Indexing Title: DCHUA’s Medical Anecdotal Report [06-1] 

MAR Title: The Operative Forest 

Date of Medical Observation: December 24, 2005 

Narration: 

A forty-eight-year-old male from Manila was referred from Internal Medicine for acute exacerbation of abdominal pain and constipation, with three days abdominal distension and vomiting.  Abdominal x-rays did not show a characteristic marked dilatation of the bowels even if flatus had not passed for a couple of days and the rectal vault was empty and collapsed.  The latter finding made him a surgical patient on the outset, even if abdominal tenderness or fever were not significant. 

With his age and absence of any prior abdominal surgery, I was expecting an obstructing tumor.  After some preparations, I operated on the patient, noting an unexpected amount of bowel adhesions within the virgin abdomen, clear peritoneal fluid, and a loop of intestine twisting around a band causing a complete obstruction.  I took a picture, released the band and left the other adhesions alone. 

My service consultant arrived with me failing to anticipate needs for a proper reception.  He was chided by the nurse for entering the operating suite without a complete attire, turned around and left, feeling offended by our disrespect. 

My impression was complete small intestinal obstruction due to an acquired adhesive band from recurrent primary peritonitis.  I suspected the fluid being ascites from cirrhosis, noting a discolored liver which was otherwise smooth and normal-sized.  I took a biopsy and some fluid for bacterial culturing. 

The patient recovered quickly, the obstruction relieved and having no active infection.  He had neither the stigmata of cirrhosis nor a history of viral or alcoholic hepatitis.  I sent him home with the laboratories still pending.  On occasions thereafter, the service consultant would ask me what happened to the patient.  I had no straight answers as he had not followed up since going home. 

A month later, the patient turned up asking for a medical certification for work.  He appeared well enough.  I explained that I had just relieved a symptom and had not cured his disease, and that I needed the results of the workups in order to try and do the latter.  He retrieved the biopsy results which surprised me with findings of chronic liver schistosomiasis.  He had not gone out of the city since his childhood days in a farm.

He returned a couple of days later informing me of his inability to find the uncommon antiparasitic medications I prescribed.  I gave some suggestions where he could find such.  I believe he will get well, as someone had watched over him when he was operated on Christmas. 

Insights: (Physical, Psychosocial, Ethical) (Discovery, Stimulus, Reinforcement) 

I was proverbially focusing so much on a tree that I forgot to prepare for the arrival of my service consultant.  I should never count on luck however to see me through cases that may turn out to be more difficult.  Again, this reflects a lack of preparedness. 

One can never be too careful with one’s words.  It was quickly in retrospect that I understood why the consultant left then. 

It is folly to enter a battlefield knowing neither the terrain nor the parties involved.  At times however, one is forced to operate without a clear diagnosis.  A prudent amount of caution and sober amount of foresight might just lead one through without being scathed.  Know when to operate and when not to.  Restrict any procedure to the least needed to address the problem safely but also maximize the situation and obtainable information before closing the chapter.