Cast & Curious

Tag: Orthopedics Practice

  • A Perspective on Non-Compliant Patients and the Contractual Doctor-Patient Relationship

    I have long been an advocate of a no refusal, admit all patients policy for physicians . Any physician is bound by his Hippocratic oath and the law to treat any patient (within the bounds of his skill and expertise) whatever the circumstances of that patient will be. The physician also has the social responsibility of reporting any patient (to proper authorities)  that  may pose danger to any other person or to the society for which the patient belongs.

    Lately however,  I’ve noticed a few non-compliant patients pushing limits of our patience and  resources. My case in point.

    A thirty something male patient brought to the ER (allegedly from another hospital) for a 2 day old gun shot wound. The GSW entry point is at the postero-medial portion of his right leg, with no exit wound noted. He has a comminuted fracture on the middle part his tibia. On examination, the bullet  slug is palpable on the  postero-lateral side of his knee. I noted a wide area of contused skin from the leg, extending to the lateral posterior of his right thigh. Patient is febrile and have an elevated BP. We immediately started IV antibiotics and  scheduled the patient for an emergency debridement and external fixation of the fracture.  Surgery went well and while the skin contusion did grew to a alarming size, the patient eventually recovered and was on his recovery 5 days  after surgery.  The patient ran away from the hospital without proper discharge procedure and without paying his bills. As we learned later, all patient’s data and circumstances were dubious and the patient is nowhere to be found.  My worst fear is the danger of this patient contracting osteomyletis if ever his fracture isn’t followed up carefully.

    If he ever goes back to any hospital, and if you are the physician, what would you do?

    The dilemma is much more difficult in government hospitals. In the Philippines, government hospitals are funded by people’s taxes. Funding that are at less than optimal and is finite. Government physicians sometimes sees patients, that for some reason,are rarely compliant. Most often these patient’s’ non compliance results to complications and prolonged treatment. Prolonged treatment siphons physician and hospital resources that could have been allocated to other patients. This is where the decision making abilities of a physician enters and is very crucial. It can actually make or break his career because litigation and malpractice suits isn’t easy to come by.

    My take on this? I’d still treat the patient according to what his medical problem requires and to what treatment the patients consents to. But I’m going to document it very carefully and protect myself with detailed consents and waivers. I will also get the opinions of  appropriate legal or social services department. Sometimes, its more with communicating with the patient and convincing them of their most beneficial treatment option. This is not easy. But aren’t we surgeons and doctors now if our job is easy?

    I may sound like crap but again, the simple fact remains the same. We are the physicians, the very persons privileged to touch and care for sick people. When we treat patients, we (and the hospital) enter a ‘contract” with that patient. Contract that to an extent, requires both the doctor and the patient to work for the wellness of the patient, for so long as that treatment is not detrimental to others. It all boils down to both parties being aware of their responsibilities in this contract. If one violates this contract, that ceases the existence of the contract and therefore, ceases the doctor- patient relationship.

    If you are a physician in this situation, what would you do? If, you are a patient, what do you think should the physician do?

  • Notes to the knife II: The opposite of humility

    Again? Yes. Again and against.  I will write about humility in knife wielders until this amazement transforms into a virtue. In the professions of demigods, any opportunity to get enlightened on humility doesn’t come by so easily .  So when it knocks, one should not wait for two or three knocks before opening the door.  The great student doesn’t need the winds to howl before opening his heart to learning. Humility, I should say, comes right into your face before you even knew it did. Like what happened to me recently. When I took the role of patient..

    My mortal lessons
    Notes to the Knife II

    It probably was just a viral infection but before the lab result got out and the diagnosis made, I took the role of the patient religiously and found time to interest myself with observing people around me. A physician admitted in room 204 is something a phenomena to everyone else. Including myself. Not the fondest role any physician would want, but certainly the most engaging. Of course, not until some real patients ask you about this ‘anomaly’.

    Being the patient, in the reversal of roles, is it really that easy for you? You know, relative to us, real patients, you (the actor patient) have almost everything you needed within your reach.(Unlike us patients, where we often cry for help on this and that..)- real patient X.

    Hell, NO.

    When this  knife wielding body go awry for one infinitesimal  reason, our chaotic hordes of Hippocratic knowledge put more distress on thyself than any other patient could ever think. Let me exaggerate. A hundredth decimal change in our body temperature would trigger a bazillion neuro impulses on our cerebrum that would then, extrapolate a gazillion more differential diagnosis that are rarely confirmed that is true. In short, we have more worries because we knew a bit more. Yes, my dear patient, sometimes, ignorance is bliss. Knowing something worse than just cold, flu or skin allergy as a differential diagnosis is no fun! It burns our distress horns more than you can imagine.

    Knife wielders are good actors. But we are not that good as a patient. We are the worst patient a doctor can get. Of course we really wanted to act like we’re patients when we are the patient. But it ain’t easy when you know for example, that a skin test is more painful than a deep laceration. I for one would rather sew myself up  than have someone stick a needle into my arm. There’s too much pain when you know whats coming right into your skin.

