Put out of place...

I had an unfortunate run-in with a pair of nursing staff looking after a specific patient the other day. The patient has severe respiratory compromise associated with consolidation and had low levels of saturation- of which physiotherapy was indicated. Initially, I tried to discuss with the patients nurses when the most appropriate time would be for me to come and assess and treat their patient. This took several attempts due to the fact that the nurse continually ignored my questions and walked away from me several times. After persevering with a nice smile and patience, eventually I was given the ‘ok’ to continue. Between my assessment and treatment, where I had to consult with the supervisor as to my treatment plan etc. the nursing staff had turned the patient from the position I wanted to treat, onto their other side (draining the clear lung and with the clogged up lung on the bottom). Given the patient had been turned and secretions potentially mobilised I had to reassess again and finally treat. After the supervisor and I were happy with the results from treatment, we left the patient. Whilst writing up their notes I was abruptly interrupted by one of the nurses who walked up to me and said ‘You’ve broken the patient’ and just as abruptly walked off. I had a giggle to what happened, and went over to see the patient to make sure things were ok. Consequently the nurse was consecutively suctioning the patient 3-4 times in a row, without any sputum being brought up and without preoxygenating the patient and worried that he was dropping to 85%. Once they’d stabilised I continued writing the notes and overheard the nurse telling the other nurse what had happened, and not so obviously pointing out that it was after physio… I then again got another interruption from the second nurse talking loudly to me to “come listen to what you’ve done”. Going into the patients room and having these two nurses staring me down, I continued to listen to the patients chest (of whom they’d since moved him onto his back now- ie. Remobilised his chest which I nicely explained to them). Anyway his chest sounded fairly clear, which the nurse double-checked with his stethoscope and consequently huffed about the wheeze having disappeared.
After this incident I discussed it with the supervisor and we decided it was just something that should be laughed off, and that the patient had desaturated distinctly 5-10 mins after our treatment and that occasionally blame is passed onto students by some staff members more than others. Since this incident, I don’t feel like I’ve needed to change how to deal with the situation but am reassured that it is important to tell supervisors these things, even if you may consider then banal, so as to ensure they are aware as to any discrimination that may occur during your placement.

Mute patients

Currently being on placement where the majority of your patients are intubated and unable to communicate with you or the outside world, alerts me to the tendency to look at their “numbers” (aka ABGs, UO, ventilation settings) and easily forget patients names and details due to the lack of interaction you have with them. It was a realisation that I had when my supervisor, another student and I were talking over the patient about clinical based questions that I remember that the patient beneath could actually understand/comprehend everything we were saying. With this is mind, I recognised that it was important to still be considerate to the patient in terms of not only introducing yourself, but to still explain what you were going to do with them and the rationale behind it. Despite the fact that they won’t respond or reply to you (they may slightly during treatment), we are unaware as to what mental state they are in. A positive thing that has come out of this placement is the interaction between allied health members. Before and after treating the patient there is the enjoyable task of close liaison opportunities with the nursing staff which you don’t get on other placements. Since noticing, I have made it a focal part of treatment to talk and explain throughout the treatment about what’s happening and continue to thank them at the end of the session which I would if the patient were responsive.

character clashes

Whilst on my rural prac at a fairly large hospital, I developed a character clash with one of the physios in the department who happened to be fairly senior. I am sure everyone has found out that rural pracs are very hectic, and you are thrown in there and just have to get on with it straight away. My orientation to the hospital was good, but obviously you cant get through every small detail of the wards and the physio department in a few hours, and most supervisors and physios are aware of this and expect you to forget things and ask a hundred questions. I was responsible for being in the hydro pool twice a week, and that was all I was told. One of the days of the week, I was in the pool with the physiotherapist I clashed with. She was a lot older than all the other physios in the department, and was not the most welcoming person I have ever met. So on my first day of hydro, I was not quite sure of where all the patients paperwork was, or who was responsible for getting all the paperwork out etc. Unfortunately I was about to discover that that was my job, I just had not been told it on orientation. Also, on this day, for some reason the PTA had overbooked the pool. The physio then went on to give me a lecture on my responsibilities and to basically blame me for the mess. I tried to explain that I really had no idea that that was my job, but she would not hear of it. It was very embarrassing because all the patients were already in the pool. Anyway eventually we got on with the class and I was moving around the pool amongst the patients, and stopped for a second to stretch one of my hamstrings. At that moment she turned around and said that the pool time was for the patients to exercise, not me. I felt yet again so embarrassed and felt that she was now just targeting me for no reason. I felt that she thought I was incompetent, even though I had had good feedback from all the other physios, and I felt she was only seeing bad in me and not anything good that I did.

After the session I was very upset and spoke to my supervisor who was a fairly new grad. She told me that this physio was generally rude to everyone, and that I shouldn’t take it personally. She said that it didn’t really matter in the end what this physio thought of me because she wasn’t assessing me, but I still felt like I wanted her approval. In the end I realised that it wasn’t a personal thing, after I observed her being rude to a number of people that day. But I realised that as a student, it is probably better to just find out as much as you can from your supervisor about what your responsibilities are if you are required to take classes or hydro, so that you are always well prepared. In future I will make a point of finding these things out and clarifying what I am meant to do, so that if I am accused of not doing something I can support myself and say that I had asked but was told that I was responsible for the said job.

difficult patients

Whilst on my orthopaedic placement, I encountered a difficult situation with an elderly man who was about to be discharged after a total hip replacement. Prior to discharge patients are required to safely ascend and descend a flight of stairs in the physio gym on the ward. The patient in question had been a bit difficult from the start, not really paying much attention whenever I went over the precautions and positions to avoid after a hip replacement. I would often come into the room and he would be lying in bed with his legs crossed or lying on his side, and he did not quite seem to grasp why these positions should be avoided. Teaching him how to partial weight bear was a nightmare, and I had to ask my supervisor to help me out a few times to just reinforce to him that these precautions really were important and it wasn’t just that I was a student who was being overly cautious.

