Confronting the Consultant

 

Mon 9th December 2013

I spent a bit of time on the internet collecting as much medical evidence for an Early Weight Bearing  protocol to confront my consultant with, this was mainly abstracts from the Bone & Joint Journal, but put together they made quite a strong argument for EWB.

On entering the consulting room I realised I was not seeing the main consultant but one of his “team”, who thought I’d been in my cast for 5 weeks?. I explained that I’d had had my cast on for only 2 weeks and was there to discuss the possibility of swapping my extreamly conservative protocol to an accelerated EWB one. He  listened to my point of view looked at the amassed evidence and said “It’s your tendon if thats how you want it treated I don’t see a problem”. He then went to check with the consultant.

“That was easy” was my first reaction…….. I should have known better. The consultant came to discuss it with me and explained that they weren’t prepaired to change my protocol because “that’s how we treat ATRs here”. On pushing him about buying my own VACOped, he stated that if that is what I wanted to do they’d cut my cast off, I could fit it myself and he’d refer me to a physio. Basically wash his hands of me, not a very proffesional approach for somebody with a “duty of care”.

So that was that, he’d given me his ultimatum and even suggested if I was going to do that to wait a full 4 weeks before cutting the cast off. I left saying I’d give it some thought.

Back to the GP.
My GP had always said I was entittled to a second opinion through the NHS, which now seems like my best option. The only issue is how to make sure I get a consultant who would be willing to give me an EWB protocol.
I tried a few different sources, a local private hospital (who do ATR reconstruction surgery), e-mailed a consultant who was involved in The Royal Devon & Exeter  EWB trial to see if they knew of someone locally, put a comment in the UK section on Achillesblog.com and contacted Oped-UK to see if they had information about who they sell the VACOped to in my area.

The advice I got back from both the blog and the R.D&E was to contact Oped, which I had already done via e-mail. Their local salesman contacted me with some extreamely useful information - apparantly if I lived 50 miles further South and walked into the James Cook Hospital in Middlesborough, I would have been put straight into a VACOped boot not even bothering with a cast! Talk about treatment lottery.

I also received another lead from a neighbour, working in the medical sector who showed me a protocol from a more local consultant who is using EWB with a medi.ROM walker. I googled this and it seems to be similar to the VACOped just made by a different manufacture, it looks a bit cheaper and less resiliant but if I can get onto an EWB protocol I don’t mind.

So I’ve phoned my GP back once more and asked to be refered to this local consultant for a second opinion.  I now await her reply as to how long my wait will be for the referal.

I can put up with this cast for a bit longer if I know I’m going onto an EWB protocol.

6 Responses to “Confronting the Consultant”

  1. Good luck Ross, and keep up the good fight! I wish you could solve the problem for the next 100 patients too, but take care of your own leg first. Even if that Consultant insists on following “Eminence-Based Medicine” at least you’ve educated aome of his team, which may bear fruit.

  2. Hi Ross

    The medi rom walker seems to work with wedges, like the very popular Aircast boots which were, I think, used in the UWO trials, with great success. The Vaco boot adjusts the ROM through its hinge mechanism, and for the early days a deep wedge sole. Either make should be ok for you.

  3. No time to check now, but most boots with “ROM” in their names are hinged. Wedges and hinges are interchangeable in the earliest stages when all rehabs have boot-hinges locked or “fixed”. Vaco and others start introducing limited hinge-ing pretty early. (I waited til 7 weeks post-non-op in my modified UWO rehab for ATR #2, which felt right to me.) The Exeter people went faster than UWO and used the hinging-ROM feature of the Vaco and got excellent results. But it isn’t clear that their non-op results were any better than UWO’s, with the fixed AirCast boot. Any reasonable boot should work well — and WAY better than any cast.

  4. Norm

    Don’t you think that the hinged action helps the transition into 2 shoes?

    With a hinged increasing range of movement surely this helps to keep some strength and at least limited but controlled mobility in the bones and ligaments/tendons of the ankle, and even, to a small degree, the calf muscles. Going from a fixed boot into 2 shoes obviously does work well and on a similar time line to the hinged boot but is it as comfortable for the patient?

    With my thankfully limited experience, I don’t know the answer personally, it just seems to make sense.

    H

  5. Hillie, I think using a hinged boot is a sensible and helpful step between a fixed boot and 2 shoes. That’s why I resuscitated my old hinged boot at week 7 of my “otherwise strictly UWO” non-op rehab for my second ATR. But my reasonably careful analysis of the Exeter results, separating out the post-op from the non-op, suggests that their results — using a slightly faster protocol than UWO and a hinged boot instead of the AirCast — are probably no better than UWO’s. (Their post-op results do seem better than UWO’s, including zero reruptures in a big sample, IIRC.)

    The first days in 2 shoes are generally slow and scary, and it’s hard to scientifically compare HOW slow and scary, between hinged and non-hinged boot people.

    Everything you say sounds reasonable, but (a) I’ve seen many reasonable-sounding statements in ATR care DISproved when they were put to the test, and (b) the mechanisms you describe would certainly help explain a proven benefit of hinged boots AFTER that benefit had been proved. But they don’t substitute for that proof.

    I’m reminded of a Mensa party I once attended many years ago, when I briefly thought I’d like to socialize with the uber-bright. Another guy and I were trying to impress the same woman. His schtick was that he said he could place a person’s accent very precisely. He and I spoke for quite a while, then he proceeded to guess where I was from, and he was wrong by thousands of miles, worse than a random dart thrown at a map. THEN he proceeded to explain HOW he got to be so impressive at placing people’s accents(!). Problem was, he had totally failed to prove first that there was anything to explain, so she and I both lost interest.

    Similarly, IF patients who use hinged boots end up stronger, or with fewer reruptures, or returning to sports sooner, etc., etc., THEN we should start speculating about HOW and WHY. When the medical establishment reversed that order, they “proved” that surgery produces better results than non-op, that non-op works better on small-gap ATRs than big-gap ATRs, and that letting an ATR heal for an extra few weeks is safer. All three of those often-explained claims have since been put to the test and found to be either false or virtually false or totally backwards, despite the impressive explanations for why and how they were true. If those claims had been TRUE, there are logical reasons available to explain how and why. But since the scientific method came along, with its preference for evidence and proof over abstract logic, we’ve LARGELY stopped reversing the order. Largely.

  6. With my background in ICT and robotics, research has been an essential element in product development.

    However, I must confess here that my blog-posting has been mostly based on what I have experienced myself (as are many posts) or on findings from Exeter, Warwick, UWO, etc. Deeper research I haven’t had the time or the inclination to investigate and report. There are others who do this much better than I would.

    Within Achillesblog we have a good mix of personal experiences, based on advanced or archaic treatments, together with lots of theoretical stuff and research data. Just what a site like this should be and long may it continue in that spirit.

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