Priorities

Whilst on orthopaedic inpatients prac, for almost 3 weeks I treated a 46yr old man who had a fractured acetabulum, after falling off his boat onto the concrete ramp. Initially I saw him whilst immobilised in bed several times for his chest and maintenance bed exercises, every day for almost 2 weeks, and got to know him quite well. He was very anxious at times and always very clear on what he needed to happen during sessions. For example, he had a mild head injury a year previously which had resulted in nystagmus and occassionally nausea when he sat up too quickly, and so he was very clear on how gradually he wanted us to raise the bed tilt before he was eventually able to stand.

The post op orders stated that he was touch weightbearing (TWB) on the affected limb, and started walking with a pulpit frame. He was extremely nervous, and even told me that from the time of the accident the thing was most worried about was his first time standing and walking again, even more than the surgery or the pain. He progressed onto axillary crutches after a few days, and I tried to teach him a reciprocal gait pattern, still TWB on the affected limb. After approx 15minutes it seemed that this was too complicated for him at this time. He was very nervous about even putting his foot on the floor, making it very difficult. His personality was such that although he was very respectful of all the health professionals he felt that things needed to happen a certain way - his way.

As getting him up and walking was by far my top priority I let him adapt and use what was basically a NWB, step-through pattern instead, as he was able to ambulate at a reasonable pace independently. Two days later we walked to the PT gym to attempt stairs, as he had a couple of steps at home. My supervisor was walking with us as well, and knew about his anxiety and difficulty learning things. The consultant who had operated on this patient (a rather eccentric man!) saw him walking and said to him "you are doing very well." Then he said to me "why are you letting him walk like that?!" At first I didn't realise what he meant, thinking he believed it was unsafe. The consultant demonstrated to the patient what he should be doing in order to promote as normal gait as possible with the reciprocal pattern. The patient was then able to perform the pattern much better than 2 days previously and I looked quite foolish!

I was embarrassed that a doctor was telling me how to do my job (and rightly so to be fair), especially in front of my patient and supervisor. Fortunately all three of us knew that we had tried it already without success. I had become preoccupied by the main priority for his health as well as discharge, which was safe ambulation on the level and with stairs. Although I knew it was important to promote normal gait and avoid maladaptive movement patterns I failed to come back to this somewhat difficult task for this man once he was more likely to be able to do it correctly, and probably would have sent him home NWB, slowing his rehab.

I learnt from this experience that although there are times when priorities prevent you achieving the ideal outcome initially, it is still important not to forget that poor habits can still be changed early on once the top priorities have been met. When I am next presented with a patient who is unable to correctly perform an important task or exercise, even after demonstration, practice and feedback, I will not let this prevent them progressing to meet the main priorities from everyone's point of view. What I will do differently however, is to come back to the task frequently as they are progressing and are more likely to be able to achieve it.