Whilst on my rural practical in a small town I learnt how you must be a flexible health professional and be willing to step outside your discipline to provide optimal patient care. The town I went to had visiting occupational therapy, speech pathology and podiatry approximately once every 2 months. Therefore as the part time physiotherapist you can be expected to work as an occupational therapist and a speech pathologist too. There is a part time therapy assistant employed two days a week however these staff members must see the occupational therapist and speech pathologist when they are in town and learn what to do with patients and develop programs for them. The therapy assistants are therefore very challenged as they are learning many new assessment and treatment techniques for each patient.
During my time at the health service I saw a patient who had a skin flap on the side of her face which had caused damage to her facial nerve and consequently the patient was having difficulty speaking. As there was no speech therapist within the area I was seeing her and giving her exercises to improve her speech. The physiotherapist had a video conference with the speech pathologist in a larger town to develop assessment and treatment for this patient. I continued to assess this patient’s degree of jaw opening and perform vowel exercises with her to reduce her palsy.
In addition the physiotherapist ordered equipment for outpatients and the residential patients to improve their independence and fitted them appropriately. She also did home visits to see what equipment was needed for patients. This may be seen as an occupational therapy job however the patient may not be able to wait two months.
I really enjoyed my rural placement. I saw a large variety of patients and I saw how important it was to be an interdisciplinary team member and a flexible health professional.
Monday, August 25, 2008
Saturday, August 23, 2008
Independent OR Unreasonable?
I know as a physio one of our aims is to get people to become as independent as possible. A recent encounter with a difficult patient made me view independence at a new level and realise that each individual’s home situation plays a huge role in determining when they are appropriate for DC.
This particular patient had a TKR with a few post op complications. Unfortunately there was a large haematoma around the knee and massive swelling. We were seeing this patient 2 x daily for mobility and swelling Mx, and felt like we had good rapport with him. On a Friday, the doctor doing his morning rounds Ax the pt and told him he was allowed to go home. The doctor told him this without talking to either the OT or PT and determining his functional status or home situation.
From a PT point of view, we were not happy with his ROM he had were worried about the amount of swelling still evident. The OT had also not yet done a home review. This pt lived on his own, on a farm, about 1 hour out of the country town where the hospital was. He lived in a movable home (like caravan), with 4 steep steps up to the front. He also had family and grandkids in nearby country towns who he told us he was going to visit in the next week. So from our point of view, this pt was going home alone, would have to get up 4 steep steps, and was going to be driving in the next few days.
Both the senior OT, my supervisor and I went to see this pt and strongly advised that he live with his daughter (which was a possibility) upon DC just for a little while until he the swelling decreased. We were polite and tried to use reasons that he would relate to and understand. The pt (who had previously been polite back to us) became very adamant and quite rude, saying that he ‘had lived on his own for 15 years on the farm and who did we think we were trying to tell him that he shouldn’t go back there.’ We made it clear that he could go back there, but informed him of the effects of surgery and that some people like to have other people around when they get out of hospital. He said we could advise all we wanted ‘but he was going to do what he wanted to do.’
Furthermore, after asking if he could attend the OP clinic for follow up Rx, he told us “well if you see my feet walking through the door, you know I’ll be coming in.’
So… I guess we just have to wait and see what happens next week.
This patient also packed up all his things, sifted through the papers he had next to his bed, packed them up, and the only one he left on his bed were his Physio exercises!
It got me thinking about being independent and how people view it. This patient it seemed was very rude and bluntly refused our advice or further help. At the time I was a bit put out as I thought we had been helping him every day and he had always been grateful. I then thought that maybe his behaviour came from the fact that he wanted so badly to be independent.
I learnt how to be tactful and give strong advice without sounding forceful, however I also learnt that no matter how hard you try, some people just don’t want to listen for whatever reason.
This particular patient had a TKR with a few post op complications. Unfortunately there was a large haematoma around the knee and massive swelling. We were seeing this patient 2 x daily for mobility and swelling Mx, and felt like we had good rapport with him. On a Friday, the doctor doing his morning rounds Ax the pt and told him he was allowed to go home. The doctor told him this without talking to either the OT or PT and determining his functional status or home situation.
