Informed Consent

It would be my last call of the day. I didn't really want to go - I'd been dispatching all afternoon, when my coworker called me and passive-aggressively asked if I knew that we were now closing dispatch at 3:30 instead of 4. She didn't say so, but knowing her, she wanted me to take the call that had just come in. We had to go in order, and if I didn't get back in the pool, she'd be up next. I fumed in the hallway as I waited for the elevator about how bossy she was, but the second I arrived on scene, I was grateful I'd come.

At the bedside, along with about 3 nurses, was a handsome, strong-looking young surgeon practically shouting at a similarly young, strong-looking brown man in a hospital bed. "USTED PUEDE COMER COSAS COMO CAMARONES, MARISCO?" I was impressed by his decent vocabulary and grammar, but he looked pretty intimidating. I wasn't sure yet if this was my patient, but decided I didn't care. There was a good chance it was, and either way, this man deserved better communication. So I approached the bed and, projecting my voice above the machines, side-conversations, and the loud surgeon said, "Need an interpreter?" One of the nurses turned around and said, "Oh, perfect timing!" - as if I'd arrived by accident. I wondered who had requested an interpreter, and, for the millionth time, why most everyone else seemed to think they could do without one. The surgeon said, with relief on his face, "Oh, great, yeah, here's someone who's trained, let the professional do it." He sped off and I took his place at the head of the bed. Clearly someone had strongarmed him into helping them "get by." Still, I was grateful for his endorsement.

The nurses took him through their usual pre-operative questions: are you allergic to anything? when was the last time you ate or drank anything? etc. The surgeon came by with the signed consent to say that there were "a few things I had to add, and I need you to initial them - unfortunately they make me do that". He was apologetic, I think because the man found it so difficult to use his hands. Obviously, whoever had gone through the consent initially had done a rush job.

In case you're not familiar with consents for surgery, a consent contains several key elements: benefits of, risks of, and alternatives to the procedure are the most basic ones. The forms I've interpreted also often contain a diagnosis, who's performing the procedure, consent to receive blood if necessary, and disclaimers about video/camera recording and student presence in the operating room, among other things. Whoever had filled this consent out with the patient initially had forgotten to write in three things: the benefits of surgery, the name of the surgeon, and under risks, the possible need for further surgery. So we briefly went through the consent again. The doctor explained that the benefits would be to reduce pain and prevent the joint from stiffening, that it would require putting in a plate and some screws to keep the bones in place, and they would stay in for life, and that the patient might need further surgery at some point, but they couldn't predict that. This last is a blanket disclaimer that often gets thrown in as a way of saying, "something might go wrong at some future point, and you might need surgery again for it" It really doesn't mean anything more than "the future is unpredictable".

Our man initialed, painstakingly, in the places he was shown, and we continued to prep for surgery. The nurse stuck a Q-tip with a nasty looking brown substance up his nostrils to disinfect them, and had him brush his teeth with a mysterious liquid from a brown bottle. Finally she bent over him and asked, "Sir, do you have any questions for us?" Maybe it was something about her kind touch, or maybe he'd just had time while he was being disinfected to think about what he'd heard. In any case, he spoke up. "Si. Yo quiero saber porque no me entablillaron la mano, porque la verdad que prefiero que no me hagan esta operacion, pienso que seria mejor regresar a Mejico y encontrar un cura-huesos que me sane." He said more, but that was as far as I got in English before the nurse looked at me sternly and said, "So we need to get the surgeon to come back here." While she did, I took a second to marvel at what he'd said. "Yes. I want to know why they didn't splint my hand, because truthfully, I would rather not have this operation, I think it would be better for me to go back to Mexico and find a bone-healer to cure me."

It has become a fundamental principle of Western medicine that we don't do anything to the patient against their will. When we fill out consent forms, we often say, "but even if you sign this, you can change your mind at any time." Well, this man had.

Another surgeon on his team came to the bedside, and explained that they were planning to put his bones back where they need to be so they can heal. The man said something I've heard many times: "Bueno, si van a hacer lo que el dice, eso esta bien. Pero el otro doctor dijo que  me iban a poner una placa y unos tornillos, y que si no queda bien, me van a tener que rajar la mano otra vez, y si hacen eso y queda mal, un cura-huesos ya no me va a poder ayudar, como es normal." I repeated, in English, "Well, if you're going to do what you're saying, that's fine. But the other doctor said you were going to put in a plate and some screws, and that if it doesn't turn out right, you'd have to cut open my hand again, and if you do that and it doesn't work, a bone-healer won't be able to help me the normal way."
"I'm sorry sir," the doctor said, "I didn't mean to confuse you. We will put the bones in their right place, but then we need to put in a plate and some screws to make sure they stay there. So what the other doctor told you is true, too. Would that be ok?" I communicated this to the patient. By this time, the whole surgery team had arrived. The patient gave an uncertain, hesitant "Yeah..."
The doctors conferred "Has he had any medication yet?" one of them asked. The other shook his head. "What about his injuries?" "Well, he didn't hit his head, and there's no sign of a TBI" I knew that stood for traumatic brain injury. In a second I realized they were trying to decide if he was fully in possession of his wits or if they could operate anyway, for his own good, since they had written consent. As it turned out, there was no loophole.

So the head surgeon, who had filled out the consent earlier, clapped him on the shoulder, in a gentle, friendly way and asked, "What are you worried about?"
At that, the man really let loose. He began talking about his employer, and his worries about being out of work but having huge bills to pay, and worry about having to have a second operation and have even more to pay; how he would rather take care of this at home, but there was no money at home; how he'd never hurt his hand this way before, and really, he didn't get it- it didn't look that bad. At this point, he began to take off the brace he'd been wearing and inspected his arm dubiously. He'd seen guys on the farm back home twist their wrists in some terrible ways, and the bone-healer had straightened them out in 5 minutes.
I did my best to keep pace with him, and finally the doctor said, "I think you have some serious concerns about this surgery. My opinion is that operating is what's best for you, but at the end of the day it's your body, and I won't do anything you don't want to have done. So why don't we wait another day or two and we can talk more, and you can think it over. We can wait two days, and if you want the surgery then, I will do it." The patient seemed on the fence still, but after everything he'd said, the team knew they couldn't operate.

They wheeled him away, and I got called away to another patient. But I was amazed and oddly elated. The patient I'd just worked with chose not to have an operation that would assuredly improve his quality of life, and yet, I had a spring in my step. It took me a minute to realize what it was... I had just witnessed true informed consent.

So often the patients I work with have reservations or questions about what the medical team decides to do. So often they don't say them out loud, or are not fully listened to. But today, there was real communication. This man's voice and his worries were really and truly heard, and it filled me with a fierce joy. I really hope that he gets to sit down with someone and really talk about his reservations. I hope he does get the operation, and that his body returns to full functioning as soon as possible. But for that day, in that moment, it amazed me to see the whole machinery and process of the medical system come to a full stop to respect this young man's wishes. This young man, a laborer from the rancho (the backwoods of Mexico), who stood no chance of getting workman's comp from his employer, even though he was hurt on the job; this man who had more faith in the cura-huesos than in a first world medical procedure, the type of person who is so rarely listened to that many they have learned not to raise their voices or their questions - this man was listened to. It felt, just a little bit, like justice.