I have recently completed my rural practical in a small country town. The physio visited nearby towns as well, so in total I visited treated in 4 towns a week. The patients were mainly musculoskeletal outpatients, however, I did see a few inpatients. After the first week of practical I realised how important patient confidentiality is in a small community. It seemed like everyone was friends, if not related to one another.
Whilst on my rural practical I asked the physiotherapist about patient confidentiality. She said that patients aren’t afraid to ask what the previous patient was being treated for. I was quite shocked at this at first but after being there for a few weeks I realized that it was a very friendly community and people may have been asking about patient’s out of concern. When asled how the therapist deals with this she said that she explains to the patient that it isn’t her place to answer the question.
The physio also told me that even though there is a continence nurse at the health service she sees patients for their continence. This is because patients are too scared that people will see her going to the nurse, or even see their car parked out the front and will talk amongst the community. A physiotherapy appointment is believed to be more accepting.
This practical taught me to be even more careful about patient confidentiality. I couldn’t talk about any of the patients in public (even with no names or age) because everyone knows everyone and anything said will get back to that patient and could potentially upset the patient.
Monday, September 1, 2008
Communicating Diagnoses with Patients
In my recent placement, I had a patient that has been an inpatient for almost a week already. At the end of one of our sessions, he told me that he’s really thankful that all of his doctors, nurses and other health professionals have been doing their best to help him and he has been feeling better for the past days. However, he also said that he wished someone would tell him what has been causing his problems. He said he’s already asked the doctors and nurses but all of them did not say a thing to him at all and that made him anxious. It was quite obvious at that point that he was going to ask me what’s been happening to him so I was having a little bit of a think what to say to him. To start with, he does not have a definite diagnosis just yet, but in his notes, there were some things that the doctors have been trying to rule out. I kept thinking if telling him the possible diagnoses would be of benefit to him. He was somehow anxious then so I had to take that into consideration. In the end, I made it clear to him that there were some possible things that the doctors are trying to rule out. I told him what those were and he said he was relieved because at least he has an idea of the possibilities. Again, I told him that those are just possibilities and the diagnosis can be something else other than those, but he was satisfied already. At that point, I wasn’t so sure if I had done the right thing. So off I went to talk to my supervisor and she said usually, it is not up to us (physios) to discuss diagnoses with patients but that she thought I handled the situation well. She also said that such situations should be approached carefully and with a great deal of sensitivity because each patient is different from another and they may very well respond differently to such situations.
Sunday, August 31, 2008
Non-compliance in paeds
On my paeds/rural placement I’ve discovered that gaining compliance with children for Ax/Rx is somewhat more difficult than with adults who understand that physio may help them and are willing and able to follow instructions..
It seems that many children get upset/anxious/scared when they feel they have lost control – whether it be not being able to control their movement or control the situation.
To gain trust and compliance we need to provide children with this feeling of control and autonomy, yet in order to achieve our treatment goals the therapist must obviously stay in control of the session! I’ve encountered children who refuse to do anything or do everything other than what you’d like them to do and also the difficult teenager who is just way too cool for physio! But I’ve learnt (from the great team of PT/OT/Speechies) that offering the children a choice is a really easy way to provide the kids with that longing to feel in control and ultimately gain their compliance. It’s much more difficult to ignore/avoid someone who is offering two options than one who is trying to make you do what they want. So, ask them whether they’d like to throw a basketball or soccer ball; find out if they’d prefer to do frog jumps or bunny hops; ask them whether they would prefer to use the stairs at the front or those inside; give the child your about to serial cast the really important decision of picking which colour plaster they should have etc etc. I’ve been amazed by how well this simple ‘trick’ works across the different ages of children on my placement. Even babies like control – let them pick the toy you’ll use for motivation and when they become irritable because your supported sitting has become too hard, make sure they get some comfort from mum before trying a new position.
