Male physios with female patients

This post does not only refer to my experiences at a paediatric placement, but also in the adult sector of the rural outpatient physiotherapy.

What i found eye-opening throughout this year was the lengths that we are taught to go to to ensure we minimise the risks of sexual harassment claims. Through both of these clinics i was taught extra steps that must be taken to make sure that i was not treating female patients individually.

When entering the clinical year i thought myself to be a very professional student with the only objective being to treat people and make them better. I never thought myself to be sexually deviant and thus when all this information was handed to me, i was somewhat confronted. I was informed that even with adult patients, i was not to be in a room with a female patient alone and needed someone else there to supervise in that situation. I can understand the relevence in the paediatric setting, but i thought these measures were somewhat overzealous in the adult sector. On speaking to my supervisor about this she informed me that they are extra careful with young male students in the rural sectors and that these measures would not stay once we are graduates and working full-time.

I was wondering if any others had any rules imposed that were confronting or have any situations were these measures were beneficial?

blogging

This blog is a reflection on this part of the course, the blogging aspect. I had varying views about the effectiveness of the blogging and how much help this would be to my knowledge base and clinical skills. At various points in the year the blogging became very tedious and coming up with a relevent topic seemed hard. Im sure some people thought that writting new posts and reflecting on our own issues was relevant, but i didnt think so. What i did find very useful was reflecting on other peoples issues and thus forcing myself to question my own responses to that scenario and how i would handle it. There were a couple of occasions throughout the latter part of the year where new scenarios i found myself in became somewhat familiar as i had heard someone comment on their response. This provided me with the oppertunity to make the right decision faster and more effectively as i already had a bank of knowledge built up from reading and thinking about the posts.

As part of the PD in my new job, they do employ some of the same tactics each week where we present an issue and then each discuss a way or technique to deal with it. It may have taken me 8 months to see the worth in all this blogging, but i think it was worthwhile!

difficult nurses

On my rural placement, I found myself in a difficult situation with one of the ward nurses who was looking after a patient who was Day 1 post THR. This patient had been extremely nauseas all morning, so myself and my supervisor saw her after lunch to transfer her out of bed. Everything went well, however upon sitting upright was feeling very nauseas and vomited. We stood the patient and took a few steps, then decided we would put her back into bed rather than have her sitting out as she was feeling extremely unwell, and tomorrow we would see her again for ambulation. Later in the day (at 4.30pm), I overhead the patients’ nurse trying to phone the OT’s- who were no longer in their office. She then spotted me as I was leaving the ward and asked if I could find a suitable chair for the lady to sit out in, as she had not yet been seen by the OTs. I informed her that the OTs were seeing the patient first thing in the morning as they like to measure up their chairs to the patients height/ leg length (especially as she was a posterior approach). I also informed her that the patient was still vomiting and feeling unwell, and had been given bed ex’s and breathing ex’s to perform until we saw her again in the morning.

The nurse insisted that the patient be transferred out of bed (OOB), and she was going to get her up whether I would help or not. I again explained the patient’s situation, and also that if we transferred her OOB now, she would need to sit out for around 2 hrs before dinner, which would be too long. The nurse then gave me big lecture/ abuse saying how I was just being selfish as I probably just wanted to get home on time (although I only had the nurses quarters to get back to?!) and that being a student I should listen to what she wanted for the patient.

Her comments really upset me, as they were not only completely wrong, but because I knew it was not in the best interest of the patient to transfer her OOB. In the end, I ended up assisting the nurse to transfer the patient into a chair that I found and sized up, the whole time of which she was trying to tell me what I was doing wrong or a better way to do something. To cut a long story short- we transferred the patient OOB (TOWARDS her operated side which again the nurse tried to tell me was wrong), the patient sat in the chair, threw up 3 times and then had to be put back into bed- all of which I could have predicted.

From this experience, I learnt that although I may have been a student, I knew what was right and I should have been more assertive and stood up for what I knew, but I ended up just trying to please the nurse and avoid conflict. My supervisor believes I did the right thing, as in small hospitals she assured me it would have been worse to get on the wrong side of the nurses, however I still feel this was not right or fair on the patient.

high care patients

This blog concerns dealing with patients in hospital who are for palliative care or high care nursing homes. I came across such a patient on my neuro placement. He was an elderly man who had a dense hemiplegia and had been on the ward for about two and a half months and still had no sitting balance, no upper limb movement or no lower limb movement even with facilitation. Our supervisor wanted us to treat him aggressively on our four weeks there. So everyday for two hours two of us would treat this patient and we would literally be sweating afterwards and he would be exhausted. But after about the second week, we noticed such an improvement in him that it motivated us to keep on going. He was able to sit for about two minutes, although with very poor alignment, and his head control was dramatically improving.

We attended a number of team meetings for this patient and strongly recommended him for rehab along with the support of our supervisor, as we really believed that with intensive therapy he would be able to achieve a level of functioning that would enable him to return home to the care of his wife. Initially the decision was made that he was awaiting a place in rehab, and we were all very pleased with this outcome. Then on our last week we found out that they had changed their minds and thought that a high care aged facility would be more appropriate. The other student and I were really disappointed with this news, as we felt that all our hard work, including the patients, had all been for nothing. We knew that in a high care facility he would not get any rehab to the level that he needed, and the thought of him lying around all day really saddened me.

I spoke with my supervisor about this and she said that it happens a lot, and that at the end of the day the decisions are made in conjunction with the family for the welfare of everyone involved. I realised that his wife probably would have really struggled to care for him, and it would have put undue stress on her. I think it just highlights the importance of not becoming attached to patients, and to try separate yourself from the emotional aspects, to an extent, so that it doesn’t affect your treatment. The supervisor also said that it is just our job to keep on working really hard with the patient until their discharge because every gain we make will make a huge difference to them. I will always take this approach from now on.

Parent Interference

I recently finished my paediatric placement. Those of you who have worked with children, know you have to spend a lot of your time explainining your activities and hep to the family/parents. One particular patient I had from Malaysia was accompanied at all times by a private teacher, a private carer and as some times his mother.

