Indexing Title: JGGuerra’s Medical Anecdotal Report (08-01)

MAR Title: When to do gastric exploration and ligation  in the face of a negative duodenal ulcer bleeding and a negative endoscopic findings

Date of Medical Observation: January, 2008

Narration:

            My story is about a 43-year-old male who was referred to our department by internal medicine for definitive ulcer surgery. The patient was chronically admitted in their service because of recurrent bouts of upper gastrointestinal bleeding. There was a clear indication of failure of medical management. Patient had undergone repeated endoscopy, in which the last still showed bleeding duodenal ulcer. All odds were against us, with his comorbidity and hemoglobin count, just to mention some. However, we still prepared the patient for surgery. Our indications were, bleeding duodenal ulcer and intractability.

            The day of the operation came. My team was prepared for anything that might happen Intraoperatively. Plan: we will get in fast, ligate the bleeding vessel and out. Low and behold! After anterior duodenotomy, we noticed no bleeding, no visible vessel whatsoever. What was clear was a ulcer bed with evidence of fibrosis. We proceeded with our exploration up to the body of the stomach which turned out to be negative. And again with the endoscopic finding of solitary duodenal ulcer.  What shall we do? Are we going to do gastrotomy? Theoretically, no ligation is indicated. We closed the incision and completed the truncal vagotomy

            My patient was recovering well postoperatively. We transfused the remaining two units of blood. We were successful in raising his hemoglobin count to 13. Until, on the 5^th postoperative day, patient had episode of massive upper GI bleed. We contemplated on another operation, however patient continuously deteriorated and succumb to death.

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

 We were puzzled. Where was the bleeding came? Rebleed on the ulcer bed or a missed bleeding point? These questions are still hanging around. I still do not have a definite answer. Should I have done gastrotomy? Should I have ligated the gastroduodenal vessel?

 But things are for sure, although the case turned out to be unsuccessful, we were able to learn from it as much as we could. First, I was fortunate to handle such a not so common case, and able to read and understand the whole topic. A good preparation for another case that might come (glad another similar case came, now with active bleeding, and we were able to save the patient, I hope).

Second, we must not largely depend on the findings of our colleague, much more if the case is for operation. We should make sure that we are present during endoscopy or paraclinicals if done.

Indexing Title: JGGuerra’s Medical Anecdotal Report (08-02)

MAR Title: How to preserve the recurrent laryngeal nerve.

Date of Medical Observation: February, 2008

Narration:

            Fact: One of the principles of thyroid surgery is to preserve the recurrent laryngeal nerve, in which case exposing its entire cervical course. There are at least two schools of thought on this topic; identification versus non identification of the nerve. Different surgical atlases also suggest different techniques. Frequently, under emphasized were those unwritten techniques hand down from generations of surgeons, in which I guess was one of the easiest one.

            I had a thyroidectomy scheduled and was fortunate enough to have my consultant scrubbing in. Prior to the operation I reviewed at least three surgical books on the procedure, one from Zollinger, another from Lore and one from Cameron. The only similarities were from incision, suplatysmal dissection, separation of strap muscles and exposure of the gland. Differences exist regarding approach on thyroid vessels ligation (which one should be ligated first, Superior thyroid vessels, Inferior TV or Median Vein) and recurrent laryngeal nerve identification.

            During the operation, I was taught how to expose, identify and preserve the recurrent laryngeal nerve without actually having the pressure to search for it. First step is to ligate the middle thyroid vein to facilitate medial traction of the gland in preparation for the identification and ligation of the superior thyroid vessels. Superior thyroid window must be identified to facilitate planar dissection. Loose areolar tissue can be bluntly dissected. Individual ligation of the superior thyroid vessels will be the next step. Once the superior pole is freed, downward medial traction is executed to facilitate identification of the superior parathyroid gland. Once identified, the goal is to separate it from the superior thyroid pole. In doing so, small vessels are encountered and ligated. Once parathyroid gland is separated, the recurrent laryngeal nerve is exposed. Its course must be followed superiorly as it enters the cricothyroid muscle. This is done by inserting a fine tip clamp just above the nerve through its course, in such a way, iatrogenic injury is prevented. Same technique is done on its inferior course. Also preserving the inferior parathyroid vessels. Afterwhich, inferior thyroid vessels are ligated

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

This particular narration points out that although different techniques are available, still the best is the combination of them probably by getting them from consultants who were able to do textbook of cases. Moreover, their techniques might be those handed to them by experts.

