On my elective placement in Orthopaedic In-patients I treated a lovely lady suffering from Parkinson’s disease. She had undergone a right total hip replacement. Her progress notes showed she had been transferring and ambulating stand by assist for a number of days with no complications. I was curious to see whether signs of her Parkinsonism would show and if I would be required to implement strategies to overcome any bradykinesia.
During the treatment she transferred independently and without prompts, from sitting in her chair, to standing with a zimmer frame, to walking outside her room. She appeared to show no signs of bradykinesia other that the slight pause in her step at times.
However when we reached the hallway, she suddenly gave a cry “I’m going to fall”. She began to fall like a tree that had been lopped from its base. She remained as straight as a soldier as she began to plummet backwards. Although she was physically capable, she was unable to implement any saving responses to prevent herself from falling. She knew she was falling, but her body was unable to act in response to this. Her bradykinesia was now a lot more evident to see!
I thought this was a perfect example of how this impairment has the potential to put a patient at risk of falling.
In the future I will consider all patients with Parkinsons disease as having potential for falls risk and guard them accordingly, until I know them well enough to decide otherwise.
Tuesday, June 17, 2008
PTs involvement with PCAs and a noble colleague
The other day I assisted in standing a patient up from bed for the first time since they underwent a total hip replacement. Those involved in the transfer included my supervisor, a fellow Curtin PT student, a ward nurse and myself. I was positioned at the top end of the bed closest to the patients PCA. We initially asked the patient if they required a bolus of analgesia and they declined. However as they began moving they requested one. As the patient had one hand on a hoist and the other on the bed, I fetched their PCA for them. The patient asked me to give them a bolus, so I pressed the button.
The transfer continued as per normal and nobody mentioned anything about what I had done. After we exited the room, the other Curtin PT student took me aside and noted what I had done. We discussed the liability I had caused myself by administering an analgesic. At the time I had not realised what I had done as the patient had asked me to do it. However my fellow colleague was correct in saying that as a qualified physiotherapist, I would not be permitted to administer analgesics nor would I be insured if complications arose.
What I learnt from this scenario was firstly, never to administer an analgesic, even upon a patients request. In the instance of PCAs, the patient is the only person permitted control. If again asked by a patient to control the PCA I will decline the request and allow them to do it. In the wider spectrum of analgesics in general, we can only advise them to contact their GP for pain control.
I also greatly appreciated the way in which my classmate approached me aside of the other professionals. This was very noble of him. He had the opportunity to look good in front of our supervisor, but chose to approach me in private so not to embarrass me. I hope to use this approach in identifying colleagues mistakes their in future clinics or workplaces.
The transfer continued as per normal and nobody mentioned anything about what I had done. After we exited the room, the other Curtin PT student took me aside and noted what I had done. We discussed the liability I had caused myself by administering an analgesic. At the time I had not realised what I had done as the patient had asked me to do it. However my fellow colleague was correct in saying that as a qualified physiotherapist, I would not be permitted to administer analgesics nor would I be insured if complications arose.
What I learnt from this scenario was firstly, never to administer an analgesic, even upon a patients request. In the instance of PCAs, the patient is the only person permitted control. If again asked by a patient to control the PCA I will decline the request and allow them to do it. In the wider spectrum of analgesics in general, we can only advise them to contact their GP for pain control.
I also greatly appreciated the way in which my classmate approached me aside of the other professionals. This was very noble of him. He had the opportunity to look good in front of our supervisor, but chose to approach me in private so not to embarrass me. I hope to use this approach in identifying colleagues mistakes their in future clinics or workplaces.
No wonder patients dislike PT!
I apologise for this being a little late, my internet connection has shut down and I couldn't make it into uni till today to submit this!
Recently I had the opportunity to witness a total hip replacement, an experience not many of us have the opportunity to do whilst still students. The patient had significant OA of the hip and as such was scheduled for surgery. My supervisor advised me that this patient would be under my care once on the ward.
Watching surgery is fascinating! The surgeon made an effort to describe to me the process of what was occuring and gave me a run down of the anatomy (it looks so different to cadavers!). What shocked me was the brutality and force that was required to dislocate the hip and drive the metal into the femur. For lack of being able to describe this better, the surgery is quite grotesque and can sort of be related to carpentry. In saying this, all measurements are extremely precise with the biomechanics of the hip, femur and knee relationships being calulated so that the appropriate instruments and hardware can be selected. This is the first time I have noticed movement science and the physics we have learnt previously being implemented in such a real situation.
Once on the ward, the patient was treated by PT, OT and nursing staff and subsequently was discharged within 10 days with no complications. The human body is incredible and considering the extent of the trauma endured during surgery, the body's ability to regenerate is quite remarkable.
As PT's we are expected that we encourage patients and guide them out of bed and standing day one post surgery. In future I will have a little more empathy for the pain and discomfort they are experiencing! After witnessing how the surgery occurs, Iam not surprised that many of us have been called slave drivers, torturers etc etc. Although it is crucial that we emphasize early movement, I will endevour from here on to be a little more understanding when treating patients who have just received surgery!
Recently I had the opportunity to witness a total hip replacement, an experience not many of us have the opportunity to do whilst still students. The patient had significant OA of the hip and as such was scheduled for surgery. My supervisor advised me that this patient would be under my care once on the ward.
Watching surgery is fascinating! The surgeon made an effort to describe to me the process of what was occuring and gave me a run down of the anatomy (it looks so different to cadavers!). What shocked me was the brutality and force that was required to dislocate the hip and drive the metal into the femur. For lack of being able to describe this better, the surgery is quite grotesque and can sort of be related to carpentry. In saying this, all measurements are extremely precise with the biomechanics of the hip, femur and knee relationships being calulated so that the appropriate instruments and hardware can be selected. This is the first time I have noticed movement science and the physics we have learnt previously being implemented in such a real situation.
Once on the ward, the patient was treated by PT, OT and nursing staff and subsequently was discharged within 10 days with no complications. The human body is incredible and considering the extent of the trauma endured during surgery, the body's ability to regenerate is quite remarkable.
As PT's we are expected that we encourage patients and guide them out of bed and standing day one post surgery. In future I will have a little more empathy for the pain and discomfort they are experiencing! After witnessing how the surgery occurs, Iam not surprised that many of us have been called slave drivers, torturers etc etc. Although it is crucial that we emphasize early movement, I will endevour from here on to be a little more understanding when treating patients who have just received surgery!
family issues
On my first placement I was confronted with a situation in which I was made uncomfortable by the wishes of a patients family. The other PT student and myself had been treating this elderly gentleman who had come in for a craniotomy and excision of a tumour. We had been treating this patient for a week before further investigations revealed metastases in his lungs. His prognosis was declared poor and our rehabilitation aims changed as a result of this.
The medical findings were explained to us in the morning and a previously scheduled family meeting was to take place that afternoon. At this meeting his family, which consisted of a wife and a few daughters, requested that the patient not be told of the new developments. It should be noted at this point that although the patient did experience occasional periods of drowsiness, he had no other significant cognitive impairments.
This was explained to us before we went and saw him again and was obviously the cause of my discomfort. The patients family are the closest people to him and as hard as we try to treat him and help him get better we did not have the same degree of responsibility and emotional attachment that the family would. On the other hand what if the patient asked me about his condition and the results of his tests? Am I supposed to mislead the patient about a condition that affects him much more than it does me or even his family?
This was made even more difficult when during one session a doctor came in and informed the patient that he was "Dr. X from Oncology" and that he would need to speak to him later. Thankfully the patient didn't ask me anything about it, as patients are quite prone to do. During the course of the day my choice of action crystallised and I knew what I would do.
After discussing this with the senior physiotherapist and medical staff, it was decided that although we would not divulge any information for the time being, if the patient asked us a question we would answer it truthfully. Even if this led to the patient finding out about the progression of his cancer.
If this situation arose again I would do exactly the same thing, I would respect the family's decision to inform the patient at an appropriate time but if the patient was fully cognisant I would always answer truthfully any questions they had about their illness.
The medical findings were explained to us in the morning and a previously scheduled family meeting was to take place that afternoon. At this meeting his family, which consisted of a wife and a few daughters, requested that the patient not be told of the new developments. It should be noted at this point that although the patient did experience occasional periods of drowsiness, he had no other significant cognitive impairments.
This was explained to us before we went and saw him again and was obviously the cause of my discomfort. The patients family are the closest people to him and as hard as we try to treat him and help him get better we did not have the same degree of responsibility and emotional attachment that the family would. On the other hand what if the patient asked me about his condition and the results of his tests? Am I supposed to mislead the patient about a condition that affects him much more than it does me or even his family?
This was made even more difficult when during one session a doctor came in and informed the patient that he was "Dr. X from Oncology" and that he would need to speak to him later. Thankfully the patient didn't ask me anything about it, as patients are quite prone to do. During the course of the day my choice of action crystallised and I knew what I would do.
After discussing this with the senior physiotherapist and medical staff, it was decided that although we would not divulge any information for the time being, if the patient asked us a question we would answer it truthfully. Even if this led to the patient finding out about the progression of his cancer.
