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OR14.1-4 | Counselling and Rehabilitation Skills — PBL Case

CLINICAL SETTING

Mr. Ramesh Babu, a 48-year-old bus driver from a semi-urban area, is brought to the orthopaedic outpatient department by his wife and adult son. He sustained a road traffic accident 8 days ago with a crush injury to his right lower leg. He was initially managed at a private clinic with wound dressing and oral antibiotics but has worsened significantly. On examination: right leg has a 12 × 8 cm wound over the mid-tibia with visible necrotic bone, purulent discharge, perilesional cellulitis extending to the thigh, and crepitus on palpation of the surrounding soft tissue. Temperature 38.9°C, pulse 112/min, BP 108/70 mmHg. He is anxious and diaphoretic. Plain X-ray shows cortical irregularity and periosteal reaction of the tibial shaft; gas shadows are visible in the soft tissues. Blood tests: WBC 18,400/µL, CRP 210 mg/L, serum glucose 18.2 mmol/L (previously undiagnosed Type 2 diabetes). Doppler assessment reveals absent flow in the anterior tibial artery and significantly reduced flow in the posterior tibial artery distal to the wound. The orthopaedic team recommends urgent below-knee amputation. Mr. Babu is alert, oriented, and states: 'I am a driver — if you cut my leg, my life is finished. I won't give consent. Give me antibiotics for one more week.' His wife is crying and his son says 'Doctor, please just fix him without the operation.'

Trigger 1: Initial Assessment — What are the Warning Signals?

The team reviews Mr. Babu's presentation: fever (38.9°C), tachycardia (112/min), hypotension (108/70), cellulitis with crepitus and gas shadows on X-ray, absent anterior tibial Doppler signal, WBC 18,400, CRP 210, new diagnosis of uncontrolled diabetes (glucose 18.2 mmol/L). The registrar says: 'We must convince him urgently — this is life-threatening, not just limb-threatening.'

DISCUSSION POINTS

  • Identify and classify the warning signals present in this case. Which signals indicate (a) systemic sepsis, (b) limb-threatening vascular compromise, and (c) gas gangrene or necrotising infection?
  • Using clinical reasoning, explain why a further one-week antibiotic trial — as Mr. Babu requests — is clinically dangerous. What is the likely outcome in 24–48 hours if definitive surgery is not performed?
  • How would you, as the orthopaedic doctor, CONVINCE Mr. Babu (not just inform him) of the urgency? Outline the specific arguments you would use in plain language, addressing his stated fear about driving.
Click to reveal Trigger 2: Consent and Communication — Navigating the Ethical Minefield (discuss previous trigger first!)

Trigger 2: Consent and Communication — Navigating the Ethical Minefield

Dr. Priya, the orthopaedic registrar, sits with Mr. Babu privately and applies the SPIKES protocol. She discovers he understands that his leg is 'badly infected' but does not know the infection has reached his bloodstream or that gas in the tissue means life-threatening bacteria. He asks: 'If I say yes to the operation — what exactly will you do? Will I feel pain? What will happen to my job?' His son then enters and says quietly to Dr. Priya: 'Can you just start the operation once he is anaesthetised? We will sign on his behalf.' Dr. Priya recognises this as a serious ethical breach.

DISCUSSION POINTS

  • Walk through the four pillars of valid informed consent as applied to this case. Which pillar is MOST at risk given the son's request, and how must Dr. Priya respond?
  • Using the SPIKES protocol, how should Dr. Priya structure her conversation with Mr. Babu? Write out (in note form) what she should say at each step, specifically addressing his concerns about pain, the operation, and returning to driving.
  • Mr. Babu has decision-making capacity. What are the legal and ethical implications of proceeding without his consent based on family agreement? Under what circumstances (if any) could surgery proceed without his explicit consent in this case?
Click to reveal Trigger 3: Post-operative Rehabilitation — Counselling the New Amputee (discuss previous trigger first!)

Trigger 3: Post-operative Rehabilitation — Counselling the New Amputee

Mr. Babu ultimately consents and undergoes urgent below-knee amputation at an ideal level (13 cm from tibial tuberosity). Surgery goes well. The stump is cylindrical with a posterior-based scar and good posterior myoplasty. Post-operative Day 3, he is afebrile, glucose normalising with insulin. He is distressed: 'My right leg is gone but I can feel it — it is burning and cramping badly. I cannot sleep. My family says I will never walk again. What kind of life is this?' The physiotherapist and orthopaedic team plan his rehabilitation.

DISCUSSION POINTS

  • Describe the ideal stump properties achieved in this case and explain why each property is important for successful PTB prosthetic fitting. What properties would you look for on a 6-week stump review to confirm readiness for prosthetic fitting?
  • Counsel Mr. Babu about his phantom limb pain: (a) validate that the pain is real and explain the neuroscience in accessible language, (b) outline evidence-based first-line treatments you would recommend, and (c) address his fear that the pain means something is wrong with the operation.
  • Mr. Babu is a bus driver. With a well-fitted PTB prosthesis and good rehabilitation, what is a realistic functional outcome for ambulation and return to occupation? Which functional classification (K-level) would you aim for, and what modifications to his occupation might be needed?

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OR14.1] What is the SPIKES protocol and how is it applied to prognosis counselling in orthopaedic conditions with functional disability? Review literature on structured communication frameworks for breaking bad news.
  2. [OR14.2] What are the four pillars of valid informed consent? How should clinicians manage situations where family pressure threatens patient voluntariness? Review Indian medicolegal context for consent in surgical emergencies.
  3. [OR14.3] What are the warning signals for (a) acute osteomyelitis, (b) septic arthritis, (c) neurovascular injury, and (d) gas gangrene requiring urgent referral? What clinical and investigative criteria define the threshold for referral to a higher centre?
  4. [OR14.4] Describe the levels of lower limb amputation and the ideal stump for below-knee prosthetic fitting. What is the PTB socket and how does it transmit weight? Describe the pathophysiology and management of phantom limb pain. What are K-level functional classifications for amputees?