In doing thyroid surgery, we must not be preoccupied by the thought that we must first identify the recurrent laryngeal nerve. When properly done, step by step, the nerve will just show up. Always make sure that what you cut is not the nerve!

Indexing Title: JGGuerra’s Medical Anecdotal Report (08-03)

MAR Title: Better to be always prepared

Date of Medical Observation: March, 2008

Narration:

            As a surgery resident, how many times have you ever experience to be caught surprise intraoperatively? In a situation wherein your operation did not pursue as planned and needed an alternative operative approach. Say, a planned appendectomy which turned out to be needing a hemicolectomy. Does it occurred to you that you should always be prepared at least theoretically equipped to do the procedure.

            My story is exactly the same as mentioned above. I had an esophago-gastric surgery scheduled a month ago which turned out to be different as planned. We scheduled a total gastrectomy with distal esophagectomy for a gastroesophageal malignancy through a thoracoabdominal approach.  After a careful review of the case including all the paraclinical results, we go ahead with the contemplated procedure.

            In order to prepare for the case, I reviewed the theoretical part, then the anatomy book and operative atlas and played imaginatively the procedure that I am going to do. I was pretty confident that I can do the operation well with my consultant as my assist. However, a day prior to the operation, I had I thought that what if there is a change of plan Intraoperatively, say a unresectable gastric cancer or worse a unresectable esophageal cancer. What will be my intraoperative plan? My inquisitive mind helped me prepared more. These preparations paid off during the operation.

            We noted an unresectable mid esophageal tumor. We did bypass through a gastric pull up with esophageal anastomosis and tube esophagostomy.

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

            Plan ahead. As what have been mentioned, planning is essential, when you fail to plan, you are planning to fail. As residents in training we are given the luxury of cases. We have to maximize our stay as residents. Our job is primarily to learn, learn and learn more. Part of learning is reading, we should always be ready one step ahead. In such case, no matter what is ahead of us, we can manage them accordingly.

Indexing Title: JGGuerra’s Medical Anecdotal Report (08-05)

MAR Title: A difficult thyroidectomy case.

Date of Observation: June, 2008

Narration:

            For quite sometime, I was confident in doing a lot of general surgery cases. This is probably a product of years of experience, handed and taught to me by my superiors, seniors and consultants alike. Not until I encountered a difficult thyroidectomy case.

            A case of a 49-year-old female who came in with enlarged right thyroid gland. She was subsequently scheduled for surgery. It was a pretty easy case, I thought, since I have done quite a number of thyroidectomy cases in the past.

            I scrubbed in and started with my usual operative technique. Low transverse collar incision, doing the superior flaps etc. Until, I was able to got hold of the thyroid gland. It was big, and adherent to all nearby structures. The sad thing was, it almost encroach the trachea and esophagus.

            I ligated the middle thyroid vein and the superior thyroid vessels but still it was difficult to scoop out the thyroid. I was dripping wet. Sweat started to flow over my forehead. It was a difficult case. I stopped for a while and began processing my thoughts again. No need to be in a hurry. Just do it meticulously, I told myself. With some maneuver, I was finally able to deliver the gland.

            My next big problem was how to look for the recurrent laryngeal nerve. I palpated and identified the tracheoesophageal groove, save the parathyroid gland superiorly in the premise that the recurrent laryngeal nerve will show up, identified the inferior thyroid vessels and tracing the nerve superiorly. All of these techniques failed.

I was in deep trouble. Still I started to repeat my techniques in finding the nerve, but still, it was futile. My only grip was that I didn’t cut any structure which look like a nerve.

