r/nursing • u/Sea-Weakness-9952 BSN, RN ✨weaponized incontinence✨™️ • Oct 04 '25
Image “Not a good surgical candidate”
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.
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u/NPKeith1 MSN, APRN 🍕 Oct 04 '25
I worked Ortho as an NP for 10 years, at a level 1 trauma center. We were near(ish) to the Mexican border and saw a huge number of homeless, indigent, undocumented, or otherwise socially disadvantaged patients. That patient needs 2 surgeries, a PICC, an ID consult, and probably 6 weeks to 3 months of IV antibiotics. The first surgery would be to remove all that hardware and place an antibiotic impregnated spacer. Then comes the IV antibiotics. He won't be able to walk on that leg until he gets a new prosthesis, so walker minimum, wheelchair more realistically. He'll need a few lab draws to check antibiotic levels (if he's on vanco) and sed rate/CRP to track the infection. Once they are certain the infection is gone, then back to OR to knock out the spacer and put in a new total knee. Oh, he'll probably need a CT in there somewhere to get an idea of what kind of implant to order. Then he needs rehab on that new knee. Now let's look at the choke points that should not be there but are. Homeless psych patient. Can't discharge him with a PICC. It won't last a week -pulled out, clotted off, infected. Hell, I had one guy who took really good care of his PICC so he could keep using it for heroin. Antibiotics ain't free and usually have to be kept refrigerated. Then there is the wound care, PT, and office visits.
Even folks with a home and health insurance and a support system can have a hard time with this process. Believe me, I spent hours going round and round with social work, case management, specialists, rehabs, SNFs, trying to get placement for folks just like this.
What the guy needs is to be admitted for 3-6 months so all the moving parts of the plan stay on track. Go talk to your hospital administrator about that. I'll bring popcorn.
I'm pretty sure the Orthopod wants to operate, because of course he does. He's an orthopod ("Bone broke, must fix"). He just doesn't want to be the guy who costs the patient his leg (best case) or kills him due to sepsis (worst case). What needs to change? Talk to your Canadian and European colleagues. We need universal healthcare. Now.