Whilst on my paediatric placement I came to learn the importance of the term 'family centered practise'. The physiotherapy department was situated at the school which the patient/child was currently attending. This yound boy was autistic, he was treated at the school and came to school every morning on the school bus. Therefore his mother did not come in regularly.
One morning a frantic call was made to the physio department and this young boy's mother was on the phone and was in a right state. Her son had started limping and she was terrified that she would be reported to child services as she believed that people would think that she had been abusing her child. Myself and the physiotherapist went to visit the mother at her home and managed to clam her down, assuring her that noone believed that she was abusing her son. We assessed her son and could not find any reason for his limping, and his limping was very inconsistent, we were able to get him walking normally after a few minuits.
The reason that the mother had worked herself up into such a state over this seemingly insignificant episode was that she was having to care for her son on her own. Her husband was working night shifts and would therefore be asleep in the days whilst she was caring for her son. Her son is only able to go to school 3/5 days due to medical reasons, her family lived a couple of hours away and the family were in a tight financial situation. As a result this poor woman had no time to herself, was unable to afford a carer or any respite for her son so that she could have some down time. We were able to find one of the teaching assistants at the school who offered to take her son for a couple of hours a week and we contacted a psychologist who she could talk to who would be able to place her in a better position to recieve respite.
From this I realised the value of looking at the whole family in a big picture and not just the patient/child that you are seeing. This mum had reached a breaking point and this was obviously beginning to effect her son, if we had been seeing her more often then this might not have happened.
Wednesday, June 25, 2008
Wednesday, June 18, 2008
Dealing with kids
During my paediatric placement I felt right at home due to my ability to pretty much let go and be a kid with the patient and make everything a game where they don’t realise they're getting treated. This is great for compliance but I soon found out you had to be careful how 'young' you become and how you treat the kids due to their condition/past.
One of the kids had a very nasty past history so not only was I playing the friendly everything’s a game physio but I was treating her differently, more gently without even realising it. She therefore was getting a little bit carried away and suddenly I had lost control of what she did. She would just laugh and think it was a game when I tried to get her to do anything a certain way as she just didn’t take me seriously. When I tried to use the stern lowered tone that works a treat on most kids she got upset, as suddenly it wasn’t all a game. This meant the compliance level dropped and I got a kid doing the arms crossed hmph that I'm sure anyone with younger siblings or nieces or nephews have seen.
I carried on the session with the other child that was there and decided to talk to the principal of the special Ed department who happened to be one of the foster carers for this child. Straight away she was giving me tips on being firm from the start and not letting her past get in the way. I had to look at her as a child from the start and not let her push the boundaries even if I did feel extremely sorry for her. Whilst I could make things into a game for compliance, rules had to be set from the start. ‘You can do this or this’ (make them believe they have the choice) or set out a layout of the treatment at the start with them and stick to it. I was also told to maybe keep the sessions shorter as the child’s attention span was not good and was another thing that was being worked on in her behaviour modification classes.
The next week when I came back I laid down the rules from the start when she was all happy to see me. I let her chose from two games at each station (balance, strength, core posture) ‘as long as she listened to me as to when each finished and the order’ and that was enough to keep her happy. I still joined in and kept most of the exercises as games (as when you have an excitable kid you have to keep them occupied and keeps the session flowing). But I changed my approach to the treatment and child and therefore got the compliance and she stopped pushing the boundaries. I may not still be on placement but I do swim teaching and still use this way of dealing with any new kid. Be the nice physio but don’t let them push your boundaries, even one inch.
One of the kids had a very nasty past history so not only was I playing the friendly everything’s a game physio but I was treating her differently, more gently without even realising it. She therefore was getting a little bit carried away and suddenly I had lost control of what she did. She would just laugh and think it was a game when I tried to get her to do anything a certain way as she just didn’t take me seriously. When I tried to use the stern lowered tone that works a treat on most kids she got upset, as suddenly it wasn’t all a game. This meant the compliance level dropped and I got a kid doing the arms crossed hmph that I'm sure anyone with younger siblings or nieces or nephews have seen.
I carried on the session with the other child that was there and decided to talk to the principal of the special Ed department who happened to be one of the foster carers for this child. Straight away she was giving me tips on being firm from the start and not letting her past get in the way. I had to look at her as a child from the start and not let her push the boundaries even if I did feel extremely sorry for her. Whilst I could make things into a game for compliance, rules had to be set from the start. ‘You can do this or this’ (make them believe they have the choice) or set out a layout of the treatment at the start with them and stick to it. I was also told to maybe keep the sessions shorter as the child’s attention span was not good and was another thing that was being worked on in her behaviour modification classes.
The next week when I came back I laid down the rules from the start when she was all happy to see me. I let her chose from two games at each station (balance, strength, core posture) ‘as long as she listened to me as to when each finished and the order’ and that was enough to keep her happy. I still joined in and kept most of the exercises as games (as when you have an excitable kid you have to keep them occupied and keeps the session flowing). But I changed my approach to the treatment and child and therefore got the compliance and she stopped pushing the boundaries. I may not still be on placement but I do swim teaching and still use this way of dealing with any new kid. Be the nice physio but don’t let them push your boundaries, even one inch.
Tuesday, June 17, 2008
Getting too close to patients
On a recent orthopaedic placement of mine I treated one woman who had undergone a total knee replacement. She was a lovely lady and would often tell me stories during treatment sessions of her dancing, or dinner parties, or her cooking (which often made it difficult for me to excuse myself to treat the other patients on my list!).
However after a while she was quite insistent that I should come to one of her dinner parties and that she would cook for me. Infact when I tried to say 'no' in any way she would go on to explain how she always had 'young' people at her dinner parties and how she would show me all her gowns etc etc... would ask for my telephone number or address repeatedly and it was terribly awkward to try and explain how I couldn't give out that information. Normally I tried to simply change the subject or leave quickly following the end of the session to avoid getting into that conversation. Upon informing my supervisor he was adamant that I do not give out personal information and would often call me away after treating her so that I could avoid having to explain (for the 10th time) why I couldnt go to dinner with her.
You probably have similar stories of patients who want to thank you but fail to understand that it is unethical for us to see them on a personal level. One of my classmates had a patient call up everyone with her lastname in the phonebook, asking for her or her mother so should could take them to a restaraunt. Luckily her number is private and not in the whitepages. I think it is tempting at times to take a gift or if we get on so well with our patients to want to get to know them on a more personal level, after all they are thanking us for our services and usually are lovely people. In future I realise that it is not always neccessary to delve so much into discussion of the personal life of my patients and that depending on their attitude sometimes a more strict and proffessional demeanor is required to avoid situations such as these. furthermore it reinforced to me that it IS definately unethical to accept a patients offer of dinner etc, and legally could be a downfall for us.
However after a while she was quite insistent that I should come to one of her dinner parties and that she would cook for me. Infact when I tried to say 'no' in any way she would go on to explain how she always had 'young' people at her dinner parties and how she would show me all her gowns etc etc... would ask for my telephone number or address repeatedly and it was terribly awkward to try and explain how I couldn't give out that information. Normally I tried to simply change the subject or leave quickly following the end of the session to avoid getting into that conversation. Upon informing my supervisor he was adamant that I do not give out personal information and would often call me away after treating her so that I could avoid having to explain (for the 10th time) why I couldnt go to dinner with her.
You probably have similar stories of patients who want to thank you but fail to understand that it is unethical for us to see them on a personal level. One of my classmates had a patient call up everyone with her lastname in the phonebook, asking for her or her mother so should could take them to a restaraunt. Luckily her number is private and not in the whitepages. I think it is tempting at times to take a gift or if we get on so well with our patients to want to get to know them on a more personal level, after all they are thanking us for our services and usually are lovely people. In future I realise that it is not always neccessary to delve so much into discussion of the personal life of my patients and that depending on their attitude sometimes a more strict and proffessional demeanor is required to avoid situations such as these. furthermore it reinforced to me that it IS definately unethical to accept a patients offer of dinner etc, and legally could be a downfall for us.
Monday, June 16, 2008
Prioritising patient
Last week showed me the importance of prioritising when you have a ward full of patients. When the physiotherapist on an opposite ward called in sick, we (the students) were brought in to take care of the patients on the ward which demonstrated the need to know what to look out for when prioritising your patient list for the day. With a basic handover, it was then a matter of looking through the files of the new patients to see whether or not they had to be seen; then rank the patients in case the load couldn’t be completely addressed during that one day.
Although this is a problem that we are taught about, its not really until we are faced with having to treat many patients that we can truly understand how to multi task. As my supervisor said “later never comes,” so if there is something that needs to be done on a ward you should never procrastinate otherwise you’ll never get back to do it. Being made to make the choices as to who needs to be seen was quite eye-opening especially as we would be expected to do this once we start working without too much previous experience. Despite being given a patient load during our placements, we aren’t given the ability to make the choices as to who should be seen and why.
