Purple heroin hits the streets; dial 9-8-8 for suicide prevention hotline; treating hip fractures
Emergency physician and toxicologist Ross Sullivan, MD, urges caution about purple heroin, a street drug appearing in Central New York. Cheryl Giarrusso from Contact Community Services talks about the new 9-8-8 phone number for the national suicide prevention hotline. Geriatrics chief Sharon Brangman, MD, and nurse Lia Fischi tell about a new way of caring for seniors with simple hip fractures.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air:" an emergency physician has a warning about purple heroin.
Ross Sullivan, MD: ... Normally, across the country, when there are purple heroins, there are additional synthetic opioids added to the heroin. And unfortunately, this makes it much more dangerous to use. ...
Host Amber Smith: A new three-digit suicide hotline number rolls out nationwide.
Cheryl Giarrusso: ... 988 will really make it easier for people to reach out. It's easy to remember. ...
Host Amber Smith: And how care is improving for seniors with simple hip fractures.
Sharon Brangman, MD: ... We want to make sure that when people start to have a long list of medical problems and medications, and they have a hip fracture, that we keep all of this in mind while we're taking care of them. ...
Host Amber Smith: All that, some expert advice and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll learn about 988, the new national suicide-prevention lifeline phone number. Then we'll hear about a program that helps seniors with simple hip fractures. But first, a warning about purple heroin, on streets throughout Central New York.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Oneida County has recently seen a wave of overdoses, some involving a more dangerous, purple-colored heroin. Dr. Ross Sullivan is here to talk about this drug. He's an emergency physician at Upstate and also the director of medical toxicology. Welcome back to "HealthLink on Air," Dr. Sullivan.
Ross Sullivan, MD: Thanks for having me, Amber. Nice to be back.
Host Amber Smith: Why is this purple-colored heroin such a concern?
Ross Sullivan, MD: Well, you know, anytime there's a new drug in the area, obviously, that becomes linked to perhaps increased deaths that we see across the population, it's something that's a real cause for concern. Specifically here, the purple heroin, we think it's maybe a marketing ploy, but it does work in people who use drugs. And, unfortunately, we don't know exactly what's in it, but normally across the country when there are purple heroins, there are additional synthetic opioids added to the heroin. And unfortunately this makes it much more dangerous to use.
Host Amber Smith: So it appears that it might be more potent than just regular heroin?
Ross Sullivan, MD: Yes. Anytime we see a spike in deaths across the population, we feel that there's something going on with the drug supply. Normally it's either tainted or some type of additive or potency, and purple heroin has been seen in the past in other parts of the country, and maybe even Oneida (County).And normally in these purple heroins, there is an added opioid to it, so we know that there's fentanyl -- which is a very potent opioid and much stronger than heroin -- already added to the heroin supply. And purple heroin may even have another opioid on top of those two added to it. And this is a pretty dangerous, a dangerous combination to occur.
Host Amber Smith: So the drugs that are added to the heroin might make it change the color to more of a purple, or there could be a coloring agent that's added, you're just not sure?
Ross Sullivan, MD: Absolutely. Most experts really don't completely know exactly what is making the purple color itself. We don't know if it's necessarily the actual additive drugs. We think that the purple itself is something that's done in the lab, to kind of denote or market a different type of drug in the market. We don't necessarily believe that the extra drug is actually purple in color. We think, though, that it's more of maybe like a marketing ploy to try to get this type of drug, or maybe even brand, to the users on the street. It does make it extraordinarily dangerous, but again, the exact reason it's purple, we're still not quite sure.
Host Amber Smith: Do the authorities think this is being made locally or is this purple heroin being imported from somewhere else?
Ross Sullivan, MD: I can't say exactly what the authorities do or don't think. Since this purple heroin has really been around for the past several years in different parts of the country, normally we feel that these things are being brought in from other areas, and are kind of part of some type of distribution type of system. There's been outbreaks of this in areas of Michigan and some other areas in the Midwest. So it's most likely part of a larger type of distribution plan, and which makes it really makes it scary. So, it has entered our area and is something really to keep an eye on.
Host Amber Smith: Now, in addition to heroin, you mentioned some of the drugs that are mixed with it, perhaps fentanyl and some other opioids. Mixing these multiple opioids together, does that necessarily mean that their strength is going to be multiplied?
