breathing. She was a 64-year-old female diagnosed with lung carcinoma stage III, post-coronary artery bypass graft, with hypertensive cardiovascular disease and diabetes mellitus type 2. I have known her since my childhood because I was very close to their family, and even having her as our godmother to me and my wife’s marriage. She was like a second mother to me. It has been more than a month already since she was diagnosed with this illness. All throughout this course, she often had symptoms of breathlessness and weakness. Although news of her illness came as a shock in their family, they were able to adapt to this problem by preparing the things needed for care. As I travelled to her house and entered her room, I found her in severe respiratory distress. She was already confused, with cold and clammy skin, and a faint pulse on her extremities. She was calling on the name of my friend while I had her lean on me, and tried pacifying her. “Ninang, ninang, I am here to see you”. We will bring you to the hospital”. We immediately transferred her to the car, after which I noted she had gone into cardio-respiratory arrest. Within minutes, we had brought her to the emergency department. In transit, with one hand holding on to her and the other hand clasping on the other, trying to compress my hands between her chest and the seat of the car as I sat at the back seat. When we arrived, I knew one of the doctors there and explained to him what had happened and the medical history of the patient. Resuscitation was initiated, but despite the measure of revival, no response was yet present. The emergency room physician had explained to my friends the futility of their efforts and the response they may get from these actions. I tried to explain everything we learned from the physician and relayed these messages to my friend because I knew he was overwhelmed by the situation. The ER physician also asked my friend if her mother had advanced directives towards her illness. My friend then told me that he recalled her mother saying that she does not want to be intubated and put on mechanical ventilator support when her time comes that she had this difficulty and the chances became bleak for her. I told him to notify his doctor cousin, who also knew of her mother’s illness and dilemma so that other than him and his siblings, their actual family doctor would know the case and give his comments of the situation. After a series of resuscitative efforts and no minimum amount of response can be elicited, we all agreed that it was time to let her rest, finally.

INSIGHT:                                                                                                         
(Physical, Professional/Ethical, Psychosocial(Discovery, Stimulus, Reinforcement)

Even in the light of our private time, resting and relaxing, we cannot deny the fact of our duty being a doctor. We can go to places on our own time, with family or friends, but even on these times we get a private consultation about their complaints and illnesses. The education and training we had, helps us handle light consultations and medical/surgical emergencies. Being pulled into that unexpected situation, I can only equip myself with what I knew about a patient in cardio-respiratory distress and what I can provide her at that time. Commanding the moment to decide what to do in a situation where the factors that play in dealing with a person in distress, a person close to us can be overwhelming. We may lose our edge in decision making and be overtly emotional. In issues critical to life prolonging measures, to halt or aggressively continue, the relatives of patients in these situations may find themselves entrenched in inaction because of their fear of blame. A moment like this, attending physicians lay upon them facts where they can base their decisions. Asking a patient or relatives in moments where a patient is incapacitated, advanced directives serves as a conduit to an all important decision based upon the wishes of a patient in this sensitive issue. Into this event of a known patient, a close patient, although asked upon by their relatives; a difficulty in providing a decision exists. When we know a patient, and a high density of familiarity is present, decisions that matter in the family, as in life or death, a doctor’s decision is often hard to provide. I did not want to bear the decision alone for my second family knowing that others, doctors of close relations and family, not present, to be out of the stream of information leading to a definitive pronouncement of certainty. In a moment like this, we can only provide facts. We can comfort and explain medical jargons a person in high emotional stress be resistant to understanding. We can be there to strengthen and guide them. We can provide emotional support and spiritual escort. In times when our patient and their family is in a crisis situation, we are there as their doctor. But in times of a family predicament, in the propinquity of our patients, our role as a friend or family should be concurrent with being a doctor.

