During my neurology prac I went to see a new patient who had been screened the day before in ED before being admitted to the ward. The handover had stated the patient had a right sided stroke and was ambulating and transferring with one minimal assistance.
When I arrived to see the patient I launched into my usual introduction and set about getting the patient ready to go to the gym. Given the reported level of function I expected to be able to walk the patient to the gym to complete my assessment. However I found the patient required significant assistance to transfer from supine and after a couple of attempted sit to stands the patient was not able to stand with minimal assistance.
At this point I returned the patient to bed and I was seriously doubting my ability to record a handover. I went and reviewed the notes which confirmed that the patient was minimal assist yesterday, so either the patient had suddenly got worse and no one had noticed or I was doing something wrong.
I decided to review the latter option first and after some more detailed attention to the notes I found that the patient had a significant hearing difficulty and required hearing aids as well as glasses for decreased vision. When I returned to the patient I was able to get the hearing aids and glasses organised and the improvement in response from the patient was noticeable. However I did not feel comfortable walking the patient to the gym and chose to use a wheelchair instead.
I completed part of my assessment in the gym and found that the patient had quite high Gowland scores with good range of motion and minimal perceptual deficits. When I explained the situation to my supervisor she simply walked over to the patient and asked her to walk to the door. To my surprise the patient stood up with minimal support and proceeded to walk comfortable to the door.
After reviewing what had occurred I realised that I had bombarded the patient with instructions that were poorly understood due to hearing loss. When the patient was not performing the task as I expected I reverted to breaking the task into obscure instructions from the patients point of view, rather focusing on a task the patient knew.
I have realised from this experience the need to make our intentions really clear with our patients and this is even truer in a patient population, such as a stroke, that has sensory and cognitive deficits. If we are able to focus on simple tasks that the patient knows initially then it will be much easier to give them into tasks that are less familiar.
Monday, December 1, 2008
Saturday, November 29, 2008
Trying new things
Whilst on my gerontology prac I treated a 70 year old woman who came into the centre with a PC of falls, BPPV and decrease muscle strength. She had previously been admitted into Fremantle Hospital with an exacerbation of BPPV and the physiotherapist there had performed the Eppley's manouvre on her twice with very good effect. My supervisor said that she would show me how to do it, and then I could perform it on her.
I was very reluctant to do it, as I had never done it before even on a peer, so to perform it on someone with a pathology was a daunting thought. When I found out that my supervisor couldn't even watch me perform it on her because she was busy in a meeting I was going to just try it in the next session. However when my patient came in and began to tell me how much trouble it was giving her, I didn't want her to have to wait for another week. I took her through the positions and she was quite severely nauseous and dizzy in the sidelying position, however by the time she was sitting up for a minute she was ok. I treated her 3 more times with the Eppley manouvre, once each time I saw her and her improvement was impressive. By the end of my prac she was no longer taking her BPPV medication and suffered a quarter of the symptoms she was at the start of my treatment sessions.
From this experience I learnt that I should embrace the opportunity to try new things, especially in this field as there are new techniques being developed all the time. If I hadn't treated her, and had simply watched my supervisor do it, I wouldn't have nearly the amount of satisfaction I derived from treating her start to finish. In future I will have more confidence in myself and my ability to adapt to new situations, and accept that even if I don't get it perfect the first time I can still help people.
I was very reluctant to do it, as I had never done it before even on a peer, so to perform it on someone with a pathology was a daunting thought. When I found out that my supervisor couldn't even watch me perform it on her because she was busy in a meeting I was going to just try it in the next session. However when my patient came in and began to tell me how much trouble it was giving her, I didn't want her to have to wait for another week. I took her through the positions and she was quite severely nauseous and dizzy in the sidelying position, however by the time she was sitting up for a minute she was ok. I treated her 3 more times with the Eppley manouvre, once each time I saw her and her improvement was impressive. By the end of my prac she was no longer taking her BPPV medication and suffered a quarter of the symptoms she was at the start of my treatment sessions.
From this experience I learnt that I should embrace the opportunity to try new things, especially in this field as there are new techniques being developed all the time. If I hadn't treated her, and had simply watched my supervisor do it, I wouldn't have nearly the amount of satisfaction I derived from treating her start to finish. In future I will have more confidence in myself and my ability to adapt to new situations, and accept that even if I don't get it perfect the first time I can still help people.