    IV bottle
    Opposite of humility

    Okay you try to act like the patient, but does your doctor treat you like your the patient?The nurses?The x-ray man?How many times did you peek at your own chart? In fact, most physicians of physician-turned-patients never mutter a single piece of conjecture to this patient until he or she is 101% sure about the diagnosis. The convoluted fear of the so many possibilities is staggering.   Easy patient huh?

    Last, and probably the most interesting phenomena I’ve noticed- when the knife wielder gets sick,  other people  would then say “he’s got it!he’s got it! We’ll get it too!’ This ‘when-doctors-get-sick, its going to be doomsday-on-us’ charade is very annoying. Exaggerated? Maybe. Got something related to the profession’s supposed infallibility. But then again, is it really that way?

    Where does humility stand in all of these?I’d say below your humility our dear patients. Doctor turned patients swallow a large chunk of their infallibility grid to be treated adequately. It takes humility to accept diagnosis a mile away from what you knew. It takes a hundred more strength just to keep shut your mouth instead of whining in pain  receiving a cut not from your own knife. It takes humility to be just a patient for even one second. It takes more humility than just humility.

    Bottom line is this. When doctors get sick, the implications creates waves more than what a regular patient will. Sort of a celebrity thing but more than that. The ripples are often beyond entertainment. Some even wreck havoc on some patients perception of their health. So maybe this is why some knife wielders need to be good actors and actresses whenever they exchange roles with their patients. Celebrity easy?!Obviously not.

  • The captain of your ship and a bosun too.

    The legal, ethical and aged (almost wise, but not quite) captain of the ship medical adage always stand true in any physician led health team. This autocracy is no more apparent anywhere else than that inside a surgical theater orchestrated by a feel god surgeon. I will not contest that Machiavellian theater governance (will write another post for that) but focus instead one ghastly annoyance that hound surgeons both inside and outside the OR once in a while. This:

    You are always the captain of your ship but oftentimes, you need to be a bosun too!

    I’m not sure if this is unique to any not so lovely practice environment but often something has to be done (short of putting a gun inside your mouth)  un-captainly in order to stop a captain’s sinking vessel.

    Take this one anecdote shared by another surgeon in one far flung province here.

    It was ten PM then when I receive a hospital call informing me of a VA victim who sustained open injuries to his right lower extremity. Already sleepy and tired from a surgery an hour earlier, I reluctantly hurled my ass to the ER and evaluate the patient around 10minutes after. While our hospital have 24 hour, “resident” staff physicians to attend to these emergencies, I rarely see one who makes an approximate diagnosis and institute an measures expected of a trained physician. So I need to go to the ER as soon as possible, if I need a better assessment of the patients status and institute immediate treatment myself less I get sued for malpractice for someone else’s missed steps.

    Anyhow, I came in 10 minutes late and was horrified  that I neither have an x-ray of the patients injured extremity (he has skull, chest and abdominal x-rays that are all significantly insignificant somehow) nor a splint stabilizing his grossly deformed extremity. I asked the nurses (couldn’t find the resident inside the ER) why this procedures wasn’t done earlier (or even prior to calling me up) and they unanimously said none has been ordered at the time patient was brought to the x-ray room. The gaping wound plus the bleeding “fracture” is repulsive prompting them not to do anything but plug the wound with tens of OS and tens more of leukoplast. In the meantime, the patient is wriggling in excruciating pain (an NSAID was already given IM earlier though) as they waited for me to appear in the ER’s doorstep. Not interested in witch hunting at the moment  and keeping my composure “respectable”, I asked for sterile gloves so I can examine the wound, pack the bleeding properly  and then put some form of splint before bringing the patient to the OR. One nurse went scurrying for something immediately, which made me sigh in hope. But this was short lived as I soon discovered, he just actually made a prescription for sterile gloves! I said, “you gotta be kidding me! If this is not for my patient, I (and the patient possibly) could have walked away in sheer disgust over the incredulous situation I am with! But we have no choice but to make sanity out of this proverbial serendipity (composure some more). I took some moment to breathe. I went to the CR and peed while waiting for God to bring in sanity to this ominous chaos.And the sterile gloves.

    On my way back to the ER I grabbed one pair of clean gloves and abdominal pack  from the sterilizing room, snatched a wooden handle from broom stick lying around, grabbed a newspaper and went back to the ER to do what I’m supposed to do. Then I waited for two more hours just so the patient can be cleared for OR. And I was ten minutes late?!!!

