Whilst on my paediatric placement I came to learn the importance of the term 'family centered practise'. The physiotherapy department was situated at the school which the patient/child was currently attending. This yound boy was autistic, he was treated at the school and came to school every morning on the school bus. Therefore his mother did not come in regularly.
One morning a frantic call was made to the physio department and this young boy's mother was on the phone and was in a right state. Her son had started limping and she was terrified that she would be reported to child services as she believed that people would think that she had been abusing her child. Myself and the physiotherapist went to visit the mother at her home and managed to clam her down, assuring her that noone believed that she was abusing her son. We assessed her son and could not find any reason for his limping, and his limping was very inconsistent, we were able to get him walking normally after a few minuits.
The reason that the mother had worked herself up into such a state over this seemingly insignificant episode was that she was having to care for her son on her own. Her husband was working night shifts and would therefore be asleep in the days whilst she was caring for her son. Her son is only able to go to school 3/5 days due to medical reasons, her family lived a couple of hours away and the family were in a tight financial situation. As a result this poor woman had no time to herself, was unable to afford a carer or any respite for her son so that she could have some down time. We were able to find one of the teaching assistants at the school who offered to take her son for a couple of hours a week and we contacted a psychologist who she could talk to who would be able to place her in a better position to recieve respite.
From this I realised the value of looking at the whole family in a big picture and not just the patient/child that you are seeing. This mum had reached a breaking point and this was obviously beginning to effect her son, if we had been seeing her more often then this might not have happened.
Wednesday, June 25, 2008
Wednesday, June 18, 2008
Dealing with kids
During my paediatric placement I felt right at home due to my ability to pretty much let go and be a kid with the patient and make everything a game where they don’t realise they're getting treated. This is great for compliance but I soon found out you had to be careful how 'young' you become and how you treat the kids due to their condition/past.
One of the kids had a very nasty past history so not only was I playing the friendly everything’s a game physio but I was treating her differently, more gently without even realising it. She therefore was getting a little bit carried away and suddenly I had lost control of what she did. She would just laugh and think it was a game when I tried to get her to do anything a certain way as she just didn’t take me seriously. When I tried to use the stern lowered tone that works a treat on most kids she got upset, as suddenly it wasn’t all a game. This meant the compliance level dropped and I got a kid doing the arms crossed hmph that I'm sure anyone with younger siblings or nieces or nephews have seen.
I carried on the session with the other child that was there and decided to talk to the principal of the special Ed department who happened to be one of the foster carers for this child. Straight away she was giving me tips on being firm from the start and not letting her past get in the way. I had to look at her as a child from the start and not let her push the boundaries even if I did feel extremely sorry for her. Whilst I could make things into a game for compliance, rules had to be set from the start. ‘You can do this or this’ (make them believe they have the choice) or set out a layout of the treatment at the start with them and stick to it. I was also told to maybe keep the sessions shorter as the child’s attention span was not good and was another thing that was being worked on in her behaviour modification classes.
The next week when I came back I laid down the rules from the start when she was all happy to see me. I let her chose from two games at each station (balance, strength, core posture) ‘as long as she listened to me as to when each finished and the order’ and that was enough to keep her happy. I still joined in and kept most of the exercises as games (as when you have an excitable kid you have to keep them occupied and keeps the session flowing). But I changed my approach to the treatment and child and therefore got the compliance and she stopped pushing the boundaries. I may not still be on placement but I do swim teaching and still use this way of dealing with any new kid. Be the nice physio but don’t let them push your boundaries, even one inch.
One of the kids had a very nasty past history so not only was I playing the friendly everything’s a game physio but I was treating her differently, more gently without even realising it. She therefore was getting a little bit carried away and suddenly I had lost control of what she did. She would just laugh and think it was a game when I tried to get her to do anything a certain way as she just didn’t take me seriously. When I tried to use the stern lowered tone that works a treat on most kids she got upset, as suddenly it wasn’t all a game. This meant the compliance level dropped and I got a kid doing the arms crossed hmph that I'm sure anyone with younger siblings or nieces or nephews have seen.
I carried on the session with the other child that was there and decided to talk to the principal of the special Ed department who happened to be one of the foster carers for this child. Straight away she was giving me tips on being firm from the start and not letting her past get in the way. I had to look at her as a child from the start and not let her push the boundaries even if I did feel extremely sorry for her. Whilst I could make things into a game for compliance, rules had to be set from the start. ‘You can do this or this’ (make them believe they have the choice) or set out a layout of the treatment at the start with them and stick to it. I was also told to maybe keep the sessions shorter as the child’s attention span was not good and was another thing that was being worked on in her behaviour modification classes.