Ross Sullivan, MD: I think that when someone is using anything in one sitting or over one use, the more of it in there, the worse, the more dangerous it can be. An example might be you think of alcohol. You know, if someone were to sit down and have one alcoholic drink at a time, compared to sitting down and immediately having two or three alcoholic drinks, there's definitely an additive effect, right? And this is the same thing with the opioids. By taking different opioids but all at the same time, there's an additive effect. And, added to that, that some of these opioids are more potent than other ones. Like we already know that fentanyl is much more potent than heroin, anywhere up to 50 times stronger. So when you have these things mixed together, you definitely have an additive or even multiple effect, on the effect that it would have on somebody. So, using these things in even one single sitting or one use can be really dangerous.
Host Amber Smith: What is brorphine, B-R-O-R-P-H-I-N-E?
Ross Sullivan, MD: Brorphine is another opioid that's synthetic, so it's not naturally occurring. So when we talk about the naturally occurring opiates, we actually talk about opiates. And I'll talk a little bit about opiate history, and really that comes from the poppy, which we've heard of. And in the poppy, there's something called latex. And this latex in it is filled with opiates, and in it is morphine and codeine,and that's really it. And from the morphine and codeine and the poppy we can make heroin. So heroin we say is semi-natural, or semi-synthetic. Almost all the other opioids that we hear about are synthetic to some degree, so as we call opioid, like an android. So brorphine is another one of these synthetic opioids that has been created by drug makers at some point. Now I believe it was actually made as an analgesic, or a pain medication, at some point. It is really not used in this country, but we're starting to see it more in this country as an additive to our drug supply. And, we really started seeing it again in the Midwest around 2018, 2019, and now we've seen it crop up at other points. So, again, it's another one of these opioids, it's just another one that has a good potency within the body and, again, when added to other opioids is very dangerous.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Ross Sullivan. He's an emergency physician and director of medical toxicology at Upstate, and we're talking about purple heroin, which is showing up in the community.
Now, what effects are people seeking when they are going to take this purple heroin? What are they looking for or expecting to have happen to them?
Ross Sullivan, MD: Well, when people use drugs or opioids, it really comes down to a few reasons in the end. One of them is obviously to feel euphoric, right? Or, we talk about feeling high. And then when people use drugs, part of this process actually neurochemically are the chemicals in the brain. We call it tolerance, right? Which means we get used to taking the same amount. And people sometimes can think about this easier when they think about alcohol, right? You know, someone who might have an alcohol problem, you can see they become tolerant, and it can be totally normal having 2, 3, 4, 5, 6, 7, 8 drinks. So this happens with any drug, and with opiates as well. So sometimes people use drugs to just feel euphoric. Sometimes they do it because they just want to feel normal. One of the things that we see is that people oftentimes are just trying to treat not feeling normal. They want to be normal. And they also don't want to have withdrawal. And that's really one of the No. 1 reasons people use. I think that there's a misconception or stigma that drug users are constantly just always trying to be as euphoric or high as possible. And certainly that's a component of using opioids and drugs. But another big component of it is just keeping themselves out of withdrawal or from feeling pretty sick or ill. So just like anything, though, when there is a new drug in the market that might be having some additional euphoric or high effects, you know, people will seek it out, to see how's it make them feel? Does it maybe allow them to not feel sick or have withdrawal? Maybe it's cheaper. I don't know about the cost, but there's a lot of reasons that would drive somebody to use this.
Host Amber Smith: Is there any way to detect whether heroin includes something like fentanyl before a person ingests it?
Ross Sullivan, MD: So great question. We have been using -- I'm talking about people in addiction -- have been using and distributing fentanyl test strips. And these fentanyl test strips are being deployed more and more by harm-reduction agencies and by drug-treatment facilities. And really what this basically is, is you can take some of your drug and you can basically put it in some type of water and basically put this fentanyl test strip in it, and it will tell you that there's fentanyl in it. And these are things that are being used and given out to people, and we're really advocating for when people are using drugs, particularly a new type or if they're getting it from a new person or place, or it looks different, we're really advocating using fentanyl test strips, and giving them out as well. It's hard to say exactly where you get them. Most drug treatment agencies now are giving them the patients, and some counties through the department of health, are also distributing them through some anti-drug programs. So, I tell people all the time to look for fentanyl test strips throughout your area, in your county. You can order them online sometimes. It's really, really lifesaving, so it's really something that we advocate strongly for.
Host Amber Smith: Now what about after ingestion? Are there symptoms that would indicate that the person is in danger of overdose?
