Whilst on my musculo placement, I was given a patient from the previous student that had initially presented to the clinic the previous month complaining of chronic pain that affected her whole body. The elderly patient described 9/10 to 10/10 pain in her neck with extensive loss of mobility. Her past medical history was extensive including chronic dermatitis, coeliac disease, IBS, hypotension, claustrophobia and agoraphobia, which causes a severe fear of social situations and distrust of people around her.
On her first treatment session with me, the patient displayed extreme anxiety walking from the waiting room to the treatment cubicle and began to, what appeared to be “hyperventilating”. Knowing her history with hypertension and anxiety, I gave her a seat and closed the curtains around the cubicle to block out the distraction of the other students and staff. Thinking that this would relieve her anxiety, she appeared only to get worse and reported that having the curtains touching her made her feel sick. As such, I opened the curtains and moved her to a cubicle that was adjacent to a door where she could see an exit. Her anxiety started to decrease and she began to elaborate on how active she had been in her 20’s, seemingly avoiding all the AROM assessments and exercises.
I didn’t want to appear rude and interject as she already has a chronic fear of trusting people however, I was frustrated that I was unable to perform any hands on treatment with her as every time I attempted to make contact, even if I asked permission and warned her, she displayed a hypersensitive reaction. I learnt that the best thing to do was talk to her during the first treatment session and slowly gain her trust. Over the 5 weeks that I saw her she told me that I was the only person that she allowed to treat her and gradually I was able to perform more invasive neck mobilizations. She seemed grateful that I took into account her phobias whilst treating her and slowly her AROM improved to near FROM and her resting pain became negligible.
I learned that her psychological conditions were feeding a fear avoidance syndrome and contributing to her chronic pain and that getting her to understand this can prove to be extremely challenging. In these circumstances pain scores are not useful in determining progress rather ROM, confidence and developing trust are better indicators. Encouragement was crucial and distracting her with conversation and getting her to copy movements I was performing was one way in which I was able to help her realise not to be afraid of movement.
In the future, I will have a better understanding of how to treat patients using a more multidisciplinary and personalized approach. It is ok if no treatment or assessment is performed on the initial visit. Building a relationship with the patient is the basis to any successful intervention.
Thursday, May 29, 2008
Leave it to the PT
I am currently on placement at RPH-SPC spinal unit. In the first week i was given 3 patients that i would eventually independently manage. My supervisor set me the task to re-assess and write a thorough SOAPIER on each patient. Obviously this includes muscle testing and sensation etc. As i was taking notes on a patient's previous MMT (which had been recorded in the integrated notes by the doctor), my supervisor advised me not to use these measures to compare with my assessment as they are rarely correct. i thought this a bit strange as surely a Doctor in this field would assess muscle function regularly. After completing my own MMT assessment i found that muscles barely scoring a grade 3 had been recorded by the doctor as grade 5.
I was astonished at how anyone who is familiar with the MMT system could get it so wrong. There is a big difference between a grade 3 (full range against gravity) and a grade 5 (full range with maximum resistance). In addition, this particular patient had been RIB for 5/52 with Halo traction so even fully innervated muscles are likely to be deconditioned. I would say this situation arises due to the time constraints and other priorities medically for a SCI patient. However i would be horrified if that patient had been informed that he had full muscle function when in fact he didn't.
i am sure that these doctors have a lot on their plate and MMT is not a priority as they know the physios are able to spend quality time doing a thorough assessment. This just demonstrates how important assessment and re-assessment is. I have learnt that for every new patient transferred to the ward, a full assessment is required prior to commencement of any treatment.
When to discharge?
On my last placement I was treating an elderly man who was 5 years post stroke – (R) MCA. He had been receiving physio at the centre for the past few months (after being referred from elsewhere) and was seeing a mixture of different physiotherapists or students each time. His impairments included:
- Increase (L) sided UL and LL tone
- No activation of (L) UL or LL (below knee) muscles
- (L) sided neglect
- Abnormal gait pattern
This man had had very little recovery of movement in the past few years even with weekly physio since his stroke. During one of my treatment sessions with him, he told me that he knew that he wasn’t getting any further recovery and that he hadn’t completed his HEP in years (even though he told the senior physio he did it daily). He said he knew he would never improve further or if he did the gains would be insignificant. The only reason he continued with physiotherapy was to get out of the house and talk with some younger people.
