GGB redux

One of my earliest blogs was about falls in the elderly and the subsequent ER visits from the injuries suffered. I bloviated about the neurological, cardiac and pharmacological issues that led to these all too frequent events.

A recent ER patient and my elderly mother reinforced for me, the extent of this increasingly common health care problem. My patient was 101 years old and lived in an assisted living facility. She had some mild dementia but was amazingly intact mentally, considering her age. She arrived on a back board in a cervical collar and was crying out in pain. She complained of right hip pain and had an obvious deformity with her right leg being shorter than the left and externally rotated. A review of her medical record showed a fall had fractured her left hip a few years ago and she had a repair and successful rehab of this injury.

Two days later I awoke from my AM nap, after working my usual three night stretch, to find a text from my sister. My 91 year old mother had fallen at her assisted living facility and broken her right hip. Two years ago my mother had fallen and fractured her left hip. The repair and rehab required only one month before she was able to return to her "home".

After a lengthy stay in the ER, my mother was finally transferred to an in-patient bed and put in traction. The next day I drove 75 minutes to spend the day with my mother. I met the surgeon and anesthesiologist and signed the consent forms for her surgery. My mother also has some mild dementia. All her memories are present and accounted for, but the filing system is not very accurate. I had an interesting conversation with her anesthesiologist. I stressed that my mother did not wish any resuscitative efforts if she had cardiac or respiratory failure. He told me that in the OR they might need to do CPR temporarily if her heart rate dropped. My mother has severe kyphoscoliosis of her back. She is shaped like a question mark. One CPR compression would shatter her rib cage. I persuaded him that no CPR should be given under any circumstances. I kissed Ma and told her I would see her after the surgery and went to wait for her return to her room.

The surgery was successful. My mother's right hip was repaired. She has been oxygen dependent since the surgery because of persistently low O2 saturation. She is depressed and says she cannot understand why God won't answer her prayers and let her die in her sleep. She is frightened and dreading the rehab process. My siblings, our spouses, her grandchildren and their spouses and partners have all been to see grandma. Her nieces and nephews have been in touch. She is the last of her generation in her family that included more than 40 first cousins.

I spent some time with Ma yesterday at the nursing home/rehab center. The place is clean, well staffed and cheerful. She is no longer actively suicidal but still says she would welcome death. The challenge is whether she can be ambulatory enough to return to her "home". She and I talked about her marriage of 50 plus years to my father. She told me she had a wonderful life. She had a loving husband, and friends from her childhood that have survived and maintained contact. She has 4 grandchildren and three great grandchildren. She is loved and cherished by all her nieces and nephews.

One week post-op, she was lucid and on the mend. She still required supplemental oxygen and the pace of her rehab is much slower than it was 2 years ago. Thanksgiving is in less than 2 weeks. My wife and I play host to our extended families on this, our favorite holiday. I set turkey day as a goal for Ma. If she can walk even 10 steps with her walker by Thanksgiving, she can celebrate with those who love her. I'll keep you posted as her recovery continues.

There are two ER relevant issues from my patient's and my mother's cases. The first is the diagnosis of dementia. Not all confusion and memory problems in the elderly are Alzheimer's disease. The loss of neurons from aging and "ministrokes" cause much of the late onset dementia in the elderly. The diagnosis of Alzheimer's disease is anatomically based. Only a brain biopsy or a post-mortum examination of brain tissue can definitively make the diagnosis. Early onset dementia is presumed to be Alzheimer's unless some other cause is found. The level of confusion and even agitation in patients with dementia fluctuate from day to day and even during the day. Sundowning, increasing confusion beginning in the late afternoon or evening, is a well established phenomenon in patients with dementia.

The other problem, highlighted by my 101 year old patient, is the back board. These are used in some form to stabilize patients who might have an injury to the spine. Their design hasn't changed for decades. They are flat. The human spine is not straight. The normal spine arches forward in the neck, posteriorly in the thoracic area and forward again in the lumbar region. New designs have incorporated this natural curvature. They would be much more comfortable for the patient and give greater stability to the spine during transport. The newer models are also more expensive and the cost of replacing all the boards used by EMS services would be prohibitive. I understand the reality of cost containment but both my patient and my mother said that the board was more painful than their fractured hip. Food for thought.