Although we have to spend a lot of time explaining what child's behaviours we need to facilitate or change, I learnt from this particular client that it is also important to observe the parent's behaviour. These particular carers were still spoon-feeding him, they constantly carried him, when he took to long to get off the floor or wasn't doing an activity correctly, they would simply do it for him. It explained a lot, as during my sessions when the child had problems with balance or doing a task, he would simply flop to the ground. I could see then, how he was just expecting me to pick him up or do the task for him.

After learning this, I spoke to the carer's/family and explained how I would like them also to alter their behaviour, and how that would benefit and strengthen the child. I feel this had a great improvement on the childs saving responses, balance and overall strength and development. I feel I learnt that you must be aware of the entire picture of your patient's lives, not just the short time you spend with them during physiotherapy sessions!

Safety incidence

On my ICU prac, I was involved with an incident where I assisted another physiotherapy student in transferring a cardiac patient from a chair to a bed. He had a tracheostomy in situ and was on CPAP via ventilator. We also had 2 orderly staff and a nurse involved in looking after lines/attachments and assisting us.

During the transfer, every student's nightmare happened... somehow his tracheostomy was pulled out of his neck... so that it was dangling down in front of his chest. When we saw this, we had a few panicky moments where i knew myself and the other student (who were leading the transfer) thought "what do we do?" and I recall the other student saying "we should put it back in" (luckily we never went through with that idea)

The patient (quite comfortably) said "I'm alright!", following which we immediately sprung into action, sitting him down and sending an orderly to get a doctor immediately. The doctor was very pleasant, simply putting a bandage over his bleeding wound where the trachy used to be, and saying "well, you got off the ventilator 1 or 2 weeks early!"

I believe we froze for a few seconds because we were still in that "student" mindset - that the more experienced nurse or orderly staff would solve the problem. Although this situation resolved well, it did remind me to be vigilant and we should have acted and got help immediately, as we were the ones responsible for the situation. Although we were students we were still the ones leading the transfer, and obviously the other staff were waiting for our cues to act.

Keeping Focus

On my paediatrics placement, I had the opportunity to work with several children aged between 5 and 12. I found the experience challenging and rewarding, and I constantly had to come up with new games. One child in particular, aged 5, would only partipate if the task was a game or 'fun' activity - often he would make them intricate!

During my second week, I came to watch the end of a treatment session he had with a second year physiotherapy student. I realised that while she was trying so hard to come up with fun activities and play the childs intricate games, she was sacrificing the actual purpose of the activity. She was concentrating so hard on the game that she wasn't noticing when the child was leaning on a chair the whole time instead of using his postural muscles to maintain 2pt positions, etc.

It was a great reminder to me that we need to step back at times and keep focused on our actual roles as physiotherapists, as well as having fun with paediatric patients! I think it made my future treatment sessions far more effective.

Preparing for work and life?

Starting work in less than four weeks is to me a very daunting task, and one that will flash by without a moments thought. With this new responsibility, time load and case load I have had to think a little bit about myself. Over the year of placements I have had to struggle with the usual stress of being on placement, not being familiar with the place/people/supervisors, but also with my personal battle with arthritis. I remember days in agony that I went to prac, so as I didn’t appear to be slacking off, but really couldn’t perform to my potential because of it. With this in mind and my current pain level 3/10 sitting here writing this, I had a decision to make as to where my professional life would lead. Given the amount of emphasis placed on how much we will learn in the first year out puts some stress on choosing the right position. When reading over contracts I had to consider whether there was an appropriate emphasis on my future learning rather than target patient numbers/month, continuing education, insurance and last of all the type of physio treatments accessible and appropriate for myself. Due to my condition and possible longevity with the profession, it was important for me to analyse what environment would be able to accommodate my needs and help me treat the when and how I can- to me hydro and gerontology will hopefully be an integral part of my client base, mainly due to my interest in both areas but that I can physically handle them in large doses. Then looking into the future, being diagnosed within the first year of my physio degree and the progression being faster than I’d have anticipated, the unfortunate task is thinking about future studies that I may need to complete to continue working. No drastic decisions to make now, but just food for thought- I guess I may just add to those statistics of people who only hang around in the profession for 5-10 years!!

Reflection on blogging?

Struggling to find a topic that has not previously been discussed has been a major issue with my blogging thus far; so instead a reflection on this process I thought was invaluable for your comments! I must admit it has been useful to share my sometimes elaborated stories and incidents with you all- but it has also been refreshing to see that what I considered an issue to be blogged about, someone else had already done. Although we believe our clinical placement experiences are somewhat individualised this process has illustrated that we go through the same situations only in different locations. I have valued the opportunity in having the time to sit down and reflect on what difficult situations have occurred, but with this I have realised that I haven’t necessarily had many moments during my placements where I have had to strategise how to deal with things. However, with writing these blogs hopefully when working if I have issues that arise I have a way of dealing with it- even if I just have to write it down and read it back to myself to gain an understanding as to how momentous or how small the issue really is. Writing these blogs have given us an avenue to reflect on our personal reactions to situations and feelings we have experienced that I know I don’t often do in my normal life.

