MBVELEZ’S MAR [15-04]: Prioritization of Patients

Medical Anecdotal Report
Indexing Title: MBVELEZ’S MAR [15-04]
MAR Title: Prioritization of Patients
Date of Medical Observation: April 2015
Tag: Learning which patients to prioritize under worse circumstances
Category: Professional/Ethical – Reinforcement
 
NARRATION:
 
I was the resident-on-duty at the emergency room when a 20-year-old male patient was referred to me by the department of Internal Medicine (IM) due to a non-healing wound on his left foot. I then approached him immediately and noticed that he looked really familiar to me. I then realized that he was a previously admitted IM patient who was diagnosed with Diabetes Mellitus Type I, who was referred to me due to a small dry gangrene on his left leg, whom I did a thorough debridement on it. I checked my previous surgical site and noted that it was properly healing. What was referred to me was yet another worse-looking wound on his left foot, which happened when he soaked it in a hot water which he did not feel that time, hence I noted at that moment that it was a wet gangrene. The IM resident-on-duty then told me that the patient was in Septic Shock (sepsis with cardiovascular collapse) due to the wet gangrene. At that moment, they were having difficulties in admitting patients since they were ordered to limit their admissions due to the hospital’s state of undergoing renovation. I referred the patient to my senior residents and all of us agreed that the patient should undergo prompt surgical removal of the source of infection. Both of our departments then made the decision that the patient should be properly managed in our institution, and not to be transferred to another hospital. After referring him to one of our Orthopedic Consultants, I then talked to the patient as well as his parents, and relayed to them of our surgical plan. Brief explanation was done, and I told the parents that all of us, including them should be aggressive enough for a timely and proper management to be done. Resuscitation of the patient’s state of shock was immediately started, appropriate antibiotics were given, and deranged laboratory results were properly addressed. After a day, the patient’s condition was optimized, and then transferred to our service. Immediately, I did a below-the-knee amputation (BKA) on his left lower extremity and successfully did it properly. After two days of post-operative management of both Surgery and IM department, he was then discharged, and well advised of proper wound care and for a good compliance for treatment of his underlying condition, and of course, a close follow-up.
 
INSIGHT:

(Physical, Professional/Ethical, Psychosocial)
(Discovery, Stimulus, Reinforcement)
 
Being a physician is one of the noblest jobs in the world. We swore to an oath that we will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. Along our journey as physicians, we are faced with a lot of different cases of patients each day, and a lot of them come with different challenging moments. Our current state of renovation is one of the toughest encounters of this institution, and we have limited choices of coping up with it. We cannot attend to all patients needing our help, despite our constant urge of being able to treat all of them. However, there really are those patients that we ourselves know who truly need our proficiencies and capabilities in the most critical moment of their lives. In accordance to this, it is very important for us to know that these are the patients who need to be prioritized during these circumstances. We should be able to learn how to maximize our institution’s capacity to accommodate patients. When worse comes to worst, and the time comes that we really have to limit accepting patients, we should know which patients need to be prioritized. There are patients who still have the window period of optimization, and who still can be transferred to other institutions that are able to manage their cases. However, those patients like the one in my narration, are the examples of those who should be admitted and properly managed in this institution. Moreover, when these patients come to our hospital for treatment, they should be cured without any delay, offering the most important aspect of our management, the prompt salvation of their lives, and at the same time, for our institution to be able to accommodate other patients, due to their early discharge from this hospital.
ROJoson’s Notes (17jan14):
Physicians will frequently use “prioritization” in their practice of medicine.  Prioritization of which patients to take care first.  Prioritization of which patients to operate first.  Prioritization of which patients to admit in the face of limited beds. Prioritization of which disease in a patient with multiple diseases to treat first.  Etc.
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