LBBERSAMIN’S MAR [15-07]:The Intake and Output

Medical Anecdotal Report
Indexing Title: LBBERSAMIN’S MAR [15-07]
MAR Title: The Intake and Output
Date of Medical Observation: August 2015
My post-surgical intensive care training reflection and recommendation
Category: Professional/Ethical– Reinforcement
It was the first post-operative day of my patient, a case of a 57-year-old female diagnosed with gastrointestinal tumor of the duodenum, having undergone an abdominal laparotomy with gastric bypass under general anesthesia. The patient, after 8 hours in the post-anesthesia care unit had been transferred back to her room with the associated contraptions of 2 intravenous fluid lines, 1 indwelling foley catheter, 1 nasogastric tube, and an abdominal closed suction drain. These were the contraptions I had previously asked to put in her prior to the operation to help me in my care. Going into her room then, I saw her with all of these contraptions, in bed and was still weakened by the operation done. I greeted her with a smile and asked her simple questions like the presence of abdominal pain, chest discomfort, difficulty in breathing and flatus. I then went on to see the monitoring chart for the patient’s vital signs, the post-operative laboratory results, medication chart, progress notes, anesthesia record, nurses notes and the intake and output monitoring.  After meticulous and careful review, I noted the inconsistency of the intake and output monitoring by the nurses compared to the intravenous fluid therapy sheet and urine output monitoring on the patient. It seems that the I & O monitoring sheet was missing between 1.5 to 2 liters of infused fluids and that the output was not congruent with recorded drains. I recomputed everything and made a quick investigation of what had really transpired. I asked the nurses, the clerks and the post-duty surgery residents of everything that happened in between then. It seems that there was an inaccuracy in recording and that those involved had cause a slip-up in these vital aspects in post-operative care. I was a bit furious about what happened and asked, even begged to the nurses that this should not be the way. I asked them to understand my process of care and although I was annoyed by this fault, I moved on. I then went on to make my progress notes and make new orders as I carefully outlined them for every medical professional involved in this post-operative patient. The following day, I noted that the problems I had incurred had been addressed and that the patient was carefully monitored and managed. On the eight post-operative day, with all the contraptions removed on the previous days prior, and the patient up and about, she was able to go home.
(Physical, Professional/Ethical, Psychosocial)
(Discovery, Stimulus, Reinforcement)
“The pursuit of perfection, leads to obsession and sometimes madness” – Peter Blaxland
In the years before this, through our books and knowledge passed on by our seniors, I had learned so much about intensive care and post-operative management. I came to understand the many things that happen in our patients and what to do. But this year, it was overtly better. Our department had recently made a partnership with one of the premiere government hospital institutions where we had the concession of rotating in their surgical intensive care unit. It was with great pleasure and excitement on my part to expand my knowledge further of what I may learn from this experience. What I may add and correct about the surgical management of a patient. And with this, it has benefited me and my patient. It was a month long period of intensive training and assimilation of facts. It was an active site for learning and stimulation. After a month of rotation, with added study and exposure, I really felt repackaged. I was no longer the same a day before this experience had started. Generally, I came to be more meticulous in care, aggressive in management, and wise about the events of my patient.

I was no longer waiting, but anticipating. I was no longer reactionary but rather forward in management. Going back to my narration, of how some medical professionals had been inefficient in this case, maybe we are the ones to be blamed. Maybe as doctors in this institution, we have become too forgiving in management and missed on the essential steps in care. Maybe we have been too reliant on the assistance of other services that we have neglected what we can do to our patients in care. Going back to that incident, I may have seemed mad because maybe the nurses did not recognize the same doctor. But it is all for the better. In what lacked in care on that day and what I pointed out, it was corrected the next day. Obsessing over these simple facts and details about our patient comes into factor for the overall being of the patient’s general status. Surgical intensive care helps us become more than just crafty surgeons, but keen and critical. We increase our patient’s chances for improvement, avoidance of systemic complications, and decreased hospital stay. We should be able to understand what old practices we should cease and continue, and what practices to carry in managing our critically ill and post-surgical patients. This part in our training as resident doctors should be continued. It is in this new practices and old predilections in reserved care, that we put our intake and output. It is in these new found obsessions where we become this madness for the betterment of our patients.
ROJoson’s Notes (16aug30):
In general surgery, there are various specialty and subspecialty rotations in the 5-year program, such orthopedics, neurosurgery, plastic surgery, surgical pathology, surgical intensive care unit, infectious disease; etc.  Such rotations give opportunity for the surgical residents to learn not only holistically and comprehensively but also other specific values like meticulousness, finesse, discipline, drive for excellence, etc.   It is an ever-improvement in learning trying to achieve perfection as much as possible.
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