ROJ@17may14

Posted in LBBERSAMIN’S MARs | Leave a comment

SSSFELICIANO’S MAR [15-01]:The Importance of our Consultants in our Training

MEDICAL ANECDOTAL REPORT
Indexing Title: SSSFELICIANO’S MAR [15-01]
MAR Title: The Importance of our Consultants in our Training
Date of Medical Observation: January 2015
Tag: Managing our patients with guidance from our consultants during training: a good practice
Category: Professional/Ethical – Reinforcement
NARRATION:
It has been traditional for us to greet our loved ones and friends a Happy New Year on the first day of the year. I’ve received a few to remind me that a new start is coming for us; however, I was saddened by news from the hospital. A 14-year-old female whom I saw on December was admitted for anemia. She was a case of a late-stage rhabdomyosarcoma of the gluteal area. I immediately informed our consultant of this admission and updated him of the patient’s status. The plan was to do palliative care, since the risks for radical excision or chemotherapy at the time outweighs the benefits for the patient. With the case of the patient, he advised me to prime the parents of her prognosis which I did. Furthermore, the patient was co-managed by Pediatrics Department and I explained to them our plan of management. Patient was accordingly referred to their Hema-Oncologist consultant who agreed with our plan for the patient. During her course, I could not help but be attached emotionally to the patient since I first saw her. I made sure that our consultant was updated and that we do everything we could for her. Her parents had been very cooperative during our course of management as well and there had been no question with how we managed their child. However, despite our plan for the patient to immediately correct her blood parameters, we had difficulty acquiring the needed blood products which eventually led to the patient’s demise. Though grieving, parents were still thankful of our efforts for their child. However, what was alarming on the day the patient was about to die was that the Hema-oncologist consultant was questioning our management. It was reiterated that there was lack of aggressiveness and that chemotherapy should have been done for the patient. The consultant wanted to call for a meeting for us to explain our side.  I informed my consultant and he thoroughly explained to me why chemotherapy was not done. He was calm enough to remind me to accept what they would say and told me to explain our side as well. The meeting did not push through, but it made me reflect that this is a learning case for me-learning that being updated on the management of a case is of utmost importance and that referring to our expert colleagues is a good practice while we are still on training.
INSIGHT:
(Physical, Psychosocial, Professional/Ethical) (Discovery, Stimulus, Reinforcement)
In any field of work, hierarchy is observed-be it in a company, government office, or a private institution. In the field of medicine, what is interesting is that we have those who have studied medicine ahead of us, hence our seniors, but at the same time, they treat us not only as juniors, but our colleagues. They are more than willing to extend their knowledge and skills to us, and are the happiest seeing us grow in our own niche. Our training could not work without our consultants, for not everything is found in our books, electronic sources nor from our experiences alone. They are the ones who have been in practice ahead of us, have most likely seen a lot more patients than us,  and saved more lives than us. They might have committed more mistakes, but these shortcomings are those which sharpened their skills, proved their theory, and made them the physician that they are now; these then are being passed to us.
As has always been reiterated, being lucky of their presence in our training, let us not forget to give them the due respect they deserve. Since we are in training and they are completely accountable of what we do to our patients, let us strive hard to be better every day, and be the best to every case we encounter. Not only should we inform them of our cases but to continuously update them with our patient’s progress. This experience I had was an awakening for me. Despite absence of any relation to this particular patient, she had been so dear to me. I will soon mother a child and this patient reminds me of a mother’s love to her daughter that is why I made sure that we give everything the patient should have. With constant communication with our consultant and the co-managing department, I assumed that I will be free of any guilt if something happens to my patient. However, sadly, the event of being doubted despite the expertise of my consultant not only taught me humility but the aggressiveness to learn more. More than the respect I had for my consultants was my admiration for their priceless effort of guiding us despite any problem that may arise, as in the case of this patient. Not only did they teach us, but they were there to back us up, in cases that we fall short of what we know and what we can do. Asking for their hands to help us out, they gave not only their hands and arms, but their all and with this, I will forever be grateful to them.  
ROJ@17may14
Posted in SSSFELICIANO'S MARs | Leave a comment