Adequate pain relief
Whilst on my cardiopulmonary prac I was treating a 65 year old gentleman who was a day one post Whipples procedure. He hadn't been out of bed yet and my supervisor came with me to provide assistance. Before we began I read through his notes to gain some idea of his PMHx and had a look at his CXR which was clear. The pain team had seen him just a few minutes earlier and I had read in the notes that he was 0/10 pain at rest and 2/10 pain with movement.
I introduced us both and told the patient we were going to get him up for a walk which caused him to begin yelling at us and telling us we were 'crazy'. We tried to explain that it was normal for people to get up the first day after their surgery but he didn't believe us. Finally he consented to sitting out in the chair. We began a two maximal assistance transfer to sit him over the edge of the bed but once we began he started screaming in agony and crying. Upon enquiry he said he was 11/10 pain. We called over another physio and were able to get him back into bed.
He told us (not very politely) to go away and said we could never come back. He seemed to associate physiotherapy with pain, and thought that we were causing him pain. As much as we tried to reinforce that his pain relief should have been enough to enable him to get out of bed we were unsuccessful. My supervisor liased with the pain team and explained what had happened, asking them to reinforce that physio is important and shouldn't be as painful as it was for him. This experience taught me that you can't always trust everything that you read in the notes. I was unaware before this that the pain score with movement reported by the pain team didn't require the patient to move and then report a score. Thus, it wasn't an accurate representation of what the patient really felt when he moved, causing major problems when he did move. Also, I learnt how important the very first treatment session is with a patient, and how easily impressions can be formed, whether positive or negative. In future I will explain to the patient before we begin that the pain relief should be enough to allow him to get out of bed, as he wasn't very receptive to this concept (or anything we said) after the fact.
I introduced us both and told the patient we were going to get him up for a walk which caused him to begin yelling at us and telling us we were 'crazy'. We tried to explain that it was normal for people to get up the first day after their surgery but he didn't believe us. Finally he consented to sitting out in the chair. We began a two maximal assistance transfer to sit him over the edge of the bed but once we began he started screaming in agony and crying. Upon enquiry he said he was 11/10 pain. We called over another physio and were able to get him back into bed.
He told us (not very politely) to go away and said we could never come back. He seemed to associate physiotherapy with pain, and thought that we were causing him pain. As much as we tried to reinforce that his pain relief should have been enough to enable him to get out of bed we were unsuccessful. My supervisor liased with the pain team and explained what had happened, asking them to reinforce that physio is important and shouldn't be as painful as it was for him. This experience taught me that you can't always trust everything that you read in the notes. I was unaware before this that the pain score with movement reported by the pain team didn't require the patient to move and then report a score. Thus, it wasn't an accurate representation of what the patient really felt when he moved, causing major problems when he did move. Also, I learnt how important the very first treatment session is with a patient, and how easily impressions can be formed, whether positive or negative. In future I will explain to the patient before we begin that the pain relief should be enough to allow him to get out of bed, as he wasn't very receptive to this concept (or anything we said) after the fact.
Friday, November 28, 2008
The dynamics of the patient-therapist relationship
At the start of my cardiopulmonary prac I sometimes found it difficult to get patients to comply with my treatment. Their favourite show had just started, or they hadn't had a good sleep last night, or they were going to have visitors in 10 minutes or they were just about to have a nap...I heard many excuses. While I think it's important to attempt to fit around other things in order to keep the patient on side, it is a balancing act.
I was treating a patient who had a sleeve gastrectomy and when I came to see her complained of nausea and stated she was unable to get out of the bed. I then arranged with the nurse to get her some antiemitics and decided to come and check later. Next time I checked on her she was watching days of our lives and it would be finished in 20 minutes. As I had another patient I could see I decided it wouldn't be a problem. Finally I came into her room after days of our lives would definitely have finished and she was sound asleep, refusing to open her eyes and just groaning at me. She was 3 days post and had gotten up the two days before, and while I came back to check frequently for the rest of the afternoon I was unsuccessful.
In a perfect world we would always be able to treat our patients and they would understand the benefits of getting out of bed. However, clearly it is very unlikely to have such a situation and we are competing for the patients time with a myriad of other health staff and the patients own complaints. As an undergrad it is harder to be really tough on patients and instill the fear of god into your patients, however from this experience I learnt that you have to establish the 'dominant' position as the treating therapist in the relationship from the start, otherwise the patient will never do what you say. I should have been firmer when I saw her and told her that once the tablets had kicked in/her show was finished we were going for a walk no matter what. It is difficult to assert yourself once the patient thinks they are in control and you have given them the upperhand. In future if I allow a patient to have a later treatment (as long as it is a valid reason) I will be stricter in gaining a promise from them that they will be compliant when that time comes, and ensure they follow through.
