DMCRUZ’S MAR [15-06]:To err is human: Redefining the attitude towards surgical complications

Medical Anecdotal Report
Index Title: DMCRUZ’S MAR [15-06]
MAR Title: To err is human: Redefining  the attitude towards surgical complications
Date Of Medical Observation: June 2015
Tag: Understanding the implication of surgical complications as a first year resident on training
Category: Professional/Ethical – Reinforcement

 
NARRATION:
 
It was half-an-hour past three in the afternoon when our team was already preparing ourselves for the after rounds at the wards when suddenly a foul smelling scent filled the Emergency Room (ER). Not for long, a familiar face greeted us at our table. A 13-year-old female who was previously admitted and operated on our institution due to acute gangrenous appendicitis who came back for follow up at the ER and complained of abdominal pain. Upon thorough history and complete physical examination, we had noted that the pungent smell that we were smelling were from the patient’s purulent discharge. Exactly a week from the day of her operation, the patient admittedly confirmed that they were not doing any form of wound care at home and the patient was not able to take a bath, not even once, since the day that they were sent home. As a consequence, the patient had been constantly febrile and tachycardic and with noted abdominal distention and wound dehiscence. While rendering wound care at that time at the ER, I was beginning to question myself and cannot help myself but to contemplate that what if one of my post-op patients also developed such complications?
 
 
INSIGHT:
(Physical, Professional/Ethical, Psychosocial)
(Discovery, Stimulus, Reinforcement)    
                             
“To err is human”, probably this is would be the famous line that most of us often used to defend our shortcomings. Even in the field of Surgery, errors or mistakes are all too frequent if we were not careful enough. We all commit mistakes, but the only difference is what we do after we have made this mistake and how we see this mistake – is it a learning experience or a failure? Whenever complications occur on our post-operative patients, the involved physician struggle with its aftermath. While most of the attention typically, and appropriately, focuses on disclosing what could be possibly went wrong and addressing the concerns of the patient, the emotions triggered on the surgeon when these complications occurs are often overlooked. All too often, surgeons deal with these emotions in isolation. As a first year resident in training, such kind of post-operative event would be of high impact not only emotionally, but would greatly define our character as to what kind of a surgeon we will be in the future. More important than the harm that it will cause to our reputation as a resident on training in this department, would be the anxiety about the future operations, thinking that these untoward incident may happen again. Overall, we tend to lose confidence not only on this particular procedure alone but to ourselves as a surgeon. Doubt and these self-perceived errors can be associated with reduced quality of our everyday work at the wards; it might probably increase the feeling of burnout, self-pity and worse, depression. According to Dennis J. Boyle, MD, a physician – risk manager for a medical liability company: “It’s important to understand the needs and the coping habits of a physician after the occurrence of such complications, namely, the opportunity to talk to someone, reaffirmation of one’s competence, validation of the decision-making process and skills, and lastly the reassurance of their self-worth”. To promote emotional healing thereafter, as a first year surgery resident on training, I need to adapt different coping mechanisms to learn the most out of this mistake and move forward. The needs to recognize, forgive, repent, and finally, imbibe the lessons that I should learned from such experience should be emphasized. As a student of this prestigious department, I should learn to realize that holding on to these past failures can actually hold me back from reaching my full potential as a surgeon and I should never forget to look back from this learning experience because this would just deprives me the opportunity to carry out the crucial exercise of understanding what went wrong to the procedure and improve on them. And would serve as a constant reminder for all of us to practice extra care in handling our patients because it is their lives that are at stake.
Boyle, D. 2011. How medical errors affect physicians emotionally. J. American Association of Orthopedic Surgeons: Volume 9, Number 7 (July 2015) retrived last June 26,2015 at http://www.aaos.org/news/aaosnow/nov11/managing8.asp
ROJoson’s Notes (17feb13):
Writing such a Medical Anecdotal Report is also a way of coping with the stress of having complications.  One reflects and one makes a resolution on what to do if there is a surgical complication.
Posted in DMCRUZ’S MARs, Surgical Complications | Leave a comment

AALVEZ’S MAR [15-03]:Written Communication

MEDICAL ANECDOTAL REPORT
Indexing Title: AALVEZ’S MAR [15-03]
MAR Title: Written Communication
Date of Medical Observation: 2015
Tag: Making a prescription in a way a patient understand
Category: Professional/Ethical – Reinforcement

 NARRATION:

It was 4AM in the morning. A 39-year-old female came to me with a letter on her hand. She was an employee from another hospital and was accompanied by her husband. She was seeking urological consult due to her ultrasound findings of a stone in her ureter. I then proceeded to interview and examined her to further assess her condition.

