Remote setting

When I was on rural prac I was given the opportunity for one day each week to travel with one of the senior physios to an Aboriginal community. The role of physiotherapy in the community was to assist with the multidisciplinary team providing home visits as well as covering a small hospital and outpatient clinic.

During my first day at the community we received a referral for Mike who had recently been released from hospital and was having problems “getting around”. We decided to do a home visit along with an OT to assess Mike’s mobility and home setup.

Driving to the house I realised very quickly that this was not the sort of home I was used to. Very few houses had windows, some were missing parts of their roof and walls and most had multiple car wrecks scattered around the yard. When we arrived at Mike’s house we were greeted by half a kangaroo carcass hanging from the car port roof and another rotting kangaroo carcass in the yard, which the dogs were feeding on. The house had no doors, windows or lighting.

When we entered the house I was confronted by the shocking condition and smell with animal waste and rubbish scattered on the floor, graffiti covered the walls and empty alcohol containers littered every corner. We found Mike in the living room he shared with three other men and piles of empty beer cans. We performed a simple gait assessment and prescribed a walking frame to improve Mike’s gait, however I had little to do with this as I was mainly focused on not being sick over the patient.

I wanted to share this experience as it really opened my eyes to the conditions that many Aboriginal people face in these remote communities. Whilst we may have many expectations and goals for our patients, these are completely insignificant if the patient does not have access to those things we consider so basic such as clean water, sanitation and food. Mike had so many other things going on in his life with lots of involvement from other health care workers so that even though it seems insignificant to just provide a walking aid, we were at least able to assist in maintaining his mobility.

Country people go wild

On my orthopaedic placement, I saw many hip and knee replacements and came to know the expected progress of recovery quite well. Even saw some drawn out and complicated recoveries. However, I severely underestimated the constitution of country folk and their resiliency.
We had two country people have the same hip replacement surgery on the same day. One, a male, had lived what can only be described as a very full life. Having fallen off a 3 meter high truck onto his back, he didn't go to have help until driving to the doctor the next day, where they found he had fractured his pelvis in several places. You get the picture. So when he walked on the day of the operation, we expected it. When he excelled with his exercises to the point of being dischargeable by the end of the second day, I was impressed. He was ready for discharge, and so we told him this. Then we lost him, only to find him down at the reception where he had walked all by himself, awaiting to be picked up. He had thought discharge meant "go now" - no papers, no prescriptions, no instructions, just ready to walk out the door. I couldn't believe it. Not the amazing confusion of events, but that he had walked across the entire hospital post op day two on his own and was entirely comfortable with that!
The other patient also had no pain, walked well, even when nauseous, and by the third day had an interesting tendency of holding her crutches off the ground when navigating tight spaces, so walking effectively full weightbearing on her own. Amazing!
You can't keep them in bed. You can't explain things to them enough. Country people have amazing abilities to get on with things, so I learned through this experience to explain in detail so there are no confusions or "runaway patients", and to challenge them beyond what I would ask of any other patient. They can do it, too!!! Also, explanations are extra important for someone who is in a fairly foreign environment, undergoing a very clinical and invasive procedure, many k's from family and friends. Their context is very different from a metro patient, and so we need to consider this - even though they seem to be made of steel!

Recognising S&S…

Recently on a neuro prac I was treating a patient who was a 33-year-old Aboriginal man from a community up at Fitzroy Crossing. He had had a L MCA CVA four weeks prior to the first time I saw him. As this is my first neuro placement and exposure to neuro patients, I wanted to have a thorough read of his notes and idea in my mind what to expect prior to my Ax session. (this patient had previously been seen by one of the other physio’s, and had just been handed over to us students)

Being a L MCA, I assumed that there may be some language difficulties, however the notes said that there were none evident.
I went in to see this patient and outlined what I would like to do in the session. He didn’t make eye contact with me or respond verbally, and when I asked him if he understood and consented to Rx, he said ‘yeah’ and that was it.

At the start of the session, I felt like he took along time to respond to any requests I made or questions asked. I felt like he didn’t understand what I was saying as he wasn’t responding quickly. However, due to the no eye contact, I then remembered that there may be some cultural differences that may be impacting on the session. I took careful note to see whether he responded appropriately to all the questions and requests, which he did.

