64.19 Mobilizing and rehabilitating the paraplegic

If you don’t interest yourself in what happens to a paraplegic after discharge, he is only too likely to die and waste all the care and attention he may have received while in hospital. This is especially likely to happen in the rural areas. So visit the patient’s home, and try to make sure that he has a suitable bed and toilet. Often, money will be the major factor. If a patient was injured at work, the workmen’s compensation fund may be able to support him.

Start to mobilize a patient when his fracture is reasonably stable and it is clear that his paralysis will be permanent. Stand him up regularly when his arms are strong enough to hold crutches. Use gutter plaster splints or walking calipers to support his knees and ankles.

Figure 64.20: REHABILITATING A PARAPLEGIC is critically important. Failure to rehabilitate paraplegics is one of the things that kills them after discharge. Kindly contributed by Peter Bewes.

Involve his whole family in rehabilitating him. He is going to need a wheel chair, and perhaps calipers and crutches to take home. Start thinking early about how to finance these. The first week of his illness is not too early for this. Early on during his stay in hospital, encourage him to develop extraordinary strength in the unparalysed parts of his body. Let him pull himself up with a Balkan beam, or give him weights to lift with his arms, so that they are strong enough to support him when he uses crutches or a wheel chair. Calipers may help him to keep his knees straight and his feet in neutral. Teach him some skill with his hands, such as making articles for sale, by basket making, weaving, or leather work. Encourage him to find markets for the things he is able to make, so that he can later earn his own living.

Aim for a date of discharge 4 or 5 months after his admission. Some caring member of the hospital staff should visit his home with a relative, to see if it is suitable for a paraplegic to live in. Is the floor flat, so that it can take a wheel chair? Are there any steps that cannot be managed with crutches? Sometimes, parallel bars can be put up outside his house so that he can exercise himself, as he did in the hospital. If his home is not like this, and many homes are not, his outlook is grim. He may have to live in a sheltered home and be found work in a sheltered workshop. Such workshops have been set up in many parts of the world, and it is a very uncaring community that cannot make some provision for its own handicapped.

Success in rehabilitating paraplegia is one of the best indicators of high quality care. Where it fails, a district hospital accumulates 3 or 4 paraplegics, and a provincial one perhaps 12, each with an average stay of perhaps 10 years, with all that this means for unnecessary expense, and for the other patients who might have been treated in their beds.

FURTHER CARE FOR PARAPLEGIA

WHEEL CHAIRS Start a patient in a wheel chair slowly, 2 hours once a day to begin with, then 2 hours twice a day. Teach him to lift up his buttocks a few times every 15 minutes. Sit him on two foam rubber cushions, or sit him on the blown up inner tube of the kind of motor cycle that has small wheels and big tyres. Cover this with a foam pad.

Give him a washable rubber bag for the time his bladder works unexpectedly.

If he develops skin sores or a urinary infection, he must return to the hospital rapidly.

AMPUTATION If a patient has grossly infected lower legs, there may be a case for amputating both of them above his knees. He can then move and be moved more easily, and some possible sites of bed sores will have gone, but he will have difficulty sitting. If you decide to amputate, don’t remove both legs on the same occasion.