Whilst on my gerontology prac I treated a 70 year old woman who came into the centre with a PC of falls, BPPV and decrease muscle strength. She had previously been admitted into Fremantle Hospital with an exacerbation of BPPV and the physiotherapist there had performed the Eppley's manouvre on her twice with very good effect. My supervisor said that she would show me how to do it, and then I could perform it on her.
I was very reluctant to do it, as I had never done it before even on a peer, so to perform it on someone with a pathology was a daunting thought. When I found out that my supervisor couldn't even watch me perform it on her because she was busy in a meeting I was going to just try it in the next session. However when my patient came in and began to tell me how much trouble it was giving her, I didn't want her to have to wait for another week. I took her through the positions and she was quite severely nauseous and dizzy in the sidelying position, however by the time she was sitting up for a minute she was ok. I treated her 3 more times with the Eppley manouvre, once each time I saw her and her improvement was impressive. By the end of my prac she was no longer taking her BPPV medication and suffered a quarter of the symptoms she was at the start of my treatment sessions.
From this experience I learnt that I should embrace the opportunity to try new things, especially in this field as there are new techniques being developed all the time. If I hadn't treated her, and had simply watched my supervisor do it, I wouldn't have nearly the amount of satisfaction I derived from treating her start to finish. In future I will have more confidence in myself and my ability to adapt to new situations, and accept that even if I don't get it perfect the first time I can still help people.
Saturday, November 29, 2008
Adequate pain relief
Whilst on my cardiopulmonary prac I was treating a 65 year old gentleman who was a day one post Whipples procedure. He hadn't been out of bed yet and my supervisor came with me to provide assistance. Before we began I read through his notes to gain some idea of his PMHx and had a look at his CXR which was clear. The pain team had seen him just a few minutes earlier and I had read in the notes that he was 0/10 pain at rest and 2/10 pain with movement.
I introduced us both and told the patient we were going to get him up for a walk which caused him to begin yelling at us and telling us we were 'crazy'. We tried to explain that it was normal for people to get up the first day after their surgery but he didn't believe us. Finally he consented to sitting out in the chair. We began a two maximal assistance transfer to sit him over the edge of the bed but once we began he started screaming in agony and crying. Upon enquiry he said he was 11/10 pain. We called over another physio and were able to get him back into bed.
He told us (not very politely) to go away and said we could never come back. He seemed to associate physiotherapy with pain, and thought that we were causing him pain. As much as we tried to reinforce that his pain relief should have been enough to enable him to get out of bed we were unsuccessful. My supervisor liased with the pain team and explained what had happened, asking them to reinforce that physio is important and shouldn't be as painful as it was for him. This experience taught me that you can't always trust everything that you read in the notes. I was unaware before this that the pain score with movement reported by the pain team didn't require the patient to move and then report a score. Thus, it wasn't an accurate representation of what the patient really felt when he moved, causing major problems when he did move. Also, I learnt how important the very first treatment session is with a patient, and how easily impressions can be formed, whether positive or negative. In future I will explain to the patient before we begin that the pain relief should be enough to allow him to get out of bed, as he wasn't very receptive to this concept (or anything we said) after the fact.
I introduced us both and told the patient we were going to get him up for a walk which caused him to begin yelling at us and telling us we were 'crazy'. We tried to explain that it was normal for people to get up the first day after their surgery but he didn't believe us. Finally he consented to sitting out in the chair. We began a two maximal assistance transfer to sit him over the edge of the bed but once we began he started screaming in agony and crying. Upon enquiry he said he was 11/10 pain. We called over another physio and were able to get him back into bed.
He told us (not very politely) to go away and said we could never come back. He seemed to associate physiotherapy with pain, and thought that we were causing him pain. As much as we tried to reinforce that his pain relief should have been enough to enable him to get out of bed we were unsuccessful. My supervisor liased with the pain team and explained what had happened, asking them to reinforce that physio is important and shouldn't be as painful as it was for him. This experience taught me that you can't always trust everything that you read in the notes. I was unaware before this that the pain score with movement reported by the pain team didn't require the patient to move and then report a score. Thus, it wasn't an accurate representation of what the patient really felt when he moved, causing major problems when he did move. Also, I learnt how important the very first treatment session is with a patient, and how easily impressions can be formed, whether positive or negative. In future I will explain to the patient before we begin that the pain relief should be enough to allow him to get out of bed, as he wasn't very receptive to this concept (or anything we said) after the fact.
Friday, November 28, 2008
The dynamics of the patient-therapist relationship
At the start of my cardiopulmonary prac I sometimes found it difficult to get patients to comply with my treatment. Their favourite show had just started, or they hadn't had a good sleep last night, or they were going to have visitors in 10 minutes or they were just about to have a nap...I heard many excuses. While I think it's important to attempt to fit around other things in order to keep the patient on side, it is a balancing act.
I was treating a patient who had a sleeve gastrectomy and when I came to see her complained of nausea and stated she was unable to get out of the bed. I then arranged with the nurse to get her some antiemitics and decided to come and check later. Next time I checked on her she was watching days of our lives and it would be finished in 20 minutes. As I had another patient I could see I decided it wouldn't be a problem. Finally I came into her room after days of our lives would definitely have finished and she was sound asleep, refusing to open her eyes and just groaning at me. She was 3 days post and had gotten up the two days before, and while I came back to check frequently for the rest of the afternoon I was unsuccessful.
In a perfect world we would always be able to treat our patients and they would understand the benefits of getting out of bed. However, clearly it is very unlikely to have such a situation and we are competing for the patients time with a myriad of other health staff and the patients own complaints. As an undergrad it is harder to be really tough on patients and instill the fear of god into your patients, however from this experience I learnt that you have to establish the 'dominant' position as the treating therapist in the relationship from the start, otherwise the patient will never do what you say. I should have been firmer when I saw her and told her that once the tablets had kicked in/her show was finished we were going for a walk no matter what. It is difficult to assert yourself once the patient thinks they are in control and you have given them the upperhand. In future if I allow a patient to have a later treatment (as long as it is a valid reason) I will be stricter in gaining a promise from them that they will be compliant when that time comes, and ensure they follow through.
I was treating a patient who had a sleeve gastrectomy and when I came to see her complained of nausea and stated she was unable to get out of the bed. I then arranged with the nurse to get her some antiemitics and decided to come and check later. Next time I checked on her she was watching days of our lives and it would be finished in 20 minutes. As I had another patient I could see I decided it wouldn't be a problem. Finally I came into her room after days of our lives would definitely have finished and she was sound asleep, refusing to open her eyes and just groaning at me. She was 3 days post and had gotten up the two days before, and while I came back to check frequently for the rest of the afternoon I was unsuccessful.
In a perfect world we would always be able to treat our patients and they would understand the benefits of getting out of bed. However, clearly it is very unlikely to have such a situation and we are competing for the patients time with a myriad of other health staff and the patients own complaints. As an undergrad it is harder to be really tough on patients and instill the fear of god into your patients, however from this experience I learnt that you have to establish the 'dominant' position as the treating therapist in the relationship from the start, otherwise the patient will never do what you say. I should have been firmer when I saw her and told her that once the tablets had kicked in/her show was finished we were going for a walk no matter what. It is difficult to assert yourself once the patient thinks they are in control and you have given them the upperhand. In future if I allow a patient to have a later treatment (as long as it is a valid reason) I will be stricter in gaining a promise from them that they will be compliant when that time comes, and ensure they follow through.
Time wasting
On my cardiopulmonary placement I had alot of experience with getting patient's to do what they didn't want to. This was particularly true when they were reluctant to get out of bed. In their head they're thinking 'someone cut down my stomach just yesterday and messed around in there and you want me to get up?' And it is a valid concern which needs to be assuaged.
Patient's are often very nervous due to the fact that you are normally the first person to get them out of bed, and possibly even more nervous that you are a student and aren't the most graceful at getting all the attachments in order. The first time I was getting a day one surgery out of bed I spent time asking subjective questions, then messing around with the attachments, and getting the oxygen ready. All the while, unbenowst to me the patient is getting more and more agitated watching me struggle and wasting time. Once I finally got the patient up they were quite anxious and didn't walk as far as they perhaps could have if they were more relaxed.
Throughout the prac I had many opportunities to improve on my first treatment as I had several mistakes I could learn from. From this experience I realised that patient's are quite nervous (as obvious as that is, I was more nervous and worried about the attachments to notice this) and that it's best to ask only the essential questions before you get them up in order to save time. Once you tell them you are getting them up, they can often become quite anxious so it's important that you are organised and have brought the portable oxygen, oximeter and have a chair set up so that more time isn't wasted. In the future I will focus on ensuring the patient's comfort and safety come first and not get so bogged down in what I am doing that I don't notice what the patient's face and movements are telling me.
