A Difficult Patient

During my current placement (orthopaedic inpatients), I had a very difficult 36 year old lady who undergone a right total knee replacement. On day 1 and 2 post-op, she complained of severe pain when bending her right knee (8/10) and she could only perform 2-3 repetitions of each knee exercises. The patient obviously appeared to be highly unmotivated and incompliant due to her severe pain. In this case, I focused on liaising with the nursing staff to ensure appropriate and regular pain relief prior to each treatment session. I educated the patient and emphasized the importance of doing the bed exercises as well as the importance of mobilizing from day 1 post-op to make sure that her pain did not stop her from doing her exercises and SOOB. I also negotiated with the patient to discuss her preferred time for physio treatment and to divide one treatment session into a few shorter sessions hoping to improve her compliance with the exercises. After discussing with my supervisor for the first time regarding her situation, given that I could not do much with her active exercises, my supervisor suggested me to put the patient on a CPM machine, hoping to at least improve her knee PROM; however it did not help much at all. The worst part was she would start crying and swearing after each treatment. At that time, I did not feel that this patient had improved much at all after her surgery which greatly reduced my confidence in persuading and encouraging her to continue with her exercises. I also became suspicious of my treatment decisions and strategies.

On day 3 post-op, an active ROM of 70° knee flexion was expected in her operated knee according to her surgeon’s protocol; however she could only flex her operated knee to an active-assisted ROM of 30° using pulleys and slings. I consulted my supervisor again and she was willing to see the patient with me this time. My supervisor attempted to push her with her exercises by putting her on CPM and flexing her knee from 0 to 40°. As expected, the patient started crying and swearing again. It took us for a while to comfort her. After this treatment, my supervisor advised me not to take what the patient had said personally and not to let this patient affect my confidence in treating other patients. She commented that this lady was just a difficult patient to treat. She suggested me to let her have the patient back and that she would give me a new patient to see. I agreed and felt much relieved. On reflection, I learnt that successful treatments should not be expected at all times and constant evaluation of the effectiveness of each treatment is essential to ensure a good outcome for the next treatment. Given that the outcomes of my first few treatments with this patient were not optimistic, I should have discussed more with my supervisor or other senior therapists to seek for other professional opinions. I also found that my gentleness with this difficult patient and her exercises during the treatment might have caused her to overstress her pain that stopped her from doing the exercises, I learnt that pushing the patients harder with their exercises in a good way may be helpful to achieve a good treatment outcome.