Death and Patients

One of Viadas' patients died this week and the doctors told me to 'let him know'. I find it harsh sometimes that a person can pass away and it is just another bed that will be filled within a few hours. I find this the harsh reality of hospital work. Just another bed... just another patient... "Can you let the other physio student know?" I hope that I don't become that desensitized.

Attachments…

After a good 4 weeks on a surgical ward, indeed, there where plenty of attachments to keep track of before moving a patient!! But after finishing this rotation, I have found myself becoming ‘attached’ to some of my patients. Not in as in tripping over drains or catching my pant leg on a drip stand (as I am so graceful) I have formulated a bond with some of my patients. It was hard to say goodbye to some as I spent a good 2+ weeks with them. Some I would see from day one to D/C, I couldn’t help but find it tough to say farewell. Even they were said to hear of my departure! Most touching were the older patient who had many life stories and those I felt the most need to help get back on their feet so they could return home. Maybe this is something you grow accustom to and are able to ‘move on’ from but for now, I don’t mind making the extra effort to send them a letter or check in on how they are going. Not sure how long it may last as crunch time is here and there are big changes & life decisions to face. I must say it has also been a GREAT couple years getting know most of you, and hope time doesn’t make the distance between us too far! Best of luck to you ALL in the PCR and those soon to be employed! Don’t forget to write :)

variable personalities

At my placement, we were discussing how different personalities learn and approach problems differently. There is the aggressor who approaches a problem and without thinking too far ahead, they just jump right into getting a solution. Basically they usually get ahead of themselves and haven't really thought things through. Then there's the reflector who will take their time and think of all the possible solutions before coming up with a plan. There's a third one but I can't seem to remember it at the moment.

One of the physios went to this workshop and everyone had to answer a questionnaire to determine which type of personaility they were. Then they all got into their respected groups and each group had to solve the same problem. She said that it was just interesting to see how different each group approached the problem. Everyone in the aggressor group began to all try to take charge and talk over each other. They all had a plan in a matter of a second. The reflector group all sat there staring at the problem and individually thought about it for a while before discussing it together.

The physio was an aggressor and she said that if a student didn't answer her questions immediately, she use to think that the student didn't know it. But now it could just be that they were reflectors and needed time to think it through.

This is quite interesting because we're all very different and if the supervisor knows what type of personality student they have, it may help the learning process for us students. She was thinking of getting the next lot of students to fill out the questionnaire on the first day of prac. I think it's a fanatastic idea and more placements should take students' problem solving approaches into account.

Knowledge is Power

This last week in cardio has cemented for me how lucky we are to be graduating with a substantial amount of knowledge and skills. Upon questioning alot of interns and RMOs this week on various issues, it became blatantly apparant that they're pretty much hopeless in their first year or two post graduating. This can however work to the advantage of physios!! If you need something done that you know for sure will benefit your patient that requires medical orders, just suggest it to them, and they believe you and organise it for you! Saves you lots of time :) Good luck in PCRs everyone!!!

Closing time….

So, we are almost at the end of the road, about to take the first step up the ladder of success perhaps?

This last week, we had a peer learning session where followed the other 2 students in our hospital to their surgical ward and had a taste of what they did. They too followed us in our general med ward and saw what we did with our COPD patients.

Subjectively we ask similar questions, objectively look for the same signs, rx wise, aim to get them up and walking. But walking a surgical patient is all about organisation. One needs to know where all the wires, drips, IDC, tubings are and how to handle them such that u still are able to place a hand on the patients back.

In terms of COPD patients, doing a detailed subjective is imperative. Not only do we ask the usual SOB, cough, sputum, chest pain, ex tolerance; we also need to determine patients’ ambulatory status, how much they can tolerate amb on a gd day, how they are on a bad day, if they have been prescribed ambulatory oxygen, or O2 at rest. Have they been to pulmonary rehab classes? (long term planning, d/c) If they have recurrent admissions (x6 in 6/12; very common in our ward), what led them in this time round, how were they coping at the time of the last discharge?

When we first started, I was missing out all the nitty gritty stuff, but as I got more familiar with it and understood why we had to ask these questions, it got smoother.

All the best for PCR !!

Communication....again

Communication has obviously been a hot topic of these blogs. This past week there have been a couple of cases where my colleague and I have had to improvise a little in the ICU. I had a patient who suffered a CVA and was also Deaf and Mute due to congenital Rubella. Trying to get the patient to take some deep breaths and have a couple of coughs was a lot harder than you think! Luckily I enlisted the help of a family member and together we got the patient to do what was needed.
My colleague had a patient who was Croatian and unable to speak English. Treatment times were spent virtually playing charades in an effort to get the patient to take some deep breaths and have a cough. We joked that the patient probably had no idea what we were trying to do and probably thought the nice 'boys in blue' were clown doctors who came around a couple of times a day and did things to try and make her laugh.......interesting experiences that's for sure.

