Saturday, July 26, 2014

Never Trust a Bone Doctor


I suppose the title above is a bit facetious and I really don’t mean it, but there have been times over the years when collaborating with my Orthopedic Surgery colleagues has caused sleepless nights; some I didn’t deserve.
Almost all these joint ventures have been on major trauma cases where severe bone injury has been paired with major vascular damage. Priority of repair, that is, who gets to go first is a common discussion. The answer to the question depends on the patient and the injury. In general life and limb threatening injury take precedence.
Such was the case of Mary, who suffered a closed fracture of her proximal tibia and fibula with associated occlusion of her popliteal artery and ischemia of her leg. The severe vascular injury could have led to Mary losing her leg and mending of the artery took precedence over the bony repair.
But, how could I have had the prescience to know that during the process of repairing the tibial fracture the orthopedic surgeon would cause a bony fragment to compress the artery which had just been patched and cleared of thrombus, (a blood clot which was occluding the vessel)? The vessel became occluded again. My protests went unheeded and I was forced to bite the bullet and redo the vascular repair utilizing a vein graft to bypass around the injured area.
At least I didn’t have to drive back to the hospital. As a resident I learned to never leave the vicinity until the bone doctor had driven his or her last screw, nailed the last nail and placed the final skin staple. Only after checking my work would it be safe to leave, secure with the knowledge that my orthopedic colleague could not wreak anymore havoc.
Mary, by the way, recovered uneventfully.
Then there was Glenn.
It was a Friday night and I was not on call. My family and I had just walked in the door after dining out when my phone went off and there was a message. Dr. Black was consulting me to see Glenn, who was admitted to the hospital with a fracture of the proximal right humerus. The nurse was concerned because she could not feel a pulse and Glenn complained of his hand being numb. It was about eight o’clock in the evening.
I called and talked to the nurse and then headed in to the hospital. Glenn was in his mid fifties, lived with his parents and had no significant medical problems other than being  “a little slow” to use his expression. He told me had tripped while on his parent’s front porch and fallen down the three stairs to the sidewalk, landing on his right arm and shoulder. This had occurred at 11:00 am, now almost ten hours earlier.
My exam confirmed that he had almost certainly injured his brachial artery. There was a large hematoma (collection of blood) in the upper arm and axilla, he could not move his hand, which was also numb, and there was no pulse in the arm, radial or brachial.
I called down to the OR where they weren’t very busy and told the crew that Glenn needed surgery immediately. Next I called Dr. Black and reported my findings and he responded that he was on his way to the hospital
I called the OR, again, and asked how quickly they would be ready, informing them, again, that this was a limb threatening emergency and that the patient should have had his surgery hours before.
“We’re opening now and anesthesia is on their way in,” was the reply.
I have to admit I was a more than a little frustrated. Mostly it was the lack of attention that threatened to cause serious harm to Glenn that bothered me. It’s not right for a patient to languish in the hospital with such an injury.
Dr. Black finally arrived.
“The ER physician told me it was an uncomplicated fracture. I had planned to fix it tomorrow,” he explained without my ever asking a question or making a comment.
Finally, at 10:00 the OR team was ready and Glenn was wheeled down to surgery. The operation began about thirty minutes later. Glenn’s arm had been ischemic for almost twelve hours.
I began to work, starting with an incision over the area where the subclavian artery emerges from beneath and behind the clavicle, following the rules and obtaining what’s called proximal control. What this means is that the artery is identified and dissected free in area closer to the heart than the injured area. Blood flows from the heart out to the organs under considerable pressure. Proximal control allows flow into the injured area to be interrupted should bleeding develop during the course of isolating the damaged artery.
I followed the artery out to the axilla, dissecting it free from the pectoralis major muscle and then into the upper arm where I encountered a large hematoma (collection of blood). This is where the artery had bled before the pressure caused by the blood spilling into Glenn’s tissues along with the body’s normal clotting mechanism caused the bleeding to stop. If this mechanism had failed Glenn would have bled to death, but the human body is remarkable in its ability to fend off such calamity.
I evacuated the large blood clot and found one end of the transected artery, pulsing away, but not actively bleeding as the end had efficiently clotted.