This was an unexpected opportunity to put to practice our ability to speed-read patients files (and gain important information) and also justify why or why you weren’t going to see the patients. It is a skill that we all require but don’t get much of an opportunity to practice until we’re out in the workforce.
Although this is a problem that we are taught about, its not really until we are faced with having to treat many patients that we can truly understand how to multi task. As my supervisor said “later never comes,” so if there is something that needs to be done on a ward you should never procrastinate otherwise you’ll never get back to do it. Being made to make the choices as to who needs to be seen was quite eye-opening especially as we would be expected to do this once we start working without too much previous experience. Despite being given a patient load during our placements, we aren’t given the ability to make the choices as to who should be seen and why.
This was an unexpected opportunity to put to practice our ability to speed-read patients files (and gain important information) and also justify why or why you weren’t going to see the patients. It is a skill that we all require but don’t get much of an opportunity to practice until we’re out in the workforce.
Lung compliance
On a particular cardiopulmonary placement I treated a memorable patient who had some issues with treatment compliance. The patient was in hospital for a number of problems including one that affected their mobility necessitating the use of a gait aid and one that required general (abdominal) surgery. By the end of my placement they had been in hospital for more than 5 weeks and were likely to require several more weeks before being transferred to a rehabilitation hospital. My role in their recovery was to provide chest physiotherapy following their surgery and encourage mobilisation around the ward to increase lower limb strength and fitness. This was no easy task.
The patient was quite capable of mobilising to the shower with their gait aid and one assist for attachments but refused to do so instead requiring the nurses to do a sponge bath each day. They were very particular about how everything was done and would frequently refuse to have bloods taken, do deep breathing exercises, sit up in bed, or use oxygen therapy (at one point SpO2 was 80%) unless it suited him/her at the time. Curtains must be drawn at all times throughout the day and blankets should be folded perfectly following treatment. When treatment was refused the patient would even dictate how it must be written- ‘patient declined treatment’ rather that ‘patient refused treatment.’
I knew from the first 10 seconds of meeting the patient that they would not be easy to treat and made an effort from the start to develop a good rapport with them. At first I would make an effort to explain exactly why we were doing each exercise and mobilising. Unfortunately the patient would agree with me that the exercises were important but promptly refuse to do them anyway. Next I tried being firm with him/her and telling them that it was about time they got serious about getting better and started listening to advice. This was made easier because they had developed a lung infection (too much immobility and resting in bed???) but still resulted in treatment being refused on more occasions than it was complied with.
I finally came across a system that seemed to work. I would see the patient early in the morning and when they refused to mobilise I would make an agreement with them to come back in the afternoon and we could walk then. This seemed to work most of the time and my fondest memory of the placement was pulling back the curtains only to find the patient sitting on the edge of the bed doing their deep breathing exercises and some knee extension exercises.
Throughout all of the time I treated the patient I tried to act in a way they he/she couldn’t dislike me and I think this was key to maximising their compliance with treatment. I would also attempt to joke as much as possible with them and try to be interested in them as a person and I think this was appreciated. I guess the most important thing I learnt is that all patients are different and need to be treated in different ways to maximise their outcome. This particular patient was definitely a challenge but the greater the challenge the better the reward and I savoured the times when treatment compliance was successful.
The patient was quite capable of mobilising to the shower with their gait aid and one assist for attachments but refused to do so instead requiring the nurses to do a sponge bath each day. They were very particular about how everything was done and would frequently refuse to have bloods taken, do deep breathing exercises, sit up in bed, or use oxygen therapy (at one point SpO2 was 80%) unless it suited him/her at the time. Curtains must be drawn at all times throughout the day and blankets should be folded perfectly following treatment. When treatment was refused the patient would even dictate how it must be written- ‘patient declined treatment’ rather that ‘patient refused treatment.’
I knew from the first 10 seconds of meeting the patient that they would not be easy to treat and made an effort from the start to develop a good rapport with them. At first I would make an effort to explain exactly why we were doing each exercise and mobilising. Unfortunately the patient would agree with me that the exercises were important but promptly refuse to do them anyway. Next I tried being firm with him/her and telling them that it was about time they got serious about getting better and started listening to advice. This was made easier because they had developed a lung infection (too much immobility and resting in bed???) but still resulted in treatment being refused on more occasions than it was complied with.
I finally came across a system that seemed to work. I would see the patient early in the morning and when they refused to mobilise I would make an agreement with them to come back in the afternoon and we could walk then. This seemed to work most of the time and my fondest memory of the placement was pulling back the curtains only to find the patient sitting on the edge of the bed doing their deep breathing exercises and some knee extension exercises.
Throughout all of the time I treated the patient I tried to act in a way they he/she couldn’t dislike me and I think this was key to maximising their compliance with treatment. I would also attempt to joke as much as possible with them and try to be interested in them as a person and I think this was appreciated. I guess the most important thing I learnt is that all patients are different and need to be treated in different ways to maximise their outcome. This particular patient was definitely a challenge but the greater the challenge the better the reward and I savoured the times when treatment compliance was successful.
When the ‘@?*#’ hits the fan (or the floor)
Last week on clinic a patient was transferred to our ward from the Intensive Care Unit of the hospital where I am placed. The physios in ICU had suffered some problems transferring the patient who was of considerable weight and was in considerable pain. The patient had required four (4) assist to ambulate just a couple of metres to a chair so they could sit out of bed. Our supervisor is a new grad who has only been working for around 5 months now and one of the friendly ICU physios decided to help out and came up to our ward to teach us the best way to transfer the patient.
Here’s the scene: Two physios and two students all gathered around this poor patient’s bed getting ready to help them to transfer to standing and then (if all goes well) maybe take a couple of steps. Now what we hadn’t been told by the nursing staff is that the patient had just been given an enema. Dictionary.com defines enema as:
1) A solution introduced into the rectum to help promote the evacuation of faeces.
2) The enemy/bane of all physios.
Our patient was on some serious pain killers and might possibly have had some communication difficulties before being admitted to the hospital, so when he/she mumbled something about need to go to the toilet, the ICU physio decided that it wasn’t a priority problem and the IDC in situ would probably solve the problem the patient was referring to. So we stood the patient and soon realised that the problem should have been a lot higher on our list of priorities. We did manage to catch a lot of the faeces in a bed pan before they hit the floor but were still left with a nice smear down the side of the bed, on the back of the patient’s legs and a few dollops strategically positioned on the floor.
The first question in my mind (after considering the patients safety of course) was whose responsibility it was to clean up all of the mess. Our supervisor had always told us that we should work closely with the nurses and help them out as much as possible so honestly they weren’t at the top of my mental list of people to do the cleaning up. This probably also has something to do with the fact my housemate’s mum is a nurse practitioner from South Africa who frequently complains that nurses in Australia are treated as nothing more than glorified cleaning maids and not qualified professionals. I wasn’t sure if there was anyone else who we should be asking to help but in the end I was very impressed by what happened next.
The ICU physio immediately said “I made the call to stand the patient up so you guys don’t have to help clean up.” Fortunately for him everyone chipped in; we grabbed a fresh sheet and hospital gown from the linen cupboard, an oversize box of cleaning wipes were found and a couple of nurses came over thanking us for finally helping the patient get his bowels moving. In the end it was a team effort in cleaning the patient up and getting them back into bed. Each of the physios and students did their bit after donning a pair of gloves and the mess was cleaned up in no time.
I hope that in the future when I come across situations like this again they are resolved in a similar way with physios and nursing staff both chipping in to ‘fix the problem.’ I think it’s key to developing a good working relationship with the nurses and we should all be working together for the patients good anyway.
Here’s the scene: Two physios and two students all gathered around this poor patient’s bed getting ready to help them to transfer to standing and then (if all goes well) maybe take a couple of steps. Now what we hadn’t been told by the nursing staff is that the patient had just been given an enema. Dictionary.com defines enema as:
1) A solution introduced into the rectum to help promote the evacuation of faeces.
2) The enemy/bane of all physios.
Our patient was on some serious pain killers and might possibly have had some communication difficulties before being admitted to the hospital, so when he/she mumbled something about need to go to the toilet, the ICU physio decided that it wasn’t a priority problem and the IDC in situ would probably solve the problem the patient was referring to. So we stood the patient and soon realised that the problem should have been a lot higher on our list of priorities. We did manage to catch a lot of the faeces in a bed pan before they hit the floor but were still left with a nice smear down the side of the bed, on the back of the patient’s legs and a few dollops strategically positioned on the floor.
