PITTFALLS ON ACUTE ABDOMEN 1 st Surabaya Gastrointestinal and Emergency Surgery (SuGIES), Hotel Novotel Surabaya, 19 – 20 May 2017 Prof. Dr. P. Soetamto Wibowo, Sp.B-KBD – Dep/SMF I. Bedah FK. Unair/RSUD Dr. Soetomo Surabaya An error the breath of a single hair can lead one a thousand miles astray Chinese Proverb
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PITTFALLS ON ACUTE ABDOMEN
1st Surabaya Gastrointestinal and Emergency Surgery (SuGIES), Hotel Novotel Surabaya, 19 – 20 May 2017
Prof. Dr. P. Soetamto Wibowo, Sp.B-KBD – Dep/SMF I. Bedah FK. Unair/RSUD Dr. Soetomo Surabaya
An error the breath of a single hair can lead one a thousand miles astray Chinese Proverb
WHY ?
Medicine : High Risk System with High Error Rate
Cross Industry Comparison of size, productivity and efficiency (the Advisory Board Company 2005 )
Complications and Adverse Events
in Surgery
10% of hospital admission suffer harm, half is preventable [1,2]
50% - 75% of hospital wide adverse events are attributable to surgical care.
Most errors occur in the OR [3]
[1] Thomas EJ, Clinical Risk Management Enhancing Patient Safety, BMJ Publ. 2001 : 31-44 [2] Vincent C. System Approaches to Surgical
Quality and Safety, Ann. Surg. 2004; 239 : 475-482 [3] Healey MA, Complications of Surgical Patients, Arch Surg. 2002; 137 : 611 – 618
Insurance Premium $ 30,000 - $ 300,000 / yr
Health Cost
Rising Cost of Health Care is just a symptom
WHAT IS THE REAL DISEASE ?
→ GREED and INCOMPETENCE ?
Do not count for double digit
(Thomas A Lee, HBR, Apr 2010)
Pitfalls on Acute Abdomen
The Paradox
Institute of Medicine (IOM) 1999 :
“To Err is Human” (1)
not an explanation accepted by the media, the public, the insurance companies, or lawyer.
(1) Institute of Medicine. To Err is Human. Washington DC. National Academies Press, 2000.
Pitfalls on Acute Abdomen
Taking Ownership
Leape and Berwick (1) 2004 :
“ We will not became safe until we chose to become safe” → Patient’s safety.
(1) Leape L, Berwick D. Five years after To Err is Human – What we have learned ? JAMA 2005 : 293 : 2384 – 2390
Leadership
Performance
Pitfalls on Acute Abdomen
Errors in Human Performance
Errors Categories (1) :
Knowledge base
Lack of experience or knowledge or misintepretation of the problem
Rules based
Misperception or misapplication of the rule
Skill based = “slips”
Reason J. Human error. Cambridge, MA. Cambridge University Press 1992
Case 1
54 years old man with sudden right upper abdominal pain for 5 days
Fever + → ED
PE : Abdomen – RUQ
Rigidity +
Murphy signs +
General peritonitis −
USG : Gallbladder – stone +
Thicken wall
Double layer
Pericystic fluid
Perforated gallbladder ?
Rules Tokyo Guidelines → Surgery ?
Evidence Based Golden Rules
Emergency Surgery
Usually doing less is betterbut
Occasionally doing more may be life saving
Acute Abdomen :Operate only when necessary and do the minimum possible
butDo not delay a necessary operation
and do the maximum when indicated
Pitfalls on Acute Abdomen
Errors Training
Whoever refuses to admit error may be a great scholarbut
He is not a great learnerJohann Wolfgang von Goethe 1749 – 1832
Fitts and Posner Model (1) :
If you commit any mistake – there are 3 things to do :
Admit it
Learn from it
Don’t repeat it
(1) Fitts P, Posner MI. Human Performance, Belmont, CA : Brooks / Cole Publ. 1969
Compassion
Pitfalls on Acute Abdomen
Acute Abdomen
Definition :
Pain of non traumatic origin with a maximum
duration of 5 days (1)
Account 7 – 10 % of all Emergency Department
(ED) (2)
(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31
(2) Hasting RS, Power s RD. Abdominal pain in the ED. A 35 years retrospective . Am.J. Emerg.Med 2011; 29 711 – 716.
Pitfalls on Acute Abdomen
Acute Abdominal Pain (AAP)
Great caution – Problem
AAP can be caused by variety of diseases from mild –self limiting – live threatening diseases
Early – accurate diagnosis → better outcomes
Diagnostic practice varies within hospitals and within specialities
Antibiotic therapy within the first hour of recognition of sepsis (1)
Morphin – Analgetic ?
Administration of opioids / analgesic decrease the intensity of the pain and DOES NOT affect the accuracy of physical examination and diagnostic (ELA2) (2,3,4,5)
(1) Intensive Care Medicine : Surviving Sepsis Campaign : International Guidelines for Management of Sepsis and Septic Shock; 2016
(2) Lo Veccio F, Osler N, Sturmann K et al : the use of analgesic in patients with acute abdominal pain. J.Emeg 1997; 15 : 775 – 779
(3) Gallagher EJ, Esses D, Lee C et al : Randomized Clinical Trial of Morphin in acute abdominal pain. Ann Emerg Med 2006; 48 : 150 – 160
(4) GungorF, Kartal M, Bektas F et al : Randomized Controlled Trial of Morphine in elderly patients with acute abdominal pain. Turkish J of