A wide variety of devices can be improvised to assist patients' mobility or to help them perform their daily activities.
The cane is the easiest mobility device to improvise. Patients often do not use their cane because it is the wrong size for them or they are not told how to use it correctly.
To use a cane, patients should hold it in the hand opposite to their injury or weakness. In addition, they need sufficient upper-extremity strength to bear 20% to 25% of their body weight on the cane. (If they use it in the wrong hand, they need to support > 50% of their weight.)
To determine the correct size of cane, measure the cane against the patient while he is standing. Turn the cane upside down and rest it on the ground next to the standing patient. Cut the bottom of the cane at the level of the patient's flexor wrist crease. Then, apply a rubber tip to the end of the cane.
Canes are easier to fashion than are crutches. You can make canes from a tree limb or small tree that has a small sturdy branch that extends at a right angle. It should be light enough so that the patient can easily use the cane. Remove any bark, extra branches, or leaves and smooth down the surface. Canes and walking sticks are used for balance rather than to support an injured limb.2 A cane with an arm brace can be fashioned by attaching a piece of polyvinyl chloride (PVC) pipe to the tree limb (Fig. 36-2).
Makeshift cane with polyvinyl chloride (PVC) arm brace.
Crutches must be used when the patient's leg, ankle, or foot injury requires that he bear no, or only minimal (that is, toe-touching), weight on them. Crutches can be used individually or in pairs. Not everyone needs two crutches. When crutches are in short supply, give only one crutch to those patients for whom one will suffice. This allows another patient to use the extra crutch.
To fit crutches correctly, align the axillary pad three fingerbreadths below the axilla. When crutches are in use, the patient's elbows should be slightly bent.
To make crutches, start with one sturdy tree branch (or a matched pair of branches if two crutches are needed). Use the "Y" formed by the branches (Fig. 36-3A). When choosing a branch, remember that the crutch has to support his weight, but should be light enough so the patient can use it. You can also use a straight green sapling (2.5 cm diameter if hardwood, 3 cm diameter if soft wood). Split a sapling halfway down its length (Fig. 36-3B), then insert a crosspiece (2.5- to 3.5-cm-diameter dowel or similar piece of wood) as a handhold for the patient about a third of the way down; firmly secure the crosspiece to the two sides using screws or cement. Tape the area where the split ends to prevent the sapling from continuing to split on its own. To finish the crutch, secure a padded crosspiece at the top and put a piece of rubber at the bottom.2 Hang a basket from one of the crosspieces, so the patient can carry items (e.g., phone, keys) that they need to access quickly.
Making a crutch: begin with either a "Y" tree limb (A) or by cutting a straight pole (B). Add padding to the top (C), then wrap the padding and add a rubber piece to the bottom (D).
Although there are kits to transform plastic lawn chairs into wheelchairs,3 the materials for makeshift wheelchairs most often need to be scrounged locally. Alternatives include removing the legs from an easy chair and fastening the chair to the frame of a baby carriage (Fig. 36-4, left), fastening the upper half of a chair to a child's wagon (Fig. 36-4, right), and fastening a pair of roller skates onto a rocking chair's runners.4
Multiple conversions of chairs to wheelchairs.4
A simple alternative is to use a child's wagon to transport small children or small adults. However, using a wagon as a wheelchair for long periods is not recommended because (a) there is no support for the patient's back, although one can easily be fashioned; (b) patients must keep their legs extended rather than dependent; and (c) this method of transport is difficult for patients to use on their own.
Another way to make a wheelchair is to use a chair as the base, and attach bicycle wheels (especially those from mountain bikes) and an axle to the back legs. Simply fitting the wheels onto the back legs of most chairs will not work; you must use the axle as well. Smaller wheels that swivel, such as from a grocery cart, can be fitted to the bottom of the chair's front legs—metal chairs work best because they are stronger. Fashion a handle out of metal or wood to fit onto the back of the chair to assist in moving the patient.
A common problem for patients is not being able to hold a zipper pull to zip it closed. (Or, the pull has fallen out and you need a substitute.) To remedy this, you can slide a jumbo paper clip, a large safety pin, a string, a twist tie, or a ribbon through the hole at the end of the existing zipper pull or on the slider to make it easier to grip.
