On my paeds/rural placement I’ve discovered that gaining compliance with children for Ax/Rx is somewhat more difficult than with adults who understand that physio may help them and are willing and able to follow instructions..
It seems that many children get upset/anxious/scared when they feel they have lost control – whether it be not being able to control their movement or control the situation.
To gain trust and compliance we need to provide children with this feeling of control and autonomy, yet in order to achieve our treatment goals the therapist must obviously stay in control of the session! I’ve encountered children who refuse to do anything or do everything other than what you’d like them to do and also the difficult teenager who is just way too cool for physio! But I’ve learnt (from the great team of PT/OT/Speechies) that offering the children a choice is a really easy way to provide the kids with that longing to feel in control and ultimately gain their compliance. It’s much more difficult to ignore/avoid someone who is offering two options than one who is trying to make you do what they want. So, ask them whether they’d like to throw a basketball or soccer ball; find out if they’d prefer to do frog jumps or bunny hops; ask them whether they would prefer to use the stairs at the front or those inside; give the child your about to serial cast the really important decision of picking which colour plaster they should have etc etc. I’ve been amazed by how well this simple ‘trick’ works across the different ages of children on my placement. Even babies like control – let them pick the toy you’ll use for motivation and when they become irritable because your supported sitting has become too hard, make sure they get some comfort from mum before trying a new position.
There are so many examples and I think it is finally starting to become second nature for me to ask a child if they want to sit on the blue chair or the red chair instead of simply asking them to sit. And it is really paying off! My sessions have become much more productive by guiding the children to complete the activities I want them to do, simply by allowing them a choice which is inconsequential to my treatment goals.
Sunday, August 31, 2008
Non-productive sessions
I recently encountered a child who had been diagnosed with arnold-chiari malformation (structural defect of cerebellum, may force cerebellar tonsils and brainstem downwards, often progressive, symptoms include balance/co-ordination problems, muscle weakness which all obviously affect motor development). She also has some other undiagnosed behavioural/social problems. This 3 yo client had really struggled to achieve every motor skill she had acquired and through much support of her very patient mother she was now walking; which is what we were hoping to assess.
Unfortunately, upon seeing the physio (whom I think probably represents a lot of hard work in the mind of the child), the child starting screaming. Mum carried her into our treatment room where she continued to scream and cry. Being able to actually treat the child was an idea written off early in the session, but we tried to console/ distract/ bribe her in order to achieve some sort of assessment to guide our advice to mum. Eventually it seemed we were not going to be able to assess the child who continued to cling to mum and scream until she was hoarse, for 40 minutes. The physio indicated that we were giving up and I assumed this would be the end of the session. Instead though, the physio asked mum to read an entire book to the child before they could go. Mum calmly read the book and the therapist addressed the child, saying “now that you’ve finished reading it’s time to go home”. We arranged a home visit for our next session, where Mum suggested we hide in the next room and observe through the window while mum played with the child!
Anyway after this first session I asked about the book reading and I soon realised that whilst this session was obviously non-productive, the therapist was preparing the child for next time, trying to change her negative associations with the physio and with therapy. By allowing the child to read with mum then go home, her association to the centre might be with something more fun like reading. I realised I would not have thought of this very simple idea. We have all had patients who for some reason are non-compliant on particular days and we want only for the session to be over so we can start afresh next time. I now appreciate how important it is to think about not only the individual session aims but your long term goals and remember that your actions have the potential to influence not only the current session, but future sessions as well.
Unfortunately, upon seeing the physio (whom I think probably represents a lot of hard work in the mind of the child), the child starting screaming. Mum carried her into our treatment room where she continued to scream and cry. Being able to actually treat the child was an idea written off early in the session, but we tried to console/ distract/ bribe her in order to achieve some sort of assessment to guide our advice to mum. Eventually it seemed we were not going to be able to assess the child who continued to cling to mum and scream until she was hoarse, for 40 minutes. The physio indicated that we were giving up and I assumed this would be the end of the session. Instead though, the physio asked mum to read an entire book to the child before they could go. Mum calmly read the book and the therapist addressed the child, saying “now that you’ve finished reading it’s time to go home”. We arranged a home visit for our next session, where Mum suggested we hide in the next room and observe through the window while mum played with the child!
