My referral sent me to evaluate an elderly woman in an institution. I arrived in her room to find a woman moaning. The referral had a diagnosis of dementia but when I did a physical evaluation I found an unhealed fracture of her right humerus (upper arm). Any movement caused the broken fragments to grind against each other and the patient screamed. I ran into the hallway and found the floor supervisor. I asked her how long this person had been this way. She said that she had fallen several weeks ago but administration refused to send her to the hospital so she has remained in bed.
I checked my referral sheet and called her primary physician. I reported my observations of the patient’s right humerus to the primary care physician and was told, “I’m the doctor. You are the physical therapist. I outrank you. Shut up.” He hung up.
I asked the floor supervisor to call 911 and to send her to the emergency room. The floor supervisor said that she did not want to lose her job and that I had to talk to the head clinical administrator. I went to clinical administration and reported my observations to the head clinical administrator. She told me that no emergency existed. The patient’s primary care physician has seen the patient and declared that she had dementia and that was why she was screaming. They had put her in a room away from the other residents so she would not disturb them.
I said that the patient had an unstable fracture of the right humerus and that the unstable fracture constituted a life-threatening situation. I said that fragments of bone could enter the blood stream and cause a heart attack, a stroke or a lung collapse. The clinical administrator said that she noted my report and that I was dismissed. When I returned to my car my cell phone rang. The head of the home care agency who sent me the referral on this patient said that she received a call from the clinical administrator and that she requested that I be replaced as this patient’s physical therapist. The agency head went along with the clinical administrator and I was off this case. Later, I would learn that the facility failed state inspection standards and that the patient’s physician had disappeared. The patient’s bed was empty on my next visit and clinical administrator told me that my services were no longer welcome in the facility. I was barred from seeing any more patients.
I know what I saw. The patient had a malunion fracture of her right humerus. She may have dementia, also, but she did have an unstable fracture and that presented a life-threatening situation. Fragments of bone can enter the blood stream and cause a stroke, a heart attack, or can collapse a lung. The primary care physician needed to send his patient to the hospital for emergency intervention. The floor supervisor feared for her job so she would not let me call 911. The clinical administrator feared that a regulation had been broken so she fired me to protect the facility. I understand this rection but who protects the patient?
Theoretically, patients have a team of health professionals who assess patients from multiple aspects and address a multitude of clinical problems. What happens if a single member or multiple members of the team cannot meet the clinical obligations and cannot competently care for the patient? Do we have loyalty obligations to our clinical colleagues? What happens if the team members have unequal status? Can a professional subordinate (ie: physical therapist) call a professional superior (ie.: a physician) professionally incompetent? Ultimately, who has the obligation to protect the patient?
For the uninitiated, Strawberry Mansion might invoke the image of a magic castle, an elegant manor house, or luxurious living. People who know Philly have other ideas about this neighborhood. When I got the referral on Patient B, any illusion of elegance melted away. The referral described a 21 year old male with “5 GSW” (gunshot wounds) to both legs. His history said that he had been shot in the stomach when he was 18 years old and I would later learn that he fathered a son, spent 2 years in jail, and had been released home 2 weeks when he had been shot point-blank in both legs. I had an address but I knew that no street sign would guide me to this street and no house numbers would identify the house. When I called the night before to arrange my visit, I requested that someone meet me at the house and that someone guard my car during the session. Patient B grunted approval to these conditions. As I turned into the street I saw a large young man lounging on the marble steps of a row house. He raised his chin at me so I pulled up to the curb. He tilted his head towards the door so I let myself in.
I entered into a living room with circa-1960’s décor. A large black velvet wall hanging pictured the heads of John F. Kennedy, Robert Kennedy and Martin Luther King. An elderly woman sat on a sofa by a TV with her arms crossed. I identified myself and she responded, “How do I get these people out of my house?” I asked about my patient and she waved her hand towards the stairs.
On the second floor in the back bedroom, Patient B lay on the bed watching music videos. I identified myself and asked him to turn off the TV so I could do my physical therapy evaluation. He ignored me. I explained that I needed to hear his heart beat and lungs sounds and that I could not get a good assessment over the loud music. He ignored me. I told him that he had the right to refuse physical therapy so I collected my coat and my bag and started for the door.