If this situation arose again I would do exactly the same thing, I would respect the family's decision to inform the patient at an appropriate time but if the patient was fully cognisant I would always answer truthfully any questions they had about their illness.
Monday, June 16, 2008
Priorities
Whilst on orthopaedic inpatients prac, for almost 3 weeks I treated a 46yr old man who had a fractured acetabulum, after falling off his boat onto the concrete ramp. Initially I saw him whilst immobilised in bed several times for his chest and maintenance bed exercises, every day for almost 2 weeks, and got to know him quite well. He was very anxious at times and always very clear on what he needed to happen during sessions. For example, he had a mild head injury a year previously which had resulted in nystagmus and occassionally nausea when he sat up too quickly, and so he was very clear on how gradually he wanted us to raise the bed tilt before he was eventually able to stand.
The post op orders stated that he was touch weightbearing (TWB) on the affected limb, and started walking with a pulpit frame. He was extremely nervous, and even told me that from the time of the accident the thing was most worried about was his first time standing and walking again, even more than the surgery or the pain. He progressed onto axillary crutches after a few days, and I tried to teach him a reciprocal gait pattern, still TWB on the affected limb. After approx 15minutes it seemed that this was too complicated for him at this time. He was very nervous about even putting his foot on the floor, making it very difficult. His personality was such that although he was very respectful of all the health professionals he felt that things needed to happen a certain way - his way.
As getting him up and walking was by far my top priority I let him adapt and use what was basically a NWB, step-through pattern instead, as he was able to ambulate at a reasonable pace independently. Two days later we walked to the PT gym to attempt stairs, as he had a couple of steps at home. My supervisor was walking with us as well, and knew about his anxiety and difficulty learning things. The consultant who had operated on this patient (a rather eccentric man!) saw him walking and said to him "you are doing very well." Then he said to me "why are you letting him walk like that?!" At first I didn't realise what he meant, thinking he believed it was unsafe. The consultant demonstrated to the patient what he should be doing in order to promote as normal gait as possible with the reciprocal pattern. The patient was then able to perform the pattern much better than 2 days previously and I looked quite foolish!
I was embarrassed that a doctor was telling me how to do my job (and rightly so to be fair), especially in front of my patient and supervisor. Fortunately all three of us knew that we had tried it already without success. I had become preoccupied by the main priority for his health as well as discharge, which was safe ambulation on the level and with stairs. Although I knew it was important to promote normal gait and avoid maladaptive movement patterns I failed to come back to this somewhat difficult task for this man once he was more likely to be able to do it correctly, and probably would have sent him home NWB, slowing his rehab.
I learnt from this experience that although there are times when priorities prevent you achieving the ideal outcome initially, it is still important not to forget that poor habits can still be changed early on once the top priorities have been met. When I am next presented with a patient who is unable to correctly perform an important task or exercise, even after demonstration, practice and feedback, I will not let this prevent them progressing to meet the main priorities from everyone's point of view. What I will do differently however, is to come back to the task frequently as they are progressing and are more likely to be able to achieve it.
The post op orders stated that he was touch weightbearing (TWB) on the affected limb, and started walking with a pulpit frame. He was extremely nervous, and even told me that from the time of the accident the thing was most worried about was his first time standing and walking again, even more than the surgery or the pain. He progressed onto axillary crutches after a few days, and I tried to teach him a reciprocal gait pattern, still TWB on the affected limb. After approx 15minutes it seemed that this was too complicated for him at this time. He was very nervous about even putting his foot on the floor, making it very difficult. His personality was such that although he was very respectful of all the health professionals he felt that things needed to happen a certain way - his way.
As getting him up and walking was by far my top priority I let him adapt and use what was basically a NWB, step-through pattern instead, as he was able to ambulate at a reasonable pace independently. Two days later we walked to the PT gym to attempt stairs, as he had a couple of steps at home. My supervisor was walking with us as well, and knew about his anxiety and difficulty learning things. The consultant who had operated on this patient (a rather eccentric man!) saw him walking and said to him "you are doing very well." Then he said to me "why are you letting him walk like that?!" At first I didn't realise what he meant, thinking he believed it was unsafe. The consultant demonstrated to the patient what he should be doing in order to promote as normal gait as possible with the reciprocal pattern. The patient was then able to perform the pattern much better than 2 days previously and I looked quite foolish!
I was embarrassed that a doctor was telling me how to do my job (and rightly so to be fair), especially in front of my patient and supervisor. Fortunately all three of us knew that we had tried it already without success. I had become preoccupied by the main priority for his health as well as discharge, which was safe ambulation on the level and with stairs. Although I knew it was important to promote normal gait and avoid maladaptive movement patterns I failed to come back to this somewhat difficult task for this man once he was more likely to be able to do it correctly, and probably would have sent him home NWB, slowing his rehab.
I learnt from this experience that although there are times when priorities prevent you achieving the ideal outcome initially, it is still important not to forget that poor habits can still be changed early on once the top priorities have been met. When I am next presented with a patient who is unable to correctly perform an important task or exercise, even after demonstration, practice and feedback, I will not let this prevent them progressing to meet the main priorities from everyone's point of view. What I will do differently however, is to come back to the task frequently as they are progressing and are more likely to be able to achieve it.
bladder and bowel accidents
A 19 year old male had a MVA, leaving him a complete T7 paraplegic. He has been attending physio rehab daily and is keen to become as independent as possible so that he is not a burden on his parents. The gym is a very friendly and open environment where all the physios and patients are in the same space, socialising and doing rehab. Last week, this particular patient had a bowel accident during treatment. The patient was embarressed over the ordeal. I was lucky enough to have another physio with me at the time and together we calmly alerted the patient, cleaned the area, put a bluey on his W/C and sent his back to the ward.
In conjunction to loosing all motor and sensory function below the level of the lesion, having a complete spinal cord injury (and incomplete, depending on the extent of injury) leaves the patient with an involuntary bowel and bladder. For this patient (as the lesion is above T12), he has a neurogenic/reflexive bladder and bowel, whereby the spinal reflexes are still intact without allowing cortical voluntary inhibition and voiding. Therefore to prevent leaking and overdistention a strict bladder and bowel routine needs to be inplace. This patient can do his own catheters, however needs assistance with his bowels. I think before this placement i was unaware of the reality of having a involuntary bowel and bladder. We being physios, focus on the motor and sensory areas.
I was glad that another physio was present at the time, so the issue was dealt with discreately and quickly. Having the guidance has shown me how to deal with situation if it is to arise again. In addition, this patient being so young and close to my age, i felt that he was more embarressed with me there. i feel that i acted appropriately, staying calm and asured him not to worry. The issue was obviously dealt with appropriately as at physio the next day, he felt comfortable to talk about it and continue rehab.
My supervisor explained that most of these patients are not bothered by their loss of limb function later down the track, its the bowel and bladder problems that become the main concern and frustration. In the future i will now endevour to educate patients on the importance of a strick bowel and bladder routine to prevent accidents not only in hospital but in the community where people will not understand. i am now confident i will be able to handle this situation adaquetely if it is to arise again. I just thought it would be interesting to inform you guys of additional issues we may have to deal with and to stay calm infront of the patient. Just put yourself in their shoes.
More than talking...
On my current placement I am working with a patient who has quite severe communication difficulties. He is very dysarthric, making his speech difficult to understand and he has problems achieving appropriate volume. He is also totally deaf in his left ear, and has significant hearing loss in his right ear. The main stepping stone to overcome when treating this patient has been dealing with communication, in order to perform the desired treatment. The patient has deteriorated quickly in the past 12 months, and he becomes very frustrated when he can’t relay his message or understand what we tell him. Although we cover communication strategies at university, it is quite challenging dealing with a situation like this.
His wife or parents accompany him to every physiotherapy session, and they assist with communication as required. To overcome this communication barrier, we have used a number of techniques that we have tried out and adapted as required to suit the patient:
- facilitation and contact to show him what is required
- speaking loudly and slowly on his right side
- gestures (his wife showed us the ones that she uses and we employed these)
- if we can’t get our message across, we ask for help from his family, and they tell him
- he has a writing board that can be utilized as required
- limit outside noise
I have been seeing this patient twice a week for an hour at a time for the past month, and over that time have learnt to be able to communicate quite easily with him. Having never worked with a patient like this before, I now feel confident that I can apply the communication techniques used here to other patients. As therapists we need to take time to find out what works for the patient, observe others communicating with the patient and take on board what they do, and we need to be able to think on our feet and adapt as the situation requires. This is also a situation that likely involves a mutildisciplinary approach and we need to liase with speech pathology, OT etc to ensure that the patient receives best possible care and optimal communication is achieved. As students we can often find ourselves talking until we run out of breath, but it is important that we work on developing our physical communication skills as sometimes action truly speak louder than words.
Patient re-injury?
