Dr. Orthochick: Amputation

During my first month of internship (that would be Vascular Surgery), we had a patient come in with gas gangrene. She was totally septic and actively dying, so about the only thing we could do was amputate her leg in a guillotine amputation. We cut it off a little below the knee and didn't even bother to cover the stump because we knew we'd have to go back to revise it. You could see the ends of the bones and the muscles like some sort of weird cross sectional drawing. Anyway, we then went back and revised her to an above knee amputation. By that point she was doing a little better, but she was still in florid renal failure and I don't even remember what else. So she started getting better and one day I was rounding on her while she was in the dialysis center, she was a little more with it, and then I went to write my note.

I have no idea what happened, but she started crying and the nurse ran over there and the patient said "I want to know what happened."

The only person in the room who knew exactly what happened was yours truly, I was writing a note, I was running low on time, and really, I didn't know how to explain to a woman that we just cut off her knee. (This was long before I had to tell people they were going to die/their spouse was going to die/their spouse already died/they were never going to walk again/they had metastatic unresectable pancreatic cancer...) So the nurse asked me to talk to the patient despite the fact that I was practically hiding under the computer in an effort to be innocuous, and I went over there to see her.
Her: What happened?
Me: Well...you got really sick, you know? And the only way to get you better was to, uh, cut off your leg.
She was crying and said, "I don't want to hear this anymore."
Me: No, I want to talk about this with you. We cut off your knee. You don't have any leg past your knee. But your infection is mostly gone. You're getting a lot better. I've been talking to your husband and he's been here every day to see you and he's excited to see you get better--he told me your anniversary is next week. So you don't have a knee. But it was the only way we could get you better.

I remember I had her reach down and feel her stump and that really made her cry. Truth be told, I don't think I did a great job breaking the news, but looking back I'm not sure how I would have done it all that differently. I guess i could have eased into it a little more, although it's pretty hard to soften up "we cut off your leg."

***

Flash forward a year and a half and I still really hate having to tell people we amputated their bodyparts. I've had to do it 2 or 3 times since July of 2010 and really, it's up there with the "you will never walk again" speech for me. Anyway, yesterday I had a guy come into the ER with a huge open hand laceration. I took about three looks at it and called Dr. Pregnant.
Me: This is going to have to go to the OR
Her: What is it?
Me: An emergency. I'll call the OR and get everything started.
He had gotten his hand stuck in a woodchopper and there was a huge gash going across the palm. Through the gash, you could see the tendons were cut, as were the bones. Bone fragments were stuck in the severed tendon ends, and the whole thing was bleeding profusely. I touched the index finger and it flopped backwards. The joints of the middle finger were dislocated, so it was bent the wrong way in the middle. There was still wood in the whole thing.

We got that case booked pretty quickly, Dr. Pregnant came in from home, and we started working on him, at which point we realized all the tendons, nerves, blood vessels, and bones to the index finger were cut, which meant the finger was totally dead. This also explained why it was so cold and it didn't bleed when we cut it. So we had to amputate it, because you can't keep dead fingers on your hands due to the high risk of infection. (and really, would you want a finger that was only attached to the rest of your hand by skin?) We then did some exploration and discovered that a lot of his blood vessels were ripped in half. We repaired the tendons, fixed most of the bones, and sewed him up, with the plan being to watch him for the next 24--48 hours and see if his fingers survived. If they did, we would go back and fix the nerves, if not, choppy-choppy.

That ended kind of late at night so I wrote my orders and figured I would tell the patient the details in the morning. So I was doing my morning rounds and the nurse came up to me and said "[the patient] is really worried that his index finger is numb." I said "that's because we cut it off." She said "I didn't know that," I said "neither does he. I was about to tell him."

Me: Can I talk to you for a little bit?
Patient: OK. Why is my hand numb?
Me: That's what I wanted to talk to you about. See, when I saw you in the ER, I told you it was a really bad injury.
Him: Yeah, it was bad.
Me: Well, it was so bad, that we had to cut off your index finger because it died because it was so badly injured.
Him: Oh my G-d.
Me: So now you only have 4 fingers. But we're really worried about your middle finger and your ring finger. Because when we saw it in the operating room, a lot of blood vessels were cut. If you don't have blood vessels, the finger is going to die. So we're going to watch you closely for the next 2 days to see what happens.
Him: I could lose my hand?
Me: No, you're not going to lose your hand, but I will tell you now, I think there's a greater than 50% chance you could lose your middle and ring finger. Your pinky is fine and your thumb is fine, but those two fingers didn't look good in the operating room.

He cried. As I would too if you told me you were going to start cutting off my fingers.

I wonder if this is the sort of thing you get used to doing. The other day I was talking to an attending and he said he called his dad to talk after he had to amputate an arm and it made me feel really good to know that other people also feel weird and guilty about cutting off bodyparts. As much as I appreciate a good amputation, it just feels so unnatural. Especially when you do it and they don't even know. I mean, how do you explain 'while you were sleeping, we cut off part of your body?'