Clinical Geriatrics

For the past few months, I have been focusing my attention, both from an academic and clinical perspective, on the growing problem of the older person who has suffered a traumatic injury. A great deal of this concern and excitement relates to the fact that I have decided, after many years of focusing my efforts more on Medical Education and Medical Administration, to return to my roots and once again devote the majority of my professional life to being a Geriatrician. This summer, I will be assuming a new role as Director of Geriatric Medicine at the University of Maryland Medical Center in Baltimore. One of my goals is to establish a Geriatric Trauma Program at the R. Adams Cowley Shock Trauma Center, a regional Trauma Center serving not only Baltimore and Maryland, but also several surrounding states. It is the busiest civilian trauma program in the United States and the clinical hub of Maryland’s statewide system of trauma care.

Persons over the age of 65 currently represent 11% of trauma victims nationwide, a number expected to rise to 40% by the year 2050. The total cost for this population alone in 2000 was more than $31 billion in medical expenses and lost productivity. Older trauma patients have in-hospital complications approximately twice as often as younger patients, a greater length of hospital stay, and higher morbidity and mortality. While our efforts to focus on this at-risk population are not totally unique, and a few other similar programs have surfaced in recent times throughout the country, trauma care for the elderly remains problematic. The customary way that medical care is provided following a traumatic injury does not take into account the special needs and problems of the older person, now faced with additional issues to complicate his or her care even further.

This issue became even more real last month when I received a call from my wife telling me that her foot had caught unexpectedly in a deep hole that was hidden by grass at a local public garden. She fell, and after hearing a “crack,” she knew that something was seriously wrong. She lay on the ground in pain and called for help for approximately 20 minutes to various people in clear sight; no one came to help her. She fortunately remembered that she had a cell phone in her pocket and was able to reach me. After a car ride that seemed much longer than the 15 minutes it took to arrive at the site, I was able to assess the situation and call an ambulance. She had an obvious compound fracture that we later learned was an ankle dislocation with five fractured—no, shattered—bones. She had surgery the next day, with a plate, screws, and pins used to reconstruct the ankle, and was told that she could not put any weight on her foot for approximately 8 weeks. Postoperatively, the recovery room nurse attempted to control the pain and announced that she had the authority to administer 10 intravenous treatments. We learned that the only thing ordered for my wife, other than some oral medication that due to nausea was ill-advised, was a very short-acting pain medication that provided only fleeting relief, as her baseline pain level continued to escalate to an intolerable level. A variety of pain medications were later tried after I insisted that a physician be called to reassess the situation. The end result was, in fact, pain relief, but also with associated severe nausea, pruritus, hallucinations, and lethargy. She was unable to eat for 3 days due to the severe nausea, and her electrolytes were now in need of adjustment. Ice packs were recommended by the physician, but only as an afterthought; even when started, they were often warm when I came to visit. Being left on a commode with instructions to “wait for the aide to return” at times became a prolonged agony, and on more than one occasion almost led to my wife having a syncopal episode.