Patient's are often very nervous due to the fact that you are normally the first person to get them out of bed, and possibly even more nervous that you are a student and aren't the most graceful at getting all the attachments in order. The first time I was getting a day one surgery out of bed I spent time asking subjective questions, then messing around with the attachments, and getting the oxygen ready. All the while, unbenowst to me the patient is getting more and more agitated watching me struggle and wasting time. Once I finally got the patient up they were quite anxious and didn't walk as far as they perhaps could have if they were more relaxed.
Throughout the prac I had many opportunities to improve on my first treatment as I had several mistakes I could learn from. From this experience I realised that patient's are quite nervous (as obvious as that is, I was more nervous and worried about the attachments to notice this) and that it's best to ask only the essential questions before you get them up in order to save time. Once you tell them you are getting them up, they can often become quite anxious so it's important that you are organised and have brought the portable oxygen, oximeter and have a chair set up so that more time isn't wasted. In the future I will focus on ensuring the patient's comfort and safety come first and not get so bogged down in what I am doing that I don't notice what the patient's face and movements are telling me.
Depressed patients
As much as we are told that we are not psychologists, the nature of this profession is such that patients can often open up. In these situations it is difficult to know where to draw the line between what you can handle and what needs to be referred on.
Whilst on my gerontology prac I had a patient who was 85 and had lost his month 4 months ago. Since this time his balance and strength had declined and he reported feeling quite depressed. Throughout the course of the session he expressed that he 'didn't know what he was living for', 'would be happier if he was dead' and several other phrases relating to dying. I was unsure of what to say, however attempted to offer reassurance, asking him what all the neighbours he helped would do without him (he often gardened and brought meals to people on his street). However, despite my best attempts he was difficult to convince.
I spoke to my supervisor about my concerns and she suggested I refer him to clinical psych. If the patient actually suffered from depression, there is nothing physiotherapy can do to fix it, and it is therefore important to listen to your patients and take them seriously when the say things like this. The way he said it, it was as if he wanted you to think he was joking, but it was clear he was not. From this experience, I took the knowledge that you have to be vigilant otherwise you could miss an important sign that someone needs help. In the future I will find out about a patient especially if I think they might be having problems at home or need other help which I cannot provide.
Whilst on my gerontology prac I had a patient who was 85 and had lost his month 4 months ago. Since this time his balance and strength had declined and he reported feeling quite depressed. Throughout the course of the session he expressed that he 'didn't know what he was living for', 'would be happier if he was dead' and several other phrases relating to dying. I was unsure of what to say, however attempted to offer reassurance, asking him what all the neighbours he helped would do without him (he often gardened and brought meals to people on his street). However, despite my best attempts he was difficult to convince.
I spoke to my supervisor about my concerns and she suggested I refer him to clinical psych. If the patient actually suffered from depression, there is nothing physiotherapy can do to fix it, and it is therefore important to listen to your patients and take them seriously when the say things like this. The way he said it, it was as if he wanted you to think he was joking, but it was clear he was not. From this experience, I took the knowledge that you have to be vigilant otherwise you could miss an important sign that someone needs help. In the future I will find out about a patient especially if I think they might be having problems at home or need other help which I cannot provide.
Multidisciplinary interactions
While on my gerontolgy prac I had the opportunity to work quite closely with the OTs at that centre. Often we saw the same patients, and such was the nature of the centre that you often had a very limited time to see the patients because they came late and had transport coming at specific times. The patients notes were shared between the treating therapists as there was only one set, so it was often difficult to coordinate it so that everyone was able to read them thoroughly.
One morning during the first week of the prac whilst I was reading through a patients notes the OT burst through the door and said 'where are the notes for Mr ___?' He seemed very annoyed as I handed over the notes I was reading and grabbed them off me saying 'you should have given these to me before I need to read them and I'm going to be late for the patient'. I apologised, and once he had left i looked at my watch and saw it was still 5 minutes until the patient would be arriving.
I wasn't aware at this stage of the prac that I should have gone and given the notes to the OT, my supervisor had given me the notes to read with no instructions that the OT was seeing him first and to make sure I gave them to him with enough time so that he could read them also. I suppose that I could have been proactive and asked this however I felt his aggressive reaction was uncalled for. After this interaction I had trouble liasing with him about patients and didn't make an effort to talk to him in the lunch room. This was quite childish of me and I shouldn't have taken his behaviour so personally. However, several other incidents similar to this occurred where he appeared quite annoyed at me after I had done nothing wrong. This experience taught me that you can't get on with everyone and if you take everything to heart it will get in the way of being able to do your job. There was no way I could avoid talking to him and feeling upset about it intefered with how effectively I could get my point across, which could in turn affect the way a patient was treated. So regardless of my personal feelings it's important to focus on the clinical situation.
One morning during the first week of the prac whilst I was reading through a patients notes the OT burst through the door and said 'where are the notes for Mr ___?' He seemed very annoyed as I handed over the notes I was reading and grabbed them off me saying 'you should have given these to me before I need to read them and I'm going to be late for the patient'. I apologised, and once he had left i looked at my watch and saw it was still 5 minutes until the patient would be arriving.
I wasn't aware at this stage of the prac that I should have gone and given the notes to the OT, my supervisor had given me the notes to read with no instructions that the OT was seeing him first and to make sure I gave them to him with enough time so that he could read them also. I suppose that I could have been proactive and asked this however I felt his aggressive reaction was uncalled for. After this interaction I had trouble liasing with him about patients and didn't make an effort to talk to him in the lunch room. This was quite childish of me and I shouldn't have taken his behaviour so personally. However, several other incidents similar to this occurred where he appeared quite annoyed at me after I had done nothing wrong. This experience taught me that you can't get on with everyone and if you take everything to heart it will get in the way of being able to do your job. There was no way I could avoid talking to him and feeling upset about it intefered with how effectively I could get my point across, which could in turn affect the way a patient was treated. So regardless of my personal feelings it's important to focus on the clinical situation.
Patient compliance
On my rural prac I was treating a 22 yr old male who required musculo outpatient treatment following his # distal tibia. The fracture had occurred 2 months ago but such was the waitlist that this was his first opportunity for treatment. When it occurred, he was in hospital for 13 days before it was operated on as the swelling hadn't reduced to a satisfactory level. When he came to me he was complaining of pain with walking and into all ranges of ankle motion and stiffness. It was also still slightly swollen compared to the other side.
As he hadn't performed any strengthening or ROM exercises since he had come out of hospital (and he stated he hadn't done anything much whilst in hospital) this was the major cause of his problem. It also meant that a large focus of the treatment was prescribing a suitable program of exercises in order to address the loss of range and strength. However, as part of my treatment consisted of mobilisations and soft tissue techniques the patient approached physiotherapy with the attitude: 'can't you just fix it for me?' He openly admitted to me that he did the exercises I had given him on 2 days out of the month that I treated him over, and then complained to me that he wasn't making very much progress.
As much as I alternately ancouraged and bullied him, he was next to impossible to motivate. I would do my best, and by the end of a session think that he might be going to do them, only to be disappointed the next time I saw him. In the end, I discharged him to my supervisor, and after discussing his behaviour with her I felt that she might be able to get through to him. This experience taught me that as much as you want to treat someone sometimes there is no way that you can get through to them and you need to ask for help. I think it is difficult as an undergrad to be really tough on patients as you don't have the experience to know how far you can go but in this situation i needed to perhaps be even firmer in order to get any results.
As he hadn't performed any strengthening or ROM exercises since he had come out of hospital (and he stated he hadn't done anything much whilst in hospital) this was the major cause of his problem. It also meant that a large focus of the treatment was prescribing a suitable program of exercises in order to address the loss of range and strength. However, as part of my treatment consisted of mobilisations and soft tissue techniques the patient approached physiotherapy with the attitude: 'can't you just fix it for me?' He openly admitted to me that he did the exercises I had given him on 2 days out of the month that I treated him over, and then complained to me that he wasn't making very much progress.
As much as I alternately ancouraged and bullied him, he was next to impossible to motivate. I would do my best, and by the end of a session think that he might be going to do them, only to be disappointed the next time I saw him. In the end, I discharged him to my supervisor, and after discussing his behaviour with her I felt that she might be able to get through to him. This experience taught me that as much as you want to treat someone sometimes there is no way that you can get through to them and you need to ask for help. I think it is difficult as an undergrad to be really tough on patients as you don't have the experience to know how far you can go but in this situation i needed to perhaps be even firmer in order to get any results.
