I was treating a male with an ACL rupture. He was in a Richard’s splint, movable between 0 – 30 degrees. His consultant told him he needed physio and admitted him due to his extreme pain. Surgery was not discussed. The patient was a young, fit, strong guy who was a labourer and played sport quite competitively. He exhibited the classic ‘yellow flags’ of a pt who was fixated on pain – his face displayed exaggerated agony with any movement, even of the unaffected leg! Yet when asked to stand, he would SLR his affected leg and swing it over the side of the bed, only complaining about the pain as he tried to stand. He was always on the phone, telling people about his extreme pain, taking many photos of his leg and the questions I asked were only answered relative to pain. He catastrophised (“I’ll never walk again”) and although he could move his knee within the splint, he would stop the cpm machine as soon as I left the room, even though it was set to a max of 30 degrees. He was also non-compliant with unsupervised exercises. The patient was on the maximum analgesia, including morphine shots prior to physio. Additionally he was a worker’s comp pt, which was clearly identified on his notes as was the statement “NO OPERATION WITHOUT EMPLOYER’S CONSENT”, which I thought was an odd request – I was under the impression worker’s comp covered all necessary treatment, that it was not at the employer’s discretion..
I was concerned about this patient due to his pain fixation and lack of commitment to helping himself. However, I thought that the patient’s demographic, lack of co-morbidities and high activity level would have warranted at least a conversation about surgery? Anyways, he was an inpatient for only a few days then he was abruptly discharged and told that we were unable to help him further.. It was suggested to me that the consultant and pt had clashed personalities and that this discharge was similar to others with this particular dr. Whether this was true or merely gossip, ACLs don’t heal themselves and as we all know, there are some pretty sound pathways for intervention post ACL injury. Although this was a difficult patient who I personally found quite draining to treat, I felt that he had been denied some quite standard treatment.
Anyway.. the discharged pt asked me if he should get a second opinion as he didn’t understand why ACL recon wasn’t offered. I found this situation very difficult – I did think surgery should have at least been discussed, but a capable surgeon had decided not to. I handled the situation poorly and said I wasn’t qualified to give that advice and that it was entirely a personal decision..
Patients respond differently to situations and to pain, but trying as they may be, they all deserve appropriate levels of care. As medical professionals we are privileged to more information than those who do not work in this field – is it then our duty to advise others not privy to this knowledge?? As a qualified physio I think I would give the patient honest advice (ie get a second opinion), but be really careful about maintaining professionalism and not affecting the dr’s reputation.
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I think we are at a difficult time as students... as we are STILL 'students' although are soon to be qualified. It becomes difficult in situations like you have discussed, in terms of knowing what to say and when its appropriate. We obviously have our opinions about certain treatment and management procedures, but have yet to gain the clinical experience to feel confident in expressing these opinions!
I dont think you handled it poorly at all, I think we are all very hard on ourselves when it comes to handling new situations, and want to do things, and have the answers perfect first time! We need to come to the realisation that there will be heaps of new situations, to learn from them and use the experience gained for future situations!
I have also found it difficult in a hospital setting, when patients turn to you and ask your opinion, especially on a matter usually decided by a docter. You dont realise how much some patients take in what you say, and you dont want to give the wrong advice!!
I found that talking to my supervisor, after the conversation with the patient, about how to discuss sensitive issues (ie not wanting to influence the docters reputation as you discussed) helped alot. They recommened that you can be as honest as possible, and say that some issues are best to discuss with the docter, or another docter.
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