As a student, it can be difficult to deal with a patient who may be sexually inappropriate. Even though this experience did not happen to me, discussing the situation with another student did make me question what I would have done in the same situation.
A patient presented to the student with low back pain. This student was very professional in their manner, and from what I had observed in the past, was very efficient when treating a patient. Despite this, the patient was not appropriately responding to questions, but preferred the conversation to centre around how often he went to the gym and how much he could bench-press. Furthermore, the patient continuously made sexual innuendos throughout the session, for example, offering to remove more items of his clothing than his shirt. Despite these comments, the student ignored the way the patient was acting and what he was saying, and continued to perform the appropriate assessment and treatment. However, it did make the student feel very uncomfortable and resulted in them not wanting to treat the patient again.
As we discussed the situation afterwards, we all realised that it is quite difficult to know what to do in these situations. Do you simply ignore the patient’s comments? Do you tell them their comments are inappropriate? Do you continue or refuse to treat them? Even though I know I would have liked to speak up against the patient (in a professional way…), I don’t know if I would have had the confidence to do so and probably would have just ignored the patient and continued to treat. I think as a student, we can sometimes feel we are not empowered enough to speak against a patient. We all like a placement to go as smoothly as possible, not ruffle too many feathers and give ourselves a good name. However, the truth of the matter is we deserved to be treated with respect. We should never feel under obligation to treat someone if we are putting ourselves in a vulnerable or uncomfortable situation.
It is important that if situations like this do occur, speak up to the patient and bring it to someone’s attention. Furthermore, see if the patient can be transferred to another physio, or alternatively see if another person can be present during the session. These are the strategies I would try to implement. It would be good to hear other people’s viewpoints on this matter.
Tuesday, October 28, 2008
Inappropriate Patients
As a student, it can be difficult to deal with a patient who may be sexually inappropriate. Even though this experience did not happen to me, discussing the situation with another student did make me question what I would have done in the same situation.
A patient presented to the student with low back pain. This student was very professional in their manner, and from what I had observed in the past, was very efficient when treating a patient. Despite this, the patient was not appropriately responding to questions, but preferred the conversation to centre around how often he went to the gym and how much he could bench-press. Furthermore, the patient continuously made sexual innuendos throughout the session, for example, offering to remove more items of his clothing than his shirt. Despite these comments, the student ignored the way the patient was acting and what he was saying, and continued to perform the appropriate assessment and treatment. However, it did make the student feel very uncomfortable and resulted in them not wanting to treat the patient again.
As we discussed the situation afterwards, we all realised that it is quite difficult to know what to do in these situations. Do you simply ignore the patient’s comments? Do you tell them their comments are inappropriate? Do you continue or refuse to treat them? Even though I know I would have liked to speak up against the patient (in a professional way…), I don’t know if I would have had the confidence to do so and probably would have just ignored the patient and continued to treat. I think as a student, we can sometimes feel we are not empowered enough to speak against a patient. We all like a placement to go as smoothly as possible, not ruffle too many feathers and give ourselves a good name. However, the truth of the matter is we deserved to be treated with respect. We should never feel under obligation to treat someone if we are putting ourselves in a vulnerable or uncomfortable situation.
It is important that if situations like this do occur, speak up to the patient and bring it to someone’s attention. Furthermore, see if the patient can be transferred to another physio, or alternatively see if another person can be present during the session. These are the strategies I would try to implement. It would be good to hear other people’s viewpoints on this matter.
A patient presented to the student with low back pain. This student was very professional in their manner, and from what I had observed in the past, was very efficient when treating a patient. Despite this, the patient was not appropriately responding to questions, but preferred the conversation to centre around how often he went to the gym and how much he could bench-press. Furthermore, the patient continuously made sexual innuendos throughout the session, for example, offering to remove more items of his clothing than his shirt. Despite these comments, the student ignored the way the patient was acting and what he was saying, and continued to perform the appropriate assessment and treatment. However, it did make the student feel very uncomfortable and resulted in them not wanting to treat the patient again.
