My daughter Emily and I were skiing in Vail this weekend. She has skied a few times since her accident, but she hadn't attempted the "bump" runs. Prior to her accident, she was an expert on these challenging trails. The conditions were good and she did it! The tears were coming to my eyes. It has been nearly seven years since she was a victim of multiple trauma. The wonders of modern trauma care along with expert physicians saved Emily's life and miraculously restored her to essentially normal function.
May 9, 2001 … the day that irreversibly changed the life of my daughter—the day that irreversibly changed the life of my family. My wife and I were sitting in Yankee Stadium with our best friends on a balmy late spring evening, enjoying Roger Clemens' pitch. A mother's sixth sense detected trouble. "I think I'll call home to make sure everything is okay." My wife dialed home on her cell phone, and as she was dialing my pager signaled 911. Emily, our oldest daughter, had been in an accident. The accident occurred on the last day of her sophomore year in a university a thousand miles from home. She had been transported to the emergency department of the university hospital. I called the emergency department and spoke with the orthopaedic resident. He described the initial assessment: bilateral pubic ramus fractures, a fracture-dislocation of the sacroiliac joint, a displaced acetabular fracture with a dislocation of the hip, and an extensive wound on her thigh, which most probably communicated with the pelvic fractures. "Was there a head injury?" I asked. "No, Emily is awake and talking!"
We all left the stadium and headed for LaGuardia Airport. Our friend drove, and my wife and I started making phone calls. Were there any flights available? Did we have to charter a private plane? Luckily, we arrived at LaGuardia Airport just in time to catch the last flight to Chicago. After my wife left the car, I turned to my friend and told him that Emily's injuries were associated with a 50% mortality rate.
Unfortunately, our flight to Chicago was scheduled to arrive after the departure of the last connecting flight. Our flight attendants, at my wife's panicked urgings, advised the pilot of our emergency. The pilot contacted the air traffic controllers and received a priority clearance to land. We arrived just in time and were met at the gate and escorted to our connecting flight. Luckily, our plane came with telephones built into the backs of the seats. A swipe of our credit card and both my wife and I were occupied making telephone calls. I spoke with the orthopaedic resident; an operating room was available for Emily. He gave Emily the telephone. "Hi, Honey. Mommy and I are on our way. Everything is going to be okay. You'll be in the operating room when we arrive; we'll see you when you are out of the operating room. I love you." "I love you, Daddy."
My next call was to a well-known orthopaedic traumatologist. He was someone whom I knew from local meetings and conferences, surely not a close personal friend. Despite our limited professional relationship, he immediately took charge. He knew the traumatologist who would be caring for Emily. He called the emergency department, spoke with Emily's physicians, reviewed all of the imaging studies, and discussed the initial management and surgical plan. While my wife suspected that we were withholding some information from her (we were), this surgeon gave her a modicum of comfort that everything was "under control." His involvement was invaluable to me; he knew Emily's doctors, he trusted her doctors, and he was going to be involved in the planning of her care. Most reassuringly, I was not going to be lost in a city far away from home with doctors I did not know.
When we arrived in the family waiting room adjacent to the surgical intensive care unit, we were met by a large contingent of Emily's friends. They were sitting and pacing, nervously waiting to hear how Emily was doing. It was then that we learned what had actually happened. Emily had been roller-blading in the city park on the designated walking, biking, and roller-blading path. She was going down a hill on the designated path at a location where the path crossed an intersecting road. She slipped on sand, went underneath a city bus, and was run over by the rear wheels.
Emily spent the next six weeks in a hospital a thousand miles from home. She received more than sixty units of blood and blood products. She remained on a ventilator for ten days. She went to the operating room fourteen times for emergency pelvic external fixation, an exploratory laparotomy and colostomy, definitive management of the pelvic and acetabular fractures, a second emergency laparotomy for lysis of adhesions that had created an acute intestinal obstruction, and treatment of her open wounds, massive degloving injuries, and associated soft-tissue loss. She underwent angiographic embolization the morning after the accident when her hematocrit was 12% (Table I).
Emily was subsequently transferred by air ambulance to a hospital in New York that had both acute care and rehabilitative services. She spent five and a half weeks in this institution and underwent multiple soft-tissue procedures, split-thickness skin-grafting, reversal of the colostomy, removal of the external fixator, and management of her evolving pain symptoms secondary to a lumbosacral plexus injury. Between operative procedures, she began rehabilitation training to walk without bearing weight on the extremity with the ipsilateral acetabular and sacral fractures. When she was able to walk with crutches, she came home. She continued with outpatient physical therapy but soon realized that she had to do more and began exercising on her own. Two years after her accident, she underwent open reduction and internal fixation of a painful sacral nonunion. She has subsequently undergone multiple plastic surgical procedures in an attempt to improve residual scars and soft-tissue asymmetry.
During Emily's entire hospitalization, including her time in the surgical intensive care unit, either my wife or I was at her bedside essentially twenty-four hours a day, seven days a week.
