Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses the need to assess beyond the physical properties of a scar. Scars can have deep meaning to our patients, and learning the human story behind the scar can help with better understanding a patient. Whether the scar was planned or not, the story behind the scar has value.
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EPISODE TRANSCRIPTION
INTRODUCTION
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LINDSEY HUGHEY
Good morning, PT on Ice Daily Show. How's it going? My name is Dr. Lindsey Hughey. I am extremity faculty, and I'm delighted to be with you here the day after Christmas. For those that are on YouTube Live, unfortunately, that is not working. So I'm just gonna have to send it via Instagram. Today, I'm gonna chat with you all about how scars, and I promised a month ago that I'd be chatting about actual scar management.
THE HUMAN SIDE OF SCAR MANAGEMENT
But what I didn't tell you last time was that we're gonna focus on the more human side of scar management for our post-op folks. So after surgery, no matter what extremity is involved, whether it's shoulder, maybe it's elbow, maybe it's hip, knee, ankle, maybe it's even back surgery, right, there is a scar that comes along with it. And as physical therapists, we tend to focus on the more physical part of managing that scar. And so what I mean by that is we focus mechanically, right? How's it moving? What's its pliability like? What's the elasticity surrounding that tissue, right? Is it moving well with the fascia? Are there any adhesions? Our scar tissue buildup. We are looking at the pain response of the patient, right? To show if there are any signs of infection. Think red, hot, tenderness, or spreading redness, right? We're looking for the management and guiding education accordingly. In addition, we're looking for any excessive swelling, right? Is the scar raised? Is it flat? And then we're really focusing our efforts on educating, mediating, against infection and then how to keep that scar moving. We aren't often focused on what that scar might represent from the patient. And what I mean by that is some intangible and unquantifiable measures like their emotional and their mental and their social response to having that scar. I wanna share two personal anecdotal experiences with scars that I've had myself to try to illuminate that part that's more unquantifiable, right? That emotional, social, mental piece in our scar management. So I have three kiddos, 13, 12, and seven. Some of you that know me already know this. And they were all born via C-section. C-section was not what I wanted. I had this whole natural birth plan written out, and it didn't really go according to plan. For that first one, it was emergent, and the second one was planned, and then third one was also planned, but there were some complications with actually having Luke, where he needed to be rushed off to the NICU, actually, because of some breathing issues. And I'll tell you, in general, the scar, I focus a lot on its appearance, right? That it's ugly. For those C-section mamas you know, there's like often this like shelf or invagination where that scar is and so tissue hangs over it. And besides it not being kind of the birth plan that I wanted, that appearance part of the scar really bothered me. So it represented kind of two things. Something that I didn't really want to have or how I wanted my birth experience to go and then also just the appearance like that there's this lingering scar that has now like affected my body makeup and how I'm presented to the world and The reason I share that is I don't think we think about that with our patients, right the connotation with the scar. We're again always thinking about physicality. How's it moving and is there any signs of infection and giving them tools to manage that.
THE STORY OF THE SCAR IS IMPORTANT
Well, when I realized the story is important, I want to share one particular moment that I had with my scar and the management of it. And it actually happened with my third c-section. So About a year after having Luke, I started having like spasms in my rectus when I would laugh and or when I was doing gymnastics work. So not only was the appearance kind of bothering me, it was starting to become painful because I would get these spasms that would double me over into trunk flexion. And so it made me talk with a colleague at the time I was working at Baylor and Dr. Jen Stone actually is a pelvic floor therapist and she offered to take a look at it and literally we're like in between teaching classes um on a break and she's like yeah lay down and i'll assess it and she starts assessing um the scar mobility and i was not a good pt patient and i hadn't done much scar work and so she starts you know telling me it's hypertonic and not moving well and more on that left side and she's just palpating and then she just offhandedly says what was your birth um experience like and I'm starting to tell her the story and I just start weeping. And it was so unexpected because I started telling her, basically, I'm on this OR table, in this Vitruvian man position, you can't get up. And I look over and Luke, you can see his red flashing lights. and his pulse ox was low. And the nurses were kind of telling me like, Oh, he's fine. And kind of pretending like he's fine, but really he couldn't breathe. He was having transient tachypnea, which is come to find out normal after C-section in many babies, because they don't get that birth canal squeeze. So fluid sits around their lungs, but I had never experienced that with the other two C-sections. And so like emergently he's wheeled away from me and I'm still like open on the OR table and so I start telling her this and like I'm crying as I'm telling her this and I get to kind of the end of the story how I never got to hold him like you know that first hour of nurturing time I didn't get and I didn't actually hold him for like 12 hours and we're like when I'm waiting post-operatively to see what's going on they don't really they didn't tell us much so I'm like in limbo thinking like is he gonna die but again Turns out to just be the transient tachypnea, not a really big deal. And I'm recounting this whole story to her how it was like tough. I didn't get to hold him. I didn't get the skin to skin time. And, you know, we're literally were afraid he was going to die. You know, he only needed two to three days in the NICU, it turned out, and he was all good. But in that moment, I realized like Jen gave me permission to tell my story and really unpack it because I'm kind of like a power through type of human, got through that last C-section and went back to CrossFit and thought I was fine and dandy. And it was in that moment where she just, you know, was palpating the scar and took the time to like understand the story behind it. And so it makes me pause and Consider maybe all of the folks that I kind of bypassed thinking like total knee replacement, total hip replacement, and what those scars might have meant. Or someone after trauma think ACL or getting that triad where they have this surgery where it takes them out of their season, right? It's out of their control. Those are two different kind of scenarios, right? I didn't want the C-section, right, in any of the cases. but the C-section kind of chose me. In that case of like a total knee replacement or a total hip replacement, something where we get gradual worsening pain and function and we have to elect to have the surgery.