Prison procedures

Many of us don’t really think of what our patients do in their normal day-to-day lives or what type of person they are, but with one of my patients I had an extremely interesting shock into reality. The patient, on my first day at prac, was wheeled into physio on his wheelchair shackled by his ankles. My initial reaction was ‘Cool, this will be interesting,’ but on reflection I thought what am I signed up for? I had a brief read of his notes, the normal gun shot head wound, lives in prison, IVDU… Despite my reservations the patient is really nice (despite potential frontal lobe behavioural alterations anyone?) and responds well and appropriately during treatment sessions. This leads me to my ethical issue: Following procedures this man requires being shackled to his wheelchair and has been whilst he has severe LL tone, no voluntary control of his LL (now progressing to minimal-mod control) and doesn’t have the ability to STS or stand let alone walk without assistance. Is this cruel? Apart from this I had a brief but momentous reflection on what my own limits of safety were. Obviously, this patient caused me no problems, but it got me thinking that in some situations certain patients could inflict serious harm especially when working in such close proximity to them, and even more so when treating in ways that may be challenging to their psychological situation or physical situation. It also begs to differ whether or not the university should allow some sort of reprieve for students in treating certain patients. So just a word or warning- always be on your toes, because unfortunately looks can be deceiving.

being a supervisor

The other day I was thinking about if I would be a good supervisor or not because Im sure one day I will eventually have to supervise students or other physios. On my placements I have recognised the good and the not so good things about my supervisors and what I would do differently if I were in their position. I would definatly want to make the student feel welcome and a part of the team and to gain a good rapport with them. I spose in saying all this, not only has our placements developed our knowledge and clinical skills, on a deeper level its made us unintentionally learn other skills like supervision simply from our good and bad experiences of our relationships we have with our supervisors. I hope that makes sense??

Judging patients

Sometimes it is hard to not judge your patients on either who they are or the reasons for why they were admitted into hospital. I was on a burns unit and there are many ways people sustain burns including work and home accidents but also self harm. Its sometimes hard to not get carried away with what the notes say and how other staff members percieve the patient. Anyway I had a young male patient who I built really good rapport with and our treatment sessions were always good fun and effective. For some reason or another I missed in the notes that he had a history of IV drug use but no longer did it now. When I went back and read the notes again and noticed this, i started judging the patient because of this. Luckily this passed when I went and saw the patient the next time and I carried no judgement with me. This experience made me think about our role of physios of treating every patient equally and to the best of our ability. What the patient has done in the passed or is doing should be in the back of our minds when treating the patient but in no way should it make us treat the patient less or with less quality. Sometimes judgement does gets the better of us and can affect our treatments but learning to deal with this is so important for us as well as the patient's well being!

11 year old stroke patient

Whilst on placement one of my patients was an 11 year old who had a stroke! I have a niece who is a year older ad I teach kids that age swimming, which made me absolutely shocked that you can have a stroke at any age nowadays, especially with the increase in junk food and decrease in exercise. This child was fairly obese and it was so hard watching his parents and nanny give him “oxygen” (little sweets) to get him to do the exercise. Being a student from another country I did not feel I could try get the parents to stop this practice, especially since the physios didn’t seem to have been successful in doing it themselves, the child was too spoilt and although the parents spoke English the nanny did not. From talking with my supervisor about it I was told it was slowly being cut back as originally he was having at least 10 sweets a day, however due to the need to exercise and get as much recovery as possible they had not cut it out completely. I came up with games as bribes during my sessions rather than letting him have sweets, sometimes having half games half treatments to keep the child’s motivation up. Bribery is always the best motivator in children and I mentioned a few times to the mother that using computer game time would be a great motivator but unfortunately I don’t know if that will ever happen. By the end of the placement the child had recovered so quickly, he had improved balance and had started walking and his pain levels were also decreasing in his arm. It was quite upsetting seeing him like most kids forming an attachment to us then having to say goodbye but with his age he has a very good chance of making a better recovery and I can only hope that they can get on top of his diet and become firmer with him and his two siblings (both also overweight). I really hope this is the only child I will every have to treat for a stroke as it was heartbreaking to see the confusion and pain it caused this poor kid to have “fallen down”.

Group stroke sessions

The hardest thing at the start of my international placement was dealing with taking group classes for stroke patients; a group who could walk and a group where some couldn’t even sit without support. At first I stuck to my ways and kept thinking it would be so much better to use this time for one on ones but as I got drawn into the group atmosphere and the fact that in a country where people are hidden away if they have any impairments, a place to go and meet with people who are impaired like you is a massive moral booster. They encouraged each other, joked, socialised before and after class and even the most depressed patient who had given up at least did not get any worse and maintained what they had from the classes. I started to realise when you’re the only stroke specific organisation in the area with physios pretty much working as volunteers the best you can get is enough to keep your patients from deteriorating. Many exercises done for strengthening and balance can be done better in a group setting due to the motivation from other patients. I have realised what I have learnt does work very well for physical recovery but other things can also work and include the emotional side of healing from a stroke.

Language barriers

During my International placement I was faced with not just one patient who had no idea what I was saying but nearly all my patients having no clue. There were at least 8 different languages spoken with only 5 or so patients being able to speak fairly good English. This was difficult for the one on ones and extremely difficult for the first week of group classes. To overcome this I started picking up some words from the phrase book I had bought and listening to the carers and trying to see the reaction of the patients for certain words. In the one on ones I actually tended to be silent using demonstration and guidance along with a few key words like relax, pain?, roll, sit up/stand up, up/down, left/right, keep going and of course thank you. By just learning these few words in the primary language spoken the compliance level rose immensely. During group class exercises were grouped together so that when repeated, the patients would pick up that they were doing something they had done before. I made use of those who could speak English, either learning words or getting them to explain exercises. By the end of the second week there were fewer patients doing completely different things and by then they trusted me enough to just let me do my treatments and pick up what I wanted through guidance. I just had to trust my own manual handling and demonstration skills and think of at least 5 different ways to explain or demonstrate a task... simple as that.

Dealing with no sleep, full time placement and being a tourist on the weekends

On my International placement I found out how hard it is to stay focused on the placement and not become burnt out. firstly the workload is heavy, It was a group placement so 2 2hr classes of bridges, squats, weights etc a bit like going to a gym each day. Secondly you are in a place where you have never been before and cannot just drive to get somewhere. The busses had no numbers and the destinations were in another language, they had no schedule and half the drivers were illegal immigrants therefore missed stops to prevent getting caught. Then there’s all the touristy things beckoning you to do them… like climbing a famous mountain on the weekend then having work the next day. Or going to a beautiful island only to get badly burnt and yet again having work the next day i.e. trying to do bridges with a sore back. Lastly when you did get to bed, there was no such thing as quiet, either street kids, markets or the call to prayer put on loud speaker throughout the city around 12 and 5. Basically it was all work, all explore and no sleep. Along with the rich food, this caught up me in about the 3rd week. From there all the patients were annoying when they didn’t do the work, or the kids saying hello to you (very cute) was just really repetitive and I was half asleep and sick the whole week. I finally decided I had to do something otherwise I would go through the rest of my placement missing everything due to no sleep. I ended up one night putting ear plugs in, skipping dinner, not doing any preparation and going to bed at 5. I had to make the decision to put a basic need before going to the markets or staying up to talk to all the different backpackers. By doing this the next day I perked right back up. I sought out western food the whole day and from there I was fine both energy and stomach wise. I know that this will apply for the first few years of working, although there may be times when you want to fit more stuff in you have to realise sleep and looking after yourself is essential to put in the long haul.

