1. Indexing Title: JGGuerra’s Medical Anecdotal Report (06-07) MAR Title: Trust Date of Medical Observation: March, 2006

2. Narration The woman was transferred from the stretcher to the operating table, for the third time. Her pale and weak features clearly suggested a chronic kidney disease. She must have been complaining of constant difficulty of breathing and an extreme limitation in performing even the basic activities of caring for oneself.

3. This poor quality of life may have influenced the woman’s resolve in proceeding with a procedure of creating an AV fistula, which was preceded by two failed attempts.

4. The promise of resolution of symptoms after undergoing dialysis did not ruin the woman’s hope. And besides, she trusted her surgeon explicitly.

5. I met her a couple of months ago, when a friend asked for a favor- make her aunt my patient. Acquiring a brief history, I agreed without any hesitation. I have, after all, created a number of fistulas in my three years in surgery. But in retrospect, I should have thought otherwise.

6. The first two surgeries were performed by me. During the first operation, I noted that the vein and artery were very small that chances of failure was high. Post operatively, signs of av anastomosis failure was evident.

7. I talked to my patient that she needs a second reoperation. She agreed to my plan provided I will be the one to do the procedure. Despite my hesitance, I did the second at the insistence of my friend that I be the primary surgeon. However, asking a senior to assist. But, he too, was unsuccessful.

8. So I climbed the hierachial ladder a step higher- a TCVS fellow was referred to. She was then scheduled for a Gortex graft AVF creation, which brought her to her third operation.

9. Insight (Physical, Psychosocial, Ethical) (Discovery, Stimulus, Reinforcements) In every physician-patent relationship, there is complete and sincere trust. Trust that the doctor has every good intention in mind for his patient. But we are also human, some failures must be expected.

10. Patients have complete trust in us doctors. But there are times that limitations must be placed- we cannot simply use the trust and proceed with every contemplated procedure.

11. We must look into our competencies and experience as a surgeon, and then decide whether the procedure could be done, or should help is required.

12. Experience is vital in surgery. Guidance from one’s superior is needed in the earlier phases. But as enough experience points are accumulated, the guiding hand can slowly be released, and a new skill is acquired.

13. Thank You