From a PT point of view, we were not happy with his ROM he had were worried about the amount of swelling still evident. The OT had also not yet done a home review. This pt lived on his own, on a farm, about 1 hour out of the country town where the hospital was. He lived in a movable home (like caravan), with 4 steep steps up to the front. He also had family and grandkids in nearby country towns who he told us he was going to visit in the next week. So from our point of view, this pt was going home alone, would have to get up 4 steep steps, and was going to be driving in the next few days.
Both the senior OT, my supervisor and I went to see this pt and strongly advised that he live with his daughter (which was a possibility) upon DC just for a little while until he the swelling decreased. We were polite and tried to use reasons that he would relate to and understand. The pt (who had previously been polite back to us) became very adamant and quite rude, saying that he ‘had lived on his own for 15 years on the farm and who did we think we were trying to tell him that he shouldn’t go back there.’ We made it clear that he could go back there, but informed him of the effects of surgery and that some people like to have other people around when they get out of hospital. He said we could advise all we wanted ‘but he was going to do what he wanted to do.’
Furthermore, after asking if he could attend the OP clinic for follow up Rx, he told us “well if you see my feet walking through the door, you know I’ll be coming in.’
So… I guess we just have to wait and see what happens next week.
This patient also packed up all his things, sifted through the papers he had next to his bed, packed them up, and the only one he left on his bed were his Physio exercises!
It got me thinking about being independent and how people view it. This patient it seemed was very rude and bluntly refused our advice or further help. At the time I was a bit put out as I thought we had been helping him every day and he had always been grateful. I then thought that maybe his behaviour came from the fact that he wanted so badly to be independent.
I learnt how to be tactful and give strong advice without sounding forceful, however I also learnt that no matter how hard you try, some people just don’t want to listen for whatever reason.
Monday, August 18, 2008
English as a Second Language
Whilst on prac, it was requested I see a young boy who recently had arrived in Australia and spoke very minimal English. He was admitted to the hospital post a tib/fib fracture and had been fitted with external fixation. As he was still in the acute stages, physio intervention primarily consisted of active-assisted movements of the ankle, hip and knee, as well as static and inner range quad exercises.
As my supervisor was watching, I was quite conscious of the way I approached this patient. As I know I can have the tendency to over-explain a situation, I thought I would simplify and keep my explanations to a minimum with this boy, as I did not want to overwhelm the young child. After I introduced myself to the patient and explained that we needed to do exercises, I basically got straight into the treatment. To demonstrate how to do the exercises, I would show him on his unaffected leg and then progress to his affected side, yet did not offer an explanation as to why he needed to do it. I did try to make small talk during the session, but found him to be quite unresponsive, and would initially complain of pain as I tried to move his leg. Despite this, I managed to perform what I had planned for the treatment session.
Upon leaving the room, my supervisor commented on how I did not outline and explain the treatment situation normally as I would for any other patient. I explained my reasoning, which she understood, but still said it is always best to explain the need for the exercises, in simple terms, as even the non-verbal signals I would portray during my explanations would help to put the patient at ease and receive a better response during the exercises. Another point which my supervisor mentioned was that even though the child may not fully understand English, it is quite common for a child to play on this, and use it as a mechanism to get out of exercises. Also, in future, it may have been of benefit to time physio intervention whilst having a parent in the room to act as an interpreter (if possible).
Through this situation, it has shown me that even though a patient may have limiting factors such as English being a second language, it is still important to offer the person the same opportunities to understand the reasoning and importance of the exercises. Not only will this increase compliance, but also help to develop better rapport. I will be mindful of this in the future.