Why are we telling this story? Emily has recovered fabulously well and is now in medical school. Our family has recovered. Emily is hopeful that her experience will be a motivation to other individuals facing the arduous recovery from multiple trauma. She has been a spokesperson for the New York Blood Center, and her story has been featured in the New York Blood Center Lifesaver News and promotional video1. She has met some of my trauma patients and their families and given these individuals encouragement and hope for a successful recovery from the devastation of multiple trauma.
While this narrative is written from the father's perspective, both Emily and I believe that there are many important messages to convey and we have two major goals. First, we would like to stimulate a discussion of the human side of trauma. During my twenty-two-year professional career, dramatic improvements have been made in the care of multiply injured patients. In the not too distant past, we would have been gratified if Emily was able to walk; skiing would have been out of the question. We have a better understanding of the physiology of trauma and methods to prevent complications. Orthopaedically, we have made tremendous strides in implant technology, surgical approaches, and soft-tissue management. Basic-science and clinical research have identified treatments to substantially decrease the acute complications of multiple trauma. Clearly, this focus provided invaluable breakthroughs in trauma care. Patients are not only surviving, but they are also regaining remarkable levels of function.
The trauma literature has also begun to examine the psychosocial aspects of trauma. Numerous individual and social characteristics that may affect our patient outcomes despite expert trauma care have been identified. We need to continue to study and explore these nonmedical issues to help our patients to recover. We attempt to communicate well with our patients and to be empathetic, compassionate, and humane. Despite our efforts, I believe that there is definite room for improvement. I am confident in stating that, as we improve our understanding of the psychosocial aspects of recovery from trauma and incorporate this knowledge in the care of our patients, we will see even more gratifying results in our patients' recovery. I am also confident in stating that, as we improve our communication skills and become more actively involved in the so-called nonmedical aspects of our patients' recovery, we will see our patients not only recover but also return to productive lives.
I have been as guilty as others in focusing on the surgical challenge. We forget that our patients and their families have a multitude of fears and anxieties. We forget that our patient has an independent life, a family, a job, and hobbies. We see our patients in follow-up, have radiographs made, and discuss the recovery of the injured extremity. At times, we fail to discuss the patient's psychological recovery, level of pain, family concerns, or the timing of returning to work or job training. In short, we forget about, or even avoid, discussing the human side of the injury.
Multiple trauma affects an individual, but the repercussions of the trauma may dramatically affect the patient's family and friends. It creates psychological stresses, interpersonal stresses, and financial stresses for everyone. Most of our patients recover physically and are able to return to productive lives. Unfortunately, some patients and their family members develop permanent psychological scars, which limit their ability to fully recover. No one ever forgets, and everyone's lives have been permanently altered to different degrees.
As a second goal, we believe that lessons can be learned through my observations as an orthopaedic traumatologist during my daughter's three-month hospitalization. My firsthand experience during Emily's hospitalization, as well as her subsequent care, has been enhanced by my prior interest in medical ethics and doctor-patient communication, and these topics continue to be a major focus in my professional career.
Emily was hospitalized for nearly three months. She was cared for by a large number of attending physicians and residents. I believe that a few of these interactions between the physicians and their patient could have been improved. We hope that reporting our experience will assist the practicing orthopaedic surgeon in identifying simple methods that may help to improve their patients' recovery. Our experiences highlight the delicate ethical balance between resident education and patient care. Many of the experiences we describe are frequently reported in the lay press and medical literature. Medical errors, medication errors, poor communication between treating practitioners, and inadequate communication with the patient and the family have all resulted in compromised outcomes, increased health-care expenses, and unnecessary ill feelings. The failure of physicians to effectively communicate with their patients has been shown to be a common cause of malpractice litigation2-5.
We have composed many versions of our experience in an attempt to create a framework to explain our personal recommendations. The suggestions we present are based on Emily's individual experience, the family's experience with Emily's care and recovery, and my personal experience as an orthopaedic trauma surgeon. We have referenced numerous sources of contemporary medical literature that support these recommendations.
Initial Encounter with the Family
In a split second, the life of both the injured individual and his or her family has been turned upside down. People need an initial explanation of what has happened and what is being done. Depending on the severity of the injuries, there literally may be no time to discuss them before the patient goes to the operating room. An unconscious patient requiring a life or limb-saving procedure may be brought to the operating room without an informed consent. If the patient has decision-making capacity, the physician is obligated to obtain informed consent6-11. The acuity of the situation may limit the breadth of the initial explanation and discussion, but, whenever possible, one should make an attempt to briefly summarize the problem and make recommendations for emergency management. Clearly, the presence of severe pain may affect an individual's ability to fully understand the injuries and the proposed management. Nevertheless, neither the presence of pain nor the administration of pain medication obviates the need to obtain informed consent, and prior studies have shown that an appropriate dose of narcotic pain medication is not likely to alter the decision-making capacity of the patient12,13.
