Hospital convalescence management

Copyrigbt,

A PRACTICAL

VOL. LXX1 I

1946 by Tbc Yorke Publisbing

JOURNAL BUILT ON Fijty-fifrh Year of Continuous Publication

MERIT

NOVEMBER, 1946

HOSPITAL CONVALESCENCE

D

Co., Inc.

URING the war years, a new medica service was created in the armed forces : reconditioning. Camouflaged under this name was a new departure in medica thinking, a scientific approach to the probIems of convalescence management. In the centuries during which medicine has been practiced by speciaIized personne1, very IittIe organized attention was given to convalescence. The average physician begins to Iose interest as soon as the disease or injury he is treating is brought under contro1. For him, the inteIIectua1 probIem has been soIved. Yet, second onIy to the greater chaIIenge of prevention, is that of convaIescence management in medicine today with its concomitant of maximum rehabiIitation. ConvaIescence is the greatest portion in the IongitudinaI chronoIogica1 section of most diseases and injuries. It is this feature which confers upon convaIescence its socia1 and economic significance. It is this feature which IogicaIIy forced the armed forces into a consideration of convaIescence on a scientific and practicaI basis. Large scaIe warfare in the recent situation brought Aoods of casuaIties, concentrated in a short space of time, taxing

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even the Iarge physica and personne1 resources of this reIativeIy we11 medicaIIy In order to meet the deveIoped nation. urgent miIitary needs, attention was focussed upon the process of convaIescence in order to shorten it, thus freeing hospita1 faciIities for a more rapid turnover. Not a Iesser consideration was the mora1 obIigation of a nation to provide for the weIfare of those citizens who had sacrificed themseIves for the common good by restoring them to the best possibIe status, in the best possibIe manner. The genera1 structure and objectives of the reconditioning program have been described in detai1 eIsewhere,ls2 as we11 as in many pamphIets and directives issued by the War and Navy Departments.3 For this presentation oniy the briefest of summaries wiI1 be made. Reconditioning in the armed services consisted of guidance in persona1 affairs and readjustments, orientation of the individua1 to an understanding of the basic reasons for the worth-whileness of his sacrifices, educationa opportunities, pIanned recreation, physica training and occupationaI therapy. As in a11 Iarge scaIe endeavors with new concepts, the judgments formed varied with the bias of the observer as we11 as the

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efficiency of the organization he observed. Those of us who were fortunate enough to see we11 run, efficient services couId not faiI to be impressed with successfu1 accomplishment. Let us contrast the course of a patient in a miIitary hospita1 before and after estabIishment of efficient reconditioning services. In the first case, the patient is admitted, receives emergent treatment if indicated, and is sent to a ward. He is examined and treated by a medica officer from whom he receives Iess and Iess attention as his condition is controIIed. FinaIIy, he is aIIowed up “progressiveIy,” and uItimateIy discharged from the hospita1. WhiIe convaIescent he reads a11 the avaiIabIe magazines, visits the recreation haI1, goes to an occasiona moving picture, and interminabIy pIays cards or “shoots crap.” During the convaIescent period, which may Iast weeks or months, he is terribIy bored, discouraged; and if Ieft with a residua1 disability, he is confused, perhaps visiting the chapIain or the Red Cross socia1 worker for advice. The difference afforded by a we11 functioning reconditioning service is marked. UnIess he is acuteIy ill, immediateIy upon admission the patient receives a brochure which expIains the hospita1, the facilities and services it affords.4 Within the first few days, or as soon as his physician deems him abIe, he is interviewed by a trained counseIor who questions him specificaIIy concerning his persona1 probIems, educationa needs and interests. He is pIaced in the educationa program by enroIIment in one of its activities. AI1 activities are permitted onIy to the Iimit considered advisabIe by the physician in immediate charge of the case. However, each patient is cIassified by the physician as soon as he is abIe to participate, and instructors visit the wards for individua1 attention to bed patients. AmbuIatory patients visit cIassrooms where they receive instruction from a wide variety of academic and prevocationa1 subjects. In some hospitaIs, the range of