I found out that she was having flank pain for 1 month. She was seeking consult to different doctors. She was actually confused from what was happening to her. I consulted with my senior resident regarding her case. We referred the case to the urology consultant. We were advised to have her for further diagnostics and medicines. I explained to the patient what plan we have for her and what medicines she would take. We then advised her to have a consult at the outpatient department once the diagnostics was done. We made laboratory request and prescriptions for her. I handed it over to them. They soon thanked us and made their way outside the emergency room.

A few minute has passed. The patient returned to me and asked me again about the prescription we made. She specifically asked on how to take the medicines we prescribed, what time would she take each one. I looked upon the prescription and explained to her thoroughly how to take each medicine we prescribed. After my explanation, she told me that she does not understand what we wrote in the prescription and she would appreciate if we would translate the prescription to Filipino.

Upon immediately knowing her concerns, I made another prescription in Filipino with the time needed for each medicine. I handed her over the new prescription. Immediately, the confused face was converted to a smiling one. She thanked me for the effort in doing the prescription and she promised to come back once the diagnostics has been done.

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

We encounter different kinds of patient throughout our tour of duty in the emergency room. Mostly we meet patients in need of immediate medical and surgical attention. Once the patient came in our doorsteps, we immediately assessed our patients and refer them to the proper channels to help alleviate their health concerns.

Communication is key in our patient interaction in our life as a surgeon. We discuss and explain thoroughly their condition and their choices regarding their disease. We establish rapport with our patient to gain their trust and consent in managing their health concerns.

However, communication with our patients does not end in how we converse to them. Our prescriptions, drawings and illustrations are as vital as our spoken or verbal communication to our patients. It is important to make our written notes or prescriptions not only comprehensible, but also understandable or readable in a language known to our patient. We could employ the use of illustration or symbols if needed to further instruct our patients on taking a medicine. Being able to communicate effectively with our patients is the most important of our relationship with our patient.

ROJoson’s Notes (17feb8):

Understandable communication and closed-loop communication are important in the management of patients.

Posted in AALVEZ’S MARs, Written Communication | Leave a comment

RAMOSA’S MAR [15-03]: Believe It or Not

MEDICAL ANECDOTAL REPORT
Indexing Title: RAMOSA’S MAR [15-03]
MAR Title: Believe It or Not
Date of Medical Observation: April 2015
Tag:   Filipino superstitions and folklore affecting healthcare.
Category:  Professional/Ethical, Reinforcement

NARRATION:

While I was doing my daily wound care at the wards, I noticed a peculiar looking scar on one of our patient’s abdomen. The patient is a 36-year-old female, currently pregnant for 14 weeks, who underwent operation due to complete gut obstruction. I knew the scar was not from the recent procedure she had and so I asked her about it. She said she got it after visiting a witch doctor where application of burnt herbs and garlic was advised. The patient’s mother then said “Akala kasi namin nabiktima din siya ng aswang”. (We thought she was another victim of a ghoul.) At first I thought, she was just joking. I couldn’t help but laugh and say “Ha? Niloloko mo naman ako, mommy!” (Huh? You must be kidding me, mommy!) To my surprise, she remained serious and said “Hindi ah! Totoo talaga yun”. (No! It’s the truth). She then went on telling about their relative who was once a victim of an aswang and mentioned that their neighbor is the aswang. She even shared about her personal experiences and even taught me how to detect an aswang. I was so fascinated by her stories that I didn’t realize it was almost time for our morning endorsements. I had to end her story-telling and promised to come back for more. I left the room still feeling amused and pleased. 

