MESANICO’S MAR [15-08]:Learning from the Events of a Mortality

Index Title: MESANICO’S MAR [15-08]
MAR Title: Learning from the Events of a Mortality   
Date of Medical Observation: September 2015
Tag: How mortalities can make you a better surgeon
Category: Professional / Ethical – Reinforcement 


I was at the emergency room when a 46-year-old female came in with a chief complaint of a mass on her right arm. Patient was a diagnosed case of Chronic Kidney Disease Stage V due to Hypertensive Nephrosclerosis and had an arterio-venous fistula created 2 years ago. The whole time she had been advised to undergo hemodialysis, however, due to financial constraints she had never had one session. After obtaining a complete history and physical examination we diagnosed the patient to have a pseudoaneurysm. The patient was referred to our service consultant and was prepared to undergo an emergency ligation of the pseudoaneurysm once she was optimized. After a day of transfusion of blood products we decided to bring in the patient, despite having a decreased hemoglobin value, an increased amount of creatinine and deranged serum electrolytes. We arrived at the operating room and quickly prepared the patient for the said procedure. As I was quickly but carefully dissecting the post-op site, I was able to identify the graft used and began to look for the distal connection. Suddenly I noted that blood clots began to flow through the wound followed by a gush of fresh blood. I quickly opened the axilla and clamped the artery and vein to achieve proximal control; unfortunately the patient had already gone into cardiac arrest and later on expired.

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

Operating on a patient has always given me an adrenaline rush, from the time I cut the skin with scalpel, to identifying the pathology and repairing or resecting it, to closing up the wound, even more so when I am able to discharge the patient a few days later without any complications. The procedures help me enhance my skill as a surgeon, giving me a chance to put into practice what I read from my books and learned from our consultants. Through my four years of stay here at Ospital ng Maynila I have learned that although this is the ideal setup for all procedures, not all patients end up this way. Every so often we residents on duty encounter cases which are not run-of-the-mill. Cases which may test are skills, acuity and knowledge to our very limits. Despite reading up on these cases, preparing for them by asking seniors and consultants on how to perform them, and optimizing the patient as much as possible, sometimes these patients end up paying with their lives. Such was the situation in my narration. Mortality had claimed another patient of mine, but this was the first time wherein she had expired on the operating table, leaving me stunned for the first few minutes. After we had attempted cardiopulmonary resuscitation and later pronouncing her dead, I quickly looked back at what I may have missed. My exposure to such a case has given me the chance to learn something new, if not to re-instill in my practice what I have already acquired but may have missed out at times. It taught me to be even more meticulous and careful when going about dissection of grafts and fistulas, especially when entertaining pseudoaneurysms; to go through extra lengths to prepare patients, especially when it comes to their blood picture; to prepare all materials needed for the operation and to anticipate probable situations that may occur; and most of all, to be in constant communication with our consultants, to seek their guidance and knowledge, not only for difficult cases but even those common procedures.

ROJoson’s Notes (17jan20):

Medicine is inexact. There are a lot of variations in causes, recognition and treatment.  Every physician will have his share of morbidities and mortalities, whether due to the inherent variations on the patient’s part or due to some glitches in  commission and omission on the part of the physician.  What is very important is that physicians should learn from the morbidities and mortalities, analyzing them in terms of patient’s factors as well as physician’s factors and then making a resolve to avoid a repeat.

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