There are so many examples and I think it is finally starting to become second nature for me to ask a child if they want to sit on the blue chair or the red chair instead of simply asking them to sit. And it is really paying off! My sessions have become much more productive by guiding the children to complete the activities I want them to do, simply by allowing them a choice which is inconsequential to my treatment goals.
It seems that many children get upset/anxious/scared when they feel they have lost control – whether it be not being able to control their movement or control the situation.
To gain trust and compliance we need to provide children with this feeling of control and autonomy, yet in order to achieve our treatment goals the therapist must obviously stay in control of the session! I’ve encountered children who refuse to do anything or do everything other than what you’d like them to do and also the difficult teenager who is just way too cool for physio! But I’ve learnt (from the great team of PT/OT/Speechies) that offering the children a choice is a really easy way to provide the kids with that longing to feel in control and ultimately gain their compliance. It’s much more difficult to ignore/avoid someone who is offering two options than one who is trying to make you do what they want. So, ask them whether they’d like to throw a basketball or soccer ball; find out if they’d prefer to do frog jumps or bunny hops; ask them whether they would prefer to use the stairs at the front or those inside; give the child your about to serial cast the really important decision of picking which colour plaster they should have etc etc. I’ve been amazed by how well this simple ‘trick’ works across the different ages of children on my placement. Even babies like control – let them pick the toy you’ll use for motivation and when they become irritable because your supported sitting has become too hard, make sure they get some comfort from mum before trying a new position.
There are so many examples and I think it is finally starting to become second nature for me to ask a child if they want to sit on the blue chair or the red chair instead of simply asking them to sit. And it is really paying off! My sessions have become much more productive by guiding the children to complete the activities I want them to do, simply by allowing them a choice which is inconsequential to my treatment goals.
Non-productive sessions
I recently encountered a child who had been diagnosed with arnold-chiari malformation (structural defect of cerebellum, may force cerebellar tonsils and brainstem downwards, often progressive, symptoms include balance/co-ordination problems, muscle weakness which all obviously affect motor development). She also has some other undiagnosed behavioural/social problems. This 3 yo client had really struggled to achieve every motor skill she had acquired and through much support of her very patient mother she was now walking; which is what we were hoping to assess.
Unfortunately, upon seeing the physio (whom I think probably represents a lot of hard work in the mind of the child), the child starting screaming. Mum carried her into our treatment room where she continued to scream and cry. Being able to actually treat the child was an idea written off early in the session, but we tried to console/ distract/ bribe her in order to achieve some sort of assessment to guide our advice to mum. Eventually it seemed we were not going to be able to assess the child who continued to cling to mum and scream until she was hoarse, for 40 minutes. The physio indicated that we were giving up and I assumed this would be the end of the session. Instead though, the physio asked mum to read an entire book to the child before they could go. Mum calmly read the book and the therapist addressed the child, saying “now that you’ve finished reading it’s time to go home”. We arranged a home visit for our next session, where Mum suggested we hide in the next room and observe through the window while mum played with the child!
Anyway after this first session I asked about the book reading and I soon realised that whilst this session was obviously non-productive, the therapist was preparing the child for next time, trying to change her negative associations with the physio and with therapy. By allowing the child to read with mum then go home, her association to the centre might be with something more fun like reading. I realised I would not have thought of this very simple idea. We have all had patients who for some reason are non-compliant on particular days and we want only for the session to be over so we can start afresh next time. I now appreciate how important it is to think about not only the individual session aims but your long term goals and remember that your actions have the potential to influence not only the current session, but future sessions as well.
Unfortunately, upon seeing the physio (whom I think probably represents a lot of hard work in the mind of the child), the child starting screaming. Mum carried her into our treatment room where she continued to scream and cry. Being able to actually treat the child was an idea written off early in the session, but we tried to console/ distract/ bribe her in order to achieve some sort of assessment to guide our advice to mum. Eventually it seemed we were not going to be able to assess the child who continued to cling to mum and scream until she was hoarse, for 40 minutes. The physio indicated that we were giving up and I assumed this would be the end of the session. Instead though, the physio asked mum to read an entire book to the child before they could go. Mum calmly read the book and the therapist addressed the child, saying “now that you’ve finished reading it’s time to go home”. We arranged a home visit for our next session, where Mum suggested we hide in the next room and observe through the window while mum played with the child!
