I Am Not Sure?

It was a beautiful Friday morning, a few weeks into the summer. My schedule appeared lighter than usual and I even envisioned leaving work a bit early. Maybe a challenging bike ride before dinner. I was sitting in the chairman’s office having our weekly meeting. One of our junior faculty members called . . . he needed help. He was on call and a 32–year–old pregnant woman with a displaced femoral neck fracture had just been transferred to our emergency department (ED). Ms. B tripped in her kitchen last evening. She was unable to stand and was brought to the local ED by ambulance.

My colleague was concerned that he wouldn’t be able to successfully reduce the fracture. The long–term prognosis of the hip joint depended on a successful reduction of the femoral neck fracture. In addition, there was an ongoing debate in the orthopaedic literature related to the urgency of operative care to prevent osteonecrosis of the femoral head. I reviewed the x–rays, didn’t anticipate a problem and let him know that I would come to the operating room (OR) to assist. “No”, he responded, “I am not comfortable caring for this patient”. I immediately left the office, went to the hospital and assumed care of the patient. Clearly, my plans for a bike ride were gone, but I had the opportunity to help a woman in need of expert orthopaedic care.

Ms. B had been admitted to the obstetrical service. She was a 32–year–old woman of Haitian descent who had recently immigrated to the United States. She had very limited English comprehension and her primary spoken languages were French and Creole. She was alone, in a hospital in a foreign country. She was 24 weeks pregnant with her first child and had no other co–morbidities. Her pregnancy had ben progressing uneventfully.

When I first met Ms. B she was lying on a stretcher in an observation unit on the obstetrical floor. She appeared frightened. Two orthopaedic residents were present and obtaining consent for surgical repair of the hip. In their minds there was nothing to discuss, the patient had a displaced femoral neck fracture and needed to have surgery immediately. In their minds, no other options were available and obtaining consent would be straightforward. I introduced myself, sat down on a lab stool by the bed and began a conversation. I needed to meet the patient, understand who she was and discuss treatment. I am not sure that obtaining an informed consent is ever “straightforward” when a doctor is explaining to a patient that they require emergency surgery. This discussion surely would not be easy or straightforward.

We utilized a telephone interpretation service. Every question and response required the transfer of the handset between the patient and physician. Ms. B was in pain and frightened. She immediately expressed concern about her pregnancy and her baby. I arranged for her to meet all of the physicians who would possibly be involved in her care and the care of her baby. Each consultant could explain their area of expertise and potential involvement in the care of Ms. B and her child. She met and had an opportunity to talk with the obstetrician on call, a maternal fetal medicine (MFM) fellow and a neonatologist. I supplied the orthopaedic information. I explained the severity of the injury, the risks of osteonecrosis either with or without surgery as well as concerns over non–union and traumatic arthritis of the hip. Undoubtedly, in a healthy 32–year–old woman who wasn’t pregnant, early surgical intervention would be the most appropriate management in hopes of preserving a normal hip joint. We also discussed the possibility of treating her without surgery. She would be administered pain medication, which were known to be safe during pregnancy, and allowed to begin to ambulate with a walker or crutches. I explained potential problems without surgery and what options would be available to treat any problems that developed with her hip after the child was born. Of course, hip fractures in pregnant woman are very rare, and as a result treating a...