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Hip Fractures:
Advice from a Nurse

I am a registered nurse working in the orthopedic post surgical unit of a hospital. One of the patient populations that I deal with are people with fractured hips.

It has been a real eye opener over the years to watch the patients and their families deal with the ordeal of a fractured hip, the surgery, and the post operative recovery period. Perhaps sharing some of my lessons with you might help you be a little more prepared should you find yourself in such a situation.

Just in the last week we have had multiple patients that live alone, have fallen, and lay on the floor for days. These patients arrive at the hospital with skin breakdown, dehydration, urinary and bowel problems, malnourishment, electrolyte imbalances, just to name a few issues that complicate the event of their fracture.

If you have an elderly family member or neighbor who lives alone, please take a moment to check on them daily to be sure that they are all right and do not need assist. Watch for signs at your neighbors such as mail or newspapers outside that haven't been touched that might indicate that there is a problem.

These people will tell me that they have fallen inside or outside their home and with the fracture they had no way to move themselves to the area where the phone is, and if they did accomplish that, no way to boost themselves up to get it once they got to it.

A preventative suggestion is to help them get some type of an emergency notification device that they keep with them at all times. The key then is that they do keep it with them and not leave it inside when they were just going outside for a moment to get the dog or the mail, or leave it in the bedroom when they go to the bathroom to shower or bathe.

If a patient has fallen and you are not sure if they have an injury, please bring them to a doctor to have them looked at. We had a patient whose family helped them into bed after a fall and the patient lay in the bed for 2 weeks without medical attention.

The family did bring them food, but was not with the patient at all times and the patient consequentially ended up lying in urine in the bed. By the time the patient got to us in addition to the hip fracture, they had bad breakdown of the skin both on the back side and the abdomen.

Be sure that your family knows what hospital is in network for their insurance company. You can be treated at any hospital you choose, but not every hospital is contracted with every insurance company and if you go to the wrong one you may end up being personally responsible for all or some of the bill. It is the patient's responsibility to know which hospitals are providers for their insurance company, not the hospitals.

Once at the hospital with the fracture diagnosed the surgery is usually scheduled for that day or the next day. Who is the surgeon? Usually it will be the one who is on call that day.

If you happen to know a surgeon, you can try requesting that person, but it will depend on what their schedule looks like that day. You might choose to wait a day if the surgeon you want isn't available that day, but the patient is in a lot more pain before the surgery then after the fracture is fixed, and you don't want to prolong their pain. There is also the issue of complications such as blood clots, skin breakdown and pneumonia that can develop with prolonged bed rest waiting for surgery.

So it is possible that you may end up with a surgeon that you don't know and don't know anything about. You probably won't get a good answer if you ask the staff. If they have a great opinion of the doctor they probably won't hesitate to tell you. But keep in mind that if their opinion isn't the best they have to be very careful of what they tell you as all of a hospital's doctors are considered top notch by that institution.

Even if their opinion is less than optimal, then you have the task of choosing another doctor from a pool of surgeons that you know nothing about and hoping for an opening in their schedule. Honestly, all of the surgeons at the hospital I work at are completely competent, but if my family member came in I would have preferred choices as to who the surgeon was going to be. I don't really have any good advice in resolving this situation, but wanted to let you know that it is something that you may end up facing.

I can not stress enough that each person, no matter what age, should have a living will and a durable power of attorney completed and available to the hospital. In the state of Ohio these documents only need to be witnessed by 2 non-family members, they do not require and attorney or even a notary.

If this exists and is not available to the hospital, your wishes as spelled out in these documents cannot be followed. In the event that the patient is not able to make their own decisions the best way to follow their wishes is to have these documents. If they are not available and the patient is unable to voice their preferences the hospital will turn to the next of kin in an order determined by hospital policy to make the care decisions.

I have occasionally been in situations where there are no documents and no family, and the patient is unable to speak for themselves. It then is at the discretion of the court, which can take quite a long time, or the emergency policy of the hospital to decide what the course of treatment will be.