Later I spoke to the physio who was treating him before me, and she said he had been exactly the same with her and that nothing had changed since his admission. Therefore it was not a language or understanding difficulty, it was a cultural difference.
Being my first exposure to neuro patients, I initially assumed that being a L MCA there would be language difficulties. I now know that strokes can present COMPLETELY differently and to Ax how each individual presents. I also remembered the lecture we had on Aboriginal Health and cultural differences, and realised that I needed to be more aware of these at the start of the session and not assume limited verbal responses was due to the CVA, so I will be a lot more aware of this in the future.

Another crying moment

A very lovely patient that I worked with on my neuro prac had previously been in a coma and then had a stroke. She was severely deconditioned, the muscle wasting extreme but she was improving and had a great sense of humour. A very positive out look on life seemed to be shared with her family. So it was a surprise when at the end of a physiotherapy session she began to feel hot and sweaty, faint and teary. The tears came. She expressed such a despair and feeling of hopelessness that even my supervisor was moved to tears herself. It was such a emotionally difficult moment. But I learned some interesting things from it.

My supervisor explained to the patient how Bobath philosophy involves a link between movement and emotion. For example, when stressed people tend to hunch their shoulders and extend their neck. After doing movements such as we do in physiotherapy, the movements can stir up emotions which seem either abrupt or otherwise unexplainable. I'm not sure of the specific scientific indications for this, but I found it very interesting. Also, the dramatic change of health for this patient has been a long but for much of it a passive journey. When in the coma and when awaking but heavily dependent, she was in the midst of the busy hospital full care timetable, no time to process and fully understand what was happening to her. Now that she was being challenged physically to improve and trying to achieve things that were previously everyday activities, her limitations were really being put in her face. It was potentially the aftermath of all her painful and upseting experience coming out at the first opportunity.

I had never considered this pattern of emotional processing before. But when dealing with patients in similar situations, we do need to be aware of the fact that a)movement affects emotion, and b) not everybody processes things at the same rate or in the same way as we do. It was also a learning curve for me regarding how depressed patients can become, and with good reason, but also how we as physiotherapists can encourage positivity through our expert knowledge, our humanity and our time.

First Impressions

Within the first few days of my placement I was the only witness to a senior physiotherapist ‘spitting the dummy’ (for want of a better phrase).. The equipment room was a mess and in response to not being able to find the item she was after, she yelled and threw a pt’s file on the floor. She jumped up and down, screaming, for maybe only 5 or so seconds, then turned and stormed out. I picked up all the pages from the file, which had come apart, and spent quite a bit of time trying to put it back together chronologically. The incident was never spoken of again, nor was it acknowledged. I suspected the physio had had a hard day/ was under particular stress and/or perhaps that messiness of the room was something that she had to repeatedly address. Whilst the PT had not directed her frustration at me, I soon realised that it had impacted hugely on how I perceived her.

Although this PT was not my supervisor, I was at times under her supervision. From that day forward I was very cautious around the physio and felt I didn’t always perform to the best of my ability. I found I was unwilling to ask questions or ask for guidance and thus when I saw her pts they were getting only basic treatment, which I was certain was right for them. I wasn’t willing to discuss different options or ideas I had for these pts as I wasn’t sure how the physio would respond. About half way through my placement, I soon realised that this PT has a history of doing similar things and that it was the pts suffering because I was concerned about liaising with the PT. Eventually, as I began to get to know her and the rest of the team, I was more comfortable interacting with her as I did with all the other physios.

I learnt that single mistakes can have a lasting effect.. This was a very knowledgeable physio who was excellent with pts, however her original behaviour completely undermined my confidence in her abilities and also impacted on our future interactions. I think similar circumstances can impact on the relationships we have with pts too – if we portray little self-confidence in the early days of treatment, I suspect that they too will be less willing to participate in interactions with us and we will have a long way to go to prove ourselves as worthy therapists. I guess first impressions really do count!

