Research by Andrew K Fletcher
THE DANGERS OF GOING TO BED BY R. A. J. ASHER, M.D., M.R.C.P. 1942
- Andrew K Fletcher
It is always assumed that the first thing in any illness is to put the patient to bed. Hospital accommodation is always numbered in beds. Illness is measured by the length of time in bed. Doctors are assessed by their bedside manner. Bed is not ordered like a pill or a purge, but is assumed as the basis for all treatment. Yet we should think twice before ordering our patients to bed and realize that beneath the comfort of the blanket there lurks a host of formidable dangers.
In "Hymns Ancient and Modern," No. 23, Verse 3, we find: "Teach me to live that I may dread The grave as little as my bed."
It is my intention to justify placing beds and graves in the same category and to increase the amount of dread with which beds are usually regarded. I shall describe some of the major hazards of the bed. There is hardly any part of the body which is immune from its dangers. Respiratory System. The maintenance of one position allows the collection of bronchial secretions, which, stagnating in the bases, encourage the development of hypostatic pneumonia.
Further, the absence of exercise and the diminished respiratory excursion consequent on bed rest prevent the re-expansion of collapsed or diseased lung. Blood Vessels.-Thrornbosis and thrombo-embolism are some of the most disabling and lethal catastrophes that bed rest can bring to a patient. The absence of leg movements means that the venous blood lacks the helpful squeeze from the muscles which normally speeds its flow, and the flexion of the thighs (particularly when there is Fowler's position or a knee pillow) obstructs it the more.
One theory of phlebothrombosis is that it starts with endothelial damage caused by the weight of the leg on the bed compressing emptied calf veins. Thus it may well be said that thrombophlebitis is the internal counterpart of the bed-sore. We may one day regard a thrombosis to be as much a sign of nursing mismanagement as we do the ordinary bed-sore to-day.
It is significant that Hunter, Sneedon, and others, performing post-mortem examinations of the veins of the calf in middle-aged and elderly people who had been in bed a considerable time, found thrombosis of the calf veins in 530, of the cases.
Skin.-The frequency and dangers of bed-sores are too well known to need much comment. A large bed-sore in a heavy patient, especially an incontinent one, is a nightmare to the nursing staff, and the pressure points on the heels are often a source of great pain and misery to the patient even if the skin is still unbroken.
Muscles and Joints.-The contraction of some muscles and the stretching of others are complications of rest which may cause considerable crippling. Foot-drop is of course the commonest, and stiffness and flexion of the knee-joints probably the next.
The weakness and wasting of the general skeletal musculature and the restriction of the excursion of the, joints are often manifest in the hobbling, painful gait of the convalescent patient.
Bones.-When bones are not used the calcium drains from them, and this disuse osteoporosis can be a serious matter, especially in the elderly. Fractures for that reason may take longer to heal, and the absence of weight-bearing is another reason for delayed union. This is shown by George Perkins's recently published cases where the broken ends of bone, when splinted by a metal plate, did not heal until the plate accidentally broke and the resulting increase in weight-bearing led to rapid bony union. The advantages of the Smith-Petersen pin over older methods of managing intra-capsular fractures of the femur are largely due to the shorter time in bed.
Renal Tract.-The drain of calcium from the bones that I have just mentioned causes an increased liability to urinary calculi, and both kidney and bladder stones are sometimes in part due to bed rest. Far commoner than this is retention of urine. A patient, particularly a male, with a perfectly normal urinary tract can find difficulty in using a bottle-probably because of the horizontal position of the body coupled with the nervousness and embarrassment felt on attempting this unnatural, uncomfortable, and unfamiliar method of micturition. (the discharge of urine) In older people this difficulty may lead to acute retention with overflow or to simple incontinence.
Bed-sores may develop and keep the patient to bed, so initiating a vicious circle of bedridden incontinence. Prolonged incontinence leads to a deterioration of hygienic morale, and a patient may continue to be incontinent from sanitary sloth rather than urological disease. Getting a patient out of bed may turn him from an incontinent person to a clean one. Alimentary Tract.-This too is not immune from the bad effects of rest in bed. After a few days minor dyspepsias and heartburn may be noticed; the appetite is often lost.
Constipation occurs almost invariably, and even if not of grave significance is often a grievous worry to the patient. Its causes are, first, the absence of muscular movement; secondly, the change of environment (no one can say why this causes constipation, but it does); and, thirdly and most important, the difficulties of evacuating the bowel in a hospital bed-pan. On a bed-pan the patient is unable to use his abdominal muscles and his nearness to fellow-patients discomforts him. Precariously engaged in balancing himself, he sits there, poised unhappily above his own excrement in great dissatisfaction and distress.
The constipation of bed rest is most harmful in the aged, where retained scybala may lead to a diarrhoea which marks the underlying obstruction. Retention with overflow is nearly as common at the back as in front. Quite often complete intestinal obstruction can develop from retained faeces, and when enemata fail to shift the scybala digital removal has to be practised-a procedure as unpleasant for the evacuator as for the evacuee.