NOVEMBER, 1946

instructions has varied from higher mathematics to radio technoIogy, from simpIe reading and writing for iIIiterates to job-printing.4 At the same time, whiIe stiI1 a bed patient, the patient participates in periods of physica exercise for short periods during the day, which a11 receive in unison from trained physica instructors. The exercises are standardized and modified for various types of disabiIities.3 Where possibIe, the eIement of competition is introduced by the use of simpIe games. As the patient becomes ambuIatory, he graduates to more strenuous physica activities which are administered in the gymnasium and swimming poo1 or outdoors and which preferabIy incIude modified competitive sports. PhysicaI and occupationa therapy are different modaIities which approach the same ends as physica training. The separation of these freIds in reIation to patient care is more a consequence of their historical development than of Iogic. The patient receives both as requested by his physician. Therapists visit the wards to administer physica therapy treatments and to bring craft materiaIs and prescribed activities for the individua1 patient. In the Iatter instance, craft work is chosen to suit the patients’ needs for retraining of muscIes and nerves in accordance with their interests, so that motivation is provided for sustained effort at the tasks. IndustriaI therapy may be mentioned briefly as it was tried in the “Birmingham pIan” at Birmingham General HospitaI. By cooperation with one of the major aircraft producers, a branch shop of the company was set up in conjunction with the hospita1. SeIected convaIescent patients, under carefu1 supervision and speciaIIy trained foremen, actuaIIy worked on a Iimited scale in the production of aircraft parts, receiving reguIar wage scaIes for their Iabor. It had a great moraIe buiIding effect as these handicapped men were abIe to

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see a practica1 demonstration of their empIoyabiIity, indeed took home in cash the fruits of the demonstration. Though this approach has been an interesting one, it has remained in an experimenta stage. Recreation is provided systematicaIIy. Entertainment is obtained through the Red Cross and other IocaI agencies, and shows are pIayed both in the hospita1 auditorium and by smaIIer units in the wards themselves. Moving pictures aIso are brought to the wards, especiaIIy through the use of new automatic maIittIe attention, which require chines, and are moved as a unit with incorporated screen, needing onIy a sIightIy participation in dimmed light. Patient amateur entertainment is encouraged. FinaIIy, the guidance process started with the patient’s admission is continued throughout his stay. CounseIors check on his participation and answer his new questions. Testing services are offered, both for interests and abiIities. Occupationa1 counseIIing is an important part of the program. When the patient receives his fina interview and is directed to the various civiIian agencies that exist for his aid, a great dea1 has aIready been accompIished in speeding adjustments to illness or injury, and his socia1 and menta1 adaptations to a handicap, if one wiI1 remain. The use of such methods as those described in making the process of convaIescence a more eventfu1 one rests on a basis of physiologica and psychoIogica1 considerations which is continuaIIy expanding and becoming more sound. There has been a Iag in the estabIishment of conclusive scientific evidence of the vaIue of reconditioning activities because of the nature of the subject. The fieId deveIoped under the stress of war, and it was not possibIe to conduct carefuIIy controlIed studies in the press of urgent needs. Further, the matter is different, for exampIe, from the testing of a new drug. When suIfonamides or the new anti-

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biotics appeared on the scene, it was a reIativeIy simpIe matter for appIication of the scientific method. AnimaI experiments couId be performed. AIternate cases couId be treated by two methods, using subjects from a reIativeIy homogeneous popuIation. End points are cIear. Organisms disappear, temperature descends. ConcIusions can be drawn rapidly. However, in the evaIuation of reconditioning methods, considerations are more compIex. Too many other factors affect the Iength of convalescence. Objective criteria for such intangibles as personaIity adjustments are diffIcuIt to find and apply. NevertheIess, certain things became evident to workers in the fieId. WhiIe results could not be measured in terms of days or personalities saved, some facts became obvious. An amputee who was subjected to intensive physica training and education in the use of his prosthesis was abIe to perform more tasks with it than an amputee who was simply given a prosthesis and a few perfunctory instructions for its use. Likewise, the amputee who received intensive guidance and expIoration of his occupationa possibiIities was much better abIe to adapt to his nem situation in a favorabIe manner than the patient who did not receive these advantages. Pneumonia patients who received definite graduated physica training in the hospita1 were returned to fuI1 duts faster and better abIe to carry on than those who simpIy sat around the wards for a few days after an arbitrary period of compIete bed rest. RecentIy there has been a growing interest in the physioIogica1 basis for reconditioning activities.5 In 1944, a whole series of articIes appeared on the abuse of rest in various aspects of medica practise. Bed rest has been found by certain observers to have an effect upon vital metabolic processes, such as the utilization of carbohydrates .6 CircuIatory stasis associated with bed rest has been incriminated as an etioIogica1 factor in thrombophlebitis and phIebothrombosis, with the subsequent

