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.
Tuesday, June 17, 2008
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.
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