Trauma is rarely planned: most ER trauma calls to the orthopaedic surgeon occur unexpectedly in accidents. Trauma also may involve the accidental fall from heights, or injuries that involves weapons. High and low energy injuries occur in patients who are healthy or who may have serious co-morbidities. The spectrum of what can be anticipated is variable from the infant being thrown from a car in a car seat to a frail elderly patient who falls off of the toilet seat and sustains a fracture. Injuries come in all shapes and sizes: open and closed fractures, operative and non-operative injuries, simple and complex wounds.

The orthopaedic surgeon has to be prepared, at any time day or night to handle orthopaedic consults or injuries to any patient in the emergency situation. This can include multiple patients unexpectedly.  The orthopaedic surgeon may also have to manage unexpected surgery due to complications from previous surgery such as infection or wound problems. Failure of fixation of fractures may also occur such as breakage of plate and screws, or wound dehiscence. These kinds of situations are never expected, thus never planned. How the surgeon handles the patient and the ultimate outcome is dependent on many factors and variables.

The following will be discussed:

  1. Decision making in the Emergency Room: The ability to determine the indicted surgery or surgeries is dependent upon the skill-set of the surgeon.
  2. Patient safety at all levels of the encounter and in all phases of care must be constant.
  3. Communication with the patient, family and loved ones regarding the need for surgery, timing and indicated needs for surgery are questions one has to answer. Risks and benefits with moving forward to complete the surgery will need to be explained prior to the procedure. A valid surgical consent needs to be obtained.

Trauma care is organized in three stages: primary survey, secondary survey and definitive management.  By the time the orthopaedic surgeon has accepted the patient either as the consultant, or as the primary physician, the general evaluation of the patient may have been completed. No matter what the situation, whether a low energy hip fracture or a high energy trauma with multiple injuries, the orthopaedic surgeon needs to take ownership of the patient and devise a plan of care.

Being prepared is a good way to manage the on call situation. Have books, instructional materials, operative case notes and many written resources available before call starts.

Have a plan for easy retrieval of information that may be needed if unique or very rare cases of trauma present.

Have a back-up mentor available. Frequently senior surgeons are willing to take phone calls, review films and simply give advice for difficult cases.  Ask for help if it is needed, or the area of expertise needed for the case is out of your experience.

If your expertise lies in a sub-specialty, and you encounter something out of your area or comfort, have a referral or hand off system in-place prior to taking call. This is generally agreed upon in many practices including private, health systems and academic institutions.

I. Decision Making in the Emergency Room

No doubt making the decision for a specific injury takes knowledge and experience. While the acute phase is the most critical, long term planning is also needed. Does the patient understand what this type of injury means in the long run? Does the patient realize how the function of day to day activities may be affected? Will the patient be able to go back to work?

An informed patient is critical in the management of injury. A knowledgeable surgeon is also imperative. This comes into play when surgical intervention and rehabilitation may be different for different types of patients.1

For example, an elderly patient with medical co-morbidities may have to be non-weight bearing longer after ankle fixation as compared to a younger patient who would be able to manage some weight bearing.  These considerations are important when preparing a patient for surgery, as they may have to plan and prepare for different living accommodations after surgery.

Be prepared to take some time in the emergency room to talk to the patient and family. While critical aspects of the injury must be handled, such as open fractures, the surgical decision making, obtaining the operating room and planning the surgical intervention takes time. If the decision making is straight forward, and the operating room is fairly easily obtained, you may have more time to answer questions. Frequently the patient may not be able to make an informed decision, so family members make the decision for surgery.

In an emergency situation, it is imperative the correct message is given to the family regarding the surgical intervention, the risks and benefits and how the surgery may or may not affect function afterward. In the event that the situation arises as a life or limb threatening surgery is imperative, documentation must support the gravity of the situation and it is a true emergency. Informed consent in this situation may not be obtained prior to going to the operating room.

Patients are frequently scared: they did not plan the event; they never anticipated this untoward event. Surgery is an unknown. Many patients encountered have never had surgery. Frequently children have only encountered the pediatrician as their only doctor. The surgeon can elicit fear and hesitation in some patients. A bond of trust is first encountered in the emergency room. That is where the surgeon can form an alliance with the patient for the best outcome possible. Once trust is established, the moving forward to the surgical intervention is much easier. If trust is never established, the whole experience may become difficult.

II. Patient Safety

Medical errors, adverse events and complications are included topics when patient safety is discussed.

