There’s a lot of attention in the media right now on opioids and the epidemic of overdoses and deaths, both from prescribed and black market access. Political grandstanding on penalties notwithstanding, it is a serious problem, and the trail back to the root cause is convoluted, murky, and highly fraught.
Let me tell you a story about how a country doctor and an award-winning hospital nearly killed my aging mother because nobody was paying attention.
Hip replacements are quite routine these days, as much as any major surgery could be considered routine. The process is highly refined, with admissions, pre-op, the surgery, and recovery being standardized and relatively frictionless.
But here’s the thing: human bodies can’t be standardized. It’s impossible to control for all factors in any kind of major medical event. Age, body weight, chemical sensitivities, metabolic rate, and so on — these all contribute to the overall effect that surgery and the attendant medications will have on a patient.
Surgeons tend to be a bit… insensitive, we’ll say. They might be really good at that one particular thing they do, but they are, after all, merely good technicians. As such, they tend to focus on that one thing with little regard for the other, softer factors that can affect the outcome. Surgery is much more than simply repairing — or, as in this case, replacing — body parts.
And if nobody is paying attention to the whole picture — the confluence of the physical and emotional trauma of surgery with the medications prescribed before, during, and after — disaster can happen.
My mother recently had hip surgery, and the surgeon is considered one of the best in the country — so much so that he was on call when President Obama visited the region. There’s a bit of mythology around this man, much of which is of his own making; he’s quite fond of showing off the literature on all his successes, awards, and diplomas — he’s a walking ego wall.
Not all of them, and not all to the same degree, but the absurdly egotistical surgeon has become a trope for good reason.
Many people we knew had been treated by this doctor, and raved about the results. “Life-changing” was a phrase we often heard. Well, indeed it was, though not in the way that anyone ever expected.
The hospital in which the procedure was done has been working very hard to build a reputation of excellent patient care, and the orthopedic unit has won multiple awards. As with any decent-sized hospital, of course, the actual humans involved in post-operative care are a mixed bag. We had some amazing nurses and techs, and some that really need to be in the back kitchen scrubbing pots because they should never be permitted to have contact with patients.
Going in to the process, we were all aware that my mother had waited too long to have the procedure done. Even the year before, an x-ray showed a badly degenerated hip, some remodeled vertical fracturing, bone spurs and cysts. The week before, the x-ray showed a full inch of bone loss. Frankly, it looked as though a hyena had been chewing on it.
Having waited so long, my mother had also been prescribed some medications by her primary physician, the aforementioned country doctor. She was first prescribed tramadol to help with the arthritis pain, and later diazepam to help ease anxiety. But the tramadol made her paranoid, and the diazepam made her confused and aphasic.
For all that we admire this doctor and the fact that he takes the time to read a patient’s chart in detail, he missed this.
The combination had been appalling to watch — I thought my mother was sinking into dementia because of her age and our family history until I started doing some research. That’s point number one. More on that in a moment.
Because she was in so much pain, she could hardly walk, which meant that getting to the kitchen to feed herself was such an ordeal that she went without food more often than not. She’s 78, which is not all that old. And she was starving to death, dropping to 98 pounds, maybe less, when she went in for the surgery. 98 pounds, and the primary care physician didn’t raise an alarm about this either. That’s point number two.
Total hip replacements don’t actually require general anesthesia. Instead, the anesthesiologist can do a spinal block (similar to a saddle block given during certain births), along with scopolamine, administered via transdermal patch behind the ear, antibiotics, and a battery of post-op painkillers and antibiotics in what is called a “pain bag”, a bag of this cocktail that taps directly into the surgery site. We’re told that body weight is accounted for when the pain bag is created, but in fact, it’s just 200mg of this cocktail. This I saw in writing — and it’s the same whether the patient is 298 pounds or 98.
When the surgeon came out to talk with me after he was done, he was chipper and optimistic, saying that the surgery went perfectly — she didn’t lose a lot of blood, the hip replacement itself went smoothly, he cleaned out all the bone spurs, etc., and all should be well. It sounded rehearsed, and probably was, until he chuckled and said “Nobody could accuse her of doing this too soon.” Yep, we all knew that. So far all seemed fine.
I got to see her again after she was out of recovery and in her room, where the plan was to keep her at least one night. She was dopey, and that was entirely expected in the few hours after surgery. But a day later she was still dopey, confused, uncooperative, and unable to walk.
Two days later, she was still hopelessly confused, unable to string two coherent words together, and unable to control her own bodily functions. I wept.
The nurse on duty very kindly pulled me aside and told me my mother was sunsetting (his word), and that I should prepared for long term care. This didn’t seem right to me — I had seen her in the days before the surgery, and although we were both aware that she was fogged by the medication, she was still lucid. I wasn’t satisfied with this nurse’s assessment.
