Indexing Title: RCHAN’s Medical Anectodal Report [04-7]

MAR Title: One Foot in the Grave

Date of Medical Observation: December 31, 2003

Narration:

            Our adrenaline levels were at their peak all day. New Year’s Eve would never be the same without firecracker injuries, mauling incidents, stabbing incidents, gunshot wounds and the like.  Good thing the past few days of our perpetual duty that year was fairly uneventful. I guess people try to behave during the holidays to be able to at least celebrate them.  But then, there were still a few misfits who still managed to commit demeanors here and there. 

There was a steady stream of patients that night.  Most of them were burn patients due to firecracker injuries, not too difficult to handle and too hard to dispose of.  As their wounds were attended to, the nurses did their skin testing for the anti-tetanus shots and were simultaneously given tetanus toxoid injections. After accomplishing everything, they were discharged. The routine was perfectly executed for each patient and we were on a roll.

As the incoming year was inching its way, the sound of an oncoming speeding tricycle heightened our senses (the trauma entrance was opened at that time to facilitate the influx of patients). A man in his twenties was wheeled in with his right foot wrapped in a blood-soaked piece of cloth. He was accompanied by two adults about his same age, one of whom had in his hand something that looked like the remnant of a Nike Air Jordan, the sole of which was blasted into smithereens.  No questions were asked because obviously, this poor guy had the misfortune of accidentally stepping on a firecracker.  And by the looks of his dearly departed Nike Air Jordan, it was due to the bigger and ‘tympanic-membrane busting” kind.  We slowly unwrapped his make-shift compressive dressing to be presented with a mangled right foot.  The anterior half of the ventral aspect of his foot was gaping, revealing the destructive power of the “pla-pla” his foot had landed upon.  The muscles were torn, the metatarsal bones were shattered and the tendons were tangled in between the bones.  We discussed amongst ourselves what management options we had for this patient. In my mind, this patient would not have any use of his right foot anymore and doing a Syme’s amputation would be the least surgical procedure that he can undergo. We informed our Orthopedic service consultant through text. We even sent him an MMS picture of the injury. We primed the patient and his relatives of the condition of his foot. We brought up the possibility of an amputation, of which they vehemently objected with. 

When our consultant was unable to respond to our text messages, we called him up but his phone was unattended. We then decided to do an initial debridement to decrease the contamination of the wound and remove the devitalized tissues. To the debridement, we were given consent but the amputation, they denied doing so.  They even contemplated on transferring the patient to another institution after the operation to seek a second opinion.  We operated on the patient on New Year’s Day.

 The following day, our consultant arrived and inspected the injury.  He told us that the foot can still be salvaged through open reduction and internal fixation with cross-pinning.  He scheduled the operation and did the procedure himself.  The wound eventually healed and the patient was discharged.  After two months, the defect was just a narrow strip of granulation tissue and the pins were removed. His metatarsals all had callous formation and were aligned perfectly. He vowed never to leave the safety of his home every New Year’s Day.

INSIGHTS: (DISCOVERY, stimulus, REINFORCEMENT) (physical, PSYCHOSOCIAL, ETHICAL)

            That patient reminded me of the importance of referring to consultants before making any move in managing  our patients.  I acknowledge the boundaries of my experience and skills as a surgeon, a GENERAL SURGEON at that. Even at my level, I realized the limitations of my capacity in decision-making. Had we secured the consent for amputation, we could have inadvertently made a sin of commission, a potential source of complaint and even worse, a medico-legal suite.  We were going to deprive the patient the chance to lead a normal and productive life. And now that we were able to save his limb, he is still a very proud member of the society, STANDING ON HIS OWN TWO FEET…