When a Patient Tells You They're About to Faint

I was taking a 60-year-old patient diagnosed with pneumonia for a walk on the hallway when I noticed that she’s getting short of breath. She also told me that she needed to rest for a while so I got her to lean against the wall. It was uncharacteristic of her to be short of breath after such a short distance so I did not put the chair anywhere near the spot where I got her to rest. So then whilst she was leaning on the wall it was quite obvious that she was not short of breath anymore, but then she told me she’s getting dizzy and that she felt she was going to faint. The patient was 123kg and I was panicking inside because there was no one in the hallway at that time. She was already leaning towards one side and was quite wobbly. There was a wheelchair about 8 meters from where we were and the chair that I placed on the hallway was just right beside it. Leaving the patient and quickly grab the wheelchair or chair was definitely not an option for me so I braced myself, guarded the patient’s knees, feet and torso and yelled at a nurse from a distance. She heard me and quickly came to help me get the wheelchair. That experience taught me to be extra cautious when dealing with patients who tend to get short of breath. Even though that patient did not normally get out of breath at that distance, I still would have placed the chair closer, asked a nurse to walk with us or just bring a wheelchair along. I should also have considered the fact that the patient’s weight won’t help me should she faint or collapse. 

Discharging Patients

For some reason, I find making decisions in terms of discharging patients one of the most daunting tasks that we are required to do. Many times have I found myself during team meetings during my gerontology and rural placements freeze and stutter when asked if the patient is ready for d/c. It is quite obvious in such meetings that physio input is very vital in the decision to discharge a patient.

There were plenty of times that I was undecided on whether the patient is ready to get discharged (from a physio perspective) or not because I could only base that decision on the outcome measures that I took and the physio sessions that the patient has had. You’ll never know if the patient decides to change their daily activities radically to the point of getting hospitalized again. I’m aware that it sounds silly but I struggled on that before. It’s very easy to feel responsible for the outcome of each patient post-discharge despite having the rest of the team make a decision for discharge. So the lesson I’ve learned is to continuously liaise with other health professionals and know the discharge destinations (e.g., home, high care, low care, etc). Personally I find liaising regularly with the OT and the social worker to be beneficial, as they usually know a lot about the patient’s ADLs and home/living situation.

Rural Placement Can Be Quite Tough

I learned so many things during my rural placement and perhaps one of the most important is to have a very wide knowledge on many different conditions, know how to assess and treat them, and then know how and when to adapt to the different situation you may be subjected to.

My rural placement required that I spend mornings in the medical/surgical inpatient ward and afternoons in the musculo outpatient section.

It was quite a challenge having to turn my mind on to ‘inpatient mode’ in the morning, turn that off and switch to ‘musculo mode’ in the afternoon. Since many of the patients are older, I have to switch on my gerontology mode most of the time and every now and then you get to have cardiopulmonary patients too. When I was told on the first day that that was what’s going to happen, I immediately visualized the mess I was going to cause.

I was talking to one of my supervisors who worked in Broome herself and she told me that rural placement is usually like that. You have to be ready for anything and everything. There will be many times that your treatment sessions are of interdisciplinary nature because there won’t necessarily be OT’s and SP’s in the rural areas. I thought that was a challenge.

Anyway, as I learned, the key to surviving in that particular rural placement was to get as much as you can from all the health professionals present in the facility. I found it useful to keep asking questions throughout the placement. I was lucky because all of them were quite willing to help. Also, I learned to be more active in terms of seeking knowledge on the different cases I encountered. 

Dealing with Difficult Patients

Doing clinical placements made me more comfortable dealing with lots of different patients in terms of diagnoses, impairments, personalities, cultures, etc. I could say that my attitude and confidence when dealing with patients is better than year four started earlier this year.

 

