64.13 Paraplegia

The arrival of a paraplegic patient is bad news in a district hospital because it means that a bed will be filled for a very long time. Can he be saved from bedsores, contractures, a small contracted bladder, and all the other miseries that are only too common? The answer most certainly is yes! There are some very simply equipped hospitals, with very dedicated workers, who can turn their patients every 2 hours, so that they do not get bedsores. So it can be done and it has been done! It is, however, so demanding that the care of paraplegia is perhaps the ultimate test of the real quality of a hospital, and of the morale and dedication of everyone in it. In paraplegia your aim must be—(1) no bedsores, (2) no contractures, (3) an uninfected bladder, with the early onset of reflex micturition in upper motor neurone lesions, and (4) the patient’s ability to support himself with a craft. Ultimately, most paraplegics die from the uraemia that follows chronic urinary infection, but they may live many years.

Figure 64.17: HOW PARAPLEGICS SHOULD NOT BE TREATED. They can be saved from bedsores, contractures, and small contracted bladders, even in simply equipped hospitals, if their staff are sufficiently dedicated and can turn their patients every 2 hours. This is, however, so demanding that it is the ultimate test of the real quality of a hospital. Kindly contributed by Peter Bewes—not one of his patients!

The consequences of not managing paraplegia properly can be even worse than the patient shown in Fig. 64-16. Thus one patient was seen who had been admitted in quadriparesis (not quadriplegia) one year earlier in fairly good shape. In hospital he developed pressure sores over his sacrum, both hips, both knees, and both ankles. The joints under all these lesions were open and suppurating. He had more sores on his back and forearms, and flexion contractures of both his hips and knees. He had a urinary infection, a small contracted bladder, an indwelling catheter, and chronic urethritis. Mercifully he soon died.

Although quadriplegics should never reach this state, their outlook is much worse than for paraplegia, and is always hopeless in the end. However devoted your care, they will almost certainly develop severe pressure sores, hypostatic pneumonia, and die. Although you may be tempted to reproach yourself, you should not try to set yourself impossible targets. Paraplegics, on the other hand, are very well worth fighting for.

The key to success is to prepare your staff psychologically. Make the first patient you care for your top priority, and that of your ward team. The most critical days are the first ones, especially the first and second weeks of admission. The whole battle may be lost by careless treatment then. Leaving a patient unturned for only four hours may start a bed sore that leads to osteomyelitis, dislocation of a hip, contractures, and a series of surgical operations lasting years. Should he get a bed sore, you may be unable to refer him because no hospital will accept him.