What Are We Trying to Accomplish?
I've started working in an inpatient rehab unit this week. The case load is primarily neurologic or polytrauma patients. The unit is based in a large teaching hospital so the admitting diagnoses are always interesting and varied. I've been there a week and already I'm starting to question what we're trying to accomplish. I thought the goal of rehab was to prepare patients for discharge home by making them as independent as possible. As a therapist I have two roles: One role is to educate and train my patients to return home. The other is to increase their functional level so they'll be able to do what I'm teaching them. Since this isn't a perfect world, that doesn't always happen. Sometimes we try and just can't get it done.
Currently I have two patients I don't know what to do with. Beyond the obvious, I'm not sure why they are on rehab. In both cases the discharge plan and long-term goal of the admission are unrealistic. One patient is s/p resection of a frontal lobe brain tumor. On a good day frontal lobe brain injuries are a challenge to treat. This gentleman has a long history of alcohol abuse and smoking. His personality was difficulty premorbidly. To further complicate matters he has a severe left side neglect. He doesn't want to get out of bed. He doesn't want to walk around. Unless our therapy is walking to get coffee he doesn't want to work with me. He becomes agitated whenever he is confronted with his situation. He hasn't been violent, but aggressive behavior is characteristic of frontal lesions. I keep an eye on him.
I've made little progress. I don't think I'm going to get very far at all. I understand that he needs therapy. But he has to participate for us to accomplish anything. I'm not sure what his admitting physician thinks we're going to accomplish. His mobility problems aren't nearly as severe as his cognitive problems. If he wants to get up and walk he can. It isn't pretty but he can do it. He will require 24/7 supervision when he leaves. He won't be able to return to independent living so will be placed somewhere. That will put him under 24/7 supervision. Given these circumstances he seems to have obtained his highest functional level for gait. Those same reasons are why he won't leave the unit before his anticipated DC date. I don't know what to do with him.
The second patient is a R CVA with severe hemiplegia. He is cognitively intact. He is also an AKA on his uninvolved side. He just received a new prosthesis (C-knee) prior to admission that he has never been trained to use. He is max assist of 1 -2 for all mobility. Today he finally sat EOB with SBA against no challenge. His rehab needs are fairly obvious. It's also obvious that it's going to take awhile to achieve any level of independence. The problem is he lives alone and is insisting on returning there at DC. He has some family that can assist him some of the time. Unless he gets a huge surge of motor return on the right he won't be ready to be home alone at DC time. No one but me seems to think this is a problem.
I've been told the family will step up and help him. I've been told they'll increase his provider time. He says he'll be able to do it at home. How many times have I heard that? What I want to know is how he'll go to the BR in the middle of the night when he can't even use his urinal using one hand. The referring physician wants to wait until next week to make a decision because she believes he is going to improve. I believe he is going to improve but not enough to be home alone for any length of time. I wish his physician would share what she is thinking with me so I can plan my treatments accordingly.
All I can do is continue to work with these patients. Maybe I'll be pleasantly surprised. I'm hoping the stroke patient will figure things out for himself. That doesn't address the issue of what is the expectation with these patients. Therapy isn't a cure all. We can only do so much. It's one thing to admit patients telling them they're going to get rehab so they will hopefully go home. It's another to think two weeks of therapy is going to fix everything. I sometimes wonder if I'm looking too far down the road. I look at these patients and think big picture. Maybe I need to think small picture. I could just let things work themselves out. Even if I do that I still won't understand what we're trying to accomplish.