Rotation Summary

My overall experience on my long term care rotation was very positive.  I came into the rotation not having much interest in the field, however I think I was still able to learn a lot on the rotation and improve many of my skills.

One thing I really appreciated about the rotation is the fact that there was a little less time pressure than other rotations.  This gave me the opportunity to take my time getting a history and physical from the patient, which allowed me to learn more about each individual patient and their medical conditions.  Additionally, I was able to see how patients progressed as well as what kind of problems arose over the course of my rotation. I also had the chance to improve in my note writing and documentation skills, which I think was very important at this juncture in my education.  At this point, I feel very confident in my note writing skills and having a good concept in what is pertinent to include.

Something I would have liked to get more experience in over my last rotation was procedures.  Although I volunteered to do procedures whenever the opportunity presented itself, I still did not have the chance to do as much as I would have liked.

Although long term care was not the most exciting rotation for me, I think I was able to gain a lot from my experience.  Coming away from clinical year, I feel confident I will have the skills and knowledge to be an effective, skilled, knowledgeable and compassionate provider.  I feel honored and privileged to be joining the healthcare work force and feel indebted to all the mentors a long the way who have contributed so much to my education.  I am looking forward to continue to learn and grow over the course of my career.

Attached is a log of my patients. Case Logs9

Site Evaluation 

Reflection

My last site evaluation was definitely a positive experience.  Looking back at my site evaluations, I am able to see how I have progressed in being able to pinpoint exactly what is left out from a patient’s workup and perhaps how I would tweak a patient’s medication list.  One of my favorite parts was getting to discuss the case with Professor Davidson.  It’s nice to be able to discuss the cases and feel that I am at the point in my education when we can discuss as colleagues.  One thing I could have done differently is investigate some of the existing medical problems, which would help in my overall care for the patient.

Here is the patient I presented at the site evaluation HP Rotation9

Journal Article

Article Summary

Management of Acute Hip Fracture

The clinical problem

• 5 million people disabled by hip fractures worldwide every year. Top 10 cause of disability
• Classified by intracapsular (femoral neck) and extracapsular (intertrochanteric and subtrochanteric) MC is femoral neck and intertrochanteric. Nondisplaced vs. displaced.
  • Categorized into Garden type I and II (nondisplaced) and Garden type III and IV (displaced)
• Untreated- pt at risk for cardiovascular, pulmonary, thrombotic, infections and bleeding complication- can result in death.
• Timely surgery is mainstay of treatment
• Mortality at 1 month is 10%. 1-year stats- 11% bedridden, 16% LTC and 80% required walking aid.
• Mortality at 1 year is 36% even with surgery and rehab. Rate of reoperation is 10-49%

Operative Management

• Decision to operate is made based on the patient’s health status, how quickly surgery can be performed, degree of displacement.
• Unless high risk of intraoperative death or little access to surgery, operative treatment is recommended.
• Single-center retrospective study- Patients treated nonoperatively- risk of death was 4x as high as those treated operatively.
• Retrospective study- among those treated nonoperatively, patients who were treated with bedrest had 3.8x mortality rate as those with early mobilization.

Time to surgery

• Current recommendations- surgery within 48 hours
• Observational studies- shorter time associated with improved outcomes.
• Physiology- hip fracture associated with inflammation, hypercoagulability, and catabolism.
• Admission to surgery time 6 hours- reduction of postop complications at day 30.
• Meta-analysis of observational studies (4208 pts) earlier surgery <24 hours associated with lower mortality and lower risk of in-hospital PNA.
  • Note that more often, surgery is delayed in sicker patients
• Randomized pilot trial- rate of perioperative complications was 30% in accelerated surgery (<6 hours) vs. 47% with standard care.

Femoral-neck fracture

• Internal fixation vs. hemiarthoplasty vs. total arthroplasty depending of degree of displacement and condition of patient. Decision made based on likelihood to restore blood flow.
• Nondisplaced fracture- internal fixation. Similar outcomes in internal fixation with multiple cancellous crews and single compression screw with a side plate.
• Recent large trial (1079 pts- 729 nondisplaced and 350 displaced femoral neck fracture) no significant rate of reoperation between groups in 2 years.
  • Subgroup analysis shows improved outcomes with sliding hip screw.
• Displaced femoral neck fractures in patients >65 years of age- arthroplasty
• Meta-analysis of 14 randomized trial- arthroplasty associated with lower risk of reoperation when compared to internal fixation.
  • Reoperation rates 10-48.8% from failure of fracture to unite or avascular necrosis.
• Randomized trial- hip function measured by Harris Hip score better at 17 years with total hip arthroplasty than after internal fixation.
  • Meta-analysis showed higher rates of infection with arthroplasty than internal fixation, and dislocations.
• Total hip arthroplasty vs. hemiarthoplasty
  • Metaanalysis 14 trials- lower risk of reoperation with total hip arthroplasty, rating of hip function at 12-48 months was better in total hip arthroplasty.
  • Rate of dislocation higher after total hip arthroplasty vs. hemiarthroplasty 9% vs 3%
• Advantages of internal fixation for displaced femoral neck fractures- reduced rate of infection, preferred for younger patients since prosthetic only lasts 20 years.
  • Inadequate reduction- subsequent failure for fixation.

Intertrochanteric Fractures

• Internal fixation- sliding screw or an intermedullary nail, blood supply to femoral neck is usually intact.
  • Sliding screws are more cost effective.
• Unstable fractures- intermedullary nails. Meta-analysis showed improved mobility.

Subtrochanteric Fractures

• Unstable fractures- failure of fixation rates are 35%.
• Meta-analysis- lower incidence of reoperation and nonunion rates with intramedullary screws vs. extramedullary screws.
  • Mortality and overall function rates at 1 year were similar.

Perioperative care

• Interdisciplinary care necessary to get patients back to baseline, improve mobility, ability to preform ADLs, and quality of life.
• Early mobilization
• Venous thromboprophylaxis, antibiotic prophylaxis and evaluation for osteoporosis.
  • Calcium, vitamin D, DEXA scan, prompt initiation of bisphosphonates if positive.

Attached is the original article Hip fracture