Indexing Title: NALUDINOs Medical Anecdotal Report [04-5]

 MAR Title: Stop, Look and Listen

Date of Medical Observation: Nov  2001

Narration:

     This incident happened while still a preresident of the Department of Surgery at OMMC.

      I was doing my daily routine of doing the chart rounds, daily wound care and monitoring the patient's when I was called by a resident. I was instructed to remove a Chest tube from one of the patients. She asked me if i knew how to do it and I answered yes. I learned how to do it from my readings and from watching resident doctors do it while I was still a clerk/intern.

      I prepared the materials needed and went to the room of the patient. Before I started the procedure, I tried to recall everything that i learned and then went ahead with it.

      Everything went smoothly, or so it seemed. A post Chest tube removal x-ray was ordered and carried out that same day. The x-ray showed a massive pneumothorax. Needless to say, the patient underwent another CTT.

Insights (Discovery, Stimulus, Reinforcements)

Be true to yourself, if you have any doubts on what you are about to do, stop and re-examine. Ask for help. I did not ask for help on this case because I though I aleady know how to do the procedure well. Knowledge of something, doesn't necessarily mean the ability to do it. Mastery of a procedure involves doing it with guidance from somebody who has done it before which I failed to do. I was lucky no complaint was lodged against me.

I learned a great deal deal from this experience. From that moment, everytime I am about to do a procedure, I follow these simple steps:

1. STOP - do I know what I am doing? Am I prepared?

2. LOOK - Is everything in it's proper order? Do I have consent?

3. LISTEN - Does my conscience approve? Is what I am about to do ethical?