Ax of voluntary movement

For the past few weeks of doing Neuro I've realized just how much more learning we have to do in this field alone. The physios here are absolutely amazing and creates a non-intimidating environment to learn. One major assessment that I think Curtin should go over a lot better is the assessment of voluntary movement. Yes we were taught the stages of recovery but there is so much more to that. If the patient can move a joint, is it with or against gravity?? Is it tone initiated or not? Do they have 1, 2, or 3 joint movement?? I have had to assess the voluntary movement of a few patients and I have found it challenging to get an accurate idea of the patient's movement abilities. The way you position and stimulate the joint to move is crucial.

Did anyone else find that assessing voluntary movement was a lot more complex then they expected???

Location loc...oops I mean COmmunication communication communication

This last prac has been great for liaising with other health professionals. Because I have been working in all different areas-ICU/med/surg/CCU/theatre you are engaging with all kinds of people and its great to develop some sort of rapport with the people in your environment as it makes it SOOOO much easier to do your job and do it well!! I have really found it a pleasure to work with the people at Hollywood, everyone has been so friendly and works as a team, seeking input where needed.
It's so easy to go up to the ward, see your patients, write their notes and then be on your way again but taking a couple of extra minutes to ask someone something or pass on some info about a patient really does go a long way.
Another thing that I have come away with from this placement is what sort of supervisor I would like to be if I ever get a job and am ever entrusted with students!!!!! The ability to give your students autonomy whilst at the same time providing a learning and supportive enviroment and being approachable really is an art andI was fortunate enough to have a supervisor like that.
Ok, well that's enough waffle from me. CHeerio everyone :-)

Different places

One of the frustrations of the placement I am on is that I know the requirements of the placement are different than the requirements at an equivalent placement at a different location. For example, we are still reporting to our supervisor after every subjective and objective assessment while at the other location students are doing their subjective, objective and treatment without reporting to their supervisor in between. We are also writing far more notes than students at the other placement. On one hand it may be good for us to be getting the extra feedback but it would be nice if the system was more standardised.
Mike

STUDIES SHOW…

A majority of Dr’s on our ward tend to prescribe the almighty IS (incentive spirometry) to help aid in the prevention of chest infections post surgery. Hmmm, beings there is not a lot of evidence that this piece of equipment does in fact…work, but also cost the hospital or the patient $$$, I wanted to put in a word or two. It all began when a young, fit patient day 1 post lower abdominal surgery joined our ward and as I was doing my initial Ax, Tx etc. Dr ‘old pro’ joined me and of course took over the show…for a bit…which seemed to fit his schedule, and knowing me…I aim to please and patiently awaited for him to finish! He later ADDED how physio will fit him for IS to help his chest. Nothing like putting words into one’s mouth ‘eh! Just as I was about to chime in some EBP, he was interrupted by another staff member so I attempted to utilize this time to finish my Ax. Good thing I’m a charmer cause he patiently awaited my wrap up, and politely bit his tongue for the next 2 seconds, before he asked the patient…’any questions?’ and scooted on his merry way. Upon his exit, I just couldn’t help but explain to the patient that it is WAY more beneficial to be in an up right position and/or WALK, especially for this patient. Getting up and out of bed will be 10x more effective then an IS. Not so sure if Doc would have agreed, so as you do…retrieve and dust off the ‘ol IS! Guess I’m still a bit shy on the ward because really, NOT so sure I would have corrected DOC as I am a student…and have a funny accent! I did not demean the Dr in any way, I just explained to the patient a better alternative for chest care. Were does teaching a Dr it fit in? I mean, what is a good way of bring things such as this, where we are more knowledgeable in an area, to other practitioners’ attention…politely?

Compromising Situation

Compromising Situation

I went into a patient’s room and the first thing he said was: “Are you here to have sex with me?” What do you say to that? I replied: “No, I’m the physio student and I am here to take you for a walk.” He said: “Oh, I really wish you were here to have sex with me.” I was really shocked and informed him that he was not to speak to me that way again as it was really inappropriate. I can’t even describe how I felt it was such a strange and upsetting situation. I later found out that he was transferred to the psych ward.

other health professions

I had the opportunity to sit in on an OT and speech session for one of my patients. Prior to this opportunity I had an idea of what the other health professions did but what the treatment sessions included. During her speech therapist, it was interesting to observe the strategies used to get my patient to stop slurring her speech.

