Busy day in surgery today, as well as seeing consults between cases. The surgeries went fine, but what was really hanging over the orthopaedic resident and I today was a discussion we needed to have with a patient and his family. Last week, we worked hard to save the life of the man who had a terrible injury to his pelvis and leg. You might remember a photograph of a mangled leg accompanied by warnings not to look if you would find it disturbing.
Thankfully, he has stabilized. He has gone from the intensive care unit, to the intermediate care unit, and today was able to transfer to the regular men’s ward. His blood pressure has stabilized, and we have been taking him to surgery every two or three days to clean out his wounds, and remove damaged tissue.
The leg is teetering on the edge of being salvageable. The bones and muscles are so damaged that he has little hope of a well-functioning limb. Though his hip, knee, and ankle are fine, the areas in between are mostly devoid of functioning muscle, and severely fractured. We have had discussions with him over the last days, but wanted to have a family care conference today so everyone was on the same page.
His social situation is far more complex than I could have imagined. He is an orphan. Both his mother and father have died, but we did not discuss how they died. His father had three wives, two of whom are still living, so we had the discussion with a dizzying array of uncles, in addition to his brother and older sister. Decision making authority rests with the patient, as he is lucid and capable of making his own choices. Kenya has a strongly family-oriented culture, however, so group discussions and consensus building are vital.
The relatives strongly recognize that they may be held accountable by other family members for medical decisions, so they made it clear that they would abide by “whatever the doctors decide.” This puts a little too much authority in our hands, however, as the final decision needs to be up to the patient.
Thankfully, the family had outstanding English skills, and communication skills in general, and the Kenyan resident I’m working with filled in my language and cultural blind spots. We had a long and intricate discussion, and each person voiced his perspective and concerns. I’ve been in discussions like this a number of times, and I’m often struck by the patience, careful listening, and gentle pace of the dialogue. It is vital for the health care providers to understand the depth and breadth of implications of decisions like this. In the end, we met privately with the patient, who was markedly comforted by the group consensus. We discussed his options again, prayed with him, and he expressed his decision.
The plan is to do everything we can to save his leg, regardless of cost, number of surgeries, or length of treatment. If at any point we feel like the endeavor is hopeless, or is putting his life at risk, we will communicate this with the patient and with the family.
For this man, I think this is the best decision. If things go well, his leg will work a little better than a prosthesis would. Moreover, his psychological and social situation would make amputation an unusually devastating blow. He and his extended family realize that this is a real possibility, but they would all rest easier with this decision knowing that every effort had been made. Remarkably, one of the uncles present is on a disability awareness council, and repeated the mantra that “disability doesn’t mean no ability.” He is encouraging his nephew that, regardless if he winds up with an amputation or not, he can continue with a productive life.
I feel privileged, if also saddened, to be part of discussions like this. Kenya is a country with a high incidence of motor vehicle violence, and few doctors to treat the suffering. We may or may not succeed in saving this man’s leg, but I am pleased that he knows he is cared for by his family and by the staff here at Kijabe.