Ideally, the hospital will have a consultation room equipped with computer monitors and light boxes. Standing in the hallway and holding radiographs up to the ceiling lights just doesn't work. If no consultation room is available, a quiet, private corner should be found. Everyone involved, including the attending physicians, needs to sit down. Studies have shown that patients usually perceive their doctor as more compassionate when he or she sits down14. In addition, the patient's perceived time of the encounter is greater when the physician is sitting15. The surgeon should introduce himself or herself and the trauma team and should explain the workings of a coordinated team approach to trauma care. The attending physician should lead the discussion. In an academic center, the residents on the trauma team should attend the meeting. This will introduce the patient and the family to the "team" and also serve as a learning experience for the residents. This experience for the residents is frequently called the unspoken, or hidden, curriculum when students learn by modeling their mentor's behavior16-19. Sitting down with the patient and the family allows the attending surgeon to immediately demonstrate care, concern, and compassion for the patient and the patient's family. It introduces the residents to different styles of communication between doctors and their patients and the patients' families. It also allows the students and residents to witness one of the most rewarding aspects of being a physician: the doctor-patient relationship.
One should always remember that no matter what the educational background of the family, they are hearing a whole new vocabulary and being told extremely frightening information, and their fear and anxiety are preventing them from hearing almost everything that is being said. For this reason, it may be necessary to repeat the information both at the time of the initial meeting and on subsequent visits. Most importantly, physicians and their families should not be treated any differently and we should never assume that they know or understand what is going on.
Respecting patient autonomy mandates that a patient be actively involved in his or her health care and the decision-making process. To achieve this goal, a patient needs to have a full understanding of his or her injuries and the treatment options. Clearly, different individuals seek different levels of understanding, and achieving this goal is not easy and frequently requires one to perform a challenging balancing act. Initially, I believe it is appropriate to be brief, positive, and realistic. For example, it is not necessary in the first encounter to advise a patient with a fracture-dislocation of the hip that osteonecrosis and traumatic arthritis may develop. During the subsequent hospitalization and following surgical interventions, the discussions should become more comprehensive and detailed, focusing on the long-term implications and potential complications. During these discussions, patients will usually let their physician know, through their questioning, how much information and detail they desire. Family members should be involved in the discussions at the discretion of the patient.
The Acute Phase
Every day, indeed every minute, presents new surprises, new problems, and different challenges. The morning after Emily's accident (a few hours after she arrived in the intensive care unit from the initial emergency surgery), a junior resident came into her room and advised us that her hematocrit was 12% and they were going to take her for an angiogram. No additional explanation was given. Emily was on a ventilator, in a drug-induced coma, and no explanation could be given to her, but surely a brief explanation was necessary for my wife and me. Clearly, the urgency of the situation did not allow for a comprehensive discussion. Despite the urgency of such situations, one must keep in mind the difference between the perspectives of the medical personnel and those of the family. For the traumatologist and hospital staff, Emily was a patient with a pelvic fracture who had excessive and uncontrolled bleeding develop. For the family, this was a problem that could result in the death of their daughter. Even if the resident assumed that I, as an orthopaedic traumatologist, understood the problem and the necessity for the angiogram, a very quick and brief explanation to me and my wife should have been undertaken. In such a situation, assuring the family that the doctor who was going to care for their child is "top notch" can be very comforting. If the junior resident was not able to explain the plan, a more experienced member of the trauma team should have been available to discuss it.
The integrated care of the trauma patient provides each patient with an expert to manage each of his or her problems. During Emily's hospitalization, the surgical intensivists, general surgical trauma service, orthopaedic service, interventional radiologists, and plastic surgical service cared for her, with consultations by a number of other surgical and medical specialists. Unfortunately, in such a complex organization there may be no identifiable "captain of the ship" to act as a spokesperson. This often leaves a void in communication at a time when the patient (if conscious) and the family are most fearful and most in need of a timely understanding of what is happening. Despite my familiarity with academic medical centers and the care of the trauma patient, things even became confusing to me at times. On occasion, consultants would give conflicting information and recommendations, leaving my wife and me unsure of the way to proceed. We have all performed consultations in inpatient settings and been told that our advice was different from another doctor's. When this occurs, I always promise the patient and family that I will discuss the management with their treating physician to establish a unified plan. This simple promise can often relieve a large amount of anxiety. I believe that these same efforts can be made in an acute trauma setting.
Every institution caring for the trauma patient has its own unique style and protocols. Academic centers rely heavily on residents, and many institutions now rely on full-time intensivists and hospitalists to provide much of the care. Attending physicians need to find time in their personal schedules to sit down with the patient and the patient's family. This responsibility should not be left to the residents or fellows. The attending physician will most likely be the one individual who is seen regularly in follow-up, and it is important that a strong doctor-patient relationship be developed during the initial hospitalization. I try to schedule a specific meeting time in the patient's room when the family can be present to discuss the current situation and future plans, to listen to their concerns, and, as best as possible, to allay any fears expressed by the patient and the family. In doing so, I frequently become the one physician whom the patient and family immediately recognize, feel comfortable with, and seek out for encouragement, guidance, and support. The early development of this relationship will ultimately be invaluable as the patient's recovery progresses. Numerous published studies have demonstrated an improved health outcome when there is appropriate doctor-patient communication20,21.