Thursday, November 27, 2008
My year in summary
Slings and pulleys, we have got there! I would say fourth year has been my most enjoyable year of physio. For future years if you have stumbled across this blog I want you to look fwd to your final year. During the first three years you have gained a wide range of knowledge and techniques and in fourth year you are placed in an environment to display what you have learnt. Fourth year provided me with a time to consolidate and build on these skills. I have learnt time management, maybe not yet with blogging, how to deal with a wide range of patients ranging from, muculo, neuro, cardio, paeds, gero. I was exposed to physiotherapy in mental health and for anyone wishing to pursue a challenge I found this area very rewarding. Completing a placement on ICU shows the scope of physiotherapy and although it doesnt hone in on your subjective skills patient care is paramount and for the short time you are treating you must really have your wits about you.
My neuro placement at Ward 2 really highlighted the value of physiotherapists and helped develop attention to detail. Neuro developed my observational skills and palpation techniques.
Rural provided an insight into adapting skills from patient to patient, managing a case load and working within a team.
I have realised how important mvt science is and that all the units that you complete in the first three years have an important role in your development.
If anything i would say that as physiotherapists we lack business skills and would like to see a greater component in our course curriculum. Thankyou and goodbye x
My neuro placement at Ward 2 really highlighted the value of physiotherapists and helped develop attention to detail. Neuro developed my observational skills and palpation techniques.
Rural provided an insight into adapting skills from patient to patient, managing a case load and working within a team.
I have realised how important mvt science is and that all the units that you complete in the first three years have an important role in your development.
If anything i would say that as physiotherapists we lack business skills and would like to see a greater component in our course curriculum. Thankyou and goodbye x
Educating the parents
Recently on my paediatrics placement you realise although you are treating the child your are educating the parent. As a student this poses a new skill as we are so use to just speaking to and from with our direct patient. In these settings you now have two patients that you are treating at the same time. Although you may be performing a skill with a patient you must express to the parent why you are doing this and what they can enciourage at home to compliment your techniques. Often the parent needs assurance and is looking for answers as their childs problem has been ongoing.
In one situation I had a parent nearing tears as she explained that she was lost for answers and just wanted her childs pain to cease.
From a physio POV I expressed that with optimal physio management our aim is to assist reductions in pain but I made it clear that I dont have all the answers and due to the chronic pain the child had experienced we need to set the goals at small steps in reductions in pain and return to function. It is tough to see a parent in such a helpless position and it shows that as a physio you must be compassionate.
In one situation I had a parent nearing tears as she explained that she was lost for answers and just wanted her childs pain to cease.
From a physio POV I expressed that with optimal physio management our aim is to assist reductions in pain but I made it clear that I dont have all the answers and due to the chronic pain the child had experienced we need to set the goals at small steps in reductions in pain and return to function. It is tough to see a parent in such a helpless position and it shows that as a physio you must be compassionate.
PCR
During my PCR I was placed with the challenge of treating a patient with non specific lower back pain. My reason for writing this is to learn from others as to how they treated, display how I treated and to continue blogging post graduating.
I decided this patient had non specific lower back pain as many subjectibve reports only displayed a general area of pain. Onjectively it became more specific of the area involved but given my relative raw skills in treating backs I could not confidently pin point a specific structure.
Classifying the condition as hypomobility/mvt impairment: I determined this as they had decresed range actively and this was associated with hypomobile PAVMS.
Treating this patient involved education of beliefs and expectations, treating specific impairments and ensuring they were aware of sound management to compliment physiotherapy techniques.
Presenting this information to a panel was a new challenge. Conveying all your information in a ten minute time period required practice. I had previously provided handovers but had never been aware as to how long it took. I hope everyone went well and good luck for the future.
I decided this patient had non specific lower back pain as many subjectibve reports only displayed a general area of pain. Onjectively it became more specific of the area involved but given my relative raw skills in treating backs I could not confidently pin point a specific structure.
Classifying the condition as hypomobility/mvt impairment: I determined this as they had decresed range actively and this was associated with hypomobile PAVMS.
Treating this patient involved education of beliefs and expectations, treating specific impairments and ensuring they were aware of sound management to compliment physiotherapy techniques.
Presenting this information to a panel was a new challenge. Conveying all your information in a ten minute time period required practice. I had previously provided handovers but had never been aware as to how long it took. I hope everyone went well and good luck for the future.
Rural placement
There is debate over Rockingham being a rural placement.
My argument is that it should be. Although it is manageable to drive there everyday it is more about what you are exposed to.
A general day for me at the hospital included inpatient and outpatient physio.
From 9 to 1 I treated a wide range of musculoskelatal disorders. I treated acute lower back pain, shoulder instability, non specific neck pain, ACL rehab, hamstring strain and other conditions. After lunch I would do ward rounds which i treated COPD pts, deconditioned elderly, falls risk pt and various other inpatient physio requirements.
My argument for it being a rural placement is that you are not specialised in your role. Like on more remote rural settings you may use all your physio skills. This reminds me, I was also involved in the acute rehab of an aboriginal lady who had suffered a stroke. With this lady it was important to understand her cultural background.
Until Rockingham has more specialised requirements of a physio I think it provides a great opportunity to utilise all skills.
My argument is that it should be. Although it is manageable to drive there everyday it is more about what you are exposed to.
A general day for me at the hospital included inpatient and outpatient physio.
From 9 to 1 I treated a wide range of musculoskelatal disorders. I treated acute lower back pain, shoulder instability, non specific neck pain, ACL rehab, hamstring strain and other conditions. After lunch I would do ward rounds which i treated COPD pts, deconditioned elderly, falls risk pt and various other inpatient physio requirements.
My argument for it being a rural placement is that you are not specialised in your role. Like on more remote rural settings you may use all your physio skills. This reminds me, I was also involved in the acute rehab of an aboriginal lady who had suffered a stroke. With this lady it was important to understand her cultural background.
Until Rockingham has more specialised requirements of a physio I think it provides a great opportunity to utilise all skills.
self directed
A big problem i encountered when completing my self directed was the availability of the supervisor. Completing my self directed for a private practice provided huge insight into how busy they are and the necessitity to be flexible and organised.
Quite often I had only a small window of time to liaise with the supervisor. This meant that I had to have information organised in a structured and efficient manner.
This experience provided me with a taste of working in a private practice. The case load was large and you dont have as much time to spend with each client. As a new grad I can see that it would provide a great challenge but could also burn you out if you were not use to the high turnover rate.
Before accepting a job in a private practice I think it is a necessity, if offered, to spend a week of work experience with them to see if it is really for you.
There are pros and cons for hospital and private. Personally I feel a hospital setting can assist an easier transition into becoming a physio. I feel it is necessary to consolidate your knowledge prior to being placed in such a busy environment.
Quite often I had only a small window of time to liaise with the supervisor. This meant that I had to have information organised in a structured and efficient manner.
This experience provided me with a taste of working in a private practice. The case load was large and you dont have as much time to spend with each client. As a new grad I can see that it would provide a great challenge but could also burn you out if you were not use to the high turnover rate.
Before accepting a job in a private practice I think it is a necessity, if offered, to spend a week of work experience with them to see if it is really for you.
There are pros and cons for hospital and private. Personally I feel a hospital setting can assist an easier transition into becoming a physio. I feel it is necessary to consolidate your knowledge prior to being placed in such a busy environment.
exercise prescription
Exercising patients receiving Chemo made me aware of interpreting bloods prior to treatment.
Platelet count determined the type of exercise that could be carried out and haemoglobin determined if you would have the patient out of bed etc.
This made me think about the type of exercises we perform with the elderly whos counts may also be affected.
It also places you in a predicament when a doctor is wishing the patient to exercises but as a physio you are not happy with the counts.
Before carying out the exercises with the patient you must also be aware of their risk of infection. If I was to use any equipment with the patient it was important to alcohol wipe everything to be used.
From placement to placement it really develops a broarder understanding of precautions and the importance of taking note of all obs.
Platelet count determined the type of exercise that could be carried out and haemoglobin determined if you would have the patient out of bed etc.
This made me think about the type of exercises we perform with the elderly whos counts may also be affected.
It also places you in a predicament when a doctor is wishing the patient to exercises but as a physio you are not happy with the counts.
Before carying out the exercises with the patient you must also be aware of their risk of infection. If I was to use any equipment with the patient it was important to alcohol wipe everything to be used.
From placement to placement it really develops a broarder understanding of precautions and the importance of taking note of all obs.
Wednesday, November 26, 2008
Co-existing conditions
Working in oncology you are xposed to a wide range of paients. Most patient in terms of their cancer are receiving treatment for osteosarcomas, AML or ALL. However because they have had cancer often other surgery has been necessary. I was exposed to amputees, surgical fixations of humerus to scapula and reoval of pelvises etc. Some childre had developmental delays, neuro signs and symptoms etc.