My last option was to close the patient and pray hard that I was not able to cut it.

When I did my rounds postoperatively, there was no sign of nerve paralysis.                     

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

Doing textbooks of cases will not make us immune from not experiencing troublesome and stormy operations or worse committing mistakes. All of us have our shares of difficulties, morbidities and mortalities. It is through all of these that we become mature surgeons.  

Residency training equips us with skills on how to deal with difficult operations. The anecdote above is a good example of such. How to deal with it depends on us. We have to anticipate problems, have an alternative plan, as well as support group. In my case I was lucky to get away with no morbidity. Concluding the operation without identifying the nerve was crucial or should I say a big decision to make.  

            Anticipation of such scenario equipped me with the security of a back up plan. Although I was not able to identify the nerve, I am also sort of convinced that I did not cut any structure that might be the nerve. It may sound a bit pessimistic- that of which things may not work out the way we planned it to. But sometimes situations have been known to deviate away from our planned outcome.

            More importantly, ask for help if deemed necessary.

Indexing Title: JGGuerra’s Medical Anecdotal Report (08-06)

MAR Title:  Decision making in the operating room

Date of Observation: July, 2008

Narration:

            July 03, 2008 was a very frustrating day for me. I have lost a patient under my care. It gave me a couple of sleepless nights, abdominal cramps and hyperacidity. Until now, I was pretty confused if it was because of my misjudgment. Simply put- my error. I was not ready to accept the fact that a very young female patient in her early twenties came in to seek help, awake, conversant and ambulatory eventually sent home dead.

            She was admitted as a case of thyroid malignancy complaining of occasional difficulty of breathing and choking apparently because of a huge mass encroaching practically her whole neck. We had her stayed for three days in the hospital. On her third day, while doing our morning ward rounds, I noticed her literally gasping for air. She was anxious, irritable and cannot tolerate lying down. We hooked her to oxygen and immediately wheeled her in to the operating room for tracheostomy.

            We sought the help of the anesthesia residents for possible intubation, they tried and somewhat they succeeded. We all rejoiced when the endotracheal tube was inserted. I thought I’ll have the luxury of time to insert the tracheostomy tube as well as do some anterior tumor debulking. We prepared the site until a continuous beeping was heard from the oxygen saturation machine. It was deteriorating and dropping continuously. They have the tube checked, however, according to them, it was not dislodged. There was tight air entry and wheezes. We thought initially it was due to bronchospasm of the lower trachiobronchial tree. In split seconds, we were able to give subcutaneous epinephrine injection as well as terbutaline. It took us at least 5 minutes to decide. It was a futile effort. Oxygen saturation (O2 Sat) was at 60 percent. I decided to get in and did the tracheostomy insertion. It was a bloody mess. The trachea was blocked by a huge tumor anteriorly and laterally.

            Things went steadily from bad to worse. My first anterior approached was a failure. Neither was the second, a lateral approached. Finally in desperation, a palpated what I thought was the trachea, bingo! I was able to have the tube inserted. It was 2PM, we have been looking for it for the past 15 minutes. By this time, O2 Sat. was at 50%, then 60%, 70% until it reaches 95%. We were all soaked with perspiration.

            As we were fixing the tube and suturing the lateral side of the incision, patient again began deteriorating, decreasing O2 sat. Blood pressure became palpatory and cardiac rate barely audible. We started on inotropics. She showed improvement. After a few minutes she began deteriorating again and arrested. We did cardiopulmonary resuscitation. We revived her and transferred her immediately to our surgical intensive care unit.

            On the following day, she came to rest.         

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

            I was devastated. I was still in the period of denial. I never thought it will end the way it ended, a dead patient. Am I late in making my intervention? Should I have immediately made my move when her O2 sat was dropping? Was it because of lower tracheobronchial tree spasm? Or a not properly inserted endotracheal tube?

            These questions are so important since committing to one will mean delay in intervention. I still don’t know. Another question in my mind, was 15 minutes too long for me to get it done? That was a pretty hard case, anyway.

