The late pediatric orthopaedic surgeon, Dr. Joseph Gerardi, said, "The difference between a complication and an expectation is the timing of the explanation." Many of my patients have demonstrated the importance of preoperative conversations in setting patient expectations, but two stand out for the divergence in outcomes with similar injuries.
Leo was a 13-year-old male in an electric bike crash accident resulting in a laceration of the anterior ankle with multiple fractures. Initially, the soft tissue injury appeared to be amenable to primary closure, but in the OR, a significant degloving injury was identified. We discussed with Leo and his Spanish-speaking parents the possible outcomes: skin grafting, transfer for a free flap, and amputation. I rounded on Leo every day with many long conversations about the possible outcomes. Leo underwent serial debridements, which initially looked amenable to a skin graft. However, after a week in the hospital, the soft tissue ultimately declared itself, necessitating transfer for a free flap.
I held Leo's hand while reviewing the turn of events, knowing we had done all we could to maximize his outcomes. Leo processed the recommendations with a maturity rarely seen in an adult patient. His parents were understandably scared, but they expressed understanding after our many conversations. Instead of discussing a free flap as a complication, we focused early on as this being a possible outcome. Leo's parents expressed gratitude for the days of repeat conversations reviewing risks and benefits, possible outcomes, and recommendations. Prior to transferring for plastic surgery reconstruction, Leo and his parents said how grateful they were for us being there for them, and for our direct conversations regarding expectations of his severe soft tissue injury. I left Leo with a note reminding him not to give up hope, how proud our team was of his bravery, and thanking him for helping me become a better orthopaedic surgeon. Instead of asking for a hug like he normally did, he reached out his arms, knowing I was there for him.
Leo's orthopaedic injuries closely resembled another patient I cared for, Mary, but their perceptions widely differed. Mary was a 36-year-old female in a car accident, which resulted in an obvious degloving of her ankle and foot. She also sustained multiple fractures of the foot and ankle. I was not present during her initial arrival or surgery, but when I took over her care, she had already undergone an initial debridement. She was initially upset at me when I discussed the possible outcomes with her, such as soft tissue reconstruction or an amputation.
"I was told my foot will be saved," she said between tears.
I took a breath, feeling the fear emanating from her. "We can do everything in our power to save your foot, but there are other options. Unfortunately, there are no guarantees. I will be here for you through this." I felt helpless knowing the ultimate outcome was outside of my control.
Mary underwent multiple debridements without significant improvement in her soft tissue injuries. After two weeks of daily discussions with her, she said, "Tell me honestly what my life will look like if I keep my leg." I pulled up a chair to review the options of continued limb salvage with its risks and benefits, including continued need for inpatient care and additional surgeries. I reintroduced the option of a below knee amputation.
She said, "I really thought my foot was going to be saved." After several more days, she said, "I want to move on with my life. I want an amputation." She asked if we could safely package her amputated leg so she could have it buried in a religious ceremony. I worked with the pathology and operating teams to ensure her leg was appropriately handled after removal to respect her wishes. After almost a month in the hospital, Mary underwent a below knee amputation.
When I rounded on Mary the next day, she said to her sister at the bedside, "This is my surgeon." I held back tears feeling the weight of our conversations, and seeing her relief knowing she was going home to bury her leg as she wished.
Our role as surgeons is often more about the conversations we have with our patients than the surgery itself. Mary and Leo had similar injuries, but their ability to process their injuries and make informed decisions were largely varied based on the initial conversations discussing expectations. Importantly, as Dr. Gerardi emphasized, setting expectations with humility is essential. Surgery always has the potential to make an injury worse. Patients remember when we pull up a chair and are honest of the uncertainties of their injuries. Sometimes our most powerful skill is listening without waiting for a chance to speak. My residency training has highlighted how reducing complications is often less about surgical skill and more about compassionate and honest patient communication while leaving our egos at the door.
Dr. Janae Rasmussen is an orthopaedic surgery resident at Valley Consortium for Medical Education in California. She currently leads OrthoLink Scholars, an organization designed to help medical students gain research experience in orthopaedic surgery. She is passionate about health literacy, health policy, and how we can better improve patient outcomes by caring for the whole person.
All names and identifying information have been modified to protect patient privacy.
Illustration by Jennifer Bogartz