As we discussed the situation afterwards, we all realised that it is quite difficult to know what to do in these situations. Do you simply ignore the patient’s comments? Do you tell them their comments are inappropriate? Do you continue or refuse to treat them? Even though I know I would have liked to speak up against the patient (in a professional way…), I don’t know if I would have had the confidence to do so and probably would have just ignored the patient and continued to treat. I think as a student, we can sometimes feel we are not empowered enough to speak against a patient. We all like a placement to go as smoothly as possible, not ruffle too many feathers and give ourselves a good name. However, the truth of the matter is we deserved to be treated with respect. We should never feel under obligation to treat someone if we are putting ourselves in a vulnerable or uncomfortable situation.
It is important that if situations like this do occur, speak up to the patient and bring it to someone’s attention. Furthermore, see if the patient can be transferred to another physio, or alternatively see if another person can be present during the session. These are the strategies I would try to implement. It would be good to hear other people’s viewpoints on this matter.
Monday, October 27, 2008
Locked in
I am currently treating a patient who had a pontine stroke a few years ago. As a result she has ‘locked-in syndrome’. She is in her late 20s. She is now wheelchair bound and the only voluntary control she has is a small amount of elbow flexion/extension and head control. She can laugh and smile and mouth yes and no.
My treatment involves manual stretches, foot mobs and tilt table activities for trunk control. We also work on sitting balance. When I read her notes I felt I would be able to cope with the treatments quite well, but was a little apprehensive about communicating with this patient. My first treatment sessions with other neuro patients had essentially been 1.5 hours of rapport building and I was concerned that it might not be so easy with this patient. I read in her notes that she communicated via lightscribe.. which frankly just freaked me out! I was imagining some high tech device which flashed lights which I would have to interpret..
When the patient arrived I took a deep breath and went to meet her. She smiled and typed the word ‘music’ into her keyboard, which prints and speaks whatever she writes (this is the lightscribe I was so scared of!). When we worked out how to put the radio on, we got to work and I found that communicating with her wasn’t difficult at all. Whilst on the plinth, a series of yes/no questions allows her to tell me what hurts/when she’s uncomfortable or just to make chat; all without the lightscribe, though knowing it was available if required really helped.
I soon realised that her approach to our meeting had made me comfortable with the situation and able to interact appropriately. I was annoyed at myself for being so worried initially. In the future I will have more confidence in my abilities to adapt to new situations and hopefully I will be the one making the other person feel at ease! I also really appreciated the extent to which the allied health team can go to ensure a pt is able to communicate – not being able to communicate can be the biggest frustration for pt post stroke, but this pt (whose disabilities are quite severe) was completely at ease and I suspect some of that is because she is able to communicate so well.
My treatment involves manual stretches, foot mobs and tilt table activities for trunk control. We also work on sitting balance. When I read her notes I felt I would be able to cope with the treatments quite well, but was a little apprehensive about communicating with this patient. My first treatment sessions with other neuro patients had essentially been 1.5 hours of rapport building and I was concerned that it might not be so easy with this patient. I read in her notes that she communicated via lightscribe.. which frankly just freaked me out! I was imagining some high tech device which flashed lights which I would have to interpret..
When the patient arrived I took a deep breath and went to meet her. She smiled and typed the word ‘music’ into her keyboard, which prints and speaks whatever she writes (this is the lightscribe I was so scared of!). When we worked out how to put the radio on, we got to work and I found that communicating with her wasn’t difficult at all. Whilst on the plinth, a series of yes/no questions allows her to tell me what hurts/when she’s uncomfortable or just to make chat; all without the lightscribe, though knowing it was available if required really helped.
I soon realised that her approach to our meeting had made me comfortable with the situation and able to interact appropriately. I was annoyed at myself for being so worried initially. In the future I will have more confidence in my abilities to adapt to new situations and hopefully I will be the one making the other person feel at ease! I also really appreciated the extent to which the allied health team can go to ensure a pt is able to communicate – not being able to communicate can be the biggest frustration for pt post stroke, but this pt (whose disabilities are quite severe) was completely at ease and I suspect some of that is because she is able to communicate so well.
Challenges for patient time
I am completing an outpatient placement that is focussed on treating older patients who are at risk of further injury after history of falls. The nature of the challenges that these patients face with everyday life was highlighted to me with a treatment session last week.