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

Filipinos are truly superstitious people. Even in this modern age, many Filipinos still cling to the traditional beliefs and practices our ancestors have taught us. In fact, to a lot of Filipinos, superstitious beliefs are important and can influence them in planning or making their decisions. Some people even believe that following these can help them prevent danger from happening.

 Even in health care, there are numerous superstitions. Some common examples include:

•       Taking a bath at night will cause anemia or low blood pressure.

•       After circumcision, a boy should not step on a mortar or pestle; otherwise, his organ will grow as big as these.

•       Taking pictures of a pregnant woman will cause an abortion or a difficult delivery.

We wonder where these beliefs came from and find it funny or even weird. However, many people still believe in these even here in the city. It is inevitable that we encounter patients with such superstitious beliefs.

 In my case, I initially thought our patient’s mother was trying to fool me, but she was not; she was even trying to convince me to believe in it too. Respectfully, I told her that I still do not believe in such folklore. Moreover, I told her that she may continue to believe in it as long as she still follows our medical advice. However odd and out-of-the-ordinary their beliefs and practices may seem, we should not mock or make fun of them. We should respect their beliefs but still try to convince them to see the rationale. As physicians, it is our responsibility to explain and correct common misconceptions especially those that would affect our patient’s health and welfare.

ROJoson’s Notes (17feb8):

Always respect patients’ beliefs and culture when doing problem-solving and decision-making in medicine.

Posted in RAMOSA’S MARs, Respect, Uncategorized | Leave a comment

MESANICO’S MAR [15-03]:Learning From Your Junior

MEDICAL ANECDOTAL REPORT
Index Title: MESANICO’S MAR [15-03]
MAR Title: Learning From Your Junior
Date of Medical Observation: March 2015
Tag: Learning 
Category: Professional / Ethical – Reinforcement
 
NARRATION:
 
I was at the Emergency Room (E.R.) one morning when a 3-year-old boy was brought to us by his mother. He had a lacerated wound on his left fronto-parietal area which he sustained after falling off his chair. According to the patient’s parent, her son has these types of fall almost once a month, especially once she starts doing her household chores. However, it was only in this incident where he had a deep injury on his head. Our 2nd year resident who was in charge of the E.R. at that time quickly attended to them to assess the severity of the injury. After ascertaining that the patient had no signs of neurologic deficit and had a complete history of vaccinations, he then opted to have the patient’s wound sutured and properly dressed. The procedure was uneventful and after a few minutes the patient was ready to be discharged. Prior to them leaving however, our E.R. resident quietly approached the parent of the patient. He told them that they should take care of their child and keep an eye on him always especially now that he is even more active. If the incident would ever happen again then he would be forced to report them to the authorities such as the child protection agency. The parent nodded and promised that they would take good care of her son.
 
INSIGHT:
(Physical, Psychosocial, Professional / Ethical)
(Discovery, Stimulus, Reinforcement)
 
The residency program is aimed to train medical doctors in the certain fields which they choose to specialize in. During this time, the resident is exposed to a variety of skills, knowledge and, of equal importance, these “lessons in life”, each from different type of sources. Theoretical knowledge is usually acquired through our books and lectures, as well as from our exams. Skills are mostly shown to us by our consultants, sometimes first hand, sometimes through our seniors who learned it through them. We are evaluated by our consultants in the procedures we do and shown our errors, giving us tips and the proper steps in doing certain operations. And then there are the lessons or other tips in attending to our patients, on how to be able to treat them properly and completely. These we get to learn through first hand experiences, or in my narration, from our 2nd year resident who was in charge of the emergency room. There will be patients who we encounter in duty who might veer away from what we try to impart on them, such as how to properly take care of a wound, or how to avoid having the same injuries repeatedly. The method I witnessed was a new take on patient care. By telling the patient that he would resort to a more extreme means just so you can ensure the child is protected and no further harm would come to him, the patient was clearly forced to heed the advice of our co-resident. The experience reminded of how much we can pick up new ideas not only from doing our daily activities but also from listening and observing our fellow clerks, interns, and residents. Learning new techniques may not only come from our seniors or consultants, but in general, also from our juniors. It falls onto us if we choose to retain it or not.
ROJoson’s Notes (17feb8):
We can learn and have to learn from anybody, even our juniors.
Posted in Learning | Leave a comment