Ross Sullivan, MD: Overdosing, you know, unfortunately one of the biggest risk factors of overdosing is using alone. And catching oneself or yourself overdosing is almost impossible, right? Because you, you start to become sleepy and tired, you start breathing a little bit less, and then you overdose, you're overdosing. And the self-awareness of it, or being able to treat oneself doing it, is really impossible. So when we talk about harm reduction techniques, in addition to using fentanyl test strips, we talk about using with somebody else, or not using alone, because it's a huge risk factor. The risks and what we see when people are overdosing is, obviously, is a severe altered mental status. So people will become almost in a coma or we use the word obtunded. They really can't respond to you. One of the biggest things is really shallow breathing, to stopping breathing. This is the biggest sign of an opioid or heroin or fentanyl overdose. To really identify this, though, you have to be using with somebody else, because using alone, you really will not be able to be conscious enough to be aware of this. So we advocate tohave people use with other people.
Host Amber Smith: Now this purple heroin that's on the market locally, does naloxone work to reverse the effects of that?
Ross Sullivan, MD: Absolutely. We know that naloxone or Narcan works for almost or all opioid overdoses. Certainly there are some stories out in the press that talk about all this naloxone-resistant drugs. And as a toxicologist -- we study how these drugs work, how they bind in the body -- we don't deny that maybe some people might need some additional dosing here and there, but the kind of fear that naloxone doesn't work is really unfounded. I think that what we're seeing is a couple of things. One we're seeing that naloxone has been so widely distributed and given by such an array of people that people are just giving a lot of it. And of course, when someone's not breathing and they're unconscious, a lay person or someone who doesn't have a lot of experience might give multiple doses within just two to three minutes. Those of us who are trained professionals really should only give one dose every three minutes. So that's one reason we're seeing additional doses. Another is that there are other additives to our drug supply which cause a lot of sedation. And one of the things that we see a lot is something called Xylazine. And Xylazine actually is a tranquilizer used in veterinary medicine. And we're starting to see this added to our local drug supply in Central New York. We saw it a couple of years ago, really starting in Pennsylvania, the Philadelphia area into the New York City area, and now it's becoming more ubiquitous in Central New York. And the thing about this is that it's not an opioid, so it does not respond to naloxone. And we're starting to see people who do have some type of resistance, so to speak to naloxone, it's mostly due to these other factors, just people giving it much quicker, and people having other drugs on board that don't work with naloxone.
So we absolutely recommend always if someone is in a coma, especially not breathing, that's the point of giving naloxone or Narcan, is to give it and wait two to three minutes and give it again and call the authorities or 911 and get some people there to help. But, yes, it absolutely works, and we don't really believe in naloxone- or Narcan-resistance. We think it's a lot of these other things.
Host Amber Smith: In the emergency room, if you have this patient that the naloxone is not completely working on and you suspect there's other drugs that were mixed in with whatever they took, what else can you do for them in the emergency room?
Ross Sullivan, MD: If someone's breathing, we will give naloxone and can continue to try it until we have reversed somebody not breathing. But there does come a point where, perhaps, there is no more effect, and there is another drug that is contributing. And what we call a supportive care, and supportive care doesn't mean we just watch you. We'll support the patient in ways that we need. So, for instance, like Xylazine, patients can have low blood pressure and low pulse, so we will give a medications or things that counteract those things. Sometimes people are in such a deep coma, they do lose their airway. So, we will intubate them, or put a tube in their throat, to help support them, to kind of metabolize and overcome these drugs. And there is no way to know, right, when someone's in the emergency department. I think some people think that we can just test for drugs and we know within a heartbeat what people are using, and that's actually not true. We have to use the whole picture of the patient and what's happened and support the patient. In the emergency department, we do a fairly good job. But in a community, or if people don't get to emergency services, that's where people are dying, unfortunately. This is why we advocate for some of these harm reduction techniques, with such a dangerous drug supply, to help keep people safe.
Host Amber Smith: Well, regarding this purple heroin, are there precautions for first responders or the friends of someone who was known to have ingested purple heroin? Are there precautions for those people in trying to take care of someone who may be overdosing on purple heroin?
Ross Sullivan, MD: You know, one of the biggest things that we say is, we try not to get too conflicting here, but it is perfectly safe to walk by, near, someone who's using this. These drugs could be on the ground, on the person. Obviously we always talk about, like, just very basic hygiene things, clean your hands maybe after, or maybe even wear gloves if you'd like. Certainly these drugs are safe to get on your skin. I know that there's these stories that we see in the press that often end up getting debunked, but general precautions, of course. You know, the biggest things are, be careful of needles and syringes. If there is a lot of drug paraphernalia, or even drug all over the place, sure, you might have be careful and not get it on your hands and whatnot. But it is always safe to take care of these people otherwise. Just remember to make sure you're in a safe environment and you're not around the things like drug paraphernalia or maybe needles or syringes that can cause some type of damage to you, if you were to get a needle stick, let's say.
Host Amber Smith: Well, Dr. Sullivan, I want to thank you so much for making time for this interview.
