Proffessional personality

I recently completed an inpatient prac which was my first in-hospital experience, and quite overwhelming when having a unique situation such as mine. I covered two floors, a total of 4 wards, had 5 different supervisors during that time and on top of that the normal drama of finding the relevant nurse, OT, resident and coordinator. The biggest challenge was managing to effectively interact with the multiple teams of medical professioals I was needing to coordinate with for the patient. But with each ward is a different staff, so I was constantly the new kid on the block - not good for the patient nurses. However, I really learned how important our interpersonal skills are - and not just with patients, as we tend to focus on. You often don't know the authority, level of knowledge, experience and skill that the individual's possess when you approach them for the first time in that kind of setting. You really have to maintain proffessionalism but also be sensitive to their angle, humble enough to take what's given when they sound like they know what they are talking about, be prepared for a lot of give and take with what you hoped to achieve and what they need to achieve as well.

I can confidently say I did not achieve such a level of interpersonal skill as I think is necessary or advantageous to such a situation. But I definately will focus on how important it is to be clear on your terms, your aims, the connection to the person you approach and being aware that you are depending on their graciousness a lot of the time as you bumble through in our student way. Very much a "think before you speak so that it makes sense and saves time" kind of thing.

Patients are not the be all and end all of our profession. Professionalism is the key to relating not just to patients, but to the wider health team that is also focused on the patients well-being. A good lesson to learn, I think.

time management

On my first placement (musculo outpatient), one of the challenges that I faced was to manage my time effectively. One time I met the patient at the waiting area and apologized that I was 15 minutes late. She’s usually cheery but that time I was met with a serious face. She then told me that I have been late for 3 consecutive sessions already. I did not realize that because of the volume of patients I usually have on that particular day and also she never brought it up to me. The latter, most especially, was not a good excuse at all. In the end it was entirely my fault. I should taken note of the time for every patient that I see. Also, I could have organized my time more effectively by making sure that I have enough time in between patients to allow my time to prepare for the next one. Since we (physio students) had the liberty of setting the date and time of the next appointment in that placement, I should have recognized that opportunity to leave some time gaps in between sessions to avoid inconvenience especially on the patient’s part. I was lucky that the patient brought it up to me and was extremely understanding. If that wasn’t so, the patient could have been really upset and even stopped going to the physio sessions. 

Patient decisions

I was treating a man in his late 20’s who was 6 months post ACL repair and progressing well. His rehab had progressed to the stage that he was running on a treadmill for short (<5>

At a monthly review the patient reported that he was finding his knee “unstable and mildly painful” when he runs on the treadmill for more than 8 minutes but that he is able to “push through the pain”. He also told me he was planning on going on a snowboarding holiday in 6 weeks time and that he would like a brace to support his knee. When I asked if he had spoken to the doctors about his intentions, he said he had told the registrar at the last review, who was not happy about it but told him it was his choice. He told me that as he felt his knee was doing well he would like to “test it out on some good runs, but have the brace for backup”.

I spent quite a bit of time educating the patient on the need for a graduated rehab program along with the risks of re-injury and the fact that any brace will not make up for a structurally strong and well functioning knee. After taking in this information the patient told me that he was going snowboarding no matter what and that he would be fine.

The question then in my mind was do I not provide a brace and leave the patient exposed to further injury or get the brace and risk the patient over exerting himself due to unfounded confidence in the power of the brace. After discussion with my supervisor and other physios, I decided to provide the brace as the patient was going expose himself to risk and some support was better than none.

I found this situation challenging to understand as the patient had had surgery and had progressed through to a good stage of rehabilitation which had taken 6 months, only to risk this progress for a ride on a snowboard. However it has made me realise that while we may think we know what is best for a patient, they will always be free to choose their actions.

When the patient tries to run the show

I was recently treating a 40 year old man who had been diagnosed with transverse myelitis a few months ago and had quite decreased strength of both his lower limbs. I was taking over from my supervisor and she had warned me that he appeared somewhat 'arrogant'. When I got to his room he started ordering me around, asking me to get things for him. Obviously I don't mind assisting a patient when they are stuck in bed and it's clearly easier for me to reach things, but I am used to being asked nicely with some degree of respect, not ordered and expected to obey. When we got to the gym I did a quick assessment of muscle strength then began working on some exercises for his glut meds. One of his glut meds needed assistance to do the exercise with a proper technique, so I was assisting his leg with one hand and keeping his pelvis properly rotated with the other when he said 'let me do it myself'. I told him that his muscle wasn't strong enough to perform the exercise and until it was, he needed assistance. Still, he wanted to do it himself so I thought I might as well let him see that he couldn't. I took my hands off and his pelvis rotated back, his leg barely coming up at all but still everytime I put my hands on he'd tell me to take them off. I tried explaining to him again that it was doing him more harm than good to perform the exercise poorly by himself and he finally, grudgingly accepted my help.

This behaviour continued throughout the session, the patient refusing my help and disregarding my advice. To top it off he kept scratching his groin and talking to me in a disrespectful manner. I was so sick of him I began to feel I didn't even care if he did his exercises right or not, something I have never felt about a patient before.

I endured his behaviour for a few sessions because I didn't want to admit to my supervisor that I was having trouble but in the end I went and spoke to her. She told me not to be afraid of the patient, set some boundaries and let him know that his behaviour was unacceptable and I took her advice. While I perhaps still didn't enjoy treating him, he had at least stopped telling me what to do and dictating the sessions which was an improvement.

Next time a situation like this arises I will tackle the issue straight away so the patient doesn't start to think they can get away with anything. It's also made me realise that as long as you show your supervisor that you've tried to fix the situation on your own but were unsuccessful, if they're a good supervisor they don't mind giving you a few suggestions.

Our profession

I recently had the opportunity to observe a CABG x5 on pump. It was a great experience and really makes you appreciate why our post surg pts experience the pain they do.. Anyway, just prior to surgery I was introduced to the surgical team and it was explained that I was a final year physio student who’d been on a 5 week prac in ICU.

After we all gowned up, the anaesthetist kindly explained what he was doing throughout the procedure. Whilst the surgeons were preparing, he turned to the obs monitor and explained about the ECGs, CVP and other obs. Then he asked me what I thought the red numbers might represent (they read 90/60 from memory). Of course I said BP. He seemed somewhat impressed that I recognised this.. He then proceeded to ask me how I thought this could be monitored, as the pt wasn’t wearing a BP cuff. When I replied via his arterial line, the anaesthetist seemed really surprised that I might know this. Having been in ICU for 5 weeks where EVERY pt has an art line, it would be poor form if I couldn’t recognise this basic attachment. Anyway, he had finished explaining his role and a theatre nurse started going through exactly what would happen during the procedure. She commenced by explaining that the heart had four chambers..

