As trauma and acute care surgeons we fix broken people with the aim of shipping them back out the hospital door as soon as possible. Pressures on hospital beds and the increase in the general pace of life mean that the good old days of spending 2 weeks being pampered in a hospital bed as you recuperate at a leisurely pace after a straightforward appendectomy or similar procedure are long gone. In an otherwise young and fit individual, as many of our patients are, and allowing for immediate post-op complications and difficult social circumstances, there is seldom a need to keep people in hospital beyond 48 hours. But how often do we stop to consider what life is like back in the real world as we send them off with instructions to complete a course of oral antibiotics, take simple analgesia and to pitch up in a follow-up clinic an arbitrary number of weeks down the line?
Well, in my case, never. Not until my wife’s appendix ruptured on my birthday. Following laparoscopic surgery, she was discharged the following day with antibiotics, analgesia and a follow-up appointment a few weeks down the line. For once I was seeing things from the other side. The dependence on analgesia once that local anaesthetic has worn off, the profound lack of energy, the weight loss and the frustration at the slow speed of recovery all became very clear to me. For a healthy, independent and successful professional (she’s a lawyer), the complete loss of control is somewhat disconcerting. It probably didn’t help being married to a surgeon who largely downplayed the seriousness of having a “straightforward procedure” to remove her appendix, or hearing me nonchalantly discussing how many I’d done on any given day, like it was nothing more than removing a sebaceous cyst under local anaesthetic.
In my own case I’ve just had an ACL reconstruction in one of my knees and was discharged the same day. Little did I appreciate that the uncomfortable paraesthesia involving my entire leg caused by the pneumatic tourniquet would take 48 hours to wear off. I’m sure I’ve warned patients about it when consenting for similar procedures in the past, but having first-hand experience is an entirely different kettle of fish. Thankfully my skills and knowledge have allowed me to manage my post-op wound infections through self-prescribing of antibiotics and self-evacuation of pus (excruciatingly painful) saving myself a few needless trips back to the ED. In both our cases there has been the short-term knock-on effect on our careers and also re-jigging of childcare arrangements. It’s hard to jump into the car and pick up the kids from school went you can’t get out of bed or bend your knees.
My wife and I are still (thankfully) young, fit and anatomically whole. What about the polytrauma patient who lives alone and required an emergency above-knee amputation? Or the patient with the severe spinal cord injury? Rehabilitation service provision will undoubtedly depend on individual insurance cover. Even within nationalised health systems a ‘postcode lottery’ exists which some people will be able to overcome by paying for private rehab, whereas the majority won’t. There remains a need for greater integration of telemedicine and mobile services to help level the geographical barriers to receiving effective after-care. Whilst there are an abundance of good physical therapy app on the market, these are mostly directed at elective orthopaedic patients and fail to address the psychological and emotional needs of patients who sustain major trauma. Welcome innovations such as those developed by the AfterTrauma rehab team at the Royal London Hospital are filling a gaping hole in the market.
And what about the gang member at risk of recidivism once they’re fixed and put back out onto the streets (literally). Black males, alcoholics and those who sustain penetrating trauma have higher long-term mortality risks having survived their initial trauma admission. Inpatient programs which aim to catch young gang members in that “teachable moment” in the ED when their peers are often nowhere to be seen have been shown to have some limited effect. Ultimately a wider public health approach [HN4] to violence reduction is crucial.
Considering the realities of life for patients after discharge rarely occupies the collective conscience of acute trauma physicians. And not surprisingly so, after all there are teams of physios and occupational therapist roaming the hospitals under whose remit that falls. But it can be an enlightening and humbling experience to witness the realities first hand, an experience which can only improve us as doctors.
Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.
