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Toni Talks about PT Today

Two Versions of the Same Patient

Published August 9, 2011 8:51 AM by Toni Patt

It isn't often that the doctors I work with and I disagree about the disposition of a patient. Normally we're in agreement about what the patient is able to do. The debate is over where the patient will discharge to. I now have a patient who appears to present one way to the physicians and another when I work with him. The docs swear he is alert, oriented and moving all extremities against gravity. I can't get the man to open his eyes.

This is bizarre. Usually patients present fairly consistently across the board. I've tried going at different times. I can increase his arousal and facilitate purposeful movement on the uninvolved side with noxious stimuli. I can't wake him up. The docs tell me he's always awake and moving when they see him. The nurses who I've spoken with agree with me. They say the man stays lethargic and doesn't really follow commands.

I have no idea why this is happening. I go with an open mind. I'm just not seeing what the docs are telling me they observe. Maybe they're looking at him through hopeful eyes. They want him to improve and so give him the benefit of the doubt. Whereas I look at what I see each time and base my recommendations on that because it is what an accepting facility will look at.

The man has numerous medical and social issues. He is obese, has no insurance and multiple co-morbidities. He lives in an RV and has no one to care for him after discharge. If he doesn't perk up, his future is pretty grim. I don't want him, or anyone else, to end up in a nursing home but I don't make that decision. I document what I observe so others can decide

I am probably somewhat biased. My unit is the only rehab that would accept him without insurance. We get more than our share of the obese, uninsured, low-functioning admissions. At best, they're borderline candidates but get accepted because it's their only chance. Usually the only ones who get therapy are the people transferring those patients. Since there is a chance he could be assigned to me, I am biased. I like to think that bias is the voice of experience in those situations.

He's going to be in the NICU for a while. There is plenty of time for his condition to improve. It's not unheard of for people to wake up from severe lethargy. Maybe some of his underlying medical issues will resolve so he can put more effort into therapy. Either way, I'll keep doing the best I can for him.


Maybe you could stand in the doorway and observe the interaction when the docs go in and see this patient.  That should give you the answer to whether the docs are viewing through rose colored glasses, the patient is presenting differently to them, or they are reporting on a different patient altogether!

Janey Goude August 10, 2011 5:38 PM

Is the doctor male? Are all the nurses female? Unfortunately I have encountered a couple of male patients who respond completely differently for a male therapist.

Aubrey August 10, 2011 2:22 PM

I wonder if the docs are looking at the correct patient? Not kidding, are they talking about someone in the bed next door thinking that they're talking about your patient? It happens.

Dean Metz August 9, 2011 12:06 PM

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