The next week when I came back I laid down the rules from the start when she was all happy to see me. I let her chose from two games at each station (balance, strength, core posture) ‘as long as she listened to me as to when each finished and the order’ and that was enough to keep her happy. I still joined in and kept most of the exercises as games (as when you have an excitable kid you have to keep them occupied and keeps the session flowing). But I changed my approach to the treatment and child and therefore got the compliance and she stopped pushing the boundaries. I may not still be on placement but I do swim teaching and still use this way of dealing with any new kid. Be the nice physio but don’t let them push your boundaries, even one inch.
Tuesday, June 17, 2008
Getting too close to patients
On a recent orthopaedic placement of mine I treated one woman who had undergone a total knee replacement. She was a lovely lady and would often tell me stories during treatment sessions of her dancing, or dinner parties, or her cooking (which often made it difficult for me to excuse myself to treat the other patients on my list!).
However after a while she was quite insistent that I should come to one of her dinner parties and that she would cook for me. Infact when I tried to say 'no' in any way she would go on to explain how she always had 'young' people at her dinner parties and how she would show me all her gowns etc etc... would ask for my telephone number or address repeatedly and it was terribly awkward to try and explain how I couldn't give out that information. Normally I tried to simply change the subject or leave quickly following the end of the session to avoid getting into that conversation. Upon informing my supervisor he was adamant that I do not give out personal information and would often call me away after treating her so that I could avoid having to explain (for the 10th time) why I couldnt go to dinner with her.
You probably have similar stories of patients who want to thank you but fail to understand that it is unethical for us to see them on a personal level. One of my classmates had a patient call up everyone with her lastname in the phonebook, asking for her or her mother so should could take them to a restaraunt. Luckily her number is private and not in the whitepages. I think it is tempting at times to take a gift or if we get on so well with our patients to want to get to know them on a more personal level, after all they are thanking us for our services and usually are lovely people. In future I realise that it is not always neccessary to delve so much into discussion of the personal life of my patients and that depending on their attitude sometimes a more strict and proffessional demeanor is required to avoid situations such as these. furthermore it reinforced to me that it IS definately unethical to accept a patients offer of dinner etc, and legally could be a downfall for us.
However after a while she was quite insistent that I should come to one of her dinner parties and that she would cook for me. Infact when I tried to say 'no' in any way she would go on to explain how she always had 'young' people at her dinner parties and how she would show me all her gowns etc etc... would ask for my telephone number or address repeatedly and it was terribly awkward to try and explain how I couldn't give out that information. Normally I tried to simply change the subject or leave quickly following the end of the session to avoid getting into that conversation. Upon informing my supervisor he was adamant that I do not give out personal information and would often call me away after treating her so that I could avoid having to explain (for the 10th time) why I couldnt go to dinner with her.
You probably have similar stories of patients who want to thank you but fail to understand that it is unethical for us to see them on a personal level. One of my classmates had a patient call up everyone with her lastname in the phonebook, asking for her or her mother so should could take them to a restaraunt. Luckily her number is private and not in the whitepages. I think it is tempting at times to take a gift or if we get on so well with our patients to want to get to know them on a more personal level, after all they are thanking us for our services and usually are lovely people. In future I realise that it is not always neccessary to delve so much into discussion of the personal life of my patients and that depending on their attitude sometimes a more strict and proffessional demeanor is required to avoid situations such as these. furthermore it reinforced to me that it IS definately unethical to accept a patients offer of dinner etc, and legally could be a downfall for us.
Monday, June 16, 2008
Prioritising patient
Last week showed me the importance of prioritising when you have a ward full of patients. When the physiotherapist on an opposite ward called in sick, we (the students) were brought in to take care of the patients on the ward which demonstrated the need to know what to look out for when prioritising your patient list for the day. With a basic handover, it was then a matter of looking through the files of the new patients to see whether or not they had to be seen; then rank the patients in case the load couldn’t be completely addressed during that one day.
Although this is a problem that we are taught about, its not really until we are faced with having to treat many patients that we can truly understand how to multi task. As my supervisor said “later never comes,” so if there is something that needs to be done on a ward you should never procrastinate otherwise you’ll never get back to do it. Being made to make the choices as to who needs to be seen was quite eye-opening especially as we would be expected to do this once we start working without too much previous experience. Despite being given a patient load during our placements, we aren’t given the ability to make the choices as to who should be seen and why.
This was an unexpected opportunity to put to practice our ability to speed-read patients files (and gain important information) and also justify why or why you weren’t going to see the patients. It is a skill that we all require but don’t get much of an opportunity to practice until we’re out in the workforce.
