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.

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.

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

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.

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.

Psychological Factors

Whilst on my musculo placement, I was given a patient from the previous student that had initially presented to the clinic the previous month complaining of chronic pain that affected her whole body. The elderly patient described 9/10 to 10/10 pain in her neck with extensive loss of mobility. Her past medical history was extensive including chronic dermatitis, coeliac disease, IBS, hypotension, claustrophobia and agoraphobia, which causes a severe fear of social situations and distrust of people around her.

On her first treatment session with me, the patient displayed extreme anxiety walking from the waiting room to the treatment cubicle and began to, what appeared to be “hyperventilating”. Knowing her history with hypertension and anxiety, I gave her a seat and closed the curtains around the cubicle to block out the distraction of the other students and staff. Thinking that this would relieve her anxiety, she appeared only to get worse and reported that having the curtains touching her made her feel sick. As such, I opened the curtains and moved her to a cubicle that was adjacent to a door where she could see an exit. Her anxiety started to decrease and she began to elaborate on how active she had been in her 20’s, seemingly avoiding all the AROM assessments and exercises.

I didn’t want to appear rude and interject as she already has a chronic fear of trusting people however, I was frustrated that I was unable to perform any hands on treatment with her as every time I attempted to make contact, even if I asked permission and warned her, she displayed a hypersensitive reaction. I learnt that the best thing to do was talk to her during the first treatment session and slowly gain her trust. Over the 5 weeks that I saw her she told me that I was the only person that she allowed to treat her and gradually I was able to perform more invasive neck mobilizations. She seemed grateful that I took into account her phobias whilst treating her and slowly her AROM improved to near FROM and her resting pain became negligible.

I learned that her psychological conditions were feeding a fear avoidance syndrome and contributing to her chronic pain and that getting her to understand this can prove to be extremely challenging. In these circumstances pain scores are not useful in determining progress rather ROM, confidence and developing trust are better indicators. Encouragement was crucial and distracting her with conversation and getting her to copy movements I was performing was one way in which I was able to help her realise not to be afraid of movement.

In the future, I will have a better understanding of how to treat patients using a more multidisciplinary and personalized approach. It is ok if no treatment or assessment is performed on the initial visit. Building a relationship with the patient is the basis to any successful intervention.