Uncompliant patient

I received a private referral this past week stating that my patient required a fitness assessment as he needs to lose weight for surgery. Initially I was excited about this situation as this was something different and created different challenges, although I questioned whether or not Physio referral was the best situation for him. Would he not have been better off sent to a dietician and an exercise physiologist??

"Sabrina, you're 10 o'clock patient is here" was how it all started. I went to the patient waiting room to greet my patient and he was in a wheelchair. Oh, he must have some sort of LL impairment was my first thought. Wrong!! As it turns out, he uses a wheelchair all the time because he gets short of breath and chest pain due to angina and a hernia compressing onto his heart. 6 minute walk test was the initial plan for him. I went through my spiel and he understood that he could take as many breaks as he required. Then, just as we were about to begin the test, he suddenly became uncompliant and very aggressive. There were no warning at all. Prior to his break out he was agreeing and understanding why we had to complete this fitness evaluation. He just kept saying that he did not want to do this and did not understand why people were always tyring to make him exercise. He's too short of breath to do anything and just wants to be left alone. All he wanted to do was go home and watch tv.

After calming him down and explaining that he may not be eligible for surgery if he doesn't lose some weight. I even tried negotiating and skipping the 6 minute walk test and doing a time up and go instead. He still refused. At that point, there was nothing else I could do.

As I was pushing him back to the waiting room I realised that he was a private referral, which meant that I am suppose to charge him. I don't think anyone told him that he was going to be charged prior to coming to physio. He didn't even know why he had to come in the first place. Luckily my supervisor told me not to charge him. Thank goodness because I did not even want to go there.

I think this whole scenario was not approached correctly and a lot of people's time was wasted that day. Not really mine, but the patient's and the carers who had to drive him and pick him up from physio. It should have been made clear to the patient why he was coming in and there should have been patient consent prior to him coming to physio. This was a good learning opportunity for me, to learn how to deal with non-complaint patients.

The Frustrations of Neuro

Over the last couple of weeks I have been able to a selection of neuro patients, the majority of which have conditions I have never even heard of before. I am now beginning to develop an understanding of just how complex neuro patients are to treat. With most neuro patients at shents, most cannot do the exercises you prescribe without gross compensations. Hence you have to correct them at about a million levels - ie you need to be an octopus with many eyes.

Although I am usually always able to work out that the exercise is not being performed correctly, I have heaps of trouble working out the exact ins and outs of the intricate compensations neuro patients make. According to my supervisor this skill takes years to develop, but I cant help feeling a little regretful that these patients scored a physio student!!!!!! Looking back, I think it would have been helpful to spend less time practicing on each other and have more real patients come in to visit us in the labs, rahter than just a couple in a huge lecture setting!

Light in the head

I am currently doing my placement in RPH-SPC, Neurology Outpatient. Every Thursday, we assist our supervisor in conducting a running group for patients who have had neurological conditions.

The patient I was supervising had a stroke 2-3 yrs ago and had already done his warm ups (consisting of step up 5x and walking approx 200-300m to the main gym), we then got him on the ex bike to build up his ex tolerance. After the 9th min, he complained of light headedness and I had to ask another colleague to help me get him off the bike and take a seat.

She then promptly went to get him a cup of water and instructed him to take sips from the cup and not to gulp it down. After 2-3mins, my supervisor came, asked how he felt and proceeded to take his pulse rate (which was normal) and cos she could feel his pulse rate well assumed his blood pressure was not low.

When my patient felt lightheaded, I felt it too cos I panicked and did not think of the normal protocol that I should have done ie: take PR, BR etc. Thinking back, I should have asked the patient if he had a meal before he commenced exs, as according to my colleague, that cld have led to him feeling lightheaded (low blood sugar). Although he did comment that this was his first time on the bike after a christmas and new year break. Could this have led to a further deterioration in ex tol, increasing his RR and thus hyperventilation resulting in light headedness?

