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As I entered the room my eyes went immediately to the elderly lady sitting halfway off the chair beside the bed. She appearing as if she was about to slip off onto the floor at any moment. I introduced myself and reached out to shake her hand, but her hands were occupied gripping the seat in an attempt to support her weight while lifting her hip off the chair. She attempted to smile, but her eyes and the set of her jaw belied the fact that she was in great pain. Her husband’s weathered hand rested gently on her shoulder as he watched her suffer.

“What can I help you with tonight?” I said somewhat oblivious to her situation.

“My hip hurts,” she said with the sigh of resignation that suggested that she had answered that question a few too many times.

“When did all this begin?” I began. I really did care, but I slid so easily into the questioning mode, even dropping my eyes to the chart I was scribbling on.

“Can you give her something for the pain?” the elderly man asked with an air of pleading exasperation in his voice. “She’s been suffering with this for so long. All the doctors tell her something different. I just want someone to help her stop hurting.”

“Of course,” I said, lifting my gaze to meet his. I noticed the simple gold wedding ring that had worn its way into his thick finger. It was clear that he had been her provider and protector for many years. But seeing her in such unrelenting pain was wearing him down. 

“I’m sorry for not offering something right away.” A midlevel oral analgesic would probably have been sufficient to take the edge off the pain, but I felt guilty. I ordered an IV and enough narcotics to insure that she would rest easily on the bed for at least an hour while she got a film of her hip.

As the nurses helped her into a gown and onto the bed, I couldn’t help noticing her severe scoliosis. “She was the prettiest girl in school and the class favorite when I first saw her,” he said as she finally relaxed under the influence of the drugs. “She was just a sophomore and I was a senior, headed off to the war.”

I squinted trying to think of the twisted elderly woman as the young beauty he had fallen in love with. “How long have you been married?” I asked. I could tell that it was a question he was proud to answer.

“Seventy four years,” he said with a sly smile. I didn’t know what to say. Did people stay married that long any more?

“How long has she had scoliosis?” I finally asked, getting back to my history.

“What’s that?”

“Oh, the twist in her back. Has she always had it?” He looked at me quizzically. Then his expression turned dark and angry.

“This all happened after she had her hip replaced.”

“What happened?”

“The doctor replaced her hip. And she was better for a little while. Then her back started to hurt. And now her hip is in even worse pain.”

“So that’s when she developed the curve in her back?“

“After the surgery we noticed that one leg was longer than the other.”

“OK, I understand now,” I groaned. “Who did the surgery?” I was expecting him to give me the name of some hack. Instead he mentioned the name of a colleague who had a good reputation. “Did you ask him about the leg length discrepancy?”

“Yes. He said that some hips come out more uneven than Mom’s.”

“Really?” I was incredulous. Complications were one thing. But an outcome like this that led to severe scoliosis and chronic pain was starting to look like malpractice. “Surely he gave her a lift to wear in her shoe to even up the length of her legs.” I was making excuses for him in my mind.

“The nurse gave her a little pad to wear in her shoe when she was discharged from the hospital. But nobody ever said any more about that. When it wore out, we didn’t know if she was supposed to replace it or not.”

“Didn’t you ask about it when you went back for follow up visits?”

“We got just a couple visits. Then they told us we didn’t need come back anymore.”

I finished the exam trying to hide my frustration with her previous care. The orthopedic group who did her hip was known to be a mill that ran hundreds of patients though in a rather impersonal fashion. I could see this shy elderly couple either not knowing what to ask or not wanting to complain or inconvenience the doctor. But this wasn’t right. He should have referred her for custom orthotics and given explicit instruction on their use.

Apparently he was just too busy. I debated in my mind whether I should raise the issue and possibly precipitate a suit. I finally decided that this was not my fight. He gave her a lift, I rationalized. They didn’t follow up. I couldn’t fix that now.

My current concern was that the additional stress on her joint had loosened it up and now it would need to be removed. Wouldn’t that be the last straw?

After seeing a few more patients I noticed that she was back in the room and talking pleasantly with her husband. A little pain relief had been like pouring water on a wilting flower.

“I saw your X-rays and they are fine,” I announced while re-entering the room. “I was worried that the prosthesis had loosened up and might need to be replaced.” They both looked at me with alarm, then relief that the prospect of even more surgery would be avoided. “Your husband said that you were given lifts to wear in your shoe after your hip surgery. Do you understand how important it is to wear them? Since your legs are uneven it causes your pelvis to tilt. Not wearing your lifts could cause your back to be stressed and eventually twist.” I realized that in my mind I was trying to shift the blame for this bad outcome from the surgeon who caused it to the patient who lacked the information to avoid it.

“Oh yes,” she said cheerfully, seeming to ignore my implication. “The doctor gave me some, but they wore out. I bought some more at the drug store.”

“Do you wear them all the time?” I asked. There was an element of chiding in my voice because I knew the answer was no. How could she have such a severe scoliosis if she wore her lifts? She contributed to this disaster, I thought.

“I do sometimes,” she said apologetically. “But they make my foot hurt. And that hurts more than my hip. So I wear sandals or nothing on that foot. Should I have worn the lifts? Did I cause this?”

“It’s my fault,” her husband chimed in. “I could have gotten the lifts. But it’s hard for me to drive any more.”

Now I felt guilty. I could see in their faces that they were willing to take the full weight of guilt for the situation. But there was more than enough blame to go around. The truth is that her doctor should have done better work. Given that the outcome was less than satisfactory, he should have corrected his mistake. At least if he had followed up with her he could have seen the evolving scoliosis before it became severe. But then again she should have worn the lifts. I went back and forth in my mind trying to decide who was more responsible for this outcome. Finally I gave up.

“No, no,” I reassured them. “Sometimes these things just happen.” I rationalized that it wasn’t my job to try to right all the wrongs in the world. They just wanted to feel better. 

“I’ll give you a referral for a custom lift and a prescription for a stronger pain medication. I hope that the two things will help you a little.” In my mind, however, I knew that little would change this situation much.

“I really appreciate you telling us what’s going on,” he said. “No one seems to explain things much anymore.”

I had one last chance to come clean with them about what had actually happened with their care. But I chose expedient silence. All I could do was nod an acknowledgment and put my hand on his shoulder as I left the room.

 

Comments   

# Eric 2013-07-16 10:00
In your fine article the concept of having a primary physician who takes responsibility for the patient's overall health remain unmentioned. If there was a caring primary physician to follow the patient's health and manage the patient rather than expecting specialists such as ortho or ED to manage their primary care, this sad tale wouldn't have happened. Having a primary physician to manage a patients health with referrals to competant specialists and then return to the primary is a model that has never been improved upon but has been cheapened and distorted.
Thanks for a sad but real tale of those distortions.
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