FORUM

Keeping Patients First

Graham Ramsay Joseph Ladapo

Mrs. D was a frail, 70-something-year-old woman who had fallen at home and dislocated her hip. Upon arriving in the emergency department with her husband, she was promptly triaged into a low-acuity treatment room. One of the junior orthopedic residents was called downstairs to examine her. He decided to perform a closed reduction of her dislocation, a procedure that consists of manually manipulating the hip and leg in order to return the head of the femur to its normal location in the pelvis. With adequate pain control and proper technique, this method is often successful and is generally preferred to performing the same procedure in the operating room under general anesthesia.

The orthopedic resident ordered some pain medication for Mrs. D and asked her husband to step out of the room. I was in the middle of working up another patient when the attending emergency medicine physician glanced at me, nodded toward Mrs. D’s room, and said, “Why don’t you go in there and help?” Eager to learn more about the procedure, I scurried into the room and joined a few other residents who were already positioning themselves around Mrs. D’s bed in preparation. The orthopedic resident would need our help stabilizing her pelvis while he applied the necessary traction force to her knee and leg. “Hold here and push when I tell you,” he said to me, as he placed my hands over a blanket that had been wrapped strategically around Mrs. D’s hip.

Mrs. D was somnolent from the pain medication, but seemed to be tuned into our preparations. She braced herself as the orthopedic resident signaled us to execute our orders. Within moments, we were tugging and pressing on her limbs and hips, and though Mrs. D’s small, 130-pound frame seemed no match for the youthful bodies surrounding her gurney, her femur refused to budge. She was also in obvious pain, despite the medications she had taken.

The resident pressed on, pausing between attempts to modify his instructions and administer more pain medication, but Mrs. D’s hip joint was obstinate, and her pain seemed only to intensify. She cried for us to stop.

As her pleas grew louder, the atmosphere in the room became increasingly uncomfortable, and I could see the doubt and uneasiness in the eyes of the residents in the room. I was bewildered. Why were we pushing so hard to perform a non-emergent procedure that could be successfully performed in the OR? I knew that the risk of avascular necrosis of the femoral head—a frequent complication of hip dislocations—increases if treatment is delayed for longer than six hours. But we were well within the window of safety. Why had no one challenged the orthopedic resident’s actions in the face of Mrs. D’s discomfort? Would I be out of line as a medical student if I said something?

The ordeal continued until one of the senior orthopedic residents made his way downstairs and declared the procedure unsuccessful, stating that it would be performed under general anesthesia in the operating room. “If you don’t get it in the first couple tries, you’re not gonna get it,” he said to me as we stood outside her room.

Later on in my shift, I ran into the same senior resident and asked how Mrs. D was doing. They successfully reduced her hip, he told me, and she was now in recovery. I was relieved to hear the news, but still puzzled about the earlier events as I continued to wonder how something that seemed so misguided could have occurred without intervention.

Mrs. D’s story is a particularly disturbing example of a paradigm that has unfolded many times during my training as a medical student. Indeed, pain and discomfort are often unavoidable parts of clinical care, but I have witnessed occasions in which health care providers, unconstrained by clinical demands or other challenges, have apparently done less than they could have, when doing more would have meant much for the patient and come at a small price to the provider.

These situations have been the focus of some of my conversations with other medical students, and I often wonder what choices we will make when our time comes to direct the course of patient management. Ultimately, we are all individually responsible for how we choose to deal with these challenges, but my personal belief is that leadership and the examples set by our colleagues and teachers play an important role in how respectful we are of patient needs.

As medical students, we learn the clinical aspects of medicine from our residents and attendings, but we also learn the informal, day-to-day aspects of medicine from them, too—in a much less explicit fashion. For example, the level of detail we include in our patient notes, the care we take to respect a patient’s modesty during a physical exam by draping him with a sheet, and how clean we leave a room after completing a medical supply–laden procedure are all behaviors that most of us pick up through active or passive observation as opposed to the more formal processes that characterize the rest of our training.

My suspicion is that the attention we pay to a patient’s pain and discomfort is also molded through these informal channels. To the graduating Class of 2008: I hope we can continue to adhere to the values that drew us to medicine in the first place and set examples that inspire excellence, responsibility, and compassion in those who follow us.

—Joseph Ladapo is a Harvard medical student and a PhD student in health policy who is graduating this year.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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