During our morning meeting I was allocated Mr A to treat and informed that he has mobility issues, a history of falls and is considered a ‘wanderer’ due to his short term memory loss. Given this situation it had been arranged that his wife assists him into a taxi and then phones us to let us know he is coming so we can meet him and assist him to the treatment gym.
On this particular day Mr A was booked in for an 11am appointment but the taxis regularly drop patients early so I had to ensure I was free to treat Mr A from 10:30. Mr A arrived at 11am and we completed a productive session that lasted approximately 40 minutes. 15 minutes prior to the end of the session I phoned the taxi so that we could minimise the wait at the end of the session.
However the taxi was running late and did not arrive until 12:20. Given that Mr A was not safe to be left on his own I was needed to stay with him to ensure that he did not wander from the pick up point.
The timing of this treatment session meant I spent longer organising to see the patient than I actually did treating, which is quite a change from my recent musculo outpatients clinic. However I had plenty of paper work to do and was able to spend my time efficiently while waiting for the taxi. In that time Mr A explained to me that he had been ready from 9am waiting for the taxi and found it frustrating he spent so much time waiting with control over what he can and can’t do.
Given that patients like Mr A can sometimes have three visits a week to the hospital for various appointments, the inefficiencies in the system mean that so much of the patients time is spent in transit compared to the actual reason of their visit. In our clinic we try to be flexible with our treatment times and dates so that we minimise the amount of trips a patient has to make but sometimes this is unavoidable.
This experience had highlighted to me the need for us as health professionals to be an advocate for the patient so that delivery of services through appointments can be better managed for the patient and those who are responsible for their transport.
During our morning meeting I was allocated Mr A to treat and informed that he has mobility issues, a history of falls and is considered a ‘wanderer’ due to his short term memory loss. Given this situation it had been arranged that his wife assists him into a taxi and then phones us to let us know he is coming so we can meet him and assist him to the treatment gym.
On this particular day Mr A was booked in for an 11am appointment but the taxis regularly drop patients early so I had to ensure I was free to treat Mr A from 10:30. Mr A arrived at 11am and we completed a productive session that lasted approximately 40 minutes. 15 minutes prior to the end of the session I phoned the taxi so that we could minimise the wait at the end of the session.
However the taxi was running late and did not arrive until 12:20. Given that Mr A was not safe to be left on his own I was needed to stay with him to ensure that he did not wander from the pick up point.
The timing of this treatment session meant I spent longer organising to see the patient than I actually did treating, which is quite a change from my recent musculo outpatients clinic. However I had plenty of paper work to do and was able to spend my time efficiently while waiting for the taxi. In that time Mr A explained to me that he had been ready from 9am waiting for the taxi and found it frustrating he spent so much time waiting with control over what he can and can’t do.
Given that patients like Mr A can sometimes have three visits a week to the hospital for various appointments, the inefficiencies in the system mean that so much of the patients time is spent in transit compared to the actual reason of their visit. In our clinic we try to be flexible with our treatment times and dates so that we minimise the amount of trips a patient has to make but sometimes this is unavoidable.
This experience had highlighted to me the need for us as health professionals to be an advocate for the patient so that delivery of services through appointments can be better managed for the patient and those who are responsible for their transport.
Monday, October 20, 2008
During my rural prac I was confronted by many new experiences and challenges, however I think the biggest eye opener for me was the minimal resources provided to cover such a large area and the skills required to cope with this.
The health service where I was placed is based at a regional centre and is responsible for providing health care to the local town, between the hospital and the community health centre, as well as five other towns, two within driving distance and three within flying distance. Given the distance between the towns and even centres within the town, readily available transport is essential for these services to be delivered.
The major problem faced by the allied health team was that the allocation of government cars was poorly organised and a bit biased towards visiting medical staff. There were numerous instances of missed treatment sessions or even whole days at a community due to therapists not being able to find a car. Similarly the contract to provide flight to rural centres was shared with mining companies and so mining staff took priority over allied health staff, which resulted in staff being stranded in towns overnight as they were unable to get a flight home.
The large distances, lack of staff and transport problems mean that rural staff have to be extremely flexible and continually change their plan to ensure the best care is given to the patients. With treatments sometimes spread so far apart and little follow up available, I was made aware of the need to focus on the main priority for the patient and try to treat that the best we could with the time available.