Emily's Trauma Center Care
Emily received state-of-the-art care. She was stabilized by trained emergency medical technicians at the scene, was transported to a trauma center, and was initially managed by an emergency department that was physically designed and philosophically focused on the care of multiply injured patients, and all of this occurred within the critical so-called golden hour from the time of injury. Thanks to the expertise of the entire hospital staff, as well as good fortune, Emily's recovery was not complicated by respiratory problems, systemic sepsis, or multiple system organ failure, all of which are common, life-threatening complications of multiple trauma and massive transfusions22-25.
When I first received the call, I was totally unaware of the capabilities of the institution where my daughter was being treated. What I did know was that my daughter had sustained life-threatening injuries and that the capabilities of the institution where she was treated would dramatically affect her chance of survival26-30. The most important question that I needed to address was: Did I have to request an immediate transfer to a trauma center to improve the likelihood of her survival?31
My call to an orthopaedic traumatologist in the New York area was not made because I did not trust the doctors and the local institution; it was made because I just did not know what the capabilities of the hospital were. Once these qualities were established, my confidence in Emily's care improved dramatically, and, furthermore, it was comforting to know that an experienced traumatologist was involved in my daughter's care.
Health care in the United States is extraordinarily expensive. Emily's direct health-care expenses were well over $1 million. Fortunately, our New York State no-fault insurance policy, followed by our family health insurance policy, covered nearly all of Emily's health-care expenses (including transport by air ambulance). Many others are not so fortunate, and the personal financial liability can become staggering very quickly32.
Beyond the actual expense of the health care, trauma creates a tremendous economic burden on the family33,34. We were immediately faced with airfare expenses, housing in another city, food expenses, and a sudden change in both my wife's and my employment. When we first heard of the accident, our only goal was to be with Emily. We did not inquire about the airfares, and we just used our credit card. As time went on, our professional lives were dramatically disrupted and both of our practices were temporarily curtailed. I was in a group private practice, began to work three days a week, and suspended my operative practice. My wife, a nurse practitioner in private practice, closed her practice. Fortunately, we had sufficient financial resources that allowed us to focus our attention on Emily. For most individuals, this would not have been an economically feasible plan. The Family Medical Leave Act allows family members to take time off from work, but it does not guarantee salary support during the time away from work. As trauma surgeons, we should remain cognizant of the financial stresses related to the trauma. We need to remember that health care is expensive, and even well-insured patients may incur considerable personal financial liability34.
Economic concerns also stress the availability of social support. The continued presence and support of family members has been shown to improve recovery, and we were fortunate that Emily's grandparents could care for our other two children until we all returned to New York. Family members and friends can miss much time from work and may not be able to afford to lose additional time. Therefore, additional surgical interventions that become necessary in the months and years after trauma should be scheduled at a time that best accommodates the availability of family members. Ideally, discharge plans should include input from involved family members, and transfer to a rehabilitation facility should include consideration of where it will be easiest for the patient's friends and family members to remain involved in the recovery process.
Recovery and Rehabilitation
The ultimate goal of the orthopaedic surgeon is to restore function. Our training gives us the unique perspective of understanding musculoskeletal injuries, their natural history, and the acute and long-term complications of these injuries.
We all have algorithms and protocols to follow in guiding our patients through their recovery. But, recovery is much more than securing fracture-healing or enabling the patient to walk without assistance. To recover fully, one must regain what has been lost. Ideally, individuals will return to their preinjury level of function. If not, they must learn to adapt and function at the maximum level that accommodates their disability. Recovery also means returning to work for the individuals who were employed prior to the injury. We should encourage all of our patients to return to work, and individuals who are unable to do so should be referred for vocational training.
Patients who sustain multiple injuries may require temporary inpatient care in a rehabilitation facility. While we assume that the patient's discharge and transfer to a rehabilitation facility is a positive milestone in recovery, it is also a time when the patient and family may experience periods of increased anxiety and fear of the future. This is actually the time when regular contact with the orthopaedic surgeon may be crucial. You probably have become the one physician whom the patient and family readily seek for support, and you are the individual who may best be able to guide a patient through the peaks and valleys of recovery. In addition to regularly scheduled follow-up appointments to assess fracture-healing, joint mobility, and strength, more frequent visits to assess recovery are often helpful. Regular e-mail communication to answer questions and concerns can also be very helpful. We need to remain a continuous source of encouragement for our patients. We have to remind our patients that we have seen people recover from similar injuries and return to successful, productive, and fulfilling lives. The orthopaedic surgeon should remain an ever-present cheerleader, encouraging their patients through the rehabilitation phase. Emily describes below how, despite episodes of exacerbations of musculoskeletal and neurogenic pain, she was able to persevere because of my continued encouragement.
