"We can rebuild him" ... Or... can we?
When I see a patient with a horrible injury, as I did last week, I'm always reminded of the hit 70s TV show The Six Million Dollar Man, starring Lee Majors. I know of it peripherally, but never watched very much - it was cancelled almost a decade before I was born (editorial note: remind me to talk about older generations blaming younger generations for not knowing about the culture that preceded theirs).
(Bonus editorial rant: $6M is a pittance compared to what it would REALLY cost today to rebuild a human to that degree. Even partially. $6M might cover part of the surgery and/or maybe part of the ICU stay. But you'd need to tack on a whole lot more to that tab, such as the nursing, the drugs, the anesthesiologist, the post-operative therapy... and who would pay for the dozens of administrators necessary to ensure quality, safety, reliability, and 17 other things that end in "-ty"?)
Invariably, someone will jokingly refer to the most famous line from that show: "We can rebuild him. We have the technology." And then, equally invariably, the rest of the room will roll their eyes because of course Karly would be the one to say that. That is such a Karly joke to make.
That line is such a tired cliche that just about everyone in the hospital has heard it before, from the PICU nurses to the garage attendants. But what they might not all know is that the line continues: "We have the capability to build the world's first bionic man. Steve Austin will be that man. Better than he was before. Better, stronger, faster."
And no, that's not a Stone Cold joke. Steve Austin was the name of the protagonist in the show.
But to bring this back to the patient for a second (I know, what a downer), the irony is that the orthopedic surgeon is the only one in the room who knows that no, we cannot in fact rebuild him. We certainly couldn't do it in the 70's and we still can't today.
The nurses, anesthesiologists, and medical students all think that we are bringing the patient to the OR to put plates and screws in, or replace joints, and make the patient "bionic" as a result. Okay they realize he maybe won't be better and faster, but they are typically under the impression that the main goal in these cases is restore the patients back to how they were.
That's simply not the case, however, with most of the more intense trauma work we do. Patients return to function when it goes well. But it doesn't always. And even when it does, the function they return to is not usually normal. As one attending so eloquently puts it: "She'll do okay, if she does alright."
So what's with the disconnect? Why does everyone in the room except the surgeon think that the polytrauma patient will run again since we're in there operating on his femur, calcaneus, and ankle fractures, and his pelvic fracture, and his wrist fracture? I mean, we're "fixing" him, aren't we?
Yes and no. Surgery in general, and specifically Orthopedic surgery, has evolved so much over the last few centuries. A patient having major orthopedic surgery 200 years ago (i.e. an amputation) may not have had much of an anesthetic (unless you count grain alcohol), zero antisepsis, would be operated on with crude instruments like a two-man saw, would have a disastrously high risk of complications and death, and there'd be next to no hope for recovery of function.
Yet today we can anesthetize the patient, we have aseptic tools and techniques, we have fourth-generation intramedullary nails and customized titanium plates and screws, we have total joint replacement arthroplasties that are engineered specifically for each patient's unique anatomy.
We have made great strides. But we still have a long way to go. Blunt muscle injury is still basically ignored and left to heal on its own, since we know of nothing better (not for lack of trying), and we possess essentially no ability to induce regenerative or restorative powers within the human body. We can grow cartilage in a lab, but in very small quantities, and it may not be as durable, and even just for a small amount it is preposterously expensive. These two factors alone, severe muscle injury with resulting scarring and inability to fully restore cartilage, can lead predictably to stiffness and joint degeneration in post-traumatic settings. And that's ignoring the trouble with nerve injuries, which is a discipline that's advancing, sort of.
In other words, we can fix the bone, but not everything around it.
And in some cases, we can't even get the bones to heal. Every fracture we treat has its own risk profile. Some are very apt to heal, and, for the humerus and clavicle, the saying goes "as long as the bones are in the same room, they will heal." But try getting a scaphoid or a talus to heal and your odds decrease significantly - these bones naturally have a very tenuous blood supply and any time they break, there's a risk they won't heal. Even the oft-fractured clavicle can present with issues (especially when it's a borderline indication for surgery and the patient wants it fixed... guaranteed non-union!).
Non-union (failure of the bone fragments to unite) is a real risk. It happens. Sometimes we aren't sure why. Other times (such as when all the nutrient-supplying bone-lining tissue called periosteum is stripped from the bone, or when the bone has other reasons to have limited blood supply, such as nicotine use) the factors are somewhat more obvious.
So we can't even reliably fix the bones every time.
