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.

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.

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.

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.

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.

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.

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!