The first question in my mind (after considering the patients safety of course) was whose responsibility it was to clean up all of the mess. Our supervisor had always told us that we should work closely with the nurses and help them out as much as possible so honestly they weren’t at the top of my mental list of people to do the cleaning up. This probably also has something to do with the fact my housemate’s mum is a nurse practitioner from South Africa who frequently complains that nurses in Australia are treated as nothing more than glorified cleaning maids and not qualified professionals. I wasn’t sure if there was anyone else who we should be asking to help but in the end I was very impressed by what happened next.
The ICU physio immediately said “I made the call to stand the patient up so you guys don’t have to help clean up.” Fortunately for him everyone chipped in; we grabbed a fresh sheet and hospital gown from the linen cupboard, an oversize box of cleaning wipes were found and a couple of nurses came over thanking us for finally helping the patient get his bowels moving. In the end it was a team effort in cleaning the patient up and getting them back into bed. Each of the physios and students did their bit after donning a pair of gloves and the mess was cleaned up in no time.
I hope that in the future when I come across situations like this again they are resolved in a similar way with physios and nursing staff both chipping in to ‘fix the problem.’ I think it’s key to developing a good working relationship with the nurses and we should all be working together for the patients good anyway.
Proctopedia
I am currently completing my cardio placement in a general surgical ward and a fellow student and myself coined the term ‘proctopedia’ to refer to the amount of information we have learnt about bowels and the more distal parts of the digestive system. After only four weeks on the ward I’m amazed at how many new concepts I’m now comfortable with although I can promise you that working around rectal drains is definitely not a barrel of laughs.
This got me thinking about how as 4th year students our learning experiences are so varied and we end up consolidating a lot of knowledge in one area and missing a lot in another area. I know that this is inevitable and the School of Physiotherapy does its best to ensure we have equitable learning experiences, but there is a world of difference between having a musculoskeletal placement in Swan Districts Hospital than at the Curtin Clinic (roughly 4-5 patients a day from what I gather).
I guess the ‘guts’ (haha) of the issue is that come December when we can finally put ‘BSc (Physiotherapy)’ after our name we need to realise that while we might be proctopedias we might not even be close to becoming thoracopedias or whateverelseopedias. I remember a lecturer telling us once that after several years of working as a Physiotherapist they looked back at what they knew as a new graduate and were amazed at how inadequate it now seemed to be. I’m sure that most of us will feel the same way in a few years but I want to be able to look back and know that I’ve done everything I can during that time to become the best physio I can be.
Personally after graduating, I’m planning to work in a large hospital for a year or two to consolidate what I’ve already learnt. I’m really looking forward to the rotational system that the large teaching hospitals have in place. In Fremantle Hospital physiotherapists rotate positions every 3 months, Charlies is every 4 months and Royal Perth is every 6 months. Smaller hospitals and private clinics will have their own continuing education programs and I think this is an important consideration to make when applying for a job as a new graduate. We are fortunate enough to be entering the workforce in a time when there is an abundance of positions available and we are able to consider continuing education as well as salary and location as important factors in accepting a position.
But I think we can even limit ourselves to just seeing ahead to the first few years as a physiotherapist. Looking past that I’ve decided that I never want to get into the position where I think I know everything there is to know about a particular topic. I guess what I really want is to be a lifelong learner who is content to be a the level that I am, but not content to just stay there.
This got me thinking about how as 4th year students our learning experiences are so varied and we end up consolidating a lot of knowledge in one area and missing a lot in another area. I know that this is inevitable and the School of Physiotherapy does its best to ensure we have equitable learning experiences, but there is a world of difference between having a musculoskeletal placement in Swan Districts Hospital than at the Curtin Clinic (roughly 4-5 patients a day from what I gather).
I guess the ‘guts’ (haha) of the issue is that come December when we can finally put ‘BSc (Physiotherapy)’ after our name we need to realise that while we might be proctopedias we might not even be close to becoming thoracopedias or whateverelseopedias. I remember a lecturer telling us once that after several years of working as a Physiotherapist they looked back at what they knew as a new graduate and were amazed at how inadequate it now seemed to be. I’m sure that most of us will feel the same way in a few years but I want to be able to look back and know that I’ve done everything I can during that time to become the best physio I can be.
Personally after graduating, I’m planning to work in a large hospital for a year or two to consolidate what I’ve already learnt. I’m really looking forward to the rotational system that the large teaching hospitals have in place. In Fremantle Hospital physiotherapists rotate positions every 3 months, Charlies is every 4 months and Royal Perth is every 6 months. Smaller hospitals and private clinics will have their own continuing education programs and I think this is an important consideration to make when applying for a job as a new graduate. We are fortunate enough to be entering the workforce in a time when there is an abundance of positions available and we are able to consider continuing education as well as salary and location as important factors in accepting a position.
But I think we can even limit ourselves to just seeing ahead to the first few years as a physiotherapist. Looking past that I’ve decided that I never want to get into the position where I think I know everything there is to know about a particular topic. I guess what I really want is to be a lifelong learner who is content to be a the level that I am, but not content to just stay there.
Patient 'X'
Over the past few placements one recurring problem has continually cropped up for me. I have a real problem remembering patient names. This might sound like a simple enough issue but it even when you’ve got the right diagnosis and the right treatment a few more problems seem to crop up:
1) It’s a struggle to develop rapport with a patient if you have to keep referring to them as ‘you.’
2) When a doctor asks you a question about a patient and you don’t know which patient they are talking about you look like a fool.
3) When your supervisor asks you to treat a list of patient and you have to look up their files to remember them, it wastes a lot of time.
4) It’s definitely not a confidence booster when you’re talking to a patient only to realise that you’ve already forgotten their name.
This isn’t a new problem either. Each semester when it came time for OSPE’s I would write on my palm the name of the patient so that if I could refer to the patient by name.
I know that there are a lot of tricks that you can use to help remember names. A quick google search of ‘tricks to remembering names’ found the following: Be interested (I hope that I am), Verify it (patient files- easy enough), Picture it written on their forehead (apparently Franklin Roosevelt used this trick to good effect), Imagine writing the name (related to motor programming memory- should work well for physios), Use word associations (remember a patient named Arnold by associating them with the terminator), Use it frequently (hello Mr ‘X’, how are you doing Mr ‘X’) and Record the name (I think most students would agree that we seem to be doing enough of this already.)
I’ve put quite a bit of thought into how best to deal with this problem and already have done a number of things to try and improve it. Every time before I enter a patients room I check on the ward list to make sure their name is firmly in my head. When I forget the name during treatment I pretend to make a note on my page and have a quick look at the name. I try to use their name as much as possible to make sure it’s in my long term memory banks.
But you know what? I think the real answer is that like everything else, it just takes practice. After the first couple of weeks of a placement everything becomes a bit more familiar and instead of having to think about exactly how to handle this drain and what question to ask before standing someone up, it just happens and you can spend more time considering the patient rather than the condition. Somehow it all seems to work. So I guess in the future I’ll keep doing what I am doing and let time, practice and confidence fill in the blanks with my ailing memory.
1) It’s a struggle to develop rapport with a patient if you have to keep referring to them as ‘you.’
2) When a doctor asks you a question about a patient and you don’t know which patient they are talking about you look like a fool.
3) When your supervisor asks you to treat a list of patient and you have to look up their files to remember them, it wastes a lot of time.
4) It’s definitely not a confidence booster when you’re talking to a patient only to realise that you’ve already forgotten their name.
This isn’t a new problem either. Each semester when it came time for OSPE’s I would write on my palm the name of the patient so that if I could refer to the patient by name.
I know that there are a lot of tricks that you can use to help remember names. A quick google search of ‘tricks to remembering names’ found the following: Be interested (I hope that I am), Verify it (patient files- easy enough), Picture it written on their forehead (apparently Franklin Roosevelt used this trick to good effect), Imagine writing the name (related to motor programming memory- should work well for physios), Use word associations (remember a patient named Arnold by associating them with the terminator), Use it frequently (hello Mr ‘X’, how are you doing Mr ‘X’) and Record the name (I think most students would agree that we seem to be doing enough of this already.)
I’ve put quite a bit of thought into how best to deal with this problem and already have done a number of things to try and improve it. Every time before I enter a patients room I check on the ward list to make sure their name is firmly in my head. When I forget the name during treatment I pretend to make a note on my page and have a quick look at the name. I try to use their name as much as possible to make sure it’s in my long term memory banks.
But you know what? I think the real answer is that like everything else, it just takes practice. After the first couple of weeks of a placement everything becomes a bit more familiar and instead of having to think about exactly how to handle this drain and what question to ask before standing someone up, it just happens and you can spend more time considering the patient rather than the condition. Somehow it all seems to work. So I guess in the future I’ll keep doing what I am doing and let time, practice and confidence fill in the blanks with my ailing memory.