GPVILLANUEVA’S MAR [15-03]: Autonomy versus Paternalism

MEDICAL ANECDOTAL REPORT
Indexing Title: GPVILLANUEVA’S MAR [15-03]
MAR Title: Autonomy versus Paternalism
Date of Medical Observation: April 2015
Tag: Learning from experience the principles between autonomy and paternalism
Category: Professional/ Ethical – Reinforcement
 
NARRATION:

I was then busy talking to a patient in the Out-Patient Department when my senior, already a graduate and the one that I highly regard, called up. He was endorsing a patient, his distant relative, a 74-year-old female with a mass on her left breast. He already knew that the mass was malignant and so he requested that the patient be scheduled immediately for Modified Radical Mastectomy. I assured my senior that I will take care of her relative’s preoperative preparation. The following day however, I was surprised when I met the patient. By further history taking I have learned that she already had a previous surgery of excision of the mass which revealed a malignant lesion upon histopathologic analysis. She has now an approximately 6cm by 6cm lesion with scar on the upper outer quadrant area involving the skin.
A patient on her age with the same lesion should still undergo neoadjuvant chemotherapy (meaning chemotherapy be given to the patient prior to operation) based on the Breast Cancer Guidelines. I then showed the patient to our consultant and the details of the treatment were further discussed, options were laid down to her. The patient was then told of a five to ten year disease free survival. On this part of the conversation patient caught us off guard when she told us that she is already grateful that she has reached her ripe old age and would no longer want anything more in her life. She understood the ideal treatment but for her, she is already contented with what Modified Radical Mastectomy would give to her. It was only at that time when I realized again that the patient is already on the late stages of her life and that five to ten years from now, her age would cause her demise and not the actual disease of cancer.
 
INSIGHT:
(Physical, Psychosocial, Professional/ Ethical)
(Discovery, Stimulus, Reinforcement)
 
During our days learning the Ethics of Medicine, we were taught of the 5 principles essential in our practice – Respect for Autonomy, Beneficence, Non-maleficence, Justice, and Paternalism. These are the principles that help us doctors to make decisions when reflecting on moral issues that arise at work. These five principles do not have any hierarchy and thus ideally we have to uphold all of them. However, in the actual world, we must determine which carries more weight.  My experience with the patient made me to once again review each of the five principles. Based on the Principle of Beneficence, I as the patient’s doctor have the duty to take positive steps to prevent and remove the patient from harm meaning I have the duty to make sure that the patient receives a beneficial treatment procedure. While based on the Principle of Paternalism, I as her doctor also have to guide her to take the ideal route of management. However this  Principle of Paternalism comes into conflict with the Principle of Respect for Autonomy. Despite adequate and repeated explanation of the benefits of undergoing neoadjuvant chemotherapy, the patient in her right mind and along with discussion with her inner circle of relatives have decided to forgo with such procedure. The patient has the utmost right for her own body and so her decision in this case should take precedence. There lies the clincher, the patient should be properly and compassionately informed of her options and let her ultimately make the final decision. Thru the guidance of the principles and our consultants, we now learn from the actual experience of how decision making process should be done.
ROJoson’s Notes (17feb18):
Inform and guide patients in their decision-making  but in the long run, respect whatever decision they make. Balance all the known ethical principles in advising patients.
Posted in GPVILLANUEVA’S MARs, Patient's Decision-making and Ethical Principles | Leave a comment

PJCGAGNO’S MAR [15-04]:Ripples Run Far

MEDICAL ANECDOTAL REPORT
Index Title: PJCGAGNO’S MAR [15-04]
MAR Title: Ripples Run Far
Period of Observation: May 2015
Tag: Inspiring others from a simple procedure done.
Category: Professional/Ethical-Reinforcement
 
NARRATION:
 
I was duty at the emergency room when a colleague from the Department of Internal Medicine referred a patient who was managed as a case of heart failure. The patient, also a known case of benign prostatic hyperplasia, was referred for Foley catheter insertion after several times of attempt. I gladly accepted the referral and came to find out that the patient was the former chairman of the Department of Surgery of Ospital Ng Maynila Medical Center. I immediately went to his bed and saw that one of the nursing heads accompanied him. I introduced myself and asked consent for Foley catheter insertion, which he voluntarily permitted. I then asked for a larger sized Foley catheter. As I performed the procedure properly using Fr 24 Foley catheter, the nursing head was observing me. I was able to insert the catheter successfully without any complications. The patient and the nursing head then thanked me for the successful insertion of the catheter.
           