I went home that night, knowing that I desperately needed sleep so that I could get to the heart of what was going on. The next day my mother was still completely incoherent, and hospital staff treated her as though she were a senile old woman. “Confused” was all they said, and yelled at her and heaved her around as though she were a side of beef.
Somewhere in the course of that day, she asked if she could lie on her side. The nurse on duty (hands down the best person on our care team, a real angel) came to help and happened to notice the scopolamine patch, still there after two days, and which she immediately removed, shaking her head in wordless disapproval.
With my mother settled quietly on her side (and tied in place because she still didn’t understand the post-op precautions), I went out to the nurses’ station.
“Help me understand why she’s still so confused after all this time.”
“The scopolamine is sometimes really hard on older people. Give it a day or so, and it should clear out of her system.”
I nodded and went back to the room.
Later in the day, she was able to sit up a little bit, but was still drifting in and out of her deep fog. She would try to carry on a conversation, but still couldn’t get more than a word or two out before her thought ran off for the hinterlands and the words disappeared.
After a while, I noticed that her mind was still working — I could see it in her face — and I tried to keep something like a conversation going to keep her engaged. She would say something that seemed to make no sense until I remembered that we had talked about it a few stops back. This went on for a while, and gradually I recognized a pattern in her speech. It was the same kind of tangential meandering that I had experienced under the influence of morphine after a medical emergency of my own many years ago.
I went back to the nurses’ station (yes, I’m a nurse’s worst nightmare: a patient family member with a brain and a will) and told our same angel nurse what I observed. Then I asked for the list of medications she’d been given.
Any one of those things will make most people loopy. A cocktail of them would send me to Mars, and I weigh more than twice what my mother does. And despite the fact that we had specifically asked them not to give her diazepam, the night nurse had done so anyway. I asked how long it would stay in her system, and the answer that came back was that it might be a day or two.
I like more distinct targets than that, so I started doing my own research. The scopolamine would stop affecting her by the end of the day. The diazepam, on the other hand, would probably stay with her for 100 hours, maybe more. More than four days, plus a long tail.
I told the nurse to take them all off. No more narcotics. This insane stack of psychotropic drugs was killing my mother, and nobody was monitoring the potential interactions, or her reaction to it. They were just shrugging and assuming that this was how it was going to be. The surgeon, who was also her attending physician, was shockingly cavalier and unapologetic about it, waving it off and saying that she was merely exceptionally sensitive to the medications.
Looking up diazepam, I also looked up various indications about age and body weight. It turns out that she was overdosing on it long before she entered the hospital. For her age and body weight, she should have been prescribed 2-2.5 mg a day. Instead, her prescription was for 5 mg a day, and she was taking two or more a day by mistake. She couldn’t read the label. And in the middle of the night, overwhelmed with pain, she’d grab one, and then another a few hours later. She was fogged by the meds, and the fog slowed her reasoning to the point where she couldn’t remember to limit herself to one a day. It was a cascade of failures, starting with her primary physician.
The next step was to find out who was responsible for prescribing the medications during and after the surgery. That was two people: the anesthesiologist and the surgeon. According to the nurse manager, they would have conferred after the surgery.
But who was really monitoring that crossover between the surgical cocktail and the post-op one? Nobody seemed to be paying attention to the fact that my mother was not getting better, and in fact she was declining. I watched her blood pressure gradually sink, while her heart rate fluttered. How long before she would have gone into shock? Days, maybe. Floor staff labeled her as merely confused and uncooperative, and didn’t look any further into why she was declining. So I asked questions, and more questions, and generally made an utter nuisance of myself until it was clear that we were entirely unhappy with her post-op care.
The issue is really that there was not a single care coordinator overseeing the entire process and monitoring the results; there should have been. If I hadn’t been there, heaven only knows what might have happened.
One sad part about all this is that it’s clear that the medical system is designed to scale — to maximize efficiency and therefore maximize profit — but that usually comes at the expense of actual patient care. I’m all for scalability; it’s part of my job as a consultant to help enterprise organizations build efficient, repeatable processes. But it should never be at the expense of the customer experience. Somehow our healthcare systems do not understand this yet. Between obscenely expensive pharmaceuticals and insurance companies out for maximum revenue, the patient is sacrificed.
Here’s the irony: my mother’s case will end up costing the system significantly more than if they had paid attention the way they should have in the first place. As it is now, there will be thousands of dollars’ worth of additional rehab and recovery (and likely a lawsuit) on top of the original procedure.
As of this writing, it’s been four days since we took her off all those narcotics. She is sitting up, eating like a horse, having lively conversations, and actively participating in her own recovery. I have my mother back, but she still has a very, very long road ahead of her.
If we hadn’t started asking questions, she might have died or at the very least been another zombie in a nursing home, written off as merely another senile old lady, an unfortunate statistic, a casualty of a heartless system. They’d shake their heads sadly, chalk it up to dementia and personal neglect and forget about her 30 seconds later.
Not on my watch.