not much done?

Patient was a 60 year old lady who is a R-hemi. She had been admitted the night before with an undisplaced fractured R ankle. She previously ambulated with a quad stick but is unable to transfer at present. According to the nurse, she has a fear of falling and is not willing to use her quad stick at all. The nurses are having huge problems with her transfers. I went to see her and found that she was either unable to extend or flex her knee. I did suspect that she did not understand what I wanted but I tried demonstration and moving her limb to show her what I wanted and she was still unable to move her r knee. I did the same with her L and she was able to demonstrate what I wanted so I believe that she was either unable or unwilling to move her R knee. However, I did not know if she was unable to move her R knee prior to her fracture.
I brought her a zimmer frame for better balance and she agreed to try standing. Initially she was like a dead weight, however with some encouragement, she managed to stand with one minimal assist. Her R hand had very high flexor tone and she required assistance to get a grip on the zimmer frame with her R hand. In the standing position, we were still unable to get any movement at the knee. Since it was too painful and probably not advisable to put any weight on the R foot, she had to take her weight through her arms in order to hop or pivot on the L leg. However, due to the involuntary control in her R arm, this was not possible. I ran out of ideas and so consulted my supervisor to see if I had really exhausted my options. She agreed with me that the best we could do is to get patient to stand for the nurses to get the wheelchair or commode behind her. We then went to the nurse and she was happy enough with what we managed to achieve. The nurse shared that they had problems even getting her standing so although I felt that I did not achieve much with the patient, it was significant enough for the nurses.
I was glad to have such a patient that really challenged my problem solving skills. It also made me realise that some things such as transfer can seem like a very basic intervention yet it can have a very significant outcome both for the patient and for the team providing services to the patient. With this perspective, I can go into future practices without stressing too much about doing a proper treatment session when a lot of times the assessment will already form part of your treatment for the day.

when a patient slips through the cracks

While on my rural prac I went out with a staff member to perform an ACAT Ax on an illiterate patient who was exercising his power of attorney and in doing so required a review of the current services he was receiving. All that was known about his PMH was that he had long suffered from COPD and HTN. When queried about his current health status he stated that he was due for a consultation with a specialist in the city for reasons unknown to him. He also stated that his bowel weren't working properly and that he had lost a lot of weight in recent months. His exercise tolerance was extremely poor and as such he had barely moves from his chair not even to go to bed. The only meds he was on to assist with chest function was ventolin.

I questioned the pt over whether he gets any pain, numbness or tingling due to prolonged sitting and rapid wt loss, however this had gone unoticed by all the carers and medical reviews that he had had. The patient's memory was intact and while asking the patient these questions it seemed that the rapid wt loss, poor bowel function, lack of mobility and conflict in medications was pointing to something more sinister.

It apeared that with all the services this patient was receiving and all the appointments with varying Dr's it appeared that each health professional had diagnosed this patient with something different yet no one ha bothered to Ax this pt as a whole & look at his health in the global sense.

Ideally the pt needed to be Ax by a geriatrician who can accumulate all of the findings and tailor the patients medications and services so that he receives the best care. I felt like common logic had failed in this instance not so much from an allied health perspective but from a medical one who failed to notice the change in symptoms and medications. I learned that just by being patient and asking the right questions you can gain far more important information rather than just relying on medical records.

Notes

During my last prac we were required to pick up the previous student's ongoing patient loads and continue the treatment as we felt was required. Often these patients had been receiving treatment for quite significant amounts of time. The hardest part of this was picking up the patient from where the previous student had left off, trying to make the transition as smooth as possible. The main hindrance to making this transition smooth was quality of notes. Most of the notes and handovers for the patients I was to see were great, and told me everything I needed to know and what to prepare for before I saw the patient, but on rare occasion, they had some gaps. This led to frustration on my part, and also on the part of the patient, because it meant that their initial treatment session did not run as smoothly as possible. Although I know that this is what happens in the real world, and part of our profession is being able to pick up where other therapists have left off, for a variety of reasons, it was often challenging. However, this experience made me aware of the importance of clear and concise handovers and notes, and the importance of clarity and detail when recording the main assessment findings. As a result, when the prac was drawing to a close, I ensured that I had enough time to provide the next batch of students with detailed handovers and notes to ensure that their first week was as stress-free as possible!

Reserving Judgement

Whilst on prac in paediatrics I was assessing a 3 year old girl with foetal alcohol syndrome (FAS). The clinic I was in meant that this was a one-off assessment rather than ongoing treatments and appointments. During my subjective assessment I was horrified when her mother confirmed what I had read in the notes, that she had been drinking 48 cans of beer (yes, 2 cartons) a week for several months whilst pregnant with her daughter. She also reported that she had significantly reduced her drinking since giving birth.

