It is not nice thing to have a patient develop postoperative wound breakdown and burst abdomen. It must be a terrifying experience to see one's own bowels come out of one's abdomen. It is scary for the doctor too, because he knows the serious causes of the complication, and the associated morbidity.
We had a patient with an ovarian tumor and a bad pulmonary problem who could not be operated upon because we could not get a ventilator. After a month and a half, she underwent the operation. The operating surgeon told me it was uneventful. Then I went on a short leave. When I resumed duty, I found her on IV fluids again, looking sick.
"What happened?" I asked.
"She developed a burst abdomen" they told me. "It happened on the fifth postoperative day.
"What was the cause?" I asked.
"There was no cause" the Registrar said.
"The sutures must have cut through tissues" I said.
"No. They did not" she said. "The skin and subcutaneous tissue were OK. the peritoneum and rectus sheath had separated."
"The sutures have to cut out of one edhe of the abdominal wall wound, unless the sutures broke. That does not happen. had the sutures broken?" I asked.
"No."
"Then they had cut through tissues" I said. "What is the microbiologic report of the wound discharge?".
"It was a clean wound" said the person who was in charge of the case. "There was no sepsis. It was her retching that caused the burst abdomen."
I was surprised. A number of patients vomit postoperatively. That does not cause the abdominal wound to burst.
"There has to be sepsis. She did not have any factor that impaired wound healing. Only sepsis can explain what happened."
"She had a lot of discharge" she said.
"That is the inflammatory discharge" I said. "That was sepsis."
"But there was no pus" said the Registrar.
"It looks like pus if the organisms are pyogenic" I said. "Other infections can produce clear fluid in large quantities. Even peritonitis can have a lot of clear fluid."
"Er... remember that patient of xxx unit who had such clear discharge? She had infection" said the senior of the two doctors claiming there was no infection.
"It is a known fact" I said mildly. "You don't have to quote a case report to support what I said. Have you sent that discharge for microbiologic study?"
"Yes" the Registrar said. We moved on to see other patients. Both of them had a facial expression that showed they still believed there was no sepsis, and they were humoring me because I was boss and could not be contradicted.
The microbiologic report came a day later. They grew MRSA and pseudomonas, sensitive to linezolid and piperacillin. The patient is doing well on these two antibiotics. I refrained from asking them if they still believed there was no sepsis. I do not like rubbing it in. Had I said so, they would have just added to the grudge they hold against me too.