Writing a prescription for physical therapy does not complete our role and responsibility of restoring function. Patients and families need to understand what rehabilitation is. I explain to my patients that I have the easy job. My physical and psychological stress in caring for a patient is temporary. Patients frequently face a prolonged and arduous process of recovery with progress and setbacks, peaks and valleys. Patients often require a period of one to two years or longer to truly recover; they experience pain and have to work extremely hard to regain the strength, flexibility, and endurance of the injured limb, as well as their whole body. Initially, rehabilitation is painful, and an appropriate dose of pain medication needs to be prescribed to allow the patient to optimize the rehabilitation program. As an individual's recovery progresses, the level of pain will subside and less pain medication will be required. At this point, we need to remind our patients to begin to taper their use of narcotic pain medications and begin to utilize over-the-counter analgesics.
Patients need to understand early in their recovery that working with a physical therapist is only the beginning and a small part of their rehabilitative process. The time that they spend with their physical therapist is a "drop in the bucket," compared with what will be necessary for a successful recovery. They need to implement their own rehabilitation program early in their recovery, independent from and expanding on the initial program developed and supervised by the physical therapist. While patients often perceive a need for continued physical therapy beyond what the physician (or the insurance company) deems necessary35, we need to guide them through a process of tapered supervised physical therapy, progressing toward a self-directed rehabilitation program. I have referred patients to physical therapy facilities that were integrated with a health club. Patients were allowed to use the exercise equipment on their nontherapy days. In addition, for a nominal fee, the patients were allowed and encouraged to use the exercise equipment after their physical therapy prescription had expired.
Psychosocial Support
Multiple trauma creates an immediate severe psychological stress for all involved, and often patients need professional psychological support and medications. Some may need formal treatment for symptoms of posttraumatic stress disorder. An anxious and depressed patient will lack the motivation, energy, and determination necessary to actively participate in his or her rehabilitation. Furthermore, an anxious family member may become an impediment to the patient's recovery. This can lead to a downward spiral of persistent musculoskeletal pain and other concerns, reinforcing the perceived appropriateness of a patient's depression and need for narcotic pain medication.
One day, I was sitting with Emily during her initial hospitalization and she seemed to be a little more concerned than usual. When I inquired, she was worried that she would never be able to ski again! This is a question that a patient may or may not have posed to a psychotherapist, but it is clearly a question that a therapist could not answer. Very likely, if I hadn't specifically inquired, she would have been fearful to ask the question. She may have felt that it was a silly question under the circumstances or she may have been afraid to hear the answer. I told her that, as an orthopaedic surgeon, I expected her to ski this coming winter, and she immediately had a little psychological boost.
Orthopaedic surgeons are not trained mental health professionals, and, when necessary, it is imperative that we enlist our colleagues with the appropriate expertise to assist our patients in their recovery. Some trauma patients absolutely need treatment by these professionals or they will not have as successful a recovery. Patients and family members can also receive considerable benefit from online or local support groups. The American Trauma Society has established an excellent online resource for the referral of trauma patients. The Trauma Survivors Network () links patients to support groups and also to previous trauma victims36. This interaction with prior victims, just as Emily has had with some of my patients, can serve as a tremendous boost for patients and families.
Sending patients for psychological evaluation and treatment and telling them that depression and posttraumatic stress is very common are not enough. Referring patients to support groups can be extremely helpful, but doing so does not take the place of our involvement in our patients' psychological recovery. As noted above, orthopaedic surgeons have a unique professional experience in the treatment and management of musculoskeletal trauma. We are experienced with the complications of the injuries as well as with the physical and psychological problems that occur during the recovery process. This experience, which is invaluable in helping our patients to recover from the physical trauma, is also invaluable in helping them to recover from the psychological trauma. We can frequently provide our patients with information that may greatly assist them in the management of their psychological stress, just as I assured Emily that I expected her to be able to ski again.
While I am not suggesting that orthopaedic surgeons should be responsible for the psychological management of their patients, I am recommending that they remain actively involved in educating and counseling their patients about their musculoskeletal problems. Our continued presence and involvement can be crucial in an individual's psychological recovery, even if we are not actively participating in the patient's psychotherapy. My regular discussions with Emily about the nature of her injuries and what she had to overcome allowed her to understand what was happening and to remain focused on her goal of a maximal recovery.
Patients and families have concerns, fears, and anxieties about seemingly minor issues, and patients are frequently afraid to ask what they consider to be silly, trivial, or embarrassing questions. These questions and concerns are frequently related to issues or problems that a treating physician would not normally think to ask about. Here again, the orthopaedic surgeon can be very helpful. Asking questions such as "Is there anything that you are worried about? Is there anything you are afraid of? Are you having any problems?" is far better than walking in the room and saying "How ya doing?" Ultimately, even if professional psychological counseling is pursued, the continued participation and availability of the orthopaedic surgeon to answer questions about musculoskeletal issues will likely assist the patient to a more rapid and complete recovery.