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dangers of embohzation. CaIcium excretion increases and rest&s in osteoporosis with increased incidence of urinary calcuIi during proIonged bed rest. EarIy ambuIation folIowing major operative procedures is becoming increasingIy popuIar.’ Now cIinica1 observations are being made breaking away from orthodox thinking about the significance of rest. Of interest is a recent articIe from an AAF hospita1 suggesting that compIete bed rest may not favorabIy influence the course of rheumatic fever, if judgment is based upon the patient’s subjective compIaints rather than upon the usua1 criteria.8 Under the stimuIus of the Baruch Committee on PhysicaI Medicine, a new body of basic study is arising concerning the metaboIism of resting subjects. For exampIe, what is the effect of rest on tonus of the muscuIar and circuIatory systems? There is no doubt that periphera1 circuIatory tonus is aItered and becomes more unstabIe during proIonged bed rest. After a period of bed rest, which need not be overIy proIonged, resumption of erect posture and Iimited activity is associated with asthenia, easy fatigabiIity, sweats and fIushes, near-syncopes, which manifest unstabIe periphera1 circuIatory conditions. Effects on rest on cardiac output over Iong periods are Iess we11 known than the acute changes. AppIication of reconditioning principIes to voIuntary hospitaIs has been suggested onIy recentIy. Lessons have been drawn from miIitary experience in reconditioning9 as we11 as from more theoretica considerations.lO In the former instance, Gwynn recommends extensive administrative changes, with estabIishment of a reconditioning service on the same professiona IeveI as the surgica1 and medica services. He aIso recommends faciiities based, Iike the administrative suggestions, upon his miIitary experience. Such a program wouId be effective and compIete and, in a Iarge civiIian hospita1 with suitabIe patient popuIation, wouId certainIy make an ex-

NOVEMBER, 1946

ceIIent basis for an effective program. However, it is suitabIe for operation onIy on a Iarge scaIe, and a hospita1 of more than 1,000 beds wouId be required to permit economica operation of many features. SmaII hospitaIs cannot hope to afford space or money for gymnasium and swimming ~001. In miIitary hospitaIs, pre-vocationa shops often incIuded printing, radio, jeweIry, woodwork, mechanic and weIding shops, photographic Iaboratories, cIassrooms and business machines. For men in rura1 areas, gardens and scientific farming experiments were conducted. An approach of this type is not practica1 for smaI1 hospitaIs or for many Iarge ones under present circumstances. Furthermore, the nature of the patient popuIations varies considerabIy in civiIian hospitaIs from that found in miIitary institutions. SpeciaI probIems are introduced by the wide age spread from infancy to oId age and by the varying ratio of acute cases. NevertheIess, the need for a scientific and humanistic approach to convaIescence management exists, and new methods must be devised for appIication of reconditioning methods to civiIian medicine. It is onIy a reIativeIy short time since the concept of preventive medicine became prominent, but the profession now recognizes its deep and important responsibiIities in this regard. The physician has a mora1 responsibiIity to his patients, not onIy during acute iIIness but at a11 times. He is responsibIe before iIIness or injury for hygiene and prophyIaxis. He is responsibIe Iikewise during the period of recovery for convaIescence to be managed effIcientIy and to the patient’s best advantage. When the patient Iies in bed desperateIy fretting at his idIeness, reading comic magazines or “true story ” magazines, wondering at the comments passed by the staff on rounds in his presence, the responsibiIity of the profession for that patient’s weIfare is not being discharged. We a11 know that this situation occurs

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a11 too often in the hospitals of the present time. The reason for this situation is not obscure. New therapeutic measures permit much more effective definitive treatment of disease and injury. Attention has been focussed on peniciIIin, streptomycin, thoracic surgery and other dramatic measures. Specialization has proceeded to a point where the average physician too often sees the patient as one organ system with an appended soma and psyche. The Baruch Committee on Physical Medicine has taken the lead in developing the ideas of reconditioning and rehabiIitation for appIication to civiIian situations. In a recent report, l1 the Subcommittee on CiviIian RehabiIitation Centers, under the chairmanship of Dr. Howard A. Rusk, formerly Chief of the Army Air Forces convaIescent rehabiiitation program, defined the needs for rehabiIitat~on activities on a community IeveI, and presented a carefuIIy thought out pfan for the estabIishment of mode1 centers. However, the concept shouId be extended from the emphasis on community rehabiIitation of handicapped individuaIs to the appIication of scientific convaIescence management principIes to the voIuntary hospitaIs. It is possibIe for a hospits of 250 to 500 beds to introduce many of the more essentia1 features of pIanned convaIescence for its patients without incurring unreasonable costs in terms of space, personne1 or money. Starting at the beginning, it wouId be a simpIe matter for hospitaIs to issue routineIy to patients upon admission a smaI1 but attractive brochure describing the hospita1 routines and the opportunities and faciIities afforded the patient. Guidance functions could be considerably improved by enlarging the paid socia1 service staff, bringing the worker into cIoser contact with the patient. Workers shouId be assigned specific wards, and visit their wards at specified times, Iearning to know the patients’