The skills I witnessed on this prac including coping with problems, flexibility to change at a moments notice and above all else the ability to keep a sense of humour meant that I left my rural prac with a great deal a respect for rural clinicians and the challenges they face each day just to get to treat patients.
The health service where I was placed is based at a regional centre and is responsible for providing health care to the local town, between the hospital and the community health centre, as well as five other towns, two within driving distance and three within flying distance. Given the distance between the towns and even centres within the town, readily available transport is essential for these services to be delivered.
The major problem faced by the allied health team was that the allocation of government cars was poorly organised and a bit biased towards visiting medical staff. There were numerous instances of missed treatment sessions or even whole days at a community due to therapists not being able to find a car. Similarly the contract to provide flight to rural centres was shared with mining companies and so mining staff took priority over allied health staff, which resulted in staff being stranded in towns overnight as they were unable to get a flight home.
The large distances, lack of staff and transport problems mean that rural staff have to be extremely flexible and continually change their plan to ensure the best care is given to the patients. With treatments sometimes spread so far apart and little follow up available, I was made aware of the need to focus on the main priority for the patient and try to treat that the best we could with the time available.
The skills I witnessed on this prac including coping with problems, flexibility to change at a moments notice and above all else the ability to keep a sense of humour meant that I left my rural prac with a great deal a respect for rural clinicians and the challenges they face each day just to get to treat patients.
Thursday, October 16, 2008
Reading a situation and following up…
I had been treating a patient on my neuro prac who had sustained a R MCA, CVA. She had very mild impairments, with no voluntary control of her R hand the major problem. There were NAD in her R LL. The sensation of her R and was intact, there was just a mild proprioceptive impairment of her R MCPJ JMS and JPS – anyway – the bottom line was she was not a patient who presented with ‘heavy’ stroke symptoms.
This patient was extremely optimistic and always motivated for physio. She was a pleasure to work with and felt I had really good rapport with her. I had been treating this patient since her admission (1 week).
I went to see her on this particular day, she was lying in bed and there was a gentlemen sitting next to her bed on a mobile phone. I didn’t pay much attention to him and was not listening to what he was saying when I went to her bedside. I went in with a big smile as I did everyday and was expecting her to return it as she always did. She looked at me and said “I don’t think I can come to physio today.” I asked how come and she said she had to have an operation on her neck as this was the artery which had caused the stroke.
I then tuned in to what the man on the phone was saying and realised he was talking to her daughter and saying he ‘had explained the procedure and it was scheduled for a few days.” This patient looked at me and burst into tears and said “I don’t want to die.”
I sat with the patient and consoled her until she calmed down, which she said she was very grateful for. I then said we could do physio the next day if she felt up to it. She then looked scared and said “no, I don’t think im meant to move around to much because I might re-stroke”
Not knowing a lot about the carotidendarterectomy procedure, I told her I would find out about still doing physio.
I contacted her docter and asked about continuing physio and he reported that it was completely fine (as long as we didn’t manip her neck) and that it would be beneficial to continue to improve her baseline level in the first place. He wondered why she had the impression she wasn’t allowed to move. I said to him that she may be in a bit of shock and coping with the news and may have misinterpreted him, and asked if he wouldn’t mind reassuring her it was ok to move. (this was the day before the weekend, and I was just imagining this patient not moving her neck or body for the whole weekend out of fear) he said that would be no problem and was happy to see her.
After this, the patient was SO grateful I had asked him and was so excited that she could still come up to physio, and whilst she was still slightly anxious about the op, the routine of doing physio and OT and the ‘normal’ for her during the day appeared to really benefit her.
This taught me firstly to read a patients body language and the situation better, as when I first went in to see her for physio I expected her to be like every other day. In the future I will keep in mind that anything and any news can happen very quickly in a hospital and to be aware that even the most cheerful person may just have received difficult news.
Secondly, by following up with the doctor and asking him to reassure her, had such a huge benefit for this patient and decreased her anxiety immensely. He hadn’t realised she had misunderstood the mobility issue, and by being with someone who deals with that, I was able to follow it up and continue treatment with this lady, which we both enjoyed!!
