Advice wanted from a Resident Surgery.

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Just to complete the thought: The proper forum for this discussion is the weekly M&M conference in your hospital. Hospital and department QA is set up for this process. 
 
Oh yes and I am sure (I hope) that your staff was involved in this process from the beginning. Patients should not be discharged without staff approval if you are a resident.
 
Norman
 
Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

From: trauma-list-bounces at trauma.org on behalf of McSwain, Norman E Jr.
Sent: Sun 4/19/2009 10:05 AM
To: Trauma and Critical Care mailing list
Subject: RE: Advice wanted from a Resident Surgery.


I would STRONGLY urge that this not be discussed via e-mail. I would also  suggest that you and your hospital retain legal council before any more information is exchanged. If approved then you could request discussion. An open forum such as this is NOT the place to discuss outcomes the you are worried about. 
 
I am not suggesting that you did anything wrong. My suggestion is that the legal environment is so vicious in the US the caution should always be exercised
 
Norman
 
Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

From: trauma-list-bounces at trauma.org on behalf of Dr.Asif .H.Ansari
Sent: Sun 4/19/2009 5:23 AM
To: trauma-list at trauma.org
Subject: Advice wanted from a Resident Surgery.







Hi everyone,

 

I am a resident in surgery and with 3 yrs + work exp. I need
some advice from the seniors with regard to a case for which I and others might
be investigated.

 

Day 1

A 38 female servant comes to ER c/o pain lower
abdomen-7-10days, nausea, burning urine, no constipation/diarrhea. Previous
surgery 4 yrs back  c sec. periods
normal. Preg test -ve. No known medical or surgical conditions.

History takin was difficult as pts was of sri lankan.

 

o/e febrile 38.5 C, puls- 90-95bpm, BP 120/80 mmHg

      Chest-nad

     Abd- not
distended, soft like cotton! , no guarding, no rigidity, ONLY Tendernes in
Suprapubic region, Bowel Sounds- normal. PR- NAD

 

Labs- White cell count- 20,000, other labs within normal
limits.

 

So my plan was to admit her after doing an  Chest and abdomen X ray.

 

My D/D was  1.Urinary
tract infection/cystitis

                        2.
PID

 

So after the xray, Chest Xray-nad, no free gas

                           Abdomen x ray showed  IUCD in situ!!!! When I asked here when put
in , she said 4-5 yrs, I think.

 

On co-relating all the above I thought of referring the case
to OB/Gyne resident to rule out IUCD related infection/perforation.

She saw the patient, wrote soft/lax abd. No IUCD
perforation. Gave D/D of UTI.  And
referred the case to next day clinic OBY/Gyne.

 

Patient came back and gave her Bactrim DS bid and Buscopan
tabs and gave her clinic next day morning to Urology.

 

I had discussed the case with my on call gen.surg
registrar  BUT NOT with Urology on call!

 

Day-2

 

Patients comes to OB/Gyne clinic, seen by registrar and discharged
home.

 

Day-3



Patient presents to ER again,this time c/o vomiting and pain
upper abdomen. BP-90/60 mmHg,tender epigastrium, white cell 20,000.

So seen by Meidcal resident and Admitted as Septic Shock ,
morning 3 am.

 

Patient was badly managed and refrred to Surgery after
admission. USG abdomen-free fluid.

 

Day 3 -9 pm

When the surgeons took her to OR on inotropes, laparotomy
,showed thick pus inside, but no perforation or any other pathology. They said
most probably IUCD related ascending infection. No rupture/infection of
fallopian tubes.

Don't remember how much was the urine output.

 

Patient post-OP was in ICU after 4 hrs arrested and declared
dead.

 

Now the sponsors of the servant lodged a complain and want
an enquiry into the case.

 

Please let me know how I can defend myself and what are the
strong points in favour of me that I decided to discharge the patient. i know deep down that i shudnt have discharged her,, but i just want to ask was  my judgment right to send her home with clinic next day.






 Thank You,

Dr.Asif Huda Ansari


 Please send a copy to e-mail listed below, so that I can reply at the earliest.

1. asifhansari at gmail.com


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