In the fall of 2009, Dorothy Byrd was so sick, so delirious, and so unaware of her surroundings, her desperate family was losing hope. Today, things are very different for this lively and expressive 80-year-old Fairfield resident. Not only is she now up and out of bed, but she is walking, has rejoined her various club activities and is even driving again.

Dorothy’s medical misery began about two weeks after hip replacement surgery in August 2009. She seemed to be healing well at a Fairfield rehabilitation facility until she developed a staph infection. Before long, “she was bed-ridden, withdrawn, unable to eat and didn’t know where she was,” reports her daughter, Charlene Rushing. “Everything went completely sour; it was a pretty scary time. We thought we were going to lose her.”

“I don’t remember anything and that is out of character for me. I became discouraged and thought I might just go join my husband, who passed away four years ago,” Dorothy says.

The infection and other complications had worsened her condition, and she was readmitted to the Vallejo hospital where her surgery had been performed. For several weeks, Dorothy would be treated there and then released to the Fairfield rehabilitation center, only to be rushed back to Vallejo when another complication arose. “After six weeks of going back and forth,” Charlene says, “I asked her doctor, why can’t we just go around the corner (to NorthBay)?” That’s when Dorothy came under the care of Hospitalist Andrea Ngo, M.D., and Terrell VanAken, M.D., medical director for NorthBay Bridges, a palliative care program designed for patients who have chronic and difficult-to-manage health issues. “A lot of whatwe do is to communicate—between the patient, the medical staff, the family and care facilities,” Dr. VanAken explains.

Dorothy with her daughters, Elizabeth Byrd (left), and Charlene Rushing.

Palliative care uses an interdisciplinary team approach—with a clinical social worker, program administrator, chaplain and medical director—to work with the patient’s physician to provide treatment that not only addresses pain and symptom relief, but also addresses any emotional, social, cultural and spiritual needs these patients and their families may have.

“She really turned a corner once Dr. VanAken got involved,” Charlene recalls. “He actually listened to us. He’s a real people person, just wonderful. He comforted our family.”

A conference with family members and attending physicians helped create a plan of treatment. Dorothy’s hip replacement device would be removed and an antibiotic spacer would replace it. In November, after her infections and complications were brought under control at NorthBay Medical Center, Dr. VanAken arranged for her to be transferred to a Vacaville rehabilitation facility. She spent two months “regaining strength and her appetite, and going through rehabilitation,” Charlene says. “She really responded there, because there were activities for people to do; they actually expected her to get up and get out of bed for rehabilitation! She was able to come home on the weekends, and then was discharged in January.”

Eventually, Dorothy opted to undergo a second hip replacement surgery, and Dr. VanAken helped the family find a surgeon who could handle her extremely complicated case. The surgery, performed in San Francisco, also came under the watchful eye of the NorthBay Bridges team. “My daughter introduced my surgeon there to Dr. VanAken as a ‘person of interest,’” Dorothy recalls. “After that surgery, I feel so much better. I have a better diet, I am rehabilitating. Having all these people take an interest in me has helped a lot.”