Stress and pain
On my musculo prac I had a client that I saw every week who had a lower back problem due to an irritated L4-S1 and was experiencing a 'cancer to the bone' pain in both her legs. On average she was only getting 2hr blocks of sleep and often experienced intense cramps during the night. PPIVMS really worked well on her, and would decrease her pain instantly although the pain would return after a number of days. After a number of visits I was able to get her resting pain to 0/10. At this time the patient starting having a number of family problems, which consequently increased her pain to ~6/10 and was really struggling to get to sleep at night. She was really worried why her pain was increasing and I told her that it was most likely due to the other stressors in her life. We talked for most of this session because she simply had to get it out and I gave her some suggestions of how to relax herself simply from what I do when I'm stressed. She felt really relieved from our chat. I continued to do PPIVMS, active
'opening up' patterns of movement and STM. We noticed that as her family situation was dealt with and treatment increased, her pain began to decrease again. Treating this patient was a real learning experience for me and she made me realise that psychological issues really have a major impact on pain and sometimes you just have to talk to your patient to educate them and to give them some confidence rather than just hands on treatment.
'opening up' patterns of movement and STM. We noticed that as her family situation was dealt with and treatment increased, her pain began to decrease again. Treating this patient was a real learning experience for me and she made me realise that psychological issues really have a major impact on pain and sometimes you just have to talk to your patient to educate them and to give them some confidence rather than just hands on treatment.
Sunday, June 15, 2008
difficult supervisor
Whilst on my orthopaedic placement, I had a certain situation with one of my supervisors which I had a problem with. Part of the day on this ward involves running an exercise class for patients who have had knee replacements, and another separate class for those who have had hip replacements. I had only watched one of the hip classes and was then asked by this supervisor who was only watching over us for the day, to take the hip class. I felt very unsure as to what I was meant to do, and was given no guidelines by him as what to say. To start with, he was ten minutes late for the class so I was left standing waiting for him, and in that time I started to talk to the two patients who were participating. When he eventually came in, he pulled me aside and said that I should never have started the class without him, and did not seem to care when I said that all I had been doing was talking with the two patients. As the two patients had been in the same class just the day before, I did not think it was necessary to repeat everything he had said the day before.
The class seemed to go ok, except that it finished really early. After that class, this supervisor told me I had done everything wrong and should have done better, and why had I not given the patients all the information that he had done the day before. I really felt so upset as I felt I had received no guidance before the class and was being treated unfairly. I felt that as a supervisor, his role should have been to make sure I knew what I had to cover in the class and to ask if I was unsure about anything.
I did not really speak to anyone about this as I did want to rock the boat. But the more I think about it, the more I wish I had told my actual supervisor so I could have gotten some advice from her.
In the end I just decided to take it as a learning experience, as I realised there will always be people you work with that you don’t agree with or get on with. I have decided that in the future I will make it my mission to find out exactly what is required of me and ask as many questions as necessary. And I also realised in class situations such as the one I took, it is always better to provide as much information to patients and you will most likely repeat yourself, but with people with no medical knowledge, this is usually necessary to get the point across.
The class seemed to go ok, except that it finished really early. After that class, this supervisor told me I had done everything wrong and should have done better, and why had I not given the patients all the information that he had done the day before. I really felt so upset as I felt I had received no guidance before the class and was being treated unfairly. I felt that as a supervisor, his role should have been to make sure I knew what I had to cover in the class and to ask if I was unsure about anything.
I did not really speak to anyone about this as I did want to rock the boat. But the more I think about it, the more I wish I had told my actual supervisor so I could have gotten some advice from her.
In the end I just decided to take it as a learning experience, as I realised there will always be people you work with that you don’t agree with or get on with. I have decided that in the future I will make it my mission to find out exactly what is required of me and ask as many questions as necessary. And I also realised in class situations such as the one I took, it is always better to provide as much information to patients and you will most likely repeat yourself, but with people with no medical knowledge, this is usually necessary to get the point across.
Patient non-compliance
I have spent the last week trying to win over a very non-compliant patient and after 5 days, feel I have started to make some progress.
The patient was admitted with a history of resistance to medical input, and upon reading the notes I could see he had been refusing showers, refusing obs to be taken etc. It had also been requested he have a Physio review. Prior to even meeting this man, I had formed an opinion that he would probably be rude and abrupt and want nothing to do with me or Physio treatment- I was prepared for the worst! My guess was correct, although after lots of complaining I was able to assess his mobility. He was extremely unsteady, which he knew, however he refused an aid or having someone walk with him. He reasoned that this was how he was before he came into hospital, so why should people care now- and promptly put himself back into bed and went to sleep.
After discussing the outcome of my assessment with his nurse and my supervisor, we decided the best way would be to keep a close eye on this patient and ensure standby assistance whenever we saw him ambulating. The next few days he continued to refuse any physio intervention, was non-compliant with having standby assistance and also developed a moist, productive cough. Although Physio intervention was indicated for this patient, my aim each day became to simply have a chat with him to try to build some trust and rapport. Although he refused to participate in any treatment, I liased closely with the nursing and medical staff to monitor his mobility and chest status, and simply had to document the outcome.
At first I was frustrated and found it hard to reason why I should continue to waste my time on a patient who was rude and refusing any help, although I could see he needed it. However, once I had accepted this was his preferred way and changed my aim to simply getting a conversation out of him (where I could at least observe his cough/ sputum/breath sounds) I felt I was beginning to make more progress. Although he still refuses any intervention, I can now actually have a conversation with him, and am hopeful for Monday’s attempt for ambulation.
Wednesday, June 11, 2008
foot mobs
During my neuro prac, I was treating a man who had recently had a parietal tumour. One thing himself and I wanted to work on was his standing posture to prepare him for walking. On observation his standing posture was as follows:
- good head control and shoulder alignment
- Lumbar lordosis
- Increased weight bearing through the right LL
- (L) hip adduction and IR
- (L) knee flexion
- (L) foot plantarflexion and pronated
To improve his standing alignment, strengthening of his core muscles, abdominals and LL was the main aim. However I wanted to do something that would hopefully show more 'instant' results to prove to my patient that he could stand well because he was a really intelligent and motivated guy. So i tried some foot mobs. I did as many mob directions as possible through the ankle, arches, tarsals and toes etc to get some sensory stimulation on his left side.
With some additional facilitation at his hips to gain equal weight bearing on both LL, I was so suprised how well the foot mobs worked to influence a better foot posture and in turn improved alignment of the knee and hip.
From then on we started each treatment with foot mobs to give him not only more proprioceptive awareness but confiedence as well.
That prac session really did pay off!
- good head control and shoulder alignment
- Lumbar lordosis
- Increased weight bearing through the right LL
- (L) hip adduction and IR
- (L) knee flexion
- (L) foot plantarflexion and pronated
To improve his standing alignment, strengthening of his core muscles, abdominals and LL was the main aim. However I wanted to do something that would hopefully show more 'instant' results to prove to my patient that he could stand well because he was a really intelligent and motivated guy. So i tried some foot mobs. I did as many mob directions as possible through the ankle, arches, tarsals and toes etc to get some sensory stimulation on his left side.
With some additional facilitation at his hips to gain equal weight bearing on both LL, I was so suprised how well the foot mobs worked to influence a better foot posture and in turn improved alignment of the knee and hip.
From then on we started each treatment with foot mobs to give him not only more proprioceptive awareness but confiedence as well.
That prac session really did pay off!
Monday, June 9, 2008
Third Time Lucky...
During my recent placement it has become apparent that old habits die hard. Especially in the older population group in order to introduce new things into their life they need to be produced and reproduced in a positive non-threatening environment for them to be more likely to be accepted. Four wheeled walkers are a mobility aid that are heavily prescribed in the geriatric age group, however, they also have a stigma attached to them. For many patients that come for an assessment, our aim is to provide safe independent function. Our idea of this and the patients are sometimes very different. For a few of them, they hope that by receiving treatment they may rid themselves of their already present walking stick or improve their walking without an aid; but in most cases in order to improve their exercise tolerance, safety and ability to access the outside community they would benefit from a wheeled walker.
Within the patients that are recommended a walker, some of them resist them with a passion, seeing them as being “for old people only.” On questioning, many have already had a walker suggested on previous occasions either by another physiotherapist or allied health professional. In order to overcome this problem, gentle reiteration and introduction to an actual walker has helped. By introducing it gently and slowly gives these people a time to adjust to the idea. For example, after an initial assessment is performed and it is deemed beneficial, it is a good idea to allow time for the education component of how it would benefit their specific problems. At this point in time, it can then be said that next session you would be able to physically demonstrate and provide an opportunity to trial and practice walking with the walker in the treatment session alone if they were interested. By saying that you will do this during the next treatment session, and providing some information before then gives them a week to allow the notion to whirl around their head. The most important part is not to be forceful about it because they will make their own mind up regardless- but as long as you have provided the information there is nothing more than you can do.
