This is a true story.
An 80-year-old female patient of mine with high blood pressure,chronic irregular heart beats(chronic atrial fibrillation) and moderate narrowing of the internal carotid artery in the neck,was sent to an orthopedic surgeon for consultation for carpal tunnel syndrome(pinching of the median nerve at the tunnel called carpal tunnel at the wrist)
She was treated with a wrist splint but her symptom of pain was not getting any better. The pain in her right hand was getting worse and she is right-handed. She was frustated and ask if any thing else can be done besides taking pain killer.
Without sending a consultation report to me,the orthopedist mentioned-above scheduled a surgical procedure to release the pinched median nerve within about a week or 10 days after he saw her. He did not call me. The patient called me to inform me about the date of the proposed surgery.
The patient was advised to come in to dicuss about the proposed procedure. She was advised to call the orthopedist to postpone the surgery. She did so but very reluctantly because she was afraid that she might make him mad. This prompted a call from the orthopedist asking me for the reason to postpone the procedure. I told him the reasons which were explained to the patientlater.
Even though the surgery will be done under local and or regional anesthesia,I explained to the patient that sometimes it will have to be converted to general anesthesia which will put a burden to her heart. Therefore she should be ready for that. The patient was also at high risk of developing a stroke due to atrial fibrillation and blockade of the internal carotid arteries.
The patient was sent to a cardiologist who cleared her for surgery,provided that the ventricular rate(heart rate) was under controlled. At that time her ventricular rate was a little fast and it was finally controlled by adjusting one of her medication. She was also on a blood thinner called coumadin.
A radiological procedure called CTA(CT Angiography of the carotid arteries) was done to more accurately assess the severity of the blockage of the internal carotid arteries. It turned out that the stenosis was not critical enough to require carotid endarterectomy(removal of the atherosclerotic plaque from the internal carotid aretry)
All these time,the patient was wearing the wrist splint faithfully.
On an office visit after the above work-up,the patient's symptoms of pain of the carpal tunnel compression was dramatically relieved. She did not have any more pain in the three middle fingers in the right hand. I told the patient that she should consider to postpone the surgery indefinitely because the carpal tunnel release will not accomplish any more symptom improvement. Again the patient felt so intimidated that she asked me to call the orthopedist to cancel the operation for her.
After explaining to her the concept of patient's autonomy,she began to understand that it was her right to decide whether to undergo a surgical procedure or not. A day later I received a call from her. She cancelled the surgery indefinitely.
- Always inform your primary care physician about any proposed procedure recommended by the specialist consultant.
- You have the right and autonomy to decide whether to undergo anr kind of surgery after the surgeon gives you the informed consent.
- Always ask the following questions:What is going to be done? What will happen to you if you don't want to have the procedure done? What is the usual result for the particular procedure? Will there be any complication? Will the condition come back? When will it be done? Why any rush to do it?,etc. There are no stupid questions. If the surgeon answer all your questions to to your satisfaction,and you have made a decision. This is called an informed decision and if you sign a consent to have the procedure done,the consent is called an informed consent.
- If you have multiple medical problems,and the procudure is not urgent,it is always wise to have your primary care physician perform proper preoperative assessment to prepare you to be in the optmimal condition for the surgery to prevent or minimize potential complications.
Lessons learned in this case: An elective surgical procedure is postponed indefinitely. If the diagnosis is in doubt or the pain comes back,a repeat EMG(Electromyography) can always be done.