I am on my neuro prac and this has happened just recently. One of the patients who was recently admitted to the ward following a stroke was taken to the physio gym to progress with rehabilitation and treatment. The patient proves to be a VERY strong "pusher" and is unable to maintain the vertical postition in standing as he pushes his COG over to the affected side, however due to his hemiplegia he requires the assistance of 3 people to sit to stand and remain in standing. The decision was made to attempt to provide some treatment for the patient on realignment using the tilt table with the senior physio.
At the start of the treatment session the patient displayed exceptionally high tone in the right biceps, internal rotators, adductors and wrist flexors - your typical flexor synergy of the upper limb. He is also very overactive on the unaffective side and has impulsive behaviour. The patient was incrementally raised on the tilt table, and signs for postural hypotension noted. While the physio was providing some mobilisations on the affected foot and positioning the feet the patient suddenly lost all tone in the right upper limb and his head became fixed in a side flexed position. The situation did not follow a typical lack of oxygen to the brain as in postural hypotension as the expected signs would be sudden loss of postural and voluntary control. We found it odd that the patient had fixed his head and we were unable to move it - it looked more like the patient was having a fit, or another stroke.
The patient was rapidly taken back to a horizontal position and his vitals taken - all of which returned normal values. The situation was discussed with the doctors who diagnosed the event as 'poor perfusion'. Subsequent events have since occurred, however it seems the medical staff are not taking the situation seriously as they insist that we promote standing ASAP yet disregard these incidences which would seemingly be a contraindication to stand. In this situation I think it is necessary to go with your instinct and if you don't feel comfortable continuing with the treatment session due to patient saftey then don't!
Monday, November 3, 2008
When it all becomes too much...
I am currently on my neuro prac on a stroke/rehab ward. On my first day I was writing notes at the nurses desk when a nurse hurried past calling for a doctor and some assistance. One of the patients on the small ward had tried to end his life by jumping off the balcony before the nurse had managed to get him back inside. The patient who had suffered a stroke was hemiplegic and had communication problems and was clearly frustrated and angry at the attempts made to prevent him hurting himself. The patient continued to scream on the ward, swearing and saying that the staff should of just let him die before a doctor calmed him down by sedating him.
This is not the first time this year that I have dealt with patients who have attempted to end their life however I have never been experienced to the situation actually taking place. I cannot even begin to imagine the emotional turmoil that some of these patients are going through, having to depend on others for all their basic needs when previously they were completely independent. Today I had one of my patients tell me that he wanted to die. He has been an inpatient for over 10 weeks and his progress has started to stagnate in terms of functional gain. What do you say to someone who shares that with you? Encouragement throughout treatment sessions is crucial but as Andrew said it is so important to be careful of what you say, so that you don't give people false hope.
I think it is important to be aware and very conscious of the fact that people who have had an acute neurological insult are more prone to having negative thoughts and feelings of hopelessness. This can carry over to you and be quite a burden yet you can't pretend to know how the person feels. At the end of the day, referral to psychologists may be required but patients are still going to reveal their darkest feelings on occasion and it is necessary to know how to handle these situations with tact and not disregard them.
This is not the first time this year that I have dealt with patients who have attempted to end their life however I have never been experienced to the situation actually taking place. I cannot even begin to imagine the emotional turmoil that some of these patients are going through, having to depend on others for all their basic needs when previously they were completely independent. Today I had one of my patients tell me that he wanted to die. He has been an inpatient for over 10 weeks and his progress has started to stagnate in terms of functional gain. What do you say to someone who shares that with you? Encouragement throughout treatment sessions is crucial but as Andrew said it is so important to be careful of what you say, so that you don't give people false hope.
I think it is important to be aware and very conscious of the fact that people who have had an acute neurological insult are more prone to having negative thoughts and feelings of hopelessness. This can carry over to you and be quite a burden yet you can't pretend to know how the person feels. At the end of the day, referral to psychologists may be required but patients are still going to reveal their darkest feelings on occasion and it is necessary to know how to handle these situations with tact and not disregard them.
Child Health referrals
On my current prac we receive many referrals from child health and school nurses, often for minor things that turn out to be not a problem. However, being on this prac has made me aware of the immense importance of these nurses in the development of many children in the area. Last week we received a referral regarding a little boy who walked on his toes and his feet slightly turned in. At the start of the assessment, it seemed that the boy was simply toe walking, and there turned out to be a family history of this. However, as the time with the child went on, it became obvious that something was not quite right. He didn't make eye contact, was easily distracted, and his movement patterns were not what we would have expected. Rather than starting to form words, he made very primitive noises to get what he wanted, and the more the mother told us, the more we worried. He also had some minor abnormal tone findings. As a result of our assessment, he has been further referred to see the paediatrician, with a possible diagnosis of CP or autism.
This expereince has made me realise that although many referrals come through from child health nurses, and some are just precautionary, some of the precautionary ones tend to be lifechanging for the child involved. A thorough assessment is paramount, and if possible, 2 sets of eyes are better than one. Child health nurses are an invaluable part of our healthcare system, and we should never underestimate the power of a referral. The mother in this scenario simply thought her first child was restless and was reaching all his milestones, when in reality he was not. Hopefully the intervention of the nurse, physiotherapy department and finally paediatrician will allow the child to lead as normal a life as possible.
This expereince has made me realise that although many referrals come through from child health nurses, and some are just precautionary, some of the precautionary ones tend to be lifechanging for the child involved. A thorough assessment is paramount, and if possible, 2 sets of eyes are better than one. Child health nurses are an invaluable part of our healthcare system, and we should never underestimate the power of a referral. The mother in this scenario simply thought her first child was restless and was reaching all his milestones, when in reality he was not. Hopefully the intervention of the nurse, physiotherapy department and finally paediatrician will allow the child to lead as normal a life as possible.
Saturday, November 1, 2008
protect your backs
A few days ago my supervisor and I went to see a patient who was day 2 post TKR. She is on a clinical pathway and therefore the aim for day 2 is to walk a few steps and start her knee exercises. However she was in too much pain on day 1 to stand so this was her first time getting OOB. This patient however is quite stubborn and impulsive and also weighs 170kg. After getting the doctors in to convince her to at least try standing up, she did so very reluctantly. However after a few seconds standing up she tried to sit back on the bed without telling us. As a result she nearly missed the bed and we had to really try hard to stop her falling. She's quite a short lady with little legs and therefore couldnt push off the ground to get back on the bed so we had to sort of 'pull/lift' her back on the bed. I was behind her and in charge of her trunk and as a result got quite a sore back. I think it's a tricky situation because obviously you cant let a patient fall and she was in severe pain and trying to get back into bed straight away, however you always have to make sure you protect yourself as well, especially your back. In hindsight we probably should have anticipated her having difficulty getting back into bed and asked the nurse to be around in case we needed a third pair of hands to help just to make sure everyone involved stayed safe.
Wednesday, October 29, 2008
A conservative approach
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.
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.
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.
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