CCD Informed Consent for Surgery – J. Hatch MD FRCSC

Please take a few minutes to carefully read the attached forms.

The attached material written by me contains a detailed explanation of the pertinent risks and benefits of your surgery as well as listing alternatives to the proposed surgery. The risks or complications which I consider to be of greatest concern for you personally are in bold type, highlighted, underlined or circled.

Paragraph 4 describes the more frequent, but minor potential side effects, minor complications and lesser risks which are specific to you as a patient undergoing the surgery I am recommending. Most people will never experience these risks but they definitely occur in some patients and have been reported by most surgeons even in the best of circumstances.

Pay special attention to the Specific Risks for your surgery at the end of Paragraph 4.

Paragraph 5 lists severe but quite rare events that I often refer to as the “I-95 complications”. By this I mean you to consider the risks driving down the Interstate. While traveling, there is always the very slight possibility that another car could lose control and crash into you. Yet, when you started the trip, you really didn’t imagine that as a likely event. Think of the risks of your surgery listed in paragraph 5 as you might the interstate journey – possible but not expected.

Pay special attention to the Specific Risks for your surgery at the end of Paragraph 5.

Please also remember as you read this list of complications that this consent form is used for patients of all ages and stages in life so that the risks if you are young and healthy are very different, less severe and less likely than if you might be at an advanced age or diagnosed with multiple, potentially life-shortening medical illnesses.

After you have a chance to read this information, I would like to answer any questions or concerns you may have.

Feel free to call me you before you sign this form (843) 682-7480.

Once I have answered your questions addressed any concerns you may have, the Coastal Carolina Hospital staff will witness your signature on the hospital consent form after you have had an opportunity to meet with your anesthesiologist.

1.  My illness or condition has been explained to me as:

2.  Alternate ways to treat my medical problem have been explained to me as:

·  Non-Operative Treatment: medications, injections, splints, casts

·  Operative Treatment : manipulation and casting, percutaneous pinning (pins drilled into the bone through skin punctures) external fixation (the pins in each bone are connected together by a rigid tubular frame just above the skin

·  Open Surgery: (traditional skin incision often with implants, plates and screws)

3.  The procedure recommended by Dr. Hatch is:

4.  More frequent but minor risks of the planned procedure generally include:

·  pain, persistent swelling/numbness around or below the incision

·  tethering of the tendons at the operative site, stiffness of the adjacent joints

·  prominent or unsightly implants (if used)

·  superficial wound infection at the incision, pin tract infection

Specific Minor Risks:

5.  Rare, very serious risks of the planned procedure generally include:

·  injury to the arteries & veins

·  compartment syndrome (swelling blocks off the blood supply to the limb)

·  permanent nerve damage resulting in weakness or paralysis of the limb

·  blood clots in the legs (DVT-deep vein thrombosis) or lungs (PE-lung embolism)

·  joint dislocation or tendon rupture requiring surgical repair

·  degenerative arthritis due to premature wear of the joint surface

·  deep infection (usually needs surgery and weeks/months of IV antibiotics)

·  post-operative confusion, medication reaction, stroke, permanent disability.

·  kidney or other organ failure, respiratory & cardiac arrest, death

Specific Serious Risks:

6.  Bone or tissue grafts from human donors are likely to be used: yes no

(no test will 100% detect Hepatitis and HIV (Human Immunodeficiency Virus) so there is some small risk of disease transmission with the use of “Allograft”

7.  Blood product transfusion with blood is needed in approximately % of similar cases (potentially life threatening allergic reactions, infection, kidney failure and viral infections (Hepatitis & HIV) can follow blood or blood product administration)

8.  If during my procedure, other conditions arise that need to be treated, Dr. Hatch will perform any other necessary procedures and get any needed help/consultations.

9.  I understand that no guarantees have been made to me by Dr. Hatch

Coastal Carolina Hospital / *CCD1AC*CCD1AC CCD1186 Trial 09/13
Authorization for Procedures/Interventions and Anesthesia Including Blood/Blood Products / jph 2014-7