Last placement ever!

Today as I reached the end of my last clinical placement of my undergraduate physio degree it was a funny feeling. My first thought was whether I am really read to step into the world as a physiotherapy expected to care for patients safety and help them on their journey to wellness. I probably dwell to much upon my inadequacies and don't see enough of what we have to offer as soon to be physiotherapists. When I look back to the start of this year I realise that there has really been a lot of skill development that has occurred. This is amplified if I think back to the amazing amount of knowledge that we've crammed into our heads since the start of this course.
As physio's we bring a unique perspective and skill-set to manage patients conditions. We are also in the priviledged position of spending a lot more one on one time with patients than some other health proffessionals. This means that our understanding of the patients viewpoint is another value attribute that we can bring to their management team. We also have a very extensive knowledge of anatomy (we are taught more than med students) as well as normal movement. Don't forget just how much we have to offer!
I am planning to work in the public hospital system for a couple of years to gain further experience before deciding what I'd like to do long term. I don't want to judge myself against all the physio's we've had as supervisors throughout the year because that's not who we are yet. They have all had years of experience to develop their skills and we are only just starting out on that journey. Congratulations everybody for nearing the end of this tough course. I wish you all the best in your lives and physio careers :-)

Supervisor going through personal problems

I was put in an interesting situation while on a recent placement. I was under the direct supervision of one physio and did fairly routine work day to day. I began to feel like the physio was being a bit distant with me and wasn't giving me adequate supervision but just put that down to the routine nature of the area and the personality of the supervisor.
It was only towards the end of the placement that I discovered that a member of the physio's family was going through some serious medical issues. I wasn't sure how to react to the information. She had obviously decided not to tell me about what was happening so I decided that she probably did not want to draw any attention to what she was going through.
I decided that the best way to react was to continue as normal as if I had not received the information. I continued with the work that I was given for the week or so until the end of the placement. I guess the thing that I learnt from this situation was to take into account things that our supervisors might be going through before judging them. We are beginnning to develop this skill of empathy with our patients but I think this is something that should carry over into our dealings with other health professionals as well.

Fast or slow?

On my current placement I had one patient who had been an inpatient for more than a month after contraction pneumonia and acute on chronic cardiac failure. He spent 9 days in ICU on a ventilator and had been transferred to my hospital for rehabilitation to regain his strength due to the prolonged period of bed rest. Finally he was discharged from the hospital and had been referred for Easy Breather classes to further improve his limited exercise tolerance. My job was to do a pre-assessment prior to him starting the classes.
Everything was going well with the assessment until I measured his heart rate before starting the 6 minute walk test. I wasn’t sure whether to believe the reading on the oximeter which told me that he had a heart rate of 39. I confirmed this by palpating his radial pulse and decided to talk to a nurse who had treated him as an inpatient before doing anything else. The nurse came to and confirmed the slow heart rate and was considering admitting him to the hospital again. I planned to contact his doctor to discuss the slow heart rate and then allow him to decide what to do. We were discussing this with the patient and decided to check his heart rate at the same time to make sure things weren’t making a turn for the worse. Upon palpation his heart rate was now around 82 bpm and it slowed down when he wasn’t doing anything but just sitting in his chair. After discussion with the nurse and my supervisor we decided to do the 6 minute walk test because his heart rate responded well to increased stimulation and returned to a normal level. The test went perfectly and his heart rate staying within a reasonable level during the whole test.
The main thing that this experience taught me was the ability to utilise and work with the other health professionals around me to ensure a patients safety. We worked together as a team and determined that the patient was safe to join the Easy Breather class.

Psych Issues in Patients

On my current placement I was asked to treat an elderly man who was admitted to the ward for respite because his wife was ill and unable to take care of him at home. The man was in his 80’s and I was asked to see him because he was becoming breathless and keeping the other patients awake by coughing all night. On examination he did not appear to have any problems that could be treated by physiotherapy. His SpO2 was normal and didn’t drop when he became breathless, chest sounds were clear and he didn’t have any diagnosed conditions.
During my subjective examination I discovered that he was a Jew and survived the concentration camps of the 2nd world war. He had a very hard life with a fiancé dying 2 weeks before their wedding and several other major life events taking their toll. Currently he was struggling with his wife and didn’t know whether she wanted him to come home when she was better. During our conversation he became anxious and emotional several times and it was during these episodes that he because wheezy and breathless. I had been told by a nurse that the night before he had run away from the hospital and they had to call the police to help find him and at first I wasn’t sure about the best way to help him.
My solution was to give him three exercises to do. The first was to teach him deep breathing exercises to do and I told him that this would help prevent further periods of breathlessness. The second was to teach him how to use controlled breathing when he was getting emotional to help him control the rate and depth of breathing when he was having one of these panic attacks. He final thing I asked him to do was spend the day finding one things that always makes him happy every time he thought about it. It could be a person, place or event but I told him that whenever he felt like he was going to get breathless that he should think about this thing.
I’m not sure how effective this treatment was because the next morning when I was planning to review his progress I found that he’d been discharged. I think that this was a good learning experience for me to discover how psychological issues can have such a profound physiological effect.

