14 P H Y S I O T H E R A P Y JUNE 1978 PHYSIOTHERAPY IN THE MANAGEMENT OF INJURIES TO THE CHEST* S. H . M . B L A C K W O O D , M .C .S .P . D ip . T p . D ie ro l van d ie fis io te r a p e u t in d ie h a n te r in g van 'n o n sta b iele ( ‘‘fla il" ) lo ra k s, h o e tr o m p s n e lh e id s w o n d e en veral in d ie in te n sie w e s o r g e e n h e id w o rd b e s k r y f. H a a r b e k w a a m h e id in d ie h a n te r in g van ’n n o o d to e sta n d , die v o o r k o m in g en b e h a n d e lin g v an k o m p lik a s ie s , en fin a le reha b ilita sie van d ie p a s ie n t is v an in n erste belang. T h e p u r p o s e h e re is to o u tlin e th e p la c e o f p h y s io ­ th e ra p y in th e p r e -o p e r a tiv e p r e p a r a tio n a n d p o s t­ o p e r a tiv e o r p o s t- t r a u m a t ic c a re o f in ju rie s a n d h ig h v e lo c ity w o u n d s o f th e lung. I n th e c o n te x t o f in te n s iv e c a re th e p h y s io th e r a p is t is p a r t o f a te a m w h ic h in c lu d e s d o c to rs a n d n u rse s. H e r a c tiv itie s m u s t b e d o v e -ta ile d to s u it th e re q u ir e m e n ts o f te a m w o r k w h ic h h a s as its a im th e e ffe c tiv e m a n a g e ­ m e n t o f s e rio u s ly ill p a tie n ts . T h e p h y s io th e r a p is t w h o tre a ts su c h p a tie n ts m u s t b e a w a r e o f th e sig n ific a n ce o f m o n ito rs , in tra v e n o u s th e r a p y , in te rc o s ta l d ra in a g e a n d v e n tila to rs a n d m o d if y h e r a p p r o a c h to th e p a tie n t so as n o t to d is tu r b th e s e im p e d im e n ta . S h e s h o u ld be a b le to p re c ise ly r e g is te r th e b a se lin e s o f m o n ito r e d p a r a m e te r s a t th e c o m m e n c e m e n t o f tre a tm e n t a n d re c o g n is e a n d r e c o rd c h a n g e s in th e s e in d u c e d b y h e r a c tiv itie s . N e a r ly a ll th e d u tie s o f a n u r s e in th e in ­ te n s iv e c a re a r e a a r e s h a re d b y th e p h y s io th e ra p is t. I f th e p h y s io th e r a p is t, b y h e r a c tiv itie s , in d u c e s a n e m e rg e n c y it is. s h e w h o is r e q u ir e d to re v e rs e th e s ta te o f a c u te d is e q u ilib r iu m . A d is lo d g e d tr a c h e o s to m y tu b e , a n e le c tr o c a r d io g r a p h e le c tro d e d e ta c h e d , a n i n tr a ­ v e n o u s d r ip d islo d g e d , a r e s p ir a t o r th a t f a ils d u r in g a b r i e f p e rio d o f d e ta c h m e n t f o r th e p u r p o s e o f b ro n c h ia l to ile t in re la tio n to p h y s io th e r a p y a r e a ll e x a m p le s o f m in o r b u t re a l e m e rg e n c ie s , w i th o u t d a n g e r to th e p a tie n t if p r o p e r ly re ctifie d by a n e x p e rt a n d w h ic h it m a y w ell b e th e fu n c tio n o f th e p h y s io th e r a p is t to re c tify . T h e p rim e p u rp o s e o f p h y s io th e r a p y is th e r e s to r a ­ tio n o f e v e ry n o r m a l fu n c tio n a n d ra n g e o f m o v e m e n t. H o w e v e r, e v en m in o r a d d itio n a l d e m a n d s o n th e p a tie n t’s c a p a c ity f o r e x e r tio n m a y tip th e b a la n c e b e tw e e n re s p ir a to r y a n d c a r d ia c e q u ilib r iu m a n d f a ilu r e . T h e p h y s io th e r a p is t th e r e f o r e m u s t b e a b le to re c o g n is e th e c lin ic a l fe a tu re s