The situation occurred while I was taking him through the stairs. It was his second day of trialling the stairs, and I had gone over the order of “good leg first, then the bad leg and then the crutches” for going up the stairs, and “crutches first, then the bad leg and then the good leg” for going down. He was able to repeat this with each step, so after the second trial I stopped repeating the order out loud. The man then decided to try put his good leg down first on the way down the stairs first, meaning that his bad leg was supporting him, and I immediately stopped him and tried to get him to stand up again. He was in a lot of pain understandably, but then he got angry with me because he thought I should have just let him go down as he was. My supervisor was present and came over to help. I explained to him that if he had carried on any further his bad leg would not have been able to take the weight that it was about to take, and that he probably would have fallen. My supervisor agreed and supported me, which made me feel so much better.
He was still quite angry though, and that made me really mad because he had already been so non-compliant and disinterested in listening to instructions, and I had just been waiting for something like this to happen but was kind of mad that he had the audacity to blame me. Anyway I kept my thoughts to myself and he was ok in the end.

I spoke about it with my supervisor afterwards and she was very supportive and said she would have done the same thing. That did make me feel a lot better as I was worried that my decision had been the wrong one. But what I learnt from the whole thing is that even if you think patients understand instructions and you feel that you have been repeating yourself all day, when it comes to safety it is better to just keep repeating the instructions, rather give too much than too little. So in future that is what I will do, especially with non-compliant patients. I also think that you need to tell people that failure to follow the precautions and safety instructions will lead to damage to themselves, and make it very clear from the beginning. And it also might be useful having two people around for patients like this.

China

For my international placement I was in China working in a children's rehabilitation centre. Working at the centre was a lot more different than I expected. Obviously i thought treatments would be quite different, but i didn't realise that the way the staff actually treated the children would be so different to what I am used to. On the first day at the centre I was quite shocked out how the centre was run, where children take part in therapy all day every day. Each day they do the same things in a therapy based way rather than incorporating it into play to make it more practical and interesting for the child. Many of the newer staff were also really physical to the children. Yelling, pulling and pushing was seen every day. I felt like I just wanted to change everything they were doing because it wasn't the way I have learnt. After being at the centre for a few days, I became more patient and learnt ways to show the staff alternative treatment methods without actually telling them. They were really observant in our treatment methods and really picked them up well. One thing we were suprised about was that they were also picking up our passive and calm way of treating the children and how we made therapy fun as well. This experience really made me see that you shouldn't always judge people at first glance. It also helped me develop different ways of showing people different methods of treatment and you shouldn't judge peoples ability to observe what you are doing.

Lazy Handover Forms

I feel I was extremely lucky to have a rehab in the home elective placement and have it after my main three cardiopulmonary, neurology and musculoskeletal placements. This meant I was able to challenge myself in other ways which RITH, having many extra safety and problem solving issues, was excellent for. Another major challenge for this placement was trying to decipher referrals/handover forms which were missing information such as the actual contact number for the patient (you have to ring them up before you go in the morning) and various bits of their past medical history (I mean why would I want to know that this patient who was being treated for post op joint replacement had diabetes…) I encountered forms that were missing the 2nd sheet where the various therapy goals and home risk factors for the therapist were, there was one patient who apparently had her (R) hip done on one part of the form and (L) hip done on the other and another who’s form didn’t say a word of her problems with vertigo, just that she had a history of falls. This on top of generally no notes from the hospital made going to a complete stranger’s house to treat their problem a whole lot harder, which at RITH is never easy even when you’re completely organised. Although I haven’t had a hospital placement after RITH I have vowed to make sure even if I am in a rush to lunch or to another patient that I fill out forms correctly and with overboard information rather than the bear essentials. It’s not just something that will be part of the job; it’s a major safety issue and can be a Big hassle and waste of time to the next lot of people treating the patient chasing the information up. In saying all this, I did become very good at calling up hospitals and chasing up little bits of information that was missing, so if the same happens to you just call the hospital and ask for either the referrer or ask straight up for the hospital to page (whatever the pager number on the form is) and if that parts missing start square one with the patient number and name, you cannot fail. If it is you writing the form don’t forget that you have been seeing the patient for a while therefore little bits of information may not seem relevant but imagine you haven't seen the patient and are only getting your referral.

Support for Healthcare workers

I had my cardio placement on the oncology ward at royal perth hospital. This was a challenging placement as a few of my patients passed away whilst I was there. Each of the patients are facing an uphill battle and many are palliative. These are huge considerations with any treatment that we as physiotherapists may carry out. Many of the patients are in the hospital for extended periods or are frequent visitors to the ward as they come in for their chemotherapy treatments. You get to know the patients quite well as you see them fairly often and strong connections are built. When or if these patients pass away it makes it very difficult to deal with. It's easy to say not to get too personally involved but we're in a profession that involves caring for people and we just can't help it sometimes. Mostly we are able to deal with the death of a patient in a professional manner but occasionally this may affect you on a deeper level. As I have said, a few of my patients passed away. I was able to deal with these pretty well. I felt supported in the knowledge that there was a nurse councellor on the ward and that if I needed anyone to talk to about this I could. I just thought that it would be a good point to mention to other students that there should always be some form of councelling available in most workplaces and it's would be a good idea to find out where this support can be gained before you need it. I think that I was able to deal with my patient's passing away as I knew that there was this support in place if I needed it. So as students and even when we are finally out there in the workplace find out where your support networks lie!!