chronic pain

While on my rural prac I encountered a chronic pain patient for the very first time. He was a middle aged man who had a 10 year history of lower back pain, which resulted in him quitting work and being on workers compensation for a very long time. When I first assessed him, he was very specific about where his pain was, and on physical examination I was able to establish some problems which I could treat. However, with each visit he made more and more problems became evident, and he kept remembering more things that he couldn’t do. So I became quite confused, even though I realised he was a chronic pain patient, I just wasn’t sure what exactly to do.
So I spoke with both my supervisors and they gave me a lot of education on chronic pain, because I feel this is an area we don’t get to spend a huge amount of time on in class. They educated me on the best management strategies for him, and that hands on treatment would work short term but he needed longer term management. So when my patient came in again, we spent the whole session just talking. He asked me why I wasn’t `treating` him as he always felt 99% better after treatment. I explained that he needed a much broader approach to his pain. I booked him in for hydro sessions, which he absolutely loved and which helped to keep his pain well under control. We also managed to address other issues in his daily life which may have been affecting him. The end result was a very happy patient who I felt happy to discharge from physio as I knew he had taken everything on board and would manage fine. After all the help and information from my supervisors I feel much more able at managing patients with more chronic pain now and will take the same approach as I did this time but modify it for each patient

very sick patients

Whilst on my cardio prac, I encountered a very sick 78 year old man who really challenged me. He had been admitted after NSTEMI and had had a CABG surgery. After this he was in intensive care for a few days longer than normal due to lots of complications. When he was finally admitted to the ward he was so badly deconditioned, and adding to this was the fact that he had to be on daily dialysis. So I started treating him and was able to help him clear his chest quite nicely, but I was not able to get him to ambulate. He would just tell me he was far too tired, and sometimes I would convince him to just take a few steps up and down the room with me, but other times he would just refuse. However, when my supervisor came in, he would agree with everything. So over the time he spent in hospital, he developed a pneumonia on top of everything else, and I felt really bad seeing as he was my patient.

This man also became very depressed, and started showing signs of some sort of neurological insult, but we were not quite sure what was going on and he was having head scans the day I left so I wont ever know. But I just felt that he was very untrusting of me because I was a student, and he would always comply with my supervisor. I also had times where I felt so bad going in there and waking him up for physio as he hardly slept during the night so I felt like he really needed any sleep he could get.

I spoke with my supervisor about it and she helped a lot. She said that with time you find out which patients are really really sick and those are the ones you back off on a bit. But you also learn how hard you can push someone within the limits of safety, and that this was a clinical judgement skill that would come with practice. She also said that unfortunately some patients just did not feel safe in students hands, and that was just a personal thing. And she reminded me of how much success I had had with my other patients and said that even for her there are some people she hasn’t had great success with. So in future, I will always talk over difficult patients with my supervisor along the way so that they can give me any handy hints for increasing patient compliance as a student. And I have also realised that in time I will be able to know which patients I can push a little harder than others.

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.