Anyway after this first session I asked about the book reading and I soon realised that whilst this session was obviously non-productive, the therapist was preparing the child for next time, trying to change her negative associations with the physio and with therapy. By allowing the child to read with mum then go home, her association to the centre might be with something more fun like reading. I realised I would not have thought of this very simple idea. We have all had patients who for some reason are non-compliant on particular days and we want only for the session to be over so we can start afresh next time. I now appreciate how important it is to think about not only the individual session aims but your long term goals and remember that your actions have the potential to influence not only the current session, but future sessions as well.
Friday, August 29, 2008
Dealing with Tragedy...
The hardest thing about doing a rural prac near the town where you grew up is that if something happens to someone, there is a good chance you know the person, or are close to someone else who does. Even though I grew up 50 km from the place where I am doing rural, the hospital services many towns in the surrounding area.
I was on a ward seeing patients in the morning when there was a code Blue in the hospital. Having just been at Charlies where code blues happen at least 5 times a day, I didn’t think too much about it other than I hoped the person was ok.
Later in the day I was standing at the nurses desk when I saw a family walk in that I knew. There was only the single mum and 1 of the 3 sons who came in (there were 3 sons, one of which was severely disabled with CP and in a disability care home).
As this ward was primarily for elderly people, I assumed it was a situation involving a grandparent. I also wondered why the other son wasn’t there. I looked at the two family members and had never in my life seen people look like that. The nurses then told me that a young 17-year-old boy had died that morning when the code blue was called.
I felt shocked at first and couldn’t really put 2 and 2 together. When it hit home that the other son had died that morning it was very overwhelming and upsetting.
The circumstances surrounding his death are still uncertain, however he had been admitted the night before with tonsillitis and there was a very very tragic medical complication with the Rx.
This was a very robust, high-energy young guy who died within a matter of minutes.
I know dealing with death is always hard, its just made harder when its such a young person and also seeing the family walking into the hospital to see their loved one for the first time. As I was in contact with the nurses as well I also got detail about the medical side of things, which made it even harder.
It all happened so quick and I was in shock for quite a while. It has been playing over in my head since it happened a few days ago, so I hoped writing it down might help to deal with it.
I found it really helpful chatting to some of the staff who had also known them. I also found people really support each other, especially in a country town as it is a pretty tight nit community.
I was on a ward seeing patients in the morning when there was a code Blue in the hospital. Having just been at Charlies where code blues happen at least 5 times a day, I didn’t think too much about it other than I hoped the person was ok.
Later in the day I was standing at the nurses desk when I saw a family walk in that I knew. There was only the single mum and 1 of the 3 sons who came in (there were 3 sons, one of which was severely disabled with CP and in a disability care home).
As this ward was primarily for elderly people, I assumed it was a situation involving a grandparent. I also wondered why the other son wasn’t there. I looked at the two family members and had never in my life seen people look like that. The nurses then told me that a young 17-year-old boy had died that morning when the code blue was called.
I felt shocked at first and couldn’t really put 2 and 2 together. When it hit home that the other son had died that morning it was very overwhelming and upsetting.
The circumstances surrounding his death are still uncertain, however he had been admitted the night before with tonsillitis and there was a very very tragic medical complication with the Rx.
This was a very robust, high-energy young guy who died within a matter of minutes.
I know dealing with death is always hard, its just made harder when its such a young person and also seeing the family walking into the hospital to see their loved one for the first time. As I was in contact with the nurses as well I also got detail about the medical side of things, which made it even harder.
It all happened so quick and I was in shock for quite a while. It has been playing over in my head since it happened a few days ago, so I hoped writing it down might help to deal with it.
I found it really helpful chatting to some of the staff who had also known them. I also found people really support each other, especially in a country town as it is a pretty tight nit community.
Wednesday, August 27, 2008
Interesting condition...
I came across a pt with a condition today that I had heard of, but was not very familiar with. So prior to seeing this pt I did some research into what it was, any precautions needed to Ax them and Rx ideas…. So I thought id share it incase anyone else comes across it!
The condition was Scheuermann's disease
I asked the other PT’s I was working with about it aswell and found out some handy info..
One of the PT’s actually had it. She had had an Xray for an unrelated problem, and the findings came back to say she actually had Scheuermanns aswell. She had been asymptomatic apart from some occasional mild stiffness in her mid thoracic spine. Another PT’s sister had it, and she said her sister had been very good with her initial PT ex’s and was also now asymptomatic.
So what is it?
Scheuermanns disease refers to osteochondrosis of the secondary ossification centers of the vertebral bodies.
