A Letter to Trauma Patients from Dennis J. Beck, M.D.
Dear Trauma Patient,
Unlike many other types of physician relationships, the trauma patient/trauma physician relationship is unique. It truly is my privilege and duty to provide you with the most up-to-date and excellent service possible to return you to either to work, to home, and, most importantly, to your expected and normal quality of life. I have outlined some things to expect in your recovery, my personal ideas about trauma care and rehabilitation, and some expectations for the rest of your life now that you have encountered a traumatic injury.
1. Fractures/Broken Bones/Cracks/Hairline Breaks
All of these words mean the same thing. Your bone has been broken either by sustaining an impact, a force, or a direct blow. To break a bone requires the energy to be transmitted through your skin, the soft tissue covering the bones, and down to the bones themselves. The position that your arm, leg, or your broken bone is in at the time of the injury is always more deformed than it ever is when you see it or when I see it. Nerves, blood vessels, ligaments, tendons, and muscles get strained, stretched and injured, as well as the bone. These are impossible to see on an x-ray. Therefore, broken bones hurt more than just about any other injury you can incur both at the time of the injury and through the recovery process. I understand this and will make every attempt possible to provide you with pain relief either through rehabilitation, narcotic and/or non-narcotic pain medications, and consultation with pain management specialists.
2. Pain Management
While I do want you to be as comfortable as possible during the treatment of your injury and during your recovery, I do not want to create an environment where you become addicted to narcotic medications and require drug treatment and rehabilitation for that on top of your trauma rehabilitation. To that end, I will surely prescribe whatever pain medicine is appropriate and necessary for you for a period of 12 weeks following the date of your very last surgery to treat your orthopaedic trauma. At the end of 12 weeks, I will be more than happy and will make every effort possible to facilitate either seeing a pain management specialist or managing your pain with non-narcotic pain medicines. I will not prescribe narcotic pain medicines if your fracture is healed on x-ray and there is no evidence of infection or other complications after 12 weeks. To do this and to continue to linger on and drag out the use of narcotics is not only detrimental to you but will ultimately create an atmosphere of depression, anxiety, and dependence that is not part of the standard of trauma care in this community.
3. Smoking/Nicotine/Tobacco Use
I have an obligation to tell you that there is ample evidence in research literature that the presence of nicotine–whether it be from chewing tobacco, snuff, dip, cigarette or cigar smoking, marijuana smoking, or any other tobacco product–will significantly impair fracture healing. That is to say as little as one cigarette a day, one dip per day, one wad of chew, or other nicotine in your bloodstream hurts your body's ability to heal bones. This occurs because the nicotine slows the blood flow to your bones more than any other tissue in your body. The bone is starved of its ability to heal its fracture.
While stopping smoking is the right answer and does help other facets of your overall health, I do understand that it is legal and it is a privilege. At the very least I would ask that if you are unable to stop smoking indefinitely that you stop smoking completely without any use of nicotine gums or patches for the time during which your bones are trying to heal. This will greatly affect your ability to heal fractures and your return to your life as you knew it before the injury.
4. Medications/Supplements
I believe that the use of routine multi-vitamins, including supplemental vitamin C and supplemental calcium, is very important during fracture healing and during recovery from trauma. It is well-known that your body requires more calcium when a bone is broken to heal it–the same amount required as when a woman is pregnant. To that end, I would recommend you take 4 Tums or the generic equivalent of a calcium-type antacid every single day while you are undergoing fracture healing. I also recommend 500mg vitamin C per day and a generic multi-vitamin. I do not believe there is any difference between the generic and brand-name of these supplements. I strongly encourage their use. I can help you if you need any advice regarding attaining these supplements.