o f f a ilu r e o f th e p a tie n t to b e a b le to c o p e w ith a n in c re a s e in d e m a n d . M a jo r d y s fu n c tio n s su c h as c a r d ia c a r r e s t m a y o c c u r c o in c id e n ta lly d u rin g , o r b e in d u c e d by, p r o p e rly g ra d e d p h y s io th e r a p y so t h a t it b e c o m e s th e d u ty o f th e p h y s io th e r a p is t to i n itia te tr e a tm e n t w h ile d o c to rs a n d n u rs e s a r e s u m m o n e d . T h e a le r t a n d in f o r m e d p h y s io th e r a p is t w ith t r a in e d h a n d s a n d f a m ilia r w ith th e u s e o f a s te th o s c o p e s h o u ld b e th e first to re c o g n is e a n d n e a rly a lw a y s , by a p p r o p r ia te a c tio n , b e a b le to a b o r t b r o n c h ia l o b s tr u c tio n fro m m u c u s o r o th e r f o r e ig n m a te ria l, th e r e b y a v o id in g th e n e e d f o r th e r a p e u tic b ro n c h o s c o p y , w h ic h in so m e cases m a y e n d a n g e r life . P u lm o n a r y e m b o lis m is u s u a lly a n e v e n t o f la te r c o n ­ v a le sc en c e , a n d is r a re in th e e a rly p o s t- o p e r a tiv e p e rio d , b u t n o n e th e le s s is n o t u n c o m m o n ly p r e c ip ita te d b y a n in c re a s e in a c tiv ity u n d e r th e c o n tr o l o f th e p h y s io ­ th e r a p is t, w h o m u s t b e a w a r e o f th e p o s s ib ility , re c o g ­ n ise th e p e r ip h e r a l m a n if e s ta tio n s o f v e n o u s o b s tr u c tio n t A p a p e r d e liv e re d a t a T r a u m a C o n g re ss f o r P h y s io ­ th e ra p is ts h e ld in D u r b a n , M a y 1977. a n d c lin ic a l fe a tu r e s o f m in o r o r a c u te m a s siv e pul­ m o n a ry e m b o lis m a n d ta k e th e n e c e ssa ry im m ediate a c tio n . N e ith e r is a n in d ic a tio n fo r th e p h y sio th era p ist to a b a n d o n th e p a tie n t. N o th in g d e m a n d e d o f a nurse in a n e m e rg e n c y is o u t o f th e p ro v in c e o f a physio­ th e ra p is t. T h e a p p r o a c h o f th e p h y s io th e r a p is t to th e patient in p h y s ic a l p a in a n d m e n ta l sh o c k , w h o finds himself su d d e n ly in s tra n g e s u rro u n d in g s , is o f u tm o s t im por­ tan c e. T h e r e is n o p la c e f o r th e in efficient, u n in fo rm e d p h y s io th e r a p is t. W h a te v e r th e in ju ry , tre a tm e n t must b e c a r r ie d o u t w ith c o n fid e n ce , firm ness a n d kindness. F L A IL C H E ST T h e p a tie n t w ith g ro ss d e g re e s o f fla il c h est is usually m a n a g e d by i n te r m itte n t p o s itiv e p re s s u re ven tilatio n . A u g m e n te d in fla tio n e ith e r by in te r r u p t io n o f the v e n tila to r o r b y u se o f th e A m b u Bag c a n sim ulate sig h in g a n d c o u g h in g , a n d if th e p h y s io th e r a p is t adds fine v ib r a tio n s , w it h o u t p re s s u re , to e ac h q u a d r a n t of th e c h e s t in tu r n , th e p ro x im a l flow o f se c re tio n s is a ssiste d . P r o v id e d th e re a r e n o a b d o m in a l injuries, f o rc e d e x p ir a tio n is f a c ilita te d b y g e n tle p re s s u re on th e a b d o m in a l w a ll, w h ic h e le v a te s th e d o m e s o f the d ia p h ra g m . P re c is e ly tim e d s u c tio n b y a n assistant c o m p le te s th e p u rp o s e o f th e e x erc