I told the senior physiotherapist this and that in my opinion this patient should be discharged and referred to a community program so that he could still get the social benefits. The physiotherapist however said that any improvement is worthwhile and that if he still enjoys physio he should still be treated there.
This raised issues with me of how to know when to discharge a patient who has had a stroke several years ago. I know that some people experience recovery many years post-stroke so when do you say that that particular patient has achieved as much as they can and therefore discharge them? I still fail to see how providing physio to this man is an efficient use of public health services as he has not seen improvements in years and is not actively trying to work on his recovery at home. I suppose it just takes experience to see when it is best to discharge each patient and to assess if they can receive help from a community program.
- Increase (L) sided UL and LL tone
- No activation of (L) UL or LL (below knee) muscles
- (L) sided neglect
- Abnormal gait pattern
This man had had very little recovery of movement in the past few years even with weekly physio since his stroke. During one of my treatment sessions with him, he told me that he knew that he wasn’t getting any further recovery and that he hadn’t completed his HEP in years (even though he told the senior physio he did it daily). He said he knew he would never improve further or if he did the gains would be insignificant. The only reason he continued with physiotherapy was to get out of the house and talk with some younger people.
I told the senior physiotherapist this and that in my opinion this patient should be discharged and referred to a community program so that he could still get the social benefits. The physiotherapist however said that any improvement is worthwhile and that if he still enjoys physio he should still be treated there.
This raised issues with me of how to know when to discharge a patient who has had a stroke several years ago. I know that some people experience recovery many years post-stroke so when do you say that that particular patient has achieved as much as they can and therefore discharge them? I still fail to see how providing physio to this man is an efficient use of public health services as he has not seen improvements in years and is not actively trying to work on his recovery at home. I suppose it just takes experience to see when it is best to discharge each patient and to assess if they can receive help from a community program.
dodgy discharges
I recently completed a gerontology placement where a patient of mine was discharged following the physiotherapist's approval, the physiotherapist (student) in this case being me. At the time of the discharges I didn't believe the patient weas safe to be discharged but the team collectively advised me that they would not benefit from any further inpatient stay.
The patient was an elderly gentlemen (in his 80's) who had come in with multi-focal infarcts and had also had a fall. This patient lived at home with his wife and had only minimal services to provide cleaning every fortnight. For the patient to be discharged back home he needed to be safe and independent with all bed mobility tasks and ambulation as well as having adequate balance and saving responses, this is what I had an issue with.
The patient repeatedly failed to display adequate or safe saving responses with external perturbations and would also trip walking onto or over steps at least 40% of the time. Apart from this he was functionally independent. It was believed by the team that he lacked some insight into his behaviour.
This patient seemed functionally safe and independent but upon closer inspection had significant issues, which prompted me to discuss with my supervising physiotherapist the discharge options for this patient.
Ultimately it came down to the patients refusal of any services, the team were 100% correct in advising me that he would not benefit from any further inpatient stay and the patient refused any rehabilitative services offered by allied health. This lead to the patient being sent home with a four wheel walker he was to use when walking outside, a less than optimum outcome given his almost non impaired gait.
If the situation arised again, hopefully I would be more experienced and have a better idea of what options are available to me, not to necessarily force them on the patient, but to be able to convince him or her to take the safest discharge option available.
The patient was an elderly gentlemen (in his 80's) who had come in with multi-focal infarcts and had also had a fall. This patient lived at home with his wife and had only minimal services to provide cleaning every fortnight. For the patient to be discharged back home he needed to be safe and independent with all bed mobility tasks and ambulation as well as having adequate balance and saving responses, this is what I had an issue with.
The patient repeatedly failed to display adequate or safe saving responses with external perturbations and would also trip walking onto or over steps at least 40% of the time. Apart from this he was functionally independent. It was believed by the team that he lacked some insight into his behaviour.
