Many of the patients I see as a home care physical therapist live in the most dangerous neighborhoods of Philadelphia, have the lowest income levels, and have the least amount of resources to draw on for support. Many have minimal education, visual and/or cognitive impairments, a sense of hopelessness, and a distrust of the health care professionals who provide their care. Arguably, I serve some of America’s lowest 1%. Still, I see no reason why my patients cannot have the best health care available on the planet.
After 3 decades of practice, I’ve learned a few tricks. Mostly, I’ve learned what I don’t know and Socrates said that this is the first step towards wisdom. The second step is knowing how to find someone who does know the answer. Step three involves crafting a plan that works for each patient. I offer concierge service for each of my patients and I have a lot of success. I have failures, too. Step 4 entails the realization that even with the best plans and the best intentions, not every patient can be helped.
This article will tell you some of their stories.
Mr. A’s Right Hip
This one-way, narrow street of row houses had 5 steps going up to each door. Most steps were marble and broken. A few had railings but the stairway to my patient’s home did not. A young woman answered my knock and let me into a room 14’ x 20’. Straight in front of me 14 steps with one rail led upstairs to the only bathroom in the house. In the room a 5’ x 7’ flat screen TV sat on a TV stand. A man with a small boy and a younger girl sat on a sectional sofa. The detritus of children spilled off the sofa and coffee table onto the floor. I stepped through the litter of pacifiers, doll clothes, Lego’s, and toy truck parts to my patient on a hospital bed in the far corner. A table alongside his bed contained his detritus: plastic vials of pills, a glucometer, a urinal, medication information sheets from the pharmacy, folders from various hospitals, rehab facilities and home health agencies, a plate of have eaten lunch.
I introduced myself as the physical therapist from the home health agency who had spoken to him the night before to set up this meeting. He nodded in recognition. I asked permission to put my coat and bag on the wheelchair at the foot of the hospital bed since that seemed to be the only vacant spot in the room. He agreed and we began the physical therapy evaluation.
He told me that he had severe arthritis in his right hip and had a total hip replacement 2 years ago. That artificial hip became infected so he had a second hip replacement. This hip also became infected so he had a third operation 2 months previous. He said that his right leg was now 5” shorter than the left one, moved very little, and gave him severe (10 out of 10) pain. He spent about 95% of his time in bed since only rest and large doses of pain medication gave him any relief. At my request, he demonstrated getting in and out of bed, walking across the floor using a pair of crutches, and going up and down the stairs. He showed me the surgical site that a large keloid scar with swelling. His blood pressure was 190/110 and his heart rate was 96 regular and strong. His respiratory rate was 22 and his lungs were clear. He said that he had an appointment with his surgeon the following week. I asked him if he wanted me to go with him and his daughter appeared out of nowhere and said an emphatic, “Yes”.
I met my patient a week later at the hospital where his orthopedist worked. My patient sat in his wheelchair and carried his crutches, a plastic bag with his medications, and a wallet. I wheeled him up to the receptionist’s desk. The receptionist checked his name off a list and asked for a $35 co-pay. She said that he had to go to Radiology for an x-ray and waved us away for the next person in line. I wheeled my patient down the hallway towards Radiology when he informed me that he needed to urinate. I found a plastic urinal in a storage closet, wheeled him into an alcove and guarded the entrance while he did his thing. I took the urinal with a gloved have and pumped sanitizer onto his. We passed a ladies room and I emptied the urinal, washed my hands and the urinal and wrapped it up in paper towel.
We arrived at the Radiology Department and the receptionist informed my patient that he needed a referral from his primary care physician for the radiographs. I called the patient’s primary care physician’s office and the receptionist said that since the orthopedist was requesting the films, they felt no obligation to do anything. The receptionist heard this exchange so after the PCP’s receptionist hung up on me, she called her back and explained the situation. An appropriate referral appeared in the fax and the receptionist turned to my patient and requested a $35 co-pay for the x-rays. He said that he had no more cash. The receptionist agreed to take his credit card. I wheeled my patient down the hall to the x-ray machine and assisted the technician transfer my patient onto the table and position him for the requested views. I requested that my patient get copies of the films. The radiographer left the room and a few minutes later a man walked in with a handful of forms. He explained that the patient could get copies of the films but that they would not be available for 2 weeks and that he would have to come back to the department a pick them up. I asked if I could pick up the films since the patient was in severe pain and had difficultly moving around. The patient filled out some more forms and the man agreed to let me pick up the films.
I wheeled the patient back to the Orthopedic Department and the patient was seen by his surgeon. The surgeon had the just-taken films on his computer screen. I said that I didn’t see the prosthetic hip. He said that the hip was infected so he took it out. Since the hip replacement had failed twice, he decided to let the femur fuse to the iliac bone. Since the natural hip joint had been surgically removed in the previous surgeries, the headless femur had been allowed to drift upward into the iliac bone causing the 5” shortening of the leg. The two bones had not fully fused so any movement caused severe pain. The severe pain caused the increased blood pressure and heart rate. The surgeon loaded one radiograph onto the screen and pointed out the primary bone deposition between the two bones. The bones were fusing and no infection was present. The complete healing would require a few more weeks. The surgeon prepared to go but I stopped him. I mentioned the severe pain, my patient’s difficulty in getting around, and his elevated blood pressure. I asked if the patient could have a brace on his hip to stabilize the joint until the healing was complete. The surgeon took out his script pad and wrote out a prescription for the requested brace.
I wheeled my patient into the lobby to wait for his ride home. I had just spent 5 hours with my patient in the hospital and he had not eaten or drank anything. Since he had diabetes I worried about his sugar levels. I went to the cafeteria and bought some sandwiches and fruit drinks. I let him choose a sandwich and a drink and called the transportation company. The circle in front of the door was filled with vans but none of the drivers agreed to transport my patient. He would wait five more hours before he arrived back on his doorstep.
Two weeks later with disk in hand and laptop in tow I showed the films to the patient and his daughter. I had brought along my radiology text and life-sized models of the pelvis and femur. I explained what a normal hip joint looked like and I placed the bone models in their hands. I showed them pictures of artificial hips and explained how the top part of the femur had to be surgically removed so the artificial femoral head could take its place. I showed them how the femur was shortened with the removal of the infected artificial joint. I showed them the image of the primary bone deposition indicating that infection-free healing was occurring. I explained how the brace would hold the 2 bones together until the bones fully fused resulting in less pain and more normal vital signs. The patient’s daughter said that this was the first time in 2 years she understood what was going on.
In the weeks that followed, my patient’s vital signs normalized and his pain levels fell to tolerable levels. He got himself around his house on his crutches and negotiated the stairs to bathe in the 2nd floor bathroom. He wanted to resume driving but I discharged him from physical therapy before this occurred.
His case left me with many questions. Why did the patient and his family agree to the surgery if they did not understand what the surgeon planned to do? Why did the surgeon do the procedure without getting true informed consent from the patient? If I had not gone with the patient, how would he have managed at the hospital? If I had not explained the situation to the patient and his daughter, would they have finally understood the situation on their own? Would they have chosen to have a fused hip or would they have gone to another surgeon for another attempt at a hip replacement and a movable joint?
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Dr. Jan Bruckner lives in Philadelphia, Pennsylvania. She has a PhD in bioanthropology from Indiana University, is an expert physiotherapist and the author of the “The gait workbook: a practical guide to clinical gait analysis”. Jan speaks American English, Français, Italian, Spanish, Haitian Creole and Philly gangsta.