I was treating a patient who had a sleeve gastrectomy and when I came to see her complained of nausea and stated she was unable to get out of the bed. I then arranged with the nurse to get her some antiemitics and decided to come and check later. Next time I checked on her she was watching days of our lives and it would be finished in 20 minutes. As I had another patient I could see I decided it wouldn't be a problem. Finally I came into her room after days of our lives would definitely have finished and she was sound asleep, refusing to open her eyes and just groaning at me. She was 3 days post and had gotten up the two days before, and while I came back to check frequently for the rest of the afternoon I was unsuccessful.
In a perfect world we would always be able to treat our patients and they would understand the benefits of getting out of bed. However, clearly it is very unlikely to have such a situation and we are competing for the patients time with a myriad of other health staff and the patients own complaints. As an undergrad it is harder to be really tough on patients and instill the fear of god into your patients, however from this experience I learnt that you have to establish the 'dominant' position as the treating therapist in the relationship from the start, otherwise the patient will never do what you say. I should have been firmer when I saw her and told her that once the tablets had kicked in/her show was finished we were going for a walk no matter what. It is difficult to assert yourself once the patient thinks they are in control and you have given them the upperhand. In future if I allow a patient to have a later treatment (as long as it is a valid reason) I will be stricter in gaining a promise from them that they will be compliant when that time comes, and ensure they follow through.
Time wasting
On my cardiopulmonary placement I had alot of experience with getting patient's to do what they didn't want to. This was particularly true when they were reluctant to get out of bed. In their head they're thinking 'someone cut down my stomach just yesterday and messed around in there and you want me to get up?' And it is a valid concern which needs to be assuaged.
Patient's are often very nervous due to the fact that you are normally the first person to get them out of bed, and possibly even more nervous that you are a student and aren't the most graceful at getting all the attachments in order. The first time I was getting a day one surgery out of bed I spent time asking subjective questions, then messing around with the attachments, and getting the oxygen ready. All the while, unbenowst to me the patient is getting more and more agitated watching me struggle and wasting time. Once I finally got the patient up they were quite anxious and didn't walk as far as they perhaps could have if they were more relaxed.
Throughout the prac I had many opportunities to improve on my first treatment as I had several mistakes I could learn from. From this experience I realised that patient's are quite nervous (as obvious as that is, I was more nervous and worried about the attachments to notice this) and that it's best to ask only the essential questions before you get them up in order to save time. Once you tell them you are getting them up, they can often become quite anxious so it's important that you are organised and have brought the portable oxygen, oximeter and have a chair set up so that more time isn't wasted. In the future I will focus on ensuring the patient's comfort and safety come first and not get so bogged down in what I am doing that I don't notice what the patient's face and movements are telling me.
Patient's are often very nervous due to the fact that you are normally the first person to get them out of bed, and possibly even more nervous that you are a student and aren't the most graceful at getting all the attachments in order. The first time I was getting a day one surgery out of bed I spent time asking subjective questions, then messing around with the attachments, and getting the oxygen ready. All the while, unbenowst to me the patient is getting more and more agitated watching me struggle and wasting time. Once I finally got the patient up they were quite anxious and didn't walk as far as they perhaps could have if they were more relaxed.
Throughout the prac I had many opportunities to improve on my first treatment as I had several mistakes I could learn from. From this experience I realised that patient's are quite nervous (as obvious as that is, I was more nervous and worried about the attachments to notice this) and that it's best to ask only the essential questions before you get them up in order to save time. Once you tell them you are getting them up, they can often become quite anxious so it's important that you are organised and have brought the portable oxygen, oximeter and have a chair set up so that more time isn't wasted. In the future I will focus on ensuring the patient's comfort and safety come first and not get so bogged down in what I am doing that I don't notice what the patient's face and movements are telling me.
Depressed patients
As much as we are told that we are not psychologists, the nature of this profession is such that patients can often open up. In these situations it is difficult to know where to draw the line between what you can handle and what needs to be referred on.
Whilst on my gerontology prac I had a patient who was 85 and had lost his month 4 months ago. Since this time his balance and strength had declined and he reported feeling quite depressed. Throughout the course of the session he expressed that he 'didn't know what he was living for', 'would be happier if he was dead' and several other phrases relating to dying. I was unsure of what to say, however attempted to offer reassurance, asking him what all the neighbours he helped would do without him (he often gardened and brought meals to people on his street). However, despite my best attempts he was difficult to convince.