Then there is the issue of being medically cleared for the surgery. If your medical doctor or PCP has privileges at the hospital and sees patients there then that will be the medical doctor that takes care of you along with the surgeon and determines that you are medically able to go to surgery.

At the hospital where I work if your doctor does not come there, we have an internal team of medical doctors that follow those patients. Now you may end up with a medical doctor and a surgeon that you don't know and that don't know you. I am not by any means suggesting that this is a bad thing, and most of the time it works out just fine, but to the patient and the family it can be a little scary and unsettling.

We sometimes have patients that a language barrier can make this an even more unsettling experience. If this is your case, for both the patient's and the hospital's sake, please make every effort to have someone there that speaks the patients language as much of the time as possible. Sure, we have interpreter services that we use, but that usually means the interpreter is on the end of the phone, I tell them what I want the patient to know, then hand the phone to the patient so that the interpreter can pass on the message.

If you think about the patient who is elderly, scared, and in pain, then add the communication issue, you can understand how this further complicates the situation and adds to the distress of the patient.

After the surgery the patient is monitored in the hospital for complications including, but not limited to blood clots, blood loss, pneumonia, and delirium. Getting the patient moving as soon after the surgery as possible goes a long way in preventing complications.

We have our patients work with a physical therapist the morning after surgery. Many older patients will experience some level of delirium while they are in the hospital secondary to the use of anesthesia for surgery, narcotics for pain control, noise and lights 24 hours a day, and just the event of being taken out of their own environment and routine.

The length of the hospital stay will be approximately 5 days including the day of admission. This usually is about the third post op day. The vast majority of elderly patients will need some kind of an inpatient rehabilitation facility after discharge from the hospital and prior to going home.

This whole process is going to change the dynamics of their lives. It is so different from the people we see for elective surgeries who have at least made some sketchy plans for their hospitalization and recovery. During the hospitalization the patient, and/or family will be approached by a discharge planner and/or social worker to discuss the patient's discharge plan. During this approximate 5 day process they will need to choose a rehabilitation facility for the patient. Very few families have the resources to allow this to happen at home.

This more often then not means a nursing home for at least a while. I would recommend that during this whirlwind of days that someone from the family goes out to tour the possible facilities and speak with the staff and family members of other patients already at the facility. The choice of facilities may be limited by the facilities that are in network for the insurance company. We work with some insurance companies that offer as little as 2 choices.

It will be a plus for you if you find yourself in this situation if you know ahead of time what choices your insurance company offers so that you are not completely surprised by the limitations when you do need that knowledge. The patient will be discharged to this facility when the doctors determine that they are medically and surgically stable. This is usually the third post-op day.

It comes as a surprise to many family members that the patient may still be experiencing confusion at the time of discharge, and the transfer of the patient to another unfamiliar place may yet increase this confusion. It may be quite sometime, if ever that all the confusion is resolved.

The people with fractures may not be home for weeks and have houses, pets, plants, bills or maybe someone at home that they are the care-giver for that all now need tended to. Perhaps mom, who is relatively healthy, and just broke her hip, is the primary caregiver for dad, who is at home with some level of Alzheimer's disease. He will now need to be cared for while she is in the hospital and going through rehabilitation.

If there are family members they all generally have very busy lives with little room and resources to take on these additional tasks. Many of these things are problems that need immediate solutions, not things that can wait to be worked out. There is often discourse among family member regarding who will take on the extra responsibilities and who will make the decisions.

It may be that the patient will not be able to return to their home for weeks or months, and maybe not at all. I have heard the surgeons tell patients that after a hip fracture a patent will usually take a step backwards in their mobility. If before the surgery they were a runner, they will now be a walker.

If a walker with no assistive devices, they may now use a cane. If they walked with a cane, they may now need a walker. If they used a walker, they may now need a wheelchair and have limited mobility all together.

A fractured hip will be a life-changing event for an elderly person and their family. Perhaps with a little bit of time, preparation, and knowledge, this situation can go more smoothly for all involved.

Julie Ann Coppedge

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