At OT, my patient's goal was to get her (R) arm more functional. OT on Fridays are apparently fun days so they baked brownies. It was interesting watching my patient cut up the butter, stir the mixture together, etc. During our sessions I have tried to incorporate UL ex's but this OT session was probably more beneficial. Without the patient even realizing it, she was using that arm quite a bit. The OT was telling me afterwards that once her trunk control improves (PT's role), she would be able to do a lot more of the activities in standing. In PT, our progress will be greatly improved once the patient's (R) UL becomes more functional. It will open a lot more options.

This experience has given me a greater appreciation of what the other health professions do. I encourage all of you to sit in on at least one sessioin. We all see my patients everyday and our goals all depend on how they progress in the other health professions, especially in OT, and yet we have so little idea as to what they are doing. It was made me think that maybe we should open the communication lines a little more and discuss what they are focusing on in their treatment sessions.

Pulmonary Rehab

For the last few weeks I have had the chance to attend pulmonary rehab classes with Nola for half a day. The best part about these is the so called "education sessions" where we all have a chat, usually about a random topic that someone comes up with. Last week it was the benefits of stopping smoking. It was hilarious.......one lady said she was not "physically addicted to cigarettes", just "emotionally" (it apparantly calmed her nerves). A fellow classmate tried to tell her that was impossible."Don't be stupid, the two are interconnected, you cant separate them" he fires back....and so the conversation got started. So, I learnt that really, you dont have to educate these people all that much, you put them in a room together and let them educate each other.... your job is to pull them back on track when all the war stories make their way into conversation......very interesting but not the purpose of the class unfortunately! Attending these classes has highlighted to me the benefits of group therapies. One lady said that the class was the only thing she got out to do each week, and if she didnt have it she would probably curl up and die! Moral of the story.....if you're working in a hospital or community that doesnt have a pulmonary rehab class....start one up!!!!

Part of the 'Team'

This week I've worked harder at liasing with other staff, getting to know people a bit better and integrating more into the 'Team' that is the ICU at present. Chatting with some of the Registrar's on the ward rounds, the Consultants over x-rays, asking questions and offering my opinion when asked......yes that's right, I have been asked a few times this week for my opinion, now that people realise that I am interested in what's going on and have a small portion of knowledge to go along with it. Certainly nothing life-saving, but it's nice to be asked nonetheless and be made to feel a part of the team. I guess the thing I've learnt is: although it may take a little time, keep making the effort to integrate with other health professionals in your area. I believe it has definitely helped me with my overall treatment plan with patients, given my confidence a boost and made time on the ward generally more enjoyable. Good luck to everyone in their last week!

A Tribute to the Cardio Queens

Last Wednesday one of my new patients was a 63 yo lady with severe COPD, now this lady was actually in for some Ix totally unrelated to her respiratory condition but someone had just noticed that she was very breathless with ambulation and maybe she would benefit from some ambulatory O2………anyway it turns out that this lady has NO IDEA of her respiratory condition, what it is, how it affects her or what she could be doing to help herself. It then was delegated to me to be the one to educate her and “sell” her the idea of pulmonary rehab and the ways in which she could improve her QOL. This was slightly daunting as this lady was pretty set in her ways and not that unhappy with her current state…….to add pressure before I went in to see her my curtin supervisor said, “Now do you have a plan for how you’re going to go about this because this first meeting and what you say to her will be a very important decider of whether we have “sold” the idea of pulmonary rehab and self mx.” So in I went and did my best to convey that we had a lot to offer her and help her with her disease……..to cut a long story short she was thrilled to learn that there was something she could do to improve her QOL and manage her state better, Sue and Nola would've been proud………it was a good reminder that what you say/the way you present your case is vital if you’re aiming to get your patient on side!!

when planning and execution dont match

This week, we were given the opportunity to run the ward ourselves.

*panic attack*

On the first day, it wasn’t so bad…as there were not many new patients and some did not need reviewing.

Following that, the new patients just came flowing in. They were flooding everywhere!
What irritates me the most is the fact that we need to spend time ploughing through the notes, CXR, bloods, investigations. When the time comes to put out the flood…it avoids me as if I was a ball of fire.

Sometimes, planning your day well and prioritising patients is not enough. Flexbility is the key.

This week I have been treating a pt that has end stage COPD & on Friday I went to treat her and her sats were at 79% and she was pale, had blue lips, and temors in her extremities. As you can imagine I was very hesitant to do anything with her, but this made her nervous and she asked me if she was dying. I never want to answer that question, but what do you do in a situation like this?

