Demystifying Medicine One Month at a Time

Tag: hip fractures

Orthopedic Dialogue

Six months ago I posted a story about a demented 94 year old patient who’d fractured her hip. She’d lost more than thirty pounds in the preceding months and had already had a collarbone fracture from a previous fall.

Pinning of a right hip fracture.

Pinning of a right hip fracture.

Her son wanted her to be made “comfort care only,” and avoid a trip to the operating room since she was likely within six months of death and was immobile (bedbound) even before her hip fracture. She was going to be referred to hospice. We called off the orthopedic consultants who had been kind enough to recommend (and set her up for) hip stabilization.

I felt like this was the right course of action–and the family members (the ones I’d met) supported this decision. The patient appeared comfortable, able to sit up in bed and hold conversations (albeit demented ones), and not in any distress from her fracture.

The next day, I came to the hospital to find out she was already on the operating room table to have her hip  “pinned.” No one had called me to discuss the change in plan.

I was furious. I felt betrayed by my orthopedic colleagues, who hadn’t seen fit to discuss their thinking or the change in planning (or the subsequent conversations with the family) with me. After all, I was the physician ‘in charge’ of the case; the one legally responsible for the decision-making and the outcome.

The blog post generated attention: commentary, multiple reposts (e.g. here) and some white heat.

I’ve learned a lot from the case, and from my posting of something so ‘fresh’ and full of emotion: Namely, that with the perspective of time, I now see that it was inappropriate of me to

  • blog about something so recent;
  • ‘call out’ my orthopedic colleagues without discussing the situation with them first;
  • use profanity in a blog post about something important and meaningful, thereby likely putting off the audience I would hope to capture.

I apologize for my boorishness. I was quite angry, and I let it get the best of me.

Many people wrote asking what the ‘resolution’ of the case was, and what the upshot of my post-hoc conversation with orthopedic colleagues would be.

I spoke with the department chair, after he’d had ample time to review the case and hear from the ‘players.’

I respect his approach and fact-finding, and he acknowledged that the communication over the patient’s fate (and consent to surgery) was mishandled. But he also helped me see the situation through the eyes of an orthopedic surgeon, which addressed my concern about their motivation(s). I will tackle his points one by one:

Hip fractures are an endemic problem. With our aging population and the thinning bone that comes along with it, hip fractures are an inevitability in communities and growing as a problem along with our aging loved ones. Primary care doctors do a lousy job treating osteoporosis.

Hip fractures are a local problem. At this one 500-bed hospital in a medium-sized American city, there were more than 800 hip fractures last year–more than 2 per day. The weekend before I spoke with the chairman, there had been seven hip fractures.

Orthopedic surgeons are not motivated by money when it comes to hip fractures. Unlike much of orthopedics which provides elective surgeries, hip fractures are a form of trauma, and therefore do not conform to surgical scheduling. Orthopedists perform fracture repairs as add-ons to their regular cases, and most surgeons don’t like to perform them as they occur at off-hours, over and above their regular caseloads. Medical outcomes in hip fracture improve the sooner they are repaired; therefore the addition of time pressure to these cases is another stressor for surgeons.

In the case I blogged about, the orthopedic group collected $819.27 in professional fees (i.e. the doctor’s charge) for the pinning of the 94 year-old patient’s hip. “Half of that goes to taxes, another quarter to overhead,” the chairman told me. That leaves a collection of about $205 net for the procedure. The implication is that no one is getting rich repairing hip fractures.

Communication is a two-way street. Much as I was displeased with the lack of communication in this case, the chairman provided several examples of where internists had simply not communicated with his team regarding a patient’s care. He’s absolutely right about this. It’s a fail for all of us.

They have created a center of excellence. One of the doctors who read my initial post works at the hospital in question. He pointed out, correctly, that NOT pinning the elder woman’s hip (even though she was emaciated, demented, and fragile) would be cruel. She would have pain with any position changes and likely develop bedsores. The standard of care is to repair hip fractures, not let them heal (they actually can!) over time. The time cost (and risk) is too great. That physician (an internist) has partnered with the orthopedic group to form a center of excellence in hip fractures, devoting resources to tackling this growing and costly problem in a systematic fashion. This is a great response–and I’m pleased to work and teach at a hospital that’s ready to tackle problems like this.

