Indexing Title: DCHUA’s Medical Anecdotal Report [04-2]

MAR Title: Patient with End Stage Inguinal Hernia

Date of Medical Observation:  May 19, 2004

Narration:

Five weeks ago, an Internal Medicine clerk referred to me a 37/M case of intestinal obstruction.  The patient had been admitted three days prior but just informed them then of an inguinal mass, which to them seemed to be a hernia.  My throat dried up and I hoped that this was an on and off obstruction from an intermittently incarcerating hernia.  Palpating the tender abdomen, noting the size of the hernia and the persistent fever of the patient, my parched throat dropped down straight through my belly as the patient informed me his hernia had incarcerated another two days prior to admission.  He did not think it relevant to the problem of vomiting, so he never mentioned it to all the physicians he went through, until the discomfort prompted him to do so much later.  I don’t recall if I had effectively concealed my overwhelming exasperation then towards all the people concerned, but I explained to the family what needed to be done.

In a couple of hours, the patient underwent inguinal exploration and debridement of abscess from a perforated segment of bowel, with a laparotomy for the resection-anastomosis.  Radical debridement of the abscess wall would leave a crater on the abdominal wall.  A mesh to patch this up would be contra-indicated by the gross infection present.  A herniorrhaphy with available silk sutures was performed and the wound was left open, with our fingers crossed.  The patient was assigned to the early feeding group of a departmental research study.

The case underwent a stormy morbidity case presentation.  The morbidity started out as a perforation, turned into a missed diagnosis, then to a surgical site infection, and finally back into a perforation.  The patient similarly underwent a stormy course at the wards, with the wound and medications at times being neglected.  It would be some days later before I was able to inspect and debride the wound myself.  Upon inspection, the wound was a pool of liquefied necrosis.  I instructed the wife of the patient not wait for the inconsistent daily cleaning rounds, how to do debridement by simple wet-to dry dressings over the necrotic areas, and to do this at twice a day.  The patient was eventually discharged with a still ugly wound.

Someone at the OPD cornered me two days ago.  I no longer remembered the wife of the patient but she remembered me.  The patient’s previously gaping operative site had contracted much smaller now, and all the previously exposed sutures were completely covered by healthy granulation tissue.  They requested if they could return back to their home province.  Seeing as they did a good job of taking care of the wound, I allowed them to do so with advise.  The wife apologized that they did not bring me any pasalubong as they had only just chanced upon my being there.  They repeatedly told me that I had done a great job, and I had a great record with them.  As they were going away, I silently reprimanded myself for wanting the absent pasalubong more than the praises they were lavishing on me, it being lunchtime already.  On my way out of the OPD, I bumped into our department secretary who informed me that free lunch was being served at the office.

Insights (Discovery, Stimulus, REINFORCEMENT):

Reinforcement:

Many physicians and patients alike, in focusing on just one problem instead of looking at the whole picture, miss out root cause.

Wet-to-dry dressing works even for the worst appearing wounds.

Change of dressings in infected wounds may be necessary more than once a day.

Patients have to help themselves, not just rely on doctors and nurses.

Early feeding tolerated and safe for intestinal anastomosis patients.

Stimulus:

To routinely ask, if not inspect for hernia in all patients with abdominal complaints.

To demonstrate, not just instruct on proper method.

Discovery:

How many physicians actually inspect the inguinal area of abdominal complaint patients?

Dictums in textbooks aren’t always correct.  Infected tissue with braided sutures do heal.

Debridement of all grossly nonviable tissue not always necessary during operation.