Just Relax

So after 2 weeks in the ICU and following my mid-placement assessment, I've been told I need to relax more around the patients and other staff, be a little more 'light-hearted'.
I guess I've been pretty serious since I've been working in an area that is really quite critical and been around patient families who are all very upset. There must be a fine line between being more 'relaxed' but serious enough to appear as though I am not up there joking around and patient family members wondering "who is this guy acting so casual when everyone here is critically ill?". Maybe when I underdstand everything a little better I can relax and appear more confident at the same time. At the moment I'm just happy if my patient is still alive after I've been in to treat them.....

Is harder easier?

When I first read their notes, I quivered. They had pain everywhere, I may have just coloured their body chart from head to toe and called it Pb 10/10. Complex, irritable, severe constant deep and intermittent pain with P&Ns, numbness and burning radiating pain through both legs and arms. Their past history had chapters and their medications had to be taken in courses and had an instruction manual. They don’t know they’re in Australia, never mind at a physio clinic, and they don’t even know what a physio is or does. Do you know the patient? Ok, it’s a slight exaggeration but I found myself getting really nervous about seeing the “complex patients”. Actually, I was petrified. I had a couple of complex cases this week and was pleased to learn that with a lot of these patients, you can do what seems to be a very soft and short treatment and get some amazing results. I had a patient where I did some light stroking STM and a grade I-II glide on her Tx sp process and got a large drop in her pain and a huge increase in ROM.

Motivation......anyone?

We are only 1/2 way into our third clinic now and I am having trouble staying motivated. Every day is an absolute drag getting out of bed in the morning and the days just seem to just be getting longer. Then I think of the PCR then the other whole clinic we havent even started yet. The struggle to stay perky every day and actually interested in interpreting yet another CXR or taking another pt for a walk is further zapping my enthusiasm. How do you fake interest in a topic you have absolutely no interest in? Apparantly sometimes my non-verbal communication (despite my greatest efforts) shows I am "a little bored"! Some may say I may need some skills in cardiopulmonary in the future. For those who know me, they know this will be over my dead body. I have no interest in applying for a public hospital job, just in case I get rotated to cardiopulmonary! So....does anyone have some motivating words, any words of wisdom or any tried and tested techniques to help me find my motivation? Am I alone out there???

high tolerance

Having been in gen med ward for 2 weeks now, I can safely say that I have seen all there is to see…in terms of grotesqueness.

I have seen a patient’s watery brown stools, thick green sputum, frothy white sputum and mashed up lunch from someone else’s stomach.

I have no idea why these stuff don’t get to me…I had no aversion to it when I saw/smelt it and was able to digest (pun intended) it well.

Perhaps it is because I see it as part of the patient? Or maybe I should say, the patient comes first…all other stuff that comes out from them comes second and I try not to let it bother me so.

What I cannot stand is the fact that sometimes, we cannot do anything for our patients.

This patient in my ward is very old (80+) and has severe COPD secondary to smoking. Until admission, the patient was still smoking at least 10 sticks/day. Despite being SOB and getting all anxious about it, the patient refuses BiPAP, is not for resuscitation and since today, opted for the option of getting comfortable and reducing anxiety by having morphine, thus depressing respiratory system.

I guess sometimes when they reach the palliative stage; all we can do is hope and pray.

SCARED SPEACHLESS

Hi guys, after another week at RPH ward 6G (cardiothoracic/gen med) and…I’M SCARED…of my patients! I feel they are very fragile. Some have been in ICU for over 10 days before reaching my ward. I am scared to touch them, move them or even ask them to speak because I don’t want them to get too short of breath. Ok, so maybe not that extreme, but I DO take caution with them and feel I ask too many questions of my supervisor and nurses instead of taking charge. When I do make that 'executive' decision, I overlook IMPORTANT underlying factors. I want to be independent…heck, if I’m gonna be working in a couple months…I MUST build confidence…yet I want to assure my patients aren’t in any danger. I am SO taking work home with me, loosing sleep and beating myself up about mistakes. I don’t want to be an awful Physio, but at present, I think I’d be better off working in an art gallery!

The Heat

Ok so the heat is getting to me. What else is new? But it is also getting to my patients. I find it hard to motivate them to exercise when it is too hot outside. The hospital responds by turning up the A/C and then it is too cold. I can't seem to win. I even had a patient become light headed just because she hadn't drunk enought water.

A Change is As Good As a Holiday.....Well sort of!!

