Indexing Title: JPINGULs Medical Anecdotal Report  [05-10] 

MAR Title: C.O.pathy 

Date of Medical Observation: November 6, 2005

Narration:

 She is a 47-year-old female and works as a nursing attendant in the ward of the department of medicine. She experienced on and off right upper quadrant abdominal pain for the past several months. She consulted one of the senior internal medicine residents about her condition and laboratory work up was done.  Abdominal ultrasound found a stone on her gallbladder, which then prompted her to consult a surgery resident, who advised her to have the gallbladder removed but she hesitated.

Months went by, the symptoms of right upper quadrant abdominal pain persisted, her co-workers have been encouraging her that it was a simple operation.  When we went on regular rounds at the medicine ward, one of my co-residents asked her when she would have her operation scheduled, she replied not yet. 

Then one morning, she approached me with a repeat of her ultrasound and a complete pre-operative assessment form (which was actually not needed), and asked if I was handling the service for patients with gallbladder stone, so I answered that I was and asked her when she wanted to be scheduled.  She answered anytime, so I scheduled her on the soonest available operative date. 

She was admitted and the day of operation came.  When she was wheeled into the operating room(OR), the staff were excited that it was her turn, they prepared all the materials and even had new linen for the OR bed.  She was definitely a friend of the hospital staff and hence was treated with special care.  I asked my service consultant to assist me in her operation. 

When we opened up the abdomen, we noted that the gallbladder was adherent to the surrounding structures.  Adhesiolysis was done and we proceeded to opening the triangle of Calot to isolate the cystic artery and the cystic duct.  When the cystic artery was being isolated it was noted to be larger than the usual, so my consultant decided to defer the ligation temporarily until we identified the other structures.  We then tried to isolate the cystic duct, but bile started to stain the operative area, it was coming from the neck of the gallbladder.  We clamped the spillage site and proceeded to free the gallbladder from the liver bed, which we were able to do so relatively with ease. 

And what we thought was the cystic artery was actually the right hepatic artery, as it curved back towards the liver, and the cystic artery was branching very near the wall of the gallbladder.  We removed the specimen and made sure that the common bile duct was intact.  We did adequate washing and hemostasis, and was about to close, but bile seemed to stain the most dependent part, it was apparently coming from small ducts in the liver bed.  We tried to cauterize the bed and suture ligate the apparent source of bile, but it was persistent.  So my consultant decided to put a drain and we closed the abdomen. 

On the first post-operative day the patient wondered why she had a drain, so I explained to her what we found and instructed her that we will measure the amount that was coming out of the drain. 

The next day, she was ambulatory, feeding was started, the drain output decreased, she complained of vague abdominal pain, but the abdomen was soft and was non-tender.  Eventually, the drain was removed and the patient was sent home.

INSIGHTS: (DISCOVERY, stimulus, reinforcement), (physical, PSYCHOSOCIAL, ethical) 

C.O. is the acronym for care of.  Usually the term refers to patients who are relatives of someone associated with the hospital or with city hall.  For this case, the patient is an employee of the hospital.  She was treated with extra-ordinary care because she was first of all a friend, who became a patient.  And as a friend, I did not want her to fell uncomfortable. 

I know of other doctors who were able to operate on their friends, even children or parents, and the operation went smoothly.  But why was it that when one wanted to have a straight forward operation, something always seemed to go wrong, particularly with patients whom we consider as C.O.  Or is it because that the patient is a CO that something that goes wrong, even the smallest becomes enlarged, hence the discovery of the term COpathy. 

In every operation surgeons must remain focused on what they are doing, identifying each structure as accurate as possible, the mind must be prepared and the emotion or the thinking that “this is my friend, I must not go wrong, I must not go wrong, must be set aside.”  But then it is easier to said, than holding the knife and performing the operation. 

To be positive about this, I am honored that she approached me to be her surgeon, and I realized that no matter how many operations one has done in the past, one must not be over confident at any given time, while operating on a patient, since each patient is unique.  Because of her, I have yet a lot of skills to improve on.