This patient seemed functionally safe and independent but upon closer inspection had significant issues, which prompted me to discuss with my supervising physiotherapist the discharge options for this patient.
Ultimately it came down to the patients refusal of any services, the team were 100% correct in advising me that he would not benefit from any further inpatient stay and the patient refused any rehabilitative services offered by allied health. This lead to the patient being sent home with a four wheel walker he was to use when walking outside, a less than optimum outcome given his almost non impaired gait.
If the situation arised again, hopefully I would be more experienced and have a better idea of what options are available to me, not to necessarily force them on the patient, but to be able to convince him or her to take the safest discharge option available.
Day 1 THR Fainting Adventures
I was on my ortho inpatient prac, getting a day one THR patient up for the first time. His Hb was 112, blood pressure was 116/74 (supine) Sp02 = 98%2LNP and he had adequate pain cover. His post op orders were SOOB, ambulate FWB day one.
After performing bed exercises the patient was transferred 1 * min (A) into SOEOB (sitting over edge of bed), and his oxygen was taken off. He reported he was feeling really good and was pain free sitting out of bed. Objectively he was alert, had good colour in his face and was not sweating.
My supervisor had told me to take all THR and TKR patients’ blood pressure day 1 before getting them up for the first time. So I had the blood pressure machine close by and began to take his blood pressure. Whilst I was taking this blood pressure the patient reported he was feeling dizzy. So I told him to take a deep breath and wiggle his toes. 10 seconds after he reported dizziness he lost consciousness, his eyes rolled back and his body slumped backwards. I was able to catch him and reach for the MET call button a nurse ran in straight away and assisted me to get him back into bed lying supine.
As the patient lost consciousness the blood pressure reading finished, it came back as 88/43 and Sp02 = 96%RA. Lots of doctors ran in put him on 20L 02 via a mask. His next BP reading in supine came back as 100/50 with Sp02 of 100%. The patient regained consciousness wondering what the big fuss was about not remembering the event.
I stepped back hoping I didn’t do anything wrong. The doctors asked me what happened and told me I did the right thing. I thought doing the right thing would have avoided the MET call. The doctors put the loss of consciousness to a vasovagal syncope.
Reflecting on the event, I know I should have helped him straight into supine when he first reported dizziness. I was too worried about getting a BP reading and didn’t monitor him closely enough.
After performing bed exercises the patient was transferred 1 * min (A) into SOEOB (sitting over edge of bed), and his oxygen was taken off. He reported he was feeling really good and was pain free sitting out of bed. Objectively he was alert, had good colour in his face and was not sweating.
My supervisor had told me to take all THR and TKR patients’ blood pressure day 1 before getting them up for the first time. So I had the blood pressure machine close by and began to take his blood pressure. Whilst I was taking this blood pressure the patient reported he was feeling dizzy. So I told him to take a deep breath and wiggle his toes. 10 seconds after he reported dizziness he lost consciousness, his eyes rolled back and his body slumped backwards. I was able to catch him and reach for the MET call button a nurse ran in straight away and assisted me to get him back into bed lying supine.
As the patient lost consciousness the blood pressure reading finished, it came back as 88/43 and Sp02 = 96%RA. Lots of doctors ran in put him on 20L 02 via a mask. His next BP reading in supine came back as 100/50 with Sp02 of 100%. The patient regained consciousness wondering what the big fuss was about not remembering the event.
I stepped back hoping I didn’t do anything wrong. The doctors asked me what happened and told me I did the right thing. I thought doing the right thing would have avoided the MET call. The doctors put the loss of consciousness to a vasovagal syncope.
Reflecting on the event, I know I should have helped him straight into supine when he first reported dizziness. I was too worried about getting a BP reading and didn’t monitor him closely enough.
Monday, May 26, 2008
A challenging first patient
I am presently on my musculoskeletal placement and had an interesting case for my first encounter with a patient presenting with a new problem. The patient was familiar to the permanent team at the clinic and I was told that the patient was the “attention-seeking” type of patient.
