RMAGUDA’S MAR [15-06]:Appreciation of Our Resources but Accepting Our Limitation As Well

Indexing Title: RMAGUDA’S MAR [15-06]
MAR Title: Appreciation of Our Resources but Accepting Our Limitation As Well
Date of Medical Observation: June 2015
Tag:  Accepting the limitations that we have in providing surgical care for our patients
Category: Professional/Ethical-Reinforcement 


As the night was winding down during one of our duty day, a referral from the Department of Pediatrics came. The referral was that of an 8-month-old female with a chief complaint of abdominal enlargement. The patient according to her mother was born full-term with no feto-maternal complications upon delivery. Patient had no jaundice, no abdominal pain, and with normal bowel movement. Her abdomen however was another matter. Her abdomen although soft was noted to be gradually becoming more globular as the days passed. And so when the patient’s grandmother visited them and pointed out her noticeably globular abdomen, the patient’s parents became worried and immediately brought the patient for consult.

Upon examination of the abdomen, the patient was noted to have globular, normoactive bowel sounds, soft, nontender abdomen. Digital rectal examination was unremarkable. The patient was then referred to our Pediatric Surgery Consultant, who requested for an abdominal computed tomography which revealed Cystic Dilatation of the distal common bile duct compatible with a choledochal duct cyst, probably Type 1. The dilatation is located near the area of the pancreatic head measuring 6.8×5.8×5.4 cm. There is significant obstructive dilatation of the intrahepatic bile ducts and of the gallbladder.

I immediately relayed this information to our Pediatric Surgery Consultant, who then asked if we had already done the operation needed for the patient before. I told him that unfortunately I have not yet performed nor assisted in one. To my surprise, our consultant suddenly became livelier as he told me that we would do a hepaticojejunostomy for the patient. He would teach me the step-by-step of the procedure so we could do it on our own in the future. But before our consultant could further endorse his requirements for the procedure, our conversation was cut short when he asked if we have a portable x-ray in the operating room, which is needed for an intraoperative cholangiogram. Unfortunately in our hospital we have none for the past 3 years already. Our consultant then just instructed to refer the patient at the Philippine Children’s Medical Center. With much regret, the patient’s parents were given the referral and were sent on their way.

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

Years ago, our department started with only few consultants and residents. Since then, our department has evolved and branched out from general surgery to surgical subspecialties. Under the leadership of our chairman, with influence and great effort, I, together with my fellow residents are privileged  and now enjoying to be trained and assisted by a number of great surgeons who are more than willing to do cases in our institution, be it a simple appendectomy to the more complicated by-pass procedures and operations needing multi-disciplinary care. Not only are we lucky to be graced by our consultants during our operations, but also, another factor which makes our training more challenging is the fact that  our institution has been a catch basin of indigent patients with rare diagnosis and needing complicated medical and surgical management. Patients are more often referred to our department for possible surgical intervention. After our assessment, we then refer these cases to our consultants to guide us in the proper and appropriate management of patients. Once our consultants have instructed us of the planned management, we schedule our patients for operation. However, even with our consultants who are very eager to help and very willing to teach us, the circumstance of our hospital hinders us with limited facilities that we have here in our institution. It is in these circumstances that contributed efforts from our consultants and our willingness to learn are not enough to be able to fulfill our goal of providing service to all indigent patients with complicated cases who need our utmost help. Acceptance of these limitations however is not enough to free ourselves from the guilt of failing to provide service to those who need us.   Instead, let this be an initiating event that the administration should act accordingly.

ROJoson’s Notes (17jan20):

There will be always be times of limitations in terms of lack and scarcity of resources in any hospitals.  The public, the community of patients, the staff and the hospital administration should realize this. The hospital administration, however, should strive their best to make needed resources available most of the time, if not at all time.  Needed means “required” based on the hospital’s declaration of its capacity to serve its patients primarily (example – levels 1, 2, 3 based on DOH classification) and based on the realistic expectation of the community, secondarily.

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