The etiology and pathogenesis are unknown. Probably multifactorial - including mechanical, metabolic, and endocrinologic causes.
The condition affects children aged 13-16 years, and the diagnosis is rarely made in patients younger than 10 years. Usually occurs through adolescence with initial growth spurts. It is quoted in some studies as occurring in 25% of all children to varying degrees. Patients are generally taller comparably than aged peers, and have advanced skeletal versus chronologic age.
Boys are affected more frequently than girls.
Signs and Symptoms:
It usually develops with some sort of spinal deformity, and it can be accompanied by backache and stiffness, usually aggravated by sitting. During the onset, the child's posture often changes. The back curve may become exaggerated.
A diagnosis can be established if wedging of vertebral bodies is evident, in association with other changes, including intervertebral disc space narrowing, Schmorl's nodes, and deformity. These changes can occur with or without pain. Small changes in the growing parts of the vertebrae may be seen. These changes may persist and predispose the lower thoracic spine to degenerative changes later in life.
It usually lasts as a symptomatic pain producing problem between 6 months and 3 years. It is a problem in growing adolescent, and once the growth is finished the condition recovers. The function of the spine and hamstring muscles is usually mildly affected in the long term, emphasizing a need for rehabilitative exercises.
Treatment:
Depends on the severity of pain and the degree of mechanical changes seen on examination. When more severe pain, relative rest from activity is necessary. The traditional treatment was rest, especially in large back braces, however, this treatment was excessive.
Physio involvement and Exercises:
Important to maintain mobility. As the thoracolumbar region is most affected, rotation and stretching ex’s in all ranges is needed. Strengthening exercises associated with postural modification is also important. plus Mx STRATEGIES and BEHAVIOUR MODIFICATION!!
is very important to advise the pt to keep up general fitness by adapting behaviour modification and Mx strategies ie lumbar roll in sitting. A whole body biomechanic Ax can also help eg looking at foot position/need for orthotics ect..
The more the condition is accompanied by pain, back mobility changes, postural deformities and hamstring tightness, the more that rest will be required. This can mean complete rest from active contact sports such as football, and rest from activities requiring repetitive overload, e.g. long distance running, bowling in cricket, gymnastics, ballet dancing, etc.
Sometimes mobilization and manipulation aimed at the stiffness in the lower Thoracic spine can be indicated, although it needs to be performed with care and only continued if improvement seen from that and not attributed to other exercises. swimming can be very beneficial (in heated pool) to encourage spinal rotation.
Scheuermann's disease is just one of the many conditions found in the population incidentally. Treatment should address the signs and symptoms of the presenting condition, and not the incidental radiological findings.
Unfortuntely the pt I had admitted having a ‘denial’ attitude towards having it (she was Dx at age 11) and had not managed herself well. She had had previous PT and not been compliant at all. She was now in her early 40’s and had severe chronic back pain with frequent flare ups. she is now on panadeine forte and valium every 4 hours (and has been for the last 5 years) She was so irritable, the first Rx involved giving TENS for home use (as she had used this before with good effect) and pain Mx strategies. The aim is to get her pain under control, commence Hydro (as this has previously also helped) and gentle ex’s and aim to get her out of bed as she is currently RIB most of the day. she says she is so now so debilitated that she is adament to comply to PT ex's and wish she hadnt let herself get to this stage....
info found from a number of sources including:
http://www.emedicine.com/pmr/topic129.htm
http://members.optushome.com.au/physio/schmann.html
http://www.emedicine.com/pmr/topic129.htm
The condition was Scheuermann's disease
I asked the other PT’s I was working with about it aswell and found out some handy info..
One of the PT’s actually had it. She had had an Xray for an unrelated problem, and the findings came back to say she actually had Scheuermanns aswell. She had been asymptomatic apart from some occasional mild stiffness in her mid thoracic spine. Another PT’s sister had it, and she said her sister had been very good with her initial PT ex’s and was also now asymptomatic.
So what is it?
Scheuermanns disease refers to osteochondrosis of the secondary ossification centers of the vertebral bodies.
The etiology and pathogenesis are unknown. Probably multifactorial - including mechanical, metabolic, and endocrinologic causes.
The condition affects children aged 13-16 years, and the diagnosis is rarely made in patients younger than 10 years. Usually occurs through adolescence with initial growth spurts. It is quoted in some studies as occurring in 25% of all children to varying degrees. Patients are generally taller comparably than aged peers, and have advanced skeletal versus chronologic age.