So far, I have found that by introducing them slowly but regularly into treatment sessions, those patients that have been resistant to them previously have been able to adjust to the idea and are now feeling more positive.
Within the patients that are recommended a walker, some of them resist them with a passion, seeing them as being “for old people only.” On questioning, many have already had a walker suggested on previous occasions either by another physiotherapist or allied health professional. In order to overcome this problem, gentle reiteration and introduction to an actual walker has helped. By introducing it gently and slowly gives these people a time to adjust to the idea. For example, after an initial assessment is performed and it is deemed beneficial, it is a good idea to allow time for the education component of how it would benefit their specific problems. At this point in time, it can then be said that next session you would be able to physically demonstrate and provide an opportunity to trial and practice walking with the walker in the treatment session alone if they were interested. By saying that you will do this during the next treatment session, and providing some information before then gives them a week to allow the notion to whirl around their head. The most important part is not to be forceful about it because they will make their own mind up regardless- but as long as you have provided the information there is nothing more than you can do.
So far, I have found that by introducing them slowly but regularly into treatment sessions, those patients that have been resistant to them previously have been able to adjust to the idea and are now feeling more positive.
The Difficult Musculoskeletal Patient
Over the past three years we have been given anatomical knowledge and treatment techniques to equip us as best as possible to treat a variety of outpatient problems and injuries. Recently on my musculoskeletal placement I had a lumbar spine patient with CT scan evidence of discal and facet problems, as well as having hypermobility and motor control issues. After seeing him three times and trying a variety of treatment techniques he still came the following session reporting little change and seemingly not very enthused with physiotherapy.
Upon closer examination and questioning however, (after thinking how disheartening this was!) I realised he now was pain-free on active ROM (previously 6-8/10 pain). Furthermore the pain had stopped radiating down his buttocks and legs completely when at work during the week. Once I realised this, I made sure to inform this patient (as enthusiastically as possible) that out treatment plan is indeed working and told him exactly the differences he was getting in pain compared to the first week. Finally he seemed happy and with renewed faith in the treatment (hopefully) at the end of the session.
I must admit the fact that he had reported absolutely no chance since beginning treatment really disheartened me, as I'm still hopeful that my treatment will 'fix' patients first go. It reminded me that don't neccessarily 'work miracles', and that it does take time sometimes to find the right treatment combination for each individual patient. Furthermore I was later informed by a supervisor that you can usually "talk better" up to %60 of patients. By explaining to this patient why I was using certain techniques and enthusiastically telling him how they were helping him and decreasing his pain, I felt he was far happier with the service and furthermore more motivated to continue his HEP. For future patients that are a bit difficult to treat I will definately have faith in my own abilities and treatment rationale and make sure I convey to my patient their results and improvements in each session.
Upon closer examination and questioning however, (after thinking how disheartening this was!) I realised he now was pain-free on active ROM (previously 6-8/10 pain). Furthermore the pain had stopped radiating down his buttocks and legs completely when at work during the week. Once I realised this, I made sure to inform this patient (as enthusiastically as possible) that out treatment plan is indeed working and told him exactly the differences he was getting in pain compared to the first week. Finally he seemed happy and with renewed faith in the treatment (hopefully) at the end of the session.
I must admit the fact that he had reported absolutely no chance since beginning treatment really disheartened me, as I'm still hopeful that my treatment will 'fix' patients first go. It reminded me that don't neccessarily 'work miracles', and that it does take time sometimes to find the right treatment combination for each individual patient. Furthermore I was later informed by a supervisor that you can usually "talk better" up to %60 of patients. By explaining to this patient why I was using certain techniques and enthusiastically telling him how they were helping him and decreasing his pain, I felt he was far happier with the service and furthermore more motivated to continue his HEP. For future patients that are a bit difficult to treat I will definately have faith in my own abilities and treatment rationale and make sure I convey to my patient their results and improvements in each session.
Doubting Yourself
On my current placement, I had a situation where a patient who had been discharged around a week ago was re-admitted to the ward. I had been seeing her for 3-4 days before she was discharged, generally to check on her mobility and current functional status and social situation. Prior to discharge she had been ambulating independently around the ward and performing all ADLs independently, so it came as a bit of a surprise to see her name on the patient list again and I was interested to see why she had been re-admitted. On looking through her admission summary, it was reported that she had a loss of appetite and had generally deteriorated, and that her family were not coping with her at home.
She was a palliative patient, and although had been given only months to live, was still functioning at a fairly high level. The doctors were questioning why she was readmitted, and if someone had missed something to let this happen. It was at this stage that I started to doubt myself and whether or not I had provided adequate treatment and follow up for this lady. I started going through what I had done with her before her discharge- I made sure she was independent with walking, transferring, stairs etc, reviewed her social situation (home set up, family support, etc) and made sure she had achieved her pre-admission functional level. I had also arranged reviews from OT and Social Work for anything else she may need. I was sure I had done all I could to ensure her safe discharge, but in the back of mind was still worried she had been re-admitted due to something I had missed- and could possibly get the ‘blame’ from her doctors.
On review she was independent with all mobility and had no complaints about anything at home. I again reviewed her social situation and there didn’t seem to be anything I missed from my last assessment. I reported all this back to the doctor, who told me that it was her husband who had brought her in reporting he couldn’t cope at home with her because he couldn’t get her eat, causing her to be extremely fatigued. He told me that her disease was actually much more aggressive than first thought, and this had lead to her not being able to eat, causing a more rapid deterioration than expected.
I now realize I should have stuck to my first thoughts- that I had done everything required for her safe discharge, and not doubt myself. I think the best way to avoid this stress of second guessing yourself is to ensure you are completely happy with the patient’s social history and functional status prior to their discharge. Although sometimes you can feel pressured to have a patient discharged by a certain time or day, it is important to be confident the patient is truly ready to manage at home- especially so that if they are re-admitted you can be confident that it was not because of anything you missed.
Sickness on placements
During my placement at a major hospital i developed what i thought was just a random rash. I had been feeling slightly unwell for about a week, but nothing to call in sick about. Over the following days it started to get pretty sore and then became extremely painful. At that point i asked a medical intern what he thought it could be and he stated it was most likely shingles. Although the rash was covered and not likely infectious he wasnt sure of hospital protocol and suggested i enquire what the normal protocol was.
It turns out that this condition is just an exaccerbation of the chicken pox virus in the dorsal nerve roots and only contageous to contact if the patient hasnt had chicken pox, is immunosuppressed or is late into pregnancy. I got sent home immediately and wasnt allowed back onto or near the hospital grounds until the rash had cleared.
Looking ahead in my schedule, in the next few days i was down to treat a patient preparing for a liver transplant and also a pregnant lady. Although the sickness didnt really affect me and i felt well enough to perform any daily tasks, it emphasised to me that the days away from prac when we are sick are more for the patients benefit rather than ours. Having been exposed to this situation, i would know in future to check the hospital protocols with any real sickness and get anything checked out as soon as it occurs rather than waiting until we feel unwell enough to come in.
It turns out that this condition is just an exaccerbation of the chicken pox virus in the dorsal nerve roots and only contageous to contact if the patient hasnt had chicken pox, is immunosuppressed or is late into pregnancy. I got sent home immediately and wasnt allowed back onto or near the hospital grounds until the rash had cleared.
Looking ahead in my schedule, in the next few days i was down to treat a patient preparing for a liver transplant and also a pregnant lady. Although the sickness didnt really affect me and i felt well enough to perform any daily tasks, it emphasised to me that the days away from prac when we are sick are more for the patients benefit rather than ours. Having been exposed to this situation, i would know in future to check the hospital protocols with any real sickness and get anything checked out as soon as it occurs rather than waiting until we feel unwell enough to come in.
Same question, different wording
The other week I had a new, fairly young patient who came in with lower back pain and a very long medical history with various organ difficulties. On subjective assessment she stated that she couldn't lie on her back due to her high pain and that all the pains that she experienced (her neck, shoulders, whole back and down her leg) were the same severity 4/10 (0-10 pain scale) and like her pins and needles, down her opposite leg to the pain, were constantly there. She had been like this for FOUR years and hadn't seen anyone about it. All her aggravating factors increased her pain to 4/10 which I dutifully wrote down (realising later this was the same has her resting pain) and they yet again were all considered one pain.
After talking to my supervisor about the subjective results I realised that just taking it as she said it and filling in the form was not good enough. I had to start asking specific questions and try repeating them with different wording to get a result, which added up more than 4/10 at rest And with aggravating activities. Also to diagnose a patients problems I would have to find which of her pains were increased with the various activities and compare them to the resting pains. Aggravating factors are not just there as precautions during assessment or as a measureable tool for treatment effectiveness but they also help to diagnose the issue if you have the activity, the place of pain and the pain level.