I spoke to my supervisor about my concerns and she suggested I refer him to clinical psych. If the patient actually suffered from depression, there is nothing physiotherapy can do to fix it, and it is therefore important to listen to your patients and take them seriously when the say things like this. The way he said it, it was as if he wanted you to think he was joking, but it was clear he was not. From this experience, I took the knowledge that you have to be vigilant otherwise you could miss an important sign that someone needs help. In the future I will find out about a patient especially if I think they might be having problems at home or need other help which I cannot provide.
Whilst on my gerontology prac I had a patient who was 85 and had lost his month 4 months ago. Since this time his balance and strength had declined and he reported feeling quite depressed. Throughout the course of the session he expressed that he 'didn't know what he was living for', 'would be happier if he was dead' and several other phrases relating to dying. I was unsure of what to say, however attempted to offer reassurance, asking him what all the neighbours he helped would do without him (he often gardened and brought meals to people on his street). However, despite my best attempts he was difficult to convince.
I spoke to my supervisor about my concerns and she suggested I refer him to clinical psych. If the patient actually suffered from depression, there is nothing physiotherapy can do to fix it, and it is therefore important to listen to your patients and take them seriously when the say things like this. The way he said it, it was as if he wanted you to think he was joking, but it was clear he was not. From this experience, I took the knowledge that you have to be vigilant otherwise you could miss an important sign that someone needs help. In the future I will find out about a patient especially if I think they might be having problems at home or need other help which I cannot provide.
Multidisciplinary interactions
While on my gerontolgy prac I had the opportunity to work quite closely with the OTs at that centre. Often we saw the same patients, and such was the nature of the centre that you often had a very limited time to see the patients because they came late and had transport coming at specific times. The patients notes were shared between the treating therapists as there was only one set, so it was often difficult to coordinate it so that everyone was able to read them thoroughly.
One morning during the first week of the prac whilst I was reading through a patients notes the OT burst through the door and said 'where are the notes for Mr ___?' He seemed very annoyed as I handed over the notes I was reading and grabbed them off me saying 'you should have given these to me before I need to read them and I'm going to be late for the patient'. I apologised, and once he had left i looked at my watch and saw it was still 5 minutes until the patient would be arriving.
I wasn't aware at this stage of the prac that I should have gone and given the notes to the OT, my supervisor had given me the notes to read with no instructions that the OT was seeing him first and to make sure I gave them to him with enough time so that he could read them also. I suppose that I could have been proactive and asked this however I felt his aggressive reaction was uncalled for. After this interaction I had trouble liasing with him about patients and didn't make an effort to talk to him in the lunch room. This was quite childish of me and I shouldn't have taken his behaviour so personally. However, several other incidents similar to this occurred where he appeared quite annoyed at me after I had done nothing wrong. This experience taught me that you can't get on with everyone and if you take everything to heart it will get in the way of being able to do your job. There was no way I could avoid talking to him and feeling upset about it intefered with how effectively I could get my point across, which could in turn affect the way a patient was treated. So regardless of my personal feelings it's important to focus on the clinical situation.
One morning during the first week of the prac whilst I was reading through a patients notes the OT burst through the door and said 'where are the notes for Mr ___?' He seemed very annoyed as I handed over the notes I was reading and grabbed them off me saying 'you should have given these to me before I need to read them and I'm going to be late for the patient'. I apologised, and once he had left i looked at my watch and saw it was still 5 minutes until the patient would be arriving.
I wasn't aware at this stage of the prac that I should have gone and given the notes to the OT, my supervisor had given me the notes to read with no instructions that the OT was seeing him first and to make sure I gave them to him with enough time so that he could read them also. I suppose that I could have been proactive and asked this however I felt his aggressive reaction was uncalled for. After this interaction I had trouble liasing with him about patients and didn't make an effort to talk to him in the lunch room. This was quite childish of me and I shouldn't have taken his behaviour so personally. However, several other incidents similar to this occurred where he appeared quite annoyed at me after I had done nothing wrong. This experience taught me that you can't get on with everyone and if you take everything to heart it will get in the way of being able to do your job. There was no way I could avoid talking to him and feeling upset about it intefered with how effectively I could get my point across, which could in turn affect the way a patient was treated. So regardless of my personal feelings it's important to focus on the clinical situation.
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