Boys are affected more frequently than girls.
Signs and Symptoms:
It usually develops with some sort of spinal deformity, and it can be accompanied by backache and stiffness, usually aggravated by sitting. During the onset, the child's posture often changes. The back curve may become exaggerated.
A diagnosis can be established if wedging of vertebral bodies is evident, in association with other changes, including intervertebral disc space narrowing, Schmorl's nodes, and deformity. These changes can occur with or without pain. Small changes in the growing parts of the vertebrae may be seen. These changes may persist and predispose the lower thoracic spine to degenerative changes later in life.
It usually lasts as a symptomatic pain producing problem between 6 months and 3 years. It is a problem in growing adolescent, and once the growth is finished the condition recovers. The function of the spine and hamstring muscles is usually mildly affected in the long term, emphasizing a need for rehabilitative exercises.
Treatment:
Depends on the severity of pain and the degree of mechanical changes seen on examination. When more severe pain, relative rest from activity is necessary. The traditional treatment was rest, especially in large back braces, however, this treatment was excessive.
Physio involvement and Exercises:
Important to maintain mobility. As the thoracolumbar region is most affected, rotation and stretching ex’s in all ranges is needed. Strengthening exercises associated with postural modification is also important. plus Mx STRATEGIES and BEHAVIOUR MODIFICATION!!
is very important to advise the pt to keep up general fitness by adapting behaviour modification and Mx strategies ie lumbar roll in sitting. A whole body biomechanic Ax can also help eg looking at foot position/need for orthotics ect..
The more the condition is accompanied by pain, back mobility changes, postural deformities and hamstring tightness, the more that rest will be required. This can mean complete rest from active contact sports such as football, and rest from activities requiring repetitive overload, e.g. long distance running, bowling in cricket, gymnastics, ballet dancing, etc.
Sometimes mobilization and manipulation aimed at the stiffness in the lower Thoracic spine can be indicated, although it needs to be performed with care and only continued if improvement seen from that and not attributed to other exercises. swimming can be very beneficial (in heated pool) to encourage spinal rotation.
Scheuermann's disease is just one of the many conditions found in the population incidentally. Treatment should address the signs and symptoms of the presenting condition, and not the incidental radiological findings.
Unfortuntely the pt I had admitted having a ‘denial’ attitude towards having it (she was Dx at age 11) and had not managed herself well. She had had previous PT and not been compliant at all. She was now in her early 40’s and had severe chronic back pain with frequent flare ups. she is now on panadeine forte and valium every 4 hours (and has been for the last 5 years) She was so irritable, the first Rx involved giving TENS for home use (as she had used this before with good effect) and pain Mx strategies. The aim is to get her pain under control, commence Hydro (as this has previously also helped) and gentle ex’s and aim to get her out of bed as she is currently RIB most of the day. she says she is so now so debilitated that she is adament to comply to PT ex's and wish she hadnt let herself get to this stage....
info found from a number of sources including:
http://www.emedicine.com/pmr/topic129.htm
http://members.optushome.com.au/physio/schmann.html
http://www.emedicine.com/pmr/topic129.htm
Tuesday, August 26, 2008
Emotional phonecalls
I am currently working on an inpatients ward where I was the only one available to unwittingly take an unexpected phone call. The call came from a patient who was 11 weeks post surgery, had had her hip replaced and been treated for this, however had contracted several systemic infections that impaired her ability to exercise, socialize due to photophobia and left her feeling helpless. She was seriously confused as to what was and was not appropriate exercise and movements for her to be doing at this stage of 11 weeks post THR. The phone call lasted 45minutes, the first half of which I thought I was enduring a very chatty and cautious patient. When the tears came, I knew something seriously different was going on. Then came the full story. She is seriously depressed, isolated by her family and friends, dependent, insecure and anxious to the point of avoiding all physical activity. Panic attacks prevent her from making basic phone calls for help from medical practitioners and it seems she is not proactive as necessary to become fully recovered. Being immobile for 4 weeks in a dark room does not help her situation either!
I was really caught off-guard by this phone call, and felt for the poor lady who had obviously had a hard time with her supposed rehabilitation whilst being in and out of hospitals with other problems. Then I got bothered by something that kept recurring throughout the conversation. Something that could have been within our power as physiotherapists to help was quite pivotal to improving her attitude - communication. The pamphlets given to patients after and before surgery were not clear for her as to when to progress the exercises, when particular movements were permitted, etc. She was so confused that she avoided things like bending down to pick things up off the floor, sweeping the ground and had trouble looking after her cats because she was so afraid of doing the wrong thing.
