Indexing Title:

JMDEGUZMAN’s Medical Anecdotal Report [05-02]

 MAR Title:

“Primum non nocere”

 Date of Medical Observation: February 2005

 Narration:    

             A male patient with distended abdomen was referred to us by the Department of Internal Medicine. He is 66 years old. He was been suffering from abdominal pains for the past three days associated with inability to pass flatus and unable to defecate. He experienced this before, two months ago but it was brief, lasted only a day with spontaneous relief of symptoms. He described the abdominal pains as episodic. For now it was silent and he laid still but he knows it was only temporary, the next attack will come again sooner or later, wave per wave. With each attack the patient grimaced in pain, nauseating. He was in agony. He was willing to trade anything just to keep the agony away. Examining him, I noticed outright his distended abdomen. No previous scar that would indicate past operations. In its quietness, the lull between attacks, I grabbed the opportunity to complete my full examination on the abdomen, i.e. auscultate, palpate, and percuss. I can hear peristalsis and upon percussion tympanitic sounds were elicited but these findings were nondescript. I had a distended abdomen just like a balloon not rigid without tenderness. My rectal examination showed collapsed rectal vault with fecal materials, no mass palpated. Scout film of the abdomen previously requested by the Internist was suggestive of mechanical obstruction.

            I then transferred the patient to our care and instituted conservative management (i.e. n.p.o., nasogastric tube inserted, foley catheter, IV fluids continued, given IV antibiotics and antacid). I also referred the patient to the Anesthesiologists for evaluation and possible operative intervention for any eventualities. I then informed my consultant of the case at the same time soliciting advice. Patient and relatives were also informed and be aware of my plans.

            Few hours after, I can see signs of comfort on my patient, softer abdomen, and lesser attacks of abdominal colic. Another time lapsed; I noted a more positive signs of recovery, passage of flatus and a non-collapsed rectal vault on repeat rectal examination. I then decided to admit the patient for thorough evaluation.

            At the wards, patient had complete return of gastrointestinal functions. A colonoscopy requested was essentially normal. Patient was discharged after three days of hospital stay at the surgery ward recovered without operation.

Insights (Discovery, Stimulus, Reinforcements) (Physical, Psychosocial, Ethical)

             “Primum non nocere” is a Latin expression of “First, do no harm”. It is a widely held misconception that this familiar dictum comes from the Hippocratic Oath. However, the Hippocratic Oath does not and never did contain those words. It expresses a sentiment similar in general meaning, but never employs the words "First, do no harm."

            Most patients dread being operated. Most of them associate surgeons to operations. It is our duty then to educate them. That we institute regimens best suited for their disease. Remember that as a doctor there is art to medicine and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

            As a resident on training, do not forget to inform your consultant on duty. Be humble enough to say “I do not know” and call the help of your consultant. Our priority is always patient’s recovery.

            In this situation common questions were; “How long will you observe patient with intestinal obstruction, manage conservatively?” “Do you have to wait for peritoneal signs?” These were always answered indirectly and not exactly. What is more important I think is be able to deliver your judgment with care, if you can not, call for help. For as physicians, we tread with care in matters of life and death. We are given the power to save life, but also the power to take life. This is awesome responsibility that must be faced with great humbleness and awareness of our own weakness. We must not play God.