Monday, April 4, 2011

Decision-Making in Severe Lower Leg Trauma

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

About the time I was reading the journal article on decision-making process for patients with severe lower leg trauma (full reference below), @sospokesaroj shared news article via twitter:  Nine-year-old loses leg while saving little sister’s life.
Another news article on the accident notes
Surgeons worked on Anaiah from 1 p.m. to midnight on Friday, Davis says, to try and save a shattered left leg.
On Saturday the leg was amputated. The brute force of the accident also broke Anaiah’s right leg, fractured her neck, damaged her spleen and destroyed one kidney.
Which brings me back to the journal article which is a qualitative analysis of patient preferences for amputation or reconstruction. Twenty patients with type IIIB or IIIC open tibial fractures participated in the study. These patients had undergone either amputation (4 primary, 5 secondary) or reconstruction (14) between 1997 and 2007. There were 15 men and 5 women, mean age was 47 (23 – 68) years.  Semi-structured interviews were conducted and qualitative outcomes were assessed.
It must be noted that current research has shown minimal difference in functional outcomes between patients who have below-knee amputation and those who have lower limb reconstruction following a severe open tibial fracture.
The interviews highlighted several issues involved with medical decision-making. Participants described not having a role in deciding which medical treatment to choose.
“I didn’t decide! Hospital decided for me…They all made the decision; I didn’t make no decision on nothin’.  I didn’t even see it.  All I know is that [my wife] told me that when she came to the hospital they told her that they had to take it off.”  --- Male, 67, primary amputation, 12 year post-injury
“I was conscious until I got here [to the hospital], but when I got here… from that time I was in a morphine daze for several days.  And most of those decisions were being made by my wife.”  --- Male, 53, primary amputation, 8 years post-injury
“I’m lucky my brother was here for 3 months, I mean he was here like the day after it happened… Because I wasn’t terribly coherent, I mean, it’s not that I wasn’t conscious, I was on a lotta drugs.  I had my own little morphine clicker.”  --- Female, 56, reconstruction, 8 years post-injury
As you can see from the interview snippets included (and there are others in the article), family and spouses played a greater role than the patient in decision making, often because of patients being medicated when needing to make a treatment choice.
The article notes both amputation and reconstruction patients described being satisfied with the outcomes of their surgical treatments, but also expressed second thoughts about their treatment choices.
“I have to say I am happy with the results of the surgery, who my surgeon was.  However, the problems …. Mine are not what everybody gets.  Some people never have bone spurs, some people never have neuromas.  But I do.  And why people that have trauma injuries suffer more than pain, I don’t know.  Why do we get a bursa?  It’s just there.  It’s painful.  There’s nothing they can do about it.”  --- Female, 62, primary amputation, 9 years post-injury
“I was kinda angry about it, you know, like why did they have to take my right [latissimus dorsi] one? ‘cause I’m right handed.  Like, why couldn’t they take my left?  I was really mad about it.”  -- Male, 36, reconstruction, 12 years post-injury
“No, as of today, sitting here I wouldn’t have changed my decision [to do the reconstruction], but we did second guess it, several times, as we went through the multiple surgeries and everything else that came as a result of that.”  --- Male, 41, reconstruction, 10 years post-injury

A Qualitative Analysis of the Decision-Making Process for Patients with Severe Lower Leg Trauma; Aravind, Maya; Shauver, Melissa J.; Chung, Kevin C.; Plastic & Reconstr Surgery Vol 126(6):2019-2029, December 2010; doi: 10.1097/PRS.0b013e3181f4449e

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