I am really grateful that I had this opportunity to observe surgery. The surgeons went out of their way to make sure I could see every little thing that was happening and all the support staff were really kind - It was really helpful knowing the relationship between the length of incision in the pt’s leg and its relevance to the number of grafts required of the saphenous vein; I also now understand the cardiopulmonary bypass system. The whole experience was really interesting and I did in fact learn a lot. However, I was a little alarmed by how little the team expected me to know. It made me feel that they really had very little understanding of the role/ knowledge of physios. Perhaps for them it isn’t particularly necessary.. I guess they don’t meet many physios in theatre!

What I have learnt from this experience is that we all need to be flying the flag for our profession!! It’s important to remember that our interactions with other members of the team impacts how physiotherapy is considered. I will now also make a greater effort to understand the roles and knowledge of the other members of the MDT for two main reasons. Firstly, if we aren’t aware of their scope of practice we may under utilise or inappropriately refer patients and secondly I would like to make sure that I don’t under estimate/ under value other (soon to be) health professionals!

A time when reassurance is needed but not always given

I know that a few of my posts have been about communicating with patients with expressive dysphasia, but as it turns out I have come across quite a few obstacles in this area and consequently have learnt a few lessons. One patient I am currently seeing on my neuro placement is a 54 yo female with a RMCA, left hemiplegia, left hemisensory loss and expressive dysphasia. In the morning when I came to take her to physio and stood her up I noticed she had been incontinent of her bowels on the chair she was sitting in. I found her nurse and assisted her to transfer the patient to the shower. The patient didn't appear too phased by it, and after she'd been cleaned up we were able to complete a solid hour of rehab as she seemed in relatively good spirits.

In the afternoon when I went back to see her she was lying in bed and unresponsive to my requests to go down to the gym, her body language telling me the answer was no. There was nothing extraordinary about this as I had often found she was lethargic and uncooperative in the afternoons. However, I persevered setting the wheelchair up next to the bed to see if she would at cooperate with me. Once she was sitting on the edge of the bed I could see she had been incontinent of urine in the bed and was quite wet. I told the patient I would get a nurse to clean her up and she burst into tears. I have been working with this patient for 4 weeks and haven't once seen her cry so I was quite astonished. I reassured her it wasn't her fault and was able to cheer her up to the extent she was laughing and smiling in the gym. Later I asked her if the reason she didn't want to come down was because she had wet the bed and she nodded, becoming very upset once more.

This incident made me realise that I have become almost immune to incontinence as I have seen so many patients wet the bed or a chair, and so it's not really a big deal to me. This has perhaps caused me to not be aware of the impact it has on the patient. Even though the patient I saw was incontinent maybe once every day or second day, that didn't stop it from being an embarrassing and distressing experience. This lack of awareness is possibly shared by a lot of staff, as evident by the fact that most people neglect to show the patient any reassurance or comfort when they need it. While it is obviously important to clean the patient up, it's easy to forget how you would feel yourself if you had just wet the bed. So in future I will endeavour to see things from the patient's perspective and remember that even if it isn't a big deal for me, it is probably a big deal for the patient.

Cardiac Problems

On my cardiopulmonary placement I have been exposed to a large range of patients. When doing an analysis we commonly have 10 potential problems. Are they present, what priority do they fit? In analysing the patient's problems, there are a lot of other problems that need to be considered, such as anxiety, drowsiness, nausea/dizziness, medication, sedation, ventillator settings etc. Other things like, surgical procedure (complications of, wound, pain Mx) and PMH also play a big role. For instance I presently have a patient who is on SIMV with a peep of 12 and pressure support of 10. This contrindicates the patient for manual hyperinflation. He is on these settings due to previous poor gas exchange. He is sedated, a ex heavy smoker, hx of hypertension and alcohol abuse. Every time ventillator weaning is attempted sats drop to around 91. I thus was thinking could this patient be a CO2 reatainer and we will never see really good sats when he is left to breathe on his own. He becomes agitated when the weaning occurs but this coincides with coming of the sedative meds. Suctioning rises his BP and has the potential to cause more collapse but he does have aspiration pneumonia. I understand that problems can be contrindications but i think a contrindication can also be problems. I realise that prioritising problems can be a very in depth process.

Supervision

For me, supervision on practicals can influence my learning hugely. I like a supervisor who is approachable and supportive and who provides thorough feedback.

I have been very lucky as I have found all of my supervisors this year have been very approachable. I have come across supervisors in previous years that don’t give much guidance and can make you feel like a nuisance. During these placements I found it difficult to ask questions about an assessment or treatment technique and this limited my learning. Every supervisor this year has told me throughout the placement that if there are any questions or queries they are there to help.

I particularly like it when the physiotherapist supervising me asks how I’d like to receive feedback, whether I’d like feedback during the treatments session or whether I like it left until the end. I personally like feedback during the session so I can correct my technique and practice it there and then. Not only does it benefit my learning, it also benefits the patient’s treatment session. I really like supervisor’s who provide feedback when you would like it.

On one practical I had a different supervisor each day. At first this was challenging as different supervisors can contradict each other. However, by the end of the placement I had learnt 5 ways of treating a patient instead of one. I think with more experience we will learn our own style and select techniques we have learnt from different physiotherapists.

Communicating with supervisors is vital for us as students as we want to make the most out of the placement. Approachable and supportive supervisors aid to broaden our knowledge as physiotherapists. Although each supervisor may tackle a patient differently or provide feedback differently we should recognise which qualities we like best as we are all likely to take on supervisory jobs in the future. I’d be interested to hear others ideal qualities of a supervisor.

Time Management

It’s so easy to become lost in time when working on a hospital ward, and it pays to be mindful of the effect this can have on patients. I remember whilst being on my orthopaedic inpatients clinic, I had one patient who was off-handed when receiving physiotherapy treatment. After a while, he informed me that he had a previous knee replacement, and a physio had applied CPM for his knee but had subsequently forgot to take it off. He still appeared disgruntled over this. As I had to apply CPM for his Day 1TKR, I assured him that I would be back within the hour. I wrote it on my patient list in big bold writing, to ensure I would not forget to remove the CPM, as I myself occasionally had the tendency to let time lapse. As a result, I remembered and the patient appeared surprised but happy that I remembered. From this time on, he was more respectful and compliant with physiotherapy.

Sometimes during physiotherapy sessions, I will say to the patients that I will see them later in the day, providing I get time. Occasionally, as the wards can become busy, I may not have time to see the patient again, as they are not a priority. Alternatively, I may see them a bit later than what I originally intended. Even though it does not affect my emotions, I have found that if I don’t inform the patient I will be a bit late or not get time to see them again, many can become offended and in turn not be as willing to co-operate with physiotherapy.

