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Informed Consent in Emergent Surgery and Unplanned Surgery

Thomas J. Moore, Devorah Cruze, Amy Wyrzykowski, Ravi Rajani, Maria del Carmen G Davila

Address for Correspondence:
Thomas J. Moore
Assistant Professor of Orthopaedics, Division of Trauma, 
Department of Orthopaedics, Emory University School of Medicine.
United States.


Informed consent is routinely obtained before any surgical procedure and after careful planning, includes any possible scenario occurring during the surgical treatment. Every so often during emergent surgery, not all scenarios are considered and the surgeon is faced with difficult decisions. We are presenting a case report on internal fixation of the acetabulum in a trauma patient using the ilioinguinal approach. The ilioinguinal approachto the acetabulum has been utilized for internal fixation of complex anterior column fractures, anterior wall fractures, and certain both column and transverse fractures of theacetabulum. To our knowledge, there have been no reports of unanticipated encounter of a preexisting asymptomatic inguinal hernia during the ilioinguinal surgical approach. This is a case report of such a case, and the resultant informed consent dilemma.

J.Orthopaedics 2009;6(2)e8


informed consent; unplanned surgery; emergent surgery;acetabular fracture

The ilioinguinal approach to the acetabulum was first described in 1965, and has been utilized for internal fixation of complex anterior column fractures, anterior wall fractures, and certain both column and transverse fractures of the acetabulum. (1)   The ilioinguinal approach has been associated with few complications, including minimal muscle dysfunction and a low incidence of peri-articular heterotopic ossification.  (2)  One complication much discussed but rarely encountered is laceration of the corona mortis, an anastomosis between the obturator artery and either the external iliac or inferior epigastric artery, during the surgical approach with resultant significant hemorrhage. (3)  To our knowledge, there have been no reports of unanticipated encounter of a preexisting asymptomatic inguinal hernia during the ilioinguinal surgical approach.  This is a case report of such a case, and the resultant informed consent dilemma.

Case Report:

A 33 year old obese Hispanic male presented to the Emergency Department of Grady Memorial Hospital following a high energy motor vehicle accident.  His initial survey revealed a pulmonary contusion, a left Gustilo-Anderson Type II open diaphyseal femur fracture, and a displaced right transverse acetabular fracture.  He appeared intoxicated, and a subsequent blood alcohol level was elevated.  An attempt was made to obtain informed consent for emergent surgery with a Spanish interpreter, but because of his impaired cognition from alcohol, was unsuccessful.  There were no family members with him, and an attempt to contact family members was unsuccessful.   On the night of admission, he underwent emergent irrigation and debridement and antegrade intramedullary rodding of the left diaphyseal femur fracture.  He was placed in 20 pound axial traction through a tibial pin for the right acetabular fracture.  Postoperatively, a CT scan was obtained of the pelvis which demonstrated a displaced transverse fracture of the acetabulum.  On the fourth post admission day, the patient’s cognitive status was normal, and informed consent for operative fixation of the acetabular fracture was obtained by the 2nd year orthopaedic resident. The resident is fluent in Spanish, and she subsequently was not involved in the surgical management of the patient.   Per prevailing custom, the operating surgeon on the preprinted consent form was listed as “Emory Orthopaedic Service”. The attending surgeon on rounds, who was the planned surgeon for the acetabular surgery, explained the procedure through an interpreter and wrote on the chart that “it has been discussed with the patient alternative treatment and the possible complications of excessive blood loss, nerve injury, infection and post traumatic arthrosis.”  On the 6th day following injury, the patient underwent operative stabilization of the acetabular fracture through an ilioinguinal approach.  Upon dividing the inguinal ligament, there was clear protrusion of preperitoneal contents.  At the time of the patient’s history and physical, the patient did not complain of any groin discomfort prior to the accident, and his obesity precluded physical detection of the hernia prior to surgery.   Upon completion of the internal fixation of the acetabular fracture, the orthopaedic service did not feel comfortable closing the wound as the major concern was of potential incarceration of the hernia by the closure.  Intraoperative consultation was obtained from the Emory general surgery service.  After further dissection, a large direct hernia was identified, with fat and bladder contents. An unsuccessful attempt was made to contact family members to discuss the operative findings.  A decision was made to proceed with a standard tension-free Lichtenstein mesh closure (Figure 3).   Postoperatively, the hernia repair was discussed with the patient by both the orthopaedic service as well as the general surgery service.  The patient appeared grateful, and recovery was uneventful.