ise, [n c o n sid era tio n o f th e p a tie n t ’s c o m fo rt, th e d r ip s h o u ld b e knocked f r o m th e tip o f th e s u c tio n c a th e te r b e fo re insertion. T h e p a ti e n t is tu r n e d f r o m o n e h a lf la te ra l p o s itio n to th e o th e r a t le a st e v e ry tw o h o u rs a n d p h y s io th e ra p y is tim e d to c o in c id e w ith c h an g e s in th e p o s itio n . Pleural d r a in s a n d o th e r in ju rie s m a y m o d ify access and m o b ility . T h e p h y s io th e r a p is t p lay s a n im p o r ta n t role in w e a n in g th e p a tie n t f r o m th e v e n tila to r . T h e patient is m a d e c o n s c io u s ly a w a re o f th e r h y th m o f th e re­ s p ir a tio n b y m a n u a l p re s s u re o n th e c h est by the p h y s io th e r a p is t, w ith v o c a l e n c o u ra g e m e n t to b re a th e in a n d o u t rh y th m ic a lly , w h ic h is s tim u la te d d u r in g in­ c re a sin g p e rio d s o f d e ta c h m e n t f r o m th e v e n tila to r. The s p o n ta n e o u s rh y th m o f n o rm a l r e s p ir a t io n is seemingl'H f o r g o tte n a n d p a tie n ts n e e d c o n s ta n t e n c o u ra g e m e n t r e le a r n th is . I t is th e f u n c tio n o f th e p h y s io th e r a p is t to te a c h th e m , a n d u ltim a te ly b r e a k t h e ir d e p e n d e n c e on th e v e n tila to r. H IG H V E L O C IT Y W O U N D T h e m a n a g e m e n t o f th e h ig h v e lo c ity w o u n d is con- . c e n tra te d in itia lly o n th e c o m p lic a tio n s as th e y arise, f o r e x a m p le , p n e u m o th o r a x a n d h a e m o p n e u m o th o ra x , th e n o n p r e -o p e r a tiv e p r e p a r a ti o n a n d fin a lly post­ o p e r a tiv e c a re . I t is o f u tm o s t im p o r ta n c e a n d v ita l to th e p a ti e n t ’s g e n e ra l w e ll-b e in g th a t th e lu n g s should f u n c tio n as e fficiently as p o ssib le . T h e p a tie n t is trained in r e s p i r a to r y e x e rc is e s a n d to c o u g h e ffectively. I t is n e c e s s a ry to t r a i n th e a v e ra g e p a tie n t to in c re a s e costal v e n tila tio n as w ell as th e ra n g e o f d ia p h r a g m a tic ven­ tila tio n a n d to c o - o rd in a te th ese. In th is tra in in g the h e m i th o ra c e s a re h a lv e d tra n s v e rs e ly , a n d to encourage m o v e m e n t o f th e b a sa l h a lf o f e a c h h e m ith o ra x the p h y s io th e r a p is t p la c e s h e r h a n d s , f o r e a n d a ft, o v e r the lo w e r rib s o f o n e s id e a n d th e p a tie n t c o n sc io u s ly and a c tiv e ly e x p a n d s th a t q u a d r a n t b y d e e p in s p ira tio n . In o r d e r to e n c o u ra g e d e e p e r i n s p ir a tio n a n d th e move- R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNIE 1978 F I S I O T E R A P I E 15 ment o f m u c u s , p r e s s u r e w i t h v i b r a t i o n s a n d s h a k i n g is applied b y t h e p h y s i o t h e r a p i s t t o p r o l o n g e x h a l a t i o n . If per for med i n s i d e l y i n g , e x c u r s i o n o f t h e h e m i t h o r a x . not b e i n g se l e c t i ve l y e x e r c i s e d , is l i m i t e d . E x p a n s i o n o f each q u a d r a n t is s i mi l a r l y a n d i n d e p e n d e n t l y e n c o u r a g e d , especially in t h e p o s t e r i o r b a s a l a n d a p i c o - l