During my neurology prac I went to see a new patient who had been screened the day before in ED before being admitted to the ward. The handover had stated the patient had a right sided stroke and was ambulating and transferring with one minimal assistance.
When I arrived to see the patient I launched into my usual introduction and set about getting the patient ready to go to the gym. Given the reported level of function I expected to be able to walk the patient to the gym to complete my assessment. However I found the patient required significant assistance to transfer from supine and after a couple of attempted sit to stands the patient was not able to stand with minimal assistance.
At this point I returned the patient to bed and I was seriously doubting my ability to record a handover. I went and reviewed the notes which confirmed that the patient was minimal assist yesterday, so either the patient had suddenly got worse and no one had noticed or I was doing something wrong.
I decided to review the latter option first and after some more detailed attention to the notes I found that the patient had a significant hearing difficulty and required hearing aids as well as glasses for decreased vision. When I returned to the patient I was able to get the hearing aids and glasses organised and the improvement in response from the patient was noticeable. However I did not feel comfortable walking the patient to the gym and chose to use a wheelchair instead.
I completed part of my assessment in the gym and found that the patient had quite high Gowland scores with good range of motion and minimal perceptual deficits. When I explained the situation to my supervisor she simply walked over to the patient and asked her to walk to the door. To my surprise the patient stood up with minimal support and proceeded to walk comfortable to the door.
After reviewing what had occurred I realised that I had bombarded the patient with instructions that were poorly understood due to hearing loss. When the patient was not performing the task as I expected I reverted to breaking the task into obscure instructions from the patients point of view, rather focusing on a task the patient knew.
I have realised from this experience the need to make our intentions really clear with our patients and this is even truer in a patient population, such as a stroke, that has sensory and cognitive deficits. If we are able to focus on simple tasks that the patient knows initially then it will be much easier to give them into tasks that are less familiar.
Monday, December 1, 2008
Saturday, November 29, 2008
Trying new things
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.
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.
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.
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