Shit Happens!

On my list of top 5 most dreaded bedside procedure : peritoneal catheter insertion. I think a lot is left to chance when, despite all the precautions we take, some mesenteric vessel or bowel might be sitting right where you intend to stab with a trocar with "gentle force", but force nonetheless, waiting to be perforated. Yes, it's a blind procedure, and I hate being in the "dark"! Is there no better way? Induction of a false ascites isn't necessarily trauma-proof either. I recall an incident sometime last year when my house officer informed me that, on withdrawing the 16G cannula after infusing adequate amounts of fluid into the peritoneal cavity, she had noticed the tip to be faecal-soiled. True enough, after staring at it for a good minute, I finally decided it was faecal material after all. I complimented my HO for her keen eye (it was a tiny speck!) and good sense not to have proceeded with the procedure, but informing me instead. In a place where someone is always to blame for something bad that happens, I told myself that night that I would stand up for this girl if anyone were to start finger-pointing. She had performed the procedure correctly; the patient was unfortunately a victim of a recognized complication of peritoneal dialysis. A former consultant of mine in Kuching once asked me, "So (my name), how many of the stab PDs you did that were complicated by bowel perforation/vascular injury?". Then, having been in service for 3 years, and having performed quite a number of such a procedure, I said none, feeling rather pleased with myself for the clean sheet. He said, "Then you haven't done enough!" and went on with his collection of horror stories associated with PD gone awry during his younger days. No, he's not condoning this practice of unwittingly rupturing guts and tearing vessels, but simply to state a point - even when you have taken all precautions, shit (pardon the pun) sometimes happens. If it hasn't happened to you yet, you're either very fortunate or not doing enough PDs. Since then I have caused 1 case of jejunal perforation; my patient however survived the laparotomy and went home well, if only with an unsightly abdominal scar. Needless to say, I was upset. With that I guess I had done enough. These days, I'm lucky to be able to delegate this task to my HOs trained to do PD. I look forward to the day when stab PD will no longer be mentioned in standard medical text, except perhaps under the section "A History of Renal Support"!