Anyway after this first session I asked about the book reading and I soon realised that whilst this session was obviously non-productive, the therapist was preparing the child for next time, trying to change her negative associations with the physio and with therapy. By allowing the child to read with mum then go home, her association to the centre might be with something more fun like reading. I realised I would not have thought of this very simple idea. We have all had patients who for some reason are non-compliant on particular days and we want only for the session to be over so we can start afresh next time. I now appreciate how important it is to think about not only the individual session aims but your long term goals and remember that your actions have the potential to influence not only the current session, but future sessions as well.
Friday, August 29, 2008
Dealing with Tragedy...
The hardest thing about doing a rural prac near the town where you grew up is that if something happens to someone, there is a good chance you know the person, or are close to someone else who does. Even though I grew up 50 km from the place where I am doing rural, the hospital services many towns in the surrounding area.
I was on a ward seeing patients in the morning when there was a code Blue in the hospital. Having just been at Charlies where code blues happen at least 5 times a day, I didn’t think too much about it other than I hoped the person was ok.
Later in the day I was standing at the nurses desk when I saw a family walk in that I knew. There was only the single mum and 1 of the 3 sons who came in (there were 3 sons, one of which was severely disabled with CP and in a disability care home).
As this ward was primarily for elderly people, I assumed it was a situation involving a grandparent. I also wondered why the other son wasn’t there. I looked at the two family members and had never in my life seen people look like that. The nurses then told me that a young 17-year-old boy had died that morning when the code blue was called.
I felt shocked at first and couldn’t really put 2 and 2 together. When it hit home that the other son had died that morning it was very overwhelming and upsetting.
The circumstances surrounding his death are still uncertain, however he had been admitted the night before with tonsillitis and there was a very very tragic medical complication with the Rx.
This was a very robust, high-energy young guy who died within a matter of minutes.
I know dealing with death is always hard, its just made harder when its such a young person and also seeing the family walking into the hospital to see their loved one for the first time. As I was in contact with the nurses as well I also got detail about the medical side of things, which made it even harder.
It all happened so quick and I was in shock for quite a while. It has been playing over in my head since it happened a few days ago, so I hoped writing it down might help to deal with it.
I found it really helpful chatting to some of the staff who had also known them. I also found people really support each other, especially in a country town as it is a pretty tight nit community.
I was on a ward seeing patients in the morning when there was a code Blue in the hospital. Having just been at Charlies where code blues happen at least 5 times a day, I didn’t think too much about it other than I hoped the person was ok.
Later in the day I was standing at the nurses desk when I saw a family walk in that I knew. There was only the single mum and 1 of the 3 sons who came in (there were 3 sons, one of which was severely disabled with CP and in a disability care home).
As this ward was primarily for elderly people, I assumed it was a situation involving a grandparent. I also wondered why the other son wasn’t there. I looked at the two family members and had never in my life seen people look like that. The nurses then told me that a young 17-year-old boy had died that morning when the code blue was called.
I felt shocked at first and couldn’t really put 2 and 2 together. When it hit home that the other son had died that morning it was very overwhelming and upsetting.
The circumstances surrounding his death are still uncertain, however he had been admitted the night before with tonsillitis and there was a very very tragic medical complication with the Rx.
This was a very robust, high-energy young guy who died within a matter of minutes.
I know dealing with death is always hard, its just made harder when its such a young person and also seeing the family walking into the hospital to see their loved one for the first time. As I was in contact with the nurses as well I also got detail about the medical side of things, which made it even harder.
