referals

I am currently on a burns ward and I am also involved in some outpatient classes for burns patients. A man who had been recently discharged from the ward, came to the clinic last friday. The physio that runs the outpatient department was unaware that he had an appointment because no referal had been sent down from the ward. Seeing as the gym was quiet she invited the patient to attend the session. The patient had sustained a burn to his axilla and thus the physio began some intense stretches to his upper limb. When I came in I recognised this man from the ward because I had written a referal for him that my supervisor said he would take care of. I noticed the physio doing the stretches and began uming and aring as to whether this was appropriate as he had only had a skin graft 3 days ago and thus should only be really doing active exercises. I decided it was my responsibility to let the physio know this because I was more familiar with the patient than she was because she had no referal and thus no guide to treatment. When I told her this man was only 3 days post op she immediately stopped the stretches and rung my supervisor up on the ward who told her he had forgotten to give her the referal and that I was correct in that he should only be doing AROM exercises and stretching should begin next week. I am so glad I trusted my own knowledge and told the physio about the patient otherwise the graft may have been damaged. From this experience I have realised I should trust how much I know and have learnt how important referals are and how they guide the refering physio on the expectations and plans for treatment.

Sensory bombardment

For a continuing education lecture we had at RPH, we were taught about the important role sensation plays in relearning your body’s movements. We were demonstrated different techniques of sensory bombardment and how to then incorporate the newly awakened sensory pathways into functional tasks (like reaching, grasping, WB’ing). Walking back after the tutorial I had thought of a couple of patients that I could practice this on; we had been warned that it can provide some noxious results on some patients and therefore to choose them carefully! With slight hesitation I fulfilled the sensory bombardment techniques, adding on a few extra components of scratchy and soft surfaces which I compared left to right. I then followed this up with some WBing activities of the UL with facilitation of shoulder girdle and arm extension (as the patient has no voluntary control of UL), reaching and grasping activities etc. By the end of the session the most rewarding part of it was that the patient said to me “my arm actually feels a part of me.”
Despite my reservations of not having used the technique before, and not knowing if I was applying it to the appropriate patient it was very fulfilling for the patient to have responded in that way without any verbal prompting. From this, I learnt that it doesn’t matter if a treatment is not perfect, or if you’re not sure if it’ll work because if it doesn’t work out you just don’t have to do it again! It also reiterated the importance that we should not neglect the impact that sensation has on patients movement and spatial awareness, and that it should be integrated into patients programmes as early as tolerated despite them not having any return of voluntary control. If we can encourage the patient with sensory bombardment techniques, visualisation techniques and any activities to involve limbs that have no movement, this may enhance their speed of recovery or at least reduce any hurdles that may arise later due to neglect, neuropathic pain, avoidance etc.

Too many physios in charge

At the start of this prac we were under the charge of two/three different physios, and we were explained that we would receive an orientation of the ward, patients and what would be expected of us. However, the latter part was not done and instead in the confusion of who was looking after us, the physios would briefly whip us off to explain this treatment, then another treatment, then another physio would explain her treatment etc. By the end of the first week we hadn’t once followed our supposed daily treatment plan once and I was extremely confused as to what was expected of us in terms of our treatment rationale and strategies. As the patients we were seeing were also meant to be treated by the physios I thought it would be best to communicate with the patients treating physio so that we didn’t overlap in our sessions ie. If I did UL, they’d treat LL, or I treat sitting balance or standing balance, they do STS and walking etc. When I suggested this, I was told they no such collaboration was necessary and to treat irrespective of what they were going to do or their short term goals. The following week, the physios were changed and the treating physio came up to me, whilst I was treating the patient, and politely asked if next time we could talk about what we were going to treat so that didn’t both treat the same thing?!? What was I supposed to do…. It has been like that the whole way through the placement, a mixture of trying to please all the physios and not get in the way as well. I think that it would be useful if during our placements there was a definite one person who was in charge of us rather than a group. But, like most placements one needs to be extremely flexible and not take supervisors comments too personally!

Secret ally...

