I have been a nurse for over 20 years, and for the last ten years I have worked on a floor of the hospital where patients recover from orthopedic operations. I’ve noticed that over the years, the number of people with hip fractures has increased, and in talking to our unit manager, it seems like we deal with over 300 hip fractures a year now. That’s almost one per day!
It is really hard for patients and families to come to terms with all the stuff that happens around the time of a hip fracture. There is so much information to process and so many complicated decisions that need to be made and often times it happens that the patient hasn’t seen much of their family in the years leading up to the fracture. Many of the patients actually break their hip because they are sick for other reasons and they fall down. They have cardiac arrhythmia, pneumonia, urinary tract infections, or dementia. Often their fall is a symptom of how sick they are and they often “CRASH” into the hospital and need a lot of care. Over the years we’ve heard a lot of heartbreaking stories about patients who fell and couldn’t get up, couldn’t reach the phone, and were stuck on the floor in terrible pain for 1 or 2 days until someone checked on them. If there is an elderly person in your family or your neighborhood, you should consider instituting some sort of a regular check-up process so that someone looks in on them regularly.
Recently, a lot more seniors have started carrying cell phones and medical alert devices so that they can call the paramedics even if they can’t reach the house phone. Some of the new medical alert devices are worn around the neck on a lanyard and they seem to be really helpful. We also see a lot of patients who didn’t walk much before their fracture — what we call “minimal ambulators” — who stopped getting out of bed after a minor slip or fall. If the family doesn’t recognize that this may be a symptom of a broken hip the treatment is sometimes delayed and the patient may show up at the hospital with bed sores or other problems that make nursing them back to health even more difficult.
A lot of patients are scared about the costs of hospitalization. Thankfully, medicare is still good insurance, and most people with a hip fracture have medicare. While there are some plans that don’t allow medicare beneficiaries to get treated at the hospital where I work (Kaiser Permanente patients usually get shipped back to the bay area), most people are covered when they have a hip fracture. That’s a blessing, because often the real expense comes after the fall when the family needs to pay for extended nursing care or expensive in-home help.
Over the last 10 years or so, most of the community doctors have stopped taking care of their regular patients when they are hospitalized. This seems to be both good and bad. In the old days, the family doctor who knew the patient would admit them to the hospital and make sure that they were on their proper medications and would often be the one to explain the whole situation to the family and communicate with the surgeon. Now we have a team of internal medicine doctors who work exclusively in the hospital. We call them the “Hospitalist Service” and while they don’t know the patient beforehand, they are in the hospital 24 hours a day and they are up-to-date on all the latest ways of preventing bed sores, blood clots, and other medical problems. However, they work in shifts, so often its a different doctor who sees the patient each day. This can be really confusing for the family because the surgeons all like to make rounds early in the morning and then they are in their offices or in the operating room all day and the family doesn’t have anyone to talk to who knew the patient before they were hospitalized. All in all, the hospitalists have improved the quality of care. Its less personal, but its more efficient and we like it because we can get a hold of them right away.
The hardest situation that we have to deal with is when a patient can’t communicate with us because of dementia and they don’t have a living will or an advance directive. Then it is up to the family members to decide what is best for the patient, and if there aren’t any family members around, sometimes it is a neighbor or a caregiver. I wish that everyone, no matter how old they are, took the time to make a living will. Samples of living will can easily be downloaded from the internet — I know, because that’s how I did mine! They don’t need to be prepared by an attorney and the act of preparing a living will gives the family a chance to start an honest discussion about what to do in case someone in the family does get sick or needs a lot of care. People really need to specify if they want to receive cardiac resuscitation, intubation (which is where they put a breathing tube into your lungs and connect you to a ventilator if you can’t breath on your own), or other major measures, BEFORE THEY GET SICK. Once they are sick or have a broken hip, it is much harder to make good decisions about what level of care you think is appropriate.
Most of the time, when someone breaks their hip, they are admitted to the hospital and surgery is scheduled for a day or so. This gives the hospitalist service the chance to clear the patient for surgery, run a few tests, and make sure that there aren’t any medical issues that need to be treated before surgery. The family is usually really focused on the surgery — when it happens, who the surgeon is, how well he said it went. In our experience the younger surgeons do a really good job. They are up-to-date on the latest techniques and they do a better job of following the protocols for post-operative antibiotics and anti-coagulation to stop blood clots from forming. We hardly ever hear of a patient “dying on the table” or having some sort of major catastrophe in the operating room. For us, as nurses, the biggest challenge is getting the patient out of the hospital smoothly. These days it all happens so fast. Medicare wants the patient to be in the hospital for 3 days after surgery, and then out to a nursing home. The problem is that many of the nursing homes are pretty depressing places and the family really feels like the patient is being sent there to die. We have a discharge planner who will work with the family to find a suitable place, and it is best to start this process early. The family should go and look at possible nursing homes as soon as they can — preferably on the first or second day after the operation. I know that most of the families want us to keep the patient for longer, but we just can’t anymore. I think that a lot of families are alarmed that we start talking about discharge plans on the first or second day after surgery, but this is normal now.
We work with criteria for discharge, and basically once the patient doesn’t need acute nursing care with things like IV fluids and antibiotics and its been a couple of days since surgery, they are considered ready to be transferred. However, the patient is usually still disoriented by the effects of anesthesia and post-operative pain medication and a move to another facility is likely to make them even more confused. They have a hard time remembering where they are and why they were admitted to the hospital and the effects of taking them out of their familiar surroundings and normal routines can be really disorienting. They will often hallucinate or talk about events that happened twenty years ago as if they were going on now. We call this “sundowning” because this type of behavior usually occurs after the sun goes down, and it can really alarm the family. Most patients who break their hip have some sort of early dementia and the stress of surgery and hospitalization can make the symptoms of dementia even worse. This can be a real problem for the family because they suddenly need to come to grips with the fact that the age of independence is over and this is now someone is going to need a lot more care.
Most patients with a hip fracture simply can’t go home. They aren’t strong enough, they haven’t had enough physical therapy, and their home just isn’t ready for them. Someone needs to go to their house and clean up. All of the rugs, piles of books and magazines, end tables and chairs all need to be cleaned up. Most of the patients that get admitted here tripped over something at home and if their house had been “de-cluttered”, the fall might not have happened in the first place. Meanwhile, while they are in the hospital and the nursing home, someone needs to water the plants, pay the bills, feed the pets, and do all the chores that accumulate while the patient is getting better. I know that it is really hard to suddenly have to confront all of these issues and I wish the families were better prepared. Its a discussion that every family should have once someone gets over the age of 70. At that age, it’s time to start thinking about ways to prevent a major problem — by cleaning up the clutter, organizing the house, and installing night lights — as well as ways to cope after a broken hip.