Currently on my musculo outpatient placement, I sore a young guy who presented with a two week history of knee pain after a tackle in soccer whereby he hyperextented his knee. Initial examination revealed a possible lateral meniscus tear/sprain with an associated stain of popliteus. There was no additional laxity of any of the cruciate or collateral ligaments in his affected knee, although the patient was quite lax in both knees and generally hypermobile. Initial treatment consisted of mainly RICE to remove swelling, VMO exercises, quad co-contraction and taping to prevent hyperextension of the affected knee. The patient was seen a further two times and was progressing well with his HEP and was getting symptomatic relief from the taping. The patient was very eager to get back to soccer and asked if he could play a game that weekend, he was advised that his knee would most likely need 1-2 more weeks of rehab but he should test it out at training first.
He returned the following week having played a soccer game and further hurt his knee. He reported falling whilst running, with his knee collapsing laterally, he reported hearing a pop. Assessment revealed further damage to lateral meniscus, laxity and pain over LCL and possible damage to ACL/PCL. Mark was thus referred on to an orthopaedic surgeon.
Upon reflection of this event I ponded whether there was any thing I could have further done to prevent this situation. Should I have alert the patient not to play? Was further injury avoidable?
I discussed this with my supervisor and she concluded that this event was unavoidable and it was highly likely that it was going to happen at some point due to the patients generally lax ligaments. She had initially checked the ligamentous tests in the knee and was confident with the initial diagnosis. Even so, I still can’t help but think that if we had worked on his rehabilitation for a few more sessions’ maybe then re-injury was avoidable.
If a similar situation was to occur again, I think I would educate my patient to avoid sport for a longer period before returning. Testing the knee gradually at training until full intensity can be achieved. At that point, report back to the physio and then get the all clear to play. Patient advice has to be aimed at giving the patient a broader picture, explaining to them estimated time out from sport and risk of re-injury if this time is not given. By doing this, the patient can make an informed decision if they wish to play.
He returned the following week having played a soccer game and further hurt his knee. He reported falling whilst running, with his knee collapsing laterally, he reported hearing a pop. Assessment revealed further damage to lateral meniscus, laxity and pain over LCL and possible damage to ACL/PCL. Mark was thus referred on to an orthopaedic surgeon.
Upon reflection of this event I ponded whether there was any thing I could have further done to prevent this situation. Should I have alert the patient not to play? Was further injury avoidable?
I discussed this with my supervisor and she concluded that this event was unavoidable and it was highly likely that it was going to happen at some point due to the patients generally lax ligaments. She had initially checked the ligamentous tests in the knee and was confident with the initial diagnosis. Even so, I still can’t help but think that if we had worked on his rehabilitation for a few more sessions’ maybe then re-injury was avoidable.
If a similar situation was to occur again, I think I would educate my patient to avoid sport for a longer period before returning. Testing the knee gradually at training until full intensity can be achieved. At that point, report back to the physio and then get the all clear to play. Patient advice has to be aimed at giving the patient a broader picture, explaining to them estimated time out from sport and risk of re-injury if this time is not given. By doing this, the patient can make an informed decision if they wish to play.
when a patient is a friend...
The other week I was hit with quite a surprise when I went on the morning ward round and was then given my patient case load. One of the patients who had been admitted overnight was a guy I went to school with. He was BIBA with a life threatening condition and had an emergency operation that night. By the time I saw him he was stable but only just. Since I went to a really small highschool we knew everyone fairly well but I wouldnt say that we were really close friends.
I told my supervisor that I knew him and she asked whether I still wanted to treat him or not. I said that I would, especially because I knew he was awake and oriented so I could see how he was doing. It wasn't until that night that I realised I probably shouldnt have treated him. I didnt really stop to consider it from his point of view, that I would be reading all about his PMHx, getting up quite close to him and he may have thought I would then go and tell all our mutual friends about his accident. At the time I was genuinly concerned and wanted to see how he was doing and because we are so used to reading about peoples lives and getting really close, I forget that sometimes people may find this uncomfortable. I suppose part of me was just being plain nosy as well. It also affected me too as I found it quite confronting having a friend so badly hurt and seeing all the family around him, it really drives it home how upsetting it can be for family and how considerate we need to be, especially when it is something so acute.
I think that if I was unfortunate enough to get in this position again, I would try and see if there were other PTs available to treat the patient. Perhaps if I was really good friends with the patient it would be different as I would perhaps put there mind at ease as there would be one less 'white coat' hovering around them. However in this situation where I knew him but not the intimate details of his past history, I think I should have respected his privacy more and passed him on to a different student who would have been more objective than me.
I told my supervisor that I knew him and she asked whether I still wanted to treat him or not. I said that I would, especially because I knew he was awake and oriented so I could see how he was doing. It wasn't until that night that I realised I probably shouldnt have treated him. I didnt really stop to consider it from his point of view, that I would be reading all about his PMHx, getting up quite close to him and he may have thought I would then go and tell all our mutual friends about his accident. At the time I was genuinly concerned and wanted to see how he was doing and because we are so used to reading about peoples lives and getting really close, I forget that sometimes people may find this uncomfortable. I suppose part of me was just being plain nosy as well. It also affected me too as I found it quite confronting having a friend so badly hurt and seeing all the family around him, it really drives it home how upsetting it can be for family and how considerate we need to be, especially when it is something so acute.
I think that if I was unfortunate enough to get in this position again, I would try and see if there were other PTs available to treat the patient. Perhaps if I was really good friends with the patient it would be different as I would perhaps put there mind at ease as there would be one less 'white coat' hovering around them. However in this situation where I knew him but not the intimate details of his past history, I think I should have respected his privacy more and passed him on to a different student who would have been more objective than me.
Sunday, June 15, 2008
"New" patients?
A patient had an appointment for neck problems. Prior to this, the patient has been seen by 2 other therapists. Due to cancellations made by the patient, it was only the second time I am seeing the patient.
When asked about the progression of the problem, patient stated that it has plateaued and that was coupled with a tone of disappointment. Although the patient stated that there has been some much improvement since the very first assessment, the last few sessions did not seem to have helped. I probed further with leading questions, but the patient grew frustrated and said that I seem to be putting words into her mouth and that there are more stresses in life than just work stress.
I was taken aback and was lost for a second or two not knowing how to react or what to do. I then apologized to the patient for making her feel that way but reiterated that it wasn’t my intention. The patient was probably having a bad day as well because she apologized for what she said and we continued the session as normal and i decided to be more aggressive with treatment to really push the plateuing condition.
Firstly, it was probably the first time I experienced the patient coming back without feeling much improvement. Hence, I was not prepared for it and might have used too much leading questions to the extend that I was trying to get the answer i wanted to hear from the patient. Secondly, it was only the second time i was seeing the patient and the first session was spent more on getting to know the patient for myself.
I believe the next time a patient comes with no improvement, I will be better prepared to handle it by expecting that to be one of the treatment outcomes and just to progress the treatment. I will also be more aware with questioning to ensure that the leading questions are used to prompt patients to looking at areas that they might have overlooked but balancing on a fine line to make sure that it does not make the patient feel like this patient did.
Besides that, I feel that transfer summaries are very important as the first session with a patient that you are seeing for the first time is usually spent knowing the patient for yourself. Having a good transfer summary aids the therapist a fair deal in that process. Having said that, even with the best transfer summary, it will be difficult to be as effective as having the patient seen by the same therapist. Therefore, i feel it will help by adding in the transfer summary the most effective treatment for the next therapist to carry on with.
Monday, June 9, 2008
Boozy patient
In my last clinical placement at Royal Perth, I came across a situation in which I found myself reluctant to discharge a patient. I was not in fact concerned about the patient's health and safety once out of hospital but the safety of the general community. The patient had come in due to a history of falls, a surprising number of these at the local pubs. Alcohol was not suspected as a factor until his daughter visited and informed the staff that her father did in fact have some alcohol related issues.
In all aspects the patient from a physiotherapy point of view was safe to go home, with only outpatient physiotherapy for rotator cuff damage. During one of our conversations I mentioned that he probably would not be safe enough to drive due to some ROM limitations in his trunk preventing him from checking his blind spot. The patient also had coordination impairments which would not affect him unless he got behind the wheel of a car, where a quick response time is needed. On top of this the patients had the alcohol problem mentioned above.
After this discussion the patient still refused to rule out the chance that he would drive again. This stalled my decision to declare him safe for discharge as I believed he would be a danger to himself and others if he was on the road. I bought this up with the OT who informed me that the patient had been given a pamphlet detailing the legal ramifications if he chose to drive against medical advice.
I still had doubts about whether he would actually follow our advice or just keep on driving anyway. I bought this up with my supervisor and asked her what authority we had in this matter, apparently a new law means all the onus is placed on the patient to report any condition that prevents him from being safe driver. In light of this I made sure that I talked to as many of the team as possible about the patients intention to drive so that the issue was made aware of and was included more specifically in his discharge planning.
Ultimately when it comes to a situation like this, which is not usually considered the PT's domain, we are limited in what we can do about it. This doesn't mean we don't try, a pro-active attitude is needed so that issues such as these can be communicated to the medical and allied health team. We shouldn't assume that someone else will bring the topic up, it is more effective to expose them yourself as soon as you become aware of them.