Even though our time doesn’t revolve around one specific patient, it is still important to remember to be courteous and tell them what is happening, so they know we haven’t forgotten about them. I have found that I generally only focus on my own time schedule, and forget of the impact this may have on patient emotion and wellbeing, as physiotherapy sessions are an integral part of their rehabilitation and are an important part of their daily interactions. I am now writing down, along with the time, if I mentioned to a patient I may see them later in the day to ensure I do not forget to see them, and if I do not have time to see them, I will communicate this with them. Alternatively, if I am running late, I will try to pop my head into their room to let them know. By now looking beyond myself and factoring in patient emotion along with time management and communication, I find I am now developing better rapport with my patients and subsequently better results in physiotherapy, as they are now more compliant and co-operative with my instructions.

Ebstein's anomaly

I recently had the opportunity to treat a patient with some very unusual and complex conditions during my cardiopulmonary placement. This patient had been admitted with pneumonia, but had an underlying history of several previous admissions for pneumonia (since he was seven, and is now in his 60's) and cardiological anomalies, one of which was Ebstein's anomaly.

Ebstein's anomaly relates to the tricuspid valve (between R atrium and ventricle) being congenitally displaced down towards the apex of the heart. This reduces the size of the ventricle and obviously relates to poor contractility and output from the R side of the heart. There can also be a patent foramen ovale creating shunt between L and R sides of the heart, as well as enlargement of the anterior leaflet of the tricuspid valve which affects regurgitation of blood into the atria. All of these lead to a raised JVP due to the decreased effectiveness of the R side of the heart. This patient definitely had a raised JVP. He also had peripheral vasoconstriction (to the point that his feet were purple and hypothermic) and extreme tachycardia. He also had shortness of breath, especially on exertion and fatigue, all of which is typical of a patient with Ebstein's.

I was treating this patient for his chest by using the ACBT in sitting. The auscultatory findings indicated greater secretion retention in the L lung, so after doing ACBT in sitting and reauscultating, I decided to treat him in R side ly. The patient lay on his L easily but rolling over gave us both a shock. He immediately groaned, closed his eyes and raised his hand over them, and began restlessly moving on his back. He said he felt 'bad' and had to sit up. In this time he became hypoxamic, increased tachycardia, very dark colouring in his face and exhibited dizziness and distress. I was very concerned and grabbed the nurse coordinating and his own nurse. He stabilised very quickly in his SpO2, alertness and became calm quite quickly once sitting up. We mutually agreed I should leave him to recover, while the nurses proceeded to use a "bear hugger" (warm air body bag) to reduce the hypothermia.

Well. Why did it happen? Cyanosis is a resulting problem for patients with Ebsteins, especially with a severely leaking valve. I have not been able to find any information as to why L side ly was the trigger and not R side lying. Could it be the pulmonary venous volume and pressure shift by the changed position from sitting to sidelying and rolling over? Could it be a poor orthostatic adjustment? I'm not sure but it was a critical situation for a moment and I would like to know more about the mechanics for this occurance and whether it is normal or not. If any one has any other ideas relating to the incident, I'd appreciate them. Perhaps there are better ways to treat such a patient that avoid this situation, or perhaps it was a unique one. Otherwise, I hope you learned something interesting about an interesting condition. Either way, however, for your patients with unstable conditions, where cardiological, pulmonary etc, it is very important to keep monitoring their vitals - things can change very quickly!!!!!

Education = Efficiency

This is another reflection from the SDP undertaken in a Fijian Hospital…

During a ward round in the trauma/ortho ward, we questioned what sort of exercises these patients were doing. The patients in question had all sustained high impact fractures, were all in bed traction, and therefore had been, or were going to be on bed rest for anywhere up to 8-10 weeks.

The physio replied vaguely that some of them sometimes do bed exercises, however chest care was done routinely (they considered this of higher importance). We spoke to the patients on the ward, who reported ‘not really doing much’ whilst being in bed. Some had been shown exercises at the beginning of their stay, but had forgotten or not known what they were for, so hadn’t done them.

We were pretty amazed that something that is drummed into us at home in an ortho ward (the importance of bed/maintenance exercises, to prevent deconditioning and speed up recovery) was relatively overlooked at here. We were wondering if it was influenced by the patients wanting to stay in hospital (free accommodation and meals). We have the mentality in Oz that the patient needs to be D/C ASAP to make room for another patient (and how much it costs the government to keep patients in hospital) so we push bed exercises to facilitate D/C.

The time we spent with the patients on the ward, involved not only teaching them relevant bed exercises, but leaving them with hand drawn pictures of the exercises next to their bed and emphasising what they were for and how important they were.

We did appreciate that the physio’s were short staffed and lacked equipment, so we worked on a way that we could educate the local physio’s and make this an area that was done routinely. As efficiently as possible for the physio.

One of the tutorials we ran emphasised the importance of bed exercises and education and demonstrated a “Mobility continuum post orthopaedic injury and discharge facilitation”

A major point emphasised was the fact that education to a patient is SO important, and that they, as physio’s, have a MAJOR role in this education. The patient needs to know why they were given the exercises to increase compliance. The local physio’s, we found, had excellent theoretical knowledge, however there was a gap between this and their clinical application.

There were many areas that needed attention in the hospital, however our supervisor advised us to have a couple of small goals, otherwise you don’t feel like you have achieved anything.

So one goal, that we hope we achieved, was to emphasise the importance of bed exercises and a physio's role in education. We developed 2 patient handout sheets (one each for UL and LL injuries), we photocopied heaps of copies and left them on the ward, easily accessible.

I guess that our recognition that this was a major component lacking in the physio’s treatment, made us realise how important it was to us aswell. We understood the importance of education enough to teach someone else how useful it is.

Communication + + +

This is a reflection on the first prac of the year, so had not had as much experience at this stage, both with patients and supervisors!

I was undertaking a prac which involved participating in multiple areas (ortho, burns and plastics) Due to this, I also had a number of different supervisors. All the supervisors were brilliant in their area and extremely knowledgeable. The thing I found difficult was the conflicting information I was receiving about things such as my performance with patients and protocols on how to perform certain techniques ect…

It became especially evident when receiving mid placement feedback. The supervisors I had been working with liked to give feedback along the way, and discuss certain points as they arose. I had had a few discussions with a supervisor regarding how she liked to be given handovers and specific things she would like me to do with certain patients. During my mid placement feedback, another supervisor gave me feedback on length about what had happened with that other supervisor (I hope your following this!)