I don't know if this is the case with her, but we as physiotherapists can be very good at emphasising the "don'ts" that patients don't know what they can do. They also need thorough explanation of the progression of their rehabilitation because it is not always logical for them. We have restricted time when working on the wards, but her confusion and fear avoidance behaviour could have been significantly improved by just taking a little extra time with someone who obviously is not physically aware of fitness and exercise. It's our responsibility, not another medical team member. I just never realised how some people can have absolutely no idea about exercise and activity - we sometimes REALLY have to spell it out, and that's important!
I was really caught off-guard by this phone call, and felt for the poor lady who had obviously had a hard time with her supposed rehabilitation whilst being in and out of hospitals with other problems. Then I got bothered by something that kept recurring throughout the conversation. Something that could have been within our power as physiotherapists to help was quite pivotal to improving her attitude - communication. The pamphlets given to patients after and before surgery were not clear for her as to when to progress the exercises, when particular movements were permitted, etc. She was so confused that she avoided things like bending down to pick things up off the floor, sweeping the ground and had trouble looking after her cats because she was so afraid of doing the wrong thing.
I don't know if this is the case with her, but we as physiotherapists can be very good at emphasising the "don'ts" that patients don't know what they can do. They also need thorough explanation of the progression of their rehabilitation because it is not always logical for them. We have restricted time when working on the wards, but her confusion and fear avoidance behaviour could have been significantly improved by just taking a little extra time with someone who obviously is not physically aware of fitness and exercise. It's our responsibility, not another medical team member. I just never realised how some people can have absolutely no idea about exercise and activity - we sometimes REALLY have to spell it out, and that's important!
Monday, August 25, 2008
Interdisciplinary team member
Whilst on my rural practical in a small town I learnt how you must be a flexible health professional and be willing to step outside your discipline to provide optimal patient care. The town I went to had visiting occupational therapy, speech pathology and podiatry approximately once every 2 months. Therefore as the part time physiotherapist you can be expected to work as an occupational therapist and a speech pathologist too. There is a part time therapy assistant employed two days a week however these staff members must see the occupational therapist and speech pathologist when they are in town and learn what to do with patients and develop programs for them. The therapy assistants are therefore very challenged as they are learning many new assessment and treatment techniques for each patient.
During my time at the health service I saw a patient who had a skin flap on the side of her face which had caused damage to her facial nerve and consequently the patient was having difficulty speaking. As there was no speech therapist within the area I was seeing her and giving her exercises to improve her speech. The physiotherapist had a video conference with the speech pathologist in a larger town to develop assessment and treatment for this patient. I continued to assess this patient’s degree of jaw opening and perform vowel exercises with her to reduce her palsy.
In addition the physiotherapist ordered equipment for outpatients and the residential patients to improve their independence and fitted them appropriately. She also did home visits to see what equipment was needed for patients. This may be seen as an occupational therapy job however the patient may not be able to wait two months.
I really enjoyed my rural placement. I saw a large variety of patients and I saw how important it was to be an interdisciplinary team member and a flexible health professional.
During my time at the health service I saw a patient who had a skin flap on the side of her face which had caused damage to her facial nerve and consequently the patient was having difficulty speaking. As there was no speech therapist within the area I was seeing her and giving her exercises to improve her speech. The physiotherapist had a video conference with the speech pathologist in a larger town to develop assessment and treatment for this patient. I continued to assess this patient’s degree of jaw opening and perform vowel exercises with her to reduce her palsy.
In addition the physiotherapist ordered equipment for outpatients and the residential patients to improve their independence and fitted them appropriately. She also did home visits to see what equipment was needed for patients. This may be seen as an occupational therapy job however the patient may not be able to wait two months.
I really enjoyed my rural placement. I saw a large variety of patients and I saw how important it was to be an interdisciplinary team member and a flexible health professional.
Saturday, August 23, 2008
Independent OR Unreasonable?
I know as a physio one of our aims is to get people to become as independent as possible. A recent encounter with a difficult patient made me view independence at a new level and realise that each individual’s home situation plays a huge role in determining when they are appropriate for DC.
This particular patient had a TKR with a few post op complications. Unfortunately there was a large haematoma around the knee and massive swelling. We were seeing this patient 2 x daily for mobility and swelling Mx, and felt like we had good rapport with him. On a Friday, the doctor doing his morning rounds Ax the pt and told him he was allowed to go home. The doctor told him this without talking to either the OT or PT and determining his functional status or home situation.