In all aspects the patient from a physiotherapy point of view was safe to go home, with only outpatient physiotherapy for rotator cuff damage. During one of our conversations I mentioned that he probably would not be safe enough to drive due to some ROM limitations in his trunk preventing him from checking his blind spot. The patient also had coordination impairments which would not affect him unless he got behind the wheel of a car, where a quick response time is needed. On top of this the patients had the alcohol problem mentioned above.
After this discussion the patient still refused to rule out the chance that he would drive again. This stalled my decision to declare him safe for discharge as I believed he would be a danger to himself and others if he was on the road. I bought this up with the OT who informed me that the patient had been given a pamphlet detailing the legal ramifications if he chose to drive against medical advice.
I still had doubts about whether he would actually follow our advice or just keep on driving anyway. I bought this up with my supervisor and asked her what authority we had in this matter, apparently a new law means all the onus is placed on the patient to report any condition that prevents him from being safe driver. In light of this I made sure that I talked to as many of the team as possible about the patients intention to drive so that the issue was made aware of and was included more specifically in his discharge planning.
Ultimately when it comes to a situation like this, which is not usually considered the PT's domain, we are limited in what we can do about it. This doesn't mean we don't try, a pro-active attitude is needed so that issues such as these can be communicated to the medical and allied health team. We shouldn't assume that someone else will bring the topic up, it is more effective to expose them yourself as soon as you become aware of them.
Communicating effectively
Whilst on the orthopaedic inpatients ward on my last prac I had an experience with a patient and doctor which really reinforced for me the importance of communication in terms of respect for the patient as a person and their right to know what is happening in terms of their management. I had just introduced myself to the patient, an elderly man with a stable Cx fracture who also had a mild hearing impairment, though no significant cognitive deficit. I was almost finished my subjective examination when an intern came in and read the patient's drug chart. Then, without even apologising/asking/acknowledging that I was speaking to him he interrupted and told the patient that one of his medications would need to be changed. He spoke very quietly and I told him that the patient had a mild hearing impairment. Again he spoke to the patient very quietly, and was not heard.
I ended up "interpreting" for the patient by repeating everything the doctor said louder, which seemed very silly to me. He asked several questions about his new bowel condition that was preventing his transfer from the hospital as well as the changes to his medication. After twice not being heard (at a volume that I was stuggling to hear!) the doctor seemed to decide that it wasn't worth explaining things to this man as he wasn't going to understand/hear him. He continued to read the chart, when the patient asked him if he was a pharmacist. The doctor's reply was simply to hold his ID card up (which had his name, photo and the word "Doctor" on it) without so much as a glance up from the chart. To be honest I was quite appalled at this lack of any effort to communicate with the patient and explain things to him simply because he had a minor difficulty. Unsurprisingly the doctor left again without a word to myself or the patient.
For me this experience really reinforced the importance of considering the patient as a whole, and adjusting things, be they communication methods, treatment, management, education etc to suit the patient. In some cases it is extremely difficult to communicate with some patients and effectively get your message across, however more often that not it is a simple change that can make a huge difference, such as the volume of your voice. I also experienced first hand that health professionals do not always consider the patient's understanding of their situation to be important, as demonstrated by a complete lack of effort to provide him with this information.
I think if something like this happened again I would like to constuctively and respectfully suggest things to the person to help them, as part of the team, to communicate their message and answer the patient's questions. I think my surprise at being interrupted and still thinking about what I was doing prevented me really reacting to the situation, instead doing little more than standing there observing. I felt very sorry for the patient, who had no idea why he had the new bowel problems, (despite asking) so would not like to witness this again when it could be so easily avoided.
I ended up "interpreting" for the patient by repeating everything the doctor said louder, which seemed very silly to me. He asked several questions about his new bowel condition that was preventing his transfer from the hospital as well as the changes to his medication. After twice not being heard (at a volume that I was stuggling to hear!) the doctor seemed to decide that it wasn't worth explaining things to this man as he wasn't going to understand/hear him. He continued to read the chart, when the patient asked him if he was a pharmacist. The doctor's reply was simply to hold his ID card up (which had his name, photo and the word "Doctor" on it) without so much as a glance up from the chart. To be honest I was quite appalled at this lack of any effort to communicate with the patient and explain things to him simply because he had a minor difficulty. Unsurprisingly the doctor left again without a word to myself or the patient.
For me this experience really reinforced the importance of considering the patient as a whole, and adjusting things, be they communication methods, treatment, management, education etc to suit the patient. In some cases it is extremely difficult to communicate with some patients and effectively get your message across, however more often that not it is a simple change that can make a huge difference, such as the volume of your voice. I also experienced first hand that health professionals do not always consider the patient's understanding of their situation to be important, as demonstrated by a complete lack of effort to provide him with this information.
I think if something like this happened again I would like to constuctively and respectfully suggest things to the person to help them, as part of the team, to communicate their message and answer the patient's questions. I think my surprise at being interrupted and still thinking about what I was doing prevented me really reacting to the situation, instead doing little more than standing there observing. I felt very sorry for the patient, who had no idea why he had the new bowel problems, (despite asking) so would not like to witness this again when it could be so easily avoided.
Unsure of what went wrong??
Whilst on my hand therapy placement I was treating a young woman who had fallen on a broken bottle and subsequently had lacerated a great portion of her anterior forearm and palm, completely severing the majority of her flexor tendons and median nerve. She had been sutured and plastered initially for 3 weeks before doctors had decided to transfer her from Fremantle to Royal Perth to receive surgical repair. As such, she was immobilised in plaster for a total of 8 weeks prior to receiving therapeutic treatment.
She presented to hand therapy with tethering of the flexor tendons and a hypertrophic scar on the palmar aspect of her right hand that was severly restricting any movement into digital extension or wrist extension. I discussed with one of the senior hand therapists whom I was treating her with whether or not ultrasound would be an option to assist with breaking up the scar tissue as previous treatments with vibration and firm massage was having little effect. My supervisor seemed to think it was worth trying and was happy for me to proceed.
The ultrasound machine that was used at the clinic was old, one of the sonopulse ones, a model that we hadn't used at uni. I had reviewed my settings for ultrasound and selected the settings that would be most appropriate to use to break up scar tissue. Just to be sure I got one of my supervisors to check the machine settings and she was happy for me to proceed. I had gone through all precautionary questions and had performed the necessary sensory tests.
The patient displayed intact sensation and consented to continue treatment. As I was performing the treatment over the area of scar tissue on the palm one of the other hand therapists asked to speak to me outside. The PT asked me abruptly if I thought what I was doing was safe and I replied that I thought it was. He asked me why I thought so and I replied by saying that I had reviewed the unit and parameters, had checked with another PT and had permission by the other senior therapist whom I was treating the patient with as well as going through necessary precautionary sensation tests and questions. He harshy told me that the treatment was not safe and I was putting the staff in an awkward position of responsibility. I was so taken aback that and when I asked why it was unsafe he turned the question back onto me and did not respond. The only thing he said was that I was going too fast and should be moving the ultrasound head in circles. At uni we were taught not to move in circles but rather longitudinally. If the only thing I was doing wrong was going a little too fast, he could have told me in a much more professional way rather than pulling me out of the treatment room and yelling at me in front of all the other hand therapists. He then told me to continue with the treamtent, making no changes to the parameters.
To this day I am still not sure what I did wrong so if anyone can fill me in I would love to know. I know that not all therapists agree with the use of US, however in this instance it was worth giving it a go. I have gone over and over the parameters and still agree with what was chosen as did 2 of my supervisors. I was so embarassed and taken aback by this instance I am not as confident with using US, however I believe that what I did was not irresponsible or endangering the patient in any way.
She presented to hand therapy with tethering of the flexor tendons and a hypertrophic scar on the palmar aspect of her right hand that was severly restricting any movement into digital extension or wrist extension. I discussed with one of the senior hand therapists whom I was treating her with whether or not ultrasound would be an option to assist with breaking up the scar tissue as previous treatments with vibration and firm massage was having little effect. My supervisor seemed to think it was worth trying and was happy for me to proceed.
The ultrasound machine that was used at the clinic was old, one of the sonopulse ones, a model that we hadn't used at uni. I had reviewed my settings for ultrasound and selected the settings that would be most appropriate to use to break up scar tissue. Just to be sure I got one of my supervisors to check the machine settings and she was happy for me to proceed. I had gone through all precautionary questions and had performed the necessary sensory tests.
The patient displayed intact sensation and consented to continue treatment. As I was performing the treatment over the area of scar tissue on the palm one of the other hand therapists asked to speak to me outside. The PT asked me abruptly if I thought what I was doing was safe and I replied that I thought it was. He asked me why I thought so and I replied by saying that I had reviewed the unit and parameters, had checked with another PT and had permission by the other senior therapist whom I was treating the patient with as well as going through necessary precautionary sensation tests and questions. He harshy told me that the treatment was not safe and I was putting the staff in an awkward position of responsibility. I was so taken aback that and when I asked why it was unsafe he turned the question back onto me and did not respond. The only thing he said was that I was going too fast and should be moving the ultrasound head in circles. At uni we were taught not to move in circles but rather longitudinally. If the only thing I was doing wrong was going a little too fast, he could have told me in a much more professional way rather than pulling me out of the treatment room and yelling at me in front of all the other hand therapists. He then told me to continue with the treamtent, making no changes to the parameters.