Because he was repeating what I had already discussed with the other supervisor, I thought he was having a go at me (as if I hadn’t listened to the other supervisor) So I got fairly worried that I wasn’t doing things right.

I had also had an incident where one supervisor had said I had done a really good job with this patient (although she was not the usual supervisor for that ward), and the next day told by that ward supervisor that I should have done this, this and this… So again, I felt like I had not done it right!

As this was a first placement, and first feedback, I was slightly nervous about telling the supervisor that all the things he was telling me had been discussed. I spent a good day stressing that they thought I was useless. I ended up telling my main supervisor that the others had already given me feedback along the way, he acknowledged this and admitted that things were a bit haywire at the moment and not as organised as they should be. He appreciated me giving him the feedback that I was getting mixed feedback and then had a discussion with the other supervisors to try and communicate more in sync.

I guess I learnt that communication on every level is important, both between you and your supervisor, but also between the staff looking after you, otherwise feedback may get confused and create unnecessary stress.

Taking things for granted....

I recently spent a week in a hospital in Fiji as part of a self directed placement, what an eye opening experience….
There were numerous events that could be reported on, however there were a couple of things which stood out.

We were on a ward round with the local health professionals, and visited the men’s trauma ward. Due to the lack of surgical supplies (pins, plates etc) as well as anaesthetic and antibiotics, most of the fractures are managed conservatively with the patient put on traction. This in itself was pretty overwhelming, as traction in adult patients is not done routinely here (as far as I know?) The most common were LL tractions, however there were a couple of cases where skull traction was applied for spinal patients.

We listened closely in the ward round, and found the conversations and Xrays fascinating. There were many high energy/impact accidents, so the Xrays were pretty remarkable. We reached the bed of one patient who had broken his NOF, he was fairly elderly but didn’t appear to be coping too badly (elderly has a slightly different meaning here, as we were told the life expectancy was approx 61 for men and 64 for women) As like many of the other patients, he was managed conservatively as the available anaesthetics were kept for higher priority patients needing surgery.

The following day we actually sat in during surgeries run by the Australian hand surgeon we were travelling with, so were not up on the ortho/trauma ward.

The next day we made our way back up to the ward to help out the ortho physio. Upon entering the ward, we were aware that a curtain was drawn around one of the beds and a woman could be heard sobbing hysterically. The physio told us that a patient had died over night and his wife was mourning by his bed. The rest of the staff and patients were getting on with their daily routines in the ward.

We found this very confronting for a number of reasons. We found out that the patient who died was the one with the broken NOF. Apparently it had either got infected and the infection travelled to other areas of his body, or it had been a fat embolus, the person who informed us was unsure. We were astounded that something that could be managed relatively simply in an Australian hospital, had caused a man to die. The second thing that amazed us was that they had kept the body (and the mourning family) in a fairly public place. There were heaps of people moving throughout the ward, walking around this family. I think here in Australia, death tends to be a very private affair to begin with, with a private room for people to grieve. The hospital didnt had the luxury of giving these facilities.

It made us really appreciate the facilities we have available at home. I guess until you are exposed to a completely different situation, you take little things for granted.

Giving advice to patients, contrary to their doctor's actions..

I was treating a male with an ACL rupture. He was in a Richard’s splint, movable between 0 – 30 degrees. His consultant told him he needed physio and admitted him due to his extreme pain. Surgery was not discussed. The patient was a young, fit, strong guy who was a labourer and played sport quite competitively. He exhibited the classic ‘yellow flags’ of a pt who was fixated on pain – his face displayed exaggerated agony with any movement, even of the unaffected leg! Yet when asked to stand, he would SLR his affected leg and swing it over the side of the bed, only complaining about the pain as he tried to stand. He was always on the phone, telling people about his extreme pain, taking many photos of his leg and the questions I asked were only answered relative to pain. He catastrophised (“I’ll never walk again”) and although he could move his knee within the splint, he would stop the cpm machine as soon as I left the room, even though it was set to a max of 30 degrees. He was also non-compliant with unsupervised exercises. The patient was on the maximum analgesia, including morphine shots prior to physio. Additionally he was a worker’s comp pt, which was clearly identified on his notes as was the statement “NO OPERATION WITHOUT EMPLOYER’S CONSENT”, which I thought was an odd request – I was under the impression worker’s comp covered all necessary treatment, that it was not at the employer’s discretion..

I was concerned about this patient due to his pain fixation and lack of commitment to helping himself. However, I thought that the patient’s demographic, lack of co-morbidities and high activity level would have warranted at least a conversation about surgery? Anyways, he was an inpatient for only a few days then he was abruptly discharged and told that we were unable to help him further.. It was suggested to me that the consultant and pt had clashed personalities and that this discharge was similar to others with this particular dr. Whether this was true or merely gossip, ACLs don’t heal themselves and as we all know, there are some pretty sound pathways for intervention post ACL injury. Although this was a difficult patient who I personally found quite draining to treat, I felt that he had been denied some quite standard treatment.

Anyway.. the discharged pt asked me if he should get a second opinion as he didn’t understand why ACL recon wasn’t offered. I found this situation very difficult – I did think surgery should have at least been discussed, but a capable surgeon had decided not to. I handled the situation poorly and said I wasn’t qualified to give that advice and that it was entirely a personal decision..

Patients respond differently to situations and to pain, but trying as they may be, they all deserve appropriate levels of care. As medical professionals we are privileged to more information than those who do not work in this field – is it then our duty to advise others not privy to this knowledge?? As a qualified physio I think I would give the patient honest advice (ie get a second opinion), but be really careful about maintaining professionalism and not affecting the dr’s reputation.

Continuing Development

After a short week last week and smooth operations on the ward, my inspiration for this blog concerns our professional development.
I was recently offered a position as a physiotherapist for a school rugby trip to New Zealand. The trip would have been a great learning environment and opportunity to enhance my physiotherapy skills. The problem with this trip is that it would occur whilst i was on one of my future clinical placements.
My ideal situation was that hopefully it could count as my self-directed however i did not mind if i sacrificed holidays and completed the allocated placement at another time.
Fast fwd to present. I did not go on the rugby trip and I completed my second clinical placement. My query lies with this year being concerned with our professional development however we can't have learning opportunities factored in. I understand that it is difficult to find placements for our large cohort however i have had other placements changed and it makes you wander why other changes can't be factored in.
I feel that these opportunities develop us into better physios for the future. Graduating with more experience will develop the marketing power for new grads and portray Curtin University students as having sound clinical experience.
As no-one commented on my sick days blog :( I look fwd to one piece of feedback to know that my ideas should not just remain in my head and never be heard. Haha hope all your placements are going well.

grumpy patient

I usually inform patients (and nurses) first thing in the morning that I will be seeing them later in that day. I was going to see a patient for the first time and upon reaching the ward, I learned from a nurse passing by that the patient is in the bathroom. Upon knowing that I’m seeing that patient for the first time she immediately warned me that the patient has a grumpy demeanor and is very irritable. I also read his file and learned that he has dementia. There were entries there saying that the patient is very upset that he has to stay in the hospital, that he is not very keen to do physio and that he declined physio many times already. Since I have not encountered anyone like that in that particular placement I got very anxious and thought, “What if the patient shouts at me and tells me to go out as soon as he sees me?” So I tried to think of strategies to try and convince him to do physio in case he refuses to participate.

