Dr. Dev (fictional name) was posted in Urology Department (Dealing in Surgery of Kidney, Ureter, Urinary Bladder, Testis, etc.), during his Surgery Junior Residency, in AIIMS, New Delhi. Professor (Dr.) S. N. Wadhwa was the Head of Department of Urology at that time. Prof. Wadhwa was a learned doctor, dexterous Uro-Surgeon, a great teacher and outgoing person, having a warm and friendly relationship with all.
A patient of BPH (Benign prostatic hyperplasia) was admitted under Dr. Wadhwa's care in Private (Deluxe) ward.
For Non-Medicos: The Prostate is a pyramidal shaped gland present only in males. It surrounds the urethral or urinary passage in the males. The glands become enlarged, i.e. hyperplasia as the person ages. This leads to compression/narrowing of the urinary passage causing difficulty in passing urine. This condition is known as Benign Prostatic Hyperplasia or BPH in short.
Usually, the enlarged part of the prostate gland is removed in pieces using a long telescopic instrument, the cystoscope, introduced via the external urethral opening. The urinary bladder (the urine storage organ) is not opened in this procedure.
In this particular patient, the prostate gland was quite large in size and Prof. Wadhwa decided to do an open operation. An incision (surgical cut) was made in the urinary bladder from the abdomen side. The enlarged part of the prostate gland was removed from inside the urinary bladder and the cut (incision) in the bladder repaired with sutures.
A Foley’s catheter (urine drainage pipe) was inserted in the urinary bladder from the external urethra for arresting the bleeding from the operation site (hemostatic function) and for continuous drainage of the urine from the bladder. This was to keep the bladder empty so that the wound heals without tension.
After a week Prof. (Dr.) Wadhwa asked to remove the patient’s Foley’s catheter the next day. It was the protocol in the Urology Department to remove the urinary catheter early in the morning at 6.00 AM. This was to ensure that by afternoon the ward doctor can assess if the patient is comfortable and well after removal of the urinary catheter. It was also protocoled to instill 200 ml of sterile saline (NS) solution mixed with 1 ampoule of Injection Gentamycin (an antibiotic) into the urinary bladder via the urinary catheter, let it remain for some time and then drain it out, so as to wash out the urinary bladder before the catheter’s removal.
Dr. Dev was on night duty on that night. The Urology senior resident told Dev to remove the Foley’s catheter of the patient the next morning. At 6.10 a.m. the next morning, still drowsy from sleep, with bleary eyes, Dr. Dev reached the Private (Deluxe) ward for removing the catheter.
On reaching the ward the staff nurse inquired, ‘Are you from Urology?’
‘Yes’ replied Dr. Dev.
‘Then please contact Prof. Wadhwa urgently as he has phoned and told me that he wants to talk the urology doctor as soon as he comes to the ward’ conveyed the staff nurse.
Dr. Dev became worried. What mistake has he committed that Prof. Wadhwa wants to talk to him urgently so early in the morning? Perhaps he wants to scold him for not removing the catheter at exactly 6.00 a.m. With trembling hands, he dialed Prof. Wadhwa’s home number (This was the time of fixed landlines and not cell phones). At the first ring, Prof. Wadhwa picked up the phone.
Prof. Wadhwa asked, ‘Dev, have you removed the catheter of the patient in the Deluxe ward?’
Dr. Dev become worried, but replies truthfully, ‘No sir, I have not yet removed the catheter, but I was just going to remove it.’
‘Were you going to instill NS (sterile normal saline) before removing the catheter?’ inquired Prof. Wadhwa.
‘Yes’ replied Dr. Dev brightening up, ‘I was just getting the NS and injection Gentamycin ready for instillation.’
‘How much amount of NS are you planning to instill in the urinary bladder?’ asked Prof. Wadhwa.
‘Two hundred ml as usual sir’ answered Dr. Dev.
On hearing this Prof. Wadhwa said, ‘Dear Dev, we do use 200 ml NS routinely, but in this patient, the urinary bladder was opened. If you instill 200 ml NS as in other patients you will excessively stretch his stitches in the bladder, causing them to become weak. This may lead to leakage of urine outside the bladder in the abdominal cavity causing complications for the patient. Therefore, use only 100 ml NS in this patient before removing the catheter.’
Dr. Dev did as instructed and the patient had an uneventful recovery.
Dr. Dev learned some important lessons that morning.
Prof. Wadhwa correctly assessed his junior’s limited knowledge and the tendency of juniors to follow the same procedure without thinking whether this situation is special. They do not stop to think and question themselves, does this situation demands some modification or deviation from the routine protocol? Even if faced with a new twist in the old situation your juniors may become a victim of the force of habit and do the same thing that they have been doing always.
Senior Doctors/ Managers / Supervisors should anticipate any complications/problem their junior doctors / paramedical staff/colleagues/ employees are likely to commit. They should provide clear instructions (e.g. ‘use 100 ml instead of 200 ml’ and ‘not use reduced amount than you use normally’) in a different situation to prevent any problem from occurring. It is also wise to explain the reason from deviation from routine behavior (e.g. in this case the cut/incision in the bladder) in a stimulating manner (e.g. question and answer manner by Prof. Wadhwa) to develop the thinking process in their juniors and prevent any similar problem from occurring in future. They will learn to be flexible and avoid similar problems in the future on their own. This is much better than cursing them after they have caused some problem.
Like Prof. (Dr.) Wadhwa, we should take into account our juniors/ subordinate staff experience and their understanding. We should anticipate potential problems, confirm with them their plan of action and give clear instruction, at the proper time, to our juniors when faced with some variation of old situation. We should not assume that they will think and apply their brain power when faced with some new situation and change their action accordingly.
(Based on a true incident)
— NKD
© Author. All rights reserved.
DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost.
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