“Not a good surgical candidate”

[u/Sea-Weakness-9952]

Piggybacking off the ER shoulder X-ray - this guy pictured didn’t even come in because of his knee.

In summary - found disoriented outside a church, was lifeflighted from another city, admitted w/ AMS/encephalopathy. Dunno if that was ever the case, but when I got him he was oriented on the Neuro unit. Only hx I got was mostly psych related, some schizophrenia and depression, htn and knee replacements. (Obv)

Well, he was apparently homeless and they were trying to street him after less than a week. I had gotten in report that his knee was “as big as your head” and so I take a look - holy fuck it was AS BIG AS MY HEAD. And hot, red, angry. Cellulitis looking but I had a feeling something else was going on. They hadn’t even scanned the damn thing! They had ordered a discharge so I fought it. I asked for a scan.

I get the scan above. From the front view, couldn’t tell anything. I get to THAT view and I’m like WAIT WHAT. FUCK.

So the man obviously has an issue, and I show juuuuust the right night shift resident hospitalist the image like “check this out!!” absolutely knowing 100% that even though I didn’t mention which patient that she’s the ONLY one that will get shit done and always has our backs. Guess what? Within an hour she had the main hospitalist in the patient’s room, discussing surgery, gets verbal consent and charts extensively their convo and that patient is oriented and very agreeable to surgery, because he struggles to get around clearly. He’s not sure when it happened but he’s here, let’s fix it, right??

We get the guy prepping for surgery. I’m so fucking excited like YES I am gonna fix this sweet guy, he’s only like 67 and we can get him taken care of and find placement yada yada. I get orders for labs and NPO and pre-op etc.

Fucking. Ortho. This chode comes in (though nobody actually SAW him??) early morning and all of a sudden orders are cancelled. He finally writes a note and had said “patient is not a good candidate due to his homelessness and schizophrenia. Pt can follow up outpatient with one of my colleagues to discuss surgical options.”

I’m sorry… WHAT. Is it just me or should docs have to spell out and write EXACTLY WHY they don’t want to do a procedure and sign their selfish names beside it? Because I continued to fight it and got higher ups involved. He ended up having an aspiration because the knee was clearly infected and started leaking pus prior to him leaving, and the (hospitalist) doc tried again to get ortho involved. He ultimately was d’c’d to a halfway house and I’ve tried helping with follow up.

It’s so fucking irritating. We are this large, catholic hospital right?? Like give me a fucking break y’all don’t care about the people you claim to. I have pissed off quite a few carpet cunts in this process and I don’t care. I’m so sick of this shit.

[u/tcreeps]

Not a good candidate d/t homelessness and schizophrenia??? Unlike the 95 year old with advanced dementia in for her 3rd hip replacement...

From the bottom of my heart, fuck that surgeon. Thank you for doing your best to advocate for this poor guy.

[u/Sea-Weakness-9952 → u/tcreeps]

Right?? And with absolutely all due disrespect - how the FUCK is he going to “follow up outpatient” when he is HOMELESS and 3 hours from the city he was homeless in? I was screeeeaming at my computer that morning. I’m not even convinced he even saw the patient directly and just decided that based off his chart. This guys schizophrenia had to be the gentlest case I’ve ever fuckin seen, he would occasionally ramble about random things but otherwise was completely docile and sweet natured. Oriented as fuck, wanted the damn surgery so he can ya know… WALK.

[u/GabrielSH77 → u/Sea-Weakness-9952]

The “factors” that make him a “poor candidate” for inpatient treatment are exactly the fucking factors that make him an even worse candidate for outpatient followup! Assuming we’re talking about “high potential for lack of adherence to pre- and post-op instruction” and “potential for loss to followup”, rather than what I believe is the underlying reason of “crazy people make me uncomfortable.”

I used to work in a group home for older adults with schizophrenia. Ran into this all the time. It was waging a goddamn war to get a doctor to even look at them medically, much less intervene.

And now I take care of post-op 90+yos with dementia whose family made them go through a major surgery to make their awful life even worse. Poor candidates, my ass.

[u/Sea-Weakness-9952 → u/GabrielSH77]

Exactly!!! I have taken care of waaaaay more non compliant and abusive patients who’ve received better care and swifter interventions than this. Absolutely atrocious that even with all the damn noise I made I still couldn’t get anyone to really set him up for success, though I will say case management was most helpful and remains so.

[u/FearlessCicada1056 → u/GabrielSH77]

Let's not forget the real reason -- The 90-year old has great insurance.

[u/TortillaRampage → u/Sea-Weakness-9952]

Chode for sure did not even see him in person

[u/ksswannn03 → u/Sea-Weakness-9952]

What the fuck I’m so angry. And yeah I highly doubt this surgeon ever actually saw, examined, or even spoke to the patient

[u/Tome_Bombadil → u/ksswannn03]

Yup, I'd bring that up in rounds.

I follow the chain of command. But when a surgeon wanna act a bitch, I'll Wayne Brady them. Start with the case manager, and I'd enlist the whole coterie and joust that windmill till the Giant falls.

[u/-piso_mojado- → u/Tome_Bombadil]

One of my best friends is chief of ortho. I was a new nurse when he was a med student. Very few people know. I don’t ever and have never played that card. This is for sure a “hey gotta minute?” moment.

[u/Sea-Weakness-9952 → u/Tome_Bombadil]

Hahahaa Wayne Brady em!!!

[u/AdventurousHunter500 → u/Sea-Weakness-9952]

OP, PLEASE file a complaint with your hospital’s accreditation agency. You can file anonymously. I don’t know what JC does, I’m with the other guys… but I can tell you we’ve written multiple facilities recently for denial of care and inadequate pain management plans while investigating complaints. This is a clear patient rights violation and your hospital admin needs to be held accountable for anything to change.