At the end of our chat, the chairman handed me copies of pages from the patient’s chart. “Is that your note?” he asked me. I nodded.

“I can’t read a word of it,” he told me.

Touche.

One Example of End-of-Life Care in America

She was 94 years old with advanced Alzheimer’s. She thought it was 1954 and asked if I wanted tea. Not a bad memory for someone in a hospital bed with a broken left hip.

She’d fallen at her assisted living facility. It was the second time in as many months. She’d broken her collarbone on the previous occasion.

Being there.

Being there.

Over the past year, she’d lost thirty pounds. This is natural in the progression of Alzheimer’s. But it’s upsetting to families all the same.

My patient was lucky. She’d lived to 94, and had supportive children who were involved in her care. Her son had long ago been designated as power-of-attorney for her health care. This meant officially that his decisions regarding her care were binding. She was not capable of making sound decisions, medical or otherwise.

The patient had been under the care of a geriatrician. His office chart told me that the option of hospice and palliative care had been discussed with the family. They were interested in learning more; the son had agreed that “Do Not Resuscitate” status was appropriate for his mother. Doing chest compressions on a frail 94 year-old is something none of us want to do.

The morning after her hospital admission for the broken hip, the medical intern called me with an ethical dilemma: “She’s DNR,” the intern explained. “She’s having intermittent VTach on the monitor, and I fear she won’t be stable enough to have the hip repaired. The family is open to the idea of hospice, but I don’t know whether to treat the arrhythmia or not.”

Elaine (not her real name) is one of our brightest interns. She’s thinking about going into geriatrics. Situations like this are in many ways the most meaningful for doctors. Too often we stress about minutiae at the expense of the big picture; helping guide a family and patient through a period of critical illness is of true service.

“Bearing witness is our most important role,” a mentor once taught me.

I came in to round with Elaine. We went immediately to the patient’s room. The son and one of his sisters were there supporting their mother.

In the bed I saw a pale, thin, older woman who appeared to be lying comfortably. I asked her if she was in pain. “Would you like some tea?” she asked.

I told her she didn’t look ninety-four. She smiled. I told her she had a beautiful smile, and she smiled again.

We proceeded to discuss the medical issues with the patient’s son and daughter:

  • Advanced dementia
  • Weight loss
  • Multiple falls
  • Hip fracture
  • Anemia
  • Irregular, potentially unstable heart rhythm

“What would your mother want?” I asked them. “If she could decide for herself, what would her goals be?” Given her frailty, even with repairing the hip she’d never walk again.

Understandably, the concerns were about her suffering and feeling pain. At the moment, we were all in agreement that she looked comfortable. I broached the subject of not doing anything to treat the arrhythmia or the broken hip. Of not putting the patient through surgery.

The son was clear. “She wouldn’t want surgery,” he told us. His sister agreed. Consensus! We would refer her to hospice. She’d live out her days in comfort, forgoing the indignities of further medicalization.

At that moment, the orthopedic nurse practitioner walked into the room, carrying a consent form. She approached the opposite side of the bed. Before she could launch into her speech, I cut her off. “The family has decided on hospice,” I informed her. I asked to speak with her outside.

“We’ve only not operated on two occasions that I can remember,” the nurse practitioner told me. Her comment unnerved me. Clearly we were deviating from standard operating procedure here. “If a hip’s broken, we fix it,” is what she was telling me.

She documented our conversation and the fact that the family had declined surgery in the chart.

I went back in the room. I asked the family if they had any more questions. Satisfied that we’d answered everything to the best of our abilities, I excused myself and Elaine. We thanked the son and daughter for their courage, and affirmed that I thought they were making the right decision to forgo surgery.

Outside the room, we debriefed about the encounter. I was very proud of Elaine’s poise in a difficult patient/family situation, and how well she reasoned through the multiple options. I told her that I admired her instinct to mitigate harm to the patient by not over-medicalizing the situation, as many would have done since it’s almost always the path of least resistance in the hospital.

Alas, we congratulated ourselves too soon.

NEXT POST: POOR COMMUNICATION

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