It has taken several occasions with similar circumstances for me to realise the importance of being on the conservative end of the realistic spectrum when it comes to patient outcomes.
There have been many musculoskeletal outpatients that I have treated this year who are very motivated and have very high expectations, for example chronic low back pain that will completely resolve if they do all the exercises and follow the advice I have given them. In a case such as this it may be clear that an important part of managing the patients problem is just that - educating them that managing the problem is likely to be the best outcome due to an element of irreversible damage. There have been other times however where patients have been unrealistic about their prognosis in terms of function and time taken to reach the function, and it is much easier to reflect their optimism than to "bring them down" to the most likely outcomes, trying not to reduce their enthusiasm and compliance.
It has been in my current neuro prac working on a rehab ward with stroke patients that the importance of being realistic, and even conservative with the way I influence a patients expectations. I have found that being overly optimistic and even saying "The way you are progressing at the moment you should have more movement in your hand by next week" - the type of statement several patients are clearly looking to hear can have a detrimental effect. Although in the short term it may help with compliance and motivation, I have found that when I am wrong about these types of prediction the patient loses confidence in me as a therapist and/or themself in terms of recovery.
From these many experiences I have learnt to keep certain goals for patients to myself and when I do give them my opinion on likely outcomes (which is still important), I think longer before answering to stop myself being caught in that desire to reflect their optimism and give a more cautious, considered response, erring on the conservative timeframe or level of recovery expected for their condition.
Wednesday, October 29, 2008
Tuesday, October 28, 2008
Reassessing a patients situation
Although the patient involved in this situation was not in my care it drew to my attention a situation which is not uncommon in the public health sector that is likely to result in poor patient outcome.
A patient who had a stroke was admitted to the hospital I was on prac at and acute care provided, however the initial plan was for transfer to a rehabilitation ward at a different hospital. The patient was seen by a physiotherapist who performed an assessment, some basic ROM exercises and repositioning of the patient. At this point it was assumed that the patient would receive the necessary rehab elsewhere in the next day or so and was effectively discharged from physio services on that ward. There were complications (not related to the patients status) which prevented immediate transfer to the rehab unit for more than a week, during which time the patient was hoisted on the ward and not given any form of rehabilitation from allied health.
This situation can easily occur if patients are not re-referred from the coordinating staff when discharged from a particular service such as physio, or if the judgement that it has been too long to continue waiting on a future service is not made. In most cases allied health professionals will review the ward lists and enquire as to why a patient has not been discharged after the intended period, however this needs to be common practice to ensure that a patient receives rehab as soon as feasibly possible to maximise outcomes.
A patient who had a stroke was admitted to the hospital I was on prac at and acute care provided, however the initial plan was for transfer to a rehabilitation ward at a different hospital. The patient was seen by a physiotherapist who performed an assessment, some basic ROM exercises and repositioning of the patient. At this point it was assumed that the patient would receive the necessary rehab elsewhere in the next day or so and was effectively discharged from physio services on that ward. There were complications (not related to the patients status) which prevented immediate transfer to the rehab unit for more than a week, during which time the patient was hoisted on the ward and not given any form of rehabilitation from allied health.
This situation can easily occur if patients are not re-referred from the coordinating staff when discharged from a particular service such as physio, or if the judgement that it has been too long to continue waiting on a future service is not made. In most cases allied health professionals will review the ward lists and enquire as to why a patient has not been discharged after the intended period, however this needs to be common practice to ensure that a patient receives rehab as soon as feasibly possible to maximise outcomes.
Monday, October 27, 2008
adverse neural tension
Whilst on rural placement I saw a lady who had fallen off a trailer, landing on her shoulder and forearm who was diagnosed with and treated for a distal radial fracture. She had been seeing the OT at the hospital who then referred her to physio due to shooting pain down her upper limb originating in the shoulder.
On assessment I found that she was extremely sensitive to neural tension provocation tests and palpation of the median nerve, with symptoms in this distribution. Her presentation was difficult in that she had a history of bilateral carpal tunnel syndrome from her work in embroidery as well as persistent oedema and pain around the fractured wrist.
Initially I felt overwhelmed by her problems and symptoms, which presented in a very irregular fashion - changing every couple of days when I saw her. I wasn't sure where to start as she was quite irritable and had many likely contributing factors which were difficult to differentiate. I needed to do some reading to find out more about the problem of adverse neural tension, however after doing this I became aware that these fluctuating and highly variable symptoms are quite typical of this problem. Although the evidence is not very specific in terms of treatment parameters, I learnt more about gliding versus tension in the peripheral nervous system and their roles as treatment techniques based on the irritability of the problem.