I mention this as it shows that you must use a wide array of physiotherpy skills and will often have to chase up surgical procedures that may not be in their present inpatient notes.
It is a very interesting area but you must be aware not to just focus on deconditioning that occurs with cancer. It is very rewarding work and the childrens enthusiasm makes you never wish to complain about any interuption in your day.
I mention this as it shows that you must use a wide array of physiotherpy skills and will often have to chase up surgical procedures that may not be in their present inpatient notes.
It is a very interesting area but you must be aware not to just focus on deconditioning that occurs with cancer. It is very rewarding work and the childrens enthusiasm makes you never wish to complain about any interuption in your day.
Paediatrics
Whilst working in paediatrics i thoroughly enjoyed the task of realising your physiotherapy aims and having to mold them into a game like scenario. I had a pt who required me to bark to start off the obsticle course, round the world basketball on one leg, jumping over hoops and balancing to avoid falling in crocodile creek. It made me enjoy rewinding back to the childhood memory bank.
The most importat thing was to make the exercise challenging but fun. Being specific with your objectives and developing a plan to combat this.
The kids fluctuated with enthusiasm and you do find it draining but they provide a challenge. You must alter your communication and its quite funny at times when the parent is there as you will be speaking with the child and then suddenly change your communication to explain with the parent what your goals are.
The most importat thing was to make the exercise challenging but fun. Being specific with your objectives and developing a plan to combat this.
The kids fluctuated with enthusiasm and you do find it draining but they provide a challenge. You must alter your communication and its quite funny at times when the parent is there as you will be speaking with the child and then suddenly change your communication to explain with the parent what your goals are.
Monday, November 24, 2008
ICU
ICU’s my favourite out of all my clinical placements. It was quite daunting at first because we were going to deal with people in critical condition and I was very scared to cause them harm. There was a lot of information that we had to deal with as well. The obs charts were huge and there’s so much more information there than the ones you find in other wards. It was vital that we pick out the information that we need and use a system to get such information, otherwise it will take a really long time to do so. Also, the patients had a lot of attachments, which just added to my anxiety as I did not want to be pulling any of those out. But as time went by, I got used to dealing with those things and realised that I actually enjoyed ICU. I learned something everyday and applied these straight away. The physios, nurses, doctors and PCAs were very friendly and willing to help. I had the change to watch an endoscopy/biopsy, intubation/tracheostomy and CABG. I also learned that even though the patients may not be alert all the time, it is still important to constantly communicate with them about the treatment and assessment among other things.
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Tuesday, November 18, 2008
Live life to the full!!
Looking back on all my placements I have seen patients with all different injuries and illnesses both young and old. Working in the hospitals has made me realise how fortunate I am. The paediatric placement was eye opening. It took quite a while to get used to treating such young children with such serious illnesses. I found this practical quite emotionally draining, particularly as I was treating children with brain injuries. Intensive care was similar in that all the patients were very ill and few were able to communicate with you.
During my final practical I saw most of the patients twice a week and was able to develop a lot of rapport with my patients. Many of the patients talked about how their life had changed since there stroke or neurological diagnosis. They talked about what they could do before hand and what they can't do now. The majority of them also mentioned how this stroke had changed their outlook on life. Even though they had an arm that hadn't fully recovered, perceptual deficits or motor changes they explained how they were living everyday and weren't taking things for granted. It seems a shame that people may only realise this when they are diagnosed with an illness or have a traumatic event, however I think as physiotherapists we are seeing what can happen to children, teenagers (I saw a patient who had suffered a stroke at 18) and adults and we must learn from this. Personally this has changed my outlook on life but professionally seeing how physiotherapy can improve their quality of life is rewarding.
So all the best to everyone. Live every day and congratulations on becoming physiotherapists!
During my final practical I saw most of the patients twice a week and was able to develop a lot of rapport with my patients. Many of the patients talked about how their life had changed since there stroke or neurological diagnosis. They talked about what they could do before hand and what they can't do now. The majority of them also mentioned how this stroke had changed their outlook on life. Even though they had an arm that hadn't fully recovered, perceptual deficits or motor changes they explained how they were living everyday and weren't taking things for granted. It seems a shame that people may only realise this when they are diagnosed with an illness or have a traumatic event, however I think as physiotherapists we are seeing what can happen to children, teenagers (I saw a patient who had suffered a stroke at 18) and adults and we must learn from this. Personally this has changed my outlook on life but professionally seeing how physiotherapy can improve their quality of life is rewarding.
So all the best to everyone. Live every day and congratulations on becoming physiotherapists!
Monday, November 17, 2008
Dissatisfied Patients
For my self directed placement, I was involved in the administration of a patient satisfaction survey for people on the medical and surgical wards at a hospital. The survey was based upon the physiotherapy services provided, and required a patient to rate and comment on the quality of service, the facilities available and the staff demeanour. From the responses received, it was surprising to see that there were people who were really dissatisfied with the quality of physiotherapy provided. Even more surprisingly, some of the dissatisfaction centred on the poor correlation of information and communication between the doctors, nursing staff and physios. Also, a few patients were unaware they were even being seen for physio, and rather just stated they were only given breathing and upper limb exercises.
Taking from this information, it just shows how important it is to properly educate a patient regarding the purpose of their exercises, and the role of physiotherapy in their care. It is also important to ensure there is appropriate communication between all members of the health team, and that the patient is kept informed of any appropriate communications.
I guess we’re at an advantage, as being a student, we were always been encouraged to thoroughly educate and explain to a patient what we will be doing. However, as you enter the “real” workforce next year, try and remember these few pointers and keep them in your clinical practice. By doing so, you will have more satisfied patients and staff, and therefore receive better results and compliance from your patients. I know I will be trying to keep this in mind.
Taking from this information, it just shows how important it is to properly educate a patient regarding the purpose of their exercises, and the role of physiotherapy in their care. It is also important to ensure there is appropriate communication between all members of the health team, and that the patient is kept informed of any appropriate communications.
I guess we’re at an advantage, as being a student, we were always been encouraged to thoroughly educate and explain to a patient what we will be doing. However, as you enter the “real” workforce next year, try and remember these few pointers and keep them in your clinical practice. By doing so, you will have more satisfied patients and staff, and therefore receive better results and compliance from your patients. I know I will be trying to keep this in mind.
Sunday, November 16, 2008
The nurse bell
During a previous placement I was helping on a gerontology ward, where patients were usually admitted due to falls and mobility issues. One morning I was reading notes prior to treating a patient and I was aware that a patient was continually pressing his nurse bell. This patient’s room was next to the nursing station and eventually a nurse appeared who informed the patient that she was busy and that he would have to wait.
A couple of minutes later I hear someone call for help from this patient’s room. I rushed over to find another physio student propping up this patient with their leg, so I grabbed a chair and we managed to get the patient into the chair. The nurse and medical staff were then informed.
After later questioning of the patient we found he was desperate to get to the toilet across the hall and decided that it could not wait, even though he was unable to walk without assistance. The other student happened upon this patient as they were walking past and managed to grab him before he fell.
After reading the patient notes we found that the reason he was admitted was that he had fallen at home and he had also had a similar fall earlier in the week while trying to get to the toilet by himself.
This raised a number of interesting questions about the care of this patient, most notably why a strategy, such as a bottle or portable commode, was not put in place to stop the patient from trying to get to the toilet by himself after his first fall.
Given this patients falling was motivated by such a basic need as being able to get to the toilet, it highlighted to me that if the basics are overlooked, whether due to understaffing or oversight, then there can be much more serious consequences for the patient, such as a fracture or significant laceration due to falling.
A couple of minutes later I hear someone call for help from this patient’s room. I rushed over to find another physio student propping up this patient with their leg, so I grabbed a chair and we managed to get the patient into the chair. The nurse and medical staff were then informed.
After later questioning of the patient we found he was desperate to get to the toilet across the hall and decided that it could not wait, even though he was unable to walk without assistance. The other student happened upon this patient as they were walking past and managed to grab him before he fell.
After reading the patient notes we found that the reason he was admitted was that he had fallen at home and he had also had a similar fall earlier in the week while trying to get to the toilet by himself.
This raised a number of interesting questions about the care of this patient, most notably why a strategy, such as a bottle or portable commode, was not put in place to stop the patient from trying to get to the toilet by himself after his first fall.
Given this patients falling was motivated by such a basic need as being able to get to the toilet, it highlighted to me that if the basics are overlooked, whether due to understaffing or oversight, then there can be much more serious consequences for the patient, such as a fracture or significant laceration due to falling.