To this day I am still not sure what I did wrong so if anyone can fill me in I would love to know. I know that not all therapists agree with the use of US, however in this instance it was worth giving it a go. I have gone over and over the parameters and still agree with what was chosen as did 2 of my supervisors. I was so embarassed and taken aback by this instance I am not as confident with using US, however I believe that what I did was not irresponsible or endangering the patient in any way.
Younger patients
On my current clinical placement I am working with a number of patients who are in the same age group as myself. Many of these patients have the same interests as myself, go to the same social locations and do the same things that I do on the weekend. The issue of working with patients in the same age group was raised during mid-placement assessment. My supervisor was interested in knowing how I was coping with the situation, and the following points were made.
There are several issues to be aware of when working with patients in the same age group as ourselves. The first of these is the importance of avoiding burnout by debriefing with colleagues or the like to ensure we are not taking on too much and keeping things to ourselves. One of the hardest things to cope with on this prac has been realizing that these patients were living the same sort of life as you and me before their accidents, and now they have months and years of hard work ahead in order to regain the slightest normalcy back into their lives. My tutor told me an example about a colleague who didn’t debrief or vent about the things she was dealing with at work in a similar situation each day, and eventually she left the profession because she didn’t identify what was bothering her and burnt out emotionally.
The second issue is being able to be both personal and professional towards these younger patients. That is, we need to be able to build rapport, and connect with our patients to increase things like compliance. However in building rapport, we also need to be able to establish a clear ‘patient-therapist’ relationship, without letting age similarities get in the way. Another student mentioned one lunchtime that she had a patient who acted totally differently around her compared to older members of staff, which is not fair, as we need to be respected as professionals in our field, regardless of age. This is as much our responsibility as it is the patient’s and we need to ensure that there are clear lines in the sand outlining our position and their’s, to ensure that the patients receive the best care possible.
I found this discussion with the supervisor to be very useful, and was glad that she identified these things to me. As therapists, we need to take care of ourselves both mentally and physically, and this experience has highlighted to me the importance of talking things over and debriefing about emotional or stressful situations. In the future I will ensure that I share with colleagues, and talk things through to ensure I do not ‘burn out’. It is also important for us to be aware of our professional standing, and to ensure that we are treated correctly with the right amount of respect from our patients. We’ve worked hard to get where we are, and should be treated as such.
Friday, June 6, 2008
Patients in reality...
I have had quite a fair amount of complex patients where either they present with more than one symptom or present with a totally different problem that I was told they are coming in for. This has proved to be very challenging even with two weeks before the end of this placement.
I will usually prepare by planning a standard assessment and reading about the involved joint or area. This has proved to be very helpful in straightforward cases, I am able to be very efficient with time and the session tends to flow seamlessly. However, reality is that people are dynamic creatures and they do not usually fall directly into presentations of conditions that we learn in theory.
With more than one symptom involved, we will have to establish if there is any relationship between the different symptoms which requires detailed questioning about the aggravating factors, fill up the body chart and map the pain pattern throughout the day for the different symptoms. Many a times it feels as though I am seeing 3 or 4 patients combined into one!! This is compounded by the fact that we have to work out all these within a certain period of time which always seems to be too little for me. It also does not help the situation if patients give you random information from everywhere that does not direct the investigation of the symptoms.
Although it is very challenging especially within a set amount of time, I actually welcome the challenge. I believe I need to be a bit firm with patients who tend to ramble, to interrupt them without seeming rude. This is also good practice for me to think on the spot, having all the random information in my head to and being able to organise them into information that forms a clinical picture of the patient in front of me. I guess I might have been too concerned with recording all the details of P1s, R2s, quantity of P2s instead of relying a bit more of my active memory to add all these to the clinical picture that is forming throughout the session. This is a good pit stop to reflect on how I can improve by making full use of the remaining time at this placement to develop the above strategies.
I will usually prepare by planning a standard assessment and reading about the involved joint or area. This has proved to be very helpful in straightforward cases, I am able to be very efficient with time and the session tends to flow seamlessly. However, reality is that people are dynamic creatures and they do not usually fall directly into presentations of conditions that we learn in theory.
With more than one symptom involved, we will have to establish if there is any relationship between the different symptoms which requires detailed questioning about the aggravating factors, fill up the body chart and map the pain pattern throughout the day for the different symptoms. Many a times it feels as though I am seeing 3 or 4 patients combined into one!! This is compounded by the fact that we have to work out all these within a certain period of time which always seems to be too little for me. It also does not help the situation if patients give you random information from everywhere that does not direct the investigation of the symptoms.
Although it is very challenging especially within a set amount of time, I actually welcome the challenge. I believe I need to be a bit firm with patients who tend to ramble, to interrupt them without seeming rude. This is also good practice for me to think on the spot, having all the random information in my head to and being able to organise them into information that forms a clinical picture of the patient in front of me. I guess I might have been too concerned with recording all the details of P1s, R2s, quantity of P2s instead of relying a bit more of my active memory to add all these to the clinical picture that is forming throughout the session. This is a good pit stop to reflect on how I can improve by making full use of the remaining time at this placement to develop the above strategies.
Tuesday, June 3, 2008
Differences in opinion
Extremely sorry for the late reply, forgot that today is in fact Tuesday and not Monday.
My first placement was a Neuro placement in which another student and I were subjected to three different tutors (2 facility supervisors and 1 CCT) who all had a say in our assessment. This was due to our initial facility supervisor going on holiday half way through the prac. Luckily for us all three tutors were experienced, senior PT's with a ridiculous amount of knowledge and the ability to facilitate (sometimes painfully) a great placement for me. The downside of this situation is that all three tutors had significantly different methods to their madness. These differences encompassed how we recorded and set out our notes, our methods of assessment/treatment and the way we interacted with patients.
This led to the fear that our end of prac assessments would be affected due to the fact that we were expected to learn and re-learn three different ways to achieve the same goal. A Neuro placement is hard enough but on top of that how are we supposed to cater to three different clinicians?
Nonetheless I was able to turn my initial frown upside down. I realised that during the final year of my Physiotherapy course I was being given the opportunity to not only learn from practicing PT's but to experiment with and trial different schools of thought. It is unrealistic to think that all PT's go about their business in the same manner and it is up to the student to be able to analyse these different methods so that by the end of the year we have a basic, yet individual philosophy towards our profession and the manner in which we act.
As for the fear of being given a less than satisfactory final assessment, remember that P's get the degrees. We should concern ourselves with taking as much from our learning experience as we can and maybe not worrying too much about our end of prac assessment as that should sort itself out.
My first placement was a Neuro placement in which another student and I were subjected to three different tutors (2 facility supervisors and 1 CCT) who all had a say in our assessment. This was due to our initial facility supervisor going on holiday half way through the prac. Luckily for us all three tutors were experienced, senior PT's with a ridiculous amount of knowledge and the ability to facilitate (sometimes painfully) a great placement for me. The downside of this situation is that all three tutors had significantly different methods to their madness. These differences encompassed how we recorded and set out our notes, our methods of assessment/treatment and the way we interacted with patients.
This led to the fear that our end of prac assessments would be affected due to the fact that we were expected to learn and re-learn three different ways to achieve the same goal. A Neuro placement is hard enough but on top of that how are we supposed to cater to three different clinicians?
Nonetheless I was able to turn my initial frown upside down. I realised that during the final year of my Physiotherapy course I was being given the opportunity to not only learn from practicing PT's but to experiment with and trial different schools of thought. It is unrealistic to think that all PT's go about their business in the same manner and it is up to the student to be able to analyse these different methods so that by the end of the year we have a basic, yet individual philosophy towards our profession and the manner in which we act.
As for the fear of being given a less than satisfactory final assessment, remember that P's get the degrees. We should concern ourselves with taking as much from our learning experience as we can and maybe not worrying too much about our end of prac assessment as that should sort itself out.
Late to appointments
Whilst on prac in musculoskeletal outpatients earlier this semester I encountered a private (ie paying per session) patient who was always late for her appointments. Between the student before me and I we had diagnosed as a medial collateral ligament sprain and medial meniscal tear of her knee. Follow-up appointments were initially one hour in length, and the patient was 15, 20 and 35minutes late for her first three appointments with me. For two of those she also had to leave 5-10 minutes before the scheduled finish time, which she informed me of at the start of the sessions.
I was becoming increasingly annoyed and frustrated as it became evident that this was not a one-off, and that she clearly expected me to race through assessments and treatments, without any concern for the pressure that put me under as a student. She would say things like "Oh don't worry about measuring that again, it's basically the same again" when I was reassessing my asterisk signs to determine the brief treatments I would provide. It felt to me like she had very unrealistic expectations - that she could turn up when she was ready for 20 minutes after being told she needed to allow an hour for all sessions, and that I could just spend all that time treating the impairments that may or may not have been getting better without me knowing. In addition to this, I believe she was not resting her knee as I was recommending she do - with the limited treatment I had time to provide and constant exacerbation on her part, her knee was not going to get better for some time. This also seemed to frustrate her (understandably), even when I explained this to her.