Hey there everyone,
My new place of torture……I mean learning is Hollywood hospital for cardio. Now here because it is largely for veterans, the average pt age is slightly higher than you would find anywhere except on your long term care placement in a nursing home, approximately 80yrs I’d say!! But I would have to say so far it has not been torture at all and surprise surprise I have REALLY been enjoying it!! Yes, you all heard me correctly, I have had some lovely patients who I just want to hug, and some of their stories are just enthralling!!! One of my patients is a vet from WWII and the Korean war, was a jet fighter pilot in the airforce and was shot down 3 times!! When he was telling me this I felt really privileged to be working with this man who had fought for our country……I know this may sound a bit dramatic but I truly felt like that and can’t even begin to imagine the things he has witnessed in his lifetime!! To add to the intrigue, he was telling me that he and his wife weren’t able to have children as she was caught in IRA crossfire as a child and got 2 bullets through the stomach. So I have really enjoyed being able to learn about my patients while I have been treating them (all this came out as we were taking a leisurely stroll for his ambulation/strengthening Rx). As much as I enjoyed the difference you saw you could make in neuro, cardio has been a welcomed change and relief for my aching body!!! Have a great 2nd week guys J

Death by notes

The mountain notes in my musculo clinic is the most challenging aspect of the placement so far. For a new patient, I have written up to nine pagers of notes. And this is the standard amount for all of us who are there. I think it’s really good that we need to analyse every part of the assessment and treatment process, but I’m finding some of the notes repetitive and redundant. We have to write the problem list and plan for the patient three times in three different ways.

Mike

Life in the ICU

I have just spent my first week in ICU and it has been an interesting experience to date. The one glaring difference between the ICU and many other wards is communication between patient and therapist. Many patients are sedated and unable to respond. Nevertheless, we have learnt that it is still very important to speak to these patients as if they are awake. Because patients aren’t able to respond it is imperative to let them know who you are, what you are planning to do and what is going on around them. It is wrong to assume that someone in their position doesn’t get anxious or stressed by our treatment. The only way we can tell how they are responding is by what the machines tell us (HR, BP, SpO2 etc etc). On occasions we have introduced ourselves as physios and the patients HR and BP immediately goes up, so we know they can hear us! Realising its importance, this is what I have been working hard on this week, therapist-patient communication….even if it is in a slightly different setting than usual.

Patient Prognosis

I came across the following scenario on a number of occasions whilst on my neuro placement. A patient asks you a question about their condition… then comes the question about how much function they’ll get back and how long “all this rehab stuff” is going to take?
Initially I was not able to answer this question, due in most part to the fact that I had little to no experience with these patients, so that is what I told them. Nevertheless, this doesn’t really put to rest the curiosity/anxiousness of the patient. I consulted my supervisor who gave me some sound advice regarding various strategies for what I should and, perhaps more importantly, should not say to my patients. Armed with this knowledge I was able to satisfy patient curiosity or direct their questioning to someone in a better position to answer than myself. All the while ensuring I was both sensitive and positive in my attitude, which may be just as important as the answers themselves, that these people are seeking.

No team spirit

What is the point in having a multidisciplinary team if the doctors make their decisions without first consulting the others in the team??

We had a patient who required chest physio at least x2/day and were planning to see him again in the afternoon as stated in our documentation. Then out of nowhere, we were told that the patient was going to be discharged to a high care facility.

What had we missed? Maybe the doctors could argue that the patient was on the “not to be resuscitated” list and only required chest maintenance, he had no need to be in the hospital anymore. Or did he? His chest was definitely in need of more chest physio though.

Is having a high turn over rate / allocating new patients to each hospital bed to see which bed has had the record number of patients the priority now?

What happened to multidisciplinary team care? Where did we go wrong?

Neuro prac

I'm at Shents now doing my neuro placement on the head trauma ward. It was quite intimidating the first week because there is so many things wrong with the patients and most are so young. In class we have stressed the importance of finding the impairments and retraining the functional movement. It's easier said than done. There's so much that needs to be done for these patients I don't even know what to do. In strokes there is somewhat of a pattern of recovery but in head traumas, you just don't know how much recovery they will get. Even if movement is regained their cognive abilities may be their limitations. On top of that most patients are barely communicative, using thumbs up or thumbs down sign. It has been a frustrating week as I haven't had a chance to do much of an assessment on my patients and have not even read their notes until the end of the week. Hopefully I'll be a little more settled in next week.

Sputum Surprises

The time has finally arrived for me to face my phobia of sputum. Having become highly sensitised to the grossness of sputum from assisting with bronchoscopies for the last few years (yes I have been known to throw up at work!), I now find myself surrounded by cupfulls of this disgusting substance 5 days a week. I have been unsuccessful in the past in "getting over" my brain's disgust for this substance. This can pose a problem when looking professional in front of patients. Heck, it can even be a problem with me staying in the same room with the patient I am trying to treat! I have been told numerous times that this is something I will just "get over eventually". For 10 years now I have been patiently waiting. I am after any advice to assist me with my cause - mind distraction techniques are simply not strong enough. Any ideas?

CRYING WOLF

Hello ALL, welcome back to another fun filled month of clinics! Well done everyone thus far!

