Almost successful treatment session

This week, I was treating a 72 y/o male admitted onto the respiratory ward due to an exacerbation of COPD. He has a PMH of motor neuron disease (diagnosed in 2001, very slow progression, no bulbar signs), IHD, GORD and gout. His exercise tolerance is limited by SOB, pain/ache in both knees and weakness in both legs, and therefore is able to ambulate independently for about 5 m with a 4WW. The problem list included, 1) dyspnoea, 2) decreased exercise tolerance 3) Impaired gas exchange 4) impaired airway clearance. The considerations for treatment included musculoskeletal problems (pain in both knees, and weakness in the lower limb).

On the Friday before the 3 day long weekend, I did a follow up treatment session. The plan was to ambulate the patient for about 5-10m with 1x rest, then do ACBT (TEE with BC). I went to see the patient in the morning, but he was resting in bed refusing treatment due to complaints of increased pain and general fatigue. I said I’d come back in the afternoon which I did.

In the afternoon, I spoke to the nurse, who said that the patient has not gotten out of bed for the whole day. It was going to be a 3 day long weekend and there were no indications for the patient to be put on the weekend list. And it was highly likely that the patient would stay in bed for the 3 days. For these reasons, I was quite determined to get the patient out of bed. However the patient again refused to get out of bed to ambulate. Frustrating!

First, I told the patient the plan and its importance (get him out of bed and amb), to which he was very reluctant. I then proceeded to ask if I could just have a listen to his chest and to check his SpO2. He agreed to that, and I completed my usual subjective questions (SOB, cough, sputum) while he was resting in bed. During which, also listened to his complains about pain/feeling tired. After that, I asked if he could sit up over the edge of the bed to finish up the auscultation. He agreed. At the same time, I was also listening to his complains about his frustration at the doctors about being treating like a “specimen” instead of a real person.

Since he was already sitting up in bed, I thought it would be good if he could t/f to the high back chair using a step t/f with the 4 WW. I then explained how sitting up would be good for lung function. And assured the patient that he could stop if he wanted to and all he needed to do was to sit in the chair for ½ hour. To my surprise, he was willing to give it a shot. The t/f went well, with some c/o increased pain in the knees due to weight bearing. While in the chair, I finished off with some ACBT.

After the session, I asked if the patient preferred to remain sitting or be t/f back into bed. He said that he wanted to stay in the chair for a while longer. I then went and got the patient a foot stool as he mentioned earlier that he was more comfortable with his legs stretched out.

Through this experience, I realized that building a rapport with the patient is very important as the patient will trust you and it will enable a treatment session to be successful. With this patient, persistence, lots of encouragement and compromise/flexibility is the key to a successful treatment session. Good listening skills and plenty of patience is vital with every patient you come across.