Medical Anecdotal Report
Indexing Title: PCORACION’S MAR [15-07]
Title: Resident’s Realizations From A Morbidity
Date of Observation: July 2015
Tag: Realizing the lessons learned from a morbidity and importance of a morbidity conference
Category: Professional/Ethical – Reinforcement
A 66-year-old male with complete gut obstruction probably secondary to colonic malignancy was transferred from a provincial hospital for which I did an emergency exploratory laparotomy, sigmoidectomy and anastomosis. Post-operatively, the patient showed improvement clinically. Vital signs were stable, urine was adequate, bowel sounds were normoactive and the abdomen was soft, nondistended and nontender. Diet was slowly progressed from clear liquids to full diet. Patient was tolerating the feeding. He had flatus and bowel movement and vital signs were stable. By the sixth post-operative day, there were changes from the output of the Jackson-pratt drain but the vital signs were stable and abdomen was soft with no rigidity. I was entertaining an anastomotic leak and tried to conservatize however by the ninth post-operative day there was tenderness in the left upper, left lower and right lower quadrants. Patient had tachycardia and fever. I then decided to wheel-in the patient to the operating room. I did a laparotomy, peritoneal lavage, Hartman’s procedure. The patient improved and was eventually discharged. I presented the case in the morbidity conference and had several reaffirmations of what I have learned from it. It was gruelling to control the mix of nervousness, fear and embarrassment while I answered the questions one by one. Sometimes I couldn’t even answer. I was scrambling to compose my thoughts and construct my response. I thought I had read enough but apparently not. In the end, I managed to survive.
(Physical, Psychosocial, Professional/Ethical)
(Discovery, Stimulus, Reinforcement)
It is said that when you’re in residency, you are bound to have a morbidity and/or a mortality. It can happen for many reasons and can be multifactorial at times. It is important that these occurrences are discussed and the triggers and factors contributory to the morbidity or mortality be identified and resolved. That is the purpose of the morbidity/mortality conference. It is a venue for the resident to analyze and critic what has transpired in order to facilitate learning and improvement not only of himself but as well as the other residents.
It is therefore incumbent for residents to not only learn from his or other’s morbidity or mortality but to put into practice what resolutions were agreed upon to veer away from replicating such incidents. These untoward events are not merely a rite of passage as others may claim but it is an eye-opener. Having a morbidity or mortality does not necessarily equate to being incompetent. It is a testament that residents in a training program have a learning curve. It is expected that you do not know everything. It is also expected that your clinical judgement can have lapses because you have yet to see in actuality what you had only read in books.
Yes you might feel sad because you see your inadequacies but it should not discourage you from continuing with the training. It should serve as a motivation for you to persevere and constantly improve on yourself. Hone your skills and acquire knowledge from your mentors and colleagues.
My experience brings me to a realization that leak rate is high in primary anastomosis in operations where there is no bowel preparation done however one can either perform an on-table lavage or a protective ileostomy to minimize leaks. More importantly, I realized that though having to present in a morbidity/mortality conference is dreaded by most if not all residents, it should be embraced. I realize now that such activities are not held just to torture residents but to create an avenue to instill objective analytical thinking and humility. It opens your eyes to the level you’re at in your training. It enlightens you to see that you’ve still got a long way to go and it points out where you should focus to improve yourself. I also realized that mentors are like our parents. They’re disciplinarians and will be stern with you. If you make a mistake, they will get angry especially when you do it again. However, if you admit it, if you own up to it and understand your faults they appreciate it. They know that you’re okay, that you are going to be okay.
ROJoson’s Notes (17jan2):
Whether a surgeon is in a training program or after, he/she will invariably encounter a morbidity and mortality. It is incumbent upon the surgeon to review what transpired and what were the direct, antecedent, and underlying causes of the morbidity and mortality. The surgeon should learn from the morbidity and mortality event and should make a resolution to improve and prevent.
In a training program, there are morbidity and mortality conferences in which the surgical residents do presentation and discussion and answer questions from the audience, particularly the mentors. The objectives are to identify the causes and to learn and to resolve to improve next time around.