Editorial

Activities of daily living: Ah, that fall!

Copyright © 2010 Society of Hospital Medicine

Tears well up in my eyes. Not from pain, but frustration.

I pleaded with my 3‐year‐olds to come to me, so I could help them wash and dress for the day. Ordinarily, I would have come into their room, leaned over their beds, and whispered good morning into their ears.

Four days after surgery, I wasn't able to do that. Not without the crutches. Even with the crutches, I was moving slowly. I scooted up, put a few pillows behind my back, and carefully lifted up my leg. Putting on the knee immobilizer would take too long; I would only be crossing the hall.

Weighing less than 800 g, the immobilizer is an adjustable aluminum frame attached to foam rubber and 4 wide Velcro straps. It is a device of torment. I can never seem to find the proper fit. If it is too tight, my leg hurts and starts turning blue. When it is too loose, it pulls on my incision, multiplying the pain. You put it on while sitting, but you only discover whether it is too tight or too loose when you stand up.

With one foot on the floor at the edge of the bed, I took one crutch in hand, shifted to the left, and grabbed for the other crutch. I squeezed the handgrips of the crutches tightly and pulled myself up.

Put your weight on your hands, NOT your armpits, the instructions said. Easier said than done, because my armpits were now sore too.

Keep your crutches even with each other. I tried to remember to make an equilateral triangle with my good foot and 2 crutches, but the instructions only seemed to account for movement in a straight line.

Keep your elbows slightly bent and close to your sides to help keep the crutches under your arm. I am trying that too.

Lock your elbows. This instruction contradicts the previous one. Which should I follow?

Place your crutches 2 to 3 inches outside of each foot. How do I do this and keep my elbows close to my sides?

Swing your injured leg through first. But not too much, or I'll pole vault across the room.

After 3 steps, my leg started to throb, and my quadriceps went into a spasm. I needed to sit down, immediately.

Non‐weight‐bearing for next 4 weeks, was written on the doctor's note. Four weeks feels like an eternity. If my heel or toe even touched the ground, I felt an immediate throb of pain in my knee.

How do my orthopedic patients do it: those with broken hips and bad or broken knees, with hip replacements, or knee replacements? I was sensitive to their pain and could optimize control. Postoperatively, I could support gastrointestinal and other organ systems. I made sure that the basic weight‐bearing order was correct. I carefully followed the physical and/or occupational therapy recommendation for home, rehabilitation, or a nursing home. I spoke with families. Yet I did not dwell on activities of daily living nor how my patients felt to be dependent on others for simple things they needed. Some patients were non‐weight‐bearing for weeks, some for months, others never walked again. How can one deeply understand it if one has never experienced it?

According to Centers for Disease Control and Prevention (CDC) statistics,1 unintentional injuries are the leading cause of death between the ages of 1 and 44 years. Accidents are again the leading cause of death after age 75 years. More startling is the fact that these numbers have not been significantly reduced since these data were first collected. Nor do these numbers reveal the number of those debilitated, but still living. In my case, I was not playing basketball, water skiing, or rock climbing: I slipped and fell while stepping into a wading pool with my children, severing ligaments, tearing meniscus, and creating a hairline fracture of my tibia.

Expect to move slowly with the crutches. Yes, I am moving very slowly, only 1 to 2 feet with each stride. If I take a longer stride, I lose my balance.

Learn to sit down with the crutches. Learn to stand up. Learn to get into a car.

Learn to go up the stairs. Learn to go down the stairs.

Avoid wet surfaces. Otherwise you'll start skating and reinjure that knee.

It was effortless to think of patients and colleagues of mine. Mr. S., how do you do it? At age 30 years, he was quadriplegic from falling from a tree as a teenager. Mr. D, how about you, in a wheelchair, after being hit by a car and multiple postoperative leg infections and amputations: living in hotels, with estranged family and no social support. How did you do it, while we nagged you about controlling your glucose. Dr. J? The sadness fills my heart. At only 60 years old, my wonderful professor now made rounds in an electric wheelchair, the victim of amyotrophic lateral sclerosis (ALS). My fate, in comparison, is fortunate; my immobility only temporary. I can still think. And talk. And use a phone. And eat, as well as write this essay. And, best of all, read stories to my children. Be careful about this leg, I remind them. Don't come too close!

Maybe what life is trying to tell you is, slow down. In fact, it's forcing you to do that, a colleague and friend said. I had prided myself in thorough and compassionate doctoring. Now, having been a patient on crutches, I have a greater understanding of how limits to mobility can impact daily living on my patients after I discharge them. And the mundane subject of accident prevention has gained a new urgency.

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