I went back to the patient and worded my questions better, breaking down each pain and starting with 'if this pain is 4/10 now what does it increase to with this activity'. By doing this I was able to separate the pains and when they happened, find out what things aggravated each part and by how much. I have now used this principle in the subjective of every new patient, it not only saves coming going back in and asking more questions but helps you with essential objective assessments, possible diagnosis and gets you thinking about treatment. Although you still have to carry out your objective using all the assessments (as you should with new patients), the specific ones you highlight from subjective results will more often than not show the results you predicted.
After talking to my supervisor about the subjective results I realised that just taking it as she said it and filling in the form was not good enough. I had to start asking specific questions and try repeating them with different wording to get a result, which added up more than 4/10 at rest And with aggravating activities. Also to diagnose a patients problems I would have to find which of her pains were increased with the various activities and compare them to the resting pains. Aggravating factors are not just there as precautions during assessment or as a measureable tool for treatment effectiveness but they also help to diagnose the issue if you have the activity, the place of pain and the pain level.
I went back to the patient and worded my questions better, breaking down each pain and starting with 'if this pain is 4/10 now what does it increase to with this activity'. By doing this I was able to separate the pains and when they happened, find out what things aggravated each part and by how much. I have now used this principle in the subjective of every new patient, it not only saves coming going back in and asking more questions but helps you with essential objective assessments, possible diagnosis and gets you thinking about treatment. Although you still have to carry out your objective using all the assessments (as you should with new patients), the specific ones you highlight from subjective results will more often than not show the results you predicted.
Patient's as Individuals
Whilst on my neuro placement I learnt the importance of veiwing each patient as an individual and how something that may be of benefit to the majority of patients will not necissarily be of benefit to some individuals.
I was treating a patient who had recently had a lateral medullary stroke with vestibular involvement. This patient was a middle aged Dr and was well aware of her condition and the importance of physiotherapy. She asked many questions and was eager to get up and about but the dizziness and vertigo prevented her from doing so. She made excellent progress in the first couple of days and pushed herself as hard as she was able. Despite these efforts she was still unsafe with her gait and required 1x minimal assistance whilst walking with a zimmer frame.
After the first few days she was eager to go home and was continually asking when she was to be discharged. Her doctors had ascertained her safe to go home and her discharge was then dependent upon her 'physiotherapy review'. I did not think that she was safe to return home and discussed this with my supervisor who agreed that she should not be going home with her current mobility level. However over the next few days her progress began to plateau as she continued to request to return home.
I then reveiwed her situation with my supervisor and we agreed to discharge her as she had a large support network within her family and she was a practising Dr and was well aware of her condition and the importance of attending outpatient physiotherapy. We discharged her with a refferal for out patient physio and exercises and management for her rehabilitation.
With the majority of patients that i have been able to see I would not have recommended that they return home but in this case the patients social history and background played a significant role in allowing her to go home. I then realised the importance of each patients individuality and how we as physiotherapists, or students, should not treat the condition but they patient themself.
I was treating a patient who had recently had a lateral medullary stroke with vestibular involvement. This patient was a middle aged Dr and was well aware of her condition and the importance of physiotherapy. She asked many questions and was eager to get up and about but the dizziness and vertigo prevented her from doing so. She made excellent progress in the first couple of days and pushed herself as hard as she was able. Despite these efforts she was still unsafe with her gait and required 1x minimal assistance whilst walking with a zimmer frame.
After the first few days she was eager to go home and was continually asking when she was to be discharged. Her doctors had ascertained her safe to go home and her discharge was then dependent upon her 'physiotherapy review'. I did not think that she was safe to return home and discussed this with my supervisor who agreed that she should not be going home with her current mobility level. However over the next few days her progress began to plateau as she continued to request to return home.
I then reveiwed her situation with my supervisor and we agreed to discharge her as she had a large support network within her family and she was a practising Dr and was well aware of her condition and the importance of attending outpatient physiotherapy. We discharged her with a refferal for out patient physio and exercises and management for her rehabilitation.
With the majority of patients that i have been able to see I would not have recommended that they return home but in this case the patients social history and background played a significant role in allowing her to go home. I then realised the importance of each patients individuality and how we as physiotherapists, or students, should not treat the condition but they patient themself.
dealing with death
The situation I am writing about in this case occurred on my Gerontology placement. Whilst there I had many older patients, usually in their late eighties or nineties, and I became quite used to dealing with them on a daily basis, and in my mind I was quite prepared for the fact that they would probably pass away one day soon due to their age and deteriorating conditions. But then I had a 65 year old man assigned to me, and for the facility that was a fairly young age. This patient had a number of problems such as heart conditions and a possible cancer, but the reason he was admitted to hospital was for poor self care, and this was something that really bothered me, that somebody could be so depressed that they just stop looking after themselves.
I developed a good relationship with this man and he became one of my most enjoyable patients. He was making such good progress and was soon to be going home. I treated him on a Thursday morning, but then on the Friday morning when I arrived he was not in his room, and I found out he had had a heart attack that night and had been rushed to another hospital. I was not given any other information, and I knew due to confidentiality reasons I had no way of finding out if he was ok. A few days later I overheard a doctor talking and realised my patient had actually died. I was very upset as this was the first patient I had had that had died and I had no idea how to deal with it all. And then I started to think about all the things we had done that day, making sure I had not done anything too much for him. I just could not understand how someone so young compared to the other patients could just die so suddenly, and how unfair it was that no one told me seeing as I had been working with him for so long.
I spoke with my supervisor about it and she managed to help me understand that it was just a part of life when working with the aged, and that the first time is always the hardest. I did feel a bit better, but I also realised that as students, none of us are really equipped to deal with death, and maybe that is something that needs further attention paid to in class. But this whole experience also made me realise that it is so important not to get attached to patients, and that you must be able to separate yourself from them in a way and just treat the problems you can treat. This is something that comes with experience though, and in future I will make sure in the back of my mind I am always prepared in some way for these things, regardless of the patients age.
I developed a good relationship with this man and he became one of my most enjoyable patients. He was making such good progress and was soon to be going home. I treated him on a Thursday morning, but then on the Friday morning when I arrived he was not in his room, and I found out he had had a heart attack that night and had been rushed to another hospital. I was not given any other information, and I knew due to confidentiality reasons I had no way of finding out if he was ok. A few days later I overheard a doctor talking and realised my patient had actually died. I was very upset as this was the first patient I had had that had died and I had no idea how to deal with it all. And then I started to think about all the things we had done that day, making sure I had not done anything too much for him. I just could not understand how someone so young compared to the other patients could just die so suddenly, and how unfair it was that no one told me seeing as I had been working with him for so long.
I spoke with my supervisor about it and she managed to help me understand that it was just a part of life when working with the aged, and that the first time is always the hardest. I did feel a bit better, but I also realised that as students, none of us are really equipped to deal with death, and maybe that is something that needs further attention paid to in class. But this whole experience also made me realise that it is so important not to get attached to patients, and that you must be able to separate yourself from them in a way and just treat the problems you can treat. This is something that comes with experience though, and in future I will make sure in the back of my mind I am always prepared in some way for these things, regardless of the patients age.
Wednesday, June 4, 2008
Social Issues
I was previously on an orthopaedic ward where I had an 80-something male patient who had undergone a standard protocol total knee replacement. Treatment however, was not so standard. As some of you know following replacements the patient is often on a spinal epidural and pain cover is a priority. This man however appeared allergic to opoids and his pain was poorly managed. Even trying to move him in bed caused him to cry, and that was at a week post-surgery (most knee replacements are in hospital 7-10 days). Not only this he would often ask why his leg hurt, or would forget who I was or what he did yesterday. I had to repeat instructions several times and demonstrate before he understood. Furthermore he would start sobbing for no apparent reason so loudly that the entire ward could hear him. Most on the ward assumed this unusual behaviour was from the pain medication and for a week I tried my best to increase his limb strength, ROM and mobility. The more i worked with him the more it became apparent that clearly he had an altered mental state. From his subjective history in notes and from him it appeared he had lived independently prior to this, and had been driving no less.
Finally his daughter came in and I asked about his social background. Turned out he lived with her and her husband, however they left for work at 6:30am and came home around 7:30, so he was alone all day and that sometimes she'd find him stuck in a room or not knowing what he was doing. When I informed her about his sobbing, she assured me that 'he always does that around the house'. not only this, she went on to explain that he self-medicates with panadol and alcohol. She appeared to believe there was nothing wrong with this, and asked me when he would be discharged. I informed a social worker and he was eventually discharged to ongoing rehab with a suggested diagnoses of alzihemers.
