difficult patients

Whilst on my orthopaedic placement, I encountered a difficult situation with an elderly man who was about to be discharged after a total hip replacement. Prior to discharge patients are required to safely ascend and descend a flight of stairs in the physio gym on the ward. The patient in question had been a bit difficult from the start, not really paying much attention whenever I went over the precautions and positions to avoid after a hip replacement. I would often come into the room and he would be lying in bed with his legs crossed or lying on his side, and he did not quite seem to grasp why these positions should be avoided. Teaching him how to partial weight bear was a nightmare, and I had to ask my supervisor to help me out a few times to just reinforce to him that these precautions really were important and it wasn’t just that I was a student who was being overly cautious.

The situation occurred while I was taking him through the stairs. It was his second day of trialling the stairs, and I had gone over the order of “good leg first, then the bad leg and then the crutches” for going up the stairs, and “crutches first, then the bad leg and then the good leg” for going down. He was able to repeat this with each step, so after the second trial I stopped repeating the order out loud. The man then decided to try put his good leg down first on the way down the stairs first, meaning that his bad leg was supporting him, and I immediately stopped him and tried to get him to stand up again. He was in a lot of pain understandably, but then he got angry with me because he thought I should have just let him go down as he was. My supervisor was present and came over to help. I explained to him that if he had carried on any further his bad leg would not have been able to take the weight that it was about to take, and that he probably would have fallen. My supervisor agreed and supported me, which made me feel so much better.
He was still quite angry though, and that made me really mad because he had already been so non-compliant and disinterested in listening to instructions, and I had just been waiting for something like this to happen but was kind of mad that he had the audacity to blame me. Anyway I kept my thoughts to myself and he was ok in the end.

I spoke about it with my supervisor afterwards and she was very supportive and said she would have done the same thing. That did make me feel a lot better as I was worried that my decision had been the wrong one. But what I learnt from the whole thing is that even if you think patients understand instructions and you feel that you have been repeating yourself all day, when it comes to safety it is better to just keep repeating the instructions, rather give too much than too little. So in future that is what I will do, especially with non-compliant patients. I also think that you need to tell people that failure to follow the precautions and safety instructions will lead to damage to themselves, and make it very clear from the beginning. And it also might be useful having two people around for patients like this.