Ross Sullivan, MD: Thanks for having me. I hope this helps some people. You know, the biggest thing, too, is there is help out there for you. You can look at any place in your county. There's quite a few places that help people that are struggling. And be safe, you know. Use Narcan. Get fentanyl test strips. You can look at your county department of health websites. They'll give you a wealth of information, both in Oneida and Onondaga. And hopefully, use safer and get help when you need it.
Host Amber Smith: My guest has been director of medical toxicology and emergency physician Dr. Ross Sullivan from Upstate Medical University. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- dial 988 for suicide prevention.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." The national suicide prevention lifeline soon will have one uniform, three-digit phone number, no matter where in the country you're calling from. Today, I'm talking with Cheryl Giarrusso. She's the division director of crisis services for Contact Community Services in Syracuse, which provides a 24-hour support service, and which celebrated 50 years of service in 2021. Welcome to "HealthLink on Air," Ms. Giarrusso.
Cheryl Giarrusso: Thank you for having me.
Host Amber Smith: Contact provides a regional suicide and crisis counseling hotline, 24 hours a day, seven days a week. How many calls do you average per day or per week?
Cheryl Giarrusso: Well, I kind of broke it down to monthly, and we're at about 7,000 calls a month right now.
And that's across all lines. So we do provide support in many different areas in the community, and our call volume ranges at about 7,000 monthly.
Host Amber Smith: What sorts of calls come in to Contact's hotline?
Cheryl Giarrusso: Our local hotline, which is celebrating its 50th year, is a "warm" line. We've been talking with folks for many, many years about whatever it is they really need to share.
So it's what we like to say, a safe place to talk things out. So we've had folks calling us since the beginning of the service in 1971. And some still do call us on a regular basis just to share what's going to happen during their day or what may have happened the night before that was worthy of having a conversation about, so it's really a safe place to talk.
Host Amber Smith: It sounds like a counseling service.
Cheryl Giarrusso: It can be, absolutely. We use an active listening model, so we're not directive, we're just a place for folks to share because we feel that people can really solve their own problems if given the space and time and ability to share whatever it is that's on their minds. People know themselves well enough that they can solve their own problems. They really just need a sounding board. And that's what we try to provide on the Contact hotline.
Host Amber Smith: What's the difference between "hotline" and -- you called it -- a "warm" line?
Cheryl Giarrusso: I think warm line is not necessarily closely associated with crisis. Although there are people who call the Contact hotline who are experiencing some level of crisis, and we're certainly prepared to respond to those folks when they call. But hotline I think is more associated with a crisis type of call, and warm line is reassurance and a listening line.
Host Amber Smith: And we should say, what is the phone number that people can dial?
Cheryl Giarrusso: 315-251-0600 is the Contact hotline number.
Host Amber Smith: And then the three-digit number that will work starting from July 2022 going forward is just simply 988?
Cheryl Giarrusso: Yes, 988 will be the three-digit number that you can call. It is currently the national suicide-prevention lifeline number, which is 1-800-273-8255. So you can see that 988 will really make it easier for people to reach out. It's easy to remember, and we're anticipating that it will be a real help to the folks in our community.
Host Amber Smith: Have you seen that the numbers of phone calls coming into Contact have been affected by the pandemic in any way?
Cheryl Giarrusso: I think that call volume has been on the rise throughout the pandemic, even prior to the pandemic, we had some losses and not necessarily in the community, but some high-profile losses, that really affected folks, and call volume began to increase at that point in time and continues to increase.
I think what we see, due to the pandemic, is that the type of call, the concern, the level of anxiety, has been elevated, I think, due to all that we've gone through because of the pandemic.
Host Amber Smith: When it's normal times, aside from the pandemic, are there fluctuations when you see phone calls coming in? are you busier in the summer or the winter or holiday times?
Cheryl Giarrusso: You know, this may seem odd, but April is a month where we seem to get an increase in, especially in, calls of a higher level of crisis. And some suicidologists say that that's because people are anticipating wellness, a feeling of wellness, coming on as the spring approaches. And if that doesn't happen, things don't change, then crisis arises again.
So April is that critical time for that to happen.
Host Amber Smith: Experts have said our nation has a child mental health crisis, even before the pandemic began. What do you think is the reason for this and what is being done to help?
Cheryl Giarrusso: I could speak to what we see here in the call center. I came to contact almost 20 years ago to head up a program focusing on child mental health. So it is a problem that's been with us for quite a long time. I think that resources are short. I think that it takes a special person to be able to address children's mental health. It's different from adult mental health. I believe that there's been a shortage of providers.