So during my final assessment of the musculo outpatient part of my rural placement, my supervisor and I were both feeling confident that I wouldn’t have any difficulties with my exam patient. She had a ® hip replacement and I felt that it was quite straightforward and that I would be ok. The patient, who’s in her 50s, handled herself in a very calm and pleasant manner and came in with an obvious limp during walking. I introduced myself and my supervisor to her and gave her an overview of what’s going to happen. As soon as I asked her to tell me to describe her complaint, she looked at me, frowned and asked, ‘Doesn’t in say what’s wrong with me in the referral?’ So I explained to her that it is important to get her to describe to me when it happened, how it happened, and so on, so we get a clearer picture of the nature of the complaint so we can address it properly. After my explanation she complained to me about every joint in her body and the nature of pain for each continuously became even more inconsistent as she kept talking. Time and again I tried to redirect the conversation to the presenting complaint, which is the ® hip pain, but she just refused to listen to me and my supervisor was very aware of that. I was getting light headed that time already because there was no way I would take charge of the situation appropriately if she kept talking and not listen to a word I say. So I excused myself and took some really deep breaths outside the room and thought about how to handle the situation. So I went back to the cubicle after a while and decided to let her talk and rant about every pain she’s had in her life. At one point she mentioned nobody would believe that she has leg length discrepancy, so I took that opportunity to ask her about it and even measured her leg length and confirmed that there actually is a discrepancy. She was so glad that someone believed her this time and since that moment, she listened to everything I said and the treatment session went well in the end.

 

I learned from this experience that it is quite important to be observant of the personality of the patient and use that for the better of the treatment sessions. It is important to take charge of the treatment session but it is just as crucial to tone it down or crank it up as needed. I learned that patient assessment and treatment don’t stop at just doing the SOAPIER parts because patients are people too and unlike diagnoses and impairments, people are a lot harder to predict (in terms of attitude, personalities) so physios have to be ready for that, after all our profession is all about dealing with people everyday. 

Treating the parents

Whilst on my paediatric placement I became aware of how important it is to treat the child and the parents. One of the patients was a one year old with meningitis. This patient had increased secretions and was seen for chest treatment twice a day. Chest treatment included positioning for drainage, percussion, vibes and suctioning. Whilst in ICU the child also experienced seizures. The parents were very anxious about their child which was understandable.

When I watched the physiotherapist treat this patient for the first time the parents were continuously asking questions. They were asking questions such as "what level should the suction be on? some nurses use 20mmHg and others use 40mmHg which is best? how deep are you suctioning? should the bed be tilted before you suctions?" The parents were very anxious and wanted the best treatment for the child. The physiotherapist stayed very calm and collected and educated the parents as to the parameters she used and explained that there was no literature to support intermittent suction or twirling the suction catheter. The parents admired the physiotherapist and seemed to want consistency between health professionals. This is difficult because everyone is taught differently and has their own style so it was discussed at a team meeting and parameters were agreed upon.

This experience and the rest of my paediatric placement made me realise that although we are physically treating the patient a huge part of paediatric physiotherapy is treating the parents. To perform a successful treatment we must treat the child and continue to educate the parents with reasons for techniques as they are very concerned for their children and want to actively be involved with their rehabilitation.

If Pain Persists..

I recently had an experience with a teenager, a little similar to V’s (pt with CRPS), though my pt didn't have a diagnosis and her pain was much less extreme:

My pt had been complaining about pain in every joint, all the time. Walking, standing, sitting, horse riding all hurt, though she was not functionally limited by her pain. She had had numerous investigations (imaging, rheumatological, orthopaedic etc) which had all turned up clear. However, via google (a most trusted medical expert!), the pt had self-diagnosed arthritis..

A thorough physio Ax showed some global deconditioning, mild joint hypermobility, some reduced muscle length and poor muscular control of loaded joints. But nothing particularly stood out as an obvious reason for her pain. I explained that poor muscular control may place undue stress on the passive structures and perhaps this may cause pain. Whilst the teenager was unimpressed with my explanation, mum was happy for us to intervene however we saw fit. The plan was for weekly land-based strength/cardio sessions and hydro sessions for 12 weeks, at which time we would re-evaluate.

The first session was a disaster! The pt complained that everything hurt too much and that every action I asked her to do caused more pain. I acknowledged her pain, but explained that some increased pain was to be expected in the beginning and thus it might be best if we didn’t think about the pain, but focused on completing the exercises accurately, just to see if they might have some benefit long time.. At the next session Mum decided not to observe. I didn’t ask about pain, just directed the pt and did all the exercises along side her. We chatted about school, her friends etc and soon enough the session was over without a single complaint! Our sessions continued in this way and the patient even suggested some progressions along the way!

