What Surgeons Were Thinking

March 8th, 2009 by Harrumpher Leave a reply »

Self-absorption in post-trauma periods seems to be pretty human. I found myself with another spasm of it yesterday when my wife presented the medical report that had come from Brigham and Women’s following my arrival by ambulance and then leg surgery.

Not one to waste the medical proxy I had signed before anesthesia and internal carpentry, she had ordered the records. We got our $6.07 worth, copying and postage. In addition to my vital signs at various times and what drugs they pumped in me in the ER when jamming the bones into rough alignment was the Operative Report.

That section is a two-page recap of what they did and why. I think I’d be just as fascinated if it described someone else’s operation. I immediately began musing on what else we might like to see such details on. Consider:

  • Your flight into Logan airport makes a sudden 180 degree turn, returns low over the water and seems ready to touch down on the tarmac when it accelerates, rises again and comes back for the real landing. The pilot may mumble a “sorry, folks” quasi-apology, or not. Wouldn’t it be great to get an email saying what caused the abrupt and maybe crash-preventing maneuver?
  • You’re happily overpaying for an occasion meal. While chefs are famous for predictable reworks of their dishes, this evening’s special entrées are great in the mouth and to the eye, and unusual enough that you ask the waiter its ingredients. Wouldn’t it be better to get a little report from the chef on what she was thinking in developing the dish?

The operative report had little worthless verbiage. The exception was the long INDICATION FOR PROCEDURE paragraph. It contained the overblown CYA wording, certainly mandated by some hospital bureaucrat. They warned me of death, bleeding, scarring, re-fracture, pulmonary embolism, stroke and more. Yet, amazingly, that pathetic agonizing and broken man said to go ahead, to cut, drill and pound metal into bone.

The glory of the document is the description of the procedure. It has both the physical facts and the surgeons’ thinking and deeds.

tibia nailFor the mundane and physical, I found that my titanium rod (nail in surgeon lingo) was a proprietary product of Synthes Global. It was 360mm (a little over 14 inches) long,  which is mid range; they make these for tall and short sorts. The color image is from the company site and shows how it comes with pre-machined places for the screws (pins to surgeons).

(Pix trick: Click an image for a larger view.)

When I recently went to a follow-up with surgeons (not the ones who repaired my leg), one of my questions was about red-cell production. Before the operation, the lead surgeon glibly said the tibia was hollow and they would just push the nail in to hold me together. In reality, it contains cell-manufacturing marrow that they need to drill and ream out. According to the follow-up folk that means an insignificant decrease in blood making. The tibia is not a major player in the process.

The more interesting parts of the procedure description were what they did when I was insensate and how they decided to treat or not treat the shattered fibula.  For the first, the description made me think immediately of college students who paint their chums’ bodies and faces or pose them for absurd photographs when they are passed out drunk.

In my case, they did what was necessary for the tibia, including screws top and bottom to hold the rod and bone parts in place. Then:

At this time, we assessed rotation of the fracture. We assessed rotation by matching APs (anteroposterior, front and rear)  of both knees and then matching the AP of the affected limb to the AP at the contralateral limb. With this rotation, we locked in the distal screws. This was done with perfect circles. Next, we assessed the stability of the distal femur (sic and should read “tibia”) fracture. We stretched the ankle in multiple directions, none of which showed signs of instability at the ankle or medial joint space lining. As a result, we did not like to fix the distal fibular fracture.

That contains two punchlines. One is the manipulation of the unconscious guy. The other is the laissez-faire non-repair.

To the first, even though I’m that guy, it is amusing to think of my puppet-like treatment. While in the hospital, a kindly nurse had sympathized the day after the surgery when the residents, the big shot and the surgeon who led the operation visited to examine their work. She said she expected to hear me scream, that such was the norm for that first visit.

Sure enough, one of the residents roughly grabbed the leg from underneath where the tibia break was. A geyser of pain passed through me, taking my breath and flooding my eyes. Rather than scream, I yelled at him to show some thought and sensitivity. From that point, several surgeons in turn lifted the foot and ankle by holding my big toe. In retospect, that image is amusing.

Afterward, the nurse said that the orthopedic guys were famous for rough treatment. They did their work as the report states, when the patient is not aware and cannot scream or flinch. They seem to choose to ignore the difference physical awareness brings. That’s a reasonable shield considering the nature of their work.fibula shards

From the operating surgeons’ description, I envisioned my fibula end as a short stack of pebbles. They said that the muscles and tube of fascia around the bone would more or less hold it together.

In x-ray reality though, I see that the bottom of the bone is shattered and splintered. Yet, I can see what they were thinking when they had my leg cut open. The shards are close enough together that if moving in the next month or two does not displace anything, my body has a fair chance of putting enough ossifying mortar stuff there to create a bone where there’s bits and fragments.

“As a result, we did not like to fix the distal fibular fracture,” wrote the doctor. It was a judgment call and sensible enough. The alternative of a metal plate with wee pins to hold things together would be looking for trouble. There’s not much bone for purchase there and doing that would mean a later operation to remove the props.

Back to the report, being the guy in question, I am a bit squeamish reading the in-OR manipulation of my parts. It gives me an out-of-body experience to mentally see my anesthetized self being put through torture-like movements. Yet, overall this is a riveting (pardon the pun) exposition and explanation.

Would that we had more what-we-were-thinking docs about our lives.

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3 Responses

  1. Uncle says:

    Welcome to my world. Such literary masterpieces are my daily reading, and that of the B&W coders who had to translate all that into data so that the billers could stick your insurance carrier. One of said coders, if they’re any good, has been on that surgeon like a rash for using femur instead of tibia: dumbass mistake, that.

    Yup, that’s one comminuted fracture there, all right. Treat it nicely and don’t hurry.

  2. Harrumpher says:

    Hmm, it’s good they end up checking and double checking most things. While I was on the gurney headed to the operating room, the doctors going over the 20 pages of forms noticed such wee details as they had put the wrong birthday on my wrist as well as every page of the docs. That would have messed up insurance as well as other records.

    Less amusing was that the top sheet told the surgeon to cut the right leg. That limb, as far as we knew, needed no medical attention. The doctor whipped out a pen and corrected page after page. The lead surgeon also trotted by and signed the correct leg…just in case.

  3. Uncle says:

    I’m all for every possible precaution and I want to buy stock in Sharpies, which have become the implement of choice for marking up the patient. Two weeks after my procedure I was still finding Sharpie marks in odd places and scrubbing them off.Documentation is good.

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