    In the OR theater, the same operational amnesia goes on unabated. No available sutures, inadequate or barely working instruments, robotic assists with pillar like extremity dexterity and blurry dioptic visions. I get lots of stymied fans standing all around me doing everything except being helpful to the ongoing surgical orchestra. I cannot describe how I moved assess and turned OR cabinets to look for this and that but we managed to produced the needed stuff anyway.I bring a back up OR stash anyway for frequent detours like this. It was however, brutally exhausting and tension filled voices and breathing almost always kill the fun inside the OR. Luckily, the patient survived the procedure well and went back to his normal (drunk driving) life again despite the chaotic serendipity. Now, I know some hospitals are ill equipped and manpower deficient most of the time, but occasional like these are totally unacceptable if we want better service for our patients!

    The poor surgeon obviously was holding himself in one piece and acted magnificently composed despite his horrific ER/OR encounter. For some, this incident is rather minor and might not constitute an annoying occurrence. Me however, in my zaniest complaining attitude, will whine in sheer frustration. Not this surgeon I guess. He simply went on doing some “extraordinary” stuff to fill in gaps in the proper delivery of health care service. We are abused in our training to do more than being just the surgeon. Who couldn’t forget having to buy sutures for your patients or pleading another patient’s extra OR needs during residency? Un-surgeon-ly? In our day to day encounters as a medical and surgical professional, we might find ourselves in similar situations and do one un-captain-ly act  for patient to recover uneventfully. You might  need to be as a resourceful and quick thinking para medic just so you’ll salvaged a patient. Or your career…

  • Ironic absurdities for Bonedoc: A Mini-Series of some sorts…

    Last night when I was reading Bongi‘s blog (Other Things Amanzi), I came across his brutally hilarious (but freakishly realistic) post on (his sort of) “surgical principles”. Bongi is a general surgeon based in South Africa and though I see striking similarities between our “surgical worlds”, I found the guy’s witty and humorous ways of narrating his surgically bugged life, intriguingly interesting. Anyhow I’m particularly inspired (nah, copycat) by his post on how he came up with “his principles”. Not that I subscribe to all of  these but most went straight out of his operating theater making it egoistically fascinating for us surgeons and surgeons neck peckers. The one thing that strike me most was this “flat” referral to his bloody (or organically graphic) reality and how he finds way to “enjoy” it ( at least once ) to the point of gas-tronomic absurdity.

    So I thought, why not write about disarming eccentricities of provincial orthopedics too? I surely can make up a few wigwams out of my usually unusual orthopedic (mis)encounters. Obviously, these are anecdotal too and are tested only by me. Some may even be unique to the proverbial orthopedics to which I am helplessly thrown into. So Bongi, don’t care about my being a copycat. I call mine ‘ironic absurdities’ (instead of your principles) for Bonedoc anyway.

    1. You are (not only) the captain of your ship.
    2. Slowing down makes (near) perfect. Haste makes waste.
    3. Schedule surgeries on your vacations (and not on patient’s ‘ workdays).
    4. Flirt, to make surgeries less boring.
    5. It is always the some other surgeon’s fault. I mean, your “other” surgeon.
    6. Exercise outside OR.
    7. Have lots of fun, even when your obviously exploding in rage.

    Somehow those are the more common situational ironies I can think of for now. Others, I will add (or subtract, depending on my gut feeling) up as soon as they hit me hard with a hammer. Some I actually relish now. I will link each of these absurdities to their individual post as soon as I figured it out of my mind and into my computer’s main memory. Hopefully,I will not kill my practice and blogging career with this ghastly concoction of experiential ironies .

  • Superspecialists or super generalist orthopods?

    This question was thrown to us by one former orthopedic mentor during our lively deli-beer-ations post surgery. The discussion came about as we were thanking them for extending time and effort to do an instructional course on their field of specialty. I added that these orthopedic courses should bring up the level of our general orthopedics training and entice some residents to go on a sub specialty training. I added that this is one of the training  thrust of our department  Commending our training program, he then posted these question to us:

    1. Does your locality need  super specialist orthopedic surgeons? Do we have sufficient orthopedics cases to sustain this super specialist field?
    2. How many (percentages)of these sub specialty cases are done by generalist orthopods themselves?
    3. Having trained in a general orthopedics program, can do these cases even without sub specialty training?

    The question went further into this. “Do you need a super generalist (should mean a generalist with a higher level of skills and expertise on all areas of orthopedics) or a super specialist (capable of doing rare cases but couldn’t do other general orthopedic surgeries) orthopedic surgeons?

    The super generalist is commonly a product of an institution with a multi specialty orthopedics in place. The various sub specialty rotation gave these residents an “edge” receiving a “higher” level of training in all orthopedic sub specialties. Some institutions only have a few of these sub specialty training and thus a general orthopedic can only gain more skills by training elsewhere where a specific sub specialty training is available.

    For sure, we wanted our program to produce better orthopedic surgeons, a super generalist in a sense. A generalist with a higher and broad level of skills not just in one orthopedic sub specialty but in all other as well.To do that, we need to complement our teaching staff with orthopedic sub specialist, a kind of irony but necessary step towards achieving this goal.