|
J.Orthopaedics 2006;3(3)e1
Importance of decision making-
-
Gives a broad idea about the
expected outcome of the condition
-
Gives a direction to the
treatment plan
-
Avoids delay in the definitive
treatment
-
Utilizes the biological favorable
opportunity at the right time
Decisions in Clinical Orthopaedics are increasingly being
subjected to legal scrutiny and must be based on evidence (Data)
rather than conjunction to avoid adverse judgments in a court of
law. Timing of decision-making is very important. It should not
be too hasty. It should not be too much of delay and avoiding to
decide. Thorough and relevant clinical examination is very
important to establish a clinical diagnosis or an etiological
diagnosis. It is very important to assess the situation whether
you are dealing with OPD or emergency patients. Before decide
any treatment modalities, observe the patients during his way,
analyses gait (if patients able to walk). That is the best time
to analyses the gait, because analysis of the gait while
asking him/ her on a straight line his/her is to conscious about
his problem, the waking pattern will be confusing. Carefully
listen to the patients. Don’t irritate.
In Urgency of situation decision-making should be too early.
what to do? After through relevant clinical examination advice
relevant and feasible investigation and best modalities of
treatment. To establishing the etiology, assess in your mind the
basic cause of the condition. Whether this is congenital,
infective / inflammatory, traumatic/superimposed trauma,
neoplastic or others. Are you sure about your diagnosis? If YES-
plans the definitive treatment and if not, at least decide the
broad categories. Whether this is infective or neoplastic,
traumatic or infective, Congenital or acquired or lastly
localized or generalized? After these entire basic thing in your
mind. Decide to investigate. Your investigation should be
confirmation of diagnostic suspicion, and assessing the biology
of the condition. It is better to choose most relevant, simplest
investigation that is X-ray? Right down precise requisition. The
management decision upon the when diagnosis is clear.
When the diagnosis is unclear. How long to delay the
decision-making? It possible to pinpoint a decision in every
situation? Immediat or present plan and lastly, what are your
ultimate target? If you are decided to treat. Which modalities
you are preferring? Whether conservative or operative. Basic
thing is to conserve the function of the limb. Whichever
modalities are deciding to restores the best of function in
optimum time frame or a combination of the two.
The basic thing that must be MASTERED-through knowledge of
the relevant anatomy of the area, biology of basic inflammatory
processes as applied to the particular area, consequences of
scarring in the area and local mechanics of the bone and
concerned joint. You should know the functional demand on the
area for each patient, decision of essential components of
function (stability v/s mobility) and effect of growth in case
of children (favorable/unfavorable). Lastly you are “knife
happy” orthopaedician or “plaster happy” orthopaedician or
middle path. Newer generation orthopaedician are behaves like a
monkey, if you will give knife in his hand, He will cut any
thing? So, when to withhold the knife- when the biology is
tremendously in favors of the patient, when the organ system and
or the tissues will not tolerate the surgical insults and tissue
response is uncertain. When to operate- An unfavorable biology
can be made favorable e.g.- intra-articular fractures, helping
the biology to run the natural course- drainage of an abscess,
realignment of an area for cosmetics reasons. Principle v/s the
procedure- surgical procedure that utilizes and reinforces the
biology of the tissue response-good results, procedures that
depend on mechanics alone with lesser consideration to the
biology-questionable results, you own experience of tissue
behaviour.
What should be the your choice of
procedures-affordability/economics of treatment, trendy surgery.
What should be the common targets of both modalities of
treatments-Restoration of stable, painless, mobile limb without
deformity, prevention of delayed complications and secondary
changes and prevention of reactivation of the disease process?
What should be therapeutics in Orthopedics? Are orthopaedician
are bad physician? Where do you need drugs? Pain relief,
Infection prevention and control, disease specific drugs and
sedatives. Other supportive drugs as antiosteoporotic,
antihypertensives, antitubercular, antihelminthics and calcium
and vitamin-D derivatives.
Lastely know your basic well and keep them update, don’t try
to fitting a patient in to a book chapter, use individual
judgement, analyze the facilities, surgical expertise, ancillary
services and related social factors, no hasty decision but do
not delay unnecessary, think definitive, symptomatic treatment
cannot be continued indefinitely.
Remember decisions fail even the most experience surgeons.
TISSUE BIOLOGY IS THE ULTIMATE DECISION MARKER, GO WITH IT.
|