After the session, I wondered if there were some real concerns that have been overlooked over the years. Patient mentioned in passing that the elbow problem was the cause of the jobless situation for the past 5 years and is presently volunteering. Patient has been looking in vain for jobs through the network for disabled. From a physio’s point of view, I do not feel that his problem is disabling. However, it is manifested to the patient as such even though irritability and severity of the problem is mild. Coupled with a diagnosis of mild fibromylalgia, we might have been guilty of dismissing his authentic problem as attention seeking.
I brought up these concerns with the supervisor and the issue about jobs was new information that has never been mentioned. Supervisor was reluctant to get too caught up with that and advised me to just focus on the physical impairment.
I wondered if being told that the patient was attention seeking actually affected my assessment of the patient. I could have dismissed some the patient’s real concerns as attention seeking which would definitely have some negative bearings on investigating the root of the problem. Or it could have swung my assessment the other way, where I try to find a “real” reason for the attention seeking.
I suppose I should have given the patient the benefit of doubt in the first session and after seeing the patient for a few more sessions, I would be able to make a better judgement. Even if the eventual judgement would still be that of an “attention-seeking” patient, at least I would have gone through the rigours of identifying a patient with special characteristics which would definitely be a valuable part of my learning.
I feel that this is a very challenging experience because often when we do our subjective assessments, we tend to focus on the problem instead of looking at the person as a whole. We fail to acknowledge that there are many other issues that can perpetuate or even be the trigger for the physical problem. This is especially hard for me because I came previously from a gerontology placement where the idea was the direct opposite, not to treat impairments rather look at the big picture and identify ways to modify activities for them to be functional.
I guess it is still the first week of my musculoskeletal placement, hopefully by the end of this placement, I would be able to develop a more balanced thinking in my approach to treating different kinds of patients.
Satisfaction with treatment
On my last clinical placement I was assigned to a patient for twice daily chest clearance sessions. This particular patient had been in and out of hospital frequently for the past few years. During the last treatment session before she was discharged she picked up my note book and pen and proceeded to write me an extremely complimentary ‘report card’ to show my supervisor. She said that it was nice to have things explained to her so she could understand why we were doing a certain treatment technique.
I was extremely touched by this action, and was thrilled that as a student I was able to make such a difference to this lady. She said that she was very lonely whilst in hospital and was quite concerned about what the future held for her. Each day when I arrived for treatment at our prearranged time she was ready to go.
The situation highlighted to me the importance of a good therapist-patient relationship and how good rapport can increase compliance to treatment dramatically. It also highlighted to me how scared and alone patients can feel whilst in hospital. As students we don’t have a lot of exposure to patients prior to 4th year, so they can be quite a scary prospect. But put yourself in the patient’s shoes; I’m sure they find hospital staff scary!
My experience with this patient has reinforced the need for good communication skills in clinical practice. As therapists we need to be able to find a common thread with all of our patients, in order to build rapport and ensure that the patient receives the best possible standard of care. Simple explanations can make a world of difference. We need to use our hands to treat, but also our ears to listen. Sometimes our patients just need someone to talk to, and we’re often the ones who are there. As an aside to this, we also need to be aware of the appropriate avenues for referral if the need arises, and need to ensure that we do not take too much on, as this can be emotionally draining. Each patient is individual and should be treated as such.
I was extremely touched by this action, and was thrilled that as a student I was able to make such a difference to this lady. She said that she was very lonely whilst in hospital and was quite concerned about what the future held for her. Each day when I arrived for treatment at our prearranged time she was ready to go.
The situation highlighted to me the importance of a good therapist-patient relationship and how good rapport can increase compliance to treatment dramatically. It also highlighted to me how scared and alone patients can feel whilst in hospital. As students we don’t have a lot of exposure to patients prior to 4th year, so they can be quite a scary prospect. But put yourself in the patient’s shoes; I’m sure they find hospital staff scary!
My experience with this patient has reinforced the need for good communication skills in clinical practice. As therapists we need to be able to find a common thread with all of our patients, in order to build rapport and ensure that the patient receives the best possible standard of care. Simple explanations can make a world of difference. We need to use our hands to treat, but also our ears to listen. Sometimes our patients just need someone to talk to, and we’re often the ones who are there. As an aside to this, we also need to be aware of the appropriate avenues for referral if the need arises, and need to ensure that we do not take too much on, as this can be emotionally draining. Each patient is individual and should be treated as such.