Skills for Supervisors

I have just finished my final placement of the course and it was also the one that I enjoyed the most and learnt the most. I think that a lot of our enjoyment and learning experience in a placement come from the attitude and direction provided by our direct clinical supervisor. I thought I would talk about some of the characteristics of my supervisor that made this placement awesome.
Approachability- I guess for me this is a big one. As students, we always have questions because we are new in the area and are still gaining experience. The best supervisors make you feel comfortable enough to ask the questions that you want to. You have to know that you wont be judged negatively to be able to approach someone to ask them a question.
Accessibility- The supervisor should have time available outside their own caseload so that you can ask questions and they can even observe your treatments. This is probably one of the harder things for supervisors but I remember hearing about some research done at Sir Charles Gairdner Hospital that found that the contributions made by student physios in treating patients equated to the time lost in supervision.
Knowledge- This one is fairly obvious. The supervisor should have enough experience and knowledge in the area to pass on to us. I had one supervisor this year who had graduated the year before and was on her first rotation after working for only about 3 months.
Constructive- Feedback given my the supervisor should be practical and constructive. It’s really important for us to know was areas our skills need to improve but constructive feedback would help us to fill in the holes in our knowledge, not just let us know that they exist.
Passion- This is probably the most important of all because if a supervisor is passionate about the area of physio in which they are working, this is infectious and we catch the passion. This both makes the placement more enjoyable and us more productive. Everyone’s happy :-)

Well, that’s my thoughts on this topic. I’m not sure how much it applies to us now, but for most of us at some stage in our life we’ll be in a position of leadership or management and these would be useful skills and characteristics to develop.

Dealing with Dementia

The other day there was a bit of a buzz at the nurses station. I’m currently on my rural placement around 800km from Perth and for the first time anyone could remember a patient was transferred from Royal Perth back to this town- by ambulance! There was even a doctor who came along for the 8 hour drive from Perth. Normally patients are transferred via a Royal Flying Doctor Service (RFDS) so this was quite unusual.
The patient was an elderly lady with severe dementia who had a long history of falls and fractures and this time had suffered a fractured neck of femur. She had been in Perth for about 2 weeks and had not been out of bed during that time because she screamed and complained if anyone tried to move her. The first time I saw her was with another physio and we managed to get her to stand, walk about 1.5 metres with a frame and sit out of bed in a chair. She screamed a couple of times but the nursing staff who had known her previously thought we were amazing for managing that much with her. Without thinking about it I realised ta we had used several strategies to encourage the patient to comply with what we wanted her to do.
I guess the first thing we did was to take the time to introduce ourselves clearly and explain a little bit about what we do as physios. I tried to imagine what it would be like to be in her place not remembering from one day to the next what people do and that we were trying to help her.
The next thing I did was to try and set a goal with the patients so she would want to achieve the same thing as us. She had a Bible beside her bed so I asked her if she would like to sit in the chair next to the window so she could enjoy the view and be able to read her Bible. She seemed to like the idea so we encouraged her that each step was part of achieving that goal.
The next technique that we used was distraction. Whenever she complained of pain we would distract her by asking her what she could see out of the window or what she liked to do. Afterwards the other physio explained that people with dementia are similar to children in that they respond poorly when they focus on the pain or problems that they are suffering. This is why distraction was such a useful technique.
The final thing we did was to allow the patient to do as much as she could by herself before we helped by assisting her to step or roll. She found any passive movement very painful and she was very stiff so encouraging her to do the movement was much more effective.I learnt a lot from the experience over several days with this patient and will feel a lot more confident when treating other patients with dementia in the future.

Metro versus Rural

I am currently on my rural placement and am enjoying the mix of inpatients, outpatients and community physio that I’m doing. It got me thinking about some of the benefits and drawbacks of working as a physio in the rural area.
The town where I am based has a population of around 13,000 and is situated in a beautiful area where many different outdoor pursuits are possible such as swimming, hiking, camping and cycling. Each day at the hospital has a lot of variety with mornings spent on the two wards seeing a mixture of medical and basic surgical patients and the afternoon spend in the outpatient clinic mainly seeing acute to chronic musculoskeletal patients. There was also ‘Easy Breather’ and ‘Gait and Balance’ classes to run and I was able to attend a couple of seminars and talks run by different rural health services. I began to consider whether I would work in the country and came up with this list of things to consider.

Pros of rural physiotherapy:
· The variety of work is interesting and maintains interest
· I find the country a beautiful setting to live
· There is a very laidback lifestyle
· Pay rates can be higher than metropolitan work
· You are given more responsibility as a new-graduate
· You feel part of the community
· You work closely within a small multidisciplinary team
· I could develop skills that could then be applied in 3rd world countries

Cons of rural physiotherapy:
· I would be away from family and friends
· Continuing professional development is limited and mainly self-directed
· There aren’t as many TV channels
· Everything’s more expensive (especially in mining towns)
· There’s limited opportunity for promotion
· Limited sporting opportunities
· You are unable to specialise in a particular area
· Complex patients are flown out so you miss out on experience with them

For me, I decided that I would quite like to work in the country but I’m going to stay in the city because of my group of friends, leadership responsibilities in my church and some of the volunteer work I’m involved in. However, it’s safe to say that my rural placement was definitely my overall favourite.

Electoripoffapy?

I am currently doing my rural placement and was treating a gentleman in his 80’s as an outpatient for chronic low back pain. He had severe degeneration on X-ray had not found a way to relieve the pain.
On the first occasion I saw him he told me about an ‘electrical therapy device’ that he and his wife had just purchased from a door-to-door salesman for $3600! Apparently the device had a pad that you sit on and a handheld arm that you move along the painful limb. I was shocked that they had purchased a machine for that price because as pensioners they obviously didn’t have a lot of many and good quality TENS machines are only $200-300.
My first reaction to the situation was not to get the man upset without a getting some more information. So I continued to question him and he told me that he had felt pressured by the salesman to purchase the machine and if he had known that his doctors would refer him to physiotherapy he wouldn’t have spent the money on it at all. I told him that I was interested in the machine and asked if he could bring in the instruction manual to the next appointment so I could get an idea of exactly what it claimed to do.
When there was a good opportunity I discussed the situation with my supervisor and we both shared the same concerns about this door-to-door salesman who was preying on pensioners and selling them electrotherapy devices at ridiculous prices. When the man came in next, my supervisor and I asked to talk to him and his wife to determine how to approach the situation and whether to contact the marketing company involved. The man’s wife shed some light on the situation. She had seen an advertisement in the newspaper for the machine and had sent in a coupon requested a free in-house trial. The machine actually turned out to be a cyclic massage machine and they were both adamant that they were now happy with the purchase. I compared the price to other massage machines online and discovered that it did fall within a normal price range. After further discussion with my supervisor we agreed that there was nothing more we could do because they appeared to be happy with the purchase ad no longer had an issue with the methods the salesman used to make his sale.
I found this a really useful learning experience in how to deal with the ethical situations that I might find myself in the future as a fully fledged physiotherapist.