Preventable adverse events and medical errors are what all strive for in the operating room. Checks and balances are in place before the operating room is entered. Generally the team of health care professionals strives for the best possible outcome once the surgery is deemed necessary and the plan is put into action.

Three areas continually need to be addressed to ensure the highest in standards

  1. wrong site surgery
  2. sleep deprivation/fatigue
  3. training

To prevent wrong site surgery, it is imperative to avoid misinformation with respect to the accuracy of operating room schedule, the history and physical exam and during the informed consent process.

If discrepancies are noted or identified, the orthopaedic surgeon should immediately reconcile the discrepancies, have supporting documentation and resolve these issues before entering the operating room. “All information supporting the correct patient, procedure and site should be verified by the surgeon and nurse before the patient enters the operating room.  All verbal verifications (including during the time out) should be done with an active response-not a passive one.”2

The AAOS offers the following as a guide for surgical safety which involves the whole healthcare team. It is divided into check lists for: 1. Sign-In (Before Anesthesia) 2. Time-Out (Before Skin Incision) 3. Sign-Out (Before Leaving the Operating Room). Detailed information can be found at: http://orthoinfo.aaos.org/topic.cfm?topic=A00716

Sleep deprivation/fatigue may affect any one who is to do emergent or elective surgery. Personal reflection by every surgeon is called for if there is a real concern for patient safety and an inability to perform surgery in a safe manner, using clear judgment. Some studies have shown that to be deprived of sleep can double the error rate. Some authors recommend that surgeons should inform patient that they are fatigued.2

Some propose institutions implement policies to avoid elective surgeries by fatigued surgeons. What is finally decided in the sleep deprived surgeon ultimately rests with that surgeon. In an emergency situation, it is always wise to have a back-up person to call or a colleague that would be willing to back you up in that situation. Some hospitals even mandate a back-up plan is in place when times are very busy and trauma case volume is anticipated to be high.

It takes a mature person, some personal reflection and critical thinking to decide a safe surgery in a stressful situation. Be prepared.

III. Informed Consent

“Informed consent is a process for getting permission before conducting a healthcare intervention on a person. This process involves appropriate and accurate communication between the physician/surgeon and the patient or patient’s representative. Informed consent is collected according to guidelines from the fields of medical ethics and research ethics.”

“An informed consent can be said to have been given based upon a clear appreciation and understanding of the facts, implications, and future consequences of an action. In order to give informed consent, the individual concerned must have adequate reasoning faculties and be in possession of all relevant facts at the time consent is given. Impairments to reasoning and judgment which may make it impossible for someone to give informed consent include such factors as basic intellectual or emotional immaturity, high levels of stress such as PTSD or a severe intellectual disability, severe mental illness, intoxication, severe sleep deprivation, Alzheimer’s disease or being in a coma” may be encountered.

Informed Consent Form Templates can be found on the World Health Organization Website for practical use.3

According to a recent article in AAOS the patient, or designee giving consent,  should be free to ask questions and demonstrate understanding of procedure and make that decision to proceed with surgery voluntarily ( to be an informed consent).4

In any unexpected surgical intervention, once the surgery has been completed, rapport between orthopaedic surgeon and patient/family continues. The goal is to strive for a good outcome, a safe and successful surgery, to get the patient out of the operating room, to the recovery room and then to their post-op rehabilitation routine without morbidities.

To prepare a trauma patient or any patient for unexpected surgery takes effective communication, honesty, explanation of expectation, and obtaining an informed consent. Completing the procedure safely and getting the patient back to their pre-injury status and functioning means a relieved and satisfied patient.

Laura M Bruse Gehrig MD, FAAOS, CCD

Orthopaedic Surgeon

Sanford Orthopaedics and Sports Medicine

Bismarck, North Dakota

References:

  1. Long J. Orthopaedic Residency: Learning to be an Orthopaedic Surgeon. In: RJOS Guide for Women in Orthopaedic Surgery. Cannada LK, Connor ML eds. Rosemont, IL; AAOS; 2008. pp 40.
  1. Herndon JH. Patient safety means patient first.  April 2011 Issue Available at: http://www.aaos.org/news/aaosnow/apr11/managing5.asp
  1. http://en.wikipedia.org/wiki/Informed_consent
  1. Suk M, Udale AM, Helfet DL. Orthopaedics and the Law. J Am Acad Orthop Surg. 2005; 13:6 397-406.
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