o w e r s e g ­ ments w h i c h in t h e r e c u m b e n t p a t i e n t a r e s u b j e c t e d to constant p r e s s u r e a g a i n s t t he p i l l o w s a n d in w h i c h , because of d i m i n i s h e d m o v e m e n t a n d r e t a i n e d s e c r e t i o n s , infection c o m m o n l y c o m m e n c e s . T r a i n i n g in c o u g h i n g is a l s o a n e c e s s a r y p a r t o f both t r e a t m e n t a n d p r e - o p e r a t i v e p r e p a r a t i o n . C o u g h i n g is a s t r e n u o u s a n d p a i n f u l e x e r t i o n b u t n e c e s s a r y in order t o c l e a r b r o n c h i o f m u c u s a n d p e r h a p s b l o o d . The t e c h n i q u e o f c o u g h i n g c a n b e i m p r o v e d a n d t r i c k move me nt s t a u g h t w h i c h d i m i n i s h ef f or t a n d s t r a i n o n t h e i n c i s i o n . D u r i n g t h e p e r i o d o f o b s e r v a t i o n u n t i l t h e f i nal e x t e n t o f t h e d a m a g e is k n o w n t h e r e is a m p l e t i m e f o r b o t h to b e a c c o m p l i s h e d ef f i ci ent l y T h e p r o p u l s i o n o f b r o n c h i a l m u c u s t o a l evel a t w h i c h it c a n b e e x ­ p e c t o r a t e d is o f t e n di f f i cul t , a n d u n l e s s t h e r e is a b a c t e r i o l o g i c a l r e a s o n f o r a s p e c i m e n t o b e m a d e a v a i l ­ a b l e . it is o f n o c o n s e q u e n c e if m u c u s is s w a l l o w e d . P h y s i o t h e r a p y in p o s t - o p e r a t i v e c a r e wi l l d e p e n d o n t he o p e r a t i v e p r o c e d u r e u n d e r t a k e n . In c o n c l u s i o n , t h e s e t e c h n i q u e s c a n b e a d a p t e d f o r a n y t h o r a c i c s u r g i c a l p r o c e d u r e a n d t h e a i m s o f p h y s i o ­ t h e r a p y in t h e t r e a t m e n t o f a n y i n j u r y t o t h e c he s t i n c l u d e t h e m a i n t e n a n c e o f c l e a r a i r w a y s a n d m a x i m u m l u n g f u n c t i o n , t h e p r e v e n t i o n a n d t r e a t m e n t o f c o m p l i ­ c a t i o n s . a n d t h e final r e h a b i l i t a t i o n o f t h e p a t i e n t to n o r m a l life. SERVAMUS 1928 — 81 YEARS — 1978 G r o o t c S c h u u r H o s p i t a l w a s p r i v i l e g e d to be n e f i t f r o m s u c h a h i g h l s m o t i v a t e d c o l l e a g u e . H i s w o r k is o f a h i g h d e g r e e o f e x c c l l c n c e a n d he p e r f o r m s il w i t h a c c u r a c y , ski l l a n d k n o w l e d g e o f a v e r y h i g h o r d e r . H e h a s m a d e h i m s e l f p r o f i c i e n t w i t h all e l e c t r i c a l m o d a l i t i e s . A n i n c r e d i b l e i n s i g h t i n t o m a c h i n e o u t p u t s a n d i n c o n s i s t e n c i e s ; p o o r p e r f o r m a n c e he d i s ­ c e r n s f a r m o r e r a p i d l s t h a n hi s s i g h t e d c o l l e a g u e s . A l o v i n g , h u m a n e a p p r o a c h , a n a p p r e c i a t i v e s p i r i t a n d t ot a l d e d i c a t i o n a r e t h e h a l l m a r k s o f ( hi s d e a r c o l l e a g u e . W e . w h o h a v e b e e n p r i v i l e g e d to w o r k w i t h A l a n , h a v e c o m e to l o v e a n d a p p r e c i a t e t h e s e fine q u a l i t i e s . U n d e r t h e s u r f a c e b u b b l e s a fi ne s e n s e o f h u m o u r . W h e n I a s k e d h i s p e r m i s s i o n t o w r i t e t hi s, lie s