PJCGAGNO’S MAR [15-02]:‘To Operate Or Not To Operate’

MEDICAL ANECDOTAL REPORT
Index Title: PJCGAGNO’S MAR [15-02]
MAR Title: ‘To Operate Or Not To Operate’
Period of Observation: February 2015
Tag: Knowing when not to intervene in Surgery
Category: Professional/Ethical-Reinforcement

NARRATION:

It is a routine event that I receive clearance forms of patients for surgery. I was the urology rotator when I received a case of a 45-year-old male diagnosed with staghorn calculi (renal stones occupying the renal collecting system) for Pelvolithotomy (removal of stones located at the pelvis of the kidney). I then reviewed his chart to check if he needed anything which might be ordered by the anesthesia or internal medicine as preparation for his surgery. Unfortunately, his prothrombin time / partial thromboplastin time (PT/PTT) results were prolonged.

I called up my Urology attending and updated him that we have one patient for pelvolithotomy but noted him that he had prolonged PT/PTT. He then scheduled our patient for the next urology operating room (OR) day provided his PT/PTT be corrected before the operation. Our patient was then started on oral Vitamin K in order to correct the said deficits.

Repeat PT/PTT showed still with prolonged results. I re-interviewed our patient and found out that he wasn’t able to complete his vitamin K correction. I then reported to my attending and updated him regarding our patient’s status. He then advised not to schedule our patient for the contemplated procedure until his bleeding parameters are corrected since he might bleed continuously during the procedure and this is very dangerous to the patient.

I explained to the patient regarding our plan and eventually he understood and followed our advice. After proper administration of Vitamin K, the patient’s bleeding parameter returned to normal and he was then operated on without any complications.

INSIGHT:
(Physical, Psychosocial, Professional/Ethical)
(Stimulus, Discovery, Reinforcement)

An old dictum states that: “A good surgeon knows how to operate, better ones when to operate, and the best when not to operate.” This mantra surely has a great impact in our practice as surgeons and even across other fields. It takes a lot of guts, wisdom, experience, strength, and courage not to intervene.

Proper patient preparation is the key to every successful elective procedure done in the operating room. This is very important in order to avoid any detrimental effects during an operation. We have sworn as physicians in the Hippocratic Oath, “first do no harm”. Patient safety is our utmost priority in every operation that we do.

As narrated above, it is the best option for our patient to postpone the Pelvolithotomy operation. This is to avoid heavy bleeding given the nature of the procedure on top of his prolonged PT/PTT. In any elective cases, we are given enough time to adequately prepare our patients. This is to avoid possible problems that may arise prior to the procedure. In doing this, we could prevent any harm and minimize unwanted complications of the operation. We could also avoid unnecessary admissions and OR cancellations, which would save time, money, and effort.

It is therefore recommended to have a proper pre-operative preparation, which includes a good history taking and physical examination. Anesthesia evaluation and cardiopulmonary clearance recommendation should also be put into consideration to maximize the physiologic status. An informed consent should be given. And every updates and changes noted on their current status during pre-operative period should be explained. With these preparations, we can decide whether to push through or to hold any elective procedure.

The pre-operative dilemma of patient’s prolonged PT/PTT indicates increased risk for bleeding due to problems in extrinsic clotting factors. Therefore, it is recommended to administer oral vitamin K since he had no signs and symptoms of active bleeding. However, non-compliance of the regimen prompted IV administration of Vitamin K for faster correction. This should not be the case. As surgeons, we should also check if the patient complies with the treatment.

With all these, the success of a procedure is not only limited to the clinical decision making and skills of a surgeon, but to the amount of preparation he spent in evaluating and maximizing the condition of the patient prior to the OR.

ROJoson’s Notes (16dec30):

Preoperative preparation is important so as to promote a better chance of success of the operation.

If the surgeon detected something that may put a risk to the patient safety, he should remedy it right away.

“A good surgeon knows how to operate, better ones when to operate, and the best when not to operate.”    Right timing is also important.

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