“Yo! Where ya’ goin’?”
“You don’t seem to be interested in having a physical therapy assessment so I’m leaving.”
“Ain’t you s’posed t’ get me walkin’? Ain’t you s’posed to get me strong agin? Ain’t you…?”
“And what are you supposed to do? Do you know that I am not getting paid for this visit? It says here MA-AP- Medical assistance applied for. You have no health insurance. If you don’t want to cooperate, that’s your prerogative but I’ve got to work with people who want to work with me. Turn off the music and let me do my job or I’m out of here.”
He turned off the music and I did the physical therapy evaluation. At the end of the session he asked me if he would be able to walk again. I said that it depends.
“On where you want to walk. According to my records, last time they patched up your wounds, you fathered a child and went to jail. You’ve been out of jail 2 weeks and you’re shot up again. Maybe the safest place for you is here in your Mom-Mom’s bed. May be that’s safer for me, too.”
Wound vacs pumped breaking the silence.
“Where ya’ wan’ me t’ walk?”
“Some place that doesn’t get you shot and back on my patient load.”
He laughed. “OK, what will it take?”
I looked at the shattered tissue from the gunshots wounds and mentally calculated the number of surgeries needed to close the wounds and heal the skin. I thought about the time it would take to heal the muscles, ligaments, and other structures. Skilled nursing and rehabilitation would be necessary for him to relearn how to use these healing tissues.
“Truthfully, it will take a year of your life, a million dollars, every trick I know and more pain than you can ever imagine.”
Wound vacs pumped.
A still, small voice asked, “Ya comin’ back?”
I came back and slowly over the next few weeks we found a way to communicate and to trust each other. He learned to move around and get himself out of bed. I jimmy-rigged a system using his high-topped sneakers, some clothesline, and his father’s leather belt that stabilized his legs enough to enable him to walk to the bathroom and negotiate the stairs with crutches.
When he could walk independently 60’ and do the 14 steps from the first floor to the second, I said that the home care physical therapy goals had been met and I had to discharge him. He asked me what would happen after home care. I said that it depends. Where was he planning to walk? He said that he’d like to be a barber. His father was in jail and he didn’t want to be the father to his son that his father had been to him. He wanted his son to be proud of him. I told him that I would get him into an in-patient rehab program to get him to the next level of rehab but that he better become a barber because I had no intension of teaching him to walk again. I told him that I knew where he lived and he laughed.
I never found out if he became a barber but he never came back on my patient load. Was it fair that I made him promise to get an honest job as a condition of getting into an in-patient rehab program? Is it the responsibility of the health care system to do more than just teach someone to walk, heal wounds, and stabilize a medical condition? Should health care professionals also exert a certain amount of pressure on an individual to lead a healthier lifestyle? Should health care professionals coerce people out of harm’s way and urge them to be good citizens and productive members of society? What is the limit of good health care and who should make that decision?
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 intensions, not every patient can be helped. This blog will tell you some of their stories.
Mr. A’s Right Hip
I drove into a narrow, one-way street of row houses with 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 half 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 and motioned 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 hand 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 had to discharge 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 moveable joint? I found the whole situation troubling but how can we improve care for Mr. A and everyone like him?
Welcome to Health Care From the Ground Up.
I want to blog about health care and show you images from my patients’ homes, from the clinics and facilities that provide services, and from the administrative offices that manage the services.
I have been a licensed physical therapist for more than 3 decades and have an academic background in anthropology (AB, MA and PhD) . I use my experiences and training as a clinician and preparation as a social scientist to help me understand the current health care environment. I want to give you an intimate picture of my patients, my colleagues, and the challenges we face.
My teacher, Dr. Edmund Pelligrino, described a patient as a person with “wounded humanity”, having an assault on one’s very personhood. Today’s health care has wounded patients, wounded clinicians and a wounded system. How can we start the healing process? I don’t know but having a better understanding of the problem is always a good start. With this in mind, I start this blog.
Since I’m new to the blogosphere, I hope you’ll bear with me as I learn how to do this. Maybe you’ll help me along the way…..
OK, I’m ready- Let’s go blog.