The Role of the Family
The LEAP (Lower Extremity Assessment Project) study on open tibial fractures and numerous other analyses of trauma patients have demonstrated that patients with strong social support recover better and have improved outcomes compared with patients without such support37-42. The development of posttraumatic stress disorder and depression can substantially affect recovery and outcome42-47. Promoting and encouraging our patients to involve their family and friends in their recovery will dramatically improve their recovery, and the continued presence of social support will increase the likelihood that our patients will return to work39-41.
The benefits of the active participation of family members in the care of hospitalized adults and children have been widely reported48-51. Family involvement in the intensive-care-unit setting has also been reported and demonstrated to improve recovery52. On the other hand, restricted visiting hours in intensive care units are not beneficial for patient recovery and may be detrimental52-55. Unfortunately, some doctors, nurses, and hospitals are lagging behind in understanding the importance of the presence of a patient's family56-58. Some health-care workers view the family as meddlesome, demanding, and "trouble" 51. When our family member is confined to bed, and we are not present to advocate for their needs, they need to wait for a response to their call button for assistance. The health-care worker's patient volume or, on occasion, the health-care worker's convenience often limits the timeliness of the response to the call button. Family members can be unrealistic and unreasonable in their demands, especially when they perceive delays in responding to their loved one's needs. Therefore, hospitals, nurses, and doctors need to learn how to utilize family members to help the patients. Establishing guidelines that explain how the family can help their family member to recover should help to limit problems with unreasonably demanding families.
My family had the luxury of being able to have someone with Emily during her entire hospitalization, and we are certain that this contributed to her recovery. While the medical literature clearly supports family involvement, no study has specifically noted any special benefit to the full-time presence of a family member. Physicians should seek out and encourage family support, but each patient and family needs to develop a plan that is feasible and gives the patient the level of support that they desire. The time does not have to be spent interacting with the patient, and it may simply involve sitting quietly by the bedside. Knowing that someone you love, and who loves you, is at your side is comforting and relaxing, and hospitals need to recognize the benefit of having an involved, cooperative family member present with the patient. Furthermore, I believe that a family member of an adult patient should be permitted to accompany their loved one into the operating room just as is done with children. In summary, doctors need to discuss family involvement with their patients. Modern health-care systems have an ethical obligation to accommodate an individual's right to have their family present as long as it does not disrupt the workings of the institution or violate other patients' needs51. Depending on the wishes of the patient, the doctor may have to lobby to have the family remain with the patient.
Medical Errors
Medical errors have reached epidemic proportions in the United States. The Institute of Medicine's report, To Err Is Human: Building a Safer Health System, published in November 1999, briefly outlines the magnitude of medical errors in the United States59. They estimated a range of 44,000 to 98,000 deaths secondary to medical errors and a financial cost of $17 billion to $29 billion of excess expenditures secondary to medical errors.
Emily was hospitalized in three major teaching institutions. In one facility, a nurse came into her room to administer an injection of low-molecular- weight heparin one hour after she had received her scheduled dose. In another facility, she was given the correct intravenous medication but with another patient's name on the bag. In a third institution, Emily was administered two units of allogenic blood despite having predonated two units of autologous blood.
Hospitals are continuously developing methods to prevent errors. Despite these safeguards, errors still occur. Keeping patients well informed is a good way to prevent errors, and a member of the medical team needs to inform the patient of the plan for the day. The plan for the day may be simply a routine blood test, an imaging study, starting a new medication, discontinuing a medication, or having a consultant evaluate the patient. Patients very much appreciate knowing what is going to happen on any given day. Patients may inquire about their test results, especially when they were informed in advance of the necessity of the test. Encouraging the active participation of the patient in his or her health care is a simple way to help us to avoid making mistakes. Patients do not like being picked up by a hospital transport and simply being told, "Your doctor ordered a test." Patients can remind the hospital staff when the day's plans have not been carried out, and, when they have been advised of the medications being prescribed, they can ensure that they are receiving the correct medications in the prescribed dose.
University trauma centers incorporate house staff in the care of the trauma patient. These residents and fellows are integral members of the trauma team, and they provide a clear benefit. Despite the benefit, it is important that we, as attending surgeons, remember that, although the residents are licensed physicians, they are still "students" being trained in a field of medicine that is new to them. They are assigned responsibilities in a graduated fashion, with more senior residents and the attending physician overseeing and maintaining responsibility for patient management. The presence of the house staff often makes our lives easier, but, if we are going to be effective educators, we may at times have to work harder. We teach by example, by being available, and by letting our students know that our presence is often necessary for appropriate patient care18,19.