In my final week, I did another assessment to measure any gains. The pt stated that her pain was much the same as before we had started the program. However, when I was able to objectively show her how far she had come (improved strength and cardio endurance), she was actually really pleased with herself. And when I asked if the pt was willing to continue the program she was very enthusiastic about it, surmising she might like to join her local gym when her physio program was completed!

Whilst we still don’t know if the pain has an anatomical/pathological source, and whilst we certainly did not rid this young patient of pain, I feel that the intervention had a positive effect on her self-esteem and future health behaviours. I realised that whilst pain is an important clinical indicator, focussing on it can be very detrimental to the goals of an intervention! Also, I now appreciate that assess/intervene/reassess is not always relevant to a single session – it often takes much longer to see gains which the patient can appreciate and that sometimes we need to point out these improvements.

Complex regional pain syndrome

On my paediatric placement I had an 11 year old patient with complex regional pain syndrome! I didn't realise children could have this syndrome. This patient presented with excruciating pain in her calves. The patient couldn't extend her knees past 30 degrees of flexion and refused to walk on her heels. During the assessment the patient cried during active knee extension.

I became quite frustrated with this patient, however managed to hide it inside. It is difficult to understand the pain this patient was feeling as the pain is real to her. On assessment the patient couldn't actively extend past 30 degrees flexion however when the patient was distracted she extended her knees to 15 degrees flexion.

I took the patient to the hydrotherapy pool for treatment with another child who had severe cerebral palsy. Seeing the contrast of these 2 patients was eye opening. The child with cerebral palsy (spastic quadriplegia) was swimming and walking for the first time in 3 years. She was trying so hard and loving the pool. The patient with chronic regional pain syndrome was in tears as the other physio was doing passive knee extension.

This experience definitely made me realise that I had started to judge patients. In the future I will avoid comparing patients and their response to pain, as everyone is different, has different backgrounds and expectations. Therefore I must treat each patient as an individual and provide them with optimal treatment.

Positive team event!

Before starting the physio course, the main experiences I’d had with physio’s was in private practice where the Ax and Rx was done on a 1 to 1 basis. Since then, by doing prac mostly in a hospital setting, ive seen the whole multidisciplinary team approach and recently had a really positive experience.

Last week the local gym in this country town invited the physio’s in the department at the hospital to visit the leisure centre, which had gym, fitness classes and pool facilities. We went down as a group (booked in an hour time slot so that everyone could go together for PD). There were physio’s from every area in the hospital, not just the OP physio’s who dealt with the majority of msc conditions.

The gym managers and instructors were extremely welcoming and very informative in discussing all their equipment as well as the classes they ran. The main aim of this excursion was to have up to date knowledge on the equipment and facilities available for patients who were in their later stages of rehab and no longer needing hospital based Rx.

The gym instructors were very thorough in their explanation of their role and emphasised that they wanted to assist and were able to be involved in the later rehab for patients with our guidelines. They thoroughly assessed every new member to the gym and asked if they were or had been receiving physio Rx. They asked if we referred a patient to the gym, to send a program with them, make it clear, and they would assist them. They emphasised that open communication between them and us would be very welcomed to optimise the patients’ outcome.

Also, a few of the senior physio’s, who were older, were not very familiar with the latest gym equipment and were extremely interested in learning what each machine did, most even hopping on and trying it out!

Whilst we were there, we also discussed a patient as a type of ‘case study’ to work out a good program for him. This particular patient had been involved in a shark attack a few months ago and was progressing really well and wanting to get back to everyday fitness exercises. Their were a number of goals for this patient and all the physio’s and trainers put their heads together to develop a higher level strength and fitness program.

All the physio’s from the hospital, no matter what department they were from, were enthusiastically involved in the discussion. One of the things I learnt from this experience, is that no matter which area you worked in, you were encouraged to share your opinions, interest and skills with the other physio’s.

Another thing I learnt it that it appeared no matter how senior a physio, or how many years experience, there is always something new and interesting to learn. I spoke to the seniors who had had a go on the equipment, and they were rapt to know that now they have an idea of more advanced rehab exercises. The most overwhelming thing I learnt was how much the health professionals in this town worked together. I have not come across this type of interaction in a larger institution in the city, where most later rehab appears to be done by physio’s. I’m not sure of many areas which discuss a combined physio and gym Rx program, I’m sure there are places, and it really seems like a great idea!

