When clients suffer significant and complex upper or lower limb injury, surgeons will assess how damaged a particular limb is. Typically, the starting point is, of course, to save the limb, with amputation being a procedure of last resort. The surgeons will attempt to do all they can to reconstruct and save the limb, often over a lengthy period of time involving many operations and procedures); the majority of which are successful (i.e., the client feels better off with the limb, than without it).
Unfortunately, not all outcomes are positive and in complex cases where, despite the best efforts of the medics, some patients are left with a limb that is dysfunctional, cosmetically poor, and painful. Sometimes in these cases, amputation is still required; in others, the client is left with an unsatisfactory limb, albeit reflects a ‘successful’ outcome, medically. It is the situation concerning the latter that is particularly challenging, especially where the client requires ongoing medication and where a high level of dysfunction remains. That is typically when I find a client may say to me “I would have been better off had they amputated straight away.”
“I would have been better off had they amputated straight away“
Having discussed this with clients and surgeons on the frontlines (both within the rehab sphere and medico-legally) over the years, it, obviously, is a very difficult ‘judgement call’ to make. It is far easier, with the benefit of hindsight, to pass comment and of course there are those injuries where it is easier to make the call very early on. It’s more the cases in between where you are dealing with a higher level of uncertainty, with only time able to tell, whether it would (with the benefit of hindsight) have been more beneficial to have made an early decision to amputate as opposed to “giving up on it” having spent considerable time undergoing surgeries, appointments, rehab, whilst still suffering pain and functional limitation.
I am unsure whether this is just within my particular practice (however, I note that my colleagues have also noticed this) but it seems that there is more of a willingness for surgeons to enter into discussions about amputation with patients far sooner than before. If this is true, then I appreciate there is likely to be a range of reasons why this may be the case; none of them having any particular statistical basis and more a ‘gut-feeling’ on my part. I certainly draw no adverse conclusions from this and make no criticism of those involved in the care of such complex cases.
Elective amputation as oppose to severe pain, arthritic changes, and necrosis
In one ongoing case my client was injured when a delivery driver caused a pallet to topple onto my client’s legs. Both legs were badly injured one more than the other. At the time there was a partial (traumatic) amputation and the surgeons worked tireless to re-attach the limb. Unfortunately, despite their best efforts, my client has been left with severe pain, arthritic changes, and necrosis. She is disabled and the injuries are permanent and impact upon all facets of her life. At this eighteen-month stage, she is considering elective amputation.
In another case a motorcyclist was knocked off his bike and assessment of the lower leg suggested it was unlikely surgical repair would provide a reasonably functional limb, with an acceptable level of ongoing pain. He decided to have an amputation and is now commencing rehabilitation as an amputee. The difficult decision was influenced by the feeling that there was no ‘guarantee’ that he would be left with a limb that was “reasonably functional”. Given the ongoing pain issues, with medication only able to take the slightest edge off it, with the support of his treating surgeons, he elected to undergo amputation and to begin life as an amputee rather than face the prospect of multiple surgeries over many months with an uncertain outcome.
Amputation in cases where a far more cautious approach would normally adopted
Of course, no one decision or pathway suits all, with many factors to be carefully weighed in the balance before an informed decision can be made. Again, whilst appreciating this may be unique to my practice, my feeling, however, is that there appears to be a growing appreciation by clients / patients and clinicians that amputation is worthy of consideration in cases where, traditionally, a far more cautious approach would be adopted. The ongoing advances in the field of prosthetics and a better understanding by the wider public of the capabilities of amputees is, perhaps, causing more to pause for thought.
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