When she turned up 35mins late to the third appointment I told her that I could not treat her, as it was unfair to me, her (in terms of responding to treatment) and patients I had after seeing her if we went overtime, which was quite likely. She was not pleased to hear this at all, however my supervisor backed me up and she seemed to understand after several minutes of discussion. I suggested other options, such as qualified outpatient clinics where 20mins is a much more realistic session length, however she would still need to be on time for them as they would have a similar policy. She did not like this idea either, however she did not come back to our clinic, so she may have followed this path.
This was the only time something like this happened on my 5 week placement, however I think it was a useful experience to be put in the position where I had to put my foot down about how I was being treated. It was difficult in that she was willing to pay for the treatments and have them rushed through, though I felt it was not as effective as it should be and that I was being put under additional pressure.
After the first session I assumed her lateness was a one-off and didn't make an issue of it as she apologised and blamed traffic. At the second visit I did mention that she needed to be on time, however in hindsight I think I should have made it clear how important this was for all parties. I think being clearer when addressing the patient's expectations and trying to make them more realistic earlier on would also help to prevent her lateness and frustration with her progress, gaining better compliance to education and treatment. Does anyone else have any other suggestions of how to deal with this sort of problem or better still, prevent it?
I was becoming increasingly annoyed and frustrated as it became evident that this was not a one-off, and that she clearly expected me to race through assessments and treatments, without any concern for the pressure that put me under as a student. She would say things like "Oh don't worry about measuring that again, it's basically the same again" when I was reassessing my asterisk signs to determine the brief treatments I would provide. It felt to me like she had very unrealistic expectations - that she could turn up when she was ready for 20 minutes after being told she needed to allow an hour for all sessions, and that I could just spend all that time treating the impairments that may or may not have been getting better without me knowing. In addition to this, I believe she was not resting her knee as I was recommending she do - with the limited treatment I had time to provide and constant exacerbation on her part, her knee was not going to get better for some time. This also seemed to frustrate her (understandably), even when I explained this to her.
When she turned up 35mins late to the third appointment I told her that I could not treat her, as it was unfair to me, her (in terms of responding to treatment) and patients I had after seeing her if we went overtime, which was quite likely. She was not pleased to hear this at all, however my supervisor backed me up and she seemed to understand after several minutes of discussion. I suggested other options, such as qualified outpatient clinics where 20mins is a much more realistic session length, however she would still need to be on time for them as they would have a similar policy. She did not like this idea either, however she did not come back to our clinic, so she may have followed this path.
This was the only time something like this happened on my 5 week placement, however I think it was a useful experience to be put in the position where I had to put my foot down about how I was being treated. It was difficult in that she was willing to pay for the treatments and have them rushed through, though I felt it was not as effective as it should be and that I was being put under additional pressure.
After the first session I assumed her lateness was a one-off and didn't make an issue of it as she apologised and blamed traffic. At the second visit I did mention that she needed to be on time, however in hindsight I think I should have made it clear how important this was for all parties. I think being clearer when addressing the patient's expectations and trying to make them more realistic earlier on would also help to prevent her lateness and frustration with her progress, gaining better compliance to education and treatment. Does anyone else have any other suggestions of how to deal with this sort of problem or better still, prevent it?
Monday, June 2, 2008
Blind and Deaf?
Whilst on an outpatient geriatrics assessment clinic, I was referred a patient from Fremantle Hospital for assessment following an extensive hisotry of falls. Each patient is dedicated an hour to so that a comprehensive assessment of strength, ROM, vestibular and motor function can be preformed. The referral stated a history of falls and a solitary social history with bilateral hearing loss. Nothing else was mentioned regarding PMH. Upon viewing the pateint's medical records it was discovered that she had been admitted to hospital on multiple occasions, primarily due to falls in which a fractured NOF and radius had resulted in the past. Her records also stated glaucomas in both eyes and an extensive list of medications that were being taken.
When I called the patient through to the treating room, she displayed great difficulty getting up from the chair and was extremely unsteady ambulating with a walking stick, constantly attempting to grab onto me and any object around her. I remianed close to her but didn't provide any assistance as I was interested to see how she moved. As she approached the doorway, she was unable to negotiate it and asked me to guide her through. It then became clear the extent of her vision problems. As I sat her down to go through a subjective assessment, I realised then how significant her hearing loss was. She did not wear hearing aids therefore I pretty much had to yell. Due to her poor vision she was unable to lip read. What should of taken 10 minutes was taking much longer. There were many inconsistencies in her falls history although it appeared that all her falls were whilst ascending or descending stairs. Her short term memory seemed to be affected also.
I then attempted to follow an objective assessment. This proved to be one of the most chanllenging patients I have ever treated. How do you instruct someone to lift a limb, bend an elbow etc if they can't see what you are demonstrating and they can hardly hear your instruction?! After many futile efforts I discovered that the best thing to do was demontrate the movement by performing the movement on the patient and then asking her to copy it. On occasion this did work. Often when I went to repeat an instruction or question she became flustered and told me not to get angry with her. I assured her that I wasn't but perhaps she noted a tone of frustration in my voice. Eventually I managed to get a Berg Score of 36, extremely poor and reflected the severity of her motor issues.
I tried to become more aware of my tone and how I approached her over the coming weeks and on her 3rd visit she reported that she had fallen the previous day whilst climbing stairs and was unablke to get up for 15 minutes. She admitted that she didn't use her personal alarm pendent and when questioned why she said that she feared she would be taken away and put into a home. I tried to explain to her that that may not necessarily the case however she only became argumentative. After this incident I attempted to focus on stair use and how to use stairs safely with a walking stick. This proved futile as her memory loss prevented any gains. She kept saying that she was trying but wouldn't do any practice or make an effort to improve. It almost seemed like she had lost her will to even function any more.I felt really dishearted that after weeks of exercise trying to get her to help herself no progress was being made.
After 5 weeks my superving physio stated that she had been through the system before and all allied health professionals had tried to help her to no avail. I really felt like something should have been done. Clearly she was not safe to live at home alone and needed to be in full time care but you cannot force someone into care. My physio reassured me that I couldn't have done any more and deliberately didn't tell me to see how I would handle the situation. I was glad that I was given the challenge but can't help but feel that she the health system had failed her.
When I called the patient through to the treating room, she displayed great difficulty getting up from the chair and was extremely unsteady ambulating with a walking stick, constantly attempting to grab onto me and any object around her. I remianed close to her but didn't provide any assistance as I was interested to see how she moved. As she approached the doorway, she was unable to negotiate it and asked me to guide her through. It then became clear the extent of her vision problems. As I sat her down to go through a subjective assessment, I realised then how significant her hearing loss was. She did not wear hearing aids therefore I pretty much had to yell. Due to her poor vision she was unable to lip read. What should of taken 10 minutes was taking much longer. There were many inconsistencies in her falls history although it appeared that all her falls were whilst ascending or descending stairs. Her short term memory seemed to be affected also.
I then attempted to follow an objective assessment. This proved to be one of the most chanllenging patients I have ever treated. How do you instruct someone to lift a limb, bend an elbow etc if they can't see what you are demonstrating and they can hardly hear your instruction?! After many futile efforts I discovered that the best thing to do was demontrate the movement by performing the movement on the patient and then asking her to copy it. On occasion this did work. Often when I went to repeat an instruction or question she became flustered and told me not to get angry with her. I assured her that I wasn't but perhaps she noted a tone of frustration in my voice. Eventually I managed to get a Berg Score of 36, extremely poor and reflected the severity of her motor issues.
I tried to become more aware of my tone and how I approached her over the coming weeks and on her 3rd visit she reported that she had fallen the previous day whilst climbing stairs and was unablke to get up for 15 minutes. She admitted that she didn't use her personal alarm pendent and when questioned why she said that she feared she would be taken away and put into a home. I tried to explain to her that that may not necessarily the case however she only became argumentative. After this incident I attempted to focus on stair use and how to use stairs safely with a walking stick. This proved futile as her memory loss prevented any gains. She kept saying that she was trying but wouldn't do any practice or make an effort to improve. It almost seemed like she had lost her will to even function any more.I felt really dishearted that after weeks of exercise trying to get her to help herself no progress was being made.
After 5 weeks my superving physio stated that she had been through the system before and all allied health professionals had tried to help her to no avail. I really felt like something should have been done. Clearly she was not safe to live at home alone and needed to be in full time care but you cannot force someone into care. My physio reassured me that I couldn't have done any more and deliberately didn't tell me to see how I would handle the situation. I was glad that I was given the challenge but can't help but feel that she the health system had failed her.
pain pain go away
I am currently treating a patient who was involved in a MVA and sustained fractures to C3 and C4 vertebrae. Consequently the patient has now been in halo traction for 3 of 6 weeks and is classified as a C3 incomplete tetraplegic. This patient has a brown sequard type presentation where there is ipsilateral weakness and contralateral reduction in sensation. On assessment, the patient reports having left sided numbness and occasional burning sensations down the back of his legs.