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probiems and taking the initiative in suppIying needed counsel. In most hospitals, recreation is on a very rudimentary IeveI. An auditorium is usefu1, and most hospitaIs have them, but much can be done right on the wards. Few hospitaIs at present make the maximum use of community agencies which can provide entertainment. LocaI entertainment employers as well as IocaI unions have often proved very profitable sources for cooperation with miIitary entertainment programs and shouId be expIored for civiIian voIuntary hospitaIs as weI1, The new compact units previousIy described make possible a scheduIe of ward moving pictures with minimum effort. In hospitaIs for chronic diseases, more use couId be made of excursions to points of interest for ambuIatory patients. Educational institutions in the vicinity of hospitals usualiy are willing and gIad to arrange educationa opportunities for patients at the hospitaIs. Often instructors are wiIIing to give Iectures or to conduct practica1 cIasses. FuII utiIization of community resources is rareIy found at present. It couId be achieved through existing agencies with smaI1 effort by better Iiason mechanisms. On the basis of Army experience, two occupationa therapists couId account for a basic program in a hospita1 of 500 beds. Scheduied ward visits with carts equipped to carry tooIs and materiaIs could afford facilities for many prescription cases as we11 as constructive diversion for many others. A smaI1 room for storage and preparation, and another for treatment of prescription cases wouId make possibIe the initiation of a program which in most hospitals would constitute a reaI advance, Many hospitaIs are already equipped with pubfic address systems channeIed to each ward, and often to each bed. Often these are used mereiy for page systems, or to “pipe in” standard radio broadcasts. Yet these channeIs offer a wonderfu1 opportunity for educational

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programs and moraIe buiIding activities. Besides the obvious music education, there are possibihties for Ianguage instruction, for taIks on science, art, readings of poetry, taIks on current events and other educationa features which can serve to interest the patient in recovery and Iife. One physica training instructor couId care for approximately six to eight Iarge wards daiIy, bringing the bed and ambulatory patients a pIanned and adapted program of exercise such as been previously suggested. A smaII room couId be adapted for use in prescribed corrective exercises. These suggestions are intended onIy as an indication of the possibilities for appIication of the new approach to convaIescence. The chance for using individua1 initiative and ingenuity in developing inexpensive opportunities for the patient is endIess. These suggestions have been directed at the small hospita1, but the concepts aIso bear appIication to the practise of medicine in the offIce and the home. The basic need is for the recognition by physicians that we are a Iong way from the discharge of our responsibiIities when we Iose interest at the moment the appendix comes out or the fever breaks. The physician must be concerned with the speed and eficiency with which his home-ridden patients are returned to usefu1 socia1 occupations. Hospitals can do nothing, even with the best of faciIities, unIess the physicians understand the reason for convaIescence management and support its use. Basic research must be done, and new concepts and technic wiI1 emerge. The beginning must be made by education of the medica profession to one simpIe fact: Your job isn’t done until your patient’s on the job.

NOVEMBER, 1946 SUiMMARY

I. A brief description is presented of the reconditioning activities deveIoped in the armed forces. 2. Indication is made of the rationaIe for such program. 3. PossibiIities are described for appIying the principIes of convaIescence management to civiLan hospitaIs. 4. The physician is described as having a permanent responsibiIity to his patients, before iIIness and injury for prevention, and after iIIness and injury for effLzient ConvaIescence and rehabiIitation. REFERENCES I. RUSK, HOWARD A. ConvaIescent care and rehabilitation in Army Air Forces: new chatlenge to postwar medicine. M. Clin. Norlb America, 29: 715, 1945. 2. LOWMAN, EDWARDW. PIanned convalescence. U. S. Nav. M. Bull., 43: 61 I, 1944. 2. War Deoartment. Technicat ManuaIs: TM 8-200 a(Edu&ionaI Reconditioning), TM 8-291 (O&Ipationa1 Therapy), TM 8-292 (PhysicaI Reconditioning), TM 21-205 (Special Services Officer). 4. You’re In. Published at Bushnell Genera1 Hospital, Brigham City, Utah. What’s In It For Me? PubIished at O’ReiIIy General HospitaI, Springfield, MO. 2. LIPPMAN, RICHARD W. Medical impIications of convaIescence. Arch. Pbys. Med., (to be pubIished). 6. BLOTNER, H. Effects of prolonged physica inactivity on tolerance of sugar. Arch. Int. Med., 75: 39, 1945. 7. NELSON, H. EarIy ambuIation foIIowing abdomina1 section. Arch. Surg., 49: I, 1944. 8. ROBERTSON, SCHMIDT and FEIRING. The therapeutic vaIue of earIy physical activity in rheumatic fever. Am. J. M. SC., 2 I I : 67, 1946. 9. GWYNN, HENRY B. Reconditioning in civiIian hospitaIs. M. Ann. Disrrict of Columbia, 14: 12, 1945. IO. KEYS, ANCEL. Deconditioning and reconditioning in convalescence. S. Clin. Nortb America, 25: 442, 1945.

I I. AnnuaI Report of the Baruch Committee on Physica1 Medicine for the FiscaI Year ApriI I, 1944, to March 31, 1945. RICHARD

W.

LIPPMAN,

M.D.