Under the Sheets

I heard a great deal about Alice before I even met her. I took two steps into my hospital’s ‘short stay’ unit early one morning when I was stopped by the Care Coordinator.

“Your patient has to leave,” she said.

“Who?” I replied. I had not yet been able to print a list with the names of my patients on it.

“Your new patient with hip pain.”

“Where is she going?” I asked.

“Home. Medicare denied her stay.”

Alice was in her 80s and appeared the quintessential grandmother: she had short, neatly-cropped gray hair and a pleasantly round face that gave her the appearance of being incapable of malediction. Her shoes were arranged neatly on the floor next to her bed; they were unmistakably non-athletic, beige “grandma shoes” with thick soles and Velcro. Her husband stood dutifully at her bedside, wearing a hat bearing a Naval emblem, identifying him as a proud veteran. I took a careful history.

“I look forward to Easter, more than any other holiday,” she said. Her husband nodded in eager assent.

“Why is that?” I asked.

“It is the one day of the year the whole family comes to my house. I put on ‘The Show.’”

She spoke further, and it became clear that Easter was more than the spiced ham, leg of lamb, and the deviled eggs. It was more than the egg decoration and hunting for jelly beans with her grandchildren.

“It is having everyone there. Together.” She raised her eyebrows and gave me a knowing look.

When Alice turned “a certain way” and felt a pain in her left hip a few days before Easter, she didn’t tell anyone. The pain became progressively worse, and she had increasing trouble getting around the kitchen. Never mind that by the time she came to the Emergency Room she was unable to walk—Alice had cancelled Easter.

In the Emergency Room, x-rays demonstrated no abnormalities, and she was admitted to the internal medicine service for pain control. She was given a diagnosis of trochanteric bursitis by the admitting physician, and received narcotics for her discomfort. Medicare reviewed her admission and denied payment for her hospitalization by the time I arrived the following morning.

Her physical examination demonstrated a significant amount of pain in her left hip and the ongoing inability to bear weight.

“Alice, do you use a cane or a walker at home?”

“Heavens, no. Those are for old people,” she said with a gentle smile.

My evaluation of Alice was interrupted by the unpleasant tone of my pager. I excused myself.

“I am a physician from the consulting firm your hospital has hired to review admissions,” said the voice at other end. “Alice does not meet criteria for inpatient admission. She needs to be changed to observation.”

“She can’t walk,” I protested.

“I’m afraid that doesn’t matter.”

“What do I do with her?” My tone was as professional as I could manage.

“Send her home. I’m sorry.”

The 11 a.m. discharge deadline approached, and I was no closer to a solution. I reviewed the films: no fracture. I called her primary care physician, who was as uncomfortable with the idea of discharge as I. I exited the charting room and again was descended upon by the Care Coordinator.

“Good news!” she said cheerfully.

“What is it?” I said.

“I found a short-term rehabilitation facility that will take Alice.”

“Who’s paying?” I asked.

“Alice is. That’s the best we can do. They are ready for her—can you do the STAT dictation so that we can get the discharge order in by 11?”

Enough was enough.

“No way” I said.

“What?”

“She still has way too much pain. She can’t walk.”

“Her hip films are negative. You said so yourself.”

“I did, and I don’t believe them. I am keeping her in the hospital for a CT scan.”

“The hospital is eating these costs!”

“It is,” I said. “It is, indeed.”

Eleven a.m. came and went, much to the relief of Alice and her husband. He remained standing, holding his Navy hat in his hands and shifting it nervously.

“What am I supposed to do with her when she gets home?” he wondered.

“Tell me about this short term rehabilitation arrangement,” I said.

“I’ll go there until I can walk again,” Alice replied in earnest.

“Out of pocket, right?”

“Yes.”

“Alice, forgive me, but how are you going to pay for that?”

She didn’t answer me; instead, she looked at her husband, who fixed his gaze on the floor. They didn’t know.

“We live on a fixed income,” Alice said and pursed her lips.

The CT scan of her hip and leg happened late that same night, while I was at home with my wife, also a physician, lamenting the frustrations of Alice’s situation. We reflected on the changing lexicon of current medical care: care coordination, admission consultants, observation status, 11 a.m. discharge, and Medicare denials. Since when did throughput come to supersede patient care?

Upon my arrival the following morning, I walked straight to radiology. The radiologist and I made small talk while he pulled up the study.

“I am hoping to find a hairline fracture, something to be able to justify this unfortunate woman’s hospitalization,” I told him.

The images flashed up on the screen. I let out an audible gasp, and the radiologist smirked.

“You needed a CT for this?”

His services were not necessary. A badly displaced left hip fracture was readily apparent. I called Orthopedic Surgery, and returned to the unit feeling decidedly ill. Again, I was met at the door by the Care Coordinator.

“Your dictation isn’t ready. I can’t book Alice’s ride.”

“She’s not leaving,” I said.

Her expression said it all: ‘What now?’

“Come with me,” I said over my shoulder. I was already on my way to Alice’s room.

I found Alice still snuggled under her sheets. Her expression was unwaveringly kind.

“How is your pain?” I asked.

She opened her mouth to answer, but was interrupted by her husband.

“No problem, unless she moves or stands,” he said. He looked at me. “Something’s different,” he said. “What is it?”

I nodded and returned my attention to the bed. “Alice, forgive me but will you allow me to examine your hip again?”

“Of course, doctor.”

I pulled back the sheets to find her fully dressed. She wore a striped blouse and green polyester pants. Her beige grandma shoes were back on, with Velcro fastened. She was, after all, ready for discharge. In the flesh, her shortened, externally rotated left leg was more appalling than the CT. This was not the hip I had seen the day before. Her injury clearly worsened in the 24 hours she spent in the hospital. Did she have a hairline fracture that was displaced during her physical therapy assessment? Possibly the fracture worsened while getting dressed for her imminent discharge? I had no explanation. I did, finally, have a clear plan.

“Alice, you have broken your hip.”

Alice and her husband gave me a collectively surprised look. “It’s broken?”

“It is. You need surgery and I have a surgeon on the way up to see you.”

“Surgery? I thought I was leaving.”

“Not today.” I managed a weak smile. “I think Medicare is going to pay for your hospitalization now. And the surgery. And the rehabilitation.”

Her husband put his Navy hat back on his head, extended his hand and said “I can’t thank you enough.” He then sat down for the first time in 2 days.

Alice did not have the kind of disease that usually gets much attention: she did not have a heart attack or a devastating stroke, and she was not dying of cancer. Alice simply hurt her hip and cancelled Easter. Somehow, that should be enough.