From a PT point of view, we were not happy with his ROM he had were worried about the amount of swelling still evident. The OT had also not yet done a home review. This pt lived on his own, on a farm, about 1 hour out of the country town where the hospital was. He lived in a movable home (like caravan), with 4 steep steps up to the front. He also had family and grandkids in nearby country towns who he told us he was going to visit in the next week. So from our point of view, this pt was going home alone, would have to get up 4 steep steps, and was going to be driving in the next few days.
Both the senior OT, my supervisor and I went to see this pt and strongly advised that he live with his daughter (which was a possibility) upon DC just for a little while until he the swelling decreased. We were polite and tried to use reasons that he would relate to and understand. The pt (who had previously been polite back to us) became very adamant and quite rude, saying that he ‘had lived on his own for 15 years on the farm and who did we think we were trying to tell him that he shouldn’t go back there.’ We made it clear that he could go back there, but informed him of the effects of surgery and that some people like to have other people around when they get out of hospital. He said we could advise all we wanted ‘but he was going to do what he wanted to do.’
Furthermore, after asking if he could attend the OP clinic for follow up Rx, he told us “well if you see my feet walking through the door, you know I’ll be coming in.’
So… I guess we just have to wait and see what happens next week.
This patient also packed up all his things, sifted through the papers he had next to his bed, packed them up, and the only one he left on his bed were his Physio exercises!
It got me thinking about being independent and how people view it. This patient it seemed was very rude and bluntly refused our advice or further help. At the time I was a bit put out as I thought we had been helping him every day and he had always been grateful. I then thought that maybe his behaviour came from the fact that he wanted so badly to be independent.
I learnt how to be tactful and give strong advice without sounding forceful, however I also learnt that no matter how hard you try, some people just don’t want to listen for whatever reason.
This particular patient had a TKR with a few post op complications. Unfortunately there was a large haematoma around the knee and massive swelling. We were seeing this patient 2 x daily for mobility and swelling Mx, and felt like we had good rapport with him. On a Friday, the doctor doing his morning rounds Ax the pt and told him he was allowed to go home. The doctor told him this without talking to either the OT or PT and determining his functional status or home situation.
From a PT point of view, we were not happy with his ROM he had were worried about the amount of swelling still evident. The OT had also not yet done a home review. This pt lived on his own, on a farm, about 1 hour out of the country town where the hospital was. He lived in a movable home (like caravan), with 4 steep steps up to the front. He also had family and grandkids in nearby country towns who he told us he was going to visit in the next week. So from our point of view, this pt was going home alone, would have to get up 4 steep steps, and was going to be driving in the next few days.
Both the senior OT, my supervisor and I went to see this pt and strongly advised that he live with his daughter (which was a possibility) upon DC just for a little while until he the swelling decreased. We were polite and tried to use reasons that he would relate to and understand. The pt (who had previously been polite back to us) became very adamant and quite rude, saying that he ‘had lived on his own for 15 years on the farm and who did we think we were trying to tell him that he shouldn’t go back there.’ We made it clear that he could go back there, but informed him of the effects of surgery and that some people like to have other people around when they get out of hospital. He said we could advise all we wanted ‘but he was going to do what he wanted to do.’
Furthermore, after asking if he could attend the OP clinic for follow up Rx, he told us “well if you see my feet walking through the door, you know I’ll be coming in.’
So… I guess we just have to wait and see what happens next week.
This patient also packed up all his things, sifted through the papers he had next to his bed, packed them up, and the only one he left on his bed were his Physio exercises!
It got me thinking about being independent and how people view it. This patient it seemed was very rude and bluntly refused our advice or further help. At the time I was a bit put out as I thought we had been helping him every day and he had always been grateful. I then thought that maybe his behaviour came from the fact that he wanted so badly to be independent.
I learnt how to be tactful and give strong advice without sounding forceful, however I also learnt that no matter how hard you try, some people just don’t want to listen for whatever reason.
Monday, August 18, 2008
English as a Second Language
Whilst on prac, it was requested I see a young boy who recently had arrived in Australia and spoke very minimal English. He was admitted to the hospital post a tib/fib fracture and had been fitted with external fixation. As he was still in the acute stages, physio intervention primarily consisted of active-assisted movements of the ankle, hip and knee, as well as static and inner range quad exercises.