I found it extremely hard not to say anything to her about my opinion of what she had done to her child and the 'life' that was given to her. My supervisor was not with me at the time and I spoke to her at length after the patient and her parents had left as I could not believe what I had heard. She did not seem ashamed to admit this either, and although 3 years had passed and she had probably told a number of health professionals before me, I still could not believe what I was hearing.

I had to restrain myself in what I said and how I said it throughout the assessment, which I was able to do by focusing on the child rather than the parents (no family-centred practice here) and focus on what the current problems were as opposed to the cause which could not be reversed. I did not feel I could possibly avoid judging this mother (or father for allowing this to occur), but felt I had to keep this judgement to myself for professionalism, but more importantly so that they would continue with the assessment and treatment their child needed.

This experience was a real wake-up call for me, and although I don't think I would do anything differently if something similar happened again, it was one of those situations where I felt that I wasn't doing the right thing at the same time. This was an extreme example of a lifestyle condition that was not the fault of the person who suffers from it, which I found far more difficult to deal with than, for example, COPD sufferers who continue to smoke.

Patient responsibility...

On my current prac I am treating a number of patients with back pain due to poor postural or motor control. Treatment of these patients includes a 'hands-on' element, but the main emphasis has been on prescribing a convenient and simple home program to help strengthen their often VERY poor core stability muscles. However, most of these patients come to their subsequent treatment sessions and have very obviously not done their home program, or have only done it once and not correctly. Obviously this can be very frustrating for the therapist, and it happens not only with back pain patients but patients with any number of problems.

From this experience I have discovered the importance of explanations to patients in terms of treatment progressions and importance of self management. Often they are expecting a quick fix, or a 're-adjustment' to cure their pain, only to have a recurrence of this same pain weeks or months down the track. Often all it takes is a simple explanation of WHY we are getting them to do all of these exercises, and how long they might have to do them for, and then the patient can take more control over their recovery. Simple education can do wonders for compliance, as a number of people I have spoken to have revealed that the reason they don't perform their HEP is that they can't see the relevance of it, and don't understand that muscle activation is not instantly automatic.

For the remainder of this prac, and in future clinical practice I will ensure that each exercise I prescribe a patient is relevant, and the patient knows why they are doing it. Because after all, it's their body!!!

Rapport...

On my current prac I am treating a patient who seemed very shy at first and difficult to extract information from in both subjective and objective examination. Over the subsequent treatments, she became more and more talkative, until last week, when a simple question seemed to open the floodgates, so to speak. All of a sudden, she was telling me things about her life that I was not expecting, and I was shocked at what I was hearing. No wonder she came across shy to begin with! Patients can become very comfortable with us as physiotherapists and we need to be very aware of this. Some patients often just need to get things off their chest, and in our profession, we are often the ones to hear it. The main things I have taken away from this experience is not only how important therapist-patient confidentiality is, but also how important it is for us as professionals to have coping mechanisms and referral options when cases such as this arise. Patients may tell us very private things if they feel comfortable with us, and we need to ensure that we have ways to debrief, or refer the patient on for appropriate counselling etc if appropriate. If we take on board all of what a patient tells us it can be quite emotionally distressing, and can be a trigger for professional burnout. Therefore we need to be able to cope, and not put our health at risk for the sake of the patient.

It's nice to be noticed!

Apologies for not posting a blog earlier, my semester has been a little different from other students in regards to prac so I hope you are all well.

Whilst on my rural prac in Northam I had the opportunity to sit in on an initial geriatric assessment with a geriatrician that had travelled from Perth to assess some patients in particular. The patient had come to the consult with her son and the thought prior to the Ax was that Parkinson's Disease may be present. Fortunately, I have had experience in a particular Parkinson's Clinic and was able to understand thoroughly and contribute to the discussions taking place.

Watching the Ax take place without the geriatrician making any deductions until the end of the consult gave me the opportunity to make my own conclusions regarding the patient's health. The doctor really made me feel like part of the health team and constantly asked me to take over manual handling and asked me to clarify for the patient the physiotherapy input in the management of living with Parkinson's and occasionally even asked for my advice. I also had the opportunity to perform manual transfers, an area the doctor admitted that medical professionals needed more training in. This made me realise how important it is for our own safety and for that of the patient, to perform correct transfers particularly when their motor control is already compromised. The doctor did not explain things to me as she went along her Ax, rather she made comments to me regarding what she had found in her assessments making me feel like less of a student and more of a colleague which was really encouraging.

I have seen the signs of PD in the past many times before although in past circumstances a Dx had already been made. In this situation, because the patient did not have a Dx it was necessary to apply my clinical reasoning to the observations made and formulate a Dx by exclusion and rule out any other cause for the signs and symtoms. However, when the symptoms of akinesia, bradykinesia, rigidity, festinating gait, mask like appearance, micrographia and low BP are present, the Dx was obvious. Learning the theory behind the disease is one thing but actually obsevring the symptoms clinically is something else completely. Being told what to look for doesn't compare to seeing it first hand.

All in all, its nice to be noticed for our input as PT's and valued for our advice.