Vet Talk

Broken Bone on Thursday, Surgery on Tuesday

Orthopedic surgeries are a mix of physics, carpentry and biology

April 9, 2018 (published)

Imagine your dog gets hit by a car and breaks his femur, the long bone in the thigh. I don’t want any harm to come to your dog, but bear with me for this thought experiment.

In this scenario, let's say your dog has a badly fractured femur, meaning the bone has broken into lots of little pieces: it's an open fracture, or what used to be called a compound fracture. Thankfully there are no internal injuries, but an open fracture requires an orthopedic specialist to fix it, as opposed to a general practitioner.

How would you feel if you were told your dog had to wait four days to get the leg dealt with? Well, there could be several reasons to wait. It's important to remember that in the vast majority of cases, broken bones are not emergencies. Some dogs are not stable enough for immediate surgery. Sometimes, owners have to make economic decisions about whether they can afford to have a specialist repair the fracture. Sometimes, planning has to go into the approach or repair; these days, surgeons might even use 3D printers to get a true view of the fracture (especially if it's a pelvis) so that they can better plan their approach and even create plates that will fit the dog precisely! But sometimes, it's a problem of scheduling.

This uncomfortable situation is one I have been in with many patients and owners. What can we do in these cases?

Contrary to what you might have heard, surgeons are people. Like all people, surgeons do their best work when they have time to recharge and it isn't the middle of the night. If I treat your dog on Thursday night and contact the surgeon on Friday morning, there’s a good chance that the schedule is full. I can plead and cajole, but there are only so many hours in the day.

Orthopedic surgeries can be complex. They are a mix of physics, carpentry and biology – that’s why, in many cases, only someone with skill and experience can fix bones. I can do lots of soft tissue surgeries – C-section, remove a spleen, take a rock out of the intestines – but I would never touch a bone. I just don’t know how and I would make things way worse in the process. And I even like carpentry!

If you’ve landed at an ER in a specialty center, they might transfer internally to an orthopedic surgeon. Stand-alone ERs don’t usually have orthopedic surgeons on staff because there isn’t enough ortho work to cover a surgeon’s salary.

Asking a surgeon to fit in a complicated procedure involving specialized instruments and a good chunk of time into an already booked day may not work. Sure, some will keep a few slots open for those cases that might come in, but usually schedules are full.

So your dog with the broken femur probably can’t get surgery on Friday. If we’re lucky, I may have a few surgeons in town to choose from, so I make calls to them, too. If we’re *really* lucky, there might even be a vet school around, and they often have a different schedule than private practice surgeons. I spend a good deal of time on the phone, and maybe even call in a favor or two. Maybe we’ll get lucky and get the bone fixed on Friday.

Or maybe not.

In some areas, there may be only one or two specialists who can do the job. (As an aside, there are general practitioners who do orthopedics; I am not saying only specialists can do bones, but just that *this* case probably requires one.) Or, I might be all out of favors.

If I try those folks and no one can get your dog in for surgery, what then?

It may be possible to keep your dog out of pain with medication, and keeping the activity level down will help with pain control, too. As long as your dog is stable, then pain control becomes our main priority. The femur is one of those places in the body that you just can’t splint or apply a wrap to (trust me: many have tried, with often disastrous results), so keeping your dog quiet and resting is the best way to prevent the bones from grinding together and causing more pain or damage.

Then we are faced with the weekend. I’m not saying it’s impossible to get a bone fixed on a weekend (it’s happened) but certain snowballs in certain warm climes come to mind when I think of the chances. Many larger referral/specialty centers are trying to offer services seven days a week and may have enough staff to spread among the days of the week to be able to do it, but it’s still not the norm.

So we have to get your dog through the weekend, probably grinding our teeth with frustration the whole time. And the medical cost meter is running. Even with minimal care (say three or four pain injections per day, plus nursing care) a weekend wait can add $500 or more to a bill, and orthopedics can be expensive. The titanium plate that is often used to fix a broken bone can be hundreds of dollars alone, and then there’s the surgeon’s time, anesthesia, other supplies, etc. It all adds up and a broken bone can cost $1,500 to $2,500 without complications, and without having to wait over the weekend.

As I said, sometimes I get lucky and there’s a slot open on Friday and all’s well. Or there’s a place nearby that will do orthopedics on the weekends. But in many cases, we just have to wait. It’s hard to explain this to owners, and I have been faced with many mad folks over the years, but we do the best we can. If I’m lucky, I have owners who understand the situation and are hopefully satisfied that their dog’s pain is controlled and he is getting good care.

The last hurdle is the Monday schedule, and there’s no guarantee that we’ll get in Monday. Weekends are busy times in veterinary ERs and it’s possible that a patient with a life-threatening injury might bump our slot; remember, your dog is stable. This is why I try and not offer firm guarantees of a Monday surgery slot, even if the injury happened the week before. It’s not fun and it can make people feel like we don’t care. But it’s the reality of modern veterinary surgery. I’ve been bumped to Tuesday from a Monday surgery slot and it’s a terrible feeling.

Incidentally, it’s not all that different for people with orthopedic injuries, although you’re a little more likely to get a bone fixed on the weekend (or even at night) than pets are. But many people have to live with painful injuries for days until they can get them fixed, and the schedule is usually the culprit.

It’s hard when logistics and scheduling get in the way of pets getting the care they deserve, but when there’s only a few folks in town who can get the job done, sometimes pets get caught in the middle. I hope if this happens to you, your vet tries to pull out all the stops and get you that Friday fix, but if it can’t happen, you’ll understand why.

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