As a student, it can be difficult to deal with a patient who may be sexually inappropriate. Even though this experience did not happen to me, discussing the situation with another student did make me question what I would have done in the same situation.
A patient presented to the student with low back pain. This student was very professional in their manner, and from what I had observed in the past, was very efficient when treating a patient. Despite this, the patient was not appropriately responding to questions, but preferred the conversation to centre around how often he went to the gym and how much he could bench-press. Furthermore, the patient continuously made sexual innuendos throughout the session, for example, offering to remove more items of his clothing than his shirt. Despite these comments, the student ignored the way the patient was acting and what he was saying, and continued to perform the appropriate assessment and treatment. However, it did make the student feel very uncomfortable and resulted in them not wanting to treat the patient again.
As we discussed the situation afterwards, we all realised that it is quite difficult to know what to do in these situations. Do you simply ignore the patient’s comments? Do you tell them their comments are inappropriate? Do you continue or refuse to treat them? Even though I know I would have liked to speak up against the patient (in a professional way…), I don’t know if I would have had the confidence to do so and probably would have just ignored the patient and continued to treat. I think as a student, we can sometimes feel we are not empowered enough to speak against a patient. We all like a placement to go as smoothly as possible, not ruffle too many feathers and give ourselves a good name. However, the truth of the matter is we deserved to be treated with respect. We should never feel under obligation to treat someone if we are putting ourselves in a vulnerable or uncomfortable situation.
It is important that if situations like this do occur, speak up to the patient and bring it to someone’s attention. Furthermore, see if the patient can be transferred to another physio, or alternatively see if another person can be present during the session. These are the strategies I would try to implement. It would be good to hear other people’s viewpoints on this matter.
Tuesday, October 28, 2008
Inappropriate Patients
As a student, it can be difficult to deal with a patient who may be sexually inappropriate. Even though this experience did not happen to me, discussing the situation with another student did make me question what I would have done in the same situation.
A patient presented to the student with low back pain. This student was very professional in their manner, and from what I had observed in the past, was very efficient when treating a patient. Despite this, the patient was not appropriately responding to questions, but preferred the conversation to centre around how often he went to the gym and how much he could bench-press. Furthermore, the patient continuously made sexual innuendos throughout the session, for example, offering to remove more items of his clothing than his shirt. Despite these comments, the student ignored the way the patient was acting and what he was saying, and continued to perform the appropriate assessment and treatment. However, it did make the student feel very uncomfortable and resulted in them not wanting to treat the patient again.
As we discussed the situation afterwards, we all realised that it is quite difficult to know what to do in these situations. Do you simply ignore the patient’s comments? Do you tell them their comments are inappropriate? Do you continue or refuse to treat them? Even though I know I would have liked to speak up against the patient (in a professional way…), I don’t know if I would have had the confidence to do so and probably would have just ignored the patient and continued to treat. I think as a student, we can sometimes feel we are not empowered enough to speak against a patient. We all like a placement to go as smoothly as possible, not ruffle too many feathers and give ourselves a good name. However, the truth of the matter is we deserved to be treated with respect. We should never feel under obligation to treat someone if we are putting ourselves in a vulnerable or uncomfortable situation.
It is important that if situations like this do occur, speak up to the patient and bring it to someone’s attention. Furthermore, see if the patient can be transferred to another physio, or alternatively see if another person can be present during the session. These are the strategies I would try to implement. It would be good to hear other people’s viewpoints on this matter.
A patient presented to the student with low back pain. This student was very professional in their manner, and from what I had observed in the past, was very efficient when treating a patient. Despite this, the patient was not appropriately responding to questions, but preferred the conversation to centre around how often he went to the gym and how much he could bench-press. Furthermore, the patient continuously made sexual innuendos throughout the session, for example, offering to remove more items of his clothing than his shirt. Despite these comments, the student ignored the way the patient was acting and what he was saying, and continued to perform the appropriate assessment and treatment. However, it did make the student feel very uncomfortable and resulted in them not wanting to treat the patient again.
As we discussed the situation afterwards, we all realised that it is quite difficult to know what to do in these situations. Do you simply ignore the patient’s comments? Do you tell them their comments are inappropriate? Do you continue or refuse to treat them? Even though I know I would have liked to speak up against the patient (in a professional way…), I don’t know if I would have had the confidence to do so and probably would have just ignored the patient and continued to treat. I think as a student, we can sometimes feel we are not empowered enough to speak against a patient. We all like a placement to go as smoothly as possible, not ruffle too many feathers and give ourselves a good name. However, the truth of the matter is we deserved to be treated with respect. We should never feel under obligation to treat someone if we are putting ourselves in a vulnerable or uncomfortable situation.
It is important that if situations like this do occur, speak up to the patient and bring it to someone’s attention. Furthermore, see if the patient can be transferred to another physio, or alternatively see if another person can be present during the session. These are the strategies I would try to implement. It would be good to hear other people’s viewpoints on this matter.