            Judgment. Decision making in the operating room could be very difficult, and here it was. I had to act on my own-rationally, rapidly as possible. I was not God, by a long shot, but as far as the power was concerned, I was closer to Him than anyone else at hand. I had to play the role. I was the surgeon.

Indexing Title: JGGuerra’s Medical Anecdotal Report (08-07)

MAR Title: Importance of Blood

Date of Observation: February, 2008

Narration:

            I don’t think anyone who is not a doctor can really appreciate just how important blood is. For us surgeons, it’s a matter of life and death to our patients needing immediate transfusion. You have to try to salvage a woman who is bleeding like a devil from a peptic ulcer, or work to save a young man in shock because of penetrating abdominal vascular trauma, to realize how disastrous blood loss can be. One minute this man, woman is pink, warm calm and next he is pale, cold and irrational. It is enough to scare you out of your wits.

            I can never forget the patient I surgically corrected early this year who bled out. He was in his late twenties, came in at the emergency room literally bleeding from every os because of peptic ulcer. He was in shock, palpatory, irritable and combative, all signs of beginning hypoxic encephalopathy. We transfused him with two bags of blood, resuscitated him and prepared him for operation.

            At the blood bank, there was no available blood of his type. We had only five units of type O positive. Situation that would spell life and death to our patient Aggressive as I was, I took the courage to explain to the relatives the pros and cons of the surgical intervention and the possibility of incompatibility if I will transfuse a type O positive blood. They consented with the procedure and transfusion.

            We wheeled him to the operating room and controlled the bleeding ulcer. We also transfused him with four units of type O positive nonspecific. He survived the operation.

            The following morning, with his blood level back were it belonged, his mind was clear as water.

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

            My narration above only goes to show how important blood is to us surgeons. Its absence puts our surgical effort into jeopardy. There are several points of discussion in this report. First, how to act rationally in times of limited blood supply, in cases operation is in dire need. Second, how to have a rational blood transfusion approach. Third, how to keep our blood bank enough supply for emergency operation.

            In dealing with life and death situation, we have to have a back up plan. Base theoretical knowledge of blood transfusion, incompatibility and rejection should be understood.

            Secondly, we should not transfuse or request blood preoperatively if not indicated. More often than not, requested and crossmatched blood which is not transfused goes back to pool. We have to revisit these policies during the quarterly blood transfusion audit.

            Thirdly, probably it will be high time for our department to device methods of procurement of blood for our emergency use. How should it be done is difficult. But again, we have to take the first step in achieving this goal.

And lastly, once you have worked in a hospital where blood is in short supply, you will never lose your respect for it. Even if sometimes our blood bank is well stocked, I never order a transfusion without momentarily wondering where the pint’s coming from and what the transfusing is going to do to our credit. You can bet none of my patients get any blood unless I am sure they need it.   

Indexing Title: JGGuerra’s Medical Anecdotal Report (08-08)

MAR Title: Mutual Lack of Approbation

Date of Observation: “On occasion”

Narration:

            At one point in time in our surgical training, we encounter frictions from our colleagues in different specialty fields. Oftentimes, problems usually arise during referrals wherein they obliged us to cut a patient that they think needs surgical treatment. Or perhaps make a snide comment when we do certain bedside procedure, such as venous cut down or IJ catheter insertion. Not to mention frying us during their mortality conferences

            I can always vividly remember during my junior years how these particular incidents made me scratch my head. During those time when I was being called to do a cut down, there were always medical men breathing down on my back as I worked, making snide comments on how long it was taking me to slip a couple of iv catheters in

            On every medical division, there is at least one frustrated surgeon, a fellow who wished he was a cutting doctor but who for one reason or the other end up a medical man instead.

            Take one example on how this particular observation happened. During one duty night, we received a referral from the medicine department asking us to evaluate a failed Internal Jugular Catheterization. They attempted to do the procedure themselves and somewhat failed. We revised the catheter and found out it was incorrectly inserted.

