Monday, January 25, 2010

I lost a patient with umbilical hernia

Umbilical hernia is hardly a fatal disease. In most cases, umbilical hernia is a congenital condition. To Kelantanese, it is known as pusat bujil or uluran; and is usually seen in neonates and premature babies. Strap a 50 cent coin there or apply a 'barut perut' - settle the problem in most infants. Those who still have the hernia after the age of one year, would most probably need surgery to repair it.
This is how an umbilcal hernia looks like:

In children, the content is usually a loop of small intestine. If the umbilical hernia occurs in adult, more often than not it contains omental fat (lemak dari dalam perut).
Complications come in the form of obstruction; a loop of intestine herniates or protrudes out (into the hernial sac) and could not go back inside (into the abdominal cavity). Thus the hernia could not be reduced or pushed in. Sakitlah jadinya ! Reducible hernia is usually painless. On top of that, when the intestine gets blocked; perut jadi buncit, tak boleh makan dan muntah-muntah. It may get worse, if the blood supply to the obtructed intestinal loop is cut off by the pressure of the swollen bowel to the hernial ring. This is now called strangulated hernia. If not relieved immediately, the intestinal loop would become gangrenous (mapuh le tu!).

This is a picture of a gangrenous bowel loop in a stranguled hernia:

For many Malaysians (biasalah, selagi tak sakit, selagi itu tak buat apa-apa) they come for treatment when the hernia got obstructed. Since the last Hariraya I operated on two patients with strangulated inguinal hernia and one with strangulated umbilical hernia. The first two were operated immediately; loops of vascular-compomised intestine resected, hernioplasty done and the patients went home after few days.

The third patient came seriously ill, she came with septicemia (very ill with overwhelming infection and multiple organ failure). She was resuscitated, blood pressure stabilised and taken to the operation theatre. Her condition was made worse by her uncontrolled diabetes.

This is how her tummy looked like. This picture was taken after I had painted the abdomen with iodine solution to sterilise it for the surgery (before draping).

Once I opened the abdomen, I noted the bowel was gangrenous and feaces (tahi) all over the abdominal cavity and in the hernial sac. I had a difficult job; resecting the dead and necrotic large bowel, cleaning all the spilled-over tahi and at the same time try not to breath in too much air through my surgical mask.

Post-operatively she was pushed to the ICU and ventilated. Despite of a very aggresive management she did not recover from her septicemia and finally succumbed to her illness.
This time I did not need to put a 'sympathetic face' and say to the family ; sorry, we lost your dearest one ! Insteads, they came to me apologitically "apa nak buat, kami dah puas pujuk, suruh dia buat operation lama dulu, tapi dia yang degil"
Inilah orang kita, selagi tak nampak bayangan malaikat maut, tak mahu berubat.
Nak tidur baru nak cari bantal, nak berak baru nak korek lubang !!

Monday, January 11, 2010

Start blogging again ....... The usual Kelantanese stuff !

A 43 year old 'well-educated' gentleman presented to me last July with symptomatic anemia i.e. he complained of tiredness and breathlessness. On examination, he was pale (Hb 4.0 gm/dL), his blood pressure was normal but his heart rate was a bit faster than it should be. His lungs, heart and the abdomen were essentially normal.

On enquiry as what could be the source of his chronic blood loss, he admitted to have some bleeding piles for many years. On examination, this is what it looked like: a bleeding and prolapsed piles.

"Picture DELETED"

Piles or hemorrhoids (for treatment purposes) are classified as first, second, third or forth degree, in term of severity. First degree piles are those situated in the anal canal and they stay there. Second degree piles come out when you strain but goes back inside spontaneously when you stand up. A third degree piles needs to be pushed inside, and a forth degree could not be reduced at all.

What he need was blood transfusion to correct the anemia and a hemorrhoidectomy surgery to treat the third degree piles. He accepted the blood but refused the surgery. Fair. Many people are scared of surgical proceedures. So he was transfused with several pints of blood, given medications to treat the piles and was discharged from the hospital.

Last night, he came back(after 5 months). Again with breathlessness and severe anemia. His Hb was 4.3 gm/dL. The piles were still the same; bleeding and prolapsed. And he still refused definitive treatment. The reason is : "ada orang kata kita boleh mati ketika buat operation". I gave him a lecture on risk-management: what ever we do, there are risks involved. The important thing is how we face and manage the risks. Tak faham juga. So I told him; nanti keluar hospital jangan guna lift, kalau lift terjatuh boleh mati. Balik rumah jangan naik kereta atau motor, nanti accident, boleh mati. Jangan jalan tepi jalanraya (pedestrian), kena langgar kereta terus mati.

"Doktor, you bagi I darah cukuplah, I tak mau dengar itu semua" So he got it. But before I transfuse him with the blood, I asked him to sign the 'Blood Transfusion Consent Form'. For your information, the MOH has implemented this policy after facing few cases of medical litigation following complications of blood transfusion, mainly transfusion of HIV-infected blood.

"Masuk darah pun kena sain ke?" I told him: The chance of you dying from the blood transfusion is higher than that of dying from a hemorrhoidectomy surgery.

Itulah orang be exact....oghe kelate kito !