And even assuming all goes according to plan - the bone heals, the muscle isn't too scarred, the cartilage survives - even still, patients can develop CRPS (a syndrome of pain, swelling, and other autonomic findings that can lead to severe dysfunction and debility) after a fracture. We don't yet know what causes that. Nor how to really stop it (again, not for lack of trying, c.f. Vit. C).
Is it beginning to make sense why the orthopedic surgeon is the least optimistic person in the room during a polytrauma ORIF? Why unironically saying "we can rebuild him" strikes us as naive?
It's not just "the Six Million Dollar Man," though. The trope that we have reached peak medical ability (or that if we haven't by now we damn well should have) has been perpetuated by popular culture in films, books, and other TV shows. How many times a week do you hear or see someone saying/tweeting, "It's (insert current year) already! Shouldn't we (insert thing that's still a few decades away) by now?!"
2020 is, by most accounts, "the future". We're nearly there. So, patients expect we can just flip a switch and they'll be better, that they should experience no pain. That the medicine they knew just 20 short years ago in the 1990s for example, is ancient history and today's practices and techniques are leaps and bounds ahead. They simply have to be, don't they?
The real answer is, sadly, no. There's a ton we still do not understand about the human body and its response to injury or insult. There's also a lot of good science that looks promising, but has not undergone rigorous enough testing yet to be considered safe and effective. As a physician, my first rule is of course to do no harm. If I would use an unproven and potentially harmful new technology for a problem and it ends up hurting patients, I'd be stripped of my license and possibly even incarcerated a la Dr. Death.
These things take time. Medicine is simply not as advanced as movies and TV would lead you to believe. Arduous study and testing must be completed before new technology can be incorporated into patient care (or "go live," as the saying goes). And we're currently confined in a conflicted practice environment that champions cost-cutting blended with improving quality metrics, and patient-centered outcomes, yet implements a bewildering array of regulations and oversight committees to do so (despite a complete lack of evidence that they do any of those things well).
And that's not even getting into the insurance companies. Don't get me started.
Until legitimate studies prove new technologies to be safe and effective, we'd love to make you better, faster, and stronger, but we will have to settle for "almost as good as you were before." It ain't perfect, but it sure beats having your leg hacked off with a dirty two-man saw while a swig of bourbon takes the edge off.
So the outcome of "better/stronger" currently seems unobtainable. But if it makes you feel better, I'm confident your hospital will be happy to invoice you to the tune of six million dollars.
(Bonus editorial rant: $6M is a pittance compared to what it would REALLY cost today to rebuild a human to that degree. Even partially. $6M might cover part of the surgery and/or maybe part of the ICU stay. But you'd need to tack on a whole lot more to that tab, such as the nursing, the drugs, the anesthesiologist, the post-operative therapy... and who would pay for the dozens of administrators necessary to ensure quality, safety, reliability, and 17 other things that end in "-ty"?)
Invariably, someone will jokingly refer to the most famous line from that show: "We can rebuild him. We have the technology." And then, equally invariably, the rest of the room will roll their eyes because of course Karly would be the one to say that. That is such a Karly joke to make.
That line is such a tired cliche that just about everyone in the hospital has heard it before, from the PICU nurses to the garage attendants. But what they might not all know is that the line continues: "We have the capability to build the world's first bionic man. Steve Austin will be that man. Better than he was before. Better, stronger, faster."
And no, that's not a Stone Cold joke. Steve Austin was the name of the protagonist in the show.
But to bring this back to the patient for a second (I know, what a downer), the irony is that the orthopedic surgeon is the only one in the room who knows that no, we cannot in fact rebuild him. We certainly couldn't do it in the 70's and we still can't today.
The nurses, anesthesiologists, and medical students all think that we are bringing the patient to the OR to put plates and screws in, or replace joints, and make the patient "bionic" as a result. Okay they realize he maybe won't be better and faster, but they are typically under the impression that the main goal in these cases is restore the patients back to how they were.
That's simply not the case, however, with most of the more intense trauma work we do. Patients return to function when it goes well. But it doesn't always. And even when it does, the function they return to is not usually normal. As one attending so eloquently puts it: "She'll do okay, if she does alright."
So what's with the disconnect? Why does everyone in the room except the surgeon think that the polytrauma patient will run again since we're in there operating on his femur, calcaneus, and ankle fractures, and his pelvic fracture, and his wrist fracture? I mean, we're "fixing" him, aren't we?