Having the knowledge of the evidence that is available (much of which has been conducted in the last couple of years, after we covered it) the patient and I were able to make fairly rapid progress with what initially presented as a highly irritable and functionally limiting condition.
This really highlighted for me that even now, before we have graduated, the importance of finding suitable ways to continue learning about the ever-changing best practices to deliver the most effective treatment to our patients. This will virtually always extend beyond PD courses and journal clubs etc as they might not cover the conditions or treatment areas that are specifically required for our clients.
On assessment I found that she was extremely sensitive to neural tension provocation tests and palpation of the median nerve, with symptoms in this distribution. Her presentation was difficult in that she had a history of bilateral carpal tunnel syndrome from her work in embroidery as well as persistent oedema and pain around the fractured wrist.
Initially I felt overwhelmed by her problems and symptoms, which presented in a very irregular fashion - changing every couple of days when I saw her. I wasn't sure where to start as she was quite irritable and had many likely contributing factors which were difficult to differentiate. I needed to do some reading to find out more about the problem of adverse neural tension, however after doing this I became aware that these fluctuating and highly variable symptoms are quite typical of this problem. Although the evidence is not very specific in terms of treatment parameters, I learnt more about gliding versus tension in the peripheral nervous system and their roles as treatment techniques based on the irritability of the problem.
Having the knowledge of the evidence that is available (much of which has been conducted in the last couple of years, after we covered it) the patient and I were able to make fairly rapid progress with what initially presented as a highly irritable and functionally limiting condition.
This really highlighted for me that even now, before we have graduated, the importance of finding suitable ways to continue learning about the ever-changing best practices to deliver the most effective treatment to our patients. This will virtually always extend beyond PD courses and journal clubs etc as they might not cover the conditions or treatment areas that are specifically required for our clients.
Rural
On my current placement (rural) I am working with a lot of patients who live in remote communities, or in home situations that are not the same as what we'd experience in Perth. For me, the hardest thing about this is knowing when to change my plans or treatment sessions and goals to suit the patient and hospital better. For example, last week I saw a lady who was admitted with hip pain and was unable to walk, post MVA. She lived quite a way out of town, and appeared to live quite roughly. After assessing her strength and range, and determining that she did not require the oxygen therapy she was receiving at the time we got her out of bed and went for a walk. I would ideally have sent her home with a frame to assist her ambulation and decrease her pain, but after talking to my supervisor, this would likely not have been appopriate. A falls prevention group, regular checkups and provision of an aid would have been by discharge plan, but in this case was not appropriate.
Many walking aids are given to patients from outlying communities, and few are ever returned. Some are returned, but are often burnt or destroyed in some other fashion. My supervisor told me that many patients will use the frame for a day or two, but then discard it due to social situations, uneven or unnegotiable terrain or other factors. THe outlying communities are visited, but it is often hard to track down patients or see everyone on the limited visits.
It is therefore important that we as physios in this situation ensure that the patient recieves optimum care whilst accessible in hospital, and that they are ready to go before they go home, no just becuase the bed is needed. Plans need to be constantly updated and modified as required, and not two patients are ever the same!!!
Many walking aids are given to patients from outlying communities, and few are ever returned. Some are returned, but are often burnt or destroyed in some other fashion. My supervisor told me that many patients will use the frame for a day or two, but then discard it due to social situations, uneven or unnegotiable terrain or other factors. THe outlying communities are visited, but it is often hard to track down patients or see everyone on the limited visits.
It is therefore important that we as physios in this situation ensure that the patient recieves optimum care whilst accessible in hospital, and that they are ready to go before they go home, no just becuase the bed is needed. Plans need to be constantly updated and modified as required, and not two patients are ever the same!!!
Wednesday, October 15, 2008
Treating a Prisoner...
Recently on prac i was allocated 4 patients that i was treat everyday for my placement. When it came to my attention that one of my patients was a prisoner, i didn't know what to think. The usual thoughts went through my head: is he dangerous, do i treat him differently so he can't take advantage of the situation (i.e. use of equipment that could be a potential weapon), are there things i shouldn't say etc etc.
This man was convicted for armed robbery. He sustained his head injury from a gun shot to the head leaving him a hemiplegic and this is why he was in hospital. After seeing him for the first time i immediately knew that i could treat this patient just like any other and i was safe. Even though this patient was a hemiplegic and couldn't stand independently let alone crawl away, he had shackles around his ankles at all times (except physio) and 2 armed guards with him 24/7, which was later reduced to 1. It was intriguing to observe that all prison rules applied to him while in hospital. Visiting hours were scheduled and limited and he was only allowed to wear prison clothing and shoes.
Treatment progressed as normal, the most difficult aspects i found was the communication. What do i talk about with him? Trying to get a subjective history off him was really difficult as it was to do with his criminal history, unlike other patients where they had just a motorbike accident. I asked the standard questions and he gave me very brief answers. I didn't push for the details unless i felt some more information was necessary for the treatment. Over the next couple of weeks, most preconceptions i had of prisoners disappeared as he slowly opened up and were then able to have friendly conversation.
What i'm trying to say (as its not everyday you are treating a prisoner) is don't have preconceptions about individuals because of sterotypes. Everyone has a past and so don't judge a book by its cover. Having said that, never be complacent and treat each case individually as it presents.
If anyone has any insight though on whether there are any guidelines we have to abide by in these situations. i.e. not discussing criminal offences with the patient or if you see them on tv?? i gather that it is just up to the individual's discretion.
Monday, October 13, 2008
The patient in a holistic view
On my current placement I visited a patient post laparotomy on two occasions. He had a complicated previous medical history. His presenting complaint was yet to be diagnosed. The medical staff had changed trialled and changed his medications a number of times. He had lost 30kgs over the last 6 months, and was now 50kg. He had undergone a huge amount of investigations. He had been on a nasogastric feed for a number of days, every time he tried solids diarrhoea would follow. His gut couldn’t hold anything in.
My supervisor had asked me to check on his chest and mobility. On the first occasion his nasogastric tube was in and no diarrhoea was present. He felt confident to comply with physiotherapy treatment, which included a chest review and ambulation. On the second occasion he had trialled solids the night prior and had diarrhoea all morning. He was not confident to leave the bed. He was not compliant with physiotherapy. Initially he told me to ‘go away, I don’t need physiotherapy’. I proceeded to explain that it was only a procedural check-up, he told me ‘physiotherapy is the last thing on my mind’. His wife and I stepped aside for a moment, and she apologised, saying how he usually not like this, and usually very compliant.
At this point I considered him more as a holistic being. In my mind, the best thing for this man would be to review his chest, and maintain his ROM/strength through ambulation and strengthening exercises. But all he wanted was to understand why he had lost a third of his bodyweight in a matter of months, why he can’t eat and why his stomach hurt so much.
My decision was to assess his chest only. He was compliant with this as it did not require him moving from his bed. After this, I educated him on maintaining his breathing exercises, strengthening exercises and walk on the ward when he felt able. I left the treatment there.
In the future, I want to read my patient notes and attempt to picture my patients in a holistic view, prior to approaching them. Physiotherapy may not necessarily be top priority for them, and as much as I would like to assist, I must never force treatment on to them.
My supervisor had asked me to check on his chest and mobility. On the first occasion his nasogastric tube was in and no diarrhoea was present. He felt confident to comply with physiotherapy treatment, which included a chest review and ambulation. On the second occasion he had trialled solids the night prior and had diarrhoea all morning. He was not confident to leave the bed. He was not compliant with physiotherapy. Initially he told me to ‘go away, I don’t need physiotherapy’. I proceeded to explain that it was only a procedural check-up, he told me ‘physiotherapy is the last thing on my mind’. His wife and I stepped aside for a moment, and she apologised, saying how he usually not like this, and usually very compliant.
At this point I considered him more as a holistic being. In my mind, the best thing for this man would be to review his chest, and maintain his ROM/strength through ambulation and strengthening exercises. But all he wanted was to understand why he had lost a third of his bodyweight in a matter of months, why he can’t eat and why his stomach hurt so much.
My decision was to assess his chest only. He was compliant with this as it did not require him moving from his bed. After this, I educated him on maintaining his breathing exercises, strengthening exercises and walk on the ward when he felt able. I left the treatment there.
In the future, I want to read my patient notes and attempt to picture my patients in a holistic view, prior to approaching them. Physiotherapy may not necessarily be top priority for them, and as much as I would like to assist, I must never force treatment on to them.
The transition from a student to Qualified health professional
My recent international placement was conducted at a community centre for stroke rehabilitation. It was a non-governmental, not for profit organisation, which relied mainly on the assistance of volunteers to function. Our supervisors were local physiotherapists who also volunteered their time.
Within the first 2 hours of arrival I was expected to conduct an exercise class to a group of stroke patients. By the end of my first day I had conducted 2 exercise classes and seen 3 patients. Throughout the initial week I was the primary health professional of which these patients saw for treatment. There was another Malaysian physio present at the centre, but she had her own clients, plus her training varied from Australian physiotherapy and I was reluctant to seek her advice.
I was initially challenged by this. But by the end of the first week I had learnt to trust my observational skills, and my choices of treatment. As there was no one else to double check me, I had to be confident that the skills I’d learnt, during my practical classes and that of my previous neurological placement at SCGH, were effective.
This experience has changed my perspective of physiotherapy from a student point of view, where learning is the main focus, to that of a professional, where treating, informing and educating is the main focus. I think this experience has assisted in bridging me from being a student to a qualified health professional. I know this year is aimed at doing this as well, but I think this placement really threw me out there with no safety nets.
Within the first 2 hours of arrival I was expected to conduct an exercise class to a group of stroke patients. By the end of my first day I had conducted 2 exercise classes and seen 3 patients. Throughout the initial week I was the primary health professional of which these patients saw for treatment. There was another Malaysian physio present at the centre, but she had her own clients, plus her training varied from Australian physiotherapy and I was reluctant to seek her advice.
I was initially challenged by this. But by the end of the first week I had learnt to trust my observational skills, and my choices of treatment. As there was no one else to double check me, I had to be confident that the skills I’d learnt, during my practical classes and that of my previous neurological placement at SCGH, were effective.
This experience has changed my perspective of physiotherapy from a student point of view, where learning is the main focus, to that of a professional, where treating, informing and educating is the main focus. I think this experience has assisted in bridging me from being a student to a qualified health professional. I know this year is aimed at doing this as well, but I think this placement really threw me out there with no safety nets.
Wednesday, October 8, 2008
quality of life
During my placement on a head injury unit, i encounted various issues and situations that really made me think about quality of life. One in particular was a 25 yo man post head injury who presented with only high level balance problems. His primary problems were cognitive and he could barely retain any short term memory, lacked simple initiation and struggled to follow more than 1 stage commands. This young man always had a smile on his face and was a pleasure to treat.
I lost sleep just thinking about quality of life. this man would need a carer 24/7, he wouldn't even be able to cross a road by himself. So many thoughts went through my head. Where do you draw the line? what will this person ever achieve? His family will now be consumed by his existence; his g/f is waiting for the old him to come back. I know i would do the same if it were one of my family but is it worth it. Yes my personal views were pessimistic but i couldn't help it.
It seems as though medicine at present is caught inbetween enhancing their ability to save more and more severe head injuries, however we are left with more and more patients that require long term care. I guess it is just time before medicine improves even further.
I have learnt on this placement to put myself in the families position as much as i can and i continue to treat to my capacity in effort to maximise each patient's potential. In this particular case the patient is always happy and would brighten up the day of anyone he sees. Even though he is not the same as before he makes small improvements everyday. If anyone else has a different perspective on similar issues i would love to hear and continue to widen my awareness.
Tuesday, October 7, 2008
Cross-cultural rapport
I am currently on prac in a rural area with a large proportion of indigenous patients. Whilst treating a 22 year old indigenous woman for her chest symptoms following an acute bout of pancreatitis, I learnt first hand that rapport is often more difficult to establish, and certainly at least as important when treating patients with a different cultural background to my own.
The first time I saw this young lady I did not allow a lot of time to see her as she did not need too much intervention from a physiotherapy perspective. Although I had several communication strategies in my mind for this particular patient to avoid any perceived disrespect, such as being aware that she may prefer to avoid eye contact, I missed the most important element of communication: building rapport.
I felt I was being culturally aware, explained rationale for what I was asking her to do and (I believe) instructed her effectively. Despite this she appeared very disinterested and barely said a word, even when I asked her questions. After some thought, the next day when I saw her again I allowed more time, and for the first 15 minutes I just asked her about what she likes to do and generally made conversation. After this, although she still did not speak a lot, she appeared much more interested in what I was saying, and was able to do her breathing exercises more effectively.
What I learnt from this scenario was that I can’t expect a patient to be interested in what I am telling them if I don’t show interest in them as a person as well. Sometimes patients are eager to understand their condition and how to manage it, whilst others need to be interested in what you have to say in general rather than the specific information you are giving them. I found that I naturally establish good rapport with patients who I can identify with more easily, and so need to be more conscious of doing this when interacting with patients of other cultures or vastly different personalities to my own.
The first time I saw this young lady I did not allow a lot of time to see her as she did not need too much intervention from a physiotherapy perspective. Although I had several communication strategies in my mind for this particular patient to avoid any perceived disrespect, such as being aware that she may prefer to avoid eye contact, I missed the most important element of communication: building rapport.
I felt I was being culturally aware, explained rationale for what I was asking her to do and (I believe) instructed her effectively. Despite this she appeared very disinterested and barely said a word, even when I asked her questions. After some thought, the next day when I saw her again I allowed more time, and for the first 15 minutes I just asked her about what she likes to do and generally made conversation. After this, although she still did not speak a lot, she appeared much more interested in what I was saying, and was able to do her breathing exercises more effectively.
What I learnt from this scenario was that I can’t expect a patient to be interested in what I am telling them if I don’t show interest in them as a person as well. Sometimes patients are eager to understand their condition and how to manage it, whilst others need to be interested in what you have to say in general rather than the specific information you are giving them. I found that I naturally establish good rapport with patients who I can identify with more easily, and so need to be more conscious of doing this when interacting with patients of other cultures or vastly different personalities to my own.
Sunday, October 5, 2008
Effective physiotherapy Rx post lobectomy
On my current placement on a cardiothoracic surgery ward, I had a patient who underwent a right middle lobectomy. I saw her from Day 1 to 4 post-op, and saw remarkable results that I believe are largely due to the physiotherapy treatment she received.
Her chest x-ray from Day 1 showed consolidation of pleurae below the area of lung tissue that had been removed. The right hemidiaphragm was superiorly displaced 3 ribs higher than the left. Subjectively she reported pain with coughing and no production or clearance of sputum. Upon observation she had an upper chest breathing pattern. Auscultation showed inspiratory crackles throughout bilateral lower zones, reduced breath sounds in her right lower zones, and absent breath sounds in the area here her right posterior and lateral lower lobe should be. Chest expansion was reduced in bilateral lower zones. Cough was weak, painful (7/10), moist, ineffective, non productive. She was unable to mobilise in and out of bed due to discomfort.
For the following 3 days her treatment program consisted of; education on PCA use and importance of mobilising, deep breathing exercises (breathing control, Sustained maximal inspirations, huffs and supported cough), mobilising out of bed and ambulating on ward and IPPB (Bird).
Chest x-ray on Day 3 showed great results. Her lungs appeared to be re-expanding. The right hemidiaphragm was 1.5 ribs higher than the left. Subjectively she reported little pain with a supported cough and she was not producing or clearing any sputum. Her breathing pattern was almost normal and she consciously corrected herself when she began upper chest breathing. Auscultation showed no inspiratory crackles, and breath sounds in the right lower zone was improving. Cough was moderate, no pain and dry. She could mobilise with stand by assist. Medical staff anticipated discharge over the weekend. She had booked Therapy In The Home (TITH) to assist with her mobility for the initial week or so, and will come to Cardiothoracic rehabilitation classes for the next 4-6 weeks.
I think this is a good example of how a simple physiotherapy regime can be effective. It is nice to have an uncomplicated and rewarding case!
Her chest x-ray from Day 1 showed consolidation of pleurae below the area of lung tissue that had been removed. The right hemidiaphragm was superiorly displaced 3 ribs higher than the left. Subjectively she reported pain with coughing and no production or clearance of sputum. Upon observation she had an upper chest breathing pattern. Auscultation showed inspiratory crackles throughout bilateral lower zones, reduced breath sounds in her right lower zones, and absent breath sounds in the area here her right posterior and lateral lower lobe should be. Chest expansion was reduced in bilateral lower zones. Cough was weak, painful (7/10), moist, ineffective, non productive. She was unable to mobilise in and out of bed due to discomfort.
For the following 3 days her treatment program consisted of; education on PCA use and importance of mobilising, deep breathing exercises (breathing control, Sustained maximal inspirations, huffs and supported cough), mobilising out of bed and ambulating on ward and IPPB (Bird).
Chest x-ray on Day 3 showed great results. Her lungs appeared to be re-expanding. The right hemidiaphragm was 1.5 ribs higher than the left. Subjectively she reported little pain with a supported cough and she was not producing or clearing any sputum. Her breathing pattern was almost normal and she consciously corrected herself when she began upper chest breathing. Auscultation showed no inspiratory crackles, and breath sounds in the right lower zone was improving. Cough was moderate, no pain and dry. She could mobilise with stand by assist. Medical staff anticipated discharge over the weekend. She had booked Therapy In The Home (TITH) to assist with her mobility for the initial week or so, and will come to Cardiothoracic rehabilitation classes for the next 4-6 weeks.
I think this is a good example of how a simple physiotherapy regime can be effective. It is nice to have an uncomplicated and rewarding case!
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