LBBERSAMIN’S MAR [15-03]:Looking Back and Moving Forward

Medical Anecdotal Report
Indexing Title: LBBERSAMIN’S MAR [15-03]
MAR Title: Looking Back and Moving Forward

Date of Medical Observation: April 2015
Tag: Carrying complete practices from the lessons we learn from our patients

Category: Professiona/Ethicall– Reinforcement


It was during the final hour of the procedure and the confidence I felt then that I realized I have come a long way with my patient. We had performed a wide excision procedure with frozen section and a rotational latissimus dorsi flap on this 54-year-old male diagnosed with a malignant peripheral nerve sheath tumor on the left scapula. Intraoperatively, as we were notified that no malignant formations were seen in the margins, and that the adequacy of the flap was clearly seen, I finally felt relieved from all my concerns then. I was anxious and concerned about this case, if through the course of my management in time, something would have been missed, or a complication may arise. These thoughts had stemmed from my previous patient, a case of a 54-year-old male, diagnosed with malignant proliferating trichilemmal tumor on the temporo-parietal aspect of his left head, post wide excision and rotational advancement flap. This patient had suffered from a recurrence of the tumor to which a more extensive type of surgery and treatment would now be rendered to him by a different institution. Since this morbidity came, I had filled a pool of doubt upon myself. And so, I went back and studied the steps I made and what I could have done to have made it right. If I had gone more into depth in my technique and post-operative care, adding more assertion, would I have fulfilled this case with no complications? Every time I came to think about this patient, I go back and ask myself “what could I have done before, during, and after the procedure”. Going back to this new patient, although with relatively lesser complications in surgery, the patient still presented with the regular problems of an indigent individual. But even with this financial burden, with enough foresight, I had prepared some money for him. I referred and included a multidisciplinary team of surgeons and of other specialties to help us out. I secured the laboratory workups required and the diagnostics needed, pre-operatively and intra-operatively, sourcing funds from different sponsors and from my own pocket. I even prepared the patient psychologically for the procedure and long term care that followed. Even up to that faithful day, I was inexorable in pushing through with this case but not to the point of recklessness. And with that final hour, closing the wound after an adequate approximation of the flap, I could smell the success of the procedure with the efforts of my whole team. I was happy and thankful of all our hard work. The removal of my patient’s tumor has helped me lessen my anxiety then. It had given me a feeling as if I had removed that stone in my shoe badgering me for some time.

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

Although there are limitations to the capabilities of this institution, we get a steady stream of interesting cases who seeks us equally as they are sought. We present these cases to our consultants and other disciplines so that we may give the optimal treatment that is expected for cure. Pre-operatively, we present them in our weekly conferences and again, post-operatively, a week after. It is through these discussions that we evaluate the effectiveness and precision of our treatment, and harbor all aspects from inputs of the other consultants that may aid us eventually. We reflect on what we had missed in these special cases, and correct ourselves. The cases we encounter here may vary to its degree. We pick up the lessons we learned from our first appendectomy procedure and the management we give, up to the point where we move on to our first cholecystectomy. As a resident in training, we should always have a humble approach to our cases, no matter how simple it is. Although our consultants are always there to guide us, it is also important for us to set out what we have reinforced ourselves with thorough study. But other than the instructions and knowledge we get, we also learn to be bold. To have that boldness to learn and apply what we know. To rectify where we have blundered and slipped. Every doctor can share their own unforgettable cases where they have vowed never to have the same mistake with another patient of the same disease. Of the lessons we learned from the errors incurred, we can only get better. We become dynamic. We get to prepare our patients more meticulously pre-operatively, cut the edges of the tumor with more precision, and place our flaps with accuracy. In my last wide excision, I was better equipped. I was prepared as I have also prepared my patient. The humbling experience I had with my previous patient had taught me so much.  It made me better this time. Maybe it was my undoing. But to make the same mistake would already be unforgiveable. We learn from our patients and carry it on. We strengthen ourselves from the errors we made. We pick up the pieces and build that information we will take on to our next cases. We act with more refinement in skill and knowledge. We improve and maintain our sanctity because our patients expect this from us. In every case, we should look back only to move forward.


ROJoson’s Notes (16dec30):

Continual improvement is the name of game whether as a professional like a surgeon or as a institution like a hospital or any business establishment.  There is no such thing as enough, it is already perfect.

As a surgeon, always look back to previous patients that one has managed and either maintain the management method or improve on it, with particular attention to the latter.



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