St. Mary’s fits the pieces together for joint replacement

St. Mary’s physical therapist Chris Chubbuck explains to joint-replacement patient Bill Hassell the proper way to get in and out of a vehicle. The simulated vehicle in the orthopedic unit at St. Mary’s is part of the comprehensive therapy program for patients who have had hips and knees replaced.

Story: Nancy Lofholm/For St. Mary’s Medical Center

Joe Hassell is a strong, independent retired Army officer. But he recently needed a little help figuring out how to safely get in and out of a vehicle.

Hassell had undergone hip replacement surgery at St.

Mary’s Hospital the day before, and the lesson in the proper way to back up with his walker and ease himself onto a simulated car was just one part of the comprehensive care he received during his stay in the orthopedic unit. He also had lessons in the safest way to enter and exit a bathtub and the most efficient way to use kitchen appliances while maneuvering with a walker. He was tutored in the importance of daily walking, of using pain medications judiciously, and of eating foods that would help his bones heal.

“Oh boy, all that helped. It sure did,” Hassell said.

Choosing to replace a hip or knee can be a long-drawn-out process. The actual surgery is often viewed as the culmination of that process. But at St. Mary’s, the surgical procedure is just one piece of a comprehensive program. The 750 patients who annually choose to have diseased knees or hips replaced at St. Mary’s, begin with a class covering all the basics of joint disease and the options for treating it. The care program doesn’t end until patients are safely down the road to recovery. The initial class, called the “Pain Seminar,” is not only directed at those planning joint replacement. One of the goals of the class is to help people decide if surgery is needed, or if they can opt to use other palliative and strengthening measures and forego a joint replacement.

The class, which is free for the general public, covers the anatomy of the joints, the changes that make joints painful, the use of over-the-counter medications and other measures to control pain, and the use of assistive aids like hiking poles or canes. Participants have a chance to examine replacement joints and learn how they are surgically inserted.

Registered Nurse Connie Estridge teaches the class and shares her nearly half century of experience in the field of orthopedics. Estridge began her health care career 47 years ago as a Certified Nursing Assistant in an orthopedic unit and eventually earned her nursing degree. She worked her way up to Nurse Manager of St. Mary’s 30-bed orthopedic unit.

“This is the first phase of introduction to the public when they can ask any questions, and get all the information they might need,” Estridge said. “We don’t want people to go away with any questions unanswered.”

For those who opt to have a joint replacement, Estridge teaches a second class. This one is called the “Pre-Op” class and it is held in the 8th-floor orthopedic unit at St. Mary’s.

Those have chosen to go through joint replacement can see where they will recover and begin rehabilitation, an interval that usually lasts only two to three days. Estridge said that visit helps patients feel they are in familiar surroundings when they awaken after surgery.

Every detail of the hospital stay and recovery is covered in the pre-op class. Patients know what to bring to the hospital, where their loved ones will be waiting during surgery, what kind of therapy will begin the same day as the surgery, what kinds of pain medications they will receive and how they will be delivered, and what discomfort to expect during recovery.

“We don’t like to send people home with any surprises,” said Beth Price, the nurse practitioner who has been overseeing the joint replacement program at St.

Mary’s for the past year.

Some patients have had previous joint replacements and, if those surgeries

were more than five years in the past, they are surprised to find how things have changed. Patients no longer lie in bed and have a continuous motion machine move a joint for them. The new and improved method of accelerating healing is walking. Nurses and physical therapists help hip and knee replacement patients to walk as soon as it is safe — often the same day as surgery.

Pain management has become much more sophisticated and targeted to specific areas.

Pain control used to be guided mostly by individual physician choice. Now, it has become more standardized: the same pain control options are available for everyone. Estridge and Price refer to the current pain-control protocol as “multi-modal pain management.”

During surgery, joint replacement patients are injected with a nerve block.

That will keep a joint feeling comfortable for the first day or two when the pain would be at its highest level. Analgesics like ropivacaine can be delivered directly through the femoral artery in the leg for up to five days following surgery.

Periarticular injections of pain-killers can be given directly in the area of the joint replacement.

“We always tell people this won’t be a pain-free process. Our goal is to make it tolerable, not to take it away entirely. If we can keep patients comfortable, we can get them right into the therapy part of the healing,” Price said.

While the specialists in orthopedic pain control focus on each patient’s needs in that regard, an entire team made up of nurses, physical and occupational therapists, spiritual care representatives and unit managers, meet every morning to review each patient’s condition and progress. St.

Mary’s orthopedic surgeons, who do the joint replacements —Dr. Jeffrey Nakano, Dr.

Mark Luker, Dr. Steven Heil, and Dr. Steven Gammon — are consulted on any problems.

The comprehensive care follows patients home. They leave with pages of helpful advice about specific aspects of healing. They have had their lessons in how to function outside the hospital setting.

Price calls each patient in the week after discharge to make sure there are no problems — and to answer any new questions that may have arisen.

Hassell said all of this did prepare him well for his surgery —his second hip replacement —and for his return home. His questions had been answered, except for one that came up during his lesson with physical therapist Chris Chubbuck in the vehicle simulation.

“When can I drive again,” he asked Chubbuck, “for real?”


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