MBVELEZ’S MAR [15-10]: Learning from a Mistake

Medical Anecdotal Report
Indexing Title: MBVELEZ’S MAR [15-10]
MAR Title: Learning From a Mistake
Date of Medical Observation: September 2015
Tag: Mistake: never should be a limit but a part of a learning process
Category: Professional/Ethical – Reinforcement
There was once a one-year-old female patient referred to us by the Pediatrics Department because of a right Empyema Thoracis (purulent fluid in the thoracic cavity). After properly referring to our Thoracic and Cardiovascular Surgery (TCVS) Consultant, I carefully did a Closed Tube Thoracostomy (CTT) on the right. As I believed that I was able to drain all of the purulent fluid, I decided to remove the chest tube after three days. Two days after I removed it, a repeat chest x-ray of the patient was referred back to me which showed recurrence of the empyema thoracis. I was in complete denial at that moment, but the fact eventually drilled into me as I saw her febrile and having difficulty of breathing. I immediately referred back the case to our TCVS Consultant and did re-insertion of a chest tube. After learning more about the factors to observe during the morbidity conference, I became more careful and more meticulous of my management. Few days have passed and the patient had no febrile and dyspneic episodes, with the complete blood count (CBC) showing resolving infection. When there was no more purulent fluid draining from her CTT, I decided to remove the chest tube after referring to our TCVS consultant. Subsequently, after a few more days of having stable and unremarkable state, the patient was then sent home. One week after being discharged, the patient was brought back at the Out Patient Department (OPD) for follow-up. She looked a lot more energetic and active, which seemed like she had never been admitted with such a case of an infectious disease. As I approached her, I felt so much happiness that the young patient I was treating at the ward has already recovered from her painful sufferings before. As I checked on her, she had stable vital signs, with no chest retractions and clear breath sounds, with the wound well-apposed with no purulent nor bloody discharge. I tried to carry her and, through that simple way, make her feel that I did my best to make her get better, and that I was deeply sorry to have committed a certain mismanagement during her stay in the hospital. Although she was crying and trying to keep away from me because of being psychologically traumatized, I believe that behind her youthful and innocent mind was a genuine gratitude that I was able to help in saving her life.

(Physical, Professional/Ethical, Psychosocial)
(Discovery, Stimulus, Reinforcement)
Being a physician, as we all know even before we get into this field, is lifetime learning. Handling patients each day registers to us as a personal experience leading to either a reinforcement of what we acquired before, or an addition to our knowledge and skills. More often than not, we learn the good way – reading books and articles, personally experiencing and conducting surgical operations, and a lot of teachings from our mentors. However at times, we learn the hard way – committing mistakes in dealing with patients. We as doctors always aim to be successful in treating our patients. We never wanted to fail in making them better, nor carry out a single error, because it is their lives that are more important for us. However, as Alexander Pope said, “to err is human,” and doctors are humans too. Every one of us in this field has committed a mistake, but that does not make us less of who we are, or what we want to become, as long as we keep on doing our best to meet the goal – to give our patients the best treatment as possible. To make mistakes is one thing, but to do something to make up for it is another. How we react once we realize that we’ve committed a mistake is more important. We should never be afraid to stand up after our mistakes. When committing mistakes, we would want to know where we have gone wrong, and who’d be the best people to ask but our mentors? We should get help from them and acknowledge the fact that we need other physicians’ help. It is through our mentors’ expertise that we would see what we could not see and realize how limited our capabilities are compared to theirs and how we should strive for more. As stated by Samuel Smiles, “We learn wisdom from failure much more than from success. We often discover what will do, by finding out what will not do; and probably he who never made a mistake never made a discovery.” I, being a Surgery resident-in-training, always sought for the best for all the patients I see. I may not be the best surgeon, or I may not even be worthy to be called as such for some other people, but I always try my best to be one, not for myself but for the patients I sworn-oath to treat.
ROJoson’s Notes (17jan20):
No person is perfect. No physician is perfect.  What is important is to always learn from errors and mistakes and strive to do better next time to achieve even just near perfection.
This entry was posted in Continuous Learning towards Perfection, MBVELEZ’S MARs. Bookmark the permalink.

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