So later that day I went to this patient’s room and found him in bed watching tv. My anxiety escalated exponentially with each step I took towards him. The moment he opened his mouth I braced myself, ready to hear some profanity but instead he said, “Hello there” in a very pleasant tone. So I was thinking to myself, “What? Is this a precursor to some tirade later on?” I was half expecting to be out of his room in 5 minutes but I ended up providing him with exercises, education about his condition and building rapport in 45 minutes. At one point within that period he told me I looked a bit tense. I was surprised because I tried my very best to conceal my anxiety.

At the end of the session he thanked me for getting him to do those exercises and for explaining to him everything. He said he it upsets him that the others (health professionals) spend so little time explaining to him the procedures that are being done on him and exercises he’s doing. I then realized that that is one of the possible reasons why he was so grumpy and upset.

I also learned from that experience that while it is good to prepare yourself before seeing a patient, it is not good at all to ‘overprepare’ to the point of getting yourself anxious. I was lucky that the anxiety did not impede with the effectiveness of the treatment. This situation happened in my three-week placement in 3^rd year as well. I didn’t know how to handle it that time so I was very defensive throughout the treatment session. 

On rapport, talkative patients and treatment effectiveness

In my gerontology placement, I encountered a patient who just loves to talk. On our first session, she kept talking until the session finished and even until after I said goodbye to her. It was tough to handle especially because English is not her first language and therefore her diction and accent make it hard for me to understand what she is saying.

Most of the time she would talk about things that were not really relevant, like what she thinks about crayfish and other seafood in Australia (her Abbreviated Mini Mental Exam score is 10/10, which is good), so it was very tempting to dismiss most of what she was saying and concentrate on getting her to perform exercises instead. However, she tends to mention very relevant details sporadically, which were completely different to her answers that she gave me earlier during subjective.

After seeing her, I reflected on what the session achieved and realized that apart from good rapport, there was not much. So then I spent some time reflecting on what had gone wrong. Obviously one of these was that the patient was talkative and I don’t have lots of experience in dealing with such type of patients. Secondly, I realized that I found it difficult to interrupt people when they speak mostly because in my culture it is always perceived as rude. That made it even trickier with this patient because, with her, there were no pauses at all. Lastly, I did not put enough structure into our session that day. I had a list in my mind of the things that I wanted to do but I did not spend much time organizing them in terms of the sequence.

 

So next time I have to face a situation like that, I will make sure that I will inform the patient about the aims of the session and make sure that they understand it as well as making sure that the patient understands my questions. Also it will be very helpful to be firm about telling the patient to refocus on the task at hand. Building rapport can be limited to rests in between exercises. My clinical tutor told me that situations like these really need active listening and that I could also repeat the last sentence the patient said and quickly re-route the topic back to the exercise or task at hand. 

Dealing with doctors

During a previous placement I encountered a challenging situation in regards to professional communication and the role of the physiotherapist in a multidisciplinary team. The patient was a man in his mid sixties who was admitted for a quadruple coronary artery bypass graft who, among a significant list of co-morbidities, had chronic renal impairment that required dialysis. Following this surgery it is common for patients to have low haemoglobin levels and this is monitored by the medical team with daily blood tests. Usually a patient with a low Hb will be monitored and if they are symptomatic and Hb near 80 then they are likely to be transfused.

This patient had a Hb level between 80-83 for five days. During the four days the patient had been on our ward they reported dizziness, fatigue, high resting and exercise heart rates and low blood pressure. These symptoms impacted on our sessions to the point where the patient was only walking 40m sections before needing a rest and was not progressing anywhere near a rate expected after this surgery. I discussed this situation with my supervisor who suggested I talk to the medical team to see if a transfusion was possible. The RMO informed me that as the patient was having dialysis to remove excess fluid from the body, they were not interested in adding anymore. I asked if there was an alternative but was brushed off and told to continue with what I had.

I continued to treat the patient within these restraints but progress was very slow. The following week I attended the early morning ward round with the consultant, registrars and RMO. When we got to the patient, it was commented by the consultant that the patient was progressing slowly and it was suggested that the physiotherapist needed to work harder with the patient and see them more regularly. I did not appreciate this comment as I had been spending quite a bit of time with the patient and I felt quite intimidated in this situation; however I took the opportunity to express my concern about the patient’s symptoms. The consultant questioned why this had not been bought to his attention sooner and said that a solution to increase the Hb would be found with the renal team.

From this experience I have learnt that it is worth getting a second opinion from a medical team if you believe that something is not being dealt with appropriately, however you would want to make sure that you are 100% sure of what you are saying as dealing with the senior doctors is quite an experience. The RMO did not know there was an alternative but rather than asking the question they ignored the problem in the hope that it would go away.

Nursing staff and student physios: clash of the titans

Earlier on in the year I had an orthopaedic inpatients placement and often had trouble negotiating with the nursing staff when I wanted to treat a patient. On one particular occasion, I was meant to be seeing an elderly woman who had undergone a THR the day before. I had already checked the Xray to make sure that the joint was properly aligned, her haemaglobin levels were within normal limits and the doctors orders were for her to be WBAT today. I ran all this past my supervisor and she agreed to go ahead and get her up and standing if my objective examination deemed it appropriate.

However, when I went into the room a nurse approached me immediately saying 'she can't have physio today'. I was a little taken aback, and asked her why this was. The nurse then said that the patient had been very anxious and she had only just calmed her down and got her to sleep. I was unsure how to deal with the forcefulness of her statements and decided to ask my supervisors opinion.

When I told my supervisor of the situation and explained which nurse had been so quick to shut down my attempts at treatment she told me that this particular nurse was known for being a little pushy and thinking she knew what was best for the patients. She suggested I go back in a little while when the nurse wasn't there and see how much examination I could get done. I felt somewhat strange about what I felt was going behind the nurses back but I took her advice anyway. The patient woke up again and was calm, giving appropriate answers to questions. As she was slightly dizzy when SOEB, she only sat in that position for a short amount of time doing deep breathing. The nurse didn't come in while I was treating the patient and was probably not aware that I did unless she read the notes the next day.