Next I had to find the other end of the artery. Rather than start digging through the bloody, damaged tissue at the site of injury, I decide it would be more prudent to start at a site beyond the injury. The distal artery was easily dissected free and then followed back to the other injured end.
The two ends were a bit macerated and had retracted such that a direct end to end anastamosis (like reconnecting two ends of a pipe) was not feasible. Luckily I had the foresight to prep out Glenn’s groin so that it was already sterile and I could harvest a segment of saphenous vein. This is the same vein commonly used for heart bypass surgery. Before starting on Glenn’s leg I placed a shunt between the two divided ends of the injured artery, allowing blood to flow to the distal arm, thus giving the starved tissue a “drink” of blood, delivering oxygen and nutrients.
An adequate segment of vein was removed from his leg and the reconstruction proceeded without incident. I added a fasciotomy to my procedure, which means I divided the fibrous tissue around the muscular compartments of the forearm to allow the muscle additional room to swell after it was reperfused, thus preventing what is termed “compartment syndrome.” This condition can lead to muscle and nerve damage as the tissue swelling which can occur after prolonged periods of ischemia becomes confined by the tight, closed space of a muscular compartment.
I felt the strong pulse in the artery beyond my repair and saw that the muscle, although pale, looked viable and I believed Glenn would be left with a functional arm.
At this point I must add I had considered allowing Dr. Black to do his repair first. I could have placed the shunt to allow the arm to be perfused and then done the definitive repair after Dr. Black had finished. But, he assured me it was a simple fracture which was minimally displaced. He anticipated an uncomplicated ORIF (Open Reduction Internal Fixation). Being the trusting soul that I am performed the more vital arterial repair first.
However, I am not 100% na├»ve. I did stay around until Dr. Black finished. I’m glad I did. It was about 1:00 am when I lay down on the couch in the doctor’s lounge and dozed off and on. Over the years I’ve never slept well at the hospital and I’ve always opted for driving home for a couple of hours sleep in my own bed rather than getting an extra thirty minutes in the less comfortable confines of a hospital call room. In this case, however, it was fortunate that I did not leave.
The phone in the lounge rang at about 3:00 am.
“Dr. Gelber, you need to come check this arm,” more of a command than request from the circulating nurse.
“Is Dr. Black finished?” I queried.
“Finished and gone, but you need to come.”
“OK, OK, I’ll be there in a minute.”
I made a quick pit stop, donned my hat and mask and went back to the OR room where the surgical tech recounted the sad and tragic “saga of Glenn’s repair.”
“Well, he was doing the repair with a Rush rod and it only took a few minutes. I thought we’d be home by two, but then I picked up the arm and asked him if the rod was supposed to come out the back of the arm? So he had to pull it out and that took a while. Then he had to do it again. I’m no Orthopedic Surgeon, but I don’t think it’s positioned very well. But, fFor what it’s worth, he’s done.”
The circulator then spoke up.
“The hand looks white.”
Sure enough there was no pulse or Doppler signal. So I was back at square one. I opened the wound and looked at my repair. There was an excellent pulse at the site of the repair and for at least three or four centimeters distal. I started dissecting farther and it wasn’t long before I found the problem.
Dr. Black had not only driven that Rod through the back of Glenn’s arm, but he had also managed to put it through the brachial artery at a point beyond the original injury. So, I repaired the artery a second time. At least I didn’t have to do another fasciotomy.
I finished at around 5:00 am. Glenn woke and had much improved function of his hand. He could move it and there was some sensation. He maintained good perfusion of his arm, but did have to have the orthopedic reconstruction revised at a later date. Eventually he regained 100% full, normal function of his arm and hand.
Dr. Black never talked about this particular case with me. A couple of years later he gave up the practice of Orthopedics. He was, overall a competent surgeon and his retirement from Orthopedics was for personal and health reasons, unrelated to Glenn’s case..
I hope that anyone who reads these words does not believe that I have no regard or respect for my Orthopedic colleagues. I could never do what they do and most are excellent physicians and surgeons. They do, however, have a singlemindedness in their approach to their patients. Their job is to fix, reconstruct and otherwise mend broken, worn out, degenerated bones and joints. Orthopedic surgical procedures are designed to stay away from vital structures such as nerves, major blood vessels and other organs which are soft and not amenable to nails, screws and plates.

What I’ve learned is that injuries and medical conditions which bring me into the Orthopedic Surgeon’s realm require that I maintain my utmost vigilance. And, never completely trust a bone doctor.