Monday, October 27, 2008
Locked in
I am currently treating a patient who had a pontine stroke a few years ago. As a result she has ‘locked-in syndrome’. She is in her late 20s. She is now wheelchair bound and the only voluntary control she has is a small amount of elbow flexion/extension and head control. She can laugh and smile and mouth yes and no.
My treatment involves manual stretches, foot mobs and tilt table activities for trunk control. We also work on sitting balance. When I read her notes I felt I would be able to cope with the treatments quite well, but was a little apprehensive about communicating with this patient. My first treatment sessions with other neuro patients had essentially been 1.5 hours of rapport building and I was concerned that it might not be so easy with this patient. I read in her notes that she communicated via lightscribe.. which frankly just freaked me out! I was imagining some high tech device which flashed lights which I would have to interpret..
When the patient arrived I took a deep breath and went to meet her. She smiled and typed the word ‘music’ into her keyboard, which prints and speaks whatever she writes (this is the lightscribe I was so scared of!). When we worked out how to put the radio on, we got to work and I found that communicating with her wasn’t difficult at all. Whilst on the plinth, a series of yes/no questions allows her to tell me what hurts/when she’s uncomfortable or just to make chat; all without the lightscribe, though knowing it was available if required really helped.
I soon realised that her approach to our meeting had made me comfortable with the situation and able to interact appropriately. I was annoyed at myself for being so worried initially. In the future I will have more confidence in my abilities to adapt to new situations and hopefully I will be the one making the other person feel at ease! I also really appreciated the extent to which the allied health team can go to ensure a pt is able to communicate – not being able to communicate can be the biggest frustration for pt post stroke, but this pt (whose disabilities are quite severe) was completely at ease and I suspect some of that is because she is able to communicate so well.
My treatment involves manual stretches, foot mobs and tilt table activities for trunk control. We also work on sitting balance. When I read her notes I felt I would be able to cope with the treatments quite well, but was a little apprehensive about communicating with this patient. My first treatment sessions with other neuro patients had essentially been 1.5 hours of rapport building and I was concerned that it might not be so easy with this patient. I read in her notes that she communicated via lightscribe.. which frankly just freaked me out! I was imagining some high tech device which flashed lights which I would have to interpret..
When the patient arrived I took a deep breath and went to meet her. She smiled and typed the word ‘music’ into her keyboard, which prints and speaks whatever she writes (this is the lightscribe I was so scared of!). When we worked out how to put the radio on, we got to work and I found that communicating with her wasn’t difficult at all. Whilst on the plinth, a series of yes/no questions allows her to tell me what hurts/when she’s uncomfortable or just to make chat; all without the lightscribe, though knowing it was available if required really helped.
I soon realised that her approach to our meeting had made me comfortable with the situation and able to interact appropriately. I was annoyed at myself for being so worried initially. In the future I will have more confidence in my abilities to adapt to new situations and hopefully I will be the one making the other person feel at ease! I also really appreciated the extent to which the allied health team can go to ensure a pt is able to communicate – not being able to communicate can be the biggest frustration for pt post stroke, but this pt (whose disabilities are quite severe) was completely at ease and I suspect some of that is because she is able to communicate so well.
Challenges for patient time
I am completing an outpatient placement that is focussed on treating older patients who are at risk of further injury after history of falls. The nature of the challenges that these patients face with everyday life was highlighted to me with a treatment session last week.
During our morning meeting I was allocated Mr A to treat and informed that he has mobility issues, a history of falls and is considered a ‘wanderer’ due to his short term memory loss. Given this situation it had been arranged that his wife assists him into a taxi and then phones us to let us know he is coming so we can meet him and assist him to the treatment gym.
On this particular day Mr A was booked in for an 11am appointment but the taxis regularly drop patients early so I had to ensure I was free to treat Mr A from 10:30. Mr A arrived at 11am and we completed a productive session that lasted approximately 40 minutes. 15 minutes prior to the end of the session I phoned the taxi so that we could minimise the wait at the end of the session.
However the taxi was running late and did not arrive until 12:20. Given that Mr A was not safe to be left on his own I was needed to stay with him to ensure that he did not wander from the pick up point.
The timing of this treatment session meant I spent longer organising to see the patient than I actually did treating, which is quite a change from my recent musculo outpatients clinic. However I had plenty of paper work to do and was able to spend my time efficiently while waiting for the taxi. In that time Mr A explained to me that he had been ready from 9am waiting for the taxi and found it frustrating he spent so much time waiting with control over what he can and can’t do.
Given that patients like Mr A can sometimes have three visits a week to the hospital for various appointments, the inefficiencies in the system mean that so much of the patients time is spent in transit compared to the actual reason of their visit. In our clinic we try to be flexible with our treatment times and dates so that we minimise the amount of trips a patient has to make but sometimes this is unavoidable.
This experience had highlighted to me the need for us as health professionals to be an advocate for the patient so that delivery of services through appointments can be better managed for the patient and those who are responsible for their transport.