As my supervisor was watching, I was quite conscious of the way I approached this patient. As I know I can have the tendency to over-explain a situation, I thought I would simplify and keep my explanations to a minimum with this boy, as I did not want to overwhelm the young child. After I introduced myself to the patient and explained that we needed to do exercises, I basically got straight into the treatment. To demonstrate how to do the exercises, I would show him on his unaffected leg and then progress to his affected side, yet did not offer an explanation as to why he needed to do it. I did try to make small talk during the session, but found him to be quite unresponsive, and would initially complain of pain as I tried to move his leg. Despite this, I managed to perform what I had planned for the treatment session.
Upon leaving the room, my supervisor commented on how I did not outline and explain the treatment situation normally as I would for any other patient. I explained my reasoning, which she understood, but still said it is always best to explain the need for the exercises, in simple terms, as even the non-verbal signals I would portray during my explanations would help to put the patient at ease and receive a better response during the exercises. Another point which my supervisor mentioned was that even though the child may not fully understand English, it is quite common for a child to play on this, and use it as a mechanism to get out of exercises. Also, in future, it may have been of benefit to time physio intervention whilst having a parent in the room to act as an interpreter (if possible).
Through this situation, it has shown me that even though a patient may have limiting factors such as English being a second language, it is still important to offer the person the same opportunities to understand the reasoning and importance of the exercises. Not only will this increase compliance, but also help to develop better rapport. I will be mindful of this in the future.
Monday, August 11, 2008
Avoiding Complacency
After seeing numerous patients throughout the day, and performing standard exercises and instructions with them, I find that I (unfortunately and unintentionally) can become slightly slack and form certain predetermined expectations of a patient.
I noticed this occurred the other day when teaching a young girl NWB with crutches. I taught her the basic gait pattern for crutches, but did not demonstrate to her how to sit down with crutches. After a few laps up and down the room, we headed towards the chair and as I wanted her to increase her independence, I removed my hands from her pelvis and instead moved to a close stand-by position. As she neared closer to the chair, she hopped too closely to the chair, subsequently overbalanced and landed awkwardly on her weight-bearing ankle. Fortunately, as I was still close, I was able to prevent her from falling but she still appeared visibly upset. It’s never a good feeling when you may have compromised a patient’s safety… especially when your supervisor is watching!
Even though the patient had a tendency to be slightly impulsive and overdramatic, the fact that she almost fell was probably a reflection of me not providing sufficient instructions and not leading enough in the treatment session. As I had taught patients NWB with crutches prior, I guess I expected her to be at the same level as my other patients and therefore did not provide as thorough instructions throughout the session. It was wrong of me to do this, as each individual is different and I should never compromise their safety by my assumptions. Even though complacency occurs subconsciously, I need to make a more conscious effort to be alert and provide each patient the same opportunity to learn. I know I will be trying to do this from now on.
I noticed this occurred the other day when teaching a young girl NWB with crutches. I taught her the basic gait pattern for crutches, but did not demonstrate to her how to sit down with crutches. After a few laps up and down the room, we headed towards the chair and as I wanted her to increase her independence, I removed my hands from her pelvis and instead moved to a close stand-by position. As she neared closer to the chair, she hopped too closely to the chair, subsequently overbalanced and landed awkwardly on her weight-bearing ankle. Fortunately, as I was still close, I was able to prevent her from falling but she still appeared visibly upset. It’s never a good feeling when you may have compromised a patient’s safety… especially when your supervisor is watching!
Even though the patient had a tendency to be slightly impulsive and overdramatic, the fact that she almost fell was probably a reflection of me not providing sufficient instructions and not leading enough in the treatment session. As I had taught patients NWB with crutches prior, I guess I expected her to be at the same level as my other patients and therefore did not provide as thorough instructions throughout the session. It was wrong of me to do this, as each individual is different and I should never compromise their safety by my assumptions. Even though complacency occurs subconsciously, I need to make a more conscious effort to be alert and provide each patient the same opportunity to learn. I know I will be trying to do this from now on.
Monday, August 4, 2008
When to Discharge a Patient?
Being in the public health system, it appears there is the constant pressure to discharge patients to allow for the opening of beds. However, being a student, I find it is sometimes difficult to know exactly when the point of discharge should be.