Cup of tea treatment
During my gerontology outpatient placement I came across a treatment technique that was new to me but very effective with the older population. I had two patients present to the clinic that week that had completely over worked themselves and were not going to be able to complete a physiotherapy session. The first of these two patients decided to increase his walking from 15 minutes to 45 minutes as he was “feeling good”, another decided that she was also feeling much better and decided not to walk with her frame for two days following a # NOF.
My management for these patients simply was to offer them a cup of tea and then try to educate them about the need to follow the program and instructions that we had provided. Both of the patients agreed that they had probably done too much but were not aware of the potential problems they could encounter being so fatigued.
In one sense it was great to see that out treatment and the effort put in by the patient was making improvements however this enthusiasm needed to be reigned in. It is quite a fine line between encouraging elderly patients to continue being active after a fall and keeping a lid on that activity when their confidence returns.
I have learned from the experience the need to explain to the patient the benefits of the planned treatment but also to clearly outline the potential problems if they over do their exercise. In more general terms this experience has allowed me to consider how something as simple as an exercise program might have positive and negative impacts on someones life.
Thanks and good luck
Hi All,
Thank you for sharing so much this year in your blogs. It is obvious that your placements have challenged you in many ways and I hope you all continue to reflect on your work as you begin your careers. Good luck this week and next year.
Kate
Thank you for sharing so much this year in your blogs. It is obvious that your placements have challenged you in many ways and I hope you all continue to reflect on your work as you begin your careers. Good luck this week and next year.
Kate
My last day of clinic!
The last day of my last placement was a low activity day - for anyone that has not experienced these, my understanding is that the hospital closes down all non-essential services for the day and the staff from these services help the other staff to complete their full day's workload in the morning; then everyone gets the afternoon off. This meant that neuro outpatients (where I had my final placement) was going to be closed and we would be treating patients on ward 2 (much more acute and dependent patients, than those that we'd been treating).
To be honest, I wasn't particularly looking forward to my final day, as I felt that I would feel like a brand new student in a new setting, rather than feeling like the therapist that I nearly am! When we arrived on ward 2 we were allocated patients, given a suggested treatment plan and had very little other info about the pt.. I was a bit cautious at first, somewhat anxious about having a catastrophe on the last day of my final placement. However, I was pleasantly surprised when everything went well (there were no disasters!) and I even felt I was able to progress and make small amendments to the treatment suggestions, which were relevant to the way in which each patient presented on that particular day.
I learnt that we have more skills than we realise! Our course is carefully designed in order for us to learn the basic skills and prepare us for situations which we are not familiar with, which are in addition to the clinics we were allocated. I now have more confidence that I will be able to transfer my clinical experiences to whichever new environment I find myself working in.
To be honest, I wasn't particularly looking forward to my final day, as I felt that I would feel like a brand new student in a new setting, rather than feeling like the therapist that I nearly am! When we arrived on ward 2 we were allocated patients, given a suggested treatment plan and had very little other info about the pt.. I was a bit cautious at first, somewhat anxious about having a catastrophe on the last day of my final placement. However, I was pleasantly surprised when everything went well (there were no disasters!) and I even felt I was able to progress and make small amendments to the treatment suggestions, which were relevant to the way in which each patient presented on that particular day.
I learnt that we have more skills than we realise! Our course is carefully designed in order for us to learn the basic skills and prepare us for situations which we are not familiar with, which are in addition to the clinics we were allocated. I now have more confidence that I will be able to transfer my clinical experiences to whichever new environment I find myself working in.
Friday, November 14, 2008
Building Rapport with Languages
In my different placements I have realised how being able to speak at least one other language can be quite a bonus. I never got to appreciate this because in the past it has made it challenging for me to communicate with patients, particularly when I’m trying to explain things during assessment and treatment. One too many times, I find myself translating terms in my mind at least three times in different languages before I can finally come up with the English equivalent.
During my gerontology placement I came across an old lady who can only speak Spanish and very minimal English so the staff found it hard to communicate with her to tell her what the plans for her were. She had a daughter that visited her at most twice a week so that did not make things any easier for anyone. So when I introduced myself to her and asked if she’s ready for physio (in Spanish), her eyes lit up and she talked incessantly in Spanish. I carried out assessment and treatment for her twice a day and I also tried my best to translate for the nurses and it felt good things got a lot easier. The same thing happened during my rural placement where there was an old lady who can only speak Malay and I had to translate as well.
During my orthopedic placement, I had a Greek patient who knew how to speak English but with a very very very thick accent that it’s almost impossible to understand what she’s saying, and another patient who’s a refugee from Sudan who can only say ‘yes,’ ‘no,’ and ‘pain.’ They were put in the same room and they both weren’t very friendly. Physio sessions were a bit difficult at first because apart from myself not being able to understand them and vice versa, they didn’t seem to be interested in doing their exercises at all and therefore were not very compliant. Their families did not visit them often as well. So what I did was ask them to give me a crash course on their languages. I asked them to translate words like ‘walk,’ ‘leg,’ ‘arm,’ etc that will be really helpful for the treatment sessions and I wrote those down, after a lot of gesturing. They warmed up to me and seemed pleased that I took a lot of interest in their respective languages. It all worked out quite well in the end because I knew those sessions were effective and everyone was happy.
talking to sedated patient
I had to deal with patients in critical condition during my cardio placement. One of the patients that I had was a 17-year-old girl who had a history of drug overdose. She appeared really really drowsy and had a Ramsay sedation score of 4-5 which means she either has brisk or sluggish response to loud noise/?touch (light glabellar tap. The glabella is the skin between the eyebrows). So the intervention for her that day included manual hyperinflation, suctioning and passive limb movements. I knew I was not very good at explaining things in a really simple and concise manner and I knew that I really had to get heaps of practice explaining interventions techniques to patients in easy-to-understand terms. So I explained everything that I was about to do then and carried on with the treatment, I talked to the patient as well despite her not responding to me or even opening her eyes but I thought that was ok. At the back of my mind I had the idea that there’s this chance that she might actually be listening to me. I thought about what I read and heard about not talking over patients -that are ‘unconscious’- about their condition because they might well be able to hear what you’re saying and they may get upset, etc. I saw the patient the next day and basically carried out my treatment the same manner.
So the next day I passed by that patient’s bed and saw her family there talking to her. I got excited to see her awake and conscious so I went over to say hi. To my amazement, she told me she knew me and that I’m a physio student and then she said thanks for talking to her. So that experience taught me to always communicate effectively with every patient that I come across.
Monday, November 10, 2008
grumpy sometimes means going bad
I had two occasions where the attitude of the patient was more important than I thought in signalling their failing or recovering health. With the first on my rural placement, I had been treating the male patient from day one post-op laparotomy. Routine chest treatment. When I arrived post op day 2 the patient was irritable, grumpy and even borderline insulting with his negativity. I got the hint that today and right now would not be a good time to work with him as he was sullen and uncooperative. I was more affected by his complete turn of character than what it may have meant. It was so unlike him. An hour later he was in AF and rushed to ED. Perhaps his bad attitude was a signal that he was feeling more unwell and that was a flag I could have picked up on.
The second patient turned during a session. A post-CVA with significant expressive aphasia and apraxia, I was targeting his balance. Previously all physiotherapy had been focused on his ailing chest. So we were doing new and exciting things. Suddenly he began to get very distressed in tandem stance, saying he had had enough and was scared. He seemed very distressed. Flushed, not making eye contact, gasping and trembling. I was very concerned that I had pushed him too far too early. We stopped and sat down to rest. Then he suddenly stood up and indicated he needed to go to the toilet immediately! He was not about to wait for the portable oxygen he would need. My supervisor and I speculated later that perhaps with this apraxia and expressive aphasia that he perhaps was not realising that he needed to go earlier to prepare, and that his distress may have been related to this biological confusion. Either way, it was important to pay attention to. From then on I would prepare with taking an oxygen tank in with me incase he again needed to quickly go (which did happen again). His uncharacteristic change of attitude and irritable distress was very relevant.
These two encounters have taught me not to over look how a patient is feeling and reacting to treatment. Often we feel we have to push them on for their own good, and if we don't get to see our patient because of their attitude that it isn't good enough. But honestly, sometimes their grumpiness is a sign of sudden deteriorating health or distress to do with another problem unrelated to our physiotherapy. This is especially true if the patient is normally cooperative with you. Knowing your patient's personality and moods can really help with picking up on important signs regarding their health!