During our morning meeting I was allocated Mr A to treat and informed that he has mobility issues, a history of falls and is considered a ‘wanderer’ due to his short term memory loss. Given this situation it had been arranged that his wife assists him into a taxi and then phones us to let us know he is coming so we can meet him and assist him to the treatment gym.
On this particular day Mr A was booked in for an 11am appointment but the taxis regularly drop patients early so I had to ensure I was free to treat Mr A from 10:30. Mr A arrived at 11am and we completed a productive session that lasted approximately 40 minutes. 15 minutes prior to the end of the session I phoned the taxi so that we could minimise the wait at the end of the session.
However the taxi was running late and did not arrive until 12:20. Given that Mr A was not safe to be left on his own I was needed to stay with him to ensure that he did not wander from the pick up point.
The timing of this treatment session meant I spent longer organising to see the patient than I actually did treating, which is quite a change from my recent musculo outpatients clinic. However I had plenty of paper work to do and was able to spend my time efficiently while waiting for the taxi. In that time Mr A explained to me that he had been ready from 9am waiting for the taxi and found it frustrating he spent so much time waiting with control over what he can and can’t do.
Given that patients like Mr A can sometimes have three visits a week to the hospital for various appointments, the inefficiencies in the system mean that so much of the patients time is spent in transit compared to the actual reason of their visit. In our clinic we try to be flexible with our treatment times and dates so that we minimise the amount of trips a patient has to make but sometimes this is unavoidable.
This experience had highlighted to me the need for us as health professionals to be an advocate for the patient so that delivery of services through appointments can be better managed for the patient and those who are responsible for their transport.
Monday, October 20, 2008
During my rural prac I was confronted by many new experiences and challenges, however I think the biggest eye opener for me was the minimal resources provided to cover such a large area and the skills required to cope with this.
The health service where I was placed is based at a regional centre and is responsible for providing health care to the local town, between the hospital and the community health centre, as well as five other towns, two within driving distance and three within flying distance. Given the distance between the towns and even centres within the town, readily available transport is essential for these services to be delivered.
The major problem faced by the allied health team was that the allocation of government cars was poorly organised and a bit biased towards visiting medical staff. There were numerous instances of missed treatment sessions or even whole days at a community due to therapists not being able to find a car. Similarly the contract to provide flight to rural centres was shared with mining companies and so mining staff took priority over allied health staff, which resulted in staff being stranded in towns overnight as they were unable to get a flight home.
The large distances, lack of staff and transport problems mean that rural staff have to be extremely flexible and continually change their plan to ensure the best care is given to the patients. With treatments sometimes spread so far apart and little follow up available, I was made aware of the need to focus on the main priority for the patient and try to treat that the best we could with the time available.
The skills I witnessed on this prac including coping with problems, flexibility to change at a moments notice and above all else the ability to keep a sense of humour meant that I left my rural prac with a great deal a respect for rural clinicians and the challenges they face each day just to get to treat patients.
The health service where I was placed is based at a regional centre and is responsible for providing health care to the local town, between the hospital and the community health centre, as well as five other towns, two within driving distance and three within flying distance. Given the distance between the towns and even centres within the town, readily available transport is essential for these services to be delivered.
The major problem faced by the allied health team was that the allocation of government cars was poorly organised and a bit biased towards visiting medical staff. There were numerous instances of missed treatment sessions or even whole days at a community due to therapists not being able to find a car. Similarly the contract to provide flight to rural centres was shared with mining companies and so mining staff took priority over allied health staff, which resulted in staff being stranded in towns overnight as they were unable to get a flight home.
The large distances, lack of staff and transport problems mean that rural staff have to be extremely flexible and continually change their plan to ensure the best care is given to the patients. With treatments sometimes spread so far apart and little follow up available, I was made aware of the need to focus on the main priority for the patient and try to treat that the best we could with the time available.
The skills I witnessed on this prac including coping with problems, flexibility to change at a moments notice and above all else the ability to keep a sense of humour meant that I left my rural prac with a great deal a respect for rural clinicians and the challenges they face each day just to get to treat patients.
Thursday, October 16, 2008
Reading a situation and following up…
I had been treating a patient on my neuro prac who had sustained a R MCA, CVA. She had very mild impairments, with no voluntary control of her R hand the major problem. There were NAD in her R LL. The sensation of her R and was intact, there was just a mild proprioceptive impairment of her R MCPJ JMS and JPS – anyway – the bottom line was she was not a patient who presented with ‘heavy’ stroke symptoms.
This patient was extremely optimistic and always motivated for physio. She was a pleasure to work with and felt I had really good rapport with her. I had been treating this patient since her admission (1 week).
I went to see her on this particular day, she was lying in bed and there was a gentlemen sitting next to her bed on a mobile phone. I didn’t pay much attention to him and was not listening to what he was saying when I went to her bedside. I went in with a big smile as I did everyday and was expecting her to return it as she always did. She looked at me and said “I don’t think I can come to physio today.” I asked how come and she said she had to have an operation on her neck as this was the artery which had caused the stroke.
