Index Title:  RDELEON’s Medical Anecdotal Report [05-08] 

MAR Title: Temper! Temper! 

Date of Observation: September 3,  2005 

Narration 

            This is the case of RB, a 63-year-old male who was initially diagnosed to have a diabetic foot on the right. On further evaluation, patient was also suffering from a Chronic Kidney Disease (CKD) stage V secondary to DM Nephropathy.  

            The initial plan for the patient was to do a Below the Knee Amputation (BKA) but as we examined the patient we noted that the patient also had an occlusive vascular disease. With this, we opted to have a Doppler Scan of both Lower Extremities.

            The result of the Scan showed arteriosclerotic disease of the arteries in the lower extremity with significant stenosis at least 50%, at the left and right posterior and anterior tibial arteries and peroneal arteries. Distal superficial femoral and popliteal arteries were calcified and normal venous color Doppler study of the lower extremities. 

            With the result to guide us, we re-evaluated the patient and we referred the patient to our service consultant. He said that a  BKA won’t be a beneficial procedure, with this an Above the Knee Amputation (AKA) was advised.  

            The patient’s condition was optimized for the said procedure. While we were preparing the patient for operation, we were also preparing the materials and other needs for operation.  

            Prior to the operation, I did a cut down for a peripheral venous line. As any patient with kidney disease, all the vessels were thinning out. I have a difficult time doing the cut down. 

            After a peripheral intravenous line was secured, I proceeded with my operation. The procedure went well and I can honestly say it was a nice job. My anesthesiologist decided to delay the extubation of the patient, seeing no problem with it, I went along with the decision.  

            As the patient was being wheeled into the Recovery Room (RR), my anesthesiologist informed me that the patient had no urine output. Knowing the patient had CKD, I was not that worried that this was a problem. But my anesthesiologist gave an anti-diuretic, still no output. With this we referred the patient to the Internal Medicine (IM) Department.  

            The IM resident evaluated the patient. But unfortunately, I was not at the RR when they did their rounds. After an hour or so, I received a phone call at the Emergency Room. The call was from the RR, it was my anesthesiologist informing me that they tried to wean the patient from the ventilator but the patient can’t tolerate  

            I went to the RR to see what the problem was. I reviewed the chart. I saw the notes of the IM resident. As I was reading their orders, a feeling of anger was building inside me. They were trying to solve the absent urine output by loading the patient with fluids?! Things were running in my head like what were they trying to do to my patient?  

            How could they give fluids to a patient with a non-functioning kidney? My temper was building up and I can say that I was really angry. I won’t let my patient die knowing it was difficult for the relatives and the patient to go through this kind of scenario. The relatives were doing their best for the patient, with this in my mind I just can’t let it slipped by. 

            I looked for the IM resident so I can have a dialogue with him. I tried to call him but he was no where to be found. And as I was going to our ward, I show he was also doing his rounds there. I was trying to fight the urge to shout at him. I did my best to control my temper.  

            It was only logical to confront him but not to have a fight with him. I controlled my anger. I gave him a piece of my mind. Never did I raise my voice to him but I made it clear to him that a mistake was done to my patient.

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

            As professionals, we should try our best to control our emotions. Be as level headed as possible. No matter how frustrating the situation maybe, we should not let our emotions run amok, because the more angry we get the more illogical we think. 

            As doctors, we should be open-minded. What we think as a different way of managing the patients might be the appropriate plan for them. When we are asking help or asking other doctors to co-manage our patients, we should try to talk and listen to each other.  

            Try to exchange ideas, for this will help us understand more the condition and the needs of our patients.  And through this exchange of ideas, the more we learn.  

            In managing our patients, we should try to look back and re-examine them. It was thought to us to always re-examine our patients again and again so we won’t miss out things. If I pursue the initial plan of BKA and did not do a second look on the patient, I might have placed the patient in a situation wherein a re-operation is needed.