I learnt from this that although I am a student and it is easier to just 'go along' with the rest of the wards opinion, at times we do have to take it into our own hands and use our own initiative to find the cause of a patient's problems. Had this man been discharged home who knows what state he would have ended up in. Furthermore his family clearly had no idea of the care he required or of his mental state, or how much damage his 'self medication' could be doing him! It made me realise that we can't always take the 'notes' or more experienced allied health professionals, such as nurses, opinions as gospel, and that as students we also have a duty of care to our patients and have an obligation to investigate into every aspect of their care as required.
Finally his daughter came in and I asked about his social background. Turned out he lived with her and her husband, however they left for work at 6:30am and came home around 7:30, so he was alone all day and that sometimes she'd find him stuck in a room or not knowing what he was doing. When I informed her about his sobbing, she assured me that 'he always does that around the house'. not only this, she went on to explain that he self-medicates with panadol and alcohol. She appeared to believe there was nothing wrong with this, and asked me when he would be discharged. I informed a social worker and he was eventually discharged to ongoing rehab with a suggested diagnoses of alzihemers.
I learnt from this that although I am a student and it is easier to just 'go along' with the rest of the wards opinion, at times we do have to take it into our own hands and use our own initiative to find the cause of a patient's problems. Had this man been discharged home who knows what state he would have ended up in. Furthermore his family clearly had no idea of the care he required or of his mental state, or how much damage his 'self medication' could be doing him! It made me realise that we can't always take the 'notes' or more experienced allied health professionals, such as nurses, opinions as gospel, and that as students we also have a duty of care to our patients and have an obligation to investigate into every aspect of their care as required.
Monday, June 2, 2008
Building Rapport
Whilst on an elective placement, my communication skills were tested when I was required to facilitate the return of functional mobility to a teenage girl post burn injury. My skills were required not only to achieve the functional outcome of mobilizing my patient but to provide motivation and education in order to achieve my goal.
Due to poor pain tolerance, anxiety and poor coping strategies my patient was very reluctant to get out of bed to shower and toilet herself, let alone walk up and down the corridor and facilitate circulation and healing. Due to her age and anxiety of the unknown I found that education would play a vital role in my first interaction with her. By explaining to her the process of burns and their stages of healing, the importance of early mobilisation to reduce the risk of contracture and later functional limitations and allowing her time to process and ask questions placed her at ease. The next step was to provide some ‘orientation’ to what my role as a physiotherapist was, the expectations for daily treatment (what time, for how long) and exercises (bike, walking, squats etc) and the gym set up, reinforced to her what would be expected in terms of time and activities. I feel that this communication with her built up a good rapport and trust. This further led to some distraction methods of my ability to copy her words in a joking manner when correcting her “waddling like a duck”. If I hadn’t established a good bond with her through my communication and interpersonal skills, I would not have been able to adopt some of the treatment techniques and language used. The rapport built during that initial stage allowed me to gain her trust and compliance with my exercise program and resulted in successful mobilization and gait correction.
After this experience it reinforced that time spent with a patient providing education in some situations is more beneficial than our treatment itself as it can provide further long-term benefits via the patients compliance. Spending time building rapport with a patient is important and shouldn’t be overlooked.
Due to poor pain tolerance, anxiety and poor coping strategies my patient was very reluctant to get out of bed to shower and toilet herself, let alone walk up and down the corridor and facilitate circulation and healing. Due to her age and anxiety of the unknown I found that education would play a vital role in my first interaction with her. By explaining to her the process of burns and their stages of healing, the importance of early mobilisation to reduce the risk of contracture and later functional limitations and allowing her time to process and ask questions placed her at ease. The next step was to provide some ‘orientation’ to what my role as a physiotherapist was, the expectations for daily treatment (what time, for how long) and exercises (bike, walking, squats etc) and the gym set up, reinforced to her what would be expected in terms of time and activities. I feel that this communication with her built up a good rapport and trust. This further led to some distraction methods of my ability to copy her words in a joking manner when correcting her “waddling like a duck”. If I hadn’t established a good bond with her through my communication and interpersonal skills, I would not have been able to adopt some of the treatment techniques and language used. The rapport built during that initial stage allowed me to gain her trust and compliance with my exercise program and resulted in successful mobilization and gait correction.
After this experience it reinforced that time spent with a patient providing education in some situations is more beneficial than our treatment itself as it can provide further long-term benefits via the patients compliance. Spending time building rapport with a patient is important and shouldn’t be overlooked.
Teamwork
I am currently on my Cardiopulmonary placement in an Oncology Ward and it is here that I have come to realise the benefits of effective teamwork between staff.
This ward can often highlight patients’ misfortunes and times of grief, however these also often become uplifted by the strength and truly heroic nature of other patients. But the one thing that has stood out most since I have started on this prac, is the exceptional teamwork between the nurses, doctors and allied health team.
I started my placement on my supervisors first day on the ward, so we were both unfamiliar with the ward and its workings. The nurses and doctors were extremely helpful in showing us around and helping us out when we needed. We also tried our best to work all our treatments in with the nurses- checking when the patients were due to be showered so we could review their mobility or walk with them, letting them know when we would be walking/ exercising patient’s, ensuring timing of pain medication prior to treatments, notifying eachother of outside appointments (Xrays, CT scans etc) and keeping eachother informed about patients’ general status each day. This system has worked extremely well, as the nurses will now often ask us when we are free to walk a patient to the shower/ toilet, help to transfer them and let us know of any change in a patients status (mobility, chest symptoms) that we may need to review. They will also often ask us how they can help to carry on the benefits of our treatments, such as positioning and reminding patients of exercises. This sort of thing has also been the same with the OTs, dieticians, doctors (where one actually took the time to take me through a chest Xray and showed me a pleural drain procedure) and other team members.
On other pracs I have had, wards often run with everyone in isolation- where the main form of communication is through patient notes. I’ve found all the staff on my current placement to be so helpful and supportive of one another, that not only does it improve patient care but also team morale- which is so important on a ward like this.
The patient’s receive much more thorough care because everyone is aware of each patients’ most current status, which also ensures when patients are discharged nothing has been missed and we can all be confident the patient and their family will cope fine at home.
I think more wards should adopt this sort of teamwork, were everyone is involved and updated on the patients care. It has certainly helped to make our time more efficient- which is so important as time always seems to be precious!
Renae
This ward can often highlight patients’ misfortunes and times of grief, however these also often become uplifted by the strength and truly heroic nature of other patients. But the one thing that has stood out most since I have started on this prac, is the exceptional teamwork between the nurses, doctors and allied health team.
I started my placement on my supervisors first day on the ward, so we were both unfamiliar with the ward and its workings. The nurses and doctors were extremely helpful in showing us around and helping us out when we needed. We also tried our best to work all our treatments in with the nurses- checking when the patients were due to be showered so we could review their mobility or walk with them, letting them know when we would be walking/ exercising patient’s, ensuring timing of pain medication prior to treatments, notifying eachother of outside appointments (Xrays, CT scans etc) and keeping eachother informed about patients’ general status each day. This system has worked extremely well, as the nurses will now often ask us when we are free to walk a patient to the shower/ toilet, help to transfer them and let us know of any change in a patients status (mobility, chest symptoms) that we may need to review. They will also often ask us how they can help to carry on the benefits of our treatments, such as positioning and reminding patients of exercises. This sort of thing has also been the same with the OTs, dieticians, doctors (where one actually took the time to take me through a chest Xray and showed me a pleural drain procedure) and other team members.
On other pracs I have had, wards often run with everyone in isolation- where the main form of communication is through patient notes. I’ve found all the staff on my current placement to be so helpful and supportive of one another, that not only does it improve patient care but also team morale- which is so important on a ward like this.
The patient’s receive much more thorough care because everyone is aware of each patients’ most current status, which also ensures when patients are discharged nothing has been missed and we can all be confident the patient and their family will cope fine at home.
I think more wards should adopt this sort of teamwork, were everyone is involved and updated on the patients care. It has certainly helped to make our time more efficient- which is so important as time always seems to be precious!
Renae
Walking children
I am on my paeds prac at the moment. Most of the children have down syndrome and are delayed in their walking. I thought it was quite interesting that the Physios tend to not push the child to walk by assisting them to walk or allowing them to weight bear in a standing frame for instance. Treatments are performed in positions that the children can do independantly to improve their strength and control and hence the quality of movement when they eventually choose to walk. It sounds straight forward that you wouldn't push them to walk, but I never really thought about it in that way. One of the children I see was walking but with no control and no quality of movement because the parents wanted her to walk because they thought it was normal. We had to explain that standing their child isn't the best scenario even if at their age they should be walking. It made me realise that to get the best quality of movement, you should allow the child to develop through all the milestones even if you know they should be doing a particular task at their age normally. It's also important to explain to the parents the importance of this and pushing them to be developing normally isn't always the best approach.