5. Complications Associated with Trauma
Trauma is not a predictable type of medical practice. The injuries to your body are not planned, and their outcomes cannot be predicted. The amount of injury it takes to break a bone is enormous. After a motor vehicle accident, we are all impressed with the amount of damage the car sustains–and that is sheet metal welded together. In order for our bones to be broken in just one place requires more energy than it takes to deform sheet metal. The veins, arteries, and nerves associated with your muscles and bones are also injured at the time of trauma and do suffer damage, whether it be known or unknown to you at the time of the injury. Nerves can get stretched. Veins can get injured, torn, or bruised inside the body. Arteries can get injured, torn, or bruised inside the body. With all trauma, there is a risk of deep venous thrombosis (blood clot), nerve injuries (stretched nerves, numbness and tingling), or other complications associated with being on your back or not mobile for a long period of time (pneumonia, upper respiratory illness, bed sores, and joint stiffness). To that end, all trauma patients in my practice should consider taking, at the very least, an aspirin a day, whether it be a baby or adult aspirin, for blood clot prevention–if that is okay with your primary care doctor and your overall medical health. Some patients will be on Coumadin, Heparin, or Lovenox, all three of which are more potent blood thinners, depending on the type of injury, the extent of their immobilization, and the surgeries performed. This decision will be made by me at the time of your initial evaluation, and we will talk about it extensively. In addition to drug and chemical blood clot prevention, I also believe in anti-blood clot stockings as well as teaching patients to do ankle pumps, which means wiggling your ankles up and down as much as possible while you are in bed or in a chair, to promote circulation in your legs. The action of moving your ankles up and down is the number one way to prevent blood clots better than any chemical or drug that I can prescribe to you, and it is totally in your control. Any surgery that is done carries with it a risk of infection no matter who does the surgery, where it is done, what antibiotics are given, or under what conditions. Should you get an infection, we will be required to go back to the operating room for washing out of the infection, and you also will be prescribed IV or oral antibiotics. This is a known complication of any surgery and trauma patients being exposed to the environment during the time of their injury, and having skin, muscle, and bone torn open to the air (compound fracture) have a higher risk of infection. Should this be the case, we will continue to monitor your wounds closely and treat aggressively any issues as they may arise.
6. Bone Healing Complications
Once all of us pass the point where our bones stop growing (skeletal maturity), the healing of fractures is never guaranteed. Whether it be from smoking, other medical problems, or whether it be chance mechanical problems or issues related to the injury, i.e., many fragments of bone and soft tissue stripping. The healing of bones is never predictable. I do everything possible during surgery to restore as anatomic a position of your bones and good contact as possible. However, even though that is the case, occasionally bones go on to develop a nonunion (no healing). Should this occur, the first stages of treating a nonunited bone is to consider a bone graft and consider the source of the nonunion, whether it comes from the injury itself or whether it derives from the extent of the injury at the time of trauma, blood flow compromise, infection, or premature weightbearing and loading of the bones prior to healing. Most often a subsequent surgery with bone grafting is required and possible exchanging of the initial implant used for a different one to facilitate final healing of the bones. Nonetheless, I stress that fracture healing is not a definite science and no guarantees should ever be given regarding the status of bone healing or its definite outcome. I mean this not as a waiver of responsibility but as an honest explanation of trauma care, as if you were my family.
7. Rehabilitation and Outcome
My number one goal is to facilitate the healing of your fractures or other injuries to your musculoskeletal system. I will not rest until I have done everything I know how to do and, when necessary, will request the help of other colleagues in orthopaedic trauma around the country and the world to facilitate your recovery. The process is frustrating and does cause depression and post-traumatic stress disorder in many people. The recognition of these syndromes in clinical diagnoses is important and should be discussed on a regular basis. I can assure you that once you break a bone, whether it be the shaft of a bone or the part of the bone that connects with another bone, called a joint, the possibility for a 100% return to status is impossible. This does not mean you will hurt for the rest of your life. This does not mean you will be restricted from your job duties. However, it does mean that the risk of arthritis, stiffness, and other complications are higher once you have broken the bone than it is prior to having broken the bone. That outcome cannot be changed no matter what is done or when it is done. I will work with you. We will use rehabilitation, bracing, casting, surgery, and whatever means possible to achieve as good a result for you as possible. I can assure you that you will be treated no less than if you were one of my own personal family. At each post-operative and trauma visit, I encourage you to write down your questions so we can go through them as efficiently as possible, addressing each one and giving it the attention it deserves. I am happy to refer you to the Internet, to books, or to other pamphlets and literature about any subject on which you may have a question through this whole process. I appreciate the opportunity to be your trauma surgeon and look forward to as full of a recovery as possible.
Sincerely yours,
ORTHOPAEDIC ASSOCIATES, INC.
Dennis J. Beck, M.D.
Director of Orthopaedic Trauma
Deaconess Hospital
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