I then tuned in to what the man on the phone was saying and realised he was talking to her daughter and saying he ‘had explained the procedure and it was scheduled for a few days.” This patient looked at me and burst into tears and said “I don’t want to die.”
I sat with the patient and consoled her until she calmed down, which she said she was very grateful for. I then said we could do physio the next day if she felt up to it. She then looked scared and said “no, I don’t think im meant to move around to much because I might re-stroke”
Not knowing a lot about the carotidendarterectomy procedure, I told her I would find out about still doing physio.
I contacted her docter and asked about continuing physio and he reported that it was completely fine (as long as we didn’t manip her neck) and that it would be beneficial to continue to improve her baseline level in the first place. He wondered why she had the impression she wasn’t allowed to move. I said to him that she may be in a bit of shock and coping with the news and may have misinterpreted him, and asked if he wouldn’t mind reassuring her it was ok to move. (this was the day before the weekend, and I was just imagining this patient not moving her neck or body for the whole weekend out of fear) he said that would be no problem and was happy to see her.
After this, the patient was SO grateful I had asked him and was so excited that she could still come up to physio, and whilst she was still slightly anxious about the op, the routine of doing physio and OT and the ‘normal’ for her during the day appeared to really benefit her.
This taught me firstly to read a patients body language and the situation better, as when I first went in to see her for physio I expected her to be like every other day. In the future I will keep in mind that anything and any news can happen very quickly in a hospital and to be aware that even the most cheerful person may just have received difficult news.
Secondly, by following up with the doctor and asking him to reassure her, had such a huge benefit for this patient and decreased her anxiety immensely. He hadn’t realised she had misunderstood the mobility issue, and by being with someone who deals with that, I was able to follow it up and continue treatment with this lady, which we both enjoyed!!
This patient was extremely optimistic and always motivated for physio. She was a pleasure to work with and felt I had really good rapport with her. I had been treating this patient since her admission (1 week).
I went to see her on this particular day, she was lying in bed and there was a gentlemen sitting next to her bed on a mobile phone. I didn’t pay much attention to him and was not listening to what he was saying when I went to her bedside. I went in with a big smile as I did everyday and was expecting her to return it as she always did. She looked at me and said “I don’t think I can come to physio today.” I asked how come and she said she had to have an operation on her neck as this was the artery which had caused the stroke.
I then tuned in to what the man on the phone was saying and realised he was talking to her daughter and saying he ‘had explained the procedure and it was scheduled for a few days.” This patient looked at me and burst into tears and said “I don’t want to die.”
I sat with the patient and consoled her until she calmed down, which she said she was very grateful for. I then said we could do physio the next day if she felt up to it. She then looked scared and said “no, I don’t think im meant to move around to much because I might re-stroke”
Not knowing a lot about the carotidendarterectomy procedure, I told her I would find out about still doing physio.
I contacted her docter and asked about continuing physio and he reported that it was completely fine (as long as we didn’t manip her neck) and that it would be beneficial to continue to improve her baseline level in the first place. He wondered why she had the impression she wasn’t allowed to move. I said to him that she may be in a bit of shock and coping with the news and may have misinterpreted him, and asked if he wouldn’t mind reassuring her it was ok to move. (this was the day before the weekend, and I was just imagining this patient not moving her neck or body for the whole weekend out of fear) he said that would be no problem and was happy to see her.
After this, the patient was SO grateful I had asked him and was so excited that she could still come up to physio, and whilst she was still slightly anxious about the op, the routine of doing physio and OT and the ‘normal’ for her during the day appeared to really benefit her.
This taught me firstly to read a patients body language and the situation better, as when I first went in to see her for physio I expected her to be like every other day. In the future I will keep in mind that anything and any news can happen very quickly in a hospital and to be aware that even the most cheerful person may just have received difficult news.
Secondly, by following up with the doctor and asking him to reassure her, had such a huge benefit for this patient and decreased her anxiety immensely. He hadn’t realised she had misunderstood the mobility issue, and by being with someone who deals with that, I was able to follow it up and continue treatment with this lady, which we both enjoyed!!
Monday, October 13, 2008
Communication
I think a lot of health professionals are very good at focussing on their specific treatment and management of a patient, but I think there is room for improving communication with other health professionals and working within a team environment. In the rural setting this communication sometimes breaks down all together as there is a very high turn over of staff and information is not always passed on appropriately.
While on my rural placement I visited a remote community for a day each week and part of that visit was to cover a small hospital with four beds. “Mike” had been admitted about three months prior with progressive weakness and atrophy of his lower limbs, after his family were unwilling to care for him anymore. Mike had a history of alcohol and substance abuse and the medical staff believed that this was an expression of a long standing mental illness and was treated accordingly.