Three months after, I was approached by the said nursing head when I was in the OR completing my census. She was looking for me during her usual rounds in the operating room. She eagerly told me that she encountered the same case of benign prostatic hyperplasia in their hometown. She verbalized that she was the only medically inclined personnel in their place and tried to insert the Foley catheter recalling the technique I did before. She said: “Doc, naalala nga kita nong naglalagay ka ng Foley catheter kay Dr. M dati sa ER. Buti na lang napanood ko kung pano kayo maglagay. Salamat po.” (Doc I remembered you when you were inserting foley catheter on Dr. M. Im glad I was there to witness how you insert properly a foley catheter. Thank you.) She then happily told me that she successfully inserted the catheter.
 
INSIGHT
(Physical, Psychosocial, Professional/Ethical)
(Stimulus, Discovery, Reinforcement)
Ripples spread out when a single pebble is dropped into water” a famous saying by Dalai Lama explains that small actions of an individual can have far-reaching effects. I never expected that a simple routine procedure (Foley catheter insertion) that we usually do in the wards or emergency room could affect other lives beyond the four walls of our hospital.
The incident reinforced me on proper technique of Foley catheter insertion in patients with Benign Prostatic Hyperplasia (BPH). In dealing patients with BPH, it is recommended to use appropriately sized catheters. It is encouraged to use a catheter Fr 18-24 with BPH compared to the usual catheter size for a normal adult, which is Fr 16. Larger sized catheters are usually used because they are stiffer as compared to the usual Foley catheters. These will easily overcome the mechanical obstruction of a hyperplastic prostate obstructing the urethra. Also, there is a need to use lidocaine impregnated lubricating gel to minimize the pain upon insertion and aid the smooth insertion of catheter. Proper maneuver of handling a male genital and sterile technique should also be observed during the procedure.
For the sake of our newly rotated clerks, proper insertion of catheter are as follows: 1. Secure consent, 2. Proper aseptic technique 3. Apply sterile drapes, 4. Generously coat the distal portion of the catheter with lubricating gel, 5. If female, separate labia using non-dominant hand. If male, hold the penis with the non-dominant hand, 6. Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely coiled in palm of dominant hand, 7. In the male, lift the penis to a position perpendicular to patient’s body and apply light upward traction (with non-dominant hand), 8. identify the urinary meatus and gently insert until the bifurcation at the proximal end of the catheter, 9. Inflate balloon, using correct amount of sterile liquid, 10. Gently pull catheter until inflation balloon is snug against bladder neck, 11. Connect catheter to drainage system, and finally 12. Secure catheter to thigh.
As I learn, I was also able to educate my fellow healthcare professional in this incident. Being physicians, we must never fail to teach our fellow doctors and other members of the team despite the busy workload. We, residents, are being observed by medical clerks, interns, nurses and others from simple procedures to major clinical decision-making we do. And with these, they also learn. Hence, as physicians, we must do things with integrity and excellence. We can impart to them by being role models.
I came across a saying that says: “The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates but the great teacher inspires.” In small things we do, we must do what is right. Though mistakes are inevitable since we are still in training, we must strive for excellence because we might inspire others to touch lives unexpectedly.
ROJoson’s Notes (17feb8):
Do good things that can be seen by everybody and let them emulate you.  Be an inspiration.  Be a role model.
Posted in Inspiring Others | Leave a comment

LBBERSAMIN’S MAR [15-02]:Through This Simple Change

Medical Anecdotal Report
Indexing Title: LBBERSAMIN’S MAR [15-02]
MAR Title: Through This Simple Change