Discussion :

This case report illustrates some of the issues involved in obtaining informed consent in the surgical patient.  The case was reviewed by the Clinical Ethicist (who is also a lawyer) of the Ethics Committee of Grady Hospital.  The initial emergent surgery was performed without informed consent due to the patient’s obtunded condition. No family members were available in person or by phone.  The Official Code of Georgia Annotated (O.C.G.A.)§ 31-9-3defines an emergency procedure as “a situation wherein (1) according to competent medical judgment, the proposed surgical or medical treatment or procedures are reasonably necessary and (2) a person authorized to consent under Code section 31-9-2 is not readily available, and any delay in treatment could  reasonably be expected to jeopardize the life or health of the person affected, or could reasonably result in disfigurement or impaired faculties.” (4) The Georgia Medical Consent Law (O.C.G.A § 31-9-2) defines who can give consent for emergent surgery for obtunded patients: 1) any person authorized by the “ Durable Power of Attorney Act for Healthcare”, 2) any parent for adult or minor child, 3) any adult child for parent, 4)  any adult for sibling, 5) any grandparent for grandchild, and 6) married adult for spouse”.  If none of the above are available to give consent, emergent surgery can proceed, provided the proposed procedure or intervention meets the requirements of defined emergent surgery as listed above.  It is desirable to have a physician with similar expertise and knowledge as the planned surgeon, and who is not specifically involved in the case, to concur with the planned surgery. (5)  The initial surgery, irrigation and debridement of the open fracture and intramedullary rodding of the femur fracture, was an appropriate emergent surgery, where significant delay could result in impaired function or loss of limb.  Furthermore, the attending surgeon wrote a detailed note documenting the necessity of the procedure, the lack of someone to consent, and the emergent condition of the patient at the time of the emergent surgery.  However, a second surgeon with similar credentials as the operating surgeon, not involved in the surgery, was not available to write a note agreeing with the procedure; this is often the situation in emergent surgery during night time hours.

The second surgery, the stabilization of the acetabular fracture, presented more difficult informed consent questions.  It has been demonstrated that obtaining informed consent in several groups, including patients who do not have English as their primary language and geriatric patients, is particularly difficult. (6)  In addition, it has been estimated    that 60% of the American public is medically illiterate to understand informed consent completely(7). 

The surgical consent for the elective surgery was obtained by a 2nd year resident fluent in Spanish.  The patient signed the standard Grady preprinted consent form, which is written in English, with the operating surgeon listed as “the Emory orthopaedic service.”  The attending surgeon discussed the surgical procedure, including potential complications, with the patient through a Spanish interpreter, and documented the discussion with a note on the chart. 

It has been demonstrated that informed consent obtained in the clinic or office, with family members present, and with either a dictated or written note documenting potential complications is more desirable than a preprinted consent form obtained in the preoperative area.(8) Although not optimal, the presence of  preoperative  medications, including analgesics, does not preclude satisfactory informed consent.(9)  The Emory-Grady Ethics Committee felt that the consent form should list the individual surgeon rather a surgical service.  Ideally, a hospital-provided interpreter is preferable to a resident in providing translation for informed consent. 

The decision to proceed with the repair of the inguinal hernia was decided intraoperatively.  From a surgical standpoint, the exposure to repair the hernia was excellent, and elective repair of the hernia at a later date would be more difficult because of postoperative scarring. In addition, an inappropriate closure could result in incarceration of the hernia.  A statement in the preprinted Grady consent form states: “I understand that unforeseen complications or conditions may arise during this procedure, and I consent to any additional procedures that the physician(s) may deem advisable in their professional judgment.”   The general surgical team proceeded with the surgical repair of the hernia, including the use of mesh, on this basis.  The clinical ethicist from the Ethics Committee raised several concerns: 1) she suggested that any surgical consent should name the specific surgeon scheduled to perform the procedure. The repair of the hernia, usually an elective procedure, was done without informed consent by a surgical team not mentioned in the initial consent.  Arguably, the hernia repair was not emergent nor a known or anticipated complication. 2) The patient has the right to decide if he wants to undergo additional surgery and potential complications and this requires that he-or his surrogate decision maker-have the opportunity to receive the information required to make an informed decision.