The second patient turned during a session. A post-CVA with significant expressive aphasia and apraxia, I was targeting his balance. Previously all physiotherapy had been focused on his ailing chest. So we were doing new and exciting things. Suddenly he began to get very distressed in tandem stance, saying he had had enough and was scared. He seemed very distressed. Flushed, not making eye contact, gasping and trembling. I was very concerned that I had pushed him too far too early. We stopped and sat down to rest. Then he suddenly stood up and indicated he needed to go to the toilet immediately! He was not about to wait for the portable oxygen he would need. My supervisor and I speculated later that perhaps with this apraxia and expressive aphasia that he perhaps was not realising that he needed to go earlier to prepare, and that his distress may have been related to this biological confusion. Either way, it was important to pay attention to. From then on I would prepare with taking an oxygen tank in with me incase he again needed to quickly go (which did happen again). His uncharacteristic change of attitude and irritable distress was very relevant.
These two encounters have taught me not to over look how a patient is feeling and reacting to treatment. Often we feel we have to push them on for their own good, and if we don't get to see our patient because of their attitude that it isn't good enough. But honestly, sometimes their grumpiness is a sign of sudden deteriorating health or distress to do with another problem unrelated to our physiotherapy. This is especially true if the patient is normally cooperative with you. Knowing your patient's personality and moods can really help with picking up on important signs regarding their health!
When to ask for psych help..
I was recently confronted with a pt who has suffered a TACS – and 10 mths post CVA still has v marked activity limitations. She is the sole carer of her teenage son, yet she can no longer work/drive/do housework. She is able to walk with a very poor, inefficient gait pattern, with a quad stick for short distances. She is having to sell her house due to financial and accessibility problems. She has a mental health history of 3 ‘emotional breakdowns’ and her mother committed suicide whilst depressed..
During one of our sessions, she was very down – she often presents like this but I am usually able to motivate her to work throughout our session, but this day seemed a lost cause. She was fixated on the progress of others and just wanted to ‘walk normally., now’. She began telling me her life story and how she was terrified of depression because of “what it did” to her mother. She also intimated suicidal tendencies.. When I alerted my supervisor to this situation I was forced to make a decision about whether I thought this patient needed psych intervention immediately – this would basically have been outpatient suicide watch. On this occasion I deemed it unnecessary. However I didn’t get much sleep that night and nearly cried with joy when she arrived for physio the next day! This day she was motivated, hard working and more realistic about her goals. She is in touch with the state head injury whom I contacted to discuss my concerns and was told they are very much aware of the situation.
However, had there not been a case manager, who was aware of and was co-ordinating her psych intervention, this situation would have been much more difficult. I am extremely thankful that the outcome was good, but in retrospect, I think I probably should have erred on the side of caution – even if only for my own sanity. It is often difficult to draw on services we have little knowledge about, but I have made an effort to make myself more informed, should this situation arise again. I also realise that we are sometimes called upon to make judgement calls outwith our expertise and that in these situations it is probably best to proceed with caution. I was the only health professional that this patient came into contact with on this day and if something had happened to her I would have felt forever responsible, or at least as if I could have prevented it.
During one of our sessions, she was very down – she often presents like this but I am usually able to motivate her to work throughout our session, but this day seemed a lost cause. She was fixated on the progress of others and just wanted to ‘walk normally., now’. She began telling me her life story and how she was terrified of depression because of “what it did” to her mother. She also intimated suicidal tendencies.. When I alerted my supervisor to this situation I was forced to make a decision about whether I thought this patient needed psych intervention immediately – this would basically have been outpatient suicide watch. On this occasion I deemed it unnecessary. However I didn’t get much sleep that night and nearly cried with joy when she arrived for physio the next day! This day she was motivated, hard working and more realistic about her goals. She is in touch with the state head injury whom I contacted to discuss my concerns and was told they are very much aware of the situation.
However, had there not been a case manager, who was aware of and was co-ordinating her psych intervention, this situation would have been much more difficult. I am extremely thankful that the outcome was good, but in retrospect, I think I probably should have erred on the side of caution – even if only for my own sanity. It is often difficult to draw on services we have little knowledge about, but I have made an effort to make myself more informed, should this situation arise again. I also realise that we are sometimes called upon to make judgement calls outwith our expertise and that in these situations it is probably best to proceed with caution. I was the only health professional that this patient came into contact with on this day and if something had happened to her I would have felt forever responsible, or at least as if I could have prevented it.
Sport in the country
Sport is very important to people living in the country. Every Saturday and occasionally on Sundays too the country towns verse each other in football, hockey and netball. Whilst on my country practical I saw many sports related injuties. Usually shoulder injuries for the footballers and knees and ankles for the hockey and netball players.
One of the patients that I saw weekly on my practical was madly into her netball. For the first two sessions I continued to treat her for her baker's cyst in her right knee. I used treatment techniques such as stretches, taping, VMO strengthening and SPRICEMMM post matches. Every week when she would return to physiotherapy the knee would be more swollen and sore because she had played 1-2 games of netball over the weekend. To get optimal recovery this patient would need to stop playing netball and loading the knee. My physiotherapist however explained to me that no matter what I said this patient wouldn't give up her netball until finals were over. This meant that I was aiming to avoid further injury rather than reducing her pain completely.
This happened on many occasions. I had a lady with a sprained ankle and another with navicular pain. Both of these patients also played netball whilst having these injuries. Treatment for these patients included ultrasound for the swelling and taping for the following game. This treatment frustrated me because it was difficult to see if my treatment was effective. I guess it did make me realise that sometimes you can't stop someone from playing sport especially at finals time so it is probably best to treat to avoid further injury and be realistic.
One of the patients that I saw weekly on my practical was madly into her netball. For the first two sessions I continued to treat her for her baker's cyst in her right knee. I used treatment techniques such as stretches, taping, VMO strengthening and SPRICEMMM post matches. Every week when she would return to physiotherapy the knee would be more swollen and sore because she had played 1-2 games of netball over the weekend. To get optimal recovery this patient would need to stop playing netball and loading the knee. My physiotherapist however explained to me that no matter what I said this patient wouldn't give up her netball until finals were over. This meant that I was aiming to avoid further injury rather than reducing her pain completely.
This happened on many occasions. I had a lady with a sprained ankle and another with navicular pain. Both of these patients also played netball whilst having these injuries. Treatment for these patients included ultrasound for the swelling and taping for the following game. This treatment frustrated me because it was difficult to see if my treatment was effective. I guess it did make me realise that sometimes you can't stop someone from playing sport especially at finals time so it is probably best to treat to avoid further injury and be realistic.
The courage of a lion
As physiotherapists we are motivational, we drive patients to push through pain and frustration, to persist to reach their goals. We are their motivation to achieve health. For the first time in my physiotherapy experience I have been awed by the courage of one patient to push through.
When a frail elderly female patient was experiencing 10/10 pain, it was not the over exaggerated kind you sometimes come across. The screaming and crying were no put on. This patient was in extreme pain. Yet she was determined to move, even though moving at all caused her left hip to give her excruciating pain. We had to log roll her then do a cradle transfer with two keeping her legs straight just to sit on the edge of the bed. The pain was already tiring her out, but she continued to say "no, I want to move, let's go" and when we did with less pain she was ecstatic saying "yes, we are going girls, we are going!" Just to move without pain was a blessing. And when I say move, my sock foot was the means by which she managed to slide her left foot along the floor with two assist and a 4WW. Slow but steady we managed to go two meters. It was a miraculous moment for the severity of pain but also the immobility the patient had endured for two days.
You might ask why I persisted in mobilising this patient, considering the pain and the fact it took 40 minutes to get out of bed to walk two meters. But we all know the perils of immobility and when a patient is even more driven than you, you know you have to encourage that kind of attitude when it is safe to do so.
Through out the ordeal, breathing control and relaxation helped to reduce her pain perception and re-energise her for further efforts. She wept and was grateful to get back into bed, but she was also elated. And I must say, all three medical staff that it took to walk two meters were in awe of her courage and her persistance through excruciating pain. Some times you come across great moments of great character that inspire you to plough on. In all future situations I will remember her determination and achievement. We see alot of the negative side of health and the community in hospitals, but there are also moments of greatness.
When a frail elderly female patient was experiencing 10/10 pain, it was not the over exaggerated kind you sometimes come across. The screaming and crying were no put on. This patient was in extreme pain. Yet she was determined to move, even though moving at all caused her left hip to give her excruciating pain. We had to log roll her then do a cradle transfer with two keeping her legs straight just to sit on the edge of the bed. The pain was already tiring her out, but she continued to say "no, I want to move, let's go" and when we did with less pain she was ecstatic saying "yes, we are going girls, we are going!" Just to move without pain was a blessing. And when I say move, my sock foot was the means by which she managed to slide her left foot along the floor with two assist and a 4WW. Slow but steady we managed to go two meters. It was a miraculous moment for the severity of pain but also the immobility the patient had endured for two days.
You might ask why I persisted in mobilising this patient, considering the pain and the fact it took 40 minutes to get out of bed to walk two meters. But we all know the perils of immobility and when a patient is even more driven than you, you know you have to encourage that kind of attitude when it is safe to do so.