I encountered a situation the other day whereby I had to teach a young patient to use crutches. The doctors indicated that as soon as he had been taught and felt comfortable to use crutches, it was ok for the patient to be discharged. This patient had been rest in bed for a few days, so ambulating once again was an adjustment for him. After being taught how to use them and how to go up/down stairs, the patient practiced numerous times and appeared to mobilise effectively. The only point of concern was that twice during our session he had a slight posterior sway and required my steadying, but this was presumed to be due to the few days of bed rest.
As the patient essentially performed the tasks correctly and safely, and he had no complaints, I spoke with the nursing staff to practice ambulating with him overnight and if he appeared to be mobilising safely, it was ok from physiotherapy perspective to be discharged in the morning. I documented that he was safe for inpatient physio discharge, but did note that he had an occasional posterior sway and if the nursing staff noticed this again overnight, they could request a physio review in the morning.
The physio who was with me at the time seemed to think this was ok, but when my supervisor checked my notes the next day, he suggested that I review the patient again just to ensure he did not repeat the sway from the day prior. Unfortunately, the patient had already been discharged. My supervisor informed me that if I ever had any concern about a patient, I should not feel pressured to discharge the patient. As I had documented the patient had an occasional sway in his notes, if the patient was discharged and fell when using the crutches, the patient could sustain further injury and the blame could fall upon my head.
I guess it’s just a timely reminder that despite a patient or ward staff being eager for discharge, it is important to resolve any concerns you may have, as not only is this vital to the patients wellbeing but also to protect yourself from blame. I know I will keep this in mind from now on.
I encountered a situation the other day whereby I had to teach a young patient to use crutches. The doctors indicated that as soon as he had been taught and felt comfortable to use crutches, it was ok for the patient to be discharged. This patient had been rest in bed for a few days, so ambulating once again was an adjustment for him. After being taught how to use them and how to go up/down stairs, the patient practiced numerous times and appeared to mobilise effectively. The only point of concern was that twice during our session he had a slight posterior sway and required my steadying, but this was presumed to be due to the few days of bed rest.
As the patient essentially performed the tasks correctly and safely, and he had no complaints, I spoke with the nursing staff to practice ambulating with him overnight and if he appeared to be mobilising safely, it was ok from physiotherapy perspective to be discharged in the morning. I documented that he was safe for inpatient physio discharge, but did note that he had an occasional posterior sway and if the nursing staff noticed this again overnight, they could request a physio review in the morning.
The physio who was with me at the time seemed to think this was ok, but when my supervisor checked my notes the next day, he suggested that I review the patient again just to ensure he did not repeat the sway from the day prior. Unfortunately, the patient had already been discharged. My supervisor informed me that if I ever had any concern about a patient, I should not feel pressured to discharge the patient. As I had documented the patient had an occasional sway in his notes, if the patient was discharged and fell when using the crutches, the patient could sustain further injury and the blame could fall upon my head.
I guess it’s just a timely reminder that despite a patient or ward staff being eager for discharge, it is important to resolve any concerns you may have, as not only is this vital to the patients wellbeing but also to protect yourself from blame. I know I will keep this in mind from now on.
Monday, July 28, 2008
Anxious Patients
Whilst on my cardiopulmonary placement, I was required to see a post-op CABG patient. This patient had been transferred from a primary to a secondary hospital, and was awaiting discharge for home. Despite his relatively good post-op progress, this patient was very anxious and was always very reluctant to do his exercises. He always required constant reassurance and thorough explanations, to educate that he was doing well and that it was ok to move!
As part of his preparation for discharge, my supervisor was keen for this patient to complete a six minute walk test and compare it to previous results. When I mentioned this to the patient, he did NOT want to do this, as he had a bad experience inclusive of heightened chest pain and being “forced” to complete the test. I reassured him that this time would be different and if any of these symptoms were reproduced it would be ok to cease the test. Despite trying to reason with him (and beginning to feel a bit frustrated!), it did not change his outlook.
