Hi all,
I work in neurology outpatients on Wednesdays. This patient is a man in his 30's who has had a extensive history of neurological pain. He has been treated in this outpatient clinic for quite a long time, and recovery has been slow. Since I do not have the patient's medical notes with me, all I know from the outpatient card was that he underwent some cervical surgeries, but both failed : he's ended up as a paraplegic. Before I treated this man, I was warned by my supervisor about how difficult he is to treat, and how he always focuses on the pain and his disability. I was also told that he has been heavily spoilt by his family - does all his transfers (hoist), personal care...everything (even giving him a drink). I was also warned that his capabilities fluctuates significantly with his mood.
During my first treatment, I quickly found out that he has a fairly negative approach to all things. He constantly reminds everyone how independent he was before, and saying that his recovery is too slow. I found that explaining to him about tone, and the importance of passive stretching is for him did not help, as it made him use it to dwell back on his physical impairments. But at least, he was not in a foul mood, and I could perform all the treatment I wanted.
During my next treatment, he came in looking very dreary. He mentioned that he saw neurology specialists on Monday, and that the team could not give him a diagnosis to his constant pain and that they were unsure of what to do. I could not do anything with him! I could not touch him, I could not move his limbs, I could not help him. I got a little frustrated, cause even lifting or touching his limbs were painful. I kept asking myself "If he came in to my clinic in a motorised wheelchair - he could get at least 90 deg of hip and knee flexion, but why is getting even 10 deg not possible with me?" I tried gentle stretches to his lower limbs, and in the end had to get him into sitting to stretch his tight calf musculature. He ended the treatment by saying that I have no idea of what to do with him - and that hurt.
My views on this case is that firstly:
1) I should not treat case with such a bias on what my supervisor has told me - I should see all patients from my point of view as well and treat each of them as "new" patients
2) I should have asked him more about the pain, and get him to explain it more to me (referred, neuropathic, somatic...etc)
3) I should acknowledge the fact that this man is in his 30's - he has been through A LOT. He's lost his independence, his mobility, his self-esteem, drive to live. Furthermore, the specialists can't give him any resolution.
4) I find it really hard to do anything when it most probably a psychosomatic cause.
What do you think I should do guys? I have him again on Wednesdays.
Mark
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1 comment:
Hi Mark,
We have all had very difficult patients I'm sure, however this case sounds particularly challenging. I do agree with you that we should not be influenced by reports from others, however I think that by your supervisor warning you about this man's pain response was actually beneficial to you. Had you not known his tendency to be negative in regard to his condition, you would not have dealt with the situation so well. I feel that it is important for you to ackowledge and understand his pain, however, I think by asking him too many questions regarding his type of pain etc, may only cause him to focus more on the pain. Rather than target his pain levels, I think it would be more beneficial to act with some empathy but try to distract him by engaging him in other matter, i.e. how he likes to spend his free time and what his family memebers are like.
The next time you see this gentleman, you should definitely have an easy approach with him. At the same time act confident that you do know what you are doing and that the techniques you are performing will not be of detriment to his status. I think that with patient's like this, the effectiveness of treatment can be higher once the patient has trust in your capabilites and thus raport building is essential to their management.
Hope you have better luck with him next time,
Kate.
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