Having had this experience, I feel I am better equipped to handle such situations should it be presented to me (touch wood).

Surprise in Surgery

I had an awesome opportunity last week to attend surgery for a double CABG. Don’t worry it wasn't my heart they operated on! And, I might add that I did not feint!

For the bypass of the LAD the surgeon used the patient’s LIMA. I was quite surprised to see that the LIMA was covered in fat and appeared (even though I wasn’t wearing funky surgeon magnifying goggles) atherosclerotic. I saw how they clamped and injected the LIMA to ensure it was patent, but I couldn’t help but wonder why they are so happy to use a diseased artery to fix a diseased occluded/stenosed artery?

Mike

identity crisis

Dear all,

I'm sorry i forgot to introduce myself.

I am Davina (dav), one of the degree conversion students.

Hope u all have a good week on ur placements.

Fighting the system.......

Hi all, just joing the long line of people writing their post at the last minute... I'm at the curtin clinic this month doing musculo, which is the area of physio that i'm aiming towards. This clinic is a mix of 50% private patients made up of staff & students and local residents, and 50% referrals from the bentley health service. My post is about the limitations of this system, and how it affects the treatment of your patients. In a normal private practice, when a patient comes in with a problem, you can treat the whole body if necessary (it's all connected, as we know). On the other hand, on a referral....... I had a patient who has been a patient at the clinic for a long time (>6 mths), referred by his GP for chronic neck pain. He presents as the typical neck pain patient: terrible posture (extremely kyphosed, stiff thoracic spine, protracted chin) tight SCM/scalenes/LS/UT, weak cervical flexors, poor endurance in a good posture & decreased awareness of position & posture. His Rx to date has consisted of cervical mobilisations, stretching & soft tissue massage, with minimal effect on his overall pain levels. In my first session with him, I basically continued this line of treatment, as we were being directed by our supervisor as to how we should plan our Rx for different patients. Post Rx he was very sore, his pain levels having increased, with a small improvement in range of motion. Before seing him for a second time on friday, I asked my supervisor if I could direct my treatment more towards improving his throacic spine mobility and postural awareness. She said excellent idea, but because his referral is for his neck I really have to work on his neck, not his thoracic, even though thats basically whats causing a lot of the problems. In the end we planned to treat his upper thoracic stiffness, and keep going with the soft tissue treatment and deep neck flexor exercises concentrating on posture a lot more. Has anyone else in musculo now or in the past had this problem with public patient referrals?? thoughts????

Robotic Initial Assessments

Hi everyone, hope everyone is enjoying their placement so far. I am currently doing my musculo placement. All of my previous placements have been on inpatient wards and switching to an outpatient ward have been quite challenging. Not only is there a lot more administration stuff to take care of, but you are constantly under pressure to finish on time. If you are not done on time, it’s too bad because your next patient is in the waiting room. It has not been a problem thus far but I feel as though when I am doing my initial assessments, it seem so robotic. In an inpatient setting, you are able to read their medical records prior to seeing them and the initial assessment questions are to clarify specific details. It seem so much easier to build patient rapport with an inpatient than it is in an outpatient setting. In an outpatient setting you are given very little information and sometimes just the patient’s name. Our supervisor told us to inform our patients that we will be going through an initial assessment and will have to go through the questions in a specific order so please let us ask the questions and wait till the end to inform us of any missed information. As a student it’s good because it helps us stay focused and get all the information but it seems so formal and robotic.

A lovely elderly woman came into our clinic as a new referral. From the beginning you can tell that she was very chatty and was someone that would need constant reminder to stay on track. When you ask someone how the incident occurred and they begin with an exhaustive description of their role in an elder’s association, you know it’ll be a long assessment. I know you have to keep your patients on track and learn the fine art of cutting them off but it felt like I had to do that for every question. Maybe it’s the fact that we have to write everything down immediately but I’m afraid that I’m sacrificing patient rapport with getting all the details down. It feels like I’m conducting an interview more than anything else.