I think that, from what I hear, it's tough to think about your child or any child experiencing a mental health emergency or having mental health issues. It's just hard for people to wrap their heads around. So I think that the pandemic has really shown a strong spotlight on that. And that's a double-edged sword.
It's been sad to to see the struggles that kids have been going through, but I think that we're at the point where we can really band together as a community and use our resources to help kids.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Cheryl Giarrusso. She's the division director of crisis services for Contact Community Services in Syracuse.
Is there an age limit for callers to Contact?
Cheryl Giarrusso: No. We get callers from the very young to the very old, sometimes we have moms or dads that put their young child on the phone because they have a question or a concern, and they feel that we would be the right folks to answer that question or concern. So we've had some very young kids. We've got people on our Telecare program that are older folks, and they call or we call on a regular basis. So there's no age limit.
Host Amber Smith: And can people opt for a web chat instead of a phone call?
Cheryl Giarrusso: We provide web, we provide texting support through our 211 program. We have an opioid textline where you would text "opioid" to 898211, or if you need a resource in the community, you can text your ZIP code to 898211, and we can provide support and resources.
Host Amber Smith: I want to talk to you more about this three-digit dialing code, the 988 number and why it's important to the mental health community to have this nationwide, where everyone would dial the same number, similar to 911, only this is 988. Is it just for mental health crisis?
Cheryl Giarrusso: It's really an emotional support line. Certainly we will be prepared to address mental health crises, but it's a safe place, again, similar to the Contact hotline. It's a safe place to talk. If you are experiencing any sort of an emotional crisis, dialing 988 will be the first step toward wellness.
Host Amber Smith: Do some people who are contemplating (suicide) call the hotline?
Cheryl Giarrusso: Yes. We speak with people on a daily basis who are experiencing suicidal ideation, or thinking about ending their lives. That doesn't necessarily mean that they will take the next steps, but they know that they can call and they can share how they're feeling and they will be addressed by a nonjudgmental listener who allows them the space and the time to share what has brought them to that point. And again, once they're able to share that information and really get it out in the open, that's the beginning of finding ways to feel that life is worth living.
Host Amber Smith: So people should call 988 if they're worried about someone who might be contemplating suicide, too?
Cheryl Giarrusso: Absolutely. We are able to share information and educate people because for a person who knows of someone who's having thoughts of suicide, they're in a crisis of their own. So we've got two crises going on. So we are able to provide that concerned party with support, a little bit of education, and if they feel that they can't address the issue on their own, we're able to provide a support to a third-party call, so we can make a call on behalf of the person who's concerned.
Host Amber Smith: If someone calls 911 by mistake, and they meant to dial 988, what would happen?
Cheryl Giarrusso: If someone calls 911 and meant to dial 988, the 911 operator will be able to divert that call to our call center, and we will be able to respond.
Host Amber Smith: Well, I'd like to know more about the other services that Contact provides. What is Telecare?
Cheryl Giarrusso: Telecare is a reassurance program. We have been at that program for about 10 years now. So we provide daily, outgoing reassurance calls to people who often are homebound, sometimes isolated, people who really would benefit from a friendly connection on a daily basis. Sometimes they need a medication reminder or just to hear someone on the other end of the line who wants to make sure they're OK and safe. So it's a great program. We have grown to, I believe, over a hundred folks that we reach out to on a daily basis. And it's one of our favorites, to make the calls. And I think that the people that we call are very pleased with the program as well.
Host Amber Smith: So just to stay in touch, a well-check.
Cheryl Giarrusso: It is a wellness check,and we're actually going to expand to make it a more robust wellness check, do some fall-hazard kind of checks and home safety checks. It's a great way to keep people at home and out of institutional care, I think.
Host Amber Smith: I understand people can dial 211 in Onondaga, Oswego, Jefferson. Lewis and St. Lawrence counties. What is that for?
Cheryl Giarrusso: 211 is an information and referral number. So if you have a need andyou dial 211, then we can connect you with services that can meet that need. That could be a food pantry. It could be diapers or formula. It could be a shelter issue. You may need some legal information. It's a wide variety of services that are available in the communities. And we have a database that's up to date, and we can provide information and, again, that listening ear and that, compassionate, concerning response.
Host Amber Smith: You also offer some school services. Can you tell us a little about those?
Cheryl Giarrusso: We do. We also offer school services from preschool all the way up to high school, and we're in many of the city schools and in the North Syracuse school district. We do now have a very exciting suicide safety in schools program that we've just launched. Andwe're very excited to bridge the gap between the crisis line and the school services through the suicide safety in schools program.
Host Amber Smith: Are there additional future plans for contact that you'd like to share?