Surgeons expectations

On my rural prac i treated a man post shoulder replacement. I had been treating the man for 2 weeks with minimal gains. Both myself any the senior physio tried multiple approaches to regain ROM. These included mulligans techniques as well as PAMS and a home exercise program.
The main problem was the patients compliance. During the sessions he claimed the pain was very high and refused the majority of treatment. any movement we did do were very restricted by the pt resisting the mvts. He also openly refused to do any of the shoudler AROM exercises at home as part of the HEP. We attempted to get the pt taking adequate pain relief but still refused. We tried as many options as possible and explained the consequences of his actions on his recovery.

After the pt went for his surgical review, the pt presented back to the clinic with a letter from his surgeon. It was an extremely angry letter blaming the poor physiotherpy treatment and management for the slow recovery of ROM. We sent a letter back explaining the situation and how the pt was self-managing. Another letter was recieved the next week from the surgeon with a very clear lack of concern about the pt's lack of self-management and a quote stating the "either you do something to move his shoulder or ill manipulate it myself".

In the end we tried referring the pt to the OT, social work and counselling services at the hospital plus the exercise groups to try and increase his participation. I dont know the result of this as my placement finished, but it was a very frustrating scenario as the surgeon was being very unreasonable and clearly had very minimal knowledge of the pt prior to the operation.

what have we learnt?

This isnt really a comment about the pracs but a discussions i had about what things from the placements we would remember and take on when supervising our own students. I think that i've had such a large variety of supervisors throughout the year and know some things that i would definately use and some things i hope i never turn out like.
It actually turned into a very interesting discussion and made me think about the pro's and con's of diffferent supervisors approaches and how much we learnt on each prac as a result. I am not going to tell you what techniques i am/am not going to take on, i just think its a very worthwhile task just having a think about it. I think if we remember all these feelings about supervisions we have now, when we start supervising we can make the scenario's much moore enjoyable for all parties.
Have a think!

How much do we know?

Regularly on ICU we have to follow up patients that get transferred to the ward, mainly because they are difficult pathologies that need longer handovers and a demonstration of aspects of their treatment. Whilst i was transferring over to the nursing staff and doctors i was amazed by how much we actually know even when we dont really think it. There were several aspects of my handover that the nurses and even the doctors was unaware of, which i needed to explain. Most of this was about suctioning on a extubated patient with and without a nasopharyngeal airway. Even though i wouldnt call myself an expert on this (i had seen it performed and done it once) the questions they asked seemed to be quite routine and easy to answer. It gave me a lot of confidence as a physio.
As i was walking up to the ward i was really nervous about my handover to the doctor and felt certain he would expect answers to questions i had no idea about... but this wasnt the case. He was very grateful for the advice and thankful that i took the time to come up and speak to him. It was nice to be treated like more than student for once!

Routine physiotherapy

I am on my placement at ICU at the moment. Just a quick comment about one of the difficult aspects of the treatment i found. It appeared that with the majority of patients, the treatment was exactly the same. If the patients are sedated and ventilated, all our treatment consisted of MHI and suction. This made it very easy to fall into a routine of just completing the treatment because "thats what we always do". I found myself half way through the prac having to try hard to break that cycle and attempt different strategies depending on the different patients. Even with these attempts, the onyl real treatment options remained the same but it broke the cycle of this "routine physio" that i dont want to become. was a bit of an eye opener none-the-less.

time management

On my neuro prac at the moment, I have had to learn how to manage my time extremely well and also to be able to coordinate my day with other students and with other health professionals. We have a number of patients who require double treatment sessions, and this means having to sometimes compromise so that both of you get your patients done in the required time. On this prac, both of us who are seeing the double patients also have a number of our own patients to see, and some of these are doubles with other students. It can all get a bit complicated, but with a bit of team work and common sense it all works out.

Adding to this is the fact that the speech pathologists and occupational therapists also want to get in to see some of our patients, especially when the patients are new to the ward. So this has been really good as it has developed my communication skills with other health professionals. Additionally, I have been able to double up the sessions with these other health professionals, therefore enabling me to see what their work involves, and having greater insight to the patients impairment and a more holistic approach. I never really realised how important this really was, but with patients who have had a stroke it is of great importance.
Time management is something we are all going to have to be very good at when we graduate, and having pracs which really push us to our limits is a good way of preparing us for the days to come. Also, liasing with other health professionals is a hand skill to develop and will always stand you in good stead.

stroke patients

I am on my neurology prac at the moment and am really struggling with a few aspects of neuro. As a student, we have been taught all this information about treating a person post stroke, and have gone into great detail on this. So, coming into this prac, I was under the impression that by doing all these things, I would really see a change in my patients. However, I have been there three weeks and have been seeing certain patients twice a day and have still not really seen any improvement. This was really getting me down until this past week. I honestly was feeling like I was selling the patients short, and that I didn’t feel that these patients should have students treating them. I felt that I was really impacting on their recovery in a bad way, considering that with stroke patients we are trying to retrain normal movement patterns, and as we are only students, we can`t really notice everything that a patient is doing wrong and be able to correct it.