Unfortunately, at times the resident who initially is asked to assess a particular situation has not had the clinical experience necessary to evaluate the condition appropriately. When Emily was first brought to the intensive care unit, she needed to be placed in skeletal traction. The most junior resident was sent to perform this apparently simple task, yet he was inexperienced, with limited prior experience in setting up balanced suspension skeletal traction, and he needed my assistance. Another example of an inexperienced fellow making an inappropriate recommendation occurred a few weeks after Emily's injury. When she had nausea and vomiting develop, she was administered Reglan (metoclopramide). A relatively common side effect is a dystonic reaction (coarse nystagmus, involuntary facial movements, and confusion). A neurology consultation was requested. Prior to the arrival of the neurology fellow, the dystonic reaction was readily reversed with intravenous administration of Benadryl (diphenhydramine). Despite the complete reversal of Emily's dystonic reaction and confusion, the fellow recommended a lumbar puncture to rule out meningitis. At my insistence, an attending neurologist came to examine Emily at 3:00 AM and thought that the lumbar puncture was not indicated. Emily subsequently had classic signs of an acute small bowel obstruction: abdominal distension, vomiting bile, and pain. The surgical resident assessed the presentation and recommended the continued administration of antiemetics. Unfortunately, antiemetics are contraindicated in the face of a small bowel obstruction, and, if decompression with a nasogastric tube and observation does not resolve the situation, a laparotomy and lysis of adhesions becomes necessary. One of the most common errors made by physicians in training is a failure to recognize the severity or acuity of a situation. While experience is often said to be the best teacher, observing an experienced physician as he or she examines a patient and develops a differential diagnosis is even better. One cannot make the correct diagnosis if experience and level of training do not guide the examiner to include the presenting problem in the differential diagnosis. Ultimately, providing the best patient care will also lead to the best education.
Residency programs and academic institutions have regularly scheduled morbidity and mortality conferences. These conferences would usually not include the events we have described above, as they did not result in a complication or death. Rather, programs of quality improvement and process improvement are appropriate forums in which to discuss these problems. In these meetings, system problems and patient management issues can be discussed, strategies can be developed to prevent similar events, and resident coverage schedules and levels of supervision can be reviewed and modified as necessary. Ultimately, the goal should be to create a combination of state-of-the-art patient care alongside state-of-the-art resident education.
Know When to Refer and When to Get Help
Postgraduate education in orthopaedic surgery is a five-year program. When we start our training, we are presumed to know nothing about musculoskeletal medicine. During the five years, we develop skills and experience that allow us to appropriately and effectively treat most musculoskeletal conditions. No matter what our level of training or our experience as practicing orthopaedic surgeons, we will all have some limitations, even those of us who are fellowship trained. The welfare of the patient must always be of paramount importance. Irrespective of level of training, one should always seek help when treating a condition with which one has little or no experience.
Every human being is a distinct individual. Our personalities are a melding of our genetic makeup, environment, culture, religion, ethnicity, and personal experiences. To respect a patient's autonomy, we have to recognize the individuality of our patient and not just assume that we know what is best. We should attempt to develop a relationship that works for the patient and is acceptable to the treating physician. Doctors' schedules are extremely busy, and at times we focus on completing our tasks, forgetting that the task we are performing is on a person! A daily routine for Emily often included an evaluation by a team of residents from a variety of medical or surgical services. The interactions were usually pleasant and often broke up the monotony of the day. On a few occasions, however, a team would come into the room without knocking on the door or requesting permission to enter if the curtain was closed. They often would not greet us or introduce themselves and would just begin to examine Emily, ask questions, change a bandage, or perform some other procedure. On one occasion, bed covers were removed and Emily was inappropriately exposed without any thought among the treating physicians of protecting Emily's privacy.
We need to remember that our patients are in pain, scared, and anxious. We have to protect their privacy and support their autonomy. If the door is closed or the curtain is drawn, we need to knock and ask permission to enter. It is important to remember to introduce ourselves and to explain what our role or function is. Patients should have the option of having their family member remain with them during routine bedside procedures such as dressing changes or blood drawing. When we speak to our patients, we need to maintain an appropriate level of privacy. When friends or family members are in the room, we should inquire if the patient would like these individuals to stay or be excused during the examination and discussion.
Obtaining informed consent for medical procedures and operative intervention is a basic premise of respecting patient autonomy. Patients or, if necessary, their health-care proxy are entitled to understand the problem, the alternative treatment options, and the complications associated with each approach6-8,60-62. If the treating physician believes there is an optimal method of management, then that specific recommendation should be made clear. When it is obvious to the treating physician that there is only one appropriate way to manage a problem, the physician still has an ethical and legal responsibility to involve the patient in the treatment decision. The physician needs to discuss how the condition will be managed if the patient does not agree to the recommended treatment. The risks and benefits to each approach should be carefully reviewed. Patients are allowed to make seemingly foolish or "wrong" decisions if they have decision-making capacity, and just because a patient disagrees with the surgeon's recommendation does not mean that they lack this capacity63. Observational studies have shown that a patient's perceptions of an inadequate informed consent may lead to a malpractice action2,61. Worthington recommends that attending physicians obtain consent in the presence of their house staff to serve as a model of completing an appropriate informed consent process9.