I have been in similar situations since then, and have learnt from this occasion that while it is sometimes difficult to stand up to other professionals (especially when they have been working there for many years and are very confident of their own opinions) it is important to make your case (within reason). It is not really up to the nurses to decide whether or not you can treat your patient even though some of them will try to tell you. Obviously it's important to take any information they can provide about the patient on board, but as long as there are no safety issues and it is cleared with the doctors, it is really down to you whether or not the patient is fit for treatment.

Creating pain for gain

On a previous placement, I was working with chronic stroke patients who presented periodically to the outpatient gerontology clinic. The main issues they seemed to have were difficulty walking due to poor weightbearing on their affected side contributing to poor weight translation on to the unaffected leg. Their weight is predominantly on the unaffected side already. This means the patient will abduct and/hip hike with the affected limb to clear it through the decreased swing phase in combination with the increased lower limb tone. These patients were presenting to me at least ten years post stroke, so the habits they had formed to enable ambulating were quite strong. However, if you imagine this gait pattern, you can easily see how balance becomes an issue as they are prone to overbalancing on their unaffected side.
I spoke to my supervisor after assessing such a patient, with the plan to improve the patient's weight transfer, first in sitting then standing, and progress to gait retraining. I was also going to implement some spasticity reducing techniques. My supervisor gave me the go-ahead. I found, though, that the weight transfer strategies were not working well and the patient's really struggling to complete the task. I went back to my supervisor for assistance and she suggested SIMMS. The idea of these is to release the soft tissue by pressure application to trigger points in the muscle belly followed by release in the direction of the muscle fibers (usually towards the origin) and forcing the joint the muscle crosses into further range that stretches the muscle. My stroke patients had complained of pain between the first and second metatarsals but I had placed it low on the priorities, until now. I began focusing the SIMMS on between the metatarsal heads and in the soleus of the affected leg. The patient was immediately in so much pain that I felt I should stop. My supervisor recommended I continue until release was apparant. However,I had to dodge and block the patient's flailing arms and legs trying to kick out at me, and listen to a lot of painful moans. I felt terrible. But when I reassessed his gait, the difference was amazing.
Instead of leaning heavily on the walking stick and being overbalanced on the affected side, the patient could weightbear on both limbs, take nearly equal steps and naturally began to flex at the hip, and more importantly, dorsiflex and plantarflex the ankle to clear the foot. I was amazed, it was such a difference and the patient really appreciated it then.
Therefore, if you know there is a benefit to the technique, sometimes you have to coax a patient through pain in order to get the best result for them. I could do more for my patient through the painful way (and yes, he did come back) then I ever could have doing sitting weight transfer techniques. So if you know you will make the difference, go for it!

Confidence

I am currently completing my cardiopulmonary placement at ICU. I was seeing a multiple trauma extubated patient who was due to go to the ward that afternoon. I approached the nurse and asked what time it would suit to treat this patient. The nurse brushed me off and said he had to wash the patient and transfer him to a ward bed. I said I’d come back in a half hour and see how everything was going. When I returned to the patient the social worker was seeing the patient. As soon as the social worker left I approached the nurse. This time I was more assertive. I told the nurse that I needed to see this patient this morning before lunch and asked if now was a good time. He finally agreed.

When I auscultated the patient I heard decreased breath sounds in the lower zones. Following auscultation the patient asked what I’d heard. I explained that air wasn’t getting right down to the bottom of the lungs so we needed to do some breathing exercises. As I was explaining this to the patient the nurse was shaking his head at me and telling me to stop. The nurse then took me aside and told me that I shouldn’t be telling the patient my findings because he was very anxious following the accident. The nurse was very rude and treated me in a condescending way. I was extremely embarrassed as the patient was close by and probably realised what was going on. I went and chatted to my peers and supervisor and decided to treat him after lunch. The general consensus was that the patient had the right to know what I’d heard. I couldn’t rationalise to the patient why I was doing breathing exercises if everything was fine. There was no point in lying to the patient to limit his anxiety.

This experience taught me to be more assertive with the multidisciplinary team. I needed to see that patient in the morning and even though the nurse didn’t think the patient had to be treated I needed to be more confident when communicating with him. When the nurse questioned me about telling the patient breath sounds I should have been surer of myself and said that the patient had the right to know. Confidence is a huge part of being a physiotherapy student and is a quality I am hoping to further develop during these placements.

Communicating with Rural Aboriginals

I am currently on my cardiopulmonary placement, and have been allocated an older Aboriginal woman to treat. This woman was transferred to Perth from a small Aboriginal community east of Perth, for a surgical procedure.
As you would be aware, a pivotal component of treating a surgical/cardiopulmonary patient is ambulation. This acts to increase tidal volume to therefore increase secretion mobilisation, it positions the patient to best increase lung volumes to ensure adequate perfusion and prevent V/Q mismatch, it increases recruitment of lung units to help re-inflate atlectatic segments etc.
Initially, I found it very difficult to treat this patient. She refused to ambulate, was reluctant to take deep breaths, used offensive language, and would only intermittently answer questions. As nice as I tried to be to this patient and despite her limited English, I got the hint that she disliked physiotherapy when she kept telling me to “go away”, that I “talk too much”, and that I’m young- why don’t I walk instead of her. She was fast becoming a patient I wanted to avoid, however I still persisted with her.
I had treated Aboriginal patients prior to this experience, but no one had been from such a small community. I was aware of some cultural differences, such as they don’t make eye contact and the importance of family, but I was still vague on ways to treat this patient without causing cultural offense and the implications that these factors have upon emotions.
It wasn’t until a nurse came to the ward who had worked in an Aboriginal community that I feel my rapport with this patient began to build. This nurse told me the patient did not like being called by her name, but preferred being addressed as “nanna”. This nurse also educated me on key words from her Aboriginal dialect, such as “walk”, “foot”, and “pain”. I was also informed of additional cultural differences to take into consideration. For example, older Aboriginal woman generally sit most of the time and act as a storyteller, therefore they may not be used to walking long distances. Also, not making eye contact is not a sign of dislike but rather a sign of respect. There were also emotional considerations for this patient, such as a family funeral which she could not attend (due to her hospitalisation). Family is an integral part of Aboriginal life, and the fact that she could not participate in the process of mourning would have been very distressing. Also, this woman had not been visited by any family, which would have attributed to her frustration as she was used to being surrounded by her family. Furthermore, as she originated from a small community, she would not have been accustomed to being in the small confines of a hospital room and would be longing for her freedom.
Taking these factors into consideration has led to me develop a new understanding of this patient and resulted in better compliance from the patient. I now know that she is not trying to make my time difficult, but rather her attitudes are reflections of her frustrations. Now, I even occasionally get a “thank you” from this patient, and told that I am “a good woman”. She still does often refuse to ambulate and often uses offensive language towards me, but at least I know it’s not personal and that she must be longing to return home.
My suggestion is if there is someone on the ward who is experienced working with such individuals or within such communities, communicate with them and gain as much knowledge as you can. Not only will it help develop your own understanding, but also put the patient more so at ease. If there is no one on the ward to help, contact an Aboriginal Liaison Officer that works within the public health system, and enquire regarding optimal ways to communicate with the patient. Alternatively, see if the officer is able to visit the patient if they have not already done so. Also, if you see such a patient on the ward and you are not allocated to treat them, request to have them added to your patient list, as it is definitely a learning experience and should hopefully place you in good stead for your rural placement.

high quality reflections

Hi Everyone,

You are all obviously thinking a lot about how we as physios can impact on our patient's lives and how there is alot more to physio than giving patients some exercises to do.