a i d " I s it to b e n u o b i t u a r s ' . ’” W h i l s t I p a y g l a d t r i b u t e to A l a n it w o u l d b e u n ­ f a i r if Mr s . H a m i l t o n w e r e n o t e q u a l l s a p p r e c i a t e d . H e r r o l e o f s u p p o r t a n d s e l f l es s e n c o u r a g e m e n t h a s e n a b l e d h i m t o l i ve f u l l y : (a) p r o f e s s i o n a l ! ) : ( b) in t he f a m i l y ; a n d (c) a c t i v e l y in t h e c o m m u n i t s . M r s . M i r i a m B a k e r . T r a i n e d at M i d d l e s e x Ho s p i t a l 1936. I n 1948 s h e j o i n e d t h e st aff at G r o o t e S c h u u r H o s p i t a l w h e r e s h e h a s w o r k e d u p t o t h e p r e s e n t d a l e — a t o t a l o f 30 y e a r s c o n t i n u o u s se r vi c e ! In h e r r o l e a s a p r o f e s s i o n a l p h y s i o t h e r a p i s t , f u l l ­ t i m e . s h e a l s o r e a r e d t w o d a u g h t e r s u n a i d e d . T o k n o w h e r p e r s o n a l i s o v e r t h e s e a r s is to s e e a p h y s i o t h e r a p i s t w i t h h i g h p r i n c i p l e s a n d s t a n d a r d s of t r e a t m e n t . H e r d e d i c a t i o n a n d d e f i n i t e i n t e r e s t in s t u d e n t s u p e r v i s i o n a n d q u a l i t s c l i n i c a l t r a i n i n g d i d n o t a l w a y s m e e t w i t h a p p r o v a l . T h e u n f l a g g i n g e f f o r t s o f M i r i a m l i a s e g i s e n us t he ef f i ci ent M o w b r a y M a t e r n i t y H o m e p r e - a n d p o s t ­ n a t a l p h y s i o t h e r a p y s e r v i c e s . T h e s a m e c a n b e s a i d o f h e r w o r k w i t h n o n - E u r o p e a n s a l P e n i n s u l a M a t e r n i t s H o m e . It r e q u i r e d u n s t i n t i n g s e r v i c e a n d p e r s e v e r a n c e . In h e r t r e a t m e n t s s h e m a d e e v c r s ef f or t to r e m a i n i n f o r m e d a n d a t t e n d e d a n d e n j o s e c l s o e i e t s m e e t i n g s to t h e full. M i r i a m ' s h i g h s t a n d a r d s o f e t h i c s a n d b e h a v i o u r not o n l s to c o l l e a g u e s b u t t o t h e p a t i e n t s w h o m s h e l o v e d a n d c a r e d f o r h a v e e a r n e d h e r m u c h r e s pe c t . N o tsvo f r u i t s a r e t h e s a m e , t h u s e a c h o f ms c o l ­ l e a g u e s h a s b r o u g h t t h e i r o w n r a r e " g e s t a l t " s vhi c h is n o t e a s v t o r e p e a t o r r e p r o d u c e . E B R O O K S C a m e o t r i b u t e s t o t w o s a l u a b l e c l i n i c a l p h y s i o ­ t herapi st s w h o p r o f e s s i o n a l ! ) n o t o n l s set e x t r e m e l s high s t a n d a r d s o f p h s s i o t h c r a p s b u t h a v e l eft b e h i n d a legacs f r o m w h i c h t he p h y s i o t h e r a p i s t o f 1978 is still benefiting. A l a n H a m i h t m . A g e d 74 y e a r s , t r a i n e d at N a t i o n a l I ns t i t ut e f o r t h e Bl i n d . G r e a t P o r t l a n d S t r e e t . L o n d o n . Al an is al G r o o t e S c h u u r H o s p i t a l w o r k i n g h i s 51st year o f c o n t i n u o u s s e r vi ce! ! F i r s t l y , h e s t a r t e d at t h e Nes v S o m e r s e t H o s p i t a l . G r e e n P o i n t . C a p e T o w n in 1928 as a b l i n d p h y s i o ­ t he r a pi st . T h c i c h e c o n t i n u e d w o r k i n g u n t i l 191,'i svhen R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )