Who do I talk to?

On my most recent placement I had several patients for whom English was their second language. As a result, most of these patients brought a family member along to the initial consultation to assist with translation. This was extremely helpful and allowed me to extract the information I required for my subjective and objective. However, although it made the assessment easier in some respects, I found it difficult at times to know who to talk to. Should I talk to the patient? Or should I ask the questions through the translator? I did not want to appear rude, but I was unsure of what to do. To tackle this problem, I took a moment and came to the conclusion that the patient was the most important person out of the duo, and therefore I should talk to them and allow the translating family member to pick up when it was required. This turned out to be the right thing to do, and I received positive feedback from these patients as a result. Often patients feel isolated by their language, and find that people do not always take the time to talk to them as they assume they won't understand. But by incorporating body language and allowing the translator to step in as required rather than talking to the translator, the translator talking to the patient, patient to translator and finally translator back to therapist (although this may be yuor only option in some cases), the patient is able to be included as part of the conversation and the conversation flows naturally.

discharge planning

After being on prac in borneo for a while now, i have noticed just how large the cultural differences in regard to treatment are. Treatment here is very different to in Australia because it is expected that the family takes care of the patient as soon as they are medically stable. This means that pts are discharged from hospital straight away even though they have not had any physio and their neuro conditions are still extremely acute. After they are discharged the family will look after them and hopefully bring them back for outpt raheb however if the family decides not to come back for physio then the pt receives no treatment at all.

Before discharge the physios try to teach the family the best way to transfer the pt and do as much physio as they can fit in, in the few wks the pts are in hospital. However teaching family that have no idea about correct manual handling or any physio techniques often takes up a lot of time and results in the patient having less actual treatment time. Having the pts at home also means that often the physios spend most of the treatment time undoing all the bad habits the pt has developed whilst at home. This normally includes poor posture and inparticular a very poor gait pattern and compensatory techniques, as family members often try to walk the pt before the are even close to being ready.This has shown me how different the culture is here and how lucky we are that in Australia it is expected that we stay in hospital until we are able to be discharged from the multi- disciplinary team. It has also meant that now when a patient from a different culture comes to an australian hospital for treatment, i will have a better understanding of the family involvement and try to include them more in regard to the treatment plan for the patient.

circle of security

I attended the “sensitive parenting” workshop during my placement which talks about the circle of security (circleofsecurity.org), its origins, application and effectiveness. The circle of security is basically about how the child needs to be allowed to explore and accompanied to enjoy and support their exploration and also welcomed when the child needs comfort and reassurance. It is about being sensitive to the child’s needs at different parts of this circle.

On hindsight, I found much of what was discussed to be common sense. Yet a lot of parents and health professionals find it difficult to make sense of all these when we are involved in the situation ourselves. This is further highlighted by the method used to help parents with children who has attachment issues. The method involves videotaping the parent’s interaction with the child and how they react reuniting after separation. The parent would then watch the tape and reflect on how they treated their child. Most parents do not usually require prompting about how they should have reacted. Therefore, it is helping them gain awareness of their behaviour and their ability to reflect that contributes to the process of improving relationships.

It was also mentioned in the workshop that kids model their behaviour after their parents. This immediately reminded me about a child who has huge behavioural problems in school and it was found that the parent had similar behavioural problems too. It just reinforced the need for healthy parents to have healthy children. The parents have to sort themselves out before they are able to work on relationships with the children. I suppose this relates to physiotherapy as well because the child can very readily pick up if the adult is unhappy and that feeling will translate to the child and result in an unsuccessful therapy session.

Another point that i picked up in this workshop was the importance of recognizing that as long as the child’s emotional needs are not met, it will be difficult to attain the goals of therapy because the child’s energy and focus will be on fulfilling that need and not on learning motor skills. This can be applied to my future practice in that we have to acknowledge that therapy will sometimes have to take a backseat and not get frustrated when we are not able to do what we planned to do.

Inappropriate patient

I had an interesting experience with a patient who was verbally behaving inappropriately. Patient was admitted with exacerbation of asthma and I was seeing him for the first time. Things first felt a little awkward when I was doing subjective assessment on him. In response to my question about his smoking history, he turned the question on me and asked if I did. When I said that I did not he asked why and continued to say that I have to try to know and compared it to sex.

I was extremely disturbed because he said it with a straight face and was staring straight into my eyes waiting for an answer. I looked at him with a dead pan faced and ignored his comment, going on to ask him the next question without a smile on my face, clearly showing my displeasure.

Later into the assessment though, I managed to put aside that awkward situation and build quite a good rapport with him without putting up with any other crude jokes that he made. It also helped that i did not quite understand some of the other inappropriate comments he made although I had an idea that it was inappropriate as the nurses in the room did not look very happy when all the other male patients were laughing.

I spoke to my supervisor about this patient and he offered taking over this patient. However I decided to continue seeing this patient as it was a good learning experience having to deal with such patient. Subsequent sessions with the patient were surprisingly smooth going and he stopped his rude jokes with me and was even very complaint with treatment.

I was caught by surprise as it was the first time I’ve experienced such as situation and did not know how to react. In future I would tell the patient straight that it is an inappropriate comment and that it makes me feel uncomfortable. I struggled with figuring how much I should shrug it off as a joke and allow him to make such comments. I feel that I cannot restrict what he wants to say but at the same time, I did not feel that I had to put up with such comments. Even though i shrugged off his later remarks and that probably contributed to my rapport with him and the cut out of future inappropriate comments, I am not too sure that is the best way to go.

I am currently on prac in Kuching in Borneo and even though I’ve only been here for 2 days I have already learnt so much when it comes to communicating with people who speak very little, if any English. It is a private hospital and therefore only the wealthier people can afford to receive treatment there which means that most people speak some English however it is still so different. When I would normally babble on and give a patient a few instructions at once intermixed with a bit of conversation, ive now learnt that I just cant do this with some of these patients. Instructions and questioning often needs to be kept to the bare minimum and hand guestures have never been more helpful. It’s also forcing my facilitation to improve as this is often the easiest way to get a patient into a position without confusing them with too much English. This means that conversation to fill the silences can sometimes be difficult which is something I suppose I will just have to get use. With some people all you can really do is smile or use facial expressions to convey meaning or just rely on the tone of your voice to let them know if theyre doing an exercise right or not. Its been really helpful in developing my non verbal communication skills and has also showed me that I often rely on talking too much to explains things and need to improve my neuro facilitation.

yellow flags

I am currently on my musculo placement and am seeing quite a difficult patient in regard to diagnosis and treatment. She was referred to the clinic by her GP with severe (L) hip pain. On initial assessment however, she explained that this pain only occurred when she had her period and other than that it was usually fine. She also said that she has had 40 anaesthetics, several of which were for gyno and pelvic surgeries, of which her most recent was only 3 months ago.

On objective assessment she showed near full range of movement but it was just very painful. We went through all the usual tests for the hip and screened the joints above and below, but still found nothing too out of the ordinary that would be causing such pain. When we suggested that her pain was possibly of visceral origin as her symptoms are so closely linked with her menstrual cycle, she said we must have missed something as her doctor would not have referred her to a physio if we could not help.

My supervisor suggested a ‘working diagnosis’ of posterior capsule tightness however feels this is unlikely. I tried a caudad/lateral glide with a bit of distraction to try and open up her hip joint however this nearly brought on tears. We saw the patient every week for a month and her pain is definitely consistent with her menstrual cycle. I suppose this is the first real patient that I have had with such obvious yellow flags and whilst she does have some evidence of very minor musculoskeletal problems it is very unlikely that this is causing her extreme pain. Treating this patient has given me experience in regard to when it’s indicated to refer a patient back to their doctor for further investigations. Just because the doctor referred them for physio does not mean its necessarily indicated and it has made me more confident in knowing when to refer a patient on to someone with more experience/knowledge.

Patient with withdrawal symptoms?

I saw a patient who came in with exacerbation of COPD with my supervisor. On reading patient's notes, we got the impression that it might not be an easy patient in terms of compliance with physio and because patient was still smoking, supervisor mentioned that patient might be feeling cranky because of the inability to smoke. Moreover, I had approached patient in the morning to ask if I could see her with my supervisor. Patient's reply was short saying that we could but she will not be getting up for walks. Patient was known to the team and staff have not had an easy time with her. Nevertheless, we still headed in and surprisingly managed to have a very successful subjective and objective assessment with her. We were even able to get her to ambulate for quite a distance!

The next day however, patient was the total opposite. The smiley patient of yesterday had become grumpy. She was not willing to even sit out of bed. I tried selling the benefits and persuading her to do so. Suddenly, patient bolted out of bed and sat at the edge and loudly snapped saying she'll do it if that's what I want even though she's hates it. I calmly assured her that I acknowledged her discomfort and that I would not push her further than sitting out of bed for a while. I also mentioned that I will leave her alone for now and come back later in the afternoon to see if she's up for a walk just because it is really important for her. Patient then soften her stance and said alright in a extremely nice tone (in comparison to when she snapped)

Later that afternoon, I came back and patient smiled on seeing me saying that she is ready for a walk but the doctors were just going to see her. I said that I would take her on a walk after the doctors have seen her. The doctors took a fairly long time with the patients and it had long been past my knock off time. My supervisor suggested that I do it the next day, however I felt it was now more to do with patient's trust than the benefits of the treatment.

That decision paid off as we had a very collaborative treatment plan thereafter. Patient and I decided that late afternoons were the best times for me to see her as she feels much better at that time of the day as compared to the mornings. I did not have any problems with that patient thereafter. In fact one day when I was off in the afternoon, patient gladly agreed to have her treatment in the morning instead.

I learnt from this experience that it is important to also listen to what the patient wants. A collaborative effort will definitely reap more results than a one way traffic treatment. It gives patients a sense of control and autonomy over their treatment and recovery. This is definitely a valuable experience as I will not be startled when I get shouted at by the patient in future.