Tuesday, September 23, 2014

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?'


  1. I can't imagine how horrible it must be to have to deliver devastating news to a patient. But, in the scheme of things, loss of a leg or fingers is preferable to loss of life, so probably the initial crying is just due to the shock of the news and as the patient assimilates the new reality, they will put it in perspective. I also wonder if some of the distress is due to the fact that the absent body part is visible. I don't think people get as distressed to learn that a gall bladder was removed since you can't see it anyway. I base this conjecture on a conversation I had with a neighbor who had a melanoma on her nose and was thinking of not letting it be removed because she would be "disfigured." Without thinking and very matter-of-factly I commented, "So you'll be a very attractive corpse." She got the thing removed shortly thereafter. It's all in how you look at things.

  2. I can't imagine there's a good way to tell someone you had to cut off one of their favorite parts. For example, I don't miss my prostate (well, maybe a little), but as a guitar player, photographer, and a scratch-where-it-itches kind of person, I would seriously miss my fingers. I think the visibility of and usefulness of said part has a lot to do with it. If death is the only other option most people would prefer to live. Not all of them, though.

  3. With the index finger and all I couldn't help but thing of Irving's "A Prayer for Owen Meany" - at least in that case the amputee-to-be and the one doing the amputation knew what was going on and why, at least in the characters' framework.

    I agree with both Hildy & Jono . . . and, I don't think this is "the sort of thing you get used to doing" - and in some ways I'm not so sure I would "recognize/resonate with" you in the same way if you did, if that makes any sense . . .

  4. Great post. I work with amputees after they're discharged from your care. You have a very hard job in delivering that sort of news. Maybe you can also share some hope and encouragement that they will recover their ability to function, particularly with lower limb amputations. If the patient walked before the amputation, there is a great chance s/he will walk again after some re-conditioning and prosthetic training. There are good prosthetic and orthotic options for upper limb amputations, too. I can share more info with you via e-mail if you'd like to know more.

    I like to give patients a step-by-step plan so that they can focus on carrying out the current step. For example, in amputation generally the healing phase comes first, then rehab, temporary prosthesis after healing, then permanent prosthesis. I also emphasize that until you get the prosthesis we/other staff will teach them new ways to do things so that they can perform important self-care activities and get back to doing what they need/like to do as soon as possible.

    There is life after amputation!

  5. When I was in third year of med school (Germany), I did a course in plastic surgery (they do hand surgery and burns as well in this clinic). I happened to attend a surgery on a pretty lacerated hand (the accident was described to us as "hand got in between a truck and concrete floor" how did that happen?) and we needed to cut off half of the index and ring finger. The thumb didn't look very promising, but we left it to see if it survived,
    The next morning, the chief of surgery went on rounds. This meant nurses and medical students were rushing into the patients rooms to remove the wound dressings so he could look at the injuries. So I got to the hand patient and started to undress his hand. When I was almost done, he suddenly jerked his hand away and asked completely horryfied "What did you do to me???". No one had told him yet, so I got the 'honour'. It was bad, but I think I didn't screw up too much. At least I had been at the surgery and was actually able to tell him what happened.
    But I was so mad ad the surgeon responsible for the ward because I got in this situation. It was one of my worst moments with patients yet (next to the 40 year old mother who learned of her cancer diagnosis and the few months she would have left).
    No one really teaches you how to give bad news.
    I'll start my residency in orthopedic surgery next year.I guess I'll get pratice then.

  6. When I was getting my masters in social work, I did field work as a discharge planner. Anyways they had advanced degreed social workers working on this acute rehab until of a trauma hospital. All lot of the patients I worked with had spinal injuries. Anyways, I started an psychsocial assessment for a young athlete explained the role of discharge planners.... during this assessment it was pretty clear that the family did not have a clear understanding of the injury. I spoke to the mother in the hallway and compassionately explained to her that a doctor would never let her son play football again but with hope be able to walk again. This poor kid had a spinal injury! Nobody wanted to destroy this kids dream...

  7. First of all, I think it sounds like in these cases you do a good job of breaking the bad news; after all, there is almost no way that a patient will respond "well" to bad news so that is not a particularly helpful indicator of how it went.

    Most important is that the patient actually understands what is being said or what actually happened (i.e. that communication takes place), and secondly that the patient doesn't receive more "insult to injury" due to a poor communication technique, lack of empathy etc. on the doctor's behalf. Thirdly, the patient gets space to process the news and is not given more information (such as on future possibilities) in the first conversation as this may overwhelm them (unless they ask for the information).

    I'm surprised at the previous commenter's remark that they are not taught how to give bad news, as at my medical school we do receive thorough courses on delivering bad news to patients. It was also definitely not right of the responsible physicians to have inadvertenly put you in that situation.

    While it may never get easier to give bad news (and probably shouldn't get easier as each individual case deserves respect and attention), there are conversation techniques that achieve the aforementioned points. The things I always try to keep in mind are to respect the patient's rights to know what is happening to them and also give them time to process the news.

    As an example of how not to give bad news, my father was told that he had non-Hodgkin lymphoma by a doctor actively avoiding eye contact. Then my father totally confused still had to ask him, "so is it cancer?".

    While every delivery of bad news is hard and never feels "right", I'm really glad my medical training gave me some tools to approach it.

  8. Enough talk about amputation. Just cut it out!

  9. I took care of a guy who had an accident with a circular saw… two fingers were in a baggie and one was just attached by skin. When I raised the idea of amputation (just in a theoretical way-- I was an intern doing an ER rotation) he started talking about "don't let me be a cripple".
    But that doesn't hold a candle to the shoulder disarticulation I did for tumor… he didn't know going under and he woke up and asked what happened and all I could think of was to say "we got it all".