Indexing Title: HTURINGAN’s Medical Anecdotal Report [04-6]

MAR Title:  Be that as it may

Date of Medical Observation:  September 11, 2004

Narration:

After coming from my vacation leave, I found myself on duty again and as fate had it as some sort of a welcome, the day turned out to be buzzing with activities.  My fourth year resident earlier during the day called me to help her in the emergency surgery she brought to the operating room.  I was informed she had a lot of bleeding in what turned out to be a complicated gallbladder surgery.

Afterwards the subspecialty rotators did a craniotomy and while doing so, I was again informed that a trauma patient was at the emergency room, unstable.  I asked my fourth year resident about the details and her plan.  She informed me that the stab wound was at the third intercostal space midlclavicular line on the left.  Upon insertion of the chest tube their initial output was almost a liter of blood and still trickling.  The blood pressure was 80/50, following the protocol on hemothorax due to a stab wound she had an indication to direct the patient, and I agreed to do so.

The nurses chided that we are having a full and toxic day, in that respect there was nothing I can do about it. Upon induction however, blood stopped trickling and vital signs became stable at 100-110/80, a junior resident commented that we might not need to do the thoracotomy anymore, the bleeding seemed to have stopped and the patient was already stable.  I told myself it did not matter, massive bleeding could not have come from an insignificant vessel, if a clot get dislodged that thing could bleed again.  We proceeded on with the operation.  We located the priamary stab site on the left upper lobe of the lung, there was no bleeding, however on valsalva maneuver blood began spurting all over the stab site and what we saw were several spurting, completely transected bronchial arteries.  We tediously identified and ligated each prior to repair of the through and through stab wounds in the lung.

Insights (Discovery, Stimulus, REINFORCEMENT):

Given a high index of suspicion, one is justified on opting to operate or observe a patient.  The protocols and clinical practice guidelines constructed by the department were given for the training residents to be guided in their surgical decision making and patient management.  This has and will settle any doubts or disputes when faced with any predicament.  As often drilled to us, an error of omission is graver than an error of commission.