I have been really impressed by the quality of your reflections.

Keep up the good work.

Kate

Sick Days

I am presently on placement at ICU and in the lead up to the long weekend i started to develop a cold :( This progressed on the weekend and Monday night i was still feeling quite down and out and awoke this morning not feeling much better. This placed me with the delema, do i call in sick or go to work still coughing and with a bit of a temperature? As we are allocated sick days, I guess they are available for this purpose however i don't like to take them.

I may have not taken the day off had I been at another placement but as I previously mentioned i am at ICU. I felt that these patients have already got multiple problems, 80% have ineffective coughs and given the nature of the cold i developed i didn't wish to pass it on.

I decided to take the day off and now that leaves only 1 sick day left. If i had 0 left or i think it would play on my mind if i take another day off, knowing i would have to make up the time at a later date, or just battle through. Would this scenario mean we are going to work when we shouldn't be? Could I have gone to work today and my patients would not have caught my cold? Will it be contagious tomorrow? Would families who have someone at ICU want you treating them? Are there any objective measures, e.g. temperature checks, that can clear us to work?

Repertoire of exercises

During my women’s health practical I taught post natal mothers exercises for their pelvic floor muscles and abdominal muscles. Pelvic tilting was used for both abdominal strengthening and relief of back ache.

I began teaching a post natal woman these post natal exercises. Whilst I was teaching the exercises I realised the lady had limited English so I tried to use simple instructions. She could perform all the exercises well except the pelvic tilt exercise. I explained the exercise and demonstrated the scooping action of the pelvis in standing, but when she practiced it in crook lying she had difficulty tilting her pelvis and instead performed a bridging action. I didn’t want to give up on the exercise, but instead of changing tact I became frustrated and persisted with the same instructions. I started to facilitate with my hands and used simple verbal cues and eventually the lady grasped the aim of the exercise.

I was lucky that this patient was so determined. She didn’t become frustrated at all. I realise, however, that not all patients are this compliant. I learnt that I needed to have alternative ways to describe the exercise to the patient. I had thought about alternative positions such as 4 pt kneeling, however, this position didn’t suit this patient. Other methods of teaching the exercise could have included placing my hand in the patient’s lumbar spine and asking her to bring her back towards the bed, creating posterior pelvic tilt or describing pubic bone movement to the patient.

As physiotherapists we are continually prescribing exercises. It is very important that we can do this in a manner all patients can understand. We therefore need more than one way to teach an exercise or concept. I think watching other therapists teaching exercises and talking to other students is helping to build my repertoire of exercises.

Pain

During my musculoskeletal outpatient placement I had a patient who presented with a three month history of constant 7/10 back pain that is aggravated by even the simplest of actions such as walking or sit to stand. While completing a detailed subjective examination I was told about this patient’s long standing history of depression, multiple personality disorder and suicide attempts that have required numerous admissions to mental health units across Perth. The patient reported that she was medicated with a number of antipsychotics and antidepressants as well as strong pain killers including morphine.

In terms of the impact of her back pain on her life, the patient reported that most days she would walk for about 10 minutes before her pain was so bad that she would take a morphine tablet and sleep for a couple of hours. The patient was under the care of multiple teams of doctors and had had a number of investigations to rule out more sinister causes of this lower back pain; however no clear diagnosis had been made.

After completing my subjective I felt quite overwhelmed by the amount of information and the severity of this patient’s problem. I was really not confident about how to approach assessment and treatment for a patient with such severe pain and irritability. I discussed what I had found with my supervisor and that I felt that Physiotherapy may not be appropriate for this patient. We agreed that it was still worth completing a modified objective assessment to try and get as much of a picture as possible.

Objectively I found a tight, hypomobile Lx spine and poor habitual sitting postures. This was treated with STM, gentle PAIVMS and education about posture and the use of heat for muscular pain.

The patient reported that they while her pain had not really changed with the treatment she felt that she was doing something proactive about trying to help it, which is something that she found hard with her other conditions. After discussing this with my supervisor I can see that while we may not be able to alter many aspects that contribute to the patient’s problem, it is possible that we can help the patient both with hands on treatment and providing an opportunity for developing self management of contributing factors like posture and exercise habits. I feel this experience has allowed me to more clearly see that while the patient can have many issues in their life, we can have a role in changing those factors within our control.

Stroke patients are people too

Last week on my neuro placement I was asked to help one of the physios treat a woman who had recently come in with right sided hemiplegia as a result of a stroke. She has expressive aphasia, and was in a much earlier phase than the other patient I had seen with this condition. She answered 'yes' and 'no' to direct questions, but sometimes didn't answer at all. She would sporadically say an actual word, but for the most part was very uncommuncative, which made me glad I wasn't alone to treat her.

The physio told me to go in and introduce myself and have a look at her tone and voluntary movement and she would catch up with me. So I went in, started chatting to her, remembering to ask lots of closed questions to give her a chance to communicate. However, she didn't say anything in reply and her face was expressionless, which left me feeling more than a little bit stupid. As the treatment session progressed she answered two of the physios questions with 'yes-no' answers but had not yet said anything to me. Even though I knew she had expressive aphasia I found myself getting quite annoyed because I felt like she was ignoring me and I wasn't used to this sort of treatment from patients. I decided to just concentrate on getting the most work done in the treatment session, and while I was focussing on this I made a silly joke about the patient getting her foot in the right position on the step (we were practicing step-ups). The patient looked down at me, smiling with one eyebrow raised, and for the first time I could see the personality hidden behind her diagnosis.