This patient was extremely optimistic and always motivated for physio. She was a pleasure to work with and felt I had really good rapport with her. I had been treating this patient since her admission (1 week).
I went to see her on this particular day, she was lying in bed and there was a gentlemen sitting next to her bed on a mobile phone. I didn’t pay much attention to him and was not listening to what he was saying when I went to her bedside. I went in with a big smile as I did everyday and was expecting her to return it as she always did. She looked at me and said “I don’t think I can come to physio today.” I asked how come and she said she had to have an operation on her neck as this was the artery which had caused the stroke.
I then tuned in to what the man on the phone was saying and realised he was talking to her daughter and saying he ‘had explained the procedure and it was scheduled for a few days.” This patient looked at me and burst into tears and said “I don’t want to die.”
I sat with the patient and consoled her until she calmed down, which she said she was very grateful for. I then said we could do physio the next day if she felt up to it. She then looked scared and said “no, I don’t think im meant to move around to much because I might re-stroke”
Not knowing a lot about the carotidendarterectomy procedure, I told her I would find out about still doing physio.
I contacted her docter and asked about continuing physio and he reported that it was completely fine (as long as we didn’t manip her neck) and that it would be beneficial to continue to improve her baseline level in the first place. He wondered why she had the impression she wasn’t allowed to move. I said to him that she may be in a bit of shock and coping with the news and may have misinterpreted him, and asked if he wouldn’t mind reassuring her it was ok to move. (this was the day before the weekend, and I was just imagining this patient not moving her neck or body for the whole weekend out of fear) he said that would be no problem and was happy to see her.
After this, the patient was SO grateful I had asked him and was so excited that she could still come up to physio, and whilst she was still slightly anxious about the op, the routine of doing physio and OT and the ‘normal’ for her during the day appeared to really benefit her.
This taught me firstly to read a patients body language and the situation better, as when I first went in to see her for physio I expected her to be like every other day. In the future I will keep in mind that anything and any news can happen very quickly in a hospital and to be aware that even the most cheerful person may just have received difficult news.
Secondly, by following up with the doctor and asking him to reassure her, had such a huge benefit for this patient and decreased her anxiety immensely. He hadn’t realised she had misunderstood the mobility issue, and by being with someone who deals with that, I was able to follow it up and continue treatment with this lady, which we both enjoyed!!
Monday, October 13, 2008
Communication
I think a lot of health professionals are very good at focussing on their specific treatment and management of a patient, but I think there is room for improving communication with other health professionals and working within a team environment. In the rural setting this communication sometimes breaks down all together as there is a very high turn over of staff and information is not always passed on appropriately.
While on my rural placement I visited a remote community for a day each week and part of that visit was to cover a small hospital with four beds. “Mike” had been admitted about three months prior with progressive weakness and atrophy of his lower limbs, after his family were unwilling to care for him anymore. Mike had a history of alcohol and substance abuse and the medical staff believed that this was an expression of a long standing mental illness and was treated accordingly.
The hospital was staffed by agency nurses who rotated every few weeks and a RMO who covered the hospital along with private rooms in two communities. When we made our weekly visit to the hospital to see Mike along with another patient we were informed that the RMO had resigned effective immediately and that a replacement doctor had started the day before. This resignation had also coincided with a change in the nursing staff.
We had read in Mike’s notes the week previously he was going to be seen by a visiting specialist as the current treatment was not working and no definitive diagnosis had been made. However when we arrived at the hospital we found that Mike had been taken to the regional hospital in order to have some additional investigations done that were ordered by the new doctor, unaware of the visit by the specialist. This meant that as the specialist was driving to the remote centre, Mike was in an ambulance driving the other way.
The additional investigations provided no further information and Mike did not get to see another specialist until over two weeks later. By that time he had deteriorated further and after review from the specialist Mike was diagnosed with an aggressive form of cancer that had spread to his spine and lungs.
I found this experience really highlighted to me again the challenges health professionals face in a rural setting with staff turn over and logistics, but more importantly it showed that when everyday things we take for granted do not happen, such as basic communication about the care of a patient, then there can be significant consequences for the patient. In this scenario I am not sure finding the cancer two weeks earlier would have helped, but I do think it is a shame the patient was at not least given that chance.
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