Patients who go on and on and on and sing…?

Over most of my placements I have primarily dealt with older patients and I’m sure all of you know… most older patients like having a personal physio student to talk to. Especially in the big hospitals where the nurses, doctors, physios and other health professionals are so busy and only have time to do the required job. On my cardiopulmonary placement this was set to extreme. I had group classes who would primarily talk in the classes rather than do the exercise, single one on one outpatient sessions where they would stop in the middle of a six minute walk test to talk to you and then when I was in the hospital inpatients would jump at the chance to tell you their exciting news that they “opened their bowels finally today” whilst you were trying to get the subjective done. One particular patient loved to tell me about his bowels, his pains, his life stories, his beliefs on God and the general meaning of life. On the first session he complained about all the staff, his breakfast, his lunch and.. that he hadn’t opened his bowels which made him sleep badly. I managed to get a treatment in, in double the usual time. I asked my supervisor what I could do and she told me I had to be firm and realise they don’t get angry if you interrupt them. The next day I was all set to be firm and interrupt and ask closed questions. I managed to get him out of bed, he talked a little bit when walking but up until when I was about to go I was very proud of myself… that was when he started passing on his heartfelt wisdom to me ending in none other than a song. I was literally mortified that the patient was singing for me and just stood there trying to not let my mouth stay open. Afterwards I quickly thanked him and hurried off (having missed morning tea) to the next patient. A few days later I was asked to treat him again and decided I needed to think smart this time. I devised a plan to see all my other patients, write their notes up and then see my singer 15 minutes before lunch. Saw him treated him, took him for his walk and with expert timing got him back to his bed right as his lunch was being served. I said to him he did very well today and deserved a good feed which he sat down, said thanks to me and got stuck into his lunch. Moral of the story, interrupting them and moving on to each task quickly works fine to stop the life stories, however clever timing and food works best. And if you do actually have the time, listen to them as I must say, some of his stories were actually pretty interesting.

reading notes

Obviously before treating a patient, reading their notes is one of the most important things to do. One thing I have often done in the past, especially if a patient has been admitted for a long time, was to glance over their history and pay the most attention to the newest issues at the end of the integrated notes. I have learnt on my prac at the moment, that taking the time to read the 'old notes' is just as important as the new ones. By just glancing over the patients older notes, you may miss important facts about surgerys, states of instability and their general pattern of treatment/management since admission. Although it takes a pretty long time to read notes (for me anyway) its so important to get an overview of how your patient has been going since their admission, no matter how long it is.

Prioritising so that safety is put first

Whilst on my RITH placement I initially found it hard to get used to the different environment set up (the massive increase in safety risks and things that could go wrong), the lack of senior/specialised people to solve the problems for you and the fact that no matter how easy the referral looked, the patient would always have more than that one simple problem.

Eventually I got used to going to peoples homes, I improvised by using a couch or bed and learnt to kneel down or get onto their bed nice and close, NOT try lean over and politely avoid going on their bed (most clients didn’t care if you asked first). I used paths around houses to get the patient to do their walking and ganged up with daughters, sons and spouses to get the patient doing the exercises and taking the precautions. Basically I learnt to do it with just another physio student and our two inventive brains. But for some reason I wasn’t planning my sessions perfectly enough for my supervisor, I would try treat their problem as a physio, for example if they had gone into hospital for a fall I would be positively itching to test muscle strength and balance and ROM…. But my supervisor kept pushing that as a RITH physio you have to go safety in the home/functional first and in subjective, you have to ask OT and social worker related questions which I had no experience with before. It took me quite a while to get this right where I wouldn’t panic inwardly and waste time if the person had dizziness problems or multiple falls or COPD (I had just come from a COPD community placement) that wasn’t on their transfer list and feel the need to fix those problems on the initial visit.

I finally got a set up in my mind where you check their function and safety around the house (walk around with them and watch them get in and out of the shower and on and off their toilet, bed and chairs) no matter how silly it feels asking them to do it. Then you go all gun ho with physio treatment/assessment with the time left and on that first session decide how you are going to discharge.

I now have firmly implanted in my head, when you have a set schedule and traffic to deal with, how to prioritise right after your subjective, on the spot. It doesn’t matter if you take a few minutes to do it and there’s that awkward silence while you write something down and sort everything out in your head. The only thing that matters is that you leave knowing that person is safe and now has a lower risk of readmitting into hospital because of your visit.

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.