RAMOSA’S MAR [15-04]:Fulfillment amidst toxicity

MEDICAL ANECDOTAL REPORT
Indexing Title: RAMOSA’S MAR [15-04]
MAR Title: Fulfillment amidst toxicity
Date of Medical Observation: March 2015
Tag:   Handling abundant workload positively
Category:  Professional/Ethical, Reinforcement

NARRATION:

It was a busy day at the wards. It was the night before our elective operations and there were about ten patients who were scheduled for operation. We had to prepare all of the patients, make sure they were cleared by Anesthesiologists and Internists. We also need to ensure that they had all the anesthetics and materials needed for their respective operations. Aside from that, there were also critical patients at the wards who had to be closely monitored for various reasons (i.e. oliguria, desaturation, persistent hypotension). You could say I was having one of those ‘toxic’ duties. As if all of those were not enough, there came three new referrals from different departments: a neonate due to hypospadia, a 57-year-old male due to Benign Prostatic Hyperplasia, and a 34-year-old female post-partum for CVP insertion. I was starting to panic because I still had a lot of things to do. I was already ranting to myself and had almost done it out loud. I was starting to get irritated with the referrals and was already questioning why the referrals had to be done at this hour? But then I realized, I was doing the same thing to Anesthesiologists and Internists. I was also “bugging” them so to speak. I also realized I had no right to complain, I was in residency training. I need these cases to learn more. Thus, with a different perspective, I went to see the referrals and tried to finish all of the tasks at hand. 

INSIGHT: (Physical, Psychosocial, Professional/Ethical), (Discovery, Stimulus, Reinforcement)

Given the amount of tasks placed in our plates, especially as first year surgery residents, we may perceive referrals as additional workload. We may try to deny it to others, even to ourselves, but there are times that we tend to choose to grab the opportunity to sleep, even for a few minutes, than to go and see the referrals from other departments. But then, come to think of it, we do not only deprive other departments or doctors of our own inputs as a surgeon, but also deprive ourselves of the learnings that come along with the cases that were referred to our department.

Attending to the referrals will also gear you toward a better attitude that will be beneficial for future practice as surgeons, especially in developing interdepartmental harmonious relationship. As surgeon, there will always be a point in your life wherein you will come across cases that will inevitably require you to consult other specialties. Seeking other’s help is not a sign of weakness, but rather, a sign of strength, that you know your limitations as a surgeon, and accept it.

Fast forward to 6 years after, we would be dealing with surmountable number of referrals from doctors of various departments, hospitals, and even from different provinces in the country.

With these, more cases means more experiences leading to more learning. Ultimately, all of these will not only benefit us, as physicians, but more importantly, to our patients.

ROJoson’s Notes (17feb19):

Just have to look at the workload of referrals positively – more learnings and more public relationship!

Posted in RAMOSA’S MARs, Workload | Leave a comment

RAMOSA’S MAR [15-05]:Reaching the Boiling Point

MEDICAL ANECDOTAL REPORT
Indexing Title: RAMOSA’S MAR [15-05]
MAR Title: Reaching the Boiling Point
Date of Medical Observation: May 2015
Tag:   Dealing with difficult patients effectively
Category:  Professional/Ethical, Stimulus

NARRATION:

I was on duty at the emergency room when a 16-year-old male arrived for medico-legal consult. He was accompanied by his father and another man. A neighbor allegedly punched the patient, hitting the side of his head and neck. Routinely, I stood up and examined the patient. The patient only complained of minimal pain on the affected area and had no headache or vomiting. Simply put, the patient had no external signs of physical injury. As I explained these to the patient and his father, the other man who accompanied them interrupted me and asked in a condescending tone “Hindi ba dapat magpa-CT Scan diyan?!” (Shouldn’t a CT Scan be done?!) I was already annoyed by his belligerent demeanor but I again explained the physical findings and said that there was no need for it. “Hindi eh! Paano ka nakakasiguro?! Dapat masulat diyan na hindi ninyo kaya tingnan pasyente.” (No! It should be written that you can’t handle the patient.) Once again, I re-explained the physical findings to him. However, he kept on insisting that we write in the medical certificate what he wanted. Again, I had to re-explain everything to him. This happened repeatedly and for each exchange, his voice would get higher. I was already irritated and was already losing my temper. The medical interns who were on duty with me were also trying to talk some sense into him. He then said “Yan na nga ba sinasabi ko eh! Pagka mahirap kasi pasyente, wala kayong pakialam. Wala naman kayong ginawa!” (That’s what I’m saying! If the patient is poor, you don’t care. You didn’t even do anything!) At that point, I was already mad. He kept on ranting but I remained silent from then on. Thankfully, my immediate senior took over and clarified everything to him. However, he still wouldn’t give up. Eventually, he had no choice but to accept the medical certificate we made. After receiving it, they immediately left.

