Recently, I read a tale in the Washington Post titled “The surgeon said he could fix the injured arm. He had an odd definition of ‘fix'” in which the author described his harrowing 8 year surgical complications odyssey to repair a left distal radial fracture and elbow dislocation acquired when he fell off a ladder one fine day.
His initial surgeon gave him two choices, described the procedure, and essentially told him that he had limited experience with the fixator device that would be used. The author consented and after the operation found himself paralyzed in that forearm and hand…permanently. He then sought a different surgeon to repair the nerve damage with a donor nerve from his left calf. That operation left him still with a paralyzed left arm and now a numb left foot as well Scar tissue set in the arm prompting another operation to clean that out. This operation was complicated by an infection with Staphylococcus epidermidis, a bacteria that normally hangs out on our skin. His last operation, a tendon reconstruction did finally restore some functionality in his left arm.
First, I would like to thank Mr. O’Connell for sharing his very thought-provoking story. Unfortunately, I would have to admit his is not an unique scenario. I have seen patients like him have operation after operation after operation…and I see them because at some point the surgical site becomes infected. Now I have the frustration of the patient on me because the surgeon has invariably told them that antibiotics will take care of the issue and I have to tell them, woah not so fast.
Antibiotics are probably only about 20% of the treatment, surgery being the bulk but somehow only infectious disease physicians believe that. As the patient sits there frustrated with me because I’m not offering them the magic antibiotic pill or drip, or not giving it to them for as long as they or their surgeon think it should be given, I wonder whether they regret having the first surgery in the first place.
Even though S.epidermidis is not as virulent as Staphylococcus aureus (whether methicillin sensitive – MSSA, or methicillin resistant – MRSA), it certainly latches on to foreign bodies and refuses to let go. It can sit there on an implanted hardware or prosthesis just chilling and the patient wouldn’t have the slightest idea that there’s a smoldering infection underneath…until one day out of nowhere it makes itself known. Treatment therefore consists mostly of removing the hardware with its bacterial cloak and not giving the bacterial cloak an antimicrobial bath with the hardware in place.
Mr. O’Connell’s story made me think of the incentives physicians (including surgeons) have to offer one therapy over another. This especially after learning the other day that arthroscopies may be no better than placebo for osteoarthritis. Clearly, with the abundance of strange-looking faces, titties, abs, and overall bodies owned by celebrities amongst others, there is a financial incentive in cosmetic surgery. But I guess it didn’t dawn on me clear as day that there might be a financial incentive for an oncologist to offer chemotherapy to a dying cancer patient or for a neurosurgeon to perform a lumbar fusion that’s unlikely to help a patient’s back pain.
One of Mr. O’Connell’s gripes is that if he “had had access to some solid, physician-specific outcome data and better information on the risks and benefits of the medical devices [his] doctors were proposing” he could have made better health-care decisions. I’m not so sure that would have helped. Physicians as patients are just as susceptible to the parade of complications he suffered.
Another poignant moment in his story is when he recounts his surgeon’s apology for giving him an infection. I was rather surprised as I don’t think I have met a surgeon who owns up to an infection. Maybe they do to the patient themselves and I’m just not privy to that discussion. More often than not, the surgeon and I discuss the infection as something that is just there with no fault or they discuss it as such a major surprise…like it’s never ever happened before in their career.
I know a surgeon whose infection rates are higher than for the others in his group. I guess that’s inside knowledge that I’m privy to and were I to need an operation I wouldn’t go to him. So maybe Mr. O’Connell has a small point there. But anyway, this surgeon is annoying because none of the countless infections he has sent my way have been his fault. Unlike others, he doesn’t leave the infection as a neutral event. No, he invariably wants me to test the patient for an immunodeficiency that has to be making him or her prone to infection. Checking HIV status and immunoglobulin levels is the first-line response to a surgical site infection in his book. If it is not that then he blames the poor wound healing on the patients obesity, diabetes, or their tobacco abuse, which contribute, yes, but everybody else has patients with those comorbidities too. Or, the fault lies with the infection control practices in the operating room which incidentally are the same ones used by all the other surgeons. Lastly, the fault is with us, the infectious disease physicians for not choosing “the correct antibiotic.” He’s really getting on my last nerve, can you tell?
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