Emily signed numerous consent forms. I was present during a number of these interactions and at times I do not believe that the discussion and explanation were as clear or comprehensive as would be necessary for an appropriate informed consent process. I believe that some of the discussions may have been abbreviated (inappropriately) under the assumption that I would explain everything to Emily. Interestingly, when you listen to the explanations and discussions you realize that the words we use and the explanations we give often do not meet the criteria for an informed consent. These words are part of our medical jargon. They seem like simple and common words to us, but they are very foreign to the large majority of individuals outside the medical profession. While it is appropriate to use the correct medical terminology, it is then necessary to explain the procedure and its complications in lay terms. For example, "I am going to be performing an open reduction and internal fixation on your fractured pelvis, which means that I am going to make an incision to locate your broken bone and use metal plates and screws to repair the broken bone."
It is important to approach the process of informed consent in exactly the same way for each patient, ensuring that the basic standard outlined above is met each time. Clearly, at times, the discussion will become more detailed and comprehensive on the basis of the questions posed by the patient and the family. Most importantly, the physician should not count on a family member to clarify or complete the discussion.
A Perspective of the Patient
I am lucky! I am alive, I am able to do essentially everything that I would like to do, and I am enjoying medical school. Yes, my back hurts on occasion, and I still experience episodes of neurogenic pain and an occasional severe leg cramp from nerve irritation. I have scars on my abdomen, buttocks, thighs, and back. I have an "ugly" soft-tissue asymmetry. I have come to accept the scars. The scars add character! Yes, I wish I didn't have them, but they also serve as a reminder of what I have been through and how fortunate I am. The accident has left me with an extraordinarily strong bond with my parents, sisters, extended family, and friends. Personal relationships are by far our most valuable assets. I am anxiously looking forward to becoming a physician and using my experience as a patient to benefit my patients.
My three-month hospitalization was frightening, painful, and depressing. I believe that the constant presence of either my mother or father greatly contributed to my recovery. The frequent presence of relatives, my parents' friends, and my friends made it much easier for both my parents and me. As I look back on my experience, I realize that some individuals who are health-care providers and hospital workers (ranging from physicians to housekeepers) love their work and strive to do whatever they can to help people recover. Others seemed to act overworked, uninterested, and surely not empathetic. In fact, at times some health-care workers seem to create rules to make their own lives easier. I hope to use this knowledge and experience to teach my fellow students to remember that our lives can change in an instant and to approach each and every one of their patients as a member of their family or a best friend.
I have definitely learned what is necessary to recover from multiple trauma. It isn't easy! It is painful, fatiguing, and frustrating. The encouragement and cheerleading of my father allowed me to be able to push myself to work hard and do what was necessary to recover. At times, I was in a lot of pain, but my father's guidance kept me from being deterred. I agree with him that physicians need to be readily available to encourage and guide their patients through the rehabilitative process.
I have used my experience, and my father has used me, to meet and reach out to other trauma patients. I believe that this experience has allowed me to help other patients and their families through the early frightening days after a serious injury. My life was saved by blood transfusions. I attempt to help others to benefit from blood transfusions by donating blood a few times a year.
My parents' familiarity with the health-care system undoubtedly benefited me. They were always available to explain to me what was happening. They were frequently explaining things to me that probably should have been explained to me by a member of the trauma team or nursing staff. They actively pursued finding a doctor with the appropriate experience for each of my many problems. I was fortunate to have this support. Hopefully, as I enter my career as a physician, health care and trauma care will evolve to allow all patients, with or without parents involved in the system, to receive the excellent care that I received.
Multiple trauma affects the patient, the patient's family, and their friends. Effective doctor-patient communication is vital to guide everyone involved through these life-altering events. Active involvement of the orthopaedic surgeon throughout the patient's rehabilitation and recovery is strongly recommended to provide the patient with crucial support and encouragement during the peaks and valleys of recovery. Family participation and support contribute to a successful recovery, and the patient's family should be encouraged to be available as much as possible. Informed consent is a basic tenet of modern medical ethics, and the process needs to be respected and completed appropriately. Residency training is an integral component of the effective functioning of trauma centers, but residents require an appropriate level of supervision that is based on their level of training and their personal experiences. Mistakes can and do occur in the complex world of health care, and physicians should work with their patients, and within their institution, to limit and hopefully to prevent medical errors.
Emily's life was saved and her function was restored by state-of-the-art trauma care. Despite her initial fears, she skied nine months after her accident, skipping the bump runs.
New York Blood Center. Traumatic accident leaves teen near death. N Y Blood Cent Lifesaver News. Winter 2005-2006.
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