INDEXING TITLE

One lazy afternoon in the emergency room, as we were exchanging pleasantries with the clerks and interns, an intern from Department X approached us. He told us that they had a referral for us. Outright he claimed it was a case of appendicitis, without giving us any pertinent data, history or physical examination findings. I reprimanded him, having been rotated with surgery as an intern and being a graduate of PLM, I expected more from him than that. He apologized andpresented the case as I required him to do so.

We then went to see the patient at the emergency room of Department X. Upon lifting the patient’s shirt, lo and behold…A RIGHT LOWER QUADRANT TRANSVERSE INCISIONAL SCAR welcomed me by surprise. I asked the patient why he had such a scar. I was still trying to give Department X the benefit of the doubt. The patient did undergo appendectomy way back 2002 in Rizal Medical Center. The mother even told me she saw the appendix to be necrotic and ruptured and sent the specimen to the laboratory personally.

I did my history and physical examination on the patient. He was a 22-year-old male patient who had two days abdominal pain and vomiting of previously ingested food. He had no bowel movement or flatus for one day. His abdomen was distended and had tenderness in the right lower quadrant area. I was thinking of intestinal obstruction secondary to postoperative adhesions. I called the attention of the intern, showing him the presence of the scar and divulged to him the history of an appendectomy two years ago.

According to the intern, as he was accomplishing the chart of the patient and doing his history and PE, he already noted the scar and the appendectomy done in 2002. He called the attention of the Department X ER resident, “Doktora, naAP na po ito!”. The resident mistook the said statement as, “Doktora, AP na po ito!”. She quickly and off-handedly got the chart without examining the patient, based her history and PE on the intern’s entry and wrote her “revised” version at the back page. Her initial impression…ACUTE APPENDICITIS. She ordered for fluids, an xray and referral to Surgery for evaluation. She signed the chart, pairing her senior resident, who in turn signed her name, confirming her junior’s diagnosis. She too committed the same error her junior did, she did not see the patient personally.

I approached the resident and in brought her to an area beyond ear shot of the clerks, interns and patients, “_______ (name withheld), na-appendectomy na yung patient nung 2002 sa RMC. Acute Appendicitis ba talaga ilalagay nyo dito?” Her eyes widened and with a flushed face she answered, “ Ay sorry po Ma’am, Intestinal Obstruction po pala kami Secondary to POA.”. She took the chart from my hand and erased the previous impression she wrote. I did not want to appear self-righteous at the time so I simply smiled and replied, “Sige transfer mo na sa amin mukha ngang POA.”

INSIGHTS: (DISCOVERY, STIMULUS, REINFORCEMENT, physical, psychosocial, ETHICAL)

I quote several passages from the HippocraticOath as I draw my insights from this experience:

- ”I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.”

It is our role as residents to be teachers to our students and lead them to the path of learning and discovery. We should guide them to become good doctors who diligently and competently examines their patients and come to a sound diagnosis and treatment plan. They look up to us as people of authority and wisdom. Any mistake, incompetencies or complacencies on our part can be imbibed and taken in as their own.

- “I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.” We should always get a good history and physical examination of all our patients to arrive at a diagnosis that will enable us to treat the patient the way he deserves to be treated with no overkill or shotgun management as much as possible.

- “I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.” The resident was right in soliciting advice from our department, the case being out of her league. But then, it was negligence on her part not to see the patient before referring to our department (which happened a lot of times in the past), therefore causing her to misdiagnose the patient.

- “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.” The patient was seen as a case as what was written on the chart, without being seen and examined. He was shortchanged of being treated as a sick human being, disregarding the fact that he is a husband to his wife, father to his son, a son to his mother and father , a brother to his siblings and a productive member of society. As doctors, we are not only answerable to the patient but to his family as well.

- “I will prevent disease whenever I can, for prevention is preferable to cure.” How can we prevent the disease or even cure the patient if we are not trying to exert our best efforts to investigate and address the real illness of the patient?

- “If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” This is our calling as physicians and may we abide by it always. By doing so we leave a legacy to our peers, collagues and students. May we ALWAYS and STILL find fulfillment in healing and curing the sick.