The hospital was staffed by agency nurses who rotated every few weeks and a RMO who covered the hospital along with private rooms in two communities. When we made our weekly visit to the hospital to see Mike along with another patient we were informed that the RMO had resigned effective immediately and that a replacement doctor had started the day before. This resignation had also coincided with a change in the nursing staff.
We had read in Mike’s notes the week previously he was going to be seen by a visiting specialist as the current treatment was not working and no definitive diagnosis had been made. However when we arrived at the hospital we found that Mike had been taken to the regional hospital in order to have some additional investigations done that were ordered by the new doctor, unaware of the visit by the specialist. This meant that as the specialist was driving to the remote centre, Mike was in an ambulance driving the other way.
The additional investigations provided no further information and Mike did not get to see another specialist until over two weeks later. By that time he had deteriorated further and after review from the specialist Mike was diagnosed with an aggressive form of cancer that had spread to his spine and lungs.
I found this experience really highlighted to me again the challenges health professionals face in a rural setting with staff turn over and logistics, but more importantly it showed that when everyday things we take for granted do not happen, such as basic communication about the care of a patient, then there can be significant consequences for the patient. In this scenario I am not sure finding the cancer two weeks earlier would have helped, but I do think it is a shame the patient was at not least given that chance.
never underestimate the new breed
I was always amazed by how most supervisors and physiotherapists would listen to what we had learned in university as the latest "new physio thing". I thought most of them were just being nice. However, when on my SDP I was videoing some third year students on their three week prac. I volunteered to play foot model for taping practise and learned a new supination taping. This is a diagonal strip from lateral calcaneum to the ball of the foot, applied after LODI taping. It was new to me, but really comfortable and effective. Then I filmed another student doing a medial patella glide taping in a way that was new way to me - a strip layed back upon itself from the medial knee which then joins the second strip that pulls the patella from lateral to medial. (If that doesn't make sense, let me know and I can explain it better). This acts (i assume) to prevent the dimpling of the suprapatella fat pad and any skin irritation, and allows for a really good line of pull. And it looked great!
These students are only one year behind but already I'm learning from them.
I have also found the more you see other peoples styles of treating and applying various techniques to the same end, the more diverse and flexible my skills become as well. So I'm definitely not discounting the experience and knowledge of those "younger" than us in physiotherapy years, because it could be really useful!! It now makes sense why most good supervisors are very open to our ideas and how we did things at university.
These students are only one year behind but already I'm learning from them.
I have also found the more you see other peoples styles of treating and applying various techniques to the same end, the more diverse and flexible my skills become as well. So I'm definitely not discounting the experience and knowledge of those "younger" than us in physiotherapy years, because it could be really useful!! It now makes sense why most good supervisors are very open to our ideas and how we did things at university.
Saturday, October 11, 2008
Importance of outcome measures:
Whilst on a neuro placement, I came across a situation that made me realise the importance of specific outcome measures for each individual patient. My supervisor had just been to a team meeting and came out a little frustrated and upset.
I asked what was wrong and she told me about what had happened at the meeting. The particular patient being discussed had sustained a L sided CVA about 3 months ago, had undergone rehab, then had re-stroked but this time on the R side. He had been at a neuro rehab hospital in the last month, and had just been transferred to our hospital to a smaller rehab program as his prognosis for recovery was not fantastic as he now had 2 sides affected.
The team at our hospital were discussing his rehab and discharge plan. My supervisor had been working with this patient from the beginning, before his 2nd stroke prior to him being transferred to the other neuro rehab hospital, and then after, once he had been transferred back again. She was seeing some small signs of recovery and improvement in his tone and sensation, however not a significant change in his functional ability. It was now about 6 weeks since his 2nd stroke.
My supervisor had gone into the meeting with the thought in mind that this pt would need to go to a high level care facility once DC, and thought that is what the other members of the team had decided too and this meeting was just to clarify the issue. In the meeting, all team members spoke their part, and my supervisor mentioned about he had had early signs of small recovery, none recently and no change in functional status. After that, there were some members of the team who fixated on this point and pushed the idea that because small signs of recovery had been seen, and who’s to say he wouldn’t improve significantly. My supervisor tried to explain his poor prognosis and his realistic outcomes.
She came out feeling frustrated, as she knew this patient was unlikely to improve significantly, and she thought by keeping him in hospital and continuing his fairly intensive rehab (with little improvement) was not going to benefit the patients mental state. She said it’s a difficult call to make whether to continue a patients rehab, as there is always hope for improvement, however with clinical experience you also need to use your judgement as to what is best for the patient. It’s hard for both the physio and the patient to continue something with no improvements.
It made me realise the importance of outcome measures, not only for the patient, but for other team members to see where the patient is at and how there rehab is going. I felt like I was focusing and improving my ability at one day Ax and Rx, whereas I needed to focus on the bigger picture and discharge planning. It also made me realise that so many people are involved with one patient, and it would be good to liase with other teams such as OT’s, who we work more closely with, prior to team meetings to work out if we are on the same page and have the same ideas for the patient. I will definitely keep this in mind, (both the importance of presenting outcome measures and liasing with other people), for the future to avoid the same frustration my supervisor felt.