I spoke to my supervisor about it, and she explained to me that it basically has nothing to do with us as students. She explained that the prognosis of recovery from a stroke is largely based on where the stroke occurred. She used my patient with a basal ganglia stroke as an example, saying his chances of recovering upper limb function were much less. She said that if it wasn’t for us students, most of the patients would miss out on treatment sessions. And she also added that if the supervisors thought we were doing anything that was interfering with the patients normal recovery then the supervisors would have intervened very early on.

This really helped me understand that even the knowledge we gained from class is enough for us to be effective therapists and give our patients a thorough treatment, even if we don’t think so. The key thing I have learnt is that it is good to talk about any questions you have, even when we are all qualified, we should never think we know enough to stop asking. And also, that continuing education should something that all of us take seriously, so that we continue learning new treatment techniques which will be of advantage to our patients.

Supervision

I know there have been a few blogs about supervisors and what not but i thought i might share my experience. On my prac at the moment I too have 3 different supervisors, all of which have completely different ways of teaching. Ones very particular, ones very flexible and ones in between. Seeing my curtin tutor once a week is the most supervision i have as my facility supervisors usually just check what patients i will see that day and then they will go off to outpatients or to another ward. Anyway its getting to the third week and i think my facility supervisors are realising they haven't really had the oppurtunity to assess me because they haven't seen me much with patients. So today my 'particular' supervisor decided to tag along to one of my sessions. By now I have got my own routine of how and when I assess, treat and educate my patients. I am in burns and usually assess my patient first and whilst treating them I will educate them on how important it is to keep moving etc etc. While I was assessing the patient this morning, my supervisor kept interupting and asking me what else would I ask them and what education would i provide which i was eventually going to get to. His questions were so vague that I had to keep asking him what he meant. I could tell he was getting a bit annoyed and probably thinking this girl is in her 3rd week and still doesn't know what to tell her patients! I am still a bit baffled by this situation and for some reason find it really difficult to work with this supervisor because he doesn't give me feedback of what I need to improve on or what I am doing well. It made me realise how important feedback really is whether it be good or bad because it points you in the right direction on how you are going and what you need to work on. Luckily for me I have 2 other supervisors that give me feedback and that gives me confidence that I am doing well but they also give me advice on how to improve certain aspects of my assessment and treatment.

Falls

‘Fall’

This is a scary word in the physio world and none of us want to have a patient fall while they are being treated by us. Most especially us students. We go to great lengths, or we should, to prepare our treatment sessions to ensure the utmost safety of our patients! Unfortunately we are bound to have several occasions over our careers where a patient, slips, trips or collapses on us and they have a fall. Sometimes this is due to unavoidable causes and sometimes it is due to a lack of planning or forethought. I have luckily not experienced this but have known of other students and physios who have had ‘falls’ or near falls throughout my placements.
Most institutions have a whole lot of paperwork that needs to be filled out following a fall and everyone makes such a big deal about this. I think that it is an excellent method of getting people to think about how the situation could have been avoided. To know what you could have done better or differently if it was due to something you did, or how to adapt the environment or equipment used to prevent the same thing from happening again. So try not to think of the paperwork as a bad thing but think of it as a method in which to improve your skills as a physio and how to make a safer environment for your patients!!

Exercise Classes

On my placement with Community Physiotherapy Services I was able to observe and run several different exercise classes. I got to see many different styles of leadership in a class and among several different levels of abilities among the clients.

I learnt that one of the most important aspects of running a class is the level at which you aim the class. I thought that I would share a few of the tips that were given to me.
First you need to know what the age group you are targeting is. However this may be misleading as you will need to look into the various conditions of the patients. Even by looking at these two factors you will not be able to tell the functional level of the clients/patients. This information might be gained from a handover from a previous physio. If there is no handover available to you my advice would be to take it easy for the first few sessions and observe the clients carefully as they walk into and out of the class and their participation during the class. Once you have gauged the client’s different functional abilities you need to structure the class around these. The class should be targeted towards the lowest functioning individual and then progressions made available for the higher functioning individuals within the class. This becomes difficult when you have a large class or if the difference between the clients is quite significant. If one or two of the clients are much more able than anyone else in the class you might want to consider different options such as attending a gym or community exercise class.

One of the physiotherapists I observed took an aquatic exercise class and she targeted her class very highly. I found it quite a challenge keeping up with her and wondered how all the little old ladies were keeping up. I asked her about this after the class and she said to me that she liked to make the class a challenge so that everyone in the class would progress. She stated that even if they were unable to perform some of the tasks they would be putting in 100% to attempt them as opposed to putting in a smaller amount of effort doing tasks they could already do. I thought that this was an interesting point and made me think about how I target my classes. I hope that all of this info helps. But bear in mind that she has been practising physio for many years and has been taking these classes for a long time. We don’t quite have that experience yet so still err on the side of caution.

Hospitality

We have all been on many different community and hospital placements this year, and by now are getting used to different staff and supervisors every month! I'd just like to say, however, how much of a difference it is having staff make the effort to be welcoming.

Although most staff go through the standard "orientation" checklist, on my current placement I found the staff so much more hospitable. Every one of the therapists I have worked with has assured me, many times, that they'd like me to ask lots of questions, and that if I have any problems whatsoever to let them know. I have found that some supervisors think asking questions is a sign of 'poor knowledge' of a lack of independence, so this meant a was a lot more comfortable asking them and could therefore learn as much as possible!

Furthermore I found that in hospitals, a lot of the time staff come and go and you barely learn their names. Even other therapists have often not learnt my name over the month id been at their hospital. At this facility, my supervisor makes sure to introduce me to every staff member and patient we come across. this too makes me feel so much more comfortable and part of the team.

I think that had i assessed some of my previous supervisors again, I would have definately suggested they encourage student questions and say something to that effect at the start of the placement, as by feeling so comfortable in my current prac i believe i have learnt as much as possible!