INSIGHT: (Physical, Psychosocial, Professional/Ethical), (Discovery, Stimulus, Reinforcement)

At one point or another, we would encounter difficult patients who would challenge us and try to stretch our patience to its limit. My previous encounter was a prime example of such. I was already annoyed at him at the very start but I tried my best and still talked to him. In the end, I lost my temper and just couldn’t handle it anymore. I then opted to remain silent. I knew that if I talked back, he wouldn’t like what I would have to say and matters would get worse.

Being emotional, I admit that I still have difficulty controlling my temper and masking it. Having my senior take over, made me rethink. Years from now, I would be a senior. What if I encounter another difficult patient in the future? How would I handle the situation? I don’t think that remaining silent would be enough. I would have to learn how to handle such difficult patients.

I came across an article and found some useful tips in managing difficult patients:

1. Gain personal emotional control. Don’t react, be proactive, and know your triggers. Slow down your breathing, speak slowly and quietly, lower your tone, and think about your body language. When feeling frustrated or angry, try reciting to yourself a few times: “I’m alert, I’m alive and I feel good”. Although this may sound someone ridiculous it can be an effective technique in shifting your ‘flight or flight’ amygdala-mediated physiological response to a positive, calm and constructive state of mind.

2. Start with a good first impression. Smile, use an open posture, introduce yourself, extend your hand for a handshake, look patients in the eye for 3-5 seconds.

3. Help your patient get emotional control. Don’t argue (arguing will lead to a vicious cycle of attacks and counterattacks as described above). Patients want to feel heard, understood and validated. Say “I’m here to help you and hear you out”.

4. Effective empathetic listening.  Search for the patient’s agenda. Echo or paraphrase what the patient says, and acknowledge their feelings. Say “I can see you are frustrated”

ROJoson’s Notes (17feb19):

Physicians encounter such a situation every now and then – “difficult patients.”  They should learn how to handle the situation – control your emotion, act professional, ask for assistance if need be.

Posted in Difficult Patients, RAMOSA’S MARs | Leave a comment

PCOracion’s MAR [15-05]:The Dilemma with Patient Disclosure

Medical Anecdotal Report
Indexing Title: PCOracion’s MAR [15-05]
Title: The Dilemma with Patient Disclosure
Date of Observation:  July 2015
Tag: Disclosure in patients that have been managed by another physician
Category: Professional/Ethical – Reinforcement

NARRATION:

A 68-year-old female sought consult at the out-patient department for an anal mass. She noticed it a month prior to consult. It was occasionally painful and was constantly present. She claims to have undergone staple hemorrhoidectomy 3 years ago. She showed me a histopathologic report stating hemorrhoidal piles and squamous cell cancer. She asked what it meant. I didn’t answer right away. I inquired if her previous doctor had talked to her about it. She was told that she only had hemorrhoids and all of it was removed. I asked if I could examine her and she obliged. There were 2 distinct hard tender sessile masses each approximately 1 cm in size at the anal verge. The sphincter was intact with no mass in the anal canal. The patient said that when she went back to her doctor she was told to get the mass removed. She was reluctant for she didn’t want to spend as much as she did before. I tried to carefully place my words. I said that the mass I saw were unlikely to be hemorrhoids and I am suspicious that it could be malignant. She adamantly opposed it, saying that her doctor said she only had hemorrhoids and nothing else. I let her rant. I told her that she should talk to her doctor about it. She didn’t want to. I relayed this to my colleague and the patient was eventually referred to our surgical oncology service consultant. She was advised to undergo chemotherapy.