Yes and no. Surgery in general, and specifically Orthopedic surgery, has evolved so much over the last few centuries. A patient having major orthopedic surgery 200 years ago (i.e. an amputation) may not have had much of an anesthetic (unless you count grain alcohol), zero antisepsis, would be operated on with crude instruments like a two-man saw, would have a disastrously high risk of complications and death, and there'd be next to no hope for recovery of function.
Yet today we can anesthetize the patient, we have aseptic tools and techniques, we have fourth-generation intramedullary nails and customized titanium plates and screws, we have total joint replacement arthroplasties that are engineered specifically for each patient's unique anatomy.
We have made great strides. But we still have a long way to go. Blunt muscle injury is still basically ignored and left to heal on its own, since we know of nothing better (not for lack of trying), and we possess essentially no ability to induce regenerative or restorative powers within the human body. We can grow cartilage in a lab, but in very small quantities, and it may not be as durable, and even just for a small amount it is preposterously expensive. These two factors alone, severe muscle injury with resulting scarring and inability to fully restore cartilage, can lead predictably to stiffness and joint degeneration in post-traumatic settings. And that's ignoring the trouble with nerve injuries, which is a discipline that's advancing, sort of.
In other words, we can fix the bone, but not everything around it.
And in some cases, we can't even get the bones to heal. Every fracture we treat has its own risk profile. Some are very apt to heal, and, for the humerus and clavicle, the saying goes "as long as the bones are in the same room, they will heal." But try getting a scaphoid or a talus to heal and your odds decrease significantly - these bones naturally have a very tenuous blood supply and any time they break, there's a risk they won't heal. Even the oft-fractured clavicle can present with issues (especially when it's a borderline indication for surgery and the patient wants it fixed... guaranteed non-union!).
Non-union (failure of the bone fragments to unite) is a real risk. It happens. Sometimes we aren't sure why. Other times (such as when all the nutrient-supplying bone-lining tissue called periosteum is stripped from the bone, or when the bone has other reasons to have limited blood supply, such as nicotine use) the factors are somewhat more obvious.
So we can't even reliably fix the bones every time.
And even assuming all goes according to plan - the bone heals, the muscle isn't too scarred, the cartilage survives - even still, patients can develop CRPS (a syndrome of pain, swelling, and other autonomic findings that can lead to severe dysfunction and debility) after a fracture. We don't yet know what causes that. Nor how to really stop it (again, not for lack of trying, c.f. Vit. C).
Is it beginning to make sense why the orthopedic surgeon is the least optimistic person in the room during a polytrauma ORIF? Why unironically saying "we can rebuild him" strikes us as naive?
It's not just "the Six Million Dollar Man," though. The trope that we have reached peak medical ability (or that if we haven't by now we damn well should have) has been perpetuated by popular culture in films, books, and other TV shows. How many times a week do you hear or see someone saying/tweeting, "It's (insert current year) already! Shouldn't we (insert thing that's still a few decades away) by now?!"
2020 is, by most accounts, "the future". We're nearly there. So, patients expect we can just flip a switch and they'll be better, that they should experience no pain. That the medicine they knew just 20 short years ago in the 1990s for example, is ancient history and today's practices and techniques are leaps and bounds ahead. They simply have to be, don't they?
The real answer is, sadly, no. There's a ton we still do not understand about the human body and its response to injury or insult. There's also a lot of good science that looks promising, but has not undergone rigorous enough testing yet to be considered safe and effective. As a physician, my first rule is of course to do no harm. If I would use an unproven and potentially harmful new technology for a problem and it ends up hurting patients, I'd be stripped of my license and possibly even incarcerated a la Dr. Death.
These things take time. Medicine is simply not as advanced as movies and TV would lead you to believe. Arduous study and testing must be completed before new technology can be incorporated into patient care (or "go live," as the saying goes). And we're currently confined in a conflicted practice environment that champions cost-cutting blended with improving quality metrics, and patient-centered outcomes, yet implements a bewildering array of regulations and oversight committees to do so (despite a complete lack of evidence that they do any of those things well).
And that's not even getting into the insurance companies. Don't get me started.
Until legitimate studies prove new technologies to be safe and effective, we'd love to make you better, faster, and stronger, but we will have to settle for "almost as good as you were before." It ain't perfect, but it sure beats having your leg hacked off with a dirty two-man saw while a swig of bourbon takes the edge off.
So the outcome of "better/stronger" currently seems unobtainable. But if it makes you feel better, I'm confident your hospital will be happy to invoice you to the tune of six million dollars.
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