As the session continued I elicited many more smiles and even laughter from the patient, which coincided with an increased effort on her part to get the exercise right. This has reminded me that there is always still a person somewhere behind the condition you are treating, and it's unfair to the patient when you forget that they're human too. It's very easy to judge patients or not put in the effort to build a relationship, especially when on your first meeting they are sullen and unresponsive (even if you know they have good reason to be). However, in the future I will definitely persevere with patients and remember that they were a person before they suffered their stroke, or whatever it was that brought them into the hospital.

Professional Communication

I had been treating a patient every day for impaired airway clearance. He was now spontaneously breathing via trachie and our treatment included manual hyperinflation (‘bagging’), vibes and suctioning, and having the patient hoisted into a chair – none of which are probably particularly pleasant procedures for this gentleman. However, he has always been compliant, greets me with a smile and answers questions with a thumbs-up. I felt we had built some rapport.

He is certainly very ill, often tired, and always has other health professionals at his bed space – it’s sometimes difficult to find a time when he’s free! On this day I was investigating his charts and notes, whilst someone else was finishing their intervention. One of the other students on my placement approached me about the meaning of an abbreviation I had used in a handover to them – I explained that it meant a history of alcoholism. We had spoken only about the abbreviation and not in relation to any patient, thus the communication was professional.

Just then, my patient became available, but for the first time in two weeks, he refused intervention. He wouldn’t even let me auscultate. I asked was he in pain/ uncomfortable? No. Was he tired? He mouthed ‘a little’, but I got the feeling this wasn’t really the problem. Unfortunately I wasn’t able to convince him to allow me to treat him.. It was the end of the day, so my supervisor suggested handing him over to the evening physio.

At the time I thought that he was probably very tired and perhaps disappointed that he had not been transferred to another ward, which had been the original plan for that day. Whilst this may be true, I also realised later that this patient also has a prior history of alcohol abuse which has almost certainly contributed to his current condition. Perhaps he overheard and assumed we were speaking about him? This may not be the case, but it has really made me aware of any communication which takes place within earshot of a patient (or their family). We really need to remember that even when we think we are being completely professional, communication between health professionals may be easily misinterpreted by patients, and may ultimately affect rapport/ the effectiveness of our treatment. In the future I will endeavour to discuss only issues relevant to the current patient, whenever I may be overheard.

The impact of fear

My current placement is on cardiopulmonary based and many of my patients have a current or past history of cancerous complications. Sometimes, I tend to forget this part of their case history and focus with tunnel vision on the cardiopulmonary impairments and solutions. I'm learning to implement more skills than what my placement classification identifies, in order to best treat the patient, as I'm sure you have found already.
I walked into my new patient's cubicle the other day to find her sitting in the chair, head in hand, eyes closed and breathing rapidly. Alert that something was wrong, I began to gently question her about how she felt and her symptoms. She was very pleasant and responsive, but still short of breath as she talked and seemed concerned. She had the tendency to offer me large amounts of information and as I listened I noticed this phrase she used repetitively - "panic attacks". At first I skipped over it, but after hearing her mention it again I asked further. Her response was that she was suffering a panic attack ever since she had been admitted to hospital (over a week) and it was distressing her as she had never had one before. Her normal status was independency for ADLs, without a cough or dyspnoea. Being a good cardiopulmonary student I did my objective assessments and began putting things together. Auscultation showed she did have increased secretions bibasally, and she had a moist ineffective cough with 93% SpO2. I began to explain to her how secretions trapped in the lungs impede gas exchange. I used props to explain this and the fact that this was the likely reason for the breathlessness, not panic. Especially as most panic attacks do not last over a week (to my understanding). If you could have seen her face - the relief was complete. Her breathing calmed, her SpO2 improved to 97%, and she looked more alert and interested. It was quite amazing to me. Then I realised, her history of colon cancer must have been quite a fearful time for her. It is understandable that in this new, scary situation of feeling chronically short of air she would react with significant fear. By addressing the patient's mental approach to her situation, it actually achieved the majority of my physical treatment aim for that session.

How often do we get bogged down in close-answer questioning techniques for our chatty patients, because we are sure we know what we are looking for? We become good at making quick judgements and connections, but also assumptions. I assumed her anxiety was part of her normal disposition and was prepared to cope with it. I didn't consider it as an important factor until further into our discussion. A patient's medical history does have a compounding effect on their approach to health problems and how they cope with new issues, so we can't really dismiss any of it, can we?

Personal Hygiene

Unfortunately, for a lesson to be learnt, an uncomfortable or awkward situation generally must emerge. Hopefully, by sharing this story, you will be able to take on board this advice to prevent it happening to you!
Whilst on my neuro placement, I had to assist a physiotherapist and physiotherapy student in their treatment of a heavy patient at the physiotherapy gym. As this was not my patient, I was not entirely sure of his clinical history, but was aware that he had a severe stroke. This patient was reluctant to participate in physiotherapy, and required much prompting and encouragement to relieve his anxiety.
The focus of the treatment session was to improve his ability for sit to stand, and required 3 person moderate assist. To facilitate standing, the physiotherapist and I were required to place our ‘ungloved’ hands beneath his ischial tuberosities to encourage lifting of the buttocks. As you would be aware, a common sequelae of stroke is incontinent bowel and/or bladder, and as a student, I find it to be a common problem I overlook when treating a patient. Unfortunately, as we progressed to stand, his pad became loose (maybe due to our handling?) and combined with his anxiety, he progressed to perform a bowel action. As it was of copious amounts, we were all left with it being over our hands and all over the plinth. Apart from feeling physically ill, I did feel sorry for this patient as it must have also been an uncomfortable and probably humiliating experience for him. Therefore, we still continued to approach the patient in a professional manner and did not let our inward emotions be portrayed to the patient. Even though it is difficult to do this, it definitely does make the situation less embarrassing for the patient. Needless to say, I have now thoroughly disinfected myself and have resultantly never been cleaner in my life!
Fortunately in this scenario, the physiotherapist was in the room. However, if it were just the other student and myself, we would have found it extremely difficult to support this heavy, full-hoist patient whilst trying to search for cleaning equipment (e.g. gloves, towels, cloths, blueys, air freshner, cleaning detergent), as the gym was located on a different ward. In addition, it was fortunate that this patient was not a high risk infectious patient, as contact with bodily fluids predisposes one to infection.
My suggestion is to make sure you are always are oriented to where such equipment is kept on every ward, and if the patient has an incontinent bowel/bladder, have those supplies within close range. Also, if the patient does have a history of incontinence, always wear gloves when treating the patient! Infection control is an area that can be easily overlooked, especially as students, but by considering simple principles such as wearing gloves, you really are minimising the risk to both you and your patient. Unfortunately, I had to learn this lesson the hard way, but I now know that when I read in a patients notes that they have been incontinent overnight or throughout the day, I definitely will be gloving up and orienting myself to the equipment on every ward!