This patient is routinely 'turned' (moved onto side briefly while the turning team rub the skin) and repositioned to prevent pressure areas every 2 hours. Every day i have been treating this patient, primarily to maintain and strengthen innervated muscles of the weaker side as much as the supine position can allow using active assisted and active resisted methods.
One morning as i began my routine treatment, the turning team came in and i asked if they could come by this room last as i only have an hour allocated for ward patients. The patient then told me that he hadn't been turned since 2am. Reason being that the patient was fine to be left as his neck was comfortable and alignment was fine at 4am and then the 6am rotation never came. Within the first couple of minutes of treatment whereby i moved the patient's left arm from by his side, to abduction and supination the patient complained of excruciating burning pain down the medial side of the forearm in an ulnar distribution. Knowing this patient is extremly tolerable to pain and never complains, i knew this was severe. No position or movement relieved the pain, only aggrevating it more. I asked if had this pain before, he said "occasionally, but never this intense or for so long". His neuro meds had only been administered 10minutes before. I checked with my supervisor to see if there was anything i could do and only medication and possibly gentle movements will relieve the pain. 15 minutes later and gradual introduction of movement the pain eventually reduced to a tolerable level.
I felt quite helpless in this situation, as i couldn't provide the patient with a definitive answer on how long the pain will last. The pain team was alerted of this event, but re-assessment wouldn't be possible until the afternoon. Even though i was unable to make the pain go away, i was able to reinforce the importance of regular turning. this nerve pain was most likely brought on by the patient's arm resting on the ulnar nerve for a prolonged time (7 hours) as he missed 2 turns. Especially as that arm is weak and not moving. In addition the patient was educated on how the increased pressure on the nerve for such a long time may lead to neuropraxia (nerve damage) which will further stunt recovery. He is now aware why changing position is not just for realignment and that he can take responsibility to ensure moves his arms and legs regularly.
This event has reinforced how important patient education is in compliance and understanding treatment. As the turning teams are constantly changing, it is hard to grasp the full picture of each patient due to time constraints. However i think it is important that they take the time to thoroughly educate the patient and consider their approach to patients. Perhaps "If it is ok with you, we are going to turn you now" instead of "would you like to be turned?" which reduces the importance of the act. I can also reflect on how frustrating for the patient it must be to be turned every 2 hours, but a little education can help ease the situation.
Patient Compliance
Over the last week I have been treating a man post TKR. When I initially consulted him during the pre-op assessment, he seemed very eager to undergo a fast rehabilitation process. He knew a lot about TKRs as he had his right knee replaced a number of years ago. Unlike most patients who have little to no expectations of what to expect after surgery, he was quite adamant with his. He told me he would gain 90 degrees knee flexion range Day 1 Post Op (while his epidural was in situ) and that he would like to use one of the exercise bikes in the outpatient department in the final days of his hospital stay. We covered his post-op exercises and he ensured me he would do these 3 times a day without fail. His optimism was refreshing, however I did warn him not to have too high expectations as this surgery may be different to his last.
Day 1 post op he reached 85 degrees on the CPM.
I did not see him Day 2 but my supervisor did. My supervisor mentioned that the man had refused to do his exercises and had basically told him he did not want physiotherapy. My supervisor had left the man, feeling there was not much else he could do.
Then came Day 3. When I visited him he looked upset and disheartened. He mentioned how he had fallen of the bed earlier that morning. He felt it was too painful to do any of his exercises. He was stubborn and challenged everything I asked him to do. Again, it appeared that he was not going to do physiotherapy that day.
Having known his expectations prior to surgery and seeing his loss of heart at current, I chose not to walk out of the room just yet. So I reminded him of his goals and expectations. He agreed that he wanted to continue with these. I told him he must trust us physios so we can help him achieve his goals. He reluctantly agreed.
So step by step we covered every post-op exercise, right down to the last repetition. If he initially said it was too painful, I’d ask him to try just one. Usually once he achieved the first one, he got a thirst for more repetitions. Then we would set an aim (eg certain number of reps). He usually would achieve this plus one more (just to be one up on me probably). He ended up completing his entire exercise program when on the previous day he would not do even one exercise.
During this session I had spent a lot more time than I probably should have on the man. But at least I had reinspired him to continue being active with his rehabilitation process.
In the future I aim to spend more time in the pre-op assessment for a THR/TKR in reiterating not to set many expectations immediately after surgery. Realistic goals may be set, however they should not have a timeline attached to them, as each recovery process differs. This includes those patients who've already undergone surgery on the opposite limb (as the second rehabilitation process often differs from the first). After surgery I will continually remind the patient that they should still have a good long term outcome but they must maintain compliance and motivation in the meantime.
Day 1 post op he reached 85 degrees on the CPM.
I did not see him Day 2 but my supervisor did. My supervisor mentioned that the man had refused to do his exercises and had basically told him he did not want physiotherapy. My supervisor had left the man, feeling there was not much else he could do.
Then came Day 3. When I visited him he looked upset and disheartened. He mentioned how he had fallen of the bed earlier that morning. He felt it was too painful to do any of his exercises. He was stubborn and challenged everything I asked him to do. Again, it appeared that he was not going to do physiotherapy that day.
Having known his expectations prior to surgery and seeing his loss of heart at current, I chose not to walk out of the room just yet. So I reminded him of his goals and expectations. He agreed that he wanted to continue with these. I told him he must trust us physios so we can help him achieve his goals. He reluctantly agreed.
So step by step we covered every post-op exercise, right down to the last repetition. If he initially said it was too painful, I’d ask him to try just one. Usually once he achieved the first one, he got a thirst for more repetitions. Then we would set an aim (eg certain number of reps). He usually would achieve this plus one more (just to be one up on me probably). He ended up completing his entire exercise program when on the previous day he would not do even one exercise.
During this session I had spent a lot more time than I probably should have on the man. But at least I had reinspired him to continue being active with his rehabilitation process.
In the future I aim to spend more time in the pre-op assessment for a THR/TKR in reiterating not to set many expectations immediately after surgery. Realistic goals may be set, however they should not have a timeline attached to them, as each recovery process differs. This includes those patients who've already undergone surgery on the opposite limb (as the second rehabilitation process often differs from the first). After surgery I will continually remind the patient that they should still have a good long term outcome but they must maintain compliance and motivation in the meantime.
dfferences in technique
On my new prac, we are required to have a physiotherapist and a nurse at the bed side whilst we treat every patient. Normally our clinical tutor supervises us and therefore we have adopted her method of treating patients. The other day however I was suctioning a patient with a tracheotomy and a different physio from the department was with me.
The patient was fully sedated and had enormous amounts of secretions. After manually hyperinflating the patient for a few minutes, we needed to suction her twice until her chest was clear. There was large amounts of M2P3 sputum and the patient did not tolerate the suctioning well as it sent her into fits of coughing. Having suctioned many patients on the same prac already I was confident with my technique and what I needed to do. The physio used quite a different technique as our clinical tutor and suggested I practiced both ways to see which one I preferred. This was a good idea and was fine until the end of the treatment. Usually, if a patient coughs up a lot of secretions into their mouth, we use a different handpiece to clear their mouth. This is what I went do to however the physio told me not to waste my time and just to use the same suction catheter. This is something that both our lecturers and my clinical tutor had told us never to do as it was pretty gross for the patient even though they were sedated. I told the physio we always used the handpiece so that it was more hygienic for the patient and also it was easier to use as the catheter is too floppy to get over their tongue.
Afterwards, the physio was really annoyed and told me that I was not to question what she said again and should do what the physios instruct us to. I found this really annoying as I wasn't questioning her skills or knowledge, I was just doing what I had been taught earlier and what I thought to be better for the patient and easier for me. I didnt argue back as I didnt want to make things more difficult but found it absurd that I would get told off for trying to follow the 'gold standard'. I understand that physios wouldnt want their skills questioned by a student, however I think it was unfair to say that to me when I know that I was not doing anything wrong and did not accuse the physio of anything in the first place. I told my supervisor what had happened and she suggested that if the same thing happened again, to just say that until I am qualified I have to practice the gold standard at all times.
I think as a student it's difficult to know when to stand our ground if we know for sure we are doing the right thing. The physios method was not wrong however neither was mine. I think that if I'm in this situation again I will stand my ground and rationalise the reason for my treatment choice, knowing that as long as my rational is correct and the patient is safe, they are in no position to question my technique just because it is different to theirs.