SCARS TELL A STORY OF RELINQUISHING CONTROL
I have another personal story to share where even when you elect, so like those three sections not really in my control, There are surgeries we have to choose sometimes because of pain worsening function and or failure of our tissues. And so the second scenario, I want us to appreciate too, because both involve a little bit of relinquishing control, which is tough for our patients. So my second scenario is also another personal story. Having had the three C-sections, right? And we fast forward seven years to the present, I, in this last year, started experiencing a supra-intra-abdominal hernia. So I noticed this mass above my belly button to the left. So because it's asymmetrical, it wasn't like the Linnea Alba issues. It literally, or Diastasis Recti, it literally is a hernia because of that asymmetry. throughout the year kind of started getting bigger. And I consulted with some pelvic floor PTs, and they're like, that's not necessarily pelvic floor, right? Start working on your intra-abdominal pressure to help. But you should get that checked out, because the mass on your stomach is kind of concerning. And come to find out, I put it off for quite some time, at least six months, and I go to this intra-abdominal specialist, and he does, in fact, confirm that it is a supra-abdominal hernia, and that there's subcutaneous fat, and that, right, if you ignore it long enough, this can turn into an issue where there's strangulation, which then can become like an emergent issue if you become sepsis, if it were to triangulate and cut off blood flow or like your intestines, right? The reason I share this story with you is the second part is this was a surgery that I had to opt for, kind of like when someone has to choose that total knee replacement or total hip replacement. I was starting to have some pain associated with eating big meals, and then some exercise-induced nausea with high intensity. It was only intermittent, right? Sometimes, so for at least a year-ish, I had been putting it off. I've since had the surgery, right? December 13th, I had it. And now I'm in this new zone. You can't actually even see the scar, right? Because it's under steri-strips. But what I want you to think about and what has me pausing and thinking from my own personal experiences, this scar, although a little bit out of my control, right? It's abdominal wall failure due to intra-abdominal pressure issues, due to that history of C-sections. It's not really something I wanted to do. I don't want the downtime of not lifting heavy things with my friends. I don't wanna build my gymnastics from the beginning. I don't want this break of time where I'm not lifting heavy and I'm not working intensely, right? It's this forced slowdown. But in a lot of ways, like I chose this, right? I chose to schedule this surgery due to some failure in the tissue and some worsening pain and weakness. The scar, once it heals, it'll represent a pause in my story. But it also represents an opportunity, if I'll reframe it that way, right? An opportunity to work on my intra-abdominal pressure from the start, now that I don't have a 1.5 by one centimeter hole in my fascia, right? And now there's no longer subcutaneous perineal tissue sticking out.
SCARS REPRESENT A SLOW DOWN
Our patients, no matter their surgery, whether they had you know, a history of various surgeries like I had and have had to have subsequent surgeries like I just needed to have because of those, they are coming to you and they are in a time where there is some uncertainty on board, where they have to slow down in their story, right? Which affects them mentally, socially, emotionally and spiritually, like when they're not involved in the activities that like bring them joy in their life. And They have to give up some things for a time and that can be really hard. And so scars, let's approach them. Let's take the opportunity to not only obviously address that physicality piece, right? and safety about infection, and make sure the scar is moving well, but take the opportunity to understand the story behind maybe why they chose that surgery, or were advised to have that surgery, or maybe why it was emergently, right? If there's some trauma associated around having to have the surgery, that can be tough, and they've maybe never been asked to share that story, and maybe they'll have that kind of emotional release unexpectedly when you ask them that question. What I want you to reflect on is, have you even thought of the human in front of you and the story behind the incision and what that might mean to the patient? Can you take the time to give them permission to tell that story? And it may unlock some sadness and fear and angst. But if you don't invite that opportunity, then you miss the opportunity to help them reframe that experience for the better. you miss the opportunity to deliver control to their story right where they're the heroine of that story. So two real action items today is learn the story behind their scar and their incision from the beginning and then of course create a complimentary rehab program that makes their extremities, their spine, robust and that makes that scar just be in a badge of honor, right? And just a reminder of a moment to get after resilience in their story. A lot of times in our extremity management course, we can't dive into postoperative care. We speak a ton about upper quarter and lower quarter extremity resilience and how you can get after that with your patients. We have so many offerings to dive into that in January. And so if you'd love to learn more about extremity care and resilience, we would love to have you at one of our upcoming courses. We are literally stacked in January, January 13th, 14th. We are not only in Richmond, Virginia, but we are also in Greta, Louisiana, and we are also in Fayetteville, North Carolina. So all of our extremity faculty will be out on the road teaching that weekend. be there at one of those locations. In addition, January 27th, excuse me, I already said that, January 13th and 14th, we also have opportunity. I kind of flipped that actually. Check us out on btoknights.com. The 13th, 14th is when we're in Virginia and Louisiana, and then the 27th is when we have three opportunities. Forgive me for that. Fayetteville, North Carolina, Athens, Georgia, and then Burlington, New Jersey. And then literally most months of 2024, we are somewhere in a city near you. I thank you for taking the time to listen to my story today. And I hope again, that you will consider the patient's story behind their scar. Have a great day, everyone.
OUTRO
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