I have now changed lanes where cardio is my focus. At the moment, I and another colleague are seeing (for identification purposes) a 50-some year old female) post MVA suffering from # ribs and pneumothorax. (NB: pneumo is diminishing.) She has an ‘elevated’ BMI and NIDDM. I feel a bit guilty because when she sees the blue shirts coming, I peak out of the corner of my eye and notice she is either closing her eyes (as if she where sleeping) or starts to moan. We have found one has to be a bit stern with her (your chest may be sore but your legs are just fine, lets have a walk) or distract her (nice tattoo). She does sweat a lot (? due to her weight and the hospital is quite stuffy) but I just want to be sure we’re not pushing her too much. Now I would never put my patient in danger intentionally. I am pretty sure she is capable of a lot more than what we are putting her through. But what if she isn’t just crying out for the attention? I am sure she is in a fair amount of pain (she has oral pain cover), but when we left her on the toilet to ‘take care of business’ she sorted herself out behind closed doors. She can definitely mobilise, but on occasion (off O2) her sats drop…naturally. Now, this could be partially from her constant sighing and not taking deep enough breaths etc. OR I could be horribly wrong. Thus far there are two of us working with her and we/I believe (with my physio student judgement) that she is fine to ambulate but again, I do not want to end up on the chopping block! She is totally fine and very independent, but it just seems she likes to have a bit more care (that is care from others as she may not be getting this much attention whilst at home). Really I’m not a mean person…though this course has taught me I have to be tougher to get what I want!! Our supervisor and nursing staff all agree she is a bit over the top, but I hope I have finally grabbed the bull by the horns and am starting to be reasonably assertive yet still a nice, caring person…hmmm hopefully not a physioterrorist!!! I just don’t want to ignore her if something really is detrimental. Any advice??

Well done so far

Hi Physio Confessors,
I wanted to put up a post to let you know how well you have been doing in engaging in this process. I have had a brief scan through the posts and there has been a wide range of topics that you have explored as a group with some good reflection on difficult issues encountered on the placement. Many of the posts share some fairly in depth observations from clinics. Where an issue has been raised and opened for discussion it would be great for you to consider putting up some follow up reflections later in the placement as to how the scenario may have changed through the clinical placement and what you feel you have learnt or changed through the process of reflecting on that issue.

A reminder that you might want to consider writing your post in a word document, saving it and then cutting and pasting into the Blog. It will save you time if you have technical difficulties in posting your message.

Keep up the good work
PG

Tears

Hope everyone made a smooth transition to their next prac.

I had one of my hardest days on Friday: I had a patient cry. She suffered a stroke last July and although she has been making wonderful progress she felt overwhelmed and cried for the majority of our session. I found myself playing counselor, not physio and although I think she felt better after our 'chat' I was left feeling drained.

What's good for our patients???

As we complete one placement and about to start another, has anyone ever wondered how this affects our patients. Similar to other placements, the musculo outpatient clinic at Charles is a student run clinic. Every four weeks our patients get a completely new student and basically have to start all over again. With some patients you build an amazing rapport with them and rehab is going wonders for them until suddenly we tell them that a new student will be taking over next week.

I had this conversation with a few of my patients this week. One patient said that he didn't mind it now that he was in the later stages of the rehab but it was difficult in the early stages of his ACL rehab. He would get use to one student and then this new student would come in and they have to do an entire whole objective assessment again. He would that quite annoying sometimes, especially if the new student was very hesistant and unsure of themselves initially.

In general though, the more "veteran" patients simply got use to the system and have come to accept it. My new patients have informed me of their reluctancy to see a new student next week. One new private patient mentioned that she decided to come here because it was cheaper and she knew that us students would take the time and effort to "get it right". Also because there was a supervisor to ensure that. But now that we're switching placements, she's not as keen on it anymore.

It brings up the question of whether or not student run clinics are in the best interest of the patients. The question isn't whether or not the patients are getting the appropriate treatment, but whether or not continuity of therapist affects improvement rate/patient rehab.

When we were distributing our patients to the next lot of students, my supervisor mentioned to my fellow colleague that she should handover her patient to whoever she felt would gel with her best as she has some bad experiences with physio.

What happens if one student's personality and approach is completely different from the next student's?? Something to think about....or maybe I'm just a little possessive of my patients.

Of dizziness and nausea….

I saw a very interesting case today.

One of my patients could not attend physio due to a dizzy spell.
My supervisor, on further questioning, hypothesised that the patient could have positional vertigo (aka BPPV).

2/7 later, we had a tutorial with our supervisor on Ax and Rx for BPPV and it coincided with the day that patient was going to come in again for physio. I was excited as I knew I would be able to finally see a hall pike ax performed and possibly nystagmus (if the patient had it) and dx which semi circular canal was affected.

