I was all alone on that day. Our facility holds occasional Saturday hours, so one PT along with one front office member (to handle paperwork) work on a rotating schedule. I walked into the clinic, logged in to the multiple security barriers and prepped my documentation. I had 3 back to back evaluations that day, and I was less than a month into my professional career. I wanted to stay on top of the ball and get things done. Flex my clinical efficiency muscles.
Sammy, the front office staff, called me to let me know my patient was ready. I walked up to the waiting room and called Ms. Smith (not her real name) back. She smiled and clumsily pushed up on her walker as she stood and began her way back towards my eval room.
I began this eval like I do all my evaluations, with a standard list of questions (those my company policy requires me to ask). One of which I already knew the answer to: Have you fallen in the last month?
Ms. Smith, a middle aged woman who spoke with slightly garbled speech, told me she had indeed fallen. I think she knew I knew already. What struck me as odd, and likely given the following story will never leave my mind, is her response when I asked her why she fell. She told me, after a moments pause, she wasn’t really sure. I almost skipped over this information, but I’m glad I didn’t. Something caused me to inquire further. I found more intriguing information as I dug: she fell leaving another PT clinic.
Again, this might only stick in my mind given my knowledge of what is to come in the remainder of this story, but it seemed to have struck me as odd that she was being treated at another clinic.
She stated she was attempting to walk out of the clinic entrance, and as she was beginning to push the heavy glass door open, another individual was attempting to pull it open and enter at the same time. Ms. Smith said the specifics (including that information) were fuzzy, but she was even less sure about how she actually fell. She just knew she went down after that.
I was equally perplexed at this point. People don’t just fall. Not otherwise healthy individuals. Not people who are active and young. Not even middle aged people.
What unraveled as I continued throughout Ms. Smith’s subjective and objective evaluations was nothing short of jaw dropping:
Diffuse and marked motor weakness throughout bilateral lower extremities. Inability to raise her foot into dorsiflexion on both her operated side and unaffected limb. Absent deep tendon reflexes at the ankle and knee joints.
I began to panic somewhat internally, but I didn’t want to alarm her because I wasn’t sure what to do. Fortunately, Ms. Smith was seemingly unaware. She remarked, “Yeah…they’re just weak,” as I moved her foot passively into dorsiflexion and watched it drop lifelessly as I released my grip.
I informed her that I wanted to check her upper extremity strength as I agreed with her assessment of having weak legs. I wanted to ensure her arms were strong enough to support her on the walker. I also wanted to gain permission to assess her UE for like weakness or neurological findings without rousing suspicion or worry.
She consented, and began to comment on her right hand at which I immediately noticed something I did not want to see: thenar wasting. The atrophy in her first web space had been present for some time as it looked like there was nothing but skin and fascia left. She had been talking about this weakness and stated her neurosurgeon had suspicions of it originating from her elbow. I shrugged and said this was a possibility; though, internally, I doubted it almost entirely. I proceeded to gauge Ms. Smith’s upper extremity strength and it was indeed weak. Not as bad as her legs, but still what I would later explain to her as “neurologic weakness.”
I performed a few tests and examined another thing or two, then sent Ms. Smith home. I explained to her that we had plenty to work on and would like her back in the clinic early in the week. She agreed.
I saw her that following Tuesday. Actually, she was on one of our PTA’s schedules. But I saw her nonetheless. I walked over and examined her again, explained to her that I wanted to check some things again. Everything was still there.
I proceeded to explain to Ms. Smith that her clinical presentation suggested that something more was going on. That her weakness was not due to inactivity, but likely had a neurological origin. I explained that her absent deep tendon reflexes and Hoffman’s sign also suggested this neurologic cause. She broke into tears. She expressed that she knew something had been going on. She explained that even her friends had noticed her slurred speech. She stated that she had been to so many doctors trying to tell them what she had been experiencing. None of them had listened. Not that she felt.
Ms. Smith had, in fact, been under the care of 6-7 different medical doctors prior to landing in my clinic. Two primary care physicians, one neurologist, a neurosurgeon, an orthopaedic surgeon, a hospitalist (potentially), and at least 1 PM&R specialist. And not one of them had picked up on this. None of them bothered to look at the whole picture.
I referred her to a trusted neurologist in the area, who later referred her to a specialist to confirm her diagnosis of ALS.
I am telling this story not to serve as a reminder to physical therapists of how we can perform on par with medical doctors. I am telling this story because it serves as a reminder to all healthcare providers to look at the person sitting in front of them. Yes, Ms. Smith had been seen by as many physicians as listed above, but she had also seen (by my count) an additional 3-5 physical therapists. All of whom, to my knowledge, didn’t take the time to investigate her deficits any further (just like those medical doctors). None of the 7 physicians (because it was at least 7* by the time I successfully referred her), nor any of the physical therapists involved bothered to investigate any further the cause or reason behind the whole picture of this patient, the person/human being who sat in front of me. They treated an impairment. They treated an electronic medical record.
To me this story serves as a glaring reminder of the narrow focus our healthcare system has adopted. As we are busied with documentation and insurers, we’ve lost the real reason we provide healthcare. We’ve lost the patient: the person who has to rely on us for our expertise and knowledge, yet fight us to use it to help her.
Check back in a week or so for a companion piece to this one, when we discuss the most important question you can ask yourself in the direct access era.
*She had visited the emergency department that week following my explanation of my findings to her (despite telling her it would not help). She was seen by the ED physician, who ordered a CT scan. When the scan came back unremarkable, she was told that she was being hysterical and that she would be okay.