by James D. Hundley, MD
As a retired orthopaedic surgeon, I miss the hallway consultations where colleagues discuss cases while trying to determine the best course for our patients. Fortunately I am still consulted from time to time and get to enjoy sharing ideas and opinions.
A few weeks ago I was called by a young surgeon who was perplexed by what would be best for his patient, an elderly, emaciated, osteoporotic woman with end-stage Parkinson’s Disease. She had suffered a displaced, four-part fracture of her proximal humerus from a fall. He had been taught that these need open reduction and internal fixation (ORIF) if the patient is to regain good function and felt obligated to offer that as a choice. When so offered, she had stated that she did not want surgery but would think about it. When he called me, he was dreading that she would call him in the next day or two saying she wished to proceed with ORIF. How should he respond?
For me the answer was easy. Treat her with a sling and swathe until the acute pain had subsided and then begin gentle range of motion exercises. Sure, she would never regain function anywhere near normal but she could still use her elbow and hand to eat and for other similar activities. Even better, she could bypass the possibility of anesthetic complications and surgical ones such as infection, blood loss, loss of fixation, nerve injury, and so on.
Being the one “in the trenches”, however, and having been taught that the proper treatment was operative, the decision-making for him was more stressful. He felt that the right thing to do was non-surgical, but feared that that would not be acceptable morally and could put him at risk for a lawsuit. That’s when I reassured him by saying, “It’s OK to do the right thing.”
I’ve always felt that decision-making is the most difficult part of orthopaedic surgery. Sure, you must have a significant degree of core knowledge to understand the disorder and have an array of treatments at your disposal. Probably the biggest decision is whether or not to operate and when if ever to do it. If you don’t do surgery, how else would you best treat the patient? If you do surgery, what is the best procedure? If you run into surprises during surgery, what do you do then? In every instance, the best decision is what is best for that particular patient at that particular time. Sometimes, “doing the right thing” requires you to swim against the tide of current opinion and/or what you learned during your training years. Over time, however, with personal experience and through seeing a variety of perfectly acceptable ways that our colleagues manage similar problems, we can and must learn to trust our judgment as to what is best for our patients. Thus, no matter which way the fads are pointing at the time, when you include the patient’s wishes and do the right thing, it is always OK. In fact, it’s more than OK. It’s what should be done.
Epilogue: In case you’re wondering, the patient remained steadfast and decided to not have surgery. Had she requested it, I don’t know what he would have done, but I’ll bet he would have declined to do it. Thus, although the whole conversation was moot it was interesting and will hopefully help him the next time he is conflicted by what he thinks he should do vs. what he thinks others would have him do.
Dr. Hundley is a retired orthopaedic surgeon with forty years of experience. He is also a founder and the president of OrthopaedicLIST.com, a free and open-access directory of orthopaedic products and services that was established in 2003 and currently lists over 10,000 products and services for orthopaedic surgeons and related professionals.