As my supervisor was watching, I was quite conscious of the way I approached this patient. As I know I can have the tendency to over-explain a situation, I thought I would simplify and keep my explanations to a minimum with this boy, as I did not want to overwhelm the young child. After I introduced myself to the patient and explained that we needed to do exercises, I basically got straight into the treatment. To demonstrate how to do the exercises, I would show him on his unaffected leg and then progress to his affected side, yet did not offer an explanation as to why he needed to do it. I did try to make small talk during the session, but found him to be quite unresponsive, and would initially complain of pain as I tried to move his leg. Despite this, I managed to perform what I had planned for the treatment session.
Upon leaving the room, my supervisor commented on how I did not outline and explain the treatment situation normally as I would for any other patient. I explained my reasoning, which she understood, but still said it is always best to explain the need for the exercises, in simple terms, as even the non-verbal signals I would portray during my explanations would help to put the patient at ease and receive a better response during the exercises. Another point which my supervisor mentioned was that even though the child may not fully understand English, it is quite common for a child to play on this, and use it as a mechanism to get out of exercises. Also, in future, it may have been of benefit to time physio intervention whilst having a parent in the room to act as an interpreter (if possible).
Through this situation, it has shown me that even though a patient may have limiting factors such as English being a second language, it is still important to offer the person the same opportunities to understand the reasoning and importance of the exercises. Not only will this increase compliance, but also help to develop better rapport. I will be mindful of this in the future.
As my supervisor was watching, I was quite conscious of the way I approached this patient. As I know I can have the tendency to over-explain a situation, I thought I would simplify and keep my explanations to a minimum with this boy, as I did not want to overwhelm the young child. After I introduced myself to the patient and explained that we needed to do exercises, I basically got straight into the treatment. To demonstrate how to do the exercises, I would show him on his unaffected leg and then progress to his affected side, yet did not offer an explanation as to why he needed to do it. I did try to make small talk during the session, but found him to be quite unresponsive, and would initially complain of pain as I tried to move his leg. Despite this, I managed to perform what I had planned for the treatment session.
Upon leaving the room, my supervisor commented on how I did not outline and explain the treatment situation normally as I would for any other patient. I explained my reasoning, which she understood, but still said it is always best to explain the need for the exercises, in simple terms, as even the non-verbal signals I would portray during my explanations would help to put the patient at ease and receive a better response during the exercises. Another point which my supervisor mentioned was that even though the child may not fully understand English, it is quite common for a child to play on this, and use it as a mechanism to get out of exercises. Also, in future, it may have been of benefit to time physio intervention whilst having a parent in the room to act as an interpreter (if possible).
Through this situation, it has shown me that even though a patient may have limiting factors such as English being a second language, it is still important to offer the person the same opportunities to understand the reasoning and importance of the exercises. Not only will this increase compliance, but also help to develop better rapport. I will be mindful of this in the future.
Monday, August 11, 2008
Avoiding Complacency
After seeing numerous patients throughout the day, and performing standard exercises and instructions with them, I find that I (unfortunately and unintentionally) can become slightly slack and form certain predetermined expectations of a patient.
I noticed this occurred the other day when teaching a young girl NWB with crutches. I taught her the basic gait pattern for crutches, but did not demonstrate to her how to sit down with crutches. After a few laps up and down the room, we headed towards the chair and as I wanted her to increase her independence, I removed my hands from her pelvis and instead moved to a close stand-by position. As she neared closer to the chair, she hopped too closely to the chair, subsequently overbalanced and landed awkwardly on her weight-bearing ankle. Fortunately, as I was still close, I was able to prevent her from falling but she still appeared visibly upset. It’s never a good feeling when you may have compromised a patient’s safety… especially when your supervisor is watching!
Even though the patient had a tendency to be slightly impulsive and overdramatic, the fact that she almost fell was probably a reflection of me not providing sufficient instructions and not leading enough in the treatment session. As I had taught patients NWB with crutches prior, I guess I expected her to be at the same level as my other patients and therefore did not provide as thorough instructions throughout the session. It was wrong of me to do this, as each individual is different and I should never compromise their safety by my assumptions. Even though complacency occurs subconsciously, I need to make a more conscious effort to be alert and provide each patient the same opportunity to learn. I know I will be trying to do this from now on.