True enough, when the test was performed, the patient had nystagmus, but it was really subtle. And to see which direction the nystagmus is, its best to look at the veins in the eye to see which direction the eyeballs are really moving (ie: the veins will move too). I now know what it means to really “look into a person’s eye…”

We then proceeded to treat the patient, using the canalith repositioning manoeuvre and had a pretty successful outcome. It is important that post repositioning, patients remain sitting upright for 1-2 hrs. When we did the re-ax, he felt much better but, the vestib system got stimulated again and thus, his symptoms came on but was much less this time round.

Now that’s something you don’t see in the clinics often.

Have a gd weekend everyone! And enjoy the well deserved break….

Why isn't neuro what I expected?

For the last 2 years, in all honesty, I have absolutely hated studying neuro. Learning all the various nuclei of the thalamus etc and practicing tasks that seemed pointless on healthy individuals. In my opinion, the workload expected was always unrealistic. Before attending this prac I could have guaranteed you 99.9% that I would never work in neuro - EVER! Since attending 4 weeks at Shents, I have leant countless relevant information - heaps more than my entire time at uni - and to my astonishment I absolutely enjoyed myself. This got me thinking.

What could the uni have done better? I found that uni gave me an idea of how normal movement was supposed to occur, but most of my time on prac was spent having to identify deviations from normal movement and having to come up with ingenious ways to undo them. I remember learning about the upper limb and how normal reaching works but not all about excessive proximal fixation and the trunk ataxia that goes with the inability to fractionate movement. Likewise, retraining lateral weight shift does not work by getting pts to simply move their pelvis towards a plinth!!! I think we spent like 1 lab on the upper limb, just practicing one task of reaching. I now have quite a few ideas of now the neuro steam could be changed to benefit me as a student, but it is ironic that we no longer have to do "Cue" or have the opportunity for formal feedback now that we really could have some valuable feedback to provide.

In my opinion, you can show videos and practice on healthy young class mates until you're blue in the face - you're not going to learn what you really need to. There is a huge waiting list for people to attend PT in the public system. It would be extremely helpful if we could somehow have observed close up (not from a video where you can't see much or from the back of a lecture theatre) these people in out lab sessions and provide free Ax and Rx sessions for them whilst they are awaiting a place in neuro outpatients. Good for patients, good for students!

STAGE FRIGHT

HEY all…only a couple hours until we mark off another prac in our history of being physio students. GREAT WORK! I don’t know about you but I HATE being assessed. I know this is routine and there has to be SOME form of marking criterion (don’t want just anyone becoming physios). I just find it really hard to be natural and respond to questions on the spot like I do when I am with my patient alone. I would like to think that I am much smoother flying solo (with out being supervised). Again, being a ‘student’ I am still learning and remain at a basic (yet competent) level which is where I am most comfortable at the moment. This is why I continue to pay good money while I am on prac, because I am still learning!? Of course I want to expand on my horizons to be a good team player & physio as well as gain the confidence I desire. I feel I will expand on this once I have a bit of experience under my belt. As there are still a few more pracs on the line up, I would just like some pointers on how I can overcome this ‘stage fright’ and deal with this constructive critisim. Maybe even polish up on my multi tasking, things shuch as being able to answer supervisor’s questions whilst treating my patient, without loosing my mojo/rhythm/concentration..?

The hard slog....

Hi guys

Thought i'd throw in an original post for a change, in between a car overheating constantly AND breaking down twice (yes its a mitsubishi) and endless personal training and pilates classes. I want to talk on the slog that we go through everyday, week after week. I really hate it when supervisors, and even family and loved ones don't realise what we go through. We work a full-time week, for FREE. Then we go to work after clinic, often till late at night, some of us early before clinic. Then a supervisor or tutor has the nerve to turn up late for assessments, then expect us to stay late after finish time to catch up. All well and good in the real world, when thats our job. There's gonna be late days. But when I have to be really stern and forward with a curtin tutor (who holds my fate in their hands) and say no, I have to leave now as i'm meeting a client in 20 mins and if i don't meet my appts, i don't get paid and can't afford to turn up for clinic tomorrow, it worries me that they don't understand the other side of what we do and take that into account when they're making demands of us. When i've had to do that, I feel it affects their impression of me and subsequently affects my assessments, but what can you do?It'll be an ongoing problem, i reckon. But only 2 months left!!!!!!!

Then I get a sleep in :-)

Neil

Who's been sleeping in my bed?