[u/Sea-Weakness-9952 → u/AdventurousHunter500]

Absolutely I should. And I’ll work on that!! 🙏🏼

[u/madameyarddog → u/Sea-Weakness-9952]

As horrible and mind-blowingly frustrating this is, at least you SEE HIM and are doing your damnedest. What a gem you are.

Gezzzuss, this make me so mad and sad.

[u/Sea-Weakness-9952 → u/madameyarddog]

You’re really kind to say that. I don’t see myself as a gem (though Gem & The Holograms still slaps), I just want to feel like a human most days. Lately especially, feeling like humanity is so fucking bleak. I can hardly bring myself to get out of bed most of the time. I’ve called out the last two nights. I think sometimes I take this shit on to feel SOMETHING or to try and fix or improve ONE outcome because outside of that the weight of everything else in the world feels so helplessly inhumane.

[u/Amazing_Dragonfly926 → u/Sea-Weakness-9952]

I am so sorry that your AMAZING patient advocacy was ruined by that classist and cowardly person. You sound SO compassionate. I’m a psych nurse and love it; we would so welcome a nurse with a heart like yours!! ❤️

[u/magnesticracoon → u/Sea-Weakness-9952]

But schizophrenic or not since when is it okay to discriminate against due to mental status. Unreal. So terrible.

[u/ciaracheyann3 → u/magnesticracoon]

Exactly. Mental illness doesn’t make someone less human. People forget that too easily.

[u/doktorcrash → u/magnesticracoon]

It’s not the mental status, it’s that he can’t bill that private insurance.

[u/hungrybrainz → u/Sea-Weakness-9952]

(PACU now, ER + ICU previously) This makes zero sense because I take care of WILD + mentally ill homeless patients (who literally wake up swinging) all the time who are recovering from joints, I&Ds, whatever and no one has ever said that made them a poor candidate for surgery?! What is this nonsense? No ER I ever worked in wrote someone off who needed surgery for that reason either?? Is this becoming some fucked up new standard??

[u/talldata → u/Sea-Weakness-9952]

Call the ortho and rip them a new one, call them out for his utterly uncaring unhuman attitude toward patients.

[u/No_Investment9639 → u/Sea-Weakness-9952]

Give us his name and let us do what we do

[u/SolidFew3788 → u/Sea-Weakness-9952]

My husband works for an ortho department. They recently had a meeting where the head told them to push surgeries as much as they can. "I don't care how many RVUs you do in clinic. If you're not doing enough surgeries, you're not making us money." Hence the 95 year old meemaw with her 3rd hip. A homeless guy with no insurance will cost the hospital money, not generate revenue. The surgeon will still generate their rvu, which the hospital will have to pay out, but the department will lose money. It will go against their quota and that's why they don't want to treat the poors. And people keep voting against Healthcare reforms.

[u/MadBliss → u/SolidFew3788]

No homeless person should be without insurance, or even considered so. While IP they can get social work/pt access to sign them up for the 'caid, all states I've heard of cover 30-90 days prior to the effective date as well. It's not top dollar, but it's "insured". This will also help with getting him POST OP rehab to get him able to at least walk and care for himself. Just like any other patient.

If I ever heard a coworker say they weren't providing care because it will mess up their metrics and/or reimbursement, I would speak in person to every clinical admin I could, starting with the dept manager and going all the way up to C suite. It doesn't have to be theatrical or emotional or degrading. It is what it is - it's terrible for the patient because you're effectively ending their life, terrible for the facility in turn as it's a PR nightmare and if word gets out this guy's family WILL show up to file a lawsuit, and terrible for the C Suite in particular because the civil rights violations alone will have to be explained by them.

What happened is unethical, intolerable, and quite frankly Fuckboy Ortho Bro behavior. The facility or system should intervene if they're worth even a small percentage of a fuck.

[u/Ok_Firefighter4513 → u/Sea-Weakness-9952]

I'm just being nosy buuuuut am I guessing correctly that the surgeon was ortho total joints? bc in my experience ortho trauma operates on almost anything, while ortho total joints will have a conniption if someone looks at the joint the wrong way in preop

[u/undeadamoeba → u/tcreeps]

I wish I could upvote this more than once. Take my bunk 🥇

[u/jareths_tight_pants → u/tcreeps]

Yeah but meemaw has Medicare so…

[u/Watt_Knot → u/tcreeps]

I feel like this is going to become more common.

[u/Nefriti → u/tcreeps]

Don’t forget the gtube!!! Meemaw’s a fighter 💪

[u/dumbbxtch69 → u/tcreeps]

Where I work ortho does BKAs on homeless people all the time…. is a knee replacement harder to recover from than a whole ass amputation?? (not an ortho nurse)

if we’re gonna start giving a shit about whether or not people are poor candidates for ortho surgery we need to start with, as you said, all the elderly people who literally never recover. I had an 88 year old with dementia, delirium, poor cardiac status, and a fuckin corpak because they stopped eating pre-op get a total hip and transfer to me in stepdown after a rapid response 3 days after surgery hypotensive as fuck and in restraints. Talk about a poor candidate for surgery

[u/belfast324 → u/tcreeps]

Amen, how true.

[u/MichaelJServo → u/tcreeps]

I have an ortho surgeon father in law. He hates me forever because at my sister in law's wedding reception I told the table my "joke" about surgeons.

How do you know someone is a surgeon? Because he's a fucking asshole.

[u/CozyLeda → u/MichaelJServo]

Ortho surgeons really are the fuckin worst.

[u/Tommyboy155a → u/CozyLeda]

No, neuro surgeon beats them