The patient was fully sedated and had enormous amounts of secretions. After manually hyperinflating the patient for a few minutes, we needed to suction her twice until her chest was clear. There was large amounts of M2P3 sputum and the patient did not tolerate the suctioning well as it sent her into fits of coughing. Having suctioned many patients on the same prac already I was confident with my technique and what I needed to do. The physio used quite a different technique as our clinical tutor and suggested I practiced both ways to see which one I preferred. This was a good idea and was fine until the end of the treatment. Usually, if a patient coughs up a lot of secretions into their mouth, we use a different handpiece to clear their mouth. This is what I went do to however the physio told me not to waste my time and just to use the same suction catheter. This is something that both our lecturers and my clinical tutor had told us never to do as it was pretty gross for the patient even though they were sedated. I told the physio we always used the handpiece so that it was more hygienic for the patient and also it was easier to use as the catheter is too floppy to get over their tongue.
Afterwards, the physio was really annoyed and told me that I was not to question what she said again and should do what the physios instruct us to. I found this really annoying as I wasn't questioning her skills or knowledge, I was just doing what I had been taught earlier and what I thought to be better for the patient and easier for me. I didnt argue back as I didnt want to make things more difficult but found it absurd that I would get told off for trying to follow the 'gold standard'. I understand that physios wouldnt want their skills questioned by a student, however I think it was unfair to say that to me when I know that I was not doing anything wrong and did not accuse the physio of anything in the first place. I told my supervisor what had happened and she suggested that if the same thing happened again, to just say that until I am qualified I have to practice the gold standard at all times.
I think as a student it's difficult to know when to stand our ground if we know for sure we are doing the right thing. The physios method was not wrong however neither was mine. I think that if I'm in this situation again I will stand my ground and rationalise the reason for my treatment choice, knowing that as long as my rational is correct and the patient is safe, they are in no position to question my technique just because it is different to theirs.
good work teamsmurfs
Good work team smurfs,
and I've enjoyed reading the posts and comments. Hope you are finding the process of having to reflect useful and not always just another job to do. It is important for your ongoing enjoyment of your work that you make your reflections, whether shared with the team or not, something that assists you to grow into excellent therapists (not just something to satisfy the examiners requirements). All the best.
regards
Stephanie
and I've enjoyed reading the posts and comments. Hope you are finding the process of having to reflect useful and not always just another job to do. It is important for your ongoing enjoyment of your work that you make your reflections, whether shared with the team or not, something that assists you to grow into excellent therapists (not just something to satisfy the examiners requirements). All the best.
regards
Stephanie
Safety safety safety
On placement a few weeks ago, I was assisting one of the physiotherapists with a post-op stand. As the patient was in a two patient room, and the other patient was being stood at the same time, we had to move the bed first. After the bed was moved, the brakes were reapplied, and the patient was stood up without incident. After the session was over and the patient was back in bed, I was dismissed from the room. The physiotherapist remained in the room to talk to the patient and reposition the bed and told me that I could head off to find my supervisor as I was no longer needed.
Later in the day, I was at the nurse’s station reading some notes with the same physio, and we were approached by a nurse who was looking after the patient that we had seen that morning. After the session had finished and the other physio had left to see other patients, the morning tea trolley had done the rounds and the nurse helped to pass the tea to the patient. However, in doing so she leant on the bed, and it rolled. After the bed had been moved back to its original position, the brakes had not been reapplied. I had been dismissed from the room before this could happen, and I assumed that the physio was going to finish up and set the room as it had been before we came in. This had apparently not happened. Luckily nothing was spilt on the patient. The nurse firmly told us that this was not good enough, which was fair enough, but the physio let her believe that it was my fault. I understand that as students we are there to learn, but to be blamed for another’s mistakes is not very good professional practice.
As students, safety is drilled into us at all times. Whenever I start and finish my treatments I ensure that brakes are on, and that all aspects of treatment will be safe. In this case, I was simply assisting and the physio was running the session. This experience demonstrated to me the importance of diligence in terms of safety, and I believe that as students we need to double check things to ensure incidents like this do not reflect badly on us and put patients in unnecessary danger.
Sunday, June 1, 2008
A GP's complain
I was to see a patient who has had 2 episodes of falls. When I walked the patient into the gym, I noticed that she was unsteady on her feet. I felt uneasy as she seems to be more unsteady than the previous time I saw her. I asked if she was not feeling well today and she mentioned that she has been feeling that the room was spinning around her. I asked if it was normal, and she replied that she has been feeling so the whole week. As such, I got the nurse to help check her obs and stats before starting the session. The nurse checked them and they were normal, a slight irregular heartbeat which according to the nurse was normal for the patient. We then advised her to make an appointment with the gp regarding her dizziness as she might have caught the flu or an infection.
I started the objective assessment constantly monitoring the patient and asking her for feedback. I decided to do just half the berg balance assessment although the patient reiterated that she could continue. We sat down for a short chat and rest before she left and as she was putting on her shoes, she came back up with a grimace on her face. I asked about it and she told me that she was experiencing some pain in her chest. Once again, I asked if that was normal for her and she said it was. I got her a warm cup of water and her chest pains went away as quickly as they came. Since the patient had no history of heart problems, I suggested that she reported the chest pains to the gp too. I remembered reading in the notes that the patient has poor short term memory and that prompted me to write down all these in her notebook to serve as a reminder for her to ask the doctor. After 10 mins of rest, ensuring that the chest pains did not come back, I walked her out to the reception where her husband was waiting and suggested that they go to the gp as soon as they could.
The next day, the head of department came and asked if any one saw that patient. I claimed that patient and wondered what happened. It turned out that the patient was admitted to the emergency department and is now warded. I told him everything that happened and the steps I took. He then told me that the patient went to see the gp and the gp complained that the patient should have been sent straight to ED. However, he reassured me that all I did was right and that he just wanted to find out what happened. My supervisor and the nurse later told me that almost half of the patients come with chest pains and it is impossible to send them all to ED. We later found out that the patient was discharged as they could not find anything wrong with her heart.
My heart stopped for a second or two when the head of department told me what had happened. Although everyone reassured me that I made all the right decisions, it still made me question my own judgement. It was fortunate that the patient was alright this time. In future, with any patient who complains of chest pains, regardless of whether they have a history of heart problems, I will pay special attention to it and approach my supervisor instead of trying to handle the problem myself.
That was exactly what happened the next day. I had a patient who came in complaining of the worst chest pains ever experienced the night before. Immediately I alerted the nurse and the supervisor only to realise that it is not a concern because she is not having the chest pains at that point in time.
With help from my supervisor, I figured that although chest pain is an important red flag, I have the skills to discern false alarms from those that require attention. It is important in these situations to stay calm and carefully question the patient before making a decision, unless of course the patient is in obvious distress. She assured me that my clinical reasoning is alright however if it is necessary, it is still fine to seek help.
This is one experience that I hope you guys never have to experience but I guess it is almost inevitable in our practice. I was fortunate to have a very supportive supervisor and should any of you encounter these sort of situations, do not be too harsh on yourself but keep the confidence.
I started the objective assessment constantly monitoring the patient and asking her for feedback. I decided to do just half the berg balance assessment although the patient reiterated that she could continue. We sat down for a short chat and rest before she left and as she was putting on her shoes, she came back up with a grimace on her face. I asked about it and she told me that she was experiencing some pain in her chest. Once again, I asked if that was normal for her and she said it was. I got her a warm cup of water and her chest pains went away as quickly as they came. Since the patient had no history of heart problems, I suggested that she reported the chest pains to the gp too. I remembered reading in the notes that the patient has poor short term memory and that prompted me to write down all these in her notebook to serve as a reminder for her to ask the doctor. After 10 mins of rest, ensuring that the chest pains did not come back, I walked her out to the reception where her husband was waiting and suggested that they go to the gp as soon as they could.
The next day, the head of department came and asked if any one saw that patient. I claimed that patient and wondered what happened. It turned out that the patient was admitted to the emergency department and is now warded. I told him everything that happened and the steps I took. He then told me that the patient went to see the gp and the gp complained that the patient should have been sent straight to ED. However, he reassured me that all I did was right and that he just wanted to find out what happened. My supervisor and the nurse later told me that almost half of the patients come with chest pains and it is impossible to send them all to ED. We later found out that the patient was discharged as they could not find anything wrong with her heart.
My heart stopped for a second or two when the head of department told me what had happened. Although everyone reassured me that I made all the right decisions, it still made me question my own judgement. It was fortunate that the patient was alright this time. In future, with any patient who complains of chest pains, regardless of whether they have a history of heart problems, I will pay special attention to it and approach my supervisor instead of trying to handle the problem myself.
That was exactly what happened the next day. I had a patient who came in complaining of the worst chest pains ever experienced the night before. Immediately I alerted the nurse and the supervisor only to realise that it is not a concern because she is not having the chest pains at that point in time.
With help from my supervisor, I figured that although chest pain is an important red flag, I have the skills to discern false alarms from those that require attention. It is important in these situations to stay calm and carefully question the patient before making a decision, unless of course the patient is in obvious distress. She assured me that my clinical reasoning is alright however if it is necessary, it is still fine to seek help.
This is one experience that I hope you guys never have to experience but I guess it is almost inevitable in our practice. I was fortunate to have a very supportive supervisor and should any of you encounter these sort of situations, do not be too harsh on yourself but keep the confidence.
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