Angel transfers
I was assisting the phsyiotherapist on my neuro placement to transfer a non weight bearing patient with Rhabdomyolisis into his wheelchair via an angel transfer. The wheel chair was a tilt in space chair which had a high seat and inorder to complete the transfer the bed had to be raised so that the slide board could be placed across the bed and wheelchair. The physiotherapist instructed me to place the patients feet on the foot plates of the wheelchair so that we could beging the transfer.
I was not happy with this arrangement as the patients feet would then be on an unstable surface as we transferred them. I then asked the physiotherapist if they were sure that I should place the patients feet on the footplates. He reassured me that this was fine. I was still not happy but decided that the physiotherapist had more experience than I did and knew what he was doing and decided to carry on with the transfer.
My instincts turned out to be correct and as we began to transfer the patient his feet slipped off the foot plates and he fell. Luckily we managed to break his fall and he was not injured but this experience left the patient feeling very anxious and nervous about transferring and his recovery!
From this experience I have learned that your instincts are extremely important and you should follow them. We have learnt how to complete activites such as patient transfers safely at uni for a reason and even if you feel a physiotherapist has more experience than you it is more than alright to reason your thoughts with them. It is alright to stop and question what you are doing or about to do as many times as you need. The patient's safety is of utmost importance in situations like these!!
I was not happy with this arrangement as the patients feet would then be on an unstable surface as we transferred them. I then asked the physiotherapist if they were sure that I should place the patients feet on the footplates. He reassured me that this was fine. I was still not happy but decided that the physiotherapist had more experience than I did and knew what he was doing and decided to carry on with the transfer.
My instincts turned out to be correct and as we began to transfer the patient his feet slipped off the foot plates and he fell. Luckily we managed to break his fall and he was not injured but this experience left the patient feeling very anxious and nervous about transferring and his recovery!
From this experience I have learned that your instincts are extremely important and you should follow them. We have learnt how to complete activites such as patient transfers safely at uni for a reason and even if you feel a physiotherapist has more experience than you it is more than alright to reason your thoughts with them. It is alright to stop and question what you are doing or about to do as many times as you need. The patient's safety is of utmost importance in situations like these!!
acute pain post TKR
I am currently on my ortho inpatients prac and have come to realise just how much pain people who have had TKR`s must have to experience in the first few days. Although they have a PCR and all sorts of drugs available to them, there are still those patients who are in so much pain they find it so hard to bend their knee, which is so important to do as soon as possible. The situation I faced recently involved a 47 year old lady who was day 1 post-op and I was assigned to treat her. She was very teary and in so much pain, and I felt so bad making her do all her exercises. So instead of really pushing her, especially since she was only getting to 30 degrees on the CPM, I would just let her carry on getting to that range, seeing as she was already almost in tears at this stage.
So on day 2, I was assuming she would be automatically better, but again she was at the same range and still in tears. So I started to feel really bad and that I must be really doing something wrong. So eventually I asked my supervisor to go in and see her, which she was happy to do. My supervisor had enough confidence and knowledge that she was able to push her CPM right up to 55 degrees, even though the woman was in so much pain. I felt really bad after this and spoke with my supervisor and said that I felt that I had failed the patient because I had not been cruel to be kind with her. But I also explained that at this stage I did not have the confidence to do what she did without fearing I would really damage the patient.
My question to her was, `when do you learn how far you can push someone`, and `how do you deal with your feelings of guilt when you know you are really hurting someone, even though what you are doing is for their own good`. My supervisor was great and made me realise I had done nothing wrong and that I had done the right thing coming to her for help instead of carrying on as I was, because the patients knee would have suffered. So she made me realise its ok to admit that we cant handle every kind of situation yet, even though we feel we should be able to. So I did learn from this that you can push these patients past their limits and it wont damage their knee, we just need to make absolutely sure they have enough pain cover as possible and always check with your supervisor first so they are aware of the situation.
After this situation, with another patient, I did manage to be a bit firmer with his exercises, and it had such a good result that my confidence in dealing with patients with such bad pain has increased, although it still has a long way to come.
So on day 2, I was assuming she would be automatically better, but again she was at the same range and still in tears. So I started to feel really bad and that I must be really doing something wrong. So eventually I asked my supervisor to go in and see her, which she was happy to do. My supervisor had enough confidence and knowledge that she was able to push her CPM right up to 55 degrees, even though the woman was in so much pain. I felt really bad after this and spoke with my supervisor and said that I felt that I had failed the patient because I had not been cruel to be kind with her. But I also explained that at this stage I did not have the confidence to do what she did without fearing I would really damage the patient.
My question to her was, `when do you learn how far you can push someone`, and `how do you deal with your feelings of guilt when you know you are really hurting someone, even though what you are doing is for their own good`. My supervisor was great and made me realise I had done nothing wrong and that I had done the right thing coming to her for help instead of carrying on as I was, because the patients knee would have suffered. So she made me realise its ok to admit that we cant handle every kind of situation yet, even though we feel we should be able to. So I did learn from this that you can push these patients past their limits and it wont damage their knee, we just need to make absolutely sure they have enough pain cover as possible and always check with your supervisor first so they are aware of the situation.
After this situation, with another patient, I did manage to be a bit firmer with his exercises, and it had such a good result that my confidence in dealing with patients with such bad pain has increased, although it still has a long way to come.
Sunday, June 1, 2008
Chronic pain
After just two weeks at my musculoskeletal clinic im surprised by just how much I've learnt. All those prac classes taught us the tecniques needed and the lectures taught us the conditions but I've found that theres nothing like seeing the actual problem. Feeling the abnormal end feel, the really really tight joint and the results that one treatment can have on pain and decreased function. There is however patients whom you don't really understand why they are coming to a physio, when their pain is more serious and yellow flags are present.
A recent patient I saw had been coming to the physiotherapy clinic for a couple of years for more than one problem. Her problems had gone from bad to better with physiotherapy treatment, of course, but she seemed to have plateaued even with weekly treatment. After assessing her, I had planned on just giving her the same treatment that had been working - STM, PPIVMs and going over her HEP, changing/increasing it depending on my assessment. My supervisor however talked to me about the yellow flag, chronic pain side of her problem and told me how to help with this, treatment had to become less hands on (a nice massage and her back loosened each week) and handed over to the patient. On inspection of her home exercises, she reported she was doing her TA/PF exercises and her Lower traps exercises but she was just doing the set exercises and hadn't applied them to everyday life. She was therefore still experiencing lower back and neck pain and relying on physio every week to get her pain relief.
I used my supervisors advice and although i still gave her the STM as in previous treatments it had a great effect on her pain, i spent most of the treatment talking over functional uses of the exercises she had been given. She picked it up straight away using TA/PF for STS, rolling, bending and even got in before me when she bent over to do up her shoes "tighten those pelvic floor muscles". I went through sitting and standing posture and how correct posture stems from the pelvis. Its position aswell as switching on her TA which made her stand/sit straigher, her chin retract and her "chest bone lift" slightly, automatically using her upper traps. I ended the session by rebooking her for 2 weeks time to break the every week trend.
I do realise that chronic pain does not go away that easily but by handing the information and treatment over to the patient I feel she will feel powered to get herself better and be in control of her pain.
A recent patient I saw had been coming to the physiotherapy clinic for a couple of years for more than one problem. Her problems had gone from bad to better with physiotherapy treatment, of course, but she seemed to have plateaued even with weekly treatment. After assessing her, I had planned on just giving her the same treatment that had been working - STM, PPIVMs and going over her HEP, changing/increasing it depending on my assessment. My supervisor however talked to me about the yellow flag, chronic pain side of her problem and told me how to help with this, treatment had to become less hands on (a nice massage and her back loosened each week) and handed over to the patient. On inspection of her home exercises, she reported she was doing her TA/PF exercises and her Lower traps exercises but she was just doing the set exercises and hadn't applied them to everyday life. She was therefore still experiencing lower back and neck pain and relying on physio every week to get her pain relief.
I used my supervisors advice and although i still gave her the STM as in previous treatments it had a great effect on her pain, i spent most of the treatment talking over functional uses of the exercises she had been given. She picked it up straight away using TA/PF for STS, rolling, bending and even got in before me when she bent over to do up her shoes "tighten those pelvic floor muscles". I went through sitting and standing posture and how correct posture stems from the pelvis. Its position aswell as switching on her TA which made her stand/sit straigher, her chin retract and her "chest bone lift" slightly, automatically using her upper traps. I ended the session by rebooking her for 2 weeks time to break the every week trend.
I do realise that chronic pain does not go away that easily but by handing the information and treatment over to the patient I feel she will feel powered to get herself better and be in control of her pain.
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