I am currently on a Paeds placement treating inpatients with a variety of diagnoses. I am currently treating a 6 year old below knee amputee. This patient suffered from a traumatic open tib fib fracture just proximal to the ankle joint just over one month ago. The road to recovery has not been smooth, since her original operation she has undergone five washouts and debridement of necrotic tissue around the wound. The patient has been experiencing high levels of pain and in early days was needing to go to theatre and be anaesthetised for dressing changes. Throughout the patients time in hospital, there has been regular out episodes of severe distress which involves the patient being extremely non compliant with uncontrollable screaming and crying for upwards of 15minutes. This can occur upwards of twice daily and has caused great concern amongst all staff involved in the treatment of this patient. Originally it was thought that these episodes were pain triggered or phantom pain or limb hypersensitivity related and were managed with drug therapy to increase patient compliance with dressing changes and stump bandaging. This view has since changed as a large behavioural element has developed. Psyc med and social work are heavily involved in the treatment of this patient and their family.
This patient has since progressed and is now approaching discharge. Physiotherapy treatment has progressed from strength and conditioning bed exercises to ambulating the patient in the gym. I have been given the task of treating this patient twice daily for hour long sessions in the physiotherapy gym. During these sessions a concerted effort is made to disguise all formal movement tasks as games and maximise pt compliance. Screaming episodes were occurring after about the 30minute mark during every treatment. Due to the gym environment being a common area, the sessions had to terminate. This had a detrimental effect and endorsed this bad behaviour thinking that the pt can get out of anything just by screaming and complaining of stump pain.
It has been interesting to see the management of this child by all staff. Legally when a patient complains of pain, medical staff are obliged to provide drug therapy for pain relief. Although in this situation, how valid are the 6 year old's pain complaints and when do you ignore them and get on with the session? This is a very fine line.
Management of this patients behavioural issues has included giving choices, they pt is provided with two alternate games for example and is given the choice. This gives the pt a sense of control. It also gives the therapist ammunition that if an episode were to occur, the pt has made the choice and therefore has less ground to stand on should they complain. A reward system has been implemented, the pt is rewarded if they perform all exercises scream free. Four weeks of building trust with this pt and we are finally getting somewhere!
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I also had a paeds placement and found the same thing. When young children screamed or cried during treatment, I found it very hard to keep going and ignore the cries of the child. In our placement we were expected to go on with our session, mainly because not doing the treatment would be worse in the long run. We also did a reward system and ended up using cooking lessons as a way to gain the cooperation of the child. I think its great that you have been able to build trust with the child!!
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