INDEXING TITLE: RCHAN’S MAR [5-06]

TITLE: “Of Pneumoperitoneum, Aspirin and Consents…”

PERIOD OF MEDICAL OBSERVATION: July 22, 2005

NARRATION:

         A 67-year-old patient was referred to Surgery by the Department of Internal Medicine. He came in due to abdominal pain of 2 days duration. He was a S/P CVD patient with Residual which occurred way back 1985.

They worked-up the patient for the said complaint and gave medications. Lo and behold, upon doing a chest x-ray, PNEUMOPERITONEUM was noted.

         Prior to the referral I spotted one of our nurses with the relatives of the patient. I just dismissed it as the typical “care-of” situation. Maybe it was Ate Oya’s neighbor or uncle or a kababayan perhaps. The IM

ER resident on duty approached me and referred the patient to me personally. As I examined the patient,he was restless and agitated. He had weakness on theright side of his body and was toxic looking indeed.

My abdominal findings was that of an acute surgical abdomen, most probably due to a perforated peptic ulcer. The nurse approached me and asked my impression. I inquired what her relation was to the

patient, to which her answer was truly an insult to injury…”Biyenan ko po doktora.”  My knees weakened upon hearing her reply. One glaring thought ran through my mind…”Oh-oh CO-pathy in it’s worst form!”

And as Fate would have her way and was truly playing a sick joke on poor ol’ me, she delivered another punchline through Ate Oya’s lips…”Doktora, 15 years na po syang naka- Aspirin”.

         Upon hearing all the overwhelming information that I can take, I mustered enough courage to pull the relatives aside and started to explain the patient’s condition and prognosis, the  dilemma of the situation, the urgency of performing an operation and

the possible outcome.  I honestly told them that the patient may or may not make it through the operation but only God knows that.  As I was trying to keep my composure in being the bearer of bad tidings, the

patient’s wife began to break down and almost collapsed. As she was being attended by her children, I proceeded to talking to one of their sons. He asked me if ever they would not allow the patient to be

operated on, what would be the result? I explained to him the simplest way possible of the pathophysiology of the disease, the complication of sepsis and the endpoint if not addressed to at once…CERTAIN DEATH.

He requested us for a little more time to talk it out with his siblings and his mother,  to which I readily obliged.

         After 2 hours, they informed us that they cannot decide at that point and would still wait for the other relatives to arrive. We told them of how precious time was for the patient and for us but to no

avail. They still insisted that they would not give consent for the operation unless they have thoroughlydiscussed it amongst themselves. We then admitted the patient and gave him analgesics and antibiotics. He

was co-managed by IM.

         The following day, as we made our rounds, there he was, still in pain, suffering from his illness. We gave him stronger analgesics to which he responded to after a few hours. I pleaded for the consent again and

again and went through the same speech about the patient’s prognosis.  The other residents took turns in doing so as well,  only to be answered by sobs and hysteria from the wife, frantically shaking her head

against the idea of opening up her dear husband.  I was informed by the children that they already agreed to have their father operated on but their mother was firm in her decision. Even to a simple CVP insertion

or putting a peritoneal drain under local anesthesia and done at bedside, we were denied of the precious consents.

         I went home frustrated and bewildered as to how I will handle the case. I asked my mother’s opinion and pretty much gave me the same answer…NO WAY would she allow her husband to be operated on anymore if she

were in the wife’s shoes, with no guarantee that he will survive. I prayed for guidance and strength. At the back of my mind, this man cannot and not die without a fight. I knew an operation was what he badly

needed and yet, fear gripped me as to the scenario that I would encounter…another stroke, bleeding, generalized peritonitis, MI, sepsis, etc. As the minutes went by, the patient had less and less chances

of survival.

         That night, I received a text message that the relatives gave the go-signal for the operation but then, they refused to sign the chart. I then decided to go back to the hospital, in the hopes I can convince them to sign the consent.  On my way to OM, I then received another message that a case that we

previously did with a consultant was going to be brought to the OR and that the consultant had already arrived. I drove as fast as I could. I delegated the job of talking to the patients relatives to my junior.

  To my dismay, he too was unsuccessful.

         After I finished the operation with the consultant, I   dropped by the patient’s room and tried my luck again this time. I chanced upon his wife and daughter. My

litany went on for the nth time now with a more desperate and fraught tone.  I made no assurance however that their patient  would make it through the

procedure unscathed. We expect to encounter problems pre-, intra and post-operatively. I told them that thesituation was a gamble and asked them if they were

willing to take the risk, no matter how high the stakes were. A sheepish nod was given by the wife and finally with a broken voice and a broken spirit while

tears were rolling  down her face she said, “Sige po pipirma na po ako.”

         A few hours after the encounter, we opened up the patient. It was a nerve wracking experience on my part.  I expected the worse but only to find a 0.7 cm

perforation at the prepyloric area of the stomach with minimal peritonitis. I uttered sigh of relief and carried out the operation with not much difficulty.

However, post-operative course was stormy. He was still intubated, with little or no urine output, episodes of hypertension, etc.  We started giving the

necessary medications to address to the individual problems. Initially, he responded to such measures.  On the third post-op day, his urine output dropped,

had episodes of hypotension, tachycardic and became comatose.  His heartbeat was irregularly irregular. True enough, he had atrial fibrillation on ECG.

According to the internists, he suffered an MI. Despite medications, he continued to deteriorate as I am writing this MAR now. I primed the relatives that

their patient might not make it tonight.

INSIGHTS: (discovery, stimulus, REINFORCEMENT, physical, psychosocial, ETHICAL)

         Truly enough such a call was a tough one to make, especially when all the odds are against you.  The chances of survival were slim in both situations- of

whether or not to operate on such a patient.  But then we all know that not operating on the patient will hasten his demise.  We are duty bound to do our best

to save lives.  We too as doctors should learn how to gamble…even when the stakes are high. I have no regrets I took my chances on this patient.

As mentioned, there was a small perforation at the prepyloric area which had no splillage and minimal peritonitis.  We did not encounter bleeding as I

feared I would. God was with us as cliché as it may sound.

         It also helps that we take time and effort to explain everything to the relatives, the disease entity, the pathophysiology, the complications, the management and

outcomes. We should not give them false hopes. We should be honest enough to admit our capabilities as surgeons. We can only do so much for them. Our skills

and knowledge may not be enough for them.  Priming the relatives of our patient’s condition will lead  them to accept that their patient may not survive his

ordeal. We must however, show the best of our intentions and do the best we can to save the patient’s life.  No matter what the outcome may be,

they will realize that we took care of their patient until their last breath.