Remote setting

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

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

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

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

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

Country people go wild

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

Recognising S&S…

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

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

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

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

Another crying moment

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

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

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

First Impressions

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

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

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

When a Patient Tells You They're About to Faint

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

Discharging Patients

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

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