The secret is to know when to stop

Once upon a time, people would come to the ER holding their arms or getting pushed in their wheelchairs. I would X-ray their bones and see if they'd broken any. If not, I'd decide if they needed a tensor bandage, an air cast boot or a splint, and I'd send them on their way. Bone broke, me fix. Not as easy as it sounds. I've had patients ask for hematoma blocks instead of conscious sedation and then scream like an air raid siren when I reduce them. I've had to pull tricks out of my back pocket, like when that screaming patient with a Colles fracture balked under my hands, I remembered a tip from a senior resent years before, and I bent that radius like Beckham, over a crutch, and reduced that bad boy. Read: What if they're killing medicare on purpose? I once reduced a radius and ulna so beautifully that I asked the mom to applaud—and she did. Of course, what weighs on me are the many frustrating ortho stories. The one I feel saddest about is a farmer trampled by a cow. Dislocated femur. She'd been reduced by an orthopedic surgeon and was transferred and admitted to our hospital 45 minutes away, which has no surgical coverage at all, but her hip had dislocated again on the ward. "I can do this. The Captain Morgan method!" I said. Thanks to my colleagues' tips and a YouTube video, I'd reduced one before on a night shift at a bigger hospital when the orthopod on call had refused to come in. I set up with confidence. Conscious sedation, and pop. We all heard it go in, and I felt the clunk. I rushed to the patient's side when she woke up. "Pain's gone," she said. "Perfect!" I shipped her off to X-ray. We don't have a portable X-ray at our small shop. The technician looked serious. I took one look at the film and couldn't believe it. The hip had popped out again, just from wheeling down the hall to our radiology suite. "Pain's back," the farmer gasped. Read: The bonsai doctor I called the other orthopod now on call, and he agreed to take the patient immediately. The reason I feel bad is that the grapevine later told me that the surgeon didn't come see her that night. The farmer bounced in an ambulance all the way back to that hospital and spent the whole night with a dislocated hip in the ER, in agony. (Farmers don't complain easily.) Now, this did seem like a surgical case to me, so it's possible the patient was on the OR list and got bumped, but it feels awful to know that she suffered. However, I was going to tell a different orthopedic story. My last January 1 shift felt like nonstop fractures plus not one but two dislocated shoulders. Lots of ice, lots of falls, lots of alcohol. This New Year's Day, I expected chaos, especially since another local ER had closed. But when I first arrived, only one patient waited for me with … you guessed it: a Colles fracture. Not badly dislocated, so I didn't have to worry about reducing it. No, what bothered me was that I'd watched the osteoporosis lecture in rheumatology on Echo and now I knew to critically appraise fragility fractures. Sure, the person had slipped on the ice, but should your average 50-year-old really break a wrist that way? Not from a height, not at great speed. "Have you had any other fractures?" I asked. "Yes, my ankle six months ago." "See, that's too many fractures. Have you been checked for osteoporosis?" "I haven't seen my family doctor. I left a message, but I didn't get a call back." I sighed. "But I need you to follow this up." The patient stared at me helplessly. "It means that you call every day. Repeatedly. You don't let it go. Slim white and Asian women are at higher risk for osteoporosis...and do you smoke?" "Yes." "There you go." I half-waited for a response like, "You're right, doctor. Thank you. I'll get right on that!" I didn't get it. So after a hesitation, in addition to splinting her, I ordered the bone mineral density scan and prescribed calcium and vitamin D and smoking cessation mediation. Then I asked her to follow up swiftly with her family doctor as well as an orthopod. "Thank you!" I really feel for family doctors, because if you know all that, where do you stop? These tests are all relevant and require counselling, along with the new meds, so how are you supposed to get that done within 15 minutes, especially when you probably don't have a nurse or any other help? You know so much, but you have to tell patients to come back another day, and then they leave a nasty rateMD review. I've literally seen this happen, especially to women. I also feel for doctors in any other specialty who go the extra mile. It's much faster to send the patient on their way without doing those extra steps. You've technically done your job with a splint and an ortho consult, and you don't end up having to follow up on test results in a few weeks or fielding calls from the pharmacist who wonders if you really wanted 2000 IU of vitamin D. If you don't have compassion, it doesn't affect you personally if that patient breaks another bone in six months. In fact, you get paid to see them in the ER again. Good news for you. But if you're a good person and a good doctor, I know you're doing a bit or a tonne extra to keep the system afloat and patients as healthy as possible. The secret is to know where to start, when to stop, and how to look after yourself while doing it. Just a note to say that I see you and I appreciate your extra work. P.S. If you're cutting corners, I see that too.

The secret is to know when to stop

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