            Medical men don’t think and act like a surgeon and vice versa. In medical school we used to say, internist know everything and do nothing, surgeons know nothing and do everything.

It is an undeniable truth that sometimes we tend to depend and be proud of our profession. We tend to regard medical men as doctors who lack decisiveness. They hem and haw for hours over whether to give a patient what kind of antibiotics. On the other side, they tend to look upon us as technicians, not too bright. But they will be lost if they had to make up their minds in minutes whether or not to open an abdomen.

            We surgeons are the type who does not want to sit around and wait for results. We want the quick cure of a scalpel, not a slow cure of a pill. What we lack in patience, we make up for our decisiveness.

            It would be fair to say that sometimes we are guilty of such reasoning. But as we go along with our training, maturity takes over and we tend to get along with them as much as possible. 

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

            Despite this mutual lack of admiration, it is imperative that we surgeons get along with our counterparts in medicine and every specialty, as they with us.

            We can not tell when one of our postoperative patients would have a coronary disease and we will need the help and advice of an internist. They could not be certain that their patient with pneumonia would not develop stress ulcer.

            For that matter, either of us might require the services of each other. All of us, doctors from every discipline, were interdependent when it came to providing complete care for the patient.

            Learning to maintain good rapport was an important part of our training. Once we got out into practice, we have no captive referrals. Sometimes, we would have to rely on the good will of the medical men for patients.

Better learn diplomacy now when we are not under pressure than develop bad habits that could give us some lean years later on.  

Indexing Title: JGGuerra’s Medical Anecdotal Report (08-09)

MAR Title: Judgment

Date of Observation: August, 2008

Narration:

            When I became a senior resident, the tough decisions were passed to me all along the line. There, the buck stopped. I was the boss and I was expected, both by the house staff I supervised and by the consultants who supervised me, to make them. My batting average has to be high in the decision making department.

            One decision over which I sweated blood involved a 17-year-old boy referred to us by the department of pediatrics. He had been sick, with stomach pains and vomiting for almost 24 hours. Medical history was unreliable. He had alcohol binge a day before and presented with episodes of passing out fresh blood per rectum, followed by vomiting of bright red blood. The situation was worsened by bouts of colicky abdominal pain. Vital signs were stable with Physical Examination findings of direct tenderness over the epigastric area and blood on the tactating finger on rectal exam. Nasogastric tube showed coffee ground output. Our admitting Impression was LGIB vs UGIB. Medical management was started and the patient was referred for upper and lower endoscopy study.

            To complicate matters, paraclinical was not available. Although there was a significant decrease in ongoing signs of bleeding, patient continuously complained of abdominal pain. PE finding of the abdomen showed diffuse tenderness all over the quadrants, however with no signs of muscle guarding.

            That particular situation calls for a decision. To operate or not. Observe him or we might be late, operate on him with the possibility that we might find nothing. Finally with the approval of the attending and the consent of the parents, we wheeled him to the operating room.

            Low and behold, what we found was a gangrenous ileal segment. The rest of the bowel was normal. As of the cause, we don’t know.

            At least we have won in the decision making department.

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

            Removing a stomach, a gallbladder or an appendix can be a difficult job. If the ulcer is stuck to the pancreas, the gallbladder acutely inflamed, the appendix ruptured, it takes a smooth technician to do the job safely. Still, a reasonably intelligent, moderately adept individual might learn to do any of these jobs in a few months. If you can cut, sew, and tie knots, you probably can operate. When you get down to fundamentals, that is really all there in the mechanical phase of surgery

            However, when it comes to judgment, it more difficult and complicated.

It takes a long time and a lot of hard work for a doctor to acquire sound surgical judgment. It takes at least few years for a doctor to acquire the knowledge and experience he needs to do the job, whether to do the operation immediately or later. And he has to be right. It is much difficult to decide if a patients needs his stomach removed than it is to do it. Time and again, surgical problems are a matter of problem solving and decision making. As long as you are rational, you can do the job quite well.