Supervisor/Student Interactions

At the prac I am currently on, I have been allocated 3 facility supervisors. These are all with me at different times, and they are collaborating on my final assessment. Although I have worked with many different supervisors before, I found it very difficult in this situation, mostly because all three of my supervisors had very different ways of doing things, writing notes, assessing patients, etc. I found I was consistently uttering the words "oh, thats what 'other supervisor' said to do.." Only one of the supervisors acknowledged that this was occuring, the other two seemed ignorant of the fact that i was having to try an adapt constantly to whoever my supervisor was at the time (sometimes i'd go through all three in one day)

Eventually I mentioned this to the supervisor who had aknowledged the differences between their techniques, and specifically mentioned that I didn't think the other two were aware. That small initiative made my life so much easier.. the next day when i worked with the other supervisors, and they asked me to do something a certain way, they said they knew it was probably another supervisors preference. Although I still have to try an adapt to each supervisor's techniques, I now feel much better knowing that they are aware of this. I also feel more comfortable making my own choices about how I want to assess/treat a patient and letting them know that that is the way id prefer to do so.

So from this, I've learnt that if we do have problems and feel that we can't say anything or we will be looked down upon, sometimes our supervisors simply aren't aware of the issues, and by just letting them know we can save ourselves a lot of stress!

referals

I am currently on a burns ward and I am also involved in some outpatient classes for burns patients. A man who had been recently discharged from the ward, came to the clinic last friday. The physio that runs the outpatient department was unaware that he had an appointment because no referal had been sent down from the ward. Seeing as the gym was quiet she invited the patient to attend the session. The patient had sustained a burn to his axilla and thus the physio began some intense stretches to his upper limb. When I came in I recognised this man from the ward because I had written a referal for him that my supervisor said he would take care of. I noticed the physio doing the stretches and began uming and aring as to whether this was appropriate as he had only had a skin graft 3 days ago and thus should only be really doing active exercises. I decided it was my responsibility to let the physio know this because I was more familiar with the patient than she was because she had no referal and thus no guide to treatment. When I told her this man was only 3 days post op she immediately stopped the stretches and rung my supervisor up on the ward who told her he had forgotten to give her the referal and that I was correct in that he should only be doing AROM exercises and stretching should begin next week. I am so glad I trusted my own knowledge and told the physio about the patient otherwise the graft may have been damaged. From this experience I have realised I should trust how much I know and have learnt how important referals are and how they guide the refering physio on the expectations and plans for treatment.

Sensory bombardment

For a continuing education lecture we had at RPH, we were taught about the important role sensation plays in relearning your body’s movements. We were demonstrated different techniques of sensory bombardment and how to then incorporate the newly awakened sensory pathways into functional tasks (like reaching, grasping, WB’ing). Walking back after the tutorial I had thought of a couple of patients that I could practice this on; we had been warned that it can provide some noxious results on some patients and therefore to choose them carefully! With slight hesitation I fulfilled the sensory bombardment techniques, adding on a few extra components of scratchy and soft surfaces which I compared left to right. I then followed this up with some WBing activities of the UL with facilitation of shoulder girdle and arm extension (as the patient has no voluntary control of UL), reaching and grasping activities etc. By the end of the session the most rewarding part of it was that the patient said to me “my arm actually feels a part of me.”
Despite my reservations of not having used the technique before, and not knowing if I was applying it to the appropriate patient it was very fulfilling for the patient to have responded in that way without any verbal prompting. From this, I learnt that it doesn’t matter if a treatment is not perfect, or if you’re not sure if it’ll work because if it doesn’t work out you just don’t have to do it again! It also reiterated the importance that we should not neglect the impact that sensation has on patients movement and spatial awareness, and that it should be integrated into patients programmes as early as tolerated despite them not having any return of voluntary control. If we can encourage the patient with sensory bombardment techniques, visualisation techniques and any activities to involve limbs that have no movement, this may enhance their speed of recovery or at least reduce any hurdles that may arise later due to neglect, neuropathic pain, avoidance etc.

Too many physios in charge

At the start of this prac we were under the charge of two/three different physios, and we were explained that we would receive an orientation of the ward, patients and what would be expected of us. However, the latter part was not done and instead in the confusion of who was looking after us, the physios would briefly whip us off to explain this treatment, then another treatment, then another physio would explain her treatment etc. By the end of the first week we hadn’t once followed our supposed daily treatment plan once and I was extremely confused as to what was expected of us in terms of our treatment rationale and strategies. As the patients we were seeing were also meant to be treated by the physios I thought it would be best to communicate with the patients treating physio so that we didn’t overlap in our sessions ie. If I did UL, they’d treat LL, or I treat sitting balance or standing balance, they do STS and walking etc. When I suggested this, I was told they no such collaboration was necessary and to treat irrespective of what they were going to do or their short term goals. The following week, the physios were changed and the treating physio came up to me, whilst I was treating the patient, and politely asked if next time we could talk about what we were going to treat so that didn’t both treat the same thing?!? What was I supposed to do…. It has been like that the whole way through the placement, a mixture of trying to please all the physios and not get in the way as well. I think that it would be useful if during our placements there was a definite one person who was in charge of us rather than a group. But, like most placements one needs to be extremely flexible and not take supervisors comments too personally!

Secret ally...

At the moment I am treating a patient who has not only received severe trauma and multiple residual deficits but does not originally come from an English-speaking country. His mother, who cannot speak any English, is present everyday and during their first week at the ward insisted on attending every physio session. The language barrier with the mother was causing difficulties due to the fact that during our treatment we were providing rationales to the patient for the exercises, but the mother couldn’t understand these. During the sessions, her anxiety and worried looks and comments to her son were presenting a hindrance to our treatment sessions and the pain-threshold of our patient. We have since asked for the mother to stay outside for treatments and he has progressed really well. This week, we have decided to bring in a translator to help explain the rationales for encouraging as much active movement as possible, as well as providing her with a HEP they can do together in his room. The fact that she is in a foreign country and cannot freely communicate with us must be extremely stressful for her and hence on her son to translate and explain everything. So, although she has been encroaching on our progress during our sessions I think it is really necessary to keep her involved in the process. I also believe she will be a strong ally in helping gain as much potential as we can from her son.