Sunday, May 25, 2008
Messy attachment mishap
Whilst on the orthopaedic inpatient ward during my last clinic an incident occurred following a miscommunication between the physio and I. The treatment plan was to assist the patient, a 72 year old male 10 days post-THR with pain complicating things due to metastatic prostate cancer, to stand and walk with a pulpit frame. His attachments were an IV line, IDC and O2 (which he did not need when we treated him.) Whilst transferring from sitting to standing his IV line came out. As he was also taking warfarin this was particularly messy; there was blood on his gown, the frame and the floor.
My immediate reaction was concern for the pain I expected it to cause the patient, however he was only slightly bothered by the incident, and seemingly more for the mess than the discomfort. We had the patient apply pressure to the bleeding hand with his other hand and elevate the arm until I had gloves on and a dressing to apply the pressure for him. While I did this the physio found a nurse to dress it properly and organised for him to have the IV line reinserted a little later on. I was annoyed at myself for letting it happen and felt that the reason was a miscommunication between the physio and I.
Initially I saw the patient alone and had checked the patient’s chart, pulled back the sheets and positioned the IVC, which was on the side of the bed we were going to be standing on. The physio then came in and put the bed down from the opposite side of the bed and removed the oxygen. At this point she said to finish getting him ready and sit him up then she’d be back to assist us with standing. I assumed she said finish getting him ready because she was unaware of what I had already done before she came and did not notice the IV line had no extra length where it was wrapped around the gown. Failure on my part to check everything on the other side or to ask the physio rather than assuming she had checked was the cause of the incident.
Through this incident I have become more aware of the potential for misunderstanding when working with colleagues in terms of the extra communication required when you are not performing all aspects of the task yourself. There is usually a benefit of having an extra set of hands, however it is important to be mindful that the other staff member is not a mind reader and you both need to be clear who is doing what. I believe it is also important to have a leader and an assistant in these cases. As I am a student and the other physio is a senior there was some ambiguity as to who was in charge. It was my patient and therefore I should have been in charge of the session. During the rest of the placement and in the future I will check things for myself when it is “my patient” or will specifically ask if the other physio has checked particular things to avoid a similar incident. Although it was an extremely unpleasant incident it gave me a useful wake-up call and learning experience!
My immediate reaction was concern for the pain I expected it to cause the patient, however he was only slightly bothered by the incident, and seemingly more for the mess than the discomfort. We had the patient apply pressure to the bleeding hand with his other hand and elevate the arm until I had gloves on and a dressing to apply the pressure for him. While I did this the physio found a nurse to dress it properly and organised for him to have the IV line reinserted a little later on. I was annoyed at myself for letting it happen and felt that the reason was a miscommunication between the physio and I.
Initially I saw the patient alone and had checked the patient’s chart, pulled back the sheets and positioned the IVC, which was on the side of the bed we were going to be standing on. The physio then came in and put the bed down from the opposite side of the bed and removed the oxygen. At this point she said to finish getting him ready and sit him up then she’d be back to assist us with standing. I assumed she said finish getting him ready because she was unaware of what I had already done before she came and did not notice the IV line had no extra length where it was wrapped around the gown. Failure on my part to check everything on the other side or to ask the physio rather than assuming she had checked was the cause of the incident.
Through this incident I have become more aware of the potential for misunderstanding when working with colleagues in terms of the extra communication required when you are not performing all aspects of the task yourself. There is usually a benefit of having an extra set of hands, however it is important to be mindful that the other staff member is not a mind reader and you both need to be clear who is doing what. I believe it is also important to have a leader and an assistant in these cases. As I am a student and the other physio is a senior there was some ambiguity as to who was in charge. It was my patient and therefore I should have been in charge of the session. During the rest of the placement and in the future I will check things for myself when it is “my patient” or will specifically ask if the other physio has checked particular things to avoid a similar incident. Although it was an extremely unpleasant incident it gave me a useful wake-up call and learning experience!
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