I asked what was wrong and she told me about what had happened at the meeting. The particular patient being discussed had sustained a L sided CVA about 3 months ago, had undergone rehab, then had re-stroked but this time on the R side. He had been at a neuro rehab hospital in the last month, and had just been transferred to our hospital to a smaller rehab program as his prognosis for recovery was not fantastic as he now had 2 sides affected.
The team at our hospital were discussing his rehab and discharge plan. My supervisor had been working with this patient from the beginning, before his 2nd stroke prior to him being transferred to the other neuro rehab hospital, and then after, once he had been transferred back again. She was seeing some small signs of recovery and improvement in his tone and sensation, however not a significant change in his functional ability. It was now about 6 weeks since his 2nd stroke.
My supervisor had gone into the meeting with the thought in mind that this pt would need to go to a high level care facility once DC, and thought that is what the other members of the team had decided too and this meeting was just to clarify the issue. In the meeting, all team members spoke their part, and my supervisor mentioned about he had had early signs of small recovery, none recently and no change in functional status. After that, there were some members of the team who fixated on this point and pushed the idea that because small signs of recovery had been seen, and who’s to say he wouldn’t improve significantly. My supervisor tried to explain his poor prognosis and his realistic outcomes.
She came out feeling frustrated, as she knew this patient was unlikely to improve significantly, and she thought by keeping him in hospital and continuing his fairly intensive rehab (with little improvement) was not going to benefit the patients mental state. She said it’s a difficult call to make whether to continue a patients rehab, as there is always hope for improvement, however with clinical experience you also need to use your judgement as to what is best for the patient. It’s hard for both the physio and the patient to continue something with no improvements.
It made me realise the importance of outcome measures, not only for the patient, but for other team members to see where the patient is at and how there rehab is going. I felt like I was focusing and improving my ability at one day Ax and Rx, whereas I needed to focus on the bigger picture and discharge planning. It also made me realise that so many people are involved with one patient, and it would be good to liase with other teams such as OT’s, who we work more closely with, prior to team meetings to work out if we are on the same page and have the same ideas for the patient. I will definitely keep this in mind, (both the importance of presenting outcome measures and liasing with other people), for the future to avoid the same frustration my supervisor felt.
Sunday, October 5, 2008
How one Ax can have such an impact....
Recently on a neuro prac I was asked to go and Ax a patient who had just been moved from another ward. After reading her notes I found out she had had a L MCA, mild R sided weakness and severe speech dyspraxia. She had been Ax briefly by the ED Physio’s, but had not yet received any rehab PT Rx. Her mobility status had not yet been Ax.
As she had just been transferred from another ward, I was asked to go and do her initial Ax to determine her mobility status and complete the mobility chart for her bedside. This patient was 11 days post stroke, and up until now had been hoisted for all transfers. Due to this mentioned in her notes, I assumed she was going to be a ‘heavier’ stroke patient, in terms of more severe abnormal tone symptoms.
I was quite nervous before going in to see the patient, because I had never done an initial Ax and only seen patients who had been handed over by other PT’s – therefore they had mentioned any specific issues regarding the particular patient.
The patient was sitting in her wheelchair beside the bed. I had discussed with my supervisor (who had come in with me) prior to the session how I was going to structure the Ax. After beginning the subjective, it became apparent at how severe the speech dyspraxia was. The patient did not appear to have any receptive or expressive aphasia, as her body language and nodding/shaking her head was all very appropriate to the questions being asked. Her frustration at not being able to physically form the words she wanted to say became increasingly evident as the session went on.
I had come across patients with types of aphasia before, but none had seemed as frustrated as this patient, as she knew exactly what she wanted to say. She was also very insightful towards her condition and symptoms. She could follow the conversation and 2 stage requests easily.
I Ax her PROM then voluntary control, and she had very very mild weakness in her R UL and LL, but good voluntary control. She did not have any abnormal tone evident and had good strength in all her limbs.
Positioned on her R side (and supervisor standing close by aswell), I asked if she could stand up. She did very easily, the only assistance needed was to hold her R hand so she could steady herself, as this had been the first time she stood in 11 days. She was able to transfer with min assist from wheelchair to bed, and had independent bed mobility – rolling and supine to sitting on the edge.
After we had done this Ax and I told her about the mobility chart for the nurses, she burst into tears. At first I was shocked, as I thought she had done really well and I thought she would of too. After sitting and consoling her for a little while, and her using hand signals to communicate with me, I realised that one of the reasons she was crying was that she was so grateful that she could now move more independently and not have to be hoisted. I realised how vulnerable you must feel being unable to express how you are feeling, and being in a hospital environment where lots of people talk about you and make decisions for and about you, and not being able to say anything. This patient probably knew how strong she felt and how well she could move, but without being able to say anything, and with the policy that patients are hoisted until Ax, she had had no control over that aspect.
I also gave her a pad of paper and pen so that she could write things down if she needed.