Nervous System.-It is well known that, particularly in the ataxic diseases such as disseminated sclerosis or tabes dorsalis, even a short spell in bed may produce a deterioration of 'mobility which takes weeks to overcome, and any length of time in bed may leave a patient bedridden many years before the natural course of the disease would have made him so.
Mental Changes.-Lastly, consider the mental changes, the demoralizing effects of staying in bed. At the start it may produce fussiness, pettiness, and irritability. The patient may acquire an exaggerated idea of the seriousness of his illness and think, " Surely I must be very ill if I am kept in bed ? " At a later stage a dismal lethargy overcomes the victim.
He loses the desire to get up and even resents any efforts to extract him from his supine stupor. The end result can be a comatose, vegetable existence in which, like a useless but carefully tended plant, the patient lies permanently in tranquil torpidity.
Even the insomnia and nocturnal restlessness so common in hospital patients may be related to the abuse of rest. Too much sleep during the day means too little sleep at night. You may notice that many patients who disturb the ward at night are flat on their backs snoring during the day. They lie in bed with nothing much to do, and we cannot blame them for taking frequent cat naps. I am sure that many hours of half-sleeping and dozing are less beneficial than a few hours of deep sleep, and I believe they encourage a certain confusion of mind.
So much for the commoner hazards of the bed. There are many I have omitted. I have not mentioned the loss of education in children who are long in bed, nor spoken of the dangerous dust that arises during bed-making, but even those evils I have outlined may help to show that rest in bed is anatomically, physiologically, and psychologically unsound.
Look at a patient lying long in bed.
What a pathetic picture he makes!
The blood clotting in his veins,
the lime draining from his bones,
the scybala stacking up in his colon,
the flesh rotting from his seat,
the urine leaking from his distended bladder,
and the spirit evaporating from his soul.
I have painted a gloomy and unfair picture: it is not as bad as all that. There is much comfort and healing in the bed, and rest is essential in the management of many illnesses. My object has been to disclose the evils of overdose, and I want now to indicate briefly how some of them may be avoided or overcome.
DEC. 13, 1947 DANGERS OF GOING TO BED 967 968 DEC. 13, 1947 DANGERS OF GOING TO BED MEDICAL JOURNAL
First, bed rest should be prescribed and not assumed-that is to say, a sister should not confine the patient to bed without the doctor's ordering it. Secondly, doctors should revise their attitude to rest where it is unsound. In a chronic ward of which I once had charge I found a lady who had been in bed for 17 years with a diagnosis of nervous debility and whitlow. She had survived this remarkable hibernation with little damage, and though she was very upset when I ordered her up she became a different person when she was fully ambulant.
It may well be, too, that our attitude to rest in more acute cases could be modified. Rheumatic-fever cases are often kept flat on their backs for a considerable time, although there is no evidence that this modifies the incidence of heart complications and there is good evidence that the work of the heart is increased by the supine position.
Patients with coronary thrombosis traditionally have six weeks in bed, but the evidence that this diminishes the incidence of complications is slender. Indeed, Sir James Mackenzie, who had frequent angina after cardiac infarction in 1908, never spent more than a few days in bed, but continued playing golf till his exercise tolerance at last became too small. He lived an active and useful life for 17 years after his first attack.
John Powers, of Cooperstown, New York, reported on 100 consecutive patients who were allowed to sit in a chair and walk on the first day after major operations. He compared them with an equal number who remained in bed for 10 to 15 days and found fewer complications in the first group.
Further, the early ambulant cases were back at work within 4.8 weeks as compared with 8.7 weeks in the control group. All these facts encourage us to review the traditional amounts of bed rest that we order our patients.
The third way of avoiding the dangers of bed lies in altering the equipment and arrangement of a ward. There should be a day-room attached to every ward and lockers for patients to keep their ordinary clothes in. Too often a sister puts all her patients back to bed as a housewife puts all her plates back in the plate-rack-to make a generally tidy appearance. Too often patients stay in bed because, shuffling round in slippers and dressing-gown, they are cold and uncomfortable. They would welcome a warm day-room with chairs and books.
Some heart cases ought to be allowed to spend most of the day in arm-chairs and to sleep the night in them if they feel much more comfortable that way. For those that have to be in bed a commode might be allowed as an alternative to a bed-pan in most cases. More liberal attention should be paid to breathing exercises, limb-moving, and occupational therapy both to prevent complications and to distract the patient from going to sleep out of sheer boredom.
"Teach us to live that we may dread Unnecessary time in bed.
Get people up and we may save Our patients from an early grave." Source: British Medical Journal https://www.bmj.com/content/2/4536/967
Who is Doctor Richard Asher? https://en.wikipedia.org/wiki/Richard_Asher#Notable_articles