MBChB Curriculum Map

Cissy Goldman is a 75 year-old retired legal secretary. Having been active she has noticed a progressive deterioration in mobility during the last 12 months. Friends and family have noticed that she walks with shorter steps and seems unsteady at times. After attending service at her local synagogue, Cissy tripped and fell on uneven paving outside her home. Her neighbour called an ambulance to take her to Casualty. Cissy arrived in considerable distress, alternatively shouting and crying. She was assessed and told that she had broken her hip and sustained some nasty bruising. Cissy was so distressed she was confused and disoriented. All she wanted was something for the pain, now! – “I could sue you for torture under the Human Rights Act, you know! Call this a high quality service!” she shouted a few times. The charge Nurse, who admitted her as an ‘outlier’ to the medical ward, reassured Miss Goldman that she would probably have active treatment and be “…up and about in no time, Cissy!”. Miss Goldman reminded him that it is her right to be called by her full name, and then told him that “…Granny Goldman was left bedbound after a broken hip”. Charge Nurse Kelly reassured her, but added that, because she lived alone, the team ought to start thinking about the support she would need on discharge. When she was less confused, Miss Goldman asked Charge Nurse Kelly two questions: “How do I prevent another broken hip?” and “Why did my nephew’s son, Dean, only have his leg plastered when he broke it?”

Miss Goldman was transferred to the ward and started on a ‘Care pathway’ for a fractured hip. She rested in bed awaiting the operation to fix her hip. She received regular pain relief and a daily injection of low molecular weight heparin. Her tablets for high blood pressure and those to lower her cholesterol are continued but what she really wanted was a cigarette. Her ‘episode’ was added to the data in the Hospital Episode Statistics (HES), which the public health team was using, with other routine morbidity data, to monitor the effects of a primary prevention programme for accidental falls in older people. In the wake of a Healthcare Commission report, the orthopaedic team was keen to improve health care quality (especially efficiency) for patients undergoing emergency hip fixation, and use any guidance available from NICE. Charge Nurse Kelly urged them to look also at formal quality-of-life measures.