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There is one thing admirable with state ran health training institution- the constant struggle to an ideal, efficient, low cost, health care program. Residents in training are constantly hammered to provide the best health care at the least  possible cost both for the patient and the institution. This is typically a result of maximizing an undermanned and under budgeted, capacity filled government hospital. On the plus side, innovative care do evolve from these type of health training institutions. On the downside, devastating results sometimes happen because of shortcuts (treatment protocols outside of the accepted standards of care) that we were push to vis a vis the dwindling financial support and logistical problems.

One of the more common dilemma we face is the timing of surgery. It is one of the more commonly debated factor that ultimately affects health care provision and utilization. An early surgery will simply equate to a lesser hospital cost for both the patient and the health care provider. The lesser time to surgery from admission, will result to a lesser hospital stay which in turn, lessens logistical utilization and expenses for both the patients and hospital. This should be the ideal situation.

The problem lies with the accuracy of studies and the mix of factors needed to predict the “best” timing for surgery. Knowing the right mix of factors needed to achieve favorable results is quite uncertain. Timing of surgery studies are usually done on relatively ideal, controlled (developed world) health care facilities. Hospital setting and patient profiles rarely fit the situation where a third world surgeon is facing. Of course there is room for extrapolation or innovative standards of care. But that makes the predictability of results (of surgery) quite uncertain!

Take this for example.

A VA patient came in the ER 12 hours post injury with an open type II fracture of the medial malleolus and close lateral malleolar fracture . He was brought in from a far flung community with no previous medical or surgical intervention. His vital signs were stable and no other life threatening injuries were noted upon admission. After I saw the patient and his xrays, I talked to him, about the advantages and disadvantages of the different treatment options and surgical intervention for his type of injury. The options are basically between an emergency debridement plus open reduction internal fixation (ORIF) or just a debridement (repeated if necessary)  and delayed ORIF after possible infection is ruled out. Spending about an hour of explaining the risks and advantages to the patient, I got an answer like this one- “which do you think is the best doc?’.

With all honesty, I mustered to say that personally, I would prefer the delayed ORIF since all the patient and injury factors (plus the delay in treatment) points to a greater risk of infection secondary to a skin breakdown. Surprisingly, he wasn’t convinced somehow, even after that lengthy explanation. He told me he understood the risks I’m explaining  but he really wanted to get out of the hospital ASAP for financial reasons. I don’t know if that was his real reason since he’s kind of without problems procuring his medications and stuff needed for surgery. The patient which seemed to be hurrying up, wanting an immediate fixation so he can go out of the hospital after the first OR. I couldn’t convince the patient and couldn’t get a consent either for a debridement only and delayed ORIF. He then asked to be transferred to another hospital somewhere else for treatement. I got no choice but to give a referral letter. I thought that was the last time I heard of that patient.

Two months later, this patient showed up in my clinic, in crutches, with a draining sinus just below his medial malleolus. “Good afternoon doc” His previously fractured left ankle is warm and swollen. He couldn’t walk on it because of pain. His ankle is with peri-implant infection, an osteomyelitis, and probably septic ankle joint. He told me that the next day after I saw him in the ER before, he transferred to another hospital, insisted for that immediate ORIF and went home 2 days after his surgery. He never followed up with his surgeon. Still aghast at the turn of events for this patient, I was visibly distraught at the wasted extremity that needed more costly surgery now. I told the patient to go back to his surgeon and ask for advice and treatment. I sincerely told him I cannot treat him unless his other surgeon is away or will endorse him to me. The guy was devastated and was teary eyed when he left. That was the last time I saw that patient.

Looking back, I empathized with that patient. I know he was trying to save up on cost. But in the long run, it cost him his ankle joint. That for me is a the worse you can get for a shortcut that seem so easy. I’m not saying this is what will happen in ALL of such cases. I have a few of my cases too, that I got away (meaning procedure went out well and patient was satisfied with the treatment) with such “shortcuts” (call it innovation for lack of term) because of logistics and patient’s financial concerns. My point is this: That the predictability of results for an ideal  timing of surgery is quite uncertain. The right mix of factors is often very elusive and are sometimes, based on patients or surgeon biases. They are too difficult to qualify in an academic sense.

In the third world, undermanned and under buffeted  health care facility we’re practicing , chances are, we too are fraught with such dilemma. So, how do you handle such cases in your practice?