Indexing Title: RQdeLeon’s Medical Anecdotal Report [06-02]
MAR Title: Open Communication (2)
Date of Medical Observation:  Feb 2006 

Narration: 

It was one Sunday morning and my tour of duty was about to end. My first year and I was manning the Emergency Room when we received a phone call. My junior resident answered the call. It was from an OB-Gyne resident informing us that they had a patient lined up for Cesarean Section (CS) that showed that the baby had gastroschisis by ultrasound (UTZ).

It was a very informal form of referral, no other data was given except for the fact that by UTZ the baby had gastroschisis. I decided that I will gather the data once the patient was at the operating room (OR).  

The patient was not operated on immediately and I was to endorse the case to the next duty. When we were doing our endorsement, I received a text message saying “cutting na po yung CS.” Knowing it was the referral I received earlier, we went in the OR.  

When I entered the OR I saw the pediatrician and she approached me. She told me that the baby had gastroschisis, and only was the whole abdomen exposed but was the heart. She added that they will not be referring the baby to us because they believed it won’t survive long enough to undergo any drastic surgical intervention. The baby was bradycardic and had multiple congenital anomalies. 

 We examined the child and I have to agree with the pediatrician that the chances for the patient to survive was very slim. After a few minutes the baby died. 

Insights (Discovery, Stimulus, Reinforcements) (Physical, Psychosocial, Ethical)           

It’s funny that my MAR last month deals with referrals and now on my second Mar I will be discussing on referrals once more. In the department we are trying our best to improve our system of referrals and I think it’s about time that we include the whole hospital in creating a system that will benefit us all. 

Let me reiterate the points we made last time. To improve the referral system of our department (referrals to consultants or to other department) the following were suggested: 

1.         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.  

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

3.         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.  

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

5.         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. 

Its not everyday that we have a rare case such as a gastroschisis. We rarely see a defect in the abdominal wall like this with a concomitant defect in the chest wall. Regardless if the patient had a poor survival we should at least try to see and analyze such case. Since we our in a training hospital, we should try to look at all the cases we can. We our lucky to have these cases and we must learn the most that we can.