It all happened so quick and I was in shock for quite a while. It has been playing over in my head since it happened a few days ago, so I hoped writing it down might help to deal with it.
I found it really helpful chatting to some of the staff who had also known them. I also found people really support each other, especially in a country town as it is a pretty tight nit community.
Wednesday, August 27, 2008
Interesting condition...
I came across a pt with a condition today that I had heard of, but was not very familiar with. So prior to seeing this pt I did some research into what it was, any precautions needed to Ax them and Rx ideas…. So I thought id share it incase anyone else comes across it!
The condition was Scheuermann's disease
I asked the other PT’s I was working with about it aswell and found out some handy info..
One of the PT’s actually had it. She had had an Xray for an unrelated problem, and the findings came back to say she actually had Scheuermanns aswell. She had been asymptomatic apart from some occasional mild stiffness in her mid thoracic spine. Another PT’s sister had it, and she said her sister had been very good with her initial PT ex’s and was also now asymptomatic.
So what is it?
Scheuermanns disease refers to osteochondrosis of the secondary ossification centers of the vertebral bodies.
The etiology and pathogenesis are unknown. Probably multifactorial - including mechanical, metabolic, and endocrinologic causes.
The condition affects children aged 13-16 years, and the diagnosis is rarely made in patients younger than 10 years. Usually occurs through adolescence with initial growth spurts. It is quoted in some studies as occurring in 25% of all children to varying degrees. Patients are generally taller comparably than aged peers, and have advanced skeletal versus chronologic age.
Boys are affected more frequently than girls.
Signs and Symptoms:
It usually develops with some sort of spinal deformity, and it can be accompanied by backache and stiffness, usually aggravated by sitting. During the onset, the child's posture often changes. The back curve may become exaggerated.
A diagnosis can be established if wedging of vertebral bodies is evident, in association with other changes, including intervertebral disc space narrowing, Schmorl's nodes, and deformity. These changes can occur with or without pain. Small changes in the growing parts of the vertebrae may be seen. These changes may persist and predispose the lower thoracic spine to degenerative changes later in life.
It usually lasts as a symptomatic pain producing problem between 6 months and 3 years. It is a problem in growing adolescent, and once the growth is finished the condition recovers. The function of the spine and hamstring muscles is usually mildly affected in the long term, emphasizing a need for rehabilitative exercises.
Treatment:
Depends on the severity of pain and the degree of mechanical changes seen on examination. When more severe pain, relative rest from activity is necessary. The traditional treatment was rest, especially in large back braces, however, this treatment was excessive.
Physio involvement and Exercises:
Important to maintain mobility. As the thoracolumbar region is most affected, rotation and stretching ex’s in all ranges is needed. Strengthening exercises associated with postural modification is also important. plus Mx STRATEGIES and BEHAVIOUR MODIFICATION!!
is very important to advise the pt to keep up general fitness by adapting behaviour modification and Mx strategies ie lumbar roll in sitting. A whole body biomechanic Ax can also help eg looking at foot position/need for orthotics ect..
The more the condition is accompanied by pain, back mobility changes, postural deformities and hamstring tightness, the more that rest will be required. This can mean complete rest from active contact sports such as football, and rest from activities requiring repetitive overload, e.g. long distance running, bowling in cricket, gymnastics, ballet dancing, etc.
Sometimes mobilization and manipulation aimed at the stiffness in the lower Thoracic spine can be indicated, although it needs to be performed with care and only continued if improvement seen from that and not attributed to other exercises. swimming can be very beneficial (in heated pool) to encourage spinal rotation.
Scheuermann's disease is just one of the many conditions found in the population incidentally. Treatment should address the signs and symptoms of the presenting condition, and not the incidental radiological findings.