INSIGHT:
(Physical, Psychosocial, Professional/Ethical)
(Discovery, Stimulus, Reinforcement)

We can encounter patients that have been managed by another physician and want to transfer for completion/change/revision of management due mainly to financial constraints. The management becomes tricky because the case is already complicated. In a few instances, the issue lies in the incomplete disclosure of information to the patient regarding his condition. The dilemma to the new physician is whether he should or should not fully disclose what he has deduced from his own history taking and physical examination.

A physician-patient relationship is founded on trust and mutual respect. It denotes two-way communication, patient cooperation and empowered decision-making. Without complete disclosure this cannot be fully achieved. Though it is with cost for a physician to commit to full disclosure, it is incumbent for him to relay important information and details that can or will affect a patient’s disease condition, his perception of his current state and his decision in the course of his management. It is never good to withhold information.

It is ethical to call the attention of the previous physician that a patient of his has transferred to your care and discuss the patient’s disease. In our setting this does not happen. It is however expected that physicians caring for patients that have been managed by another where complications or adverse events occurred, to disclose his findings to the patient in a manner that is truthful but not derogatory to the previous physician. There is a risk that the previous physician can be implicated for neglect or malpractice but committing non-disclosure in these complicated cases will further add harm to the patient’s well-being.

As young surgeons, we must learn proper patient care. It must be ingrained in us that proper patient care encompasses the moment we first meet the patient, during pre-operative preparation, intra-operative management, post-operative care and even up to follow-up after discharge. We must be truthful always in every step of the way. If we are knowledgeable, we can handle the possible outcomes and adjust the treatment. We can educate the patient about it without losing rapport. We cannot render good patient care, avoid complaints and promote customer delight if we do not abide by this.

ROJoson’s Notes (17feb13):

The physicians should be truthful in their explanations and advices. Timing and how to communicate are what the physicians should consider when they do explain and advice.

 

Posted in PCORACION’S MARs, Truthfulness | Leave a comment

GPVILLANUEVA’S MAR [15-05]: The Last of My Bucks

MEDICAL ANECDOTAL REPORT
Indexing Title: GPVILLANUEVA’S MAR [15-05]
MAR Title: The Last of My Bucks
Date of Medical Observation: June 2015
Tag: The reward of being a doctor
Category: Professional/ Ethical – Reinforcement
 
NARRATION:
As I was about to close my eyes to start my nap at around three in the morning, my phone suddenly rang. As a senior resident on duty, a phone call at this time would mean either a trauma patient needing immediate attention or a special case in the emergency room. I was half-asleep when I answered. It was my junior resident in the E.R., referring a 48-year-old male complaining of severe abdominal pain with history of peptic ulcer disease. I stood up and while asking for the status of patient, I went down to see the patient.
The patient had shallow breathing due to the pain from his abdomen and upon physical examination, his abdomen had involuntary guarding. It was indeed a surgical abdomen. We immediately started resuscitation and prepared the patient for operation. The relatives were not around as I was explaining the situation and as a usual scenario in our hospital, there was no available radiograph machine and also most of the needed laboratories. I requested only the available and important laboratories.
Since there is no available radiograph machine, the patient needs to be conducted to a private laboratory about three minutes away from our institution. I told the post-graduate intern to prepare the patient for conduction. Since there are no relatives around, I took the responsibility in funding the patient’s x-ray. As I opened my wallet, I remembered that earlier that day, I paid for my credits and other bills for the month and I was left with only one leaf of paper although enough for the chest radiograph to be done. Although it was the last of my bucks, I gave it to the intern to pay for the laboratory.
The patient returned from conduction with a radiograph result of pneumoperitoneum. Referral to my immediate senior and consultant was done and then I directed the patient to the operating room for exlploratory laparotomy. The other materials for operation were given by the other members of my team.
The operation became unremarkable and the patient was discharged after a few days not knowing the efforts that we gave beside his actual operation.
                                                                                             
INSIGHT
(Physical, Psychosocial, Professional/ Ethical)
(Discovery, Stimulus, Reinforcement)
 
What do we get in saving the life of others?
 