The things I learnt from this experience is to not assume symptoms, especially as neuro patients with the same diagnosis can present SO differently. I assumed she would be a max assist due to the need for being hoisted, whereas she only needed minimal assistance, and it was hospital policy to hoist until Ax. I also realised how upsetting it must be to not be able to talk when being assessed, and I concentrated on how I was communicating around this patient. I tried to ask closed questions so she could answer yes/no as anything that needed explanation would frustrate her.
It also made me aware that a mobility Ax should never be ‘put off’ as it can have such an impact on the patient’s mental state. It was my first experience at having such an impact on a patients stay in hospital, as she no longer needed hoisting and was so grateful. I will keep this in mind for all types of patients in the future.
As she had just been transferred from another ward, I was asked to go and do her initial Ax to determine her mobility status and complete the mobility chart for her bedside. This patient was 11 days post stroke, and up until now had been hoisted for all transfers. Due to this mentioned in her notes, I assumed she was going to be a ‘heavier’ stroke patient, in terms of more severe abnormal tone symptoms.
I was quite nervous before going in to see the patient, because I had never done an initial Ax and only seen patients who had been handed over by other PT’s – therefore they had mentioned any specific issues regarding the particular patient.
The patient was sitting in her wheelchair beside the bed. I had discussed with my supervisor (who had come in with me) prior to the session how I was going to structure the Ax. After beginning the subjective, it became apparent at how severe the speech dyspraxia was. The patient did not appear to have any receptive or expressive aphasia, as her body language and nodding/shaking her head was all very appropriate to the questions being asked. Her frustration at not being able to physically form the words she wanted to say became increasingly evident as the session went on.
I had come across patients with types of aphasia before, but none had seemed as frustrated as this patient, as she knew exactly what she wanted to say. She was also very insightful towards her condition and symptoms. She could follow the conversation and 2 stage requests easily.
I Ax her PROM then voluntary control, and she had very very mild weakness in her R UL and LL, but good voluntary control. She did not have any abnormal tone evident and had good strength in all her limbs.
Positioned on her R side (and supervisor standing close by aswell), I asked if she could stand up. She did very easily, the only assistance needed was to hold her R hand so she could steady herself, as this had been the first time she stood in 11 days. She was able to transfer with min assist from wheelchair to bed, and had independent bed mobility – rolling and supine to sitting on the edge.
After we had done this Ax and I told her about the mobility chart for the nurses, she burst into tears. At first I was shocked, as I thought she had done really well and I thought she would of too. After sitting and consoling her for a little while, and her using hand signals to communicate with me, I realised that one of the reasons she was crying was that she was so grateful that she could now move more independently and not have to be hoisted. I realised how vulnerable you must feel being unable to express how you are feeling, and being in a hospital environment where lots of people talk about you and make decisions for and about you, and not being able to say anything. This patient probably knew how strong she felt and how well she could move, but without being able to say anything, and with the policy that patients are hoisted until Ax, she had had no control over that aspect.
I also gave her a pad of paper and pen so that she could write things down if she needed.
The things I learnt from this experience is to not assume symptoms, especially as neuro patients with the same diagnosis can present SO differently. I assumed she would be a max assist due to the need for being hoisted, whereas she only needed minimal assistance, and it was hospital policy to hoist until Ax. I also realised how upsetting it must be to not be able to talk when being assessed, and I concentrated on how I was communicating around this patient. I tried to ask closed questions so she could answer yes/no as anything that needed explanation would frustrate her.
It also made me aware that a mobility Ax should never be ‘put off’ as it can have such an impact on the patient’s mental state. It was my first experience at having such an impact on a patients stay in hospital, as she no longer needed hoisting and was so grateful. I will keep this in mind for all types of patients in the future.
The emotion of a wheelchair
During one of my previous pracs I was invited to attend the first fitting session of a new electric wheelchair for a young disabled child “Amy”. Amy had been receiving physiotherapy treatment from a very early stage when it was noticed she was a very quiet and floppy baby. Amy exhibited hypotonia, significant developmental delay and was under the care of a paediatrician however after a number of years of care, no formal diagnosis had been made as to the cause of this condition.
Given Amy’s condition she was well known to all of the multidisciplinary team who had been involved at one point or another with her care. Amy was also well known to the local community who had supported fundraising efforts by the family so that they could afford an electric wheelchair to provide her with mobility and some independence.
On the day of the fitting my supervisor, a senior OT and I travelled to their house for our appointment. We discussed that ours aims of the session was to assess and modify Amy’s posture in the chair, provide some education to her parents about its capability and assess the chair ourselves as none of us had actually seen this model before.
The session went mostly as plan as we adjusted Amy’s positions, assessed the chair and helped answer questions from her parents. However Amy’s mother complained that she was not able to drive the chair with the adult remote on the back. The chair was fitted with a set of controls that could be operated by the parents while walking behind the chair and while the controls were a bit sensitive it was not that hard to drive the chair.
