Not all medical professionals perform quite as required – therefore you should know your rehabilitation landmarks. In the first part of this series, Heinrich Grimsehl explains some basic treatment protocols
At the beginning of an article like this the disclaimers are important. You will soon see why. Everything in this article is my opinion and does not constitute definite treatment protocols. It is based on personal experience and may greatly differ from other treatment protocols. It also does not indicate that another practitioner is at fault.
In South Africa, we have to face reality. Corruption and terms like “state capture” creep into all walks of life and into all professions. When you read about the large portion of state hospital money used to settle medical malpractice claims and hear the many malpractice defence advertisements of lawyers over the radio, it becomes clear that it’s quite possible that you could run into a practitioner who doesn’t perform at the expected level.
Against this backdrop, I would like to run you through a basic amputation rehabilitation treatment protocol so that you can identify certain landmarks while recovering.
First, it’s not fair to expect a patient to choose a treating practitioner and sign for the financial commitments while still in hospital recovering from trauma, the effects of the anaesthesia and, possibly, secondary injuries or complications.
Only after instructions by the treating doctor should any form of treatment continue. The doctor who operated is the only person who knows what’s happening inside the amputated limb at that point.
The next phase is usually coning. The residual limb must be coned into a conical shape to get rid of the swelling, a common occurrence after the operation, and to fit a prosthesis. To better understand this process, take the example of a wine bottle cork.
It simply can’t be pushed back into the bottle if the shape is not correct. Similarly, the amputated limb needs to be shaped first.
Sometimes a doctor fits a coning bandage in theatre, but usually they only give instruction to cone after the wound has mostly healed and the stitches are removed. Light coning with the stitches still in place might also be prescribed, as it improves blood circulation, but this has to be done very carefully.
Stump preparation (coning) takes a few weeks. Stump atrophy (shrinking) is an ongoing process. The longer it takes before the prosthesis is fitted, the longer the prosthesis will fit comfortably. These days some sort of silicone liner (like a very large condom) usually serves as an interface between the skin and the prosthesis itself.
The liner keeps the limb suspended and cushions the impact of the prosthesis on the stump or amputated limb. However, to continue with a silicone liner if you still have stitches, scabs or wounds on the skin is risky. As South Africa typically has hot weather, you are likely to sweat inside the stump liner. Because sweat softens scabs and tissue (think how your fingers look if you spend too much time in the bath), the liner could cause infection or cause the stitches to pull out.
We will continue our rehabilitation protocol in the next issue and will also be looking at cost and components.
Heinrich Grimsehl is a prosthetist in private practice and a member of the South African Orthotic and Prosthetic Association (SAOPA). email: firstname.lastname@example.org