Unfortuntely the pt I had admitted having a ‘denial’ attitude towards having it (she was Dx at age 11) and had not managed herself well. She had had previous PT and not been compliant at all. She was now in her early 40’s and had severe chronic back pain with frequent flare ups. she is now on panadeine forte and valium every 4 hours (and has been for the last 5 years) She was so irritable, the first Rx involved giving TENS for home use (as she had used this before with good effect) and pain Mx strategies. The aim is to get her pain under control, commence Hydro (as this has previously also helped) and gentle ex’s and aim to get her out of bed as she is currently RIB most of the day. she says she is so now so debilitated that she is adament to comply to PT ex's and wish she hadnt let herself get to this stage....
info found from a number of sources including:
http://www.emedicine.com/pmr/topic129.htm
http://members.optushome.com.au/physio/schmann.html
http://www.emedicine.com/pmr/topic129.htm
The condition was Scheuermann's disease
I asked the other PT’s I was working with about it aswell and found out some handy info..
One of the PT’s actually had it. She had had an Xray for an unrelated problem, and the findings came back to say she actually had Scheuermanns aswell. She had been asymptomatic apart from some occasional mild stiffness in her mid thoracic spine. Another PT’s sister had it, and she said her sister had been very good with her initial PT ex’s and was also now asymptomatic.
So what is it?
Scheuermanns disease refers to osteochondrosis of the secondary ossification centers of the vertebral bodies.
The etiology and pathogenesis are unknown. Probably multifactorial - including mechanical, metabolic, and endocrinologic causes.
The condition affects children aged 13-16 years, and the diagnosis is rarely made in patients younger than 10 years. Usually occurs through adolescence with initial growth spurts. It is quoted in some studies as occurring in 25% of all children to varying degrees. Patients are generally taller comparably than aged peers, and have advanced skeletal versus chronologic age.
Boys are affected more frequently than girls.
Signs and Symptoms:
It usually develops with some sort of spinal deformity, and it can be accompanied by backache and stiffness, usually aggravated by sitting. During the onset, the child's posture often changes. The back curve may become exaggerated.
A diagnosis can be established if wedging of vertebral bodies is evident, in association with other changes, including intervertebral disc space narrowing, Schmorl's nodes, and deformity. These changes can occur with or without pain. Small changes in the growing parts of the vertebrae may be seen. These changes may persist and predispose the lower thoracic spine to degenerative changes later in life.
It usually lasts as a symptomatic pain producing problem between 6 months and 3 years. It is a problem in growing adolescent, and once the growth is finished the condition recovers. The function of the spine and hamstring muscles is usually mildly affected in the long term, emphasizing a need for rehabilitative exercises.
Treatment:
Depends on the severity of pain and the degree of mechanical changes seen on examination. When more severe pain, relative rest from activity is necessary. The traditional treatment was rest, especially in large back braces, however, this treatment was excessive.
Physio involvement and Exercises:
Important to maintain mobility. As the thoracolumbar region is most affected, rotation and stretching ex’s in all ranges is needed. Strengthening exercises associated with postural modification is also important. plus Mx STRATEGIES and BEHAVIOUR MODIFICATION!!
is very important to advise the pt to keep up general fitness by adapting behaviour modification and Mx strategies ie lumbar roll in sitting. A whole body biomechanic Ax can also help eg looking at foot position/need for orthotics ect..
The more the condition is accompanied by pain, back mobility changes, postural deformities and hamstring tightness, the more that rest will be required. This can mean complete rest from active contact sports such as football, and rest from activities requiring repetitive overload, e.g. long distance running, bowling in cricket, gymnastics, ballet dancing, etc.
Sometimes mobilization and manipulation aimed at the stiffness in the lower Thoracic spine can be indicated, although it needs to be performed with care and only continued if improvement seen from that and not attributed to other exercises. swimming can be very beneficial (in heated pool) to encourage spinal rotation.
Scheuermann's disease is just one of the many conditions found in the population incidentally. Treatment should address the signs and symptoms of the presenting condition, and not the incidental radiological findings.
