Patient Heal Thyself

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It must be Kismet. A patient, who I hadn’t seen for over a year, returned for evaluation after developing a medical complication. Three weeks before, he entered a private specialty hospital for a total knee replacement. After suffering with arthritis in his knee for over five years he stated that, “Enough was enough.” He went on the internet, talked to friends and colleagues and finally choose an orthopedic surgeon who came highly recommended. When he told me the surgeon’s name, I recognized him immediately: very good surgeon with a great reputation,although most patients admitted his bedside manner was ‘not Marcus Welby’.

The surgery itself went smoothly. Physical therapy had him up and walking short distances the next day. While lying in bed a machine would rhythmically  move his knee and leg up and down, preventing stiffness and increasing his mobility. Not surprisingly, he had little pain. Most patients who suffered for years with arthritis pain in a knee or hip-joint have almost immediate relief with a joint replacement. After his second postoperative day in the hospital the surgeon’s physician assistant told him it was time to go home.

“I was a little surprised,” my patient explained. “I guess I thought I’d have a week to recover in the hospital. I probably didn’t listen when they told me I’d be ‘out if a couple of days’. I thought it was a figure of speech.” He found a ride home with a friend and laughingly described how they tried to fit his leg, immobilized in a brace, into a Honda Prius. “We had to lay the seat back and I stared through the rear window during the ride home,” he joked. They made it to his apartment complex and faced another immediate challenge.

“Leave it to me to live on the third floor,” he said. With no elevator and only the stairs as his way to ascend, his friend helped him step/thump his way up five flights. By the time he got to the top step his shirt was soaked in sweat and he felt nauseated and dizzy. Once inside his apartment, he reclined on his couch already having second thoughts about the surgery. Over the next several days, with no one to help, he mostly stayed where he first reclined. It wasn’t until his leg began to swell that he started to get concerned.

“I was supposed to give myself some shots,” he related. But with all the ‘fun’ getting home in the Prius, I forgot all about getting the prescription. I guess since I wasn’t having much pain and I wouldn’t need the medication.”

Ironically, I had just read an article in the Wall Street Journal by Laura Landro, describing the trend of short hospital stays and placing the recovery burden on patients and their families. In the ‘old days’ patients could recover in the hospital for days, if not weeks. They had access to nurses, therapists and other professionals who could aid in a myriad of ways to help the patient recover. Now, insurance changes and increasingly reliance on private, for-profit hospitals has shortened hospital days and placed the onus on patients to provide, or arrange for their own care. Unfortunately, we haven’t mastered how to provide seamless, quality care with the same expectations for quality outcomes when the patient is responsible for their own care.

A quick look and palpation of his swollen lower calf immediately raised my suspicions. “We need to get an ultrasound of your leg,” I explained. “The shots you were supposed to give yourself was a blood thinner. There is an increased risk of blood clots developing after a joint replacement surgery and the shots are to help prevent that complication.” His widening eyes told me he was beginning to remember something about that potential complication. I also noted the increasing band of sweat across his shirt. When I explained how we would treat his leg, the Lovenox shots we would start and that home health nurses would be in everyday for a while, he seemed to visibly relax.

“Man, I thought it would be so simple,” he said. “Two days, new knee and ‘Dancing with the Stars’ in no time. Guess I should have listened more closely, but as usual I was in a hurry. Seemed pretty simple to me at the time.”

Related Articles

• Patient, Health Thyself (online.wsj.com)
• Knee joint replacement – All Information (umm.edu)