Fell, stand in line, die

Hip fracture is the second cause of death of elderly people after a heart attack, but there are almost no emergency operations that can save thousands of lives.

The fracture of the proximal femur is by far the most common injury in people over 60 years old, said the chief geriatrician of the Russian Ministry of Health, Olga Tkacheva. Frequent dizziness, instability of gait, impaired vision, hearing, cognitive deficit, diabetes mellitus and various neurological diseases that progress with age are aggravated by osteoporosis associated with the aging of bone tissue. The combination of these factors leads to sad consequences.

Every year more than 125,000 elderly people break the thigh neck. And almost 40% of them die in the first year after the fracture, said Acting Director of the National Medical Research Center of Traumatology and Orthopedics named after Priorov Nikolai Zagorodniy during the Eurasian Orthopedic Forum (EOF-2019). The death rates from such fractures are almost equal to the death rate from heart attack: 46 thousand versus 49 thousand.

Why it happens? Of the 125,000 patients with a fracture of the femoral neck, less than half – 55,000 – receive inpatient treatment. Of these, only 32 thousand operate, the rest are treated conservatively. At the same time, 70 thousand people do not go to hospitals at all.

According to Zagorodny, terrible figures were heard at one of the orthopedic forums: 86% of such patients remain in St. Petersburg without surgery. Most of these people simply die during the first year after the fall. For comparison, 90% of such patients are operated abroad.

Why is it important? If not operated in time, in 23% of cases patients develop lung diseases, in 18% of cases – thrombosis. At the same time, surgical intervention can reduce these figures to 9% and 1%, respectively.

“Waiting for an operation for three or more days is sometimes fraught with irreversible consequences. During this time, the patient's condition deteriorates, serious contraindications appear for surgical intervention with a high risk of postoperative mortality, ”Smolensk, chief orthopedic specialist of the Ministry of Health of the Russian Federation for Central Federal District Anatoly, told Smolensk to Rosbalt. Ovsyankin.

“We have long identified“ golden watches ”for the treatment of heart attack, stroke. The same thing needs to be done for hip fractures, ”he believes.

The need for surgery is best shown by statistics: as a result of conservative treatment, 48% of elderly people die in the first year after a fall, and 23% after surgery. That is, an emergency operation can reduce the death rate by half.

Older people who do not die without surgery often lose their independence. “One third of the patients cannot serve themselves without outside help, and some of the able-bodied relatives are forced to quit work in order to care for them,” Zagorodniy noted. However, after surgery, only 1.6% of these patients remain.

“We must not dismiss them, operate, until they have exacerbated chronic diseases,” he said.

What prevents it from doing now? Never mind. Both the money and the technical capabilities of the hospitals are there, noted Ovsyankin. The experience of the Yaroslavl region proves it. Without a team from above, without additional funding in the region, a help system was built which, within 48 hours, makes it possible to operate on almost all elderly patients with a fractured femoral neck.

Work on this began in 2010. “We looked at international clinical guidelines and took advantage of them. They said: the main thing – to do the operation in the first 48 hours. We trained doctors, took geriatrics and an exercise therapy instructor to the department, who could quickly put people on their feet, ”said Mikhail Belov, the head of the trauma department of the Solovyev Clinical Emergency Hospital in Yaroslavl.

Now patients with a fracture of the femoral neck from all district hospitals are being transported to one trauma center. The rate of hospitalization from anywhere in the area – 24 hours. The center has laboratories around the clock. Many basic studies (eg, complete blood count) are done in literally seconds. In the first two days, 88.5% of patients with a fracture of the femoral neck are operated on there.

Now Yaroslavl experience, also on its own initiative, is adopted by traumatologists-orthopedists of the Krasnoyarsk Territory. The region became the first and so far the only one, where the “gold standard” – 48 hours – was recorded in the protocols of medical care.

But at the federal level, the timing of surgical intervention is not prescribed anywhere. It turns out that the possibility of carrying out such operations quickly seems to be there, but for some reason hospitals are not interested in this. And often relatives of elderly people with such fractures hear that you can do the surgery now, but for money, or at the expense of the MLA, but after two months.

At the same time, as Ovsyankin told Rosbalt, there is no giant queue for these operations in the country. Belov explains: “It is much more profitable for medical institutions to provide this assistance for cost accounting, because the patient will pay more than the MHI fund.” “In essence, this is a medical crime. In this case, you need to contact the insurance company, because the patient has the full right to receive this help, ”he stressed.

Of course, until national clinical guidelines are accepted, it is impossible to require hospitals to operate in the first two days. But to prosecute for failure to provide assistance is quite, according to the Rosbalt interlocutor. “If there is a trial, the expert, having assessed the quality of the assistance, will write a conclusion that the assistance was rendered poorly,” he noted.

It is important to take into account the financial side of the issue. According to Tkacheva, every year in Russia about 1.3 billion rubles are spent on technical means of rehabilitation, another 1.1 billion – to provide social care for patients and 2.7 billion – to treat complications arising from a hip fracture. And this is not counting the financial losses of relatives who are forced to spend money on carers or to take care of the patient on their own, switching to part-time employment or losing their jobs altogether.

“It’s a shame when we manage to reduce the risk of heart attacks, strokes, and a person loses quality of life because of a fracture or even dies during the first year after an injury,” Tkacheva notes.

Now, according to the Chief Geriatrist of the Russian Federation, the Ministry of Health of Russia plans to introduce a uniform standard throughout the country for the provision of emergency surgical care to elderly patients with a hip fracture. One of the points of this plan is associated with patient routing for timely surgical intervention.

“No one doubts that if a patient has a hole in the stomach, it is necessary to urgently operate. With a fracture of the femoral neck, it should be the same, ”says the main traumatologist-orthopedist of Moscow, Vadim Dubrov.

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