Cheryl Giarrusso: Well, we're just really trying to get ourselves up and running with 988. And we are partnering with our 911 center around the 988 calls. Andwe're always looking to partner with the community, to make sure that the folks in Central New York are safe and have a safe place to talk.
Host Amber Smith: Well, thank you for making time for this interview, Ms. Giarusso.
Cheryl Giarrusso: Thank you for having me.
Host Amber Smith: My guest has been Cheryl Giarrusso. She's the division director of crisis services for Contact Community Services in Syracuse. I'm Amber Smith for Upstate's "HealthLink on Air."
What happens when a senior citizen breaks a hip -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Upstate has implemented a new model of care for older adults with hip fractures, designed to help them heal more quickly. Here to explain the American Geriatric Society's Ortho CoCare Program is Dr. Sharon Brangman and nurse Lia Fischi. Dr. Brangman is chair of Upstate's department of geriatrics, and she's the past president of the American Geriatric Society. Ms. Fischi is the interim orthopedic program manager. Welcome to "HealthLink on Air," both of you.
Sharon Brangman, MD: Thanks for inviting us.
Host Amber Smith: Ms. Fischi, can you first explain how common hip fractures are in people over age 65?
Nurse Lia Fischi: According to the CDC (Centers for Disease Control and Prevention), about 300,000 adults aged 65 and older are hospitalized for hip fractures.
More than 95% of hip fractures are caused by falling, so this is pretty common, and the most serious fall injury is a broken hip. Actually women experience three quarters of the hip fractures. Women fall more often than men, and women more often have osteoporosis, a disease that weakens bones and makes them more likely to break. So the chances of breaking your hip go up as you get older.
Host Amber Smith: And Dr. Brangman: Older people being more susceptible, does that mean that fractures in someone who is older than 65 are inherently different and have to be managed differently than a fracture in a younger person?
Sharon Brangman, MD: So the fracture itself needs to be managed based on their amount of osteoporosis and how the break occurred, where it broke. There's all different areas of the hipbone that could actually break.
But in general, what we try to do is look at the other medical problems that might be going on with the person. So after the age of 65 and into our 70s and 80s, we generally have other chronic medical problems that are going on, and we're often taking a lot of medications.
And all of these can have an impact when you're in the hospital, and you're getting pain medicines or other treatments. So We want to make sure that when people start to have a long list of medical problems and medications, and they have a hip fracture, that we keep all of this in mind while we're taking care of them.
Host Amber Smith: So is recovery necessarily going to take longer for someone who's older because maybe they do have other medical things going on?
Sharon Brangman, MD: Well, it can vary, depending on the person. So if they have severe thinning of their bones, if they have problems with their memory like dementia and maybe can't follow instructions, they may have a different recovery than someone who is healthier and has a simple fracture. So our team is trained to take care of people, whether their fracture is simple or more complex.
Host Amber Smith: Ms. Fischi, I was going to ask: With seniors with fractured hips, do they require surgeons that have expertise in handling more complicated fractures?
Nurse Lia Fischi: Well, our surgeons here at Upstate are fellowship trained. So that means that they received extra training to take care of these types of fractures in dealing with the older adult. So, yes, I would say that our surgeons here at Upstate Hospital have the expertise to deal with these fractures, and combined with our multidisciplinary team, with the Ortho CoCare Program, it makes a great program to take the best care of our older adult population.
Sharon Brangman, MD: So what we've really done is combined geriatric care with excellent orthopedic care so that we can get the best outcome for our patients.
Host Amber Smith: And so that's where the name co-care comes from, because you're cooperating. But what can you tell us about when this program was developed and what the overall goal is?
Sharon Brangman, MD: Well, the program was started by some of my colleagues at the University of Rochester many years ago. And it was so successful that in about 2017 or so, the American Geriatric Society stepped in and helped to make it a national model.
So there are now many hospitals across the country that have used the American Geriatric Society's template, so to speak, to help set up this system in various hospitals across the country. And what they found is that when you have a team working together, each with their own expertise, we can take better care of the patient.
So we get them to the operating room quicker, we control their pain better, we get them out of bed and into rehab quicker, because our goal is to get them back to their previous level of functioning.
Host Amber Smith: And you said it's been implemented in other hospitals, in other cities and states, it must be going well, or it wouldn't have been replicated in so many places.
Sharon Brangman, MD: So it has been shown to be an excellent program. It's based on evidence and data, so we have the information to back it up, to know that it helps to reduce the amount of time a person stays in the hospital. It reduces their likelihood of coming back to the hospital with a complication, and it reduces the potential complications that can occur when you have somebody come in, and they're on many medications, we can reduce their delirium.