Through out the ordeal, breathing control and relaxation helped to reduce her pain perception and re-energise her for further efforts. She wept and was grateful to get back into bed, but she was also elated. And I must say, all three medical staff that it took to walk two meters were in awe of her courage and her persistance through excruciating pain. Some times you come across great moments of great character that inspire you to plough on. In all future situations I will remember her determination and achievement. We see alot of the negative side of health and the community in hospitals, but there are also moments of greatness.
Sunday, November 9, 2008
Cervicogenic Headaches
An increasingly common presentation to musculoskeletal outpatient departments are cervicogenic headaches. During my four week musculo placement, I recall having three patients with this presentation. I found though, it is quite a difficult condition to treat. For example, when the patient presents to the clinic, they usually do not have the headache so it’s hard to fully determine the efficacy of you treatment.
Quite often there are associated problems, such as decreased ROM (due to tightness + pain), tight musculature (especially sub-occipitals, cervical erector spinae, upper traps), and hypomobile PAIVMS (+ pain reproduction) & PPIVMS. There is also usually poor postural awareness and poor deep neck flexor strength. Therefore, much of the treatment centres around postural education (inc. ergonomic advice) and postural re-education exercises, ROM ex’s, PAIVMS/PPIVMS and muscle length activities (e.g. STM, stretch, trigger point etc).
Despite treating these physical impairments, it is hard for the patient to judge their progress by your treatments, as cervicogenic headaches may not occur during the time of your clinical placement. Therefore, ensure the small improvements in physical signs are adequately explained, as if they are not, the patient may become despondent and not comply. Therefore, explain the gains you are making and ensure the patient monitors frequency, severity and duration of headaches to see if changes occur. Also, if the patient experiences a headache between the clinical visits, don’t be disappointed and feel as if you have failed. Rather look to see if there are any changes in duration and intensity of the headache, if they required as much medication, and if there was the same amount of time between the headaches as normal. By using these as clinical markers, I found I could be pleased with the progress that was being made, and these positive indicators could then be told to the patients.
Quite often there are associated problems, such as decreased ROM (due to tightness + pain), tight musculature (especially sub-occipitals, cervical erector spinae, upper traps), and hypomobile PAIVMS (+ pain reproduction) & PPIVMS. There is also usually poor postural awareness and poor deep neck flexor strength. Therefore, much of the treatment centres around postural education (inc. ergonomic advice) and postural re-education exercises, ROM ex’s, PAIVMS/PPIVMS and muscle length activities (e.g. STM, stretch, trigger point etc).
Despite treating these physical impairments, it is hard for the patient to judge their progress by your treatments, as cervicogenic headaches may not occur during the time of your clinical placement. Therefore, ensure the small improvements in physical signs are adequately explained, as if they are not, the patient may become despondent and not comply. Therefore, explain the gains you are making and ensure the patient monitors frequency, severity and duration of headaches to see if changes occur. Also, if the patient experiences a headache between the clinical visits, don’t be disappointed and feel as if you have failed. Rather look to see if there are any changes in duration and intensity of the headache, if they required as much medication, and if there was the same amount of time between the headaches as normal. By using these as clinical markers, I found I could be pleased with the progress that was being made, and these positive indicators could then be told to the patients.
Tuesday, November 4, 2008
Discharge?
Stroke rehabilitation can be frustrating at times particularly in the outpatient setting when you are only seeing the patient for three hours a week. It is very difficult to determine whether the patient is improving within one session or even over a week. I am currently treating a patient who had a right mca stroke. The patient can ambulate independently and perform all transfers safely so now we are working on her left upper limb.
The patient has poor scapula control due to increased tone in teres major and latissimus dorsi, weakness of serratus anterior and rhomboids and stage 5 recovery of her arm and hand. Over the past four sessions with this patient I have performed SIMMs to her teres major and latissimus dorsi, stretched the upper trapezius and neck flexors, performed passive accessory mobilisations to the shoulder and have stretched the elbow and finger flexors. I have also worked on shoulder stability in an air splint with external rotation and weight bearing through the upper limb in 4 pt kneeling. Functional tasks have included reaching, grasping and releasing. In order to improve her sensation and proprioception I have done sensory work and stereognosis testing.
This patient has shown little improvement over the past couple of weeks and in the last session I tested her stereognosis and the patient couldn't even identify if she was picking up an object or her hand was empty. As a therapist I begin to question whether my treatment techniques are having an effect or if because this patient is over 8 months post stroke my techniques won't improve her motor patterns. It is difficult to decide whether this patient should be discharged or similar treatment should continue. I am trialling hydrotherapy with this patient to improve range of movement and shoulder stability. Hopefully by using this new approach I will begin to see improvements in the patients upper limb.
The patient has poor scapula control due to increased tone in teres major and latissimus dorsi, weakness of serratus anterior and rhomboids and stage 5 recovery of her arm and hand. Over the past four sessions with this patient I have performed SIMMs to her teres major and latissimus dorsi, stretched the upper trapezius and neck flexors, performed passive accessory mobilisations to the shoulder and have stretched the elbow and finger flexors. I have also worked on shoulder stability in an air splint with external rotation and weight bearing through the upper limb in 4 pt kneeling. Functional tasks have included reaching, grasping and releasing. In order to improve her sensation and proprioception I have done sensory work and stereognosis testing.
This patient has shown little improvement over the past couple of weeks and in the last session I tested her stereognosis and the patient couldn't even identify if she was picking up an object or her hand was empty. As a therapist I begin to question whether my treatment techniques are having an effect or if because this patient is over 8 months post stroke my techniques won't improve her motor patterns. It is difficult to decide whether this patient should be discharged or similar treatment should continue. I am trialling hydrotherapy with this patient to improve range of movement and shoulder stability. Hopefully by using this new approach I will begin to see improvements in the patients upper limb.
walking with your hands
I have been treating a patient with an acute (L) CVA for two weeks now. His main impairments have been an inability to walk without two mod-max assist, a flaccid upper limb, expressive aphasia and a two assist transfer. We have focused on his poor hip mobility and ankle range to progress to walking. Recently he has progressed to a one mod and one min assist with a quad cane or parallel bars, for about 6 steps. He fatigues so quickly and becomes emotional, so our sessions are quite exhausting and yet both physios and patient are determined to persist. So today it was incredibly satisfying to witness something quite unique.
Today, he ambulated 4 times the distance he ever has before, with minimal use of a quad cane, one person supporting the UL, one min assist at the hips. The pattern was lovely, his independence incredibly improved. A day that made you appreciate being a physiotherapist.
And interestingly, the key seemed to be in his UL. We had experimented previously with UL facilitation in sitting. But today we chose to do MPG weight shift for increased weight bearing in his arms and improve weight shift. He then improved his trunk extensor activation and scapula setting, improved foot alignment in walking and posture. By facilitating the UL in his ambulation, he was centred, taking full weight through straight legs that we had struggled to get extended sufficiently for weight bearing. It was incredible to watch. And further more, he began to string words together. Where he previously mumbled yeah or no, he said a slurred version of "that's ok" and "my shoulder is hurting". It was incredible!!!!!!!
So lets not forget the UL. Lets not leave it to the OT's. It is instrumental in facilitating appropriate trunk control and therefore weight shift. The sensation of weightbearing through the upper limb facilitates this in patients post stroke and improves the subluxation. I will never again let the upper limb fall second priority in physiotherapy sessions!
Today, he ambulated 4 times the distance he ever has before, with minimal use of a quad cane, one person supporting the UL, one min assist at the hips. The pattern was lovely, his independence incredibly improved. A day that made you appreciate being a physiotherapist.
And interestingly, the key seemed to be in his UL. We had experimented previously with UL facilitation in sitting. But today we chose to do MPG weight shift for increased weight bearing in his arms and improve weight shift. He then improved his trunk extensor activation and scapula setting, improved foot alignment in walking and posture. By facilitating the UL in his ambulation, he was centred, taking full weight through straight legs that we had struggled to get extended sufficiently for weight bearing. It was incredible to watch. And further more, he began to string words together. Where he previously mumbled yeah or no, he said a slurred version of "that's ok" and "my shoulder is hurting". It was incredible!!!!!!!
So lets not forget the UL. Lets not leave it to the OT's. It is instrumental in facilitating appropriate trunk control and therefore weight shift. The sensation of weightbearing through the upper limb facilitates this in patients post stroke and improves the subluxation. I will never again let the upper limb fall second priority in physiotherapy sessions!
Monday, November 3, 2008
Healthy Living
I am currently treating an 18 yr old patient with multiple sclerosis. The patient has been diagnosed since she was 11. She does have periods of remssion however, she is now unable to stand without upper limb support and cannot ambulate.
