A few months ago I had an interesting consult that reminded me that despite what my American Board of Urology practice log may imply (and yes I will soon be flying to Dallas for that rite of passage), I am more than just a stone doctor.
The 70-year-old father of a patient on whom I had recently completed ureteroscopy for a symptomatic distal stone came to my office stating that he had been told years ago that he had a kidney stone that was too large to treat. Based on that physician’s recommendation, he lived with intermittent, but very bothersome flank pain for many years. After the good outcome his daughter had with me, they were seeking a second opinion regarding his stone. I obtained a CT that showed an impressive 2-cm distal stone with a healthy-appearing kidney and no ipsilateral hydronephrosis.
He was an otherwise reasonably healthy man for his age, with nocturia x1 and no other urinary symptoms. His only complaint was intermittent flank pain that would bother him on a weekly basis. I smiled and scheduled surgery.
A few days before surgery, my office manager notified me that the case was canceled as the patient had been admitted to the hospital recently. When I stopped by to see what was going on, with nightmares of urinary sepsis dancing in my head, I learned that he had gotten up in the middle of the night, as he commonly did to void, had tripped, fallen, and broken his hip. We exchanged pleasantries and made plans to reschedule surgery in a few weeks once he was over his hip injury. A month later I learned that he had subsequently died of pneumonia.
The case bothered me for many weeks. The family wasn't upset with me, I don't think I did anything wrong from a urologic standpoint, and I wasn't upset about losing the case. But the fact that a few months ago I had met this man, laughed and joked with him in my office, and learned that a silly fall while he got up to use the restroom proved fatal was extremely bothersome.
That experience prompted me to start reading about falls in the elderly. The CDC has a great website that summarizes some key points about this problem, including:
- In 2011 alone, over 22,900 people died from falls.
- One in three patients over age 65 fall each year.
I also read study by Castronuovo et al that showed that between 5% and 10% of patients who suffer a hip fracture from a fall are dead within a month and 20% to 30% die within one year (BMC Geriatr 2011; 11:37)! At first, I simply didn’t believe those numbers, but a quick PubMed search yields numerous other studies with similar results. Coutinho et al, for example, found a 1-year mortality of 25% after a fall-related fracture (Cad Saude Publica 2012; 28:801-5). Further, even if the patient survives the fall, 50% of those who were living independently before a hip fracture are unable to do so again.
With those statistics in mind—more out of disbelief than anything else—I started asking some of my patients about falls. There were entire days in clinic when it seemed like every patient I asked had suffered a fall within the last year! Most of them not only laughed it off but also started telling stories about how most of their friends also routinely fall. As a result, I started spending 30 seconds with my wiser (ie, older) patients at the end of each visit discussing the importance of fall prevention.
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