Delirium is an acute confusional state that an older person can get when they're under stress in the hospital. And our team has special expertise to help reduce that risk of delirium because when you have delirium, you end up staying in the hospital longer.
So we have an expert team that can look at all aspects of this person's care, so that we're not just fixing their hip.
We're also trying to optimize their health and get them back to where they were as soon as possible.
Host Amber Smith: A lot of people who have fractured a hip have other injuries from that fall, right? You've got to deal with concussion or whatever the other things are.
Sharon Brangman, MD: We're not going to take care of people who have the more complicated traumas. So if they've had a head injury or, say, a spinal fracture and a hip fracture, they're going to go to the trauma service because that's a different kind of care. But if you have a simple fall with a hip fracture, then we're going to take care of you.
Host Amber Smith: Do seniors with other kinds of fractures qualify for this program?
Sharon Brangman, MD: Not at this time, although in models across the country, they have looked at other fractures, but right now we're starting out with hips because hips are the ones that can change an older person's lifestyle so significantly. Other programs have expanded their co-care to all levels of surgical support, for general surgery, for vascular surgery, for trauma surgery. That could be something that we look at down the line, but right now we're focusing on hip fractures. We want to get this program going and help older people who have hip fractures in Central New York have the best outcome possible.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with nurse Lia Fischi and Dr. Sharon Brangman. Dr. Brangman is the chief of geriatrics at Upstate, and Ms. Fischi is the interim orthopedic program manager. And we're talking about a new program from the American Geriatric Society designed for seniors with hip fractures, called Ortho CoCare.
Ms. Fischi, how does Ortho CoCare work from the patient's point of view? I want to ask if you can walk us through what happens if someone falls and fractures their hip.
Nurse Lia Fischi: So when they do come to our hospital, like Dr. Brangman was mentioning, our key goal is standardized care for the older adult. So we provide very patient-centered care, taking the patient as a whole. We use evidence-based practice and the current clinical practice guidelines so that the patient has the best outcome. So with that, our work included standardizing order sets, our notes, staff education to allow us to provide standardized, high-quality care for the patient when they come in through the emergency room or direct admission.
Sharon Brangman, MD: What we really did was look at them from the minute they hit the emergency department, so our emergency department team is aware of them. The operating room is aware of their needs, the hospitalists, which are the doctors that manage care in the hospital, are part of our team, our physical therapists, our pharmacists, we have pain experts who are going to be involved, so that every piece of care that's needed when you have a hip fracture is being addressed.
Host Amber Smith: Now, can they come to either emergency department, either at the Community campus or downtown? Is that right?
Nurse Lia Fischi: Yes. Both downtown and Community.
Host Amber Smith: And is this the type of injury that's going to require X-rays for a diagnosis?
Nurse Lia Fischi: Yes.
Host Amber Smith: And are there any other tests that would be done, and is surgery always recommended for a hip fracture?
Nurse Lia Fischi: No, not always. It's dependent, so the orthopedic surgeons will look at the X-rays and make a determination and also speak with the family and go from there, make a treatment plan.
Host Amber Smith: Now, without getting too involved in this, in terms of the surgery, is it a replacement of the hip or are they able to insert pins, or how is it done, typically?
Nurse Lia Fischi: Both. It could be a replacement. It could be pins. So it just depends on where the break is in the hip.
Host Amber Smith: Well, can you talk to me about what recovery is typically like and what you would hope to see in patients after the surgery is finished?
Sharon Brangman, MD: Normally, recovery is, somebody is watched to see how their pain is and then they may be walked around the unit if they can bear weight, so we can see how they move. And then a physical therapist would evaluate them at that point. And then a decision would be made. Do they need to go to a rehabilitation center or can they go home?
It really depends on the person,
Host Amber Smith: But it sounds like they're out of bed relatively soon after the surgery. And that's got to be a huge change from what it used to be.
Sharon Brangman, MD: We found out that bed rest is really not as good for us as we think. So our goal is to get people out of bed. There's an old saying: "Bed rest is good if you're dying." But you really want to get out of bed if you're older because staying in bed and not moving actually causes more harm than good. And not just to your hip, but to your lungs and your heart and the way your blood pressure responds.
So we want to make sure that people are getting out of bed. We want to make sure they don't have any catheters or IV (intravenous) lines and that they're eating a good diet. And that we have a physical therapist who evaluates them to see how well they're moving and what would be the next best step for them in their recovery.
Host Amber Smith: Are there things in particular that need to be looked out for during the healing, after a hip fracture, things that might warrant a return to the hospital or a call to the doctor, at least?