In biomedical ethics, there are four major principles that are considered in determining the ethics of a given situation. (13)  Autonomy is the obligation to respect the decision making capacities of autonomous persons.  This right of self-determination is strongly supported in the fields of law and ethics.  Adherence to the principle of autonomy would suggest that the surgical team defer the hernia repair to a later date when consent could be obtained.  Non-maleficence is the obligation to avoid causing harm.  Beneficence is the obligation to provide benefits and to balance benefits against risks.  Justice is the obligation to determine fairness in the distribution of benefits. 3) The ethical principle of beneficence, doing good for the patient, could support the intraoperative repair if the evidence shows that deferring the surgery could cause greater harm to the patient.  Balancing the benefit of the surgery against the intrusion on the patient’s autonomy was required to determine whether the surgeons behaved in an ethical manner.  Both the orthopaedic and general surgical team decided that the principle of beneficence outweighed the principle of automony. 

It has been suggested that the majority of orthopaedic surgeons, both residents and attendings, are not knowledgeable about issues of informed consent. (10)  Much has been written concerning informed consent for research, but much less has been written about informed consent for emergent situations or unanticipated findings in surgery. (11)  The issue of listed surgeons on consent forms, especially residents in teaching programs, has also been a topic of recent interest.(11,12)  It is necessary to be knowledgeable about informed consent in treating patients in a trauma situation to avoid potential litigation for violating the patient’s right to decide what happens to his own body and to avoid violating the ethical principle of autonomy.

Reference :

  1. Letournel, E. : The treatment of Acetabular Fractures Through the Ilioinguinal Approach. Clin Orthop Rel Res 1993(292): 62-76

  2. Matta, J: Operative treatment of Acetabular Fractures through the Ilioinguinal Approach: a Ten Year Perspective. J Orthop Trauma 2006 (20): 20-29

  3. Darmanis S, Lewis A, Mansoor A, Bircher M: Corona mortis: an anatomic study with clinical implications in approaches to the acetabulum and pelvis. Clin Anat 2007 20(4): 433-9

  4. Official Code of Georgia Title 31: Health. Chap 9 Consent for Medical or Surgical Treatment

  5. Suk M, Udale A, Helfit D: Orthopaedics and the law. JAAOS 2005 (13) :397-406

  6. Naarden A: Informed consent. Am J Med 2006; 119: 195-197

  7. Bhattacharyya T, Yeon H, Harris M: The medical-legal aspects of informed consent in orthopaedic surgery. J Bone Joint Surg Am 2005; 87;2395-2400

  8. Lucha P, Kropcho L, Schneider J, Francis M. Acute pain and narcotic use does not impair the ability to provide informed consent: evaluation of a competency assessment tool in the acute pain patient. Am Surg 2006; 72(2): 154-7

  9. Lieberman J, Wenger N: New technology and the orthopaedic surgeon. Clin Orthop Rel Res 2004; 429: 338-341

  10. Anglen J, Mandell P, Moore T: Chap 1: Professionalism and ethics, in Orthopaedic Knowledge Update9. AAOS, 2007

  11. Kocher M: Ghost surgery: the ethical and legal implications of who does the operation. J Bone Joint Surg Am 2002; 84A; 148-50

  12.  Chiong W: Justifying patient’s risks with medical education. JAMA 2007; 298; 1046-48

  13. Beuuchamp T: Methods and principles in biomedical ethics. Journal of Medical Ethics 2003; 29: 269.

This is a peer reviewed paper 

Please cite as: Thomas J. Moore: Informed Consent in Emergent Surgery and Unplanned Surgery

J.Orthopaedics 2009;6(2)e8





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