I informed my supervisor of this, whom said that my reasoning to the patient was sufficient and to see him again in the afternoon. My supervisor informed me to tell the patient that I would not get him to perform the six minute walk test, but rather simply measure how far he could walk in six minutes simply to get a baseline measure for his return to home. Even though essentially I was explaining the same concept to the patient, it was surprising that when I explained it not using the word “test” at all in my explanation, he agreed to do it. I did not use the standardised instructions of the six minute walk test as I wanted it to be performed in a more relaxed environment (due to his heightened anxiety), but still was able to use the essential elements of the test.
As I did not use the standardised instructions, track etc for a six minute walk test, I could not call the results a true reflection, but was at least given a general idea of this patients exercise tolerance. I never really thought that changing my tact ever so slightly (e.g. not using the word “test” or making the environment more relaxed) can influence a patient’s participation in a task to such a large extent. From now on, I will try to be mindful of my explanations to patients and structure these in such a way as to best consider a patients personality and emotional status.
As part of his preparation for discharge, my supervisor was keen for this patient to complete a six minute walk test and compare it to previous results. When I mentioned this to the patient, he did NOT want to do this, as he had a bad experience inclusive of heightened chest pain and being “forced” to complete the test. I reassured him that this time would be different and if any of these symptoms were reproduced it would be ok to cease the test. Despite trying to reason with him (and beginning to feel a bit frustrated!), it did not change his outlook.
I informed my supervisor of this, whom said that my reasoning to the patient was sufficient and to see him again in the afternoon. My supervisor informed me to tell the patient that I would not get him to perform the six minute walk test, but rather simply measure how far he could walk in six minutes simply to get a baseline measure for his return to home. Even though essentially I was explaining the same concept to the patient, it was surprising that when I explained it not using the word “test” at all in my explanation, he agreed to do it. I did not use the standardised instructions of the six minute walk test as I wanted it to be performed in a more relaxed environment (due to his heightened anxiety), but still was able to use the essential elements of the test.
As I did not use the standardised instructions, track etc for a six minute walk test, I could not call the results a true reflection, but was at least given a general idea of this patients exercise tolerance. I never really thought that changing my tact ever so slightly (e.g. not using the word “test” or making the environment more relaxed) can influence a patient’s participation in a task to such a large extent. From now on, I will try to be mindful of my explanations to patients and structure these in such a way as to best consider a patients personality and emotional status.
Friday, July 18, 2008
Time Management
With all experience thus far on clinics i have found it difficult to establish the amount of time to spend with each patient. With musculoskeletal outpatients the time allocations were restricted by appointment schedules however at times by the end of the treatment session their were techniques that you still wished to apply. With experience less time would be spent on assessment, allowing a more productive treatment sessions. I understand it is a delema that will ease with clinical experience.
On placement at ICU I began to question how long to spend bagging, doing viabrations and how many times to suction etc. When the chest is cleared you have a effective treatment session but when you have remaining secretions you wish to give the patient a break from suctioning which is quite an invasive, uncomfortable treatment. With vibes and manual hyperinflation i wasnt too sure of the effective time to spend on each and literature was lacking.
On placement at Graylands i encounted time management problems as you carry out physiotherapy with non compliant patients. It made you question if you should see these patients or spend time with compliant patients. You do not wish to neglect a patient but if they can not maintain your gains with treatment should we discontinue their future treatments.
On placement at ICU I began to question how long to spend bagging, doing viabrations and how many times to suction etc. When the chest is cleared you have a effective treatment session but when you have remaining secretions you wish to give the patient a break from suctioning which is quite an invasive, uncomfortable treatment. With vibes and manual hyperinflation i wasnt too sure of the effective time to spend on each and literature was lacking.
On placement at Graylands i encounted time management problems as you carry out physiotherapy with non compliant patients. It made you question if you should see these patients or spend time with compliant patients. You do not wish to neglect a patient but if they can not maintain your gains with treatment should we discontinue their future treatments.
Subscribe to:
Posts (Atom)