At the moment I am treating a patient who has not only received severe trauma and multiple residual deficits but does not originally come from an English-speaking country. His mother, who cannot speak any English, is present everyday and during their first week at the ward insisted on attending every physio session. The language barrier with the mother was causing difficulties due to the fact that during our treatment we were providing rationales to the patient for the exercises, but the mother couldn’t understand these. During the sessions, her anxiety and worried looks and comments to her son were presenting a hindrance to our treatment sessions and the pain-threshold of our patient. We have since asked for the mother to stay outside for treatments and he has progressed really well. This week, we have decided to bring in a translator to help explain the rationales for encouraging as much active movement as possible, as well as providing her with a HEP they can do together in his room. The fact that she is in a foreign country and cannot freely communicate with us must be extremely stressful for her and hence on her son to translate and explain everything. So, although she has been encroaching on our progress during our sessions I think it is really necessary to keep her involved in the process. I also believe she will be a strong ally in helping gain as much potential as we can from her son.

too many supervisors

I am on prac at the moment and we have three supervisors each week, and things are becoming a bit confusing. I realise that every physio is different and they treat patients based on personal experience. But the problem comes when you learn something really great from one supervisor and think you are on the right track, only for the next supervisor to come along and ask you why you are doing something a certain way. This has happened a number of times. I was treating a patient with another student, and we were practicing sit to stand with the patient resting one arm on a large bolster to encourage him to make more use of his lower limbs during the task. Things were going really well, and the patient was happy with how he was going. One of the supervisors then came along, and right in front of the patients asked us to explain the rationale of using the bolster. When the other physio had explained it and had been using the bolster, it made perfect sense to us students and the performance of the task looked pretty good. The second supervisor then went on to explain all the reasons why we should not use the bolster. We did not want to say that the first physio had suggested we use it, because we did not want to sound rude. So we carried on the treatment session without the bolster, and the patient really struggled for the rest of the session. In my personal judgement, it gave him a sense of security knowing the bolster was right there in case he lost his balance, and once it was removed he really struggled to complete the task well. Due to this fact, extra load was placed on me and the other student trying to facilitate sit to stand and I needed the rests more than the patient.

This happened two or three other times last week, and I am feeling a bit confused. Who do you listen to? I have not spoken with any of the supervisors about this because I know they will just say that its all a matter of personal choice. But then isn’t it also our choice based on our capabilities as students. Is it not fair that we choose the option that we feel most comfortable with. I have spoken to another student who had this same prac and she said she experienced the same problem all the way through her prac. I think it probably wouldn’t hurt speaking to one of the supervisors at some stage and just voicing my concerns, just so that they are aware that I am willing to try different treatment options from all of them, but that we just may vary which ones we use. The other student and I have also decided that we will choose techniques based on which supervisor is there, and be able to rationalise why we are changing if we decide to do so.

Patient presence... and presents?

On my rural prac, I was treating a male outpatient for shoulder pain. On my initial assessment, he came across as a very friendly man and we chatted throughout the session. I was trying to be polite and show an interest in his hobbies etc. On the second session he was much more open, telling me about his life and interests and asking about my life and future plans etc. While still taking the conversation quite lightly, after the session I began to question whether it was apprpopriate for him to go into so much detail about his life with me. I brushed this off and just thought if he needed someone to talk to, there probably isnt any reason why it cant be me and that he was probably just trying to be nice to me as I was still very new to the town.
I was still a little unsure as to his intentions in the third session, but told myself just to listen passively and not reveal too much about myself in any answers I gave. At the end of this session, he gave me a gift of a CD which we had discussed and invited me to come and watch him and his band play on the weekend. I tried to politely refuse the CD, but he insisted I take it and just put it on to listen to in the office if we wanted. Thankfully I was able to think of a quick excuse as to why I wouldnt be able to go and thanked him politely for the offer.
This situation made me feel really uncomfortable as I was still unsure as to whether he was just being genuine and friendly or if he had other intentions. It made me realise that while it is good to build rapport with patients to earn their trust, you should have a definite 'line' set in your mind about what does and doesnt make you feel comfortable and to advise the patients of this should they approach this line.

OT vs PT

I've never really understoof why there is sometimes this rivalry between OTs and PTs. I went to China to work in a childrens rehab centre with 8 other occupational therapists. To be honest some of them had no idea what a physio does and just assumed I would be treating the patients with massage! Throughout my previous placements this year I tried to make an effort to recognise what an OT did because I didn't really understand their role. I attended my patients OT and speech sessios and began to become familiar with what my patients did outside of the physio and medical management. So i was a little bit offended that the OT students weren't familiar with our role because surely they had been exposed to a bit of it during their placements this year. Anyway on the trip I realised how well the two professions can complement each other. For example I would work with one of the children with another OT student. I would focus on the posture/positioning and challenge the child this way, whilst the OT did some UL work.
It made me realise that we shouldn't be so stubborn about our roles and who does what.
Working together, made the session so much easier, the child got more out of it and you could bounce ideas off each other to make the task more challenging etc.