What happens when patients have a disability, can’t walk and can’t get into their home? Or don’t have a home to go to?

What if you had suffered a severe spinal cord injury, couldn’t walk, required a wheelchair for mobility… and you were homeless?  How about if you had a stroke that caused one sided paralysis, inability to talk or swallow… and you lived in a remote “dry” cabin without electricity or water?  Or what if your car got hit by a moose causing a severe traumatic brain injury, leaving you to have the cognition and temperament of a two-year old, and no one in your family could take time off of work to care for you?  Or what if you fell and broke you pelvies, were unable to bear weight on your legs for six weeks, and you lived in a two-story home with the bathroom and bedroom upstairs? Where would you go after you completed your acute inpatient rehabilitation? Who would help take care of you?  What if there was no one to help you and/or nowhere to safely go?

Sound far-fetched? Not up here in Alaska, and while it’s true that discharge challenges are part of the rehabilitation puzzle, it is much more extreme in the Last Frontier. The patients I have been caring for have all the severe injuries that I have learned about in my rehabilitation textbooks: traumatic brain hemorrhages (bleeding) requiring emergent brain surgery for decompression, cervical (neck) spinal cord injuries resulting in tetraplegia (weakness or paralysis in the arms and legs), head on car accidents that leave people dead and the lucky survivors with multiple fractures, gunshot wounds to various body parts – either accidental Russian-Roulette to the head style, or purposeful suicidal attempts. Other trauma patients have survived include ATV accidents, snow mobile accidents, bicycle accidents, and accidents from falling off roofs or ladders, slipping on ice, or hitting moose.  Very few of my patients have a standard run of the mill hip fracture after tripping over the throw rug in their living room. Welcome to Alaska.

Then there are the patients that don’t take care of their physical health, either have never gone to see a doctor (live too far away from medical care), or have chosen to not take medications for conditions they have been diagnosed with (don’t believe in Western Medicine). They show up to the hospital only when they are very sick, sometimes in multi-system organ failure (intubated from respiratory distress and on dialysis for failing kidney function), or they have systemic infections in their blood, sometimes requiring lower leg amputations due to diabetic skin infections that go deep down to the bone.  

In short, our patients are very ill and have significant mobility impairments, making their discharges back to their home environments challenging, and sometimes impossible. Some patients live on islands here in Alaska that only have access by boat or small planes. Some live in dry cabins off the grid, down dirt roads with gravel walkways no conducive to walkers or canes, and homes so small wheelchairs, manual or power, won’t fit. Our admission coordinators take all of this into account when deciding if someone is appropriate for the acute rehabilitation hospital. Per Medicare criteria, there has to be a reasonable chance to discharge the patient back to their home, otherwise, we would not accept them as a patient. Unlike a skilled nursing facility or even the main hospital, patients cannot live at the rehabilitation hospital. They have to leave at some point, even if it is months later and they no longer need any therapy services.

Sometimes the discharge plan just falls through. The family—who initially stated they would take their loved one home no matter what—start to see what it’s really going to be like to care for their loved one and frustratingly, though also understandable, back out. They didn’t know they would have to wipe their loved one’s bottom after bathroom visits, or always be in the house for supervision to keep the patient safe. Or maybe the patient doesn’t make the expected progress, is unable to navigate the flight of stairs, or is deemed no longer safe to be home by themselves and there is no one else to assist. Last week on of my patients who had a lower limb amputation went for an evaluation of her apartment with our therapists to see if she could bump up her herself on her bottom from the bottom of the stairs up to the second level where her apartment was. Her neighbors looked on and cheered her attempts, while the therapists held their breath and hoped the neighbors might be around when and if the patient was having a hard day and couldn’t get up the steps without help.

This is why I was so adamant about making sure we bought a place to live here in Alaska that we could into if/when either my husband or I were injured. I made sure there were minimal steps (2 to get up to the porch outside, which I could ramp in the worse-case scenario), and a full bedroom and bathroom on the first floor. We are going to have to put this set-up to the test earlier rather than later, as my husband is injured and we learned this week that he might have to undergo back surgery. I am crossing my fingers that my own health stays strong, so that I can assist if he has to do any bumping up the stairs himself.