Moral complexity.

Abstract

An attending orthopaedic surgeon, an orthopaedic resident, and a spine Fellow are scheduled to perform a multilevel spinal decompression and instrumentation from L3 to S1. The case is delayed for several hours and begins in the late afternoon. The attending orthopaedist chooses not to wait for localization radiographs and proceeds with the decompression and four-level pedicle screw instrumentation with posterior-lateral fusion. The Fellow suggests several times during the procedure that radiographs should be obtained, but the attending surgeon is late for a meeting and declines to obtain radiographs. The attending surgeon leaves the resident and Fellow to close the wound after spinal instrumentation and fusion is complete. Radiographs are obtained prior to closure of the wound, and these indicate that the decompression has been performed at the appropriate levels but that the spinal instrumentation and fusion was from L2 to L5 rather than from L3 to S1. The Fellow notifies the attending surgeon, who has already left the hospital. The Fellow offers to remove the L2 screws, place S1 screws, and reconfigure the instrumentation prior to closing. The attending surgeon forbids the Fellow to do this and tells her, "Everything will be fine." He also states that he will discuss the surgery with the patient and family in the morning. As ordered, the Fellow and the resident close the wound.