Sunday, October 11, 2009

Hip Replacements and the HSE

Irish Racing Ambassador and Kildareman Ted Walsh once famously summed up the hazards of National Hunt racing for horse and rider with the cryptic comment " Its not the years that do the damage, Its the mileage". Recently as a forty year old ex-amateur rider and ex-marathon runner I stared at an x-ray and heard the consultant describe " the obliterated joint space" on one hip and swallowed hard as he discussed prosthetic hip implant and major surgery as if casually prescribing a muscle rub and a few days stretching. But I wanted an end to over a year's nagging hip and back pain. I needed to resume an active lifestyle and restore mobility to fulfill the demands of my active profession. I researched hip replacement and hip prosthetics and sought the earliest possible date in the Blackrock Clinic with the Surgeon known to perform more hip surgeries than anyone else.

Our private family health insurance with Hibernian Aviva has been the most important two thousand euro we have spent every year for the past decade. We have two sons who were born with congenital heart defects. Our health insurance and ability to pay ensured we obtained immediate expert care. We have never been at the mercy of the HSEs waiting list and both boys have survived and thrived. My own experience of surgery, albeit as a Veterinary Surgeon, is that the margin for error is still high for orthopaedics, high caseload is the key to success, risks of infection are one in two hundred ( too high). Prognosis is also influenced by both attention to detail in hospital processes and post-operative nursing care and expertise. My health insurance gave me the option of an excellent private orthopaedic surgical facility with only a few weeks of a wait.

I mention this to make two points. Firstly I am an advocate for universal health care for Ireland. Every citizen has the right to the same care that I had to shop around for. But the internal costs of that excellence will be high and attempts to seek efficiencies in cost will always create inequality unless excellence becomes the only standard measured. The HSE have moved Cancer Services now to eight designated centres of excellence, with plans to discontinue cancer services in thirteen smaller hospitals. This is a recognition that multi-disciplinary management in centres of excellence acheives excellent prognosis. It is also a recognition that in the high mortality context of cancer excellence is the only standard we should measure. Secondly, I am self-employed and would rather work than not, my insurance card moved me up a queue into a private bed and will help me regain productivity and run my business again in the shortest time possible. A medical card holder in my position would wait six to nine months for a hip replacement and would be medically signed off work for all that time. Unemployable because of pain, this medical card holder costs the state in welfare payments and loss of productivity. Not to mention the administration costs of a two tier system whereby that person may have the same surgeon as myself, but is queued in a different list and assigned to a different hospital.

So it was that I went under epidural and had a Bermingham right hip prosthesis implanted. This is a metal on metal resurfacing technique of screwing in a new tightly fitting metal ball and socket. More of us will have this type of surgery as life expectancy for males rises by 8% to the year 2036. The post-op information describes the surgical aftermath" You will then be able to start walking first with a frame and soon with crutches". This breezy optimistic prediction proved to be spin of Alastair Campbell proportions as I lay stuck to the bed with pain for the first few days. I dragged my misshapen, swollen and lead-weighted right leg to the edge of the bed only by the use of the two-handed hospital trapeze swing made famous by "Jerry Maguire".But there were five hips done in Blackrock that day and the nursing staff knew exactly what pain scores were normal and when precisely to rescue the average Irishman from his own low pain threshold. Furthermore their helpful post-op brochure went on to say" Normal sexual activity can be started again at 6-8 weeks. Although the warning about avoiding extreme positions of the hip applies." But of course you can never believe everything these doctors tell you. Just how well do they make artificial hips anyway ? Even cars dont need a running-in phase these days.

From my own bitter experience I can agree with the findings of a 2008 UCC School of Nursing Survey. Published in the Journal of Orthopaedic Nursing, findings reported pain to be the predominant physical experience after hip replacement, pain was more intense than expected and importantly the absense of a pain nurse specialist contributed to inadequacies in post-op pain management. The survey found that in some centres patients pain was still poorly assessed and concluded that pain management remains a major challenge for orthopaedic nurses in Irish hospitals.

Our expectations of care are very high as we know the excellence that can be acheived in Irish hospitals. We shouldnt suffer in silence. My professional insight into the challenges of infection control, pain control, margin of error control ensured I went to a centre of excellence to have a hip replacement which even so was difficult, very painful and not without setback. I believe everyone to be entitled to that level of care. A margin of error is not acceptable; someone elses brother or grandmother shouldnt suffer as a percentage with infection, bed ulcer or pain just because they have a medical card or because whats not accepted in Blackrock is tolerated somewhere else. But we shouldnt expect that excellence to be available around every corner. We must recognise that excellent people are rare, that standards remain a challenge, remain dependent on people. If medical experts CAN guarantee standards in some locations then we must accept that other locations may have lower case load and consequent resources and expertise scarcity. Those who have fought the removal of some services from regional hospitals have carried placards " Death By Geography"and seek to preserve the availability of specialist service at their own regional hospitals. But they miss the vital point that on the whole list of factors that influence positive prognosis- the medical list- geography is absent. If we allow local concerns to determine where we provide specialist care to patients then we have to expect a margin of error.And then death by geography will become a reality.

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