Index Title

Index Title: Rdeleon’s MAR [06-01]

MAR Title: Open communication!

Date Observation: February 12, 2006

Narration:

It was around 7 o’clock when I went to the Nursery to do my night rounds. There were no clerks around since they were preparing for their comprehensive examination, thus, I was looking for the patient that was endorsed to us by my co-resident. As I was looking for the patient, I happened to notice a particular baby. A 4 day-old new born, male looking particularly toxic. He was dehydrated with a distended abdomen. The Oro-gastric tube (OGT) output was billous with coffee ground material.

I approached the pediatric junior consultant on duty and told her about the baby. She examined the patient and agreed that the he was indeed septic. We exchanged ideas on how we can improve the patient’s condition. The conversation was between colleagues exchanging ideas rather than two residents referring a patient to one another. We discussed both medical and possible surgical management. At the back of my mind I know that she will be referring the patient to me.

Around 12 midnight I received a referral from Pedia-Nursery and true enough, it was the patient I saw earlier. I re-examined the patient, went through the chart and reviewed the current management. As I was going through all these, medical management was my primary choice of administration for the patient, and was not really thinking of any surgical intervention knowing that the patient may expire soon. My mind was battling with itself for a threshold to call my consultant for a patient who was dying, not to mention that it was in the middle of the night. I eventually referred the patient to my consultant. I know that I woke her from her sleep. Despite the fact that I was pointing out a possible medical diagnosis she pointed out to me that there was still a surgical diagnosis to consider. Malrotation was my consultant’s primary deliberation. And work-up was done towards the said diagnosis. I called the pediatric junior consultant and informed her of our plan of management.

Insight: (Physical, Psychosocial, Ethical) (Discovery, Stimulus, Reinforcement)

With the advancing technology and the development of the cellphones, it has become easier for us residents to refer patients to our consultants. Through text we may be able to relay the messages to our consultants regardless of the time of the day. And through phone calls, immediate lifesaving decisions can be made.

For us residents, it is still mandatory to refer all the patients under our service to our consultants, regardless of our impression, whether surgical or non-surgical. Not just for learning purposes but rather for the patients as well.

It is still better for the residents, not just in the department but in all departments that we discuss all our patients. If we can make time to exchange and share ideas, we may be able to give our patients the optimal management that they are entitled to.

To improve the referral system of our department (referrals to consultants or to other department) the following were suggested:

The residents must place or specify the reason for referring patients; To ask for opinion, ask for help in the management of patients or asking consultants to assists/help in the operation.

The resident should take a complete history and a thorough physical examination of the patient.

If the referral is through a telephone call, the resident should present it clearly and orderly. And if the referral is through writing, the resident should check and personally sign the referral form.

To facilitate the referral, send the picture of the mass or lesion through the email or the MMS (Multi-media sharing).

Interpretation of the data is one of the problems in referrals especially if it’s through the telephone call. For future improvement, a uniform patient management process referral system will be formulated. It could be in the form of a checklist, clinical practice guidelines, algorithm etc.