Personality Issues

I am currently treating a patient whom sustained FT burns to their UL, back and lateral aspect on their trunk. As the patient had a number of risk factors including obesity and diabetes they had extensive surgery 1/7 after being admitted to debride the dead tissue and have SSG’s over a substantial area of the burn. Following surgery the patient was admitted to ICU for a period of time as they had not responded well to the operation. When the patient returned to the ward they were given the all clear to begin UL exercises and ambulation ASAP (as their health was deteriorating rapidly from being in ICU and bed rest). Unfortunately the patient was not compliant with physiotherapy. Whenever the physiotherapist and I went in to treat the patient they constantly asked for us to come back later ‘at 4 o’clock’ and ‘I’ll be alright’. After some education of the importance of moving etc the patient would comply to some treatment. As the week progressed it became apparent that the patient was not moving their arm at all when we weren’t in their room standing over them and watching them do their exercises. This lead to the UL becoming v swollen and more painful – limiting their ability to regain function.

The physiotherapist and I spoke to the nursing staff and they mentioned that the patient was quite confused (they were pulling out their IDC and NGT every single night) and would not do anything for them self. In addition to being confused the nursing staff suspected that due to the patients background and culture they had not cared for them self before they were injured – also apparent with their health. I reflected on this and realised that it was going to be difficult to engage this patient in their treatment due to their personality and background. I thought of a few ways to overcome this including more education, speaking with the family, taping exercises to their wall as a constant reminder etc. A number of physios on the ward were involved in treating this patient at different times, and due to good communication everyone knew the patients history and tried to be consistent with their education and exercises. No matter whom was in the room with the patient treating them the patient constantly requested a later Rx session and stated ‘I’ll be alright’. Unfortunately due to the nature of their burn and the associated risk factors they had this patient was not going to be alright.

Following the ward round on Monday the patients UL and now LL was significantly more swollen than the previous Friday. It was apparent that even with week end physio the patient had not moved this UL at all and still appeared to be confused and unmotivated. I found this frustrating as by knowing the long term implications of this sort of injury if they continued to play a passive role in their rehabilitation it was unlikely they would use this UL again. For this sort of injury 2x daily physiotherapy will not prevent the loss of function – thus even by ensuring the patient does their exercises at least 2x a day it will not be enough. In addition if the patient is non-compliant during the sessions as well then they are almost guaranteed to lose some degree of function. This has reinforced my belief that sometimes all we can do as therapists is place the tools in the patient’s hands. We can ensure they do their exercises properly with us and provide them with all the education and resources they may need. What we can’t do is ensure they are doing their stretches etc every hour, and making lifestyle changes to optimise the healing process. Unfortunately as with the above patient factors such as culture, personality etc can work against us, and it may be difficult to treat the patient effectively. For the above patient (as their confusion is declining)what I am hoping is that with 2x daily physio teamed with repetitive ongoing education (in particular with the family present) they may begin to take some responsibility and ownership in their rehabilitation to try and first regain their lost function – and then maintain it.