Everybody has to have a crying patient

We work with patients in emotionally unstable, sometimes very painful and distressing situations that they are learning to deal with. In my orthopaedic placement, I'm seeing patients walking the day of some huge surgeries. I'm constantly amazed at how quickly patients return to independent function after such big operations. Mostly I'm treating hips and knees, which the surgeons seem to have down to a fine and fast art. But sometimes, you remember the massive trauma they have gone through, and how it affects so much of their body.

One particular lady had some abdominal surgery and was having pain laterally from the incision site, which was crippling her ability to get out of bed. The incision itself was not painful. The surgery can end up bruising the internal organs significantly and this was what was causing her pain. To determine how we could help, we tried different patterns of movement in and out of the bed. This required her to push through her pain several times as we tried different things. By the third attempt, she suddenly turned her face from me and paused. Then she slumped face down on the bed and began quietly crying. It seemed to be a mixture of pain, frustration and helplessness. There is that awkward moment, when you decide whether to gently push on with trying to help the patient with further physiotherapy, or give her time to cry it out and move on later. I wasn't sure which to do, so I decided to leave her for a moment to get her some tubigrip for support of her abdomen. She finished crying and seemed ok afterwards, still in pain and not her usually cheerful self.

Having seen so many patients recover so dramatically well, I was refreshed by this reminder that the surgery can have effects on a patient's body other than where the incision lies, and it is a truly traumatic process that we help them recover from. Having a little sensitivity and patience with their complaints and concerns is needed to best help them recover. I had not had a patient cry during my treatment before, so it was a reminder of how difficult the whole process of recovery can be for a patient. And how important our sensitivity as therapists is!

Everyone's related

I have recently completed my rural practical in a small country town. The physio visited nearby towns as well, so in total I visited treated in 4 towns a week. The patients were mainly musculoskeletal outpatients, however, I did see a few inpatients. After the first week of practical I realised how important patient confidentiality is in a small community. It seemed like everyone was friends, if not related to one another.
Whilst on my rural practical I asked the physiotherapist about patient confidentiality. She said that patients aren’t afraid to ask what the previous patient was being treated for. I was quite shocked at this at first but after being there for a few weeks I realized that it was a very friendly community and people may have been asking about patient’s out of concern. When asled how the therapist deals with this she said that she explains to the patient that it isn’t her place to answer the question.
The physio also told me that even though there is a continence nurse at the health service she sees patients for their continence. This is because patients are too scared that people will see her going to the nurse, or even see their car parked out the front and will talk amongst the community. A physiotherapy appointment is believed to be more accepting.
This practical taught me to be even more careful about patient confidentiality. I couldn’t talk about any of the patients in public (even with no names or age) because everyone knows everyone and anything said will get back to that patient and could potentially upset the patient.

Communicating Diagnoses with Patients

In my recent placement, I had a patient that has been an inpatient for almost a week already. At the end of one of our sessions, he told me that he’s really thankful that all of his doctors, nurses and other health professionals have been doing their best to help him and he has been feeling better for the past days. However, he also said that he wished someone would tell him what has been causing his problems. He said he’s already asked the doctors and nurses but all of them did not say a thing to him at all and that made him anxious. It was quite obvious at that point that he was going to ask me what’s been happening to him so I was having a little bit of a think what to say to him. To start with, he does not have a definite diagnosis just yet, but in his notes, there were some things that the doctors have been trying to rule out. I kept thinking if telling him the possible diagnoses would be of benefit to him. He was somehow anxious then so I had to take that into consideration. In the end, I made it clear to him that there were some possible things that the doctors are trying to rule out. I told him what those were and he said he was relieved because at least he has an idea of the possibilities. Again, I told him that those are just possibilities and the diagnosis can be something else other than those, but he was satisfied already. At that point, I wasn’t so sure if I had done the right thing. So off I went to talk to my supervisor and she said usually, it is not up to us (physios) to discuss diagnoses with patients but that she thought I handled the situation well. She also said that such situations should be approached carefully and with a great deal of sensitivity because each patient is different from another and they may very well respond differently to such situations.