Although this is a problem that we are taught about, its not really until we are faced with having to treat many patients that we can truly understand how to multi task. As my supervisor said “later never comes,” so if there is something that needs to be done on a ward you should never procrastinate otherwise you’ll never get back to do it. Being made to make the choices as to who needs to be seen was quite eye-opening especially as we would be expected to do this once we start working without too much previous experience. Despite being given a patient load during our placements, we aren’t given the ability to make the choices as to who should be seen and why.
This was an unexpected opportunity to put to practice our ability to speed-read patients files (and gain important information) and also justify why or why you weren’t going to see the patients. It is a skill that we all require but don’t get much of an opportunity to practice until we’re out in the workforce.
Lung compliance
On a particular cardiopulmonary placement I treated a memorable patient who had some issues with treatment compliance. The patient was in hospital for a number of problems including one that affected their mobility necessitating the use of a gait aid and one that required general (abdominal) surgery. By the end of my placement they had been in hospital for more than 5 weeks and were likely to require several more weeks before being transferred to a rehabilitation hospital. My role in their recovery was to provide chest physiotherapy following their surgery and encourage mobilisation around the ward to increase lower limb strength and fitness. This was no easy task.
The patient was quite capable of mobilising to the shower with their gait aid and one assist for attachments but refused to do so instead requiring the nurses to do a sponge bath each day. They were very particular about how everything was done and would frequently refuse to have bloods taken, do deep breathing exercises, sit up in bed, or use oxygen therapy (at one point SpO2 was 80%) unless it suited him/her at the time. Curtains must be drawn at all times throughout the day and blankets should be folded perfectly following treatment. When treatment was refused the patient would even dictate how it must be written- ‘patient declined treatment’ rather that ‘patient refused treatment.’
I knew from the first 10 seconds of meeting the patient that they would not be easy to treat and made an effort from the start to develop a good rapport with them. At first I would make an effort to explain exactly why we were doing each exercise and mobilising. Unfortunately the patient would agree with me that the exercises were important but promptly refuse to do them anyway. Next I tried being firm with him/her and telling them that it was about time they got serious about getting better and started listening to advice. This was made easier because they had developed a lung infection (too much immobility and resting in bed???) but still resulted in treatment being refused on more occasions than it was complied with.
I finally came across a system that seemed to work. I would see the patient early in the morning and when they refused to mobilise I would make an agreement with them to come back in the afternoon and we could walk then. This seemed to work most of the time and my fondest memory of the placement was pulling back the curtains only to find the patient sitting on the edge of the bed doing their deep breathing exercises and some knee extension exercises.
Throughout all of the time I treated the patient I tried to act in a way they he/she couldn’t dislike me and I think this was key to maximising their compliance with treatment. I would also attempt to joke as much as possible with them and try to be interested in them as a person and I think this was appreciated. I guess the most important thing I learnt is that all patients are different and need to be treated in different ways to maximise their outcome. This particular patient was definitely a challenge but the greater the challenge the better the reward and I savoured the times when treatment compliance was successful.
The patient was quite capable of mobilising to the shower with their gait aid and one assist for attachments but refused to do so instead requiring the nurses to do a sponge bath each day. They were very particular about how everything was done and would frequently refuse to have bloods taken, do deep breathing exercises, sit up in bed, or use oxygen therapy (at one point SpO2 was 80%) unless it suited him/her at the time. Curtains must be drawn at all times throughout the day and blankets should be folded perfectly following treatment. When treatment was refused the patient would even dictate how it must be written- ‘patient declined treatment’ rather that ‘patient refused treatment.’
I knew from the first 10 seconds of meeting the patient that they would not be easy to treat and made an effort from the start to develop a good rapport with them. At first I would make an effort to explain exactly why we were doing each exercise and mobilising. Unfortunately the patient would agree with me that the exercises were important but promptly refuse to do them anyway. Next I tried being firm with him/her and telling them that it was about time they got serious about getting better and started listening to advice. This was made easier because they had developed a lung infection (too much immobility and resting in bed???) but still resulted in treatment being refused on more occasions than it was complied with.
I finally came across a system that seemed to work. I would see the patient early in the morning and when they refused to mobilise I would make an agreement with them to come back in the afternoon and we could walk then. This seemed to work most of the time and my fondest memory of the placement was pulling back the curtains only to find the patient sitting on the edge of the bed doing their deep breathing exercises and some knee extension exercises.
Throughout all of the time I treated the patient I tried to act in a way they he/she couldn’t dislike me and I think this was key to maximising their compliance with treatment. I would also attempt to joke as much as possible with them and try to be interested in them as a person and I think this was appreciated. I guess the most important thing I learnt is that all patients are different and need to be treated in different ways to maximise their outcome. This particular patient was definitely a challenge but the greater the challenge the better the reward and I savoured the times when treatment compliance was successful.
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.
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.
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.
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