In orthopedics, there is an old saying that ”nothing ruins a good surgery like long-term follow-up.” As surgeons, we are continually trying to fix things. If we do our part correctly, then the patient should get better. That’s what our textbooks suggest.
After nearly 20 years of orthopedic practice, I will still never forget a case when I was a chief resident, just a few months from graduating and being on my own. It’s a case that taught me that doing everything right still might not be enough.
The patient was an unhealthy elderly female, suffering from many medical comorbidities, including oxygen- and steroid-dependent COPD. She sustained a ground-level fall resulting in a distal femur supracondylar fracture. Medically, the decision essentially came down to whether to surgically fix her femur to prevent her from possibly exsanguinating to death, or not doing surgery because of the health risks of her dying from such a large operation. As the chief resident on call that night, I remember calling my attending to discuss this clinical dilemma. “Jerry,” he said, “what does the patient want?” I told him that the patient would rather us do something than nothing. “In my mind,” I said, “that means we should proceed with surgery.” “Then I’ll come in and supervise,” he replied. “Let’s do it.”
We ended up doing the surgery under spinal anesthesia, which was much safer than putting her under general anesthesia. I remember pulling so hard on her leg to straighten out the fractured femur that I literally avulsed her skin, which had grown fragile and friable from decades of corticosteroids. Somehow, we managed to stabilize her femur with a retrograde supracondylar nail and to dress her skin with reston foam. She survived the surgery, and after a few days in the ICU, we transferred her to the floor for rehab.
Shortly thereafter, my attending was sent overseas to cover orthopedics at another military hospital, so I was fully in charge of the patient’s postoperative care. I checked her labs and listened to her lungs every day, adjusting her medications to keep her stable. I changed her dressings and monitored her therapy while her wounds healed. This carried on for a few weeks, and she managed to handle her non weight-bearing transfers without much shortness of breath. Her family members became familiar faces on afternoon rounds.
We nursed her back to health, and eventually it was one day before we were finally going to discharge her to home. “Let’s see how you do in therapy today,” I said, “and if all goes well, we can send you home tomorrow!” She nodded her assent, and I left her room to go see clinic that morning. A few hours later, I received a page from the floor nurse. “Mrs. A’ is not herself and having mental status changes.” I replied, “Okay. Can you call the internal medicine service that’s covering to check on her?” “Sir, she is having MENTAL STATUS CHANGES, and you need to get up here right now,” said the nurse. Those are not the words that any doctor likes to hear.
I dropped everything and climbed the stairwell up to the 12th floor. When I arrived to her room, she was breathing but not responding to questions. Because she was what we called a “blue bloater,” the nasal cannula oxygen that was applied just made her O2 sats drop even further and a full code was called. She was then intubated, and a subsequent CAT scan showed that she had a hemorrhagic stroke. She never woke up in the ICU after that.
If you’ve never been to a surgical Morbidity and Mortality Conference (M&M) as a surgical resident, it is the equivalent of being in front of a firing squad without a blindfold. All complications and deaths that occurred in your department are explained at this monthly conference. The physician who had the most involvement in the case does the presentation. It always seems like every “expert” in the audience that thinks they are smarter than you will pepper you with questions, condescendingly inquiring why you did this or that, asking with disdain what you were thinking when you made a particular decision. All of this is done with the implied intent of “teaching” you clinical lessons, no matter how painful the experience may be.
When my attending heard of the patient’s death, he wanted me to hold off on presenting at M&M until he returned from overseas, which would be another two months. So I studied every page of her medical record for nine weeks: every lab report, every nursing note, my op report, the progress notes, etc. I relived her hospitalization over and over trying to find out what went wrong. We did a risky surgery to fix her leg, and in the process we saved her life. So how did she end up dying three weeks later? How did I lose this one? I began to question whether I knew what I was doing in the field of medicine. I harbored thoughts of quitting.
Finally it was time for me to stand up in front of my orthopedic department in M&M conference. During my residency, we encountered very few deaths on the orthopedic service. (Most of the sickest patients were admitted to the internal medicine service, so they would have to present at their own M&M conference if a mutual patient died). Our patient died while she was on our service. Therefore, the failure was mine to present. I recited the case in painstaking detail, reliving her hospitalization once more. I could hardly maintain my composure, feeling the anguish of failure.
Somehow, I managed to answer all of the questions satisfactorily, and finally the ultimate question that ended every M&M case was asked: “Jerry,” my attending said, “what would you have done differently?”
“You know, sir,” I said. “I’ve been reviewing this case for two months, and I can’t identify anything that we could have done differently.”
His response was quick and to the point, “You’re right! So shut up. Sit down, and let’s move on.”
Suddenly, I felt this great weight of responsibility that I had been carrying for over nine weeks lifted off my shoulders. It was true. We had done all we could. I had done all I could. At that moment, I finally realized what it meant to practice medicine. I finally knew that I was cut out for this field. I knew, also, that I had been accepted by my orthopedic peers; they had not second-guessed any of my decisions. I realized that the success of my residency training was reflected in how I handled the failure of this case.
In orthopedics, we always say that a femur fracture in the elderly is just the “tip of the iceberg” in someone with failing health. The reason why they fell is probably going to determine their eventual prognosis. It took an inevitable death in a patient to show me that, no matter how good you are, you can’t fix everything.
Dr. Enad is an orthopedic surgeon in Port Saint Joe, FL and a 2016–17 Doximity Fellow.