Many patients need a bedside commode to avoid climbing stairs or going out to the latrine. Remove the seat from a metal kitchen-type chair, cut a hole in the seat of a wooden chair, or use a toilet seat with legs attached. Place a bucket underneath.5 (See Figs. 5-7, 5-8, and 5-9 in Chapter 5, Basic Equipment.)
Patients in spica casts find sitting on a normal toilet seat impossible. Solve this problem by cutting the bottom off a tapered plastic waste can so that it just fits into the top of the toilet bowl. Then use a heat gun to soften the plastic and mold the can top so there is an indentation two-thirds of the way toward the front and also a pointed spout at the front (Fig. 36-5). To use it, wedge the bottom firmly into the toilet bowl. For an elderly patient who simply needs a raised seat, attach a standard toilet seat to this device.
Raised toilet seat. (Redrawn from Ford.6)
Patients with limited mobility often have difficulty using low beds or cots. To raise the bed safely, drill holes into four wooden blocks of the same size and insert the bed frame legs. Use this method to raise cots for use as cholera beds; these have a hole cut in the center of their plastic-sheet mattress and a bucket placed underneath (see Fig. 32-3 in Chapter 32, Infectious Diseases).
Thick-soled protective sandals may be needed for patients with severe peripheral neuropathy, such as from diabetes or leprosy. To make an inexpensive sandal that will last about a year, have the patient step on a piece of soft insulating/microcellular/foam rubber (such as that used as packing material) and draw a pattern of his foot on it, about 1.5 cm away from the foot (Fig. 36-6). Make holes for the straps, which are made from leather or cut from a tire's inner tube. Securely sew the straps onto the foam. Cut a piece of automobile tire and glue it to the bottom of the foam. After the glue completely dries, cut the tire to match the foam's shape. If desired, sew on buckles (or attach them with rivets).
A chest, or thoracic, brace is useful for multiple purposes, including protecting chest and thoracic spine injuries while healing occurs. Figure 36-7 shows a chest brace fashioned from PVC pipe. See "Heating PVC Pipe" in Chapter 27, Ophthalmology, for how to work with PVC pipes.
Chest brace from polyvinyl chloride pipe.
Filling a rubber air mattress with water forms a cushion for the beds of patients prone to develop decubitus ulcers.7 To make a pad to use on a chair, wheelchair, or hard bed, tie inner tubes together (see Fig. 5-28 in Chapter 5, Basic Equipment). One inner tube pad can be used on a chair or several can be linked together to form a mattress (Fig. 36-8).
Patients may need support to sit upright in a chair because of weakness or instability. (Do not sit or prop them up if their difficulty sitting is due to hypotension! They will simply pass out—or maybe have a stroke.) Use sheets, folded towels, or pieces of cloth to fashion a harness similar to that shown in Fig. 36-9.
Support harness. (Redrawn from Arey.8)
Patients with a weak hand grip after a stroke, with other neuromuscular diseases, and with arthritis often have trouble holding eating utensils, writing implements, and toothbrushes. Patients often do well if a handle is enlarged so that they can grip it with their entire hand closed over the handle in a fist.
For an eating utensil, cut a hole in a large sponge or rubber ball and shove the item or its handle through it (Fig. 36-10). For a pen or pencil, push it through the hole in a spool of thread. Enlarge the hole and tape it in place, if necessary.9
Toothbrush with sponge-ball handle grip. (Reproduced with permission from Arey.10)
In resource-poor environments, you will need to fashion the prosthesis. One way to do this is, after padding the stump well, to form a plaster cast around the stump, remove the cast, and fit it with a sawn-off, thinned-down crutch. Then fix it in place with additional plaster. This works for both above-the-knee (AK) and below-the-knee (BK) amputations. (It looks similar to the pirates' peg legs in the movies and works fine.)
If both legs must be amputated above the knees, consider making short, so-called "stumpy" prostheses. These can simply be boots pulled over the stumps and held on by cords over the shoulders. They are easier for the patient to balance on, although he will need two short walking sticks to assist him.11