Unfortuntely the pt I had admitted having a ‘denial’ attitude towards having it (she was Dx at age 11) and had not managed herself well. She had had previous PT and not been compliant at all. She was now in her early 40’s and had severe chronic back pain with frequent flare ups. she is now on panadeine forte and valium every 4 hours (and has been for the last 5 years) She was so irritable, the first Rx involved giving TENS for home use (as she had used this before with good effect) and pain Mx strategies. The aim is to get her pain under control, commence Hydro (as this has previously also helped) and gentle ex’s and aim to get her out of bed as she is currently RIB most of the day. she says she is so now so debilitated that she is adament to comply to PT ex's and wish she hadnt let herself get to this stage....
info found from a number of sources including:
http://www.emedicine.com/pmr/topic129.htm
http://members.optushome.com.au/physio/schmann.html
http://www.emedicine.com/pmr/topic129.htm
Tuesday, August 26, 2008
Emotional phonecalls
I am currently working on an inpatients ward where I was the only one available to unwittingly take an unexpected phone call. The call came from a patient who was 11 weeks post surgery, had had her hip replaced and been treated for this, however had contracted several systemic infections that impaired her ability to exercise, socialize due to photophobia and left her feeling helpless. She was seriously confused as to what was and was not appropriate exercise and movements for her to be doing at this stage of 11 weeks post THR. The phone call lasted 45minutes, the first half of which I thought I was enduring a very chatty and cautious patient. When the tears came, I knew something seriously different was going on. Then came the full story. She is seriously depressed, isolated by her family and friends, dependent, insecure and anxious to the point of avoiding all physical activity. Panic attacks prevent her from making basic phone calls for help from medical practitioners and it seems she is not proactive as necessary to become fully recovered. Being immobile for 4 weeks in a dark room does not help her situation either!
I was really caught off-guard by this phone call, and felt for the poor lady who had obviously had a hard time with her supposed rehabilitation whilst being in and out of hospitals with other problems. Then I got bothered by something that kept recurring throughout the conversation. Something that could have been within our power as physiotherapists to help was quite pivotal to improving her attitude - communication. The pamphlets given to patients after and before surgery were not clear for her as to when to progress the exercises, when particular movements were permitted, etc. She was so confused that she avoided things like bending down to pick things up off the floor, sweeping the ground and had trouble looking after her cats because she was so afraid of doing the wrong thing.
I don't know if this is the case with her, but we as physiotherapists can be very good at emphasising the "don'ts" that patients don't know what they can do. They also need thorough explanation of the progression of their rehabilitation because it is not always logical for them. We have restricted time when working on the wards, but her confusion and fear avoidance behaviour could have been significantly improved by just taking a little extra time with someone who obviously is not physically aware of fitness and exercise. It's our responsibility, not another medical team member. I just never realised how some people can have absolutely no idea about exercise and activity - we sometimes REALLY have to spell it out, and that's important!
I was really caught off-guard by this phone call, and felt for the poor lady who had obviously had a hard time with her supposed rehabilitation whilst being in and out of hospitals with other problems. Then I got bothered by something that kept recurring throughout the conversation. Something that could have been within our power as physiotherapists to help was quite pivotal to improving her attitude - communication. The pamphlets given to patients after and before surgery were not clear for her as to when to progress the exercises, when particular movements were permitted, etc. She was so confused that she avoided things like bending down to pick things up off the floor, sweeping the ground and had trouble looking after her cats because she was so afraid of doing the wrong thing.
I don't know if this is the case with her, but we as physiotherapists can be very good at emphasising the "don'ts" that patients don't know what they can do. They also need thorough explanation of the progression of their rehabilitation because it is not always logical for them. We have restricted time when working on the wards, but her confusion and fear avoidance behaviour could have been significantly improved by just taking a little extra time with someone who obviously is not physically aware of fitness and exercise. It's our responsibility, not another medical team member. I just never realised how some people can have absolutely no idea about exercise and activity - we sometimes REALLY have to spell it out, and that's important!
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