Date of Medical Observation: February 2015
Tag: Changing the approach of doctors in patient presentation and acknowledgement

Category: Professiona/Ethical– Reinforcement

NARRATION:

It was at around 5 o’clock in the afternoon when I received a text message from a co-resident, of us being called for the daily afternoon rounds. It starts off with a resident presenting the case of the patient, including the planned management or procedure done, and the current treatment the patient will be in. It is through this process that we do our daily endorsements for each team’s patients, and give notice to the duty team matters of concern to focus on. Going through six rooms and on to our 14th patient, we encountered in our rounds a 38-year-old male who underwent an appendectomy due to an acute perforated appendicitis with generalized peritonitis. He was one of our patients and was on his 2nd post-operative day of recovery. He was seated on his bed and conversing with his wife when we entered the room. The patient was operated on by one of my junior residents and was originally planned to be sent home the following day. We came up to his bed, a good number of us along with the medical interns and the clerks and discussed his case.  While we were doing so, I noticed that none of us had initially greeted the patient, even though the patient had arranged himself at our arrival. Our junior resident then started with his endorsement: “Patient is a 38-year-old male diagnosed with acute perforated appendicitis with localized peritonitis, and on his 2nd post-operative day”. The endorsing resident then informed the body of the other plans of the team for the patient. Seeing the patient give us a subdued look, I can only wonder on how the patient felt then. I can only see him get lost in question, wondering how we can discuss something about him as if he was not there. As we had finished discussing his case, I greeted him by his name and asked: “Kamusta po kayo? Uuwi na po kayo bukas.” (How are you sir? You can go home tomorrow!) I only did it to break the ice. He replied: “Ok naman po ako doc, uuwi na daw po ako bukas. Salamat po sa inyo! (I am ok doc, I am going home tomorrow. Thank you!)  I then reminded him of being able to take a bath and clean his wound daily. Before the endorsement rounds went on I said goodbye and told him “Bawal mong kainin ang di masasarap na pagkain” (You are not allowed to eat food that is tasteless). He then broke out into a laugh along with his wife.

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

Every afternoon we go about our daily endorsement rounds, checking on our patients, and updating our co-residents regarding the cases we handled. These endorsement rounds are very helpful in pointing out the necessary things to remember in our patients. It is through this process that we maintain a continued means of treatment for our patients when we are not in the hospital. But at times, what we completely attain in great communication, we may lack in the genuine attitude towards our patients. The objectives we so relentlessly conquer just to see our patients get well, may lead us to miss out on the human factors of our management. Going through this moment where we had missed out on the simple greeting of a “Good afternoon sir, how are you feeling today”, prior to starting the bedside endorsement of our patients. We miss out on addressing him/her to our colleagues through their names and lack the social relationship we have with our patients. Even though our indigent patients either forgive us on missing on their names or greeting them, more often they just do forget about it because we are their doctors. Yes, sometimes as doctors we tend to get slip past these unfortunate mistakes as if we were reading from our endorsements from a piece of paper or medical journal. Sometimes looking in, putting myself in that hospital bed as the patient, I cannot help myself but feel for them. Having a group of people peer through an imaginary mirror, with sound appearing to have been deflected, but know too well people are talking about you.  As their doctors, we should know more than this. We should be able to know how we should address them in the presence of other people. We should know how to present their case respectfully to others and avoid discounting their emotional well-being. No matter how small, or simple this act of remembering our patients name and being able to greet them in and out of the hospital, gives them our commitment to them as our patients. We act in respect of our patients as an individual and give them the importance deemed for each. If we set this example, practice it and carry it every single day, we get to improve ourselves for the better. Through this conscious act and attitudinal change, we even set ourselves as a modern, educated, and civilized government doctor. We employ respect to our patients and discipline amongst ourselves; through this simple change.

ROJoson’s Notes (17feb8):

When physicians make rounds as a team, either for teaching or endorsement or both, they should not forget to greet and be mindful of the patients’ presence.   They should also cautious in what they are saying in front of the patients. There are things that should not be heard by the patients such as those that will cause undue anxiety.

Posted in LBBERSAMIN’S MARs, Making Bedside Rounds | Leave a comment