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.
Monday, June 9, 2008
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.
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