I noticed this occurred the other day when teaching a young girl NWB with crutches. I taught her the basic gait pattern for crutches, but did not demonstrate to her how to sit down with crutches. After a few laps up and down the room, we headed towards the chair and as I wanted her to increase her independence, I removed my hands from her pelvis and instead moved to a close stand-by position. As she neared closer to the chair, she hopped too closely to the chair, subsequently overbalanced and landed awkwardly on her weight-bearing ankle. Fortunately, as I was still close, I was able to prevent her from falling but she still appeared visibly upset. It’s never a good feeling when you may have compromised a patient’s safety… especially when your supervisor is watching!
Even though the patient had a tendency to be slightly impulsive and overdramatic, the fact that she almost fell was probably a reflection of me not providing sufficient instructions and not leading enough in the treatment session. As I had taught patients NWB with crutches prior, I guess I expected her to be at the same level as my other patients and therefore did not provide as thorough instructions throughout the session. It was wrong of me to do this, as each individual is different and I should never compromise their safety by my assumptions. Even though complacency occurs subconsciously, I need to make a more conscious effort to be alert and provide each patient the same opportunity to learn. I know I will be trying to do this from now on.
Monday, August 4, 2008
When to Discharge a Patient?
Being in the public health system, it appears there is the constant pressure to discharge patients to allow for the opening of beds. However, being a student, I find it is sometimes difficult to know exactly when the point of discharge should be.
I encountered a situation the other day whereby I had to teach a young patient to use crutches. The doctors indicated that as soon as he had been taught and felt comfortable to use crutches, it was ok for the patient to be discharged. This patient had been rest in bed for a few days, so ambulating once again was an adjustment for him. After being taught how to use them and how to go up/down stairs, the patient practiced numerous times and appeared to mobilise effectively. The only point of concern was that twice during our session he had a slight posterior sway and required my steadying, but this was presumed to be due to the few days of bed rest.
As the patient essentially performed the tasks correctly and safely, and he had no complaints, I spoke with the nursing staff to practice ambulating with him overnight and if he appeared to be mobilising safely, it was ok from physiotherapy perspective to be discharged in the morning. I documented that he was safe for inpatient physio discharge, but did note that he had an occasional posterior sway and if the nursing staff noticed this again overnight, they could request a physio review in the morning.
The physio who was with me at the time seemed to think this was ok, but when my supervisor checked my notes the next day, he suggested that I review the patient again just to ensure he did not repeat the sway from the day prior. Unfortunately, the patient had already been discharged. My supervisor informed me that if I ever had any concern about a patient, I should not feel pressured to discharge the patient. As I had documented the patient had an occasional sway in his notes, if the patient was discharged and fell when using the crutches, the patient could sustain further injury and the blame could fall upon my head.
I guess it’s just a timely reminder that despite a patient or ward staff being eager for discharge, it is important to resolve any concerns you may have, as not only is this vital to the patients wellbeing but also to protect yourself from blame. I know I will keep this in mind from now on.
I encountered a situation the other day whereby I had to teach a young patient to use crutches. The doctors indicated that as soon as he had been taught and felt comfortable to use crutches, it was ok for the patient to be discharged. This patient had been rest in bed for a few days, so ambulating once again was an adjustment for him. After being taught how to use them and how to go up/down stairs, the patient practiced numerous times and appeared to mobilise effectively. The only point of concern was that twice during our session he had a slight posterior sway and required my steadying, but this was presumed to be due to the few days of bed rest.
As the patient essentially performed the tasks correctly and safely, and he had no complaints, I spoke with the nursing staff to practice ambulating with him overnight and if he appeared to be mobilising safely, it was ok from physiotherapy perspective to be discharged in the morning. I documented that he was safe for inpatient physio discharge, but did note that he had an occasional posterior sway and if the nursing staff noticed this again overnight, they could request a physio review in the morning.
The physio who was with me at the time seemed to think this was ok, but when my supervisor checked my notes the next day, he suggested that I review the patient again just to ensure he did not repeat the sway from the day prior. Unfortunately, the patient had already been discharged. My supervisor informed me that if I ever had any concern about a patient, I should not feel pressured to discharge the patient. As I had documented the patient had an occasional sway in his notes, if the patient was discharged and fell when using the crutches, the patient could sustain further injury and the blame could fall upon my head.
I guess it’s just a timely reminder that despite a patient or ward staff being eager for discharge, it is important to resolve any concerns you may have, as not only is this vital to the patients wellbeing but also to protect yourself from blame. I know I will keep this in mind from now on.
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