When Amy and her dad had gone for a practice Amy’s mother confided in us that it was not so much about driving the chair but rather what it meant for her and Amy. She felt that until now Amy had been like any other child in a stroller out in public, but now everyone would look at her and know she had a disability. Emotionally Amy’s mum found the wheelchair hard to deal with as it was a real reminder of Amy’s condition, compounded by the fact that they were still without a diagnosis.
My supervisor encouraged her to talk about her feelings with friends and family and highlighted the benefits for Amy with have the chance to have her own independence to explore her environment and be mobile. I found this experience was a big eye opener for me as to the experience of a parent who has a child with a disability. I had wrongly assumed that as parents they would have come to accept her disability but now I have a better idea of how hard it is for parents in this situation.
Friday, October 3, 2008
Being textbook versus being clinically real
I had some sick days to make up for on my neuro prac and was there when the very large caseload that was normally handled by 4 students and 2 physios was all double assist patients with myself and 1-2 other physios. It was a huge caseload. We had to prioritise patient needs and treatment so that we limited our load to those who really needed physiotherapy that day, and their treatment was catapaulted. By that I mean, if a patient couldn't walk, we made a judgement call and walked them, as walking is one of the most beneficial functional tasks for the rehabiliation post stroke. We pushed patients hard in their treatment, demanded a lot from them and they responded very well. Over 3 days I noticed the difference in their sitting and standing balance after we walked them, their increased alertness and voluntary control. It was amazing! I had been worried that we were not being completely textbook thorough with each patient, but time just didn't allow it. Yet they were improving very well.
I learned to make fast but clinically accurate judgement calls, to REALLY prioritise treatment sessions to the top 2 or three items and to analyse well. This is what you face in the real world. I see why we learn the text book perfect way, as it is essential to seeing the scientific progression of physiotherapy, but we are also trained to be flexible, abstract thinkers and this enhances our analytical skills. And you know what? It feels great to be able to do a good job on so little resource and time, and know that you are making a difference in a hard situation. The real world is where we will work and it is not of perfect resource and opportunities, so our flexibility is important!
I learned to make fast but clinically accurate judgement calls, to REALLY prioritise treatment sessions to the top 2 or three items and to analyse well. This is what you face in the real world. I see why we learn the text book perfect way, as it is essential to seeing the scientific progression of physiotherapy, but we are also trained to be flexible, abstract thinkers and this enhances our analytical skills. And you know what? It feels great to be able to do a good job on so little resource and time, and know that you are making a difference in a hard situation. The real world is where we will work and it is not of perfect resource and opportunities, so our flexibility is important!
Thursday, October 2, 2008
A difficult little patient.
On my rural prac one of my patients was an 8 year old boy who had fractured his SOF 2/12 ago and hadn't had any physiotherapy yet, not even a few exercises. He also suffered from mild developmental delay which meant he was extremely shy, never made eye contact with me and spoke in grunts. He would sit in the room with his head hung as low as he could get it, playing and fidgeting with anything in sight.
I realised quite soon that I wouldn't be able to do any mobilisations because he wouldn't let me touch his knee. I tried to rely on the father to help me get some information about his pain levels but his father just yelled at him and the son wasn't very compliant with what he said. I wasn't able to simply ask the patient to bend and straighten his knee because he wouldn't do anything I asked. I hadn't done any paeds pracs and this was my first patient of his age I had ever had to treat.
I was about to go and get my supervisor for some help but decided to have one last attempt first. I asked him to hit my hand with his foot, then asked him if he could make his foot hit the bed. Then I took him next door to the gym and got him riding the bike to try and determine how much knee flexion he was getting. By turning everything into a game he began to engage and we were able to come up with some exercises which he found fun.
This experience opened my eyes about some of the difficulties of this area of physio. You have to change so much about your communication when you're talking to children and turn it into terms they understand and care about. Next time I have a young patient I'll tailor my conversation to what they're interested and try to turn abstract concepts like 'knee flexion' into a game or something they can understand.
I realised quite soon that I wouldn't be able to do any mobilisations because he wouldn't let me touch his knee. I tried to rely on the father to help me get some information about his pain levels but his father just yelled at him and the son wasn't very compliant with what he said. I wasn't able to simply ask the patient to bend and straighten his knee because he wouldn't do anything I asked. I hadn't done any paeds pracs and this was my first patient of his age I had ever had to treat.
I was about to go and get my supervisor for some help but decided to have one last attempt first. I asked him to hit my hand with his foot, then asked him if he could make his foot hit the bed. Then I took him next door to the gym and got him riding the bike to try and determine how much knee flexion he was getting. By turning everything into a game he began to engage and we were able to come up with some exercises which he found fun.
This experience opened my eyes about some of the difficulties of this area of physio. You have to change so much about your communication when you're talking to children and turn it into terms they understand and care about. Next time I have a young patient I'll tailor my conversation to what they're interested and try to turn abstract concepts like 'knee flexion' into a game or something they can understand.
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