When I met this patient she was extremely bubbly and ourgoing. I didn't expect this knowing that she had such a progressive condition. I immediately admired this patient's enthusiasm. This experience made me feel extremely lucky and I couldn't believe how much I took for granted. I looked back on my experiences as a teenager and compared it to how she had spent her past few years.
We chatted a lot during the treatment session and she began to show me photos of her family and friends and tell me stories about her weekend. During this discussion she was talking about her night out clubbing and how she'd drunk a bottle of vodka before going out. Prior to this session her notes said that she promised to reduce her alcohol intake. I'm unsure whether the physiotherapy student had advised her to stop drinking or if she had said that she wanted to reduce the amount of alcohol. In the notes it mentioned that her family were worried about her drinking havits as they were worried that she would injure herself or that men would take advantage of her.
As physiotherapists we promote a healthy lifestyle. I am unsure when a problem like this becoumes our business or responsibility. Obviously I am concerned for this patient and her well being. Even though I want this patient to be safe and to optimise her rehabilitation I want her to life her own life. She has many impairments restricting her participation in activities that teenagers would enjoy doing. Life isn't easy for this patient and occasionally she has mood swings and becomes quite depressed. I have subtly mentioned that the amount she drinks ais a lot more than the average person and I have shared my concern but I haven't told her off like previous therapists. I don't think it is our place.
I would very interested to hear if anoyone has had a similar experience or has thoughts on the issue.
When I met this patient she was extremely bubbly and ourgoing. I didn't expect this knowing that she had such a progressive condition. I immediately admired this patient's enthusiasm. This experience made me feel extremely lucky and I couldn't believe how much I took for granted. I looked back on my experiences as a teenager and compared it to how she had spent her past few years.
We chatted a lot during the treatment session and she began to show me photos of her family and friends and tell me stories about her weekend. During this discussion she was talking about her night out clubbing and how she'd drunk a bottle of vodka before going out. Prior to this session her notes said that she promised to reduce her alcohol intake. I'm unsure whether the physiotherapy student had advised her to stop drinking or if she had said that she wanted to reduce the amount of alcohol. In the notes it mentioned that her family were worried about her drinking havits as they were worried that she would injure herself or that men would take advantage of her.
As physiotherapists we promote a healthy lifestyle. I am unsure when a problem like this becoumes our business or responsibility. Obviously I am concerned for this patient and her well being. Even though I want this patient to be safe and to optimise her rehabilitation I want her to life her own life. She has many impairments restricting her participation in activities that teenagers would enjoy doing. Life isn't easy for this patient and occasionally she has mood swings and becomes quite depressed. I have subtly mentioned that the amount she drinks ais a lot more than the average person and I have shared my concern but I haven't told her off like previous therapists. I don't think it is our place.
I would very interested to hear if anoyone has had a similar experience or has thoughts on the issue.
A MET call
Last week I experienced my first MET call.
Whilst on lunch in a room adjacent to the gym, a patient started shouting for help. The physio responded immediately, with a few students in tow soon after. Another pt had arrived at the outpatient department, seated himself and whilst waiting for his session to begin he had had a seizure, fallen off the plinth and hit his head on the ground (which is the point at which the other patient started shouting for help). The pt was still in seizure for the next few minutes. During this time the physio put the pt in sidelying and I put a pillow under his bleeding head and applied pressure to the wound (even managed to remember to glove up first). Another physio entered the gym and made a MET call.
The patient was conscious throughout, was scared and was aware of his pain. He was concerned about his bleeding (he’s on blood thinning meds) and was also aware that his already hemiparetic side, which had previously made good recovery, was now weaker (he’d had a stroke 8 mths ago, which is why he was receiving rehab). The MET team took a little longer to arrive than I had expected and unfortunately the crash cart didn’t arrive with them.
The patient was much calmer now, still obviously shocked though and concerned that he had had another stroke. After the team had done their examination they decided he should be transferred to another hospital. The health team were chatting amongst themselves, when the patient asked if I thought perhaps he should see a doctor.. I quickly explained that the doctor had already assessed him and that it was thought he had had a seizure. At this point one of the physio’s explained to him that about 10% of stroke pts go on to have seizures post stroke and that the increased weakness he was currently experiencing was usually transient. The patient was visibly calmer and was even able to start making jokes.
Ultimately, the patient was ok - before leaving that afternoon we had news that he was being discharged that evening with anti-seizure meds. I was so pleased the physio was able to provide him with that info about seizures post stroke - I guess with experience we will have more to offer in such a situation. In the meantime though, this experience has re-iterated to me how important it is to keep the pt informed about who they’re seeing and what has been found, especially in an acutely ill pt.
Whilst on lunch in a room adjacent to the gym, a patient started shouting for help. The physio responded immediately, with a few students in tow soon after. Another pt had arrived at the outpatient department, seated himself and whilst waiting for his session to begin he had had a seizure, fallen off the plinth and hit his head on the ground (which is the point at which the other patient started shouting for help). The pt was still in seizure for the next few minutes. During this time the physio put the pt in sidelying and I put a pillow under his bleeding head and applied pressure to the wound (even managed to remember to glove up first). Another physio entered the gym and made a MET call.
The patient was conscious throughout, was scared and was aware of his pain. He was concerned about his bleeding (he’s on blood thinning meds) and was also aware that his already hemiparetic side, which had previously made good recovery, was now weaker (he’d had a stroke 8 mths ago, which is why he was receiving rehab). The MET team took a little longer to arrive than I had expected and unfortunately the crash cart didn’t arrive with them.
The patient was much calmer now, still obviously shocked though and concerned that he had had another stroke. After the team had done their examination they decided he should be transferred to another hospital. The health team were chatting amongst themselves, when the patient asked if I thought perhaps he should see a doctor.. I quickly explained that the doctor had already assessed him and that it was thought he had had a seizure. At this point one of the physio’s explained to him that about 10% of stroke pts go on to have seizures post stroke and that the increased weakness he was currently experiencing was usually transient. The patient was visibly calmer and was even able to start making jokes.
Ultimately, the patient was ok - before leaving that afternoon we had news that he was being discharged that evening with anti-seizure meds. I was so pleased the physio was able to provide him with that info about seizures post stroke - I guess with experience we will have more to offer in such a situation. In the meantime though, this experience has re-iterated to me how important it is to keep the pt informed about who they’re seeing and what has been found, especially in an acutely ill pt.
Sunday, November 2, 2008
Patients with Too Many Problems!
For those of you who have had your musculo placement, you would know that it is important to set time limits when performing the subjective and objective examinations. I remember I once had a new patient who was referred to the clinic with shoulder pain and headaches. As a “good” physio, I questioned her about her pain and started to fill out her body chart. As I questioned further, it became very clear this lady was a chronic pain patient. She had pain everywhere! Not only that, the pain she experienced was very severe, quite often close to 10/10. Of course, I tried to figure out the relationships between the different pains, and the aggravating/easing factors for each pain, which as you could imagine, the list became very extensive. As a result, it took me around 40 minutes just to do the subjective!
When I went to tell my supervisor what I had found, he told me that it is ok with patients like these to simply question them only about their initial presenting complaint (i.e. her shoulder pain and headaches), rather than any other associated pain. By doing so, it should help with time management. Then, over the next coming weeks, it is ok to question further about the other pain they are experiencing to better determine relationships.
She was definitely an interesting (and somewhat difficult) patient to see. I guess it’s a good learning experience though, as it is very easy to approach an initial consult as a tick box process. Quite often, I find I will know most of the questions that could be asked, and I will tend to ask them all, simply to have a thorough assessment sheet. Rather, it’s important to consider the absolutely vital parts of the examination that must be determined on the initial consult, and gather the rest of the information over coming sessions. I definitely will be trying to do this, but I guess the more I see patients, the easier this will become as our clinical reasoning process will also develop.
When I went to tell my supervisor what I had found, he told me that it is ok with patients like these to simply question them only about their initial presenting complaint (i.e. her shoulder pain and headaches), rather than any other associated pain. By doing so, it should help with time management. Then, over the next coming weeks, it is ok to question further about the other pain they are experiencing to better determine relationships.
She was definitely an interesting (and somewhat difficult) patient to see. I guess it’s a good learning experience though, as it is very easy to approach an initial consult as a tick box process. Quite often, I find I will know most of the questions that could be asked, and I will tend to ask them all, simply to have a thorough assessment sheet. Rather, it’s important to consider the absolutely vital parts of the examination that must be determined on the initial consult, and gather the rest of the information over coming sessions. I definitely will be trying to do this, but I guess the more I see patients, the easier this will become as our clinical reasoning process will also develop.
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