Nurse Lia Fischi: There would be signs of infection, fevers, chills, bleeding, new pain, new extreme pain, loss of feeling or numbness, swelling. Anything else, Dr. Brangman, to add?
Sharon Brangman, MD: Shortness of breath.
After a hip fracture, you may have an increased risk of getting a blood clot, so we want to make sure that you're on the right medications to reduce that risk.
But if anybody was to get any chest pain or problems breathing, we would certainly want them to come back to the hospital.
Host Amber Smith: What advice do you have for family and friends, if a loved one has had a hip fracture? I'm wondering what they can do to help while the person's in the hospital?
Sharon Brangman, MD: Well, I think it's just good support to make sure that their needs are being met in the hospital and to give input on the best place for them to get their rehabilitation. I think it would be important to know the reason for the fall so that we could look back and prevent any future falls.
There's a lot of reasons why people fall as they get older. There are normal changes that happen with our gait and balance as we get older, and then you can add medications and certain medical problems, but most of the time falls are due to accidents that can often be prevented. So we want to make sure that if somebody had a fall, that we talk about future fall prevention, make sure there's no clutter in the house and that no one's climbing on a ladder and they're wearing the right footwear so that they get the right support on their feet.
And we do a medication review to see if there's any medications that can make someone more prone to falls, so the next step is, after the fall and somebody has recovered, we want to reduce the chances of them falling again.
Host Amber Smith: If someone over the age of 65 arrives with a broken hip, are they automatically enrolled in this Ortho CoCare Program, or do they have to ask about it?
Nurse Lia Fischi: They're automatically enrolled into the program.
Host Amber Smith: That makes it easy. Well, I want to thank both of you for taking time to explain this to us.
Sharon Brangman, MD: We're really excited about this program, and we're so glad to be offering it to older adults in our area.
Nurse Lia Fischi: Very happy.
Host Amber Smith: My guests have been Lia Fischi -- she's a nurse and a clinical lead for the Ortho CoCare Program and the interim orthopedic program manager -- and Dr. Sharon Brangman. She's the chief of geriatrics at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from bioethicist Dr. Syd Johnson from Upstate Medical University.
What should someone consider before agreeing to serve as a health care proxy?
Syd Johnson, PhD: The proxy or the surrogate's job is to make decisions that the patient would make for themselves. And that's based on their understanding of what was important to that patient. It might be based on conversations that they had with the patient, or their knowledge of the patient, or the values and interests that they shared with that patient. For patients who've also left some kind of advance directive, the surrogate also has to honor that advance directive. If that person knows the patient well and understands their values, their religious beliefs, if they had any, and has talked to them about their preferences and their wishes, then they can make decisions that are probably pretty close to what the patient would decide for themselves.
I think every adult should have a health care proxy. And that proxy can be anyone that you think is able to represent you in making medical decisions. If you are a health care proxy, then you want to do your best to make decisions consistent with the wishes and preferences and values of the person that you're representing. If you can't do that, if, for example, you have religious or moral objections to something that the patient would want, then you should bow out and let that patient know that.
How well you know that patient, how well you understand what they want, whether or not they would want treatment continued, what kind of treatment they would want, do they want everything possible done to keep them alive for as long as possible, or would they want you to end treatment at some point, even if it means that they won't survive? Those are all difficult questions to talk about with people. But they're questions that the proxy or the surrogate really needs to know. Are there specific kinds of treatment that the patient does or does not want, like feeding tubes or ventilator or surgeries? Would they want hospice care at the end of life? These require really difficult discussions, and no one ever anticipates all the things that might happen or go wrong for them. So, fundamentally, the proxy really has to be able to put themselves into the patient's shoes, so to speak, and decide as that person would decide at the point at which decisions need to be made.
Host Amber Smith: You've been listening to bioethicist Dr. Syd Johnson from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Graveyards are wonderful places for meditation and inspiration.
Eric v.d. Luft, poet, publisher, editor and translator from Syracuse, New York, gives us a wondrous walk through time and emotions in his poem called "Pine Grove."
If, as Einstein said, our heads
Age faster than our feet,
Then surely this is true
As we stroll among the graves
Of those we knew.
Pull our feet down,
Slow our steps,
Or even stop them,
And commit us to sorrow;
Push our heads up,
Make us smile,
Make us soar
Higher and faster
Than we've ever been before;
Yet these are sad smiles all the same.
We feel split in limbo:
Hopeless death below,
Listless life above.
Gravity cracks the whip.
Thoughts fly up,
Descend as saturated rain,
Into a whole,
Heads one with feet
And everything between
Dripping with self-awareness.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": science experiments kids can do at home. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.