We are not given awards as to the number of patients we have saved, as we do it every day and encounter it very often it becomes routine that no one would actually notice. Even other staff of the hospital would just think of it as part our job.
 
In the government setting from where we are now, we are paid the same even some would stay in the hospital more than eight hours a day, work more than twenty-four hours on a busy duty and would sleep for a few hours then would be awaken by a patient asking for her abstract and papers to be signed.
ROJoson’s Notes (17feb13):
Compassion is demonstrated here regardless of the situation the residents are in.
Posted in Compassion, GPVILLANUEVA’S MARs | Leave a comment

MESANICO’S MAR [15-05]:Observing Proper Patient Care

MEDICAL ANECDOTAL REPORT
Indexing Title: MESANICO’S MAR [15-05]
MAR Title: Observing Proper Patient Care
Date of Medical Observation: May 2015
Tag: Patient Care Through Our Mentors’ Legacy
Category: Professional / Ethical – Reinforcement
           
NARRATION:
A 31-year-old female approached me at the Out-Patient Department (OPD) one afternoon. She showed me her ultrasound result which indicated she had calculus of the gallbladder (stone within the lumen of the gallbladder) and that she had already undergone her evaluation under anesthesia almost 3 weeks ago. She was to have a laparoscopic cholecystectomy done but due to her sudden busy schedule, she was forced to postpone the said procedure. She then told me that she was now finally able to have her operation push through and that it would mean a lot to her if I could immediately schedule her. Fortunately, with the drop in our census and availability of our machine, we were able to set a date and perform the elective operation itself within one week after our conversation at the OPD. The surgery was uneventful and we had the patient up and about in less than a day. Two days later the patient was set to be discharged and advised to return to the OPD after a week. The patient was so grateful that, seeing that our ward was more vacant than the usual, promised to look for even more patients with the need for an operation and send them to our institution. We then thanked her and sent her home.
 
INSIGHT:
(Physical, Psychosocial, Professional / Ethical)
 (Discovery, Stimulus, Reinforcement)
 
 “Towards Patient Safety in Surgery. Promote customer delight. Avoid complaints at all times!” This is one of the legacies instilled in us by our mentors, the words we try to live by as we go about our training, and the mentality we want to maintain when the time comes that we would have our own practice. It constantly reminds us to put the patient above everything else, be it for our own training or for the welfare of the hospital itself. With the case at hand, we were able to observe patient safety during our operation with the aid of our consultants, who would supervise us first hand while doing the procedure, teaching and guiding us through all the necessary steps. Customer delight was very much promoted especially at the end of the procedure. Not only was she satisfied with the outcome of the operation, she was more so surprised with how fast her recovery was and how she was able to return to her work, all within a week’s time. Finally all possible complaints were completely averted, with the operation taking place in a matter of days from her most recent consult, and the ease of her queries with us, her surgery residents. When all three components are observed, absolute patient care is attained. As I continue my training as a fourth year resident of this prestigious department and institution, I plan to practice and enhance my skills even more when it comes to this aspect of patient care. Hopefully, if and when I do graduate, if I am able to treat my own patients even just half as well as we are taught by our consultants here in this hospital, only then will I be able to consider myself as a true surgeon.  
ROJoson’s Notes (17feb13):
 “Towards Patient Safety in Surgery. Promote customer delight. Avoid complaints at all times!”
The tagline of the Department of Surgery of Ospital ng Maynila Medical Center. It has worked well.
Posted in Customer Delight, MESANICO'S MARs | Leave a comment