Broken bones and medical minimalism

ImageNeither of my parents ever broke a bone despite, in the case of my mother especially, numerous falls.  I don’t recall many in the extended family, either, so at some point I assumed that perhaps I had inherited good bones, as well, and would miss this particular experience of aging.  No such luck.  I broke a metatarsal in my left foot  in my 40s when I tripped down the stairs in the middle of the night  to let the cat out (she still wanted out), then broke my left wrist in a fall in Shanghai about four and a half years ago.  Over the Christmas break, I took another fall outside a bathroom at Dunn’s RIver Falls (undoubtedly the surface slick from people traipsing from the falls), and broke the right wrist.  A fracture of the distal radius –the bigger of the two forearm bones with the break right near the smaller wrist bones–is the most common one people experience, and is particularly common in postmenopausal women like me.

In Shanghai, I went to a fairly modern clinic frequented by expats which was not far from the area where I had fallen.  The doctor, who was probably in his 40s, had been trained in the United States.  My wrist  looked like a dinner fork, and so it was obviously an unstable break.  He told me he could try to set it under local anesthesia  and cast it, but that it might or might not hold position.  Or he could operate–he said that was what they would probably do in the U.S.– and put in a plate and screws.  It was my choice.  Not relishing the idea of surgery in Shanghai or a wrist full of hardware, I chose the route of having him try the more conservative approach first.   He nodded and got to work.  When he was done, he encased my arm in plaster up past my elbow, and told me to come back in a week.

A week later both of us were pleased that the fracture was holding in position, and the doctor said I should wear the elbow cast another week at least before he switched it to a forearm one.  A week or so after that I came back to the States and saw the orthopedic hand surgeon in the practice that Marty had gone to for knee surgery.  The doctor, who was in his 60s, looked at my arm in amazement.  “Where did you get that plaster cast?”  he asked.  “Haven’t seen one of those in years.”  The x-rays–two and a half or three weeks out by now–showed that the Chinese doctor’s reduction of the  fracture was still holding.  I wasn’t in any pain beyond the burden of wearing the heavy plaster, which strained my neck and shoulder.  “I can operate and put you in a whole lot more pain,”  he said, “but at this point you are better off letting it heal naturally.  That plaster cast probably helped, because it allows less movement than we can get with fiberglass.”  Noting that he doubted that any of his residents could reduce a fracture like mine that well (surgery is the preferred route), he changed  the cast to a forearm one the following week and I returned to China, where a few weeks later the Chinese doctor removed it and referred me to therapy.

This time I also broke my wrist in a foreign country–Jamaica.  It was Boxing Day and the only local hospital open was 15 miles away.  After being treated by the nurse at Dunn’s River Falls–who did a preliminary examination and then spread Ben-Gay on my forearm and gave me something for the pain (which if you have ever broken a bone before you will recall is terrific) and called the doctor, a pleasant and slender man in his late 30s or early 40s,  on call. Neither she nor the doctor could find an obvious break–my wrist was not misshapen as it had been in China– but the pain level and position of the pain meant that an x-ray was in order.  An ambulance of uncertain vintage arrived within a half hour so and we and the doctor were off to the local hospital.    We paid $20 in cash for the x-ray.  The x-ray machine was one of the old fashioned type where they develop the film, and we watched as the films dropped down into a bin in the hallway.  The doctor looked at the x-ray and could only see a partial break in the distal radius, which he thought would heal fairly quickly.  I was sent to the cast room –which looked more like a janitor’s closet, filled with papers, cleaning and medical supplies–where a small brusque man, aided by a nurse, applied a plaster splint expertly and rapidly.  Neither Marty or I had a credit card with us, so the doctor came back to our hotel with us (in the ambulance–can you imagine a U.S. ambulance giving you a ride home??).  Unfortunately, his credit card machine couldn’t get a signal, so he and Marty and the ambulance driver went downtown in Ochos RIos to a bank ATM machine where Marty forked over $400 for the ambulance and the doctor and the plaster splint.

Back home, it was the week between Christmas and New Year’s and I could not get into the orthopedics office at Dartmouth until January 6–fully 10 days after the break.  The results from the more sophisticated x-ray equipment told a different story than in Ochos Rios–it was a complete fracture and marginally displaced as well.  I was at the “higher end of the tolerance” on the displacement and surgery–though it was my choice–was being recommended.  I let myself be talked into the prep for this, but thinking it over over the next couple of days I changed my mind.  The break was already healing and given the minimal displacement,  the main risk of not doing surgery was arthritis down the road, which does run in my family anyway.   On the other hand, although most people do get through the surgery fine, some do not and the risks seemed more significant to me.  I also disliked the image of my healing fracture–by now callus, or primitive bone, was forming–being disrupted and invaded with metal and screws and made to start the process all over again.   If they had seen me a week earlier, they might have been able to reduce it manually.

Having broken both wrists and had cancer as well, the one thing I have learned about myself is that I tend to be a medical minimalist. As with the wrist, I found myself in the grey zone with chemotherapy as well, and ultimately decided not to have it.  I know that some people make very different decisions and want to throw whatever medical science has to offer against their illness.  Some of it may be age–I might make different decisions if I were younger.   I found myself doing research on the web including reading peer reviewed medical studies on distal radius fractures, as well as a thoughtful article by an orthopedic surgeon on the pervasiveness of surgery in this area in recent years.  Ultimately, I fell back on my first experience with the other wrist–and hope I’ve made the right call.

Medicine is a lot more complicated than it used to be, and as today’s New York Times outlines, it’s a market as well as a profession.  Any more,  a lot of medical decisions that used to be made by medical professionals now have to be made by the patient him or herself.  It’s a difficult position to be put in.  As I move into the age where I’m likely to have the need of at least minor repairs, it’s not an easy landscape to navigate.  Guess I’ll be reading more of those peer reviewed articles in future.