There has been a lot of talk about the shortage of hospital beds in public hospitals recently. We have a patient in the cardiothoracic ward who was admitted with unstable angina and is due for a CABG between now and the 13th of February. Why do they keep these patients in hospital when they are simply waiting for an operation some time over the next two weeks? Do they have to be hanging around incase they have a cardiac event? And if they are so acute, wouldn’t they just slot them to theatre in the next day to two?
Mike

Paper Work

Sometimes I feel like less of a physio and more of a secretary. I feel like I'm trapped under a mountain of paper work. Between writing patient notes, admission summaries and discharge summaries I never seem to catch up with all my paper work.

Getting near the end

Are others out there getting a little frustrated when it comes to constantly having to toe the line? For the last 2 years now we have been learning to jump through hoops and perfect the act of changing the way we do things or write things to please those marking us - even if we disagree with what we have to do. This placement I have had 2 supervisors, one for the first 2 weeks and one for the last 2. As part of our placement we have to write full admission summaries (like soapiers) for all of our new patients. Having shown mine to the first supervisor who suggested a couple of corrections (which I made), the second supervisor now recommends a totally different admission summary - I now have to make loads of changes which I have to try and squeeze into the day as I cannot take them home.

I feel very confident in a medical setting and believe I can often tell when things are a complete waste of time but I never know as a student how far to take things. In my opinion, supervisors tend to like students who agree with most things they say and do everything they ask without too much questioning? In my last clinic I questioned quite a bit about treatments we were asked to do that contradicted what we were taught at uni. Subsequently, in my appraisal I was told I was too "forward". What if we have serious doubts about the whats and whys? Does anyone else get sick of having to agree all the time? Where is that line?

Let’s Get it Started….

This week I’ve found a solution to patients not being showered and ready for physio by 9am (which is when we like to get things rolling in our Neuro rehab gym).
Originally we would liase with the nursing staff who would either say “yep the patient will be ready for 9am” and then they’d be good to go by 9:20 or so which would put us behind the eight ball from the word go, or “sorry I’m pretty busy at the moment, how about 10am?” Granted, the nursing staff can’t just react to our every wish and sometimes what we ask for is not possible.
This week when I enquired about a patient’s availability early in the morning I also offered to transfer/help transfer the patient in and out of the shower. The nursing staff seem much more willing to get things going if this offer of help is extended. The result has been happier nursing staff, improved nurse-physio relationships and most importantly more time for patient treatment and therefore better quality treatment time.
If anyone’s having the same problem, give it a try!

Surgeons

Question of the week: Can we, as physios, do anything about Orthopaedic surgeons treating their patients like an annoying fly in the room???

I've been treating this wonderful patient who had a TKR a few months ago and she went to see her surgeon last week. As she had quite a few questions regarding her progress, she was looking forward to the appointment. We had discussed her progress and how she is basically right on schedule, if not ahead, so she was looking forward to seeing the surgeon. She was looking for validation and confirmation from the surgeon.

Upon seeing her this week, it was clear that her appointment did not go well at all. Firstly, the surgeon was about 45 minutes late. Secondly, the surgeon simply tapped her knee and said that it was looking good without even asking her a question. Then he read my review summary and told her that she should be working harder with her exercises. Thirdly, he didn't even give her a chance to ask any of the questions because he was already walking her out of his office and simply told her to keep up with the physio. When she went back out to the front desk even the secretary was surprised at how short the session was and had to ask if he was done with the patient. It lasted all of a few minutes.

Throughout this blog we have discussed the importance of encouragement and keeping the patient motivated to do their rehab/exercises. This patient was as motivated as I've ever seen. She was a gym rat and couldn't wait to be allowed to return to the gym. After the appointment with the surgeon, she was so deflated and felt as though her progress was not enough.

For the remainder of our session, I had to do damage control and get her motivation back. This program have stressed the importance of multi-disciplinary team work and I don't think surgeons are getting preached the same message. Is there anything we can do about the way surgeons treat their patients?? This is an issue that really affects the progress of our patients. Sometimes it almost feels like whenever we get the patients to take a step forward, the surgeons come in and force them to take two steps back.

Point Break
Sorry guys, this isn’t really clinically related as such but rather a reflection on a week that started not so well but finished much better……….At the beginning of the week I was feeling really exhausted and frustrated with myself having had a couple of rather full on days and I was really asking myself what am I doing???? Why am I doing this???? It’s a bit disturbing asking yourself these kind of questions when you’ve invested so much time, effort and $$$ into doing something and you’re nearing the end………but that was how I was feeling (sob sob sob). But the last 2 days were really enjoyable, things flowed nicely with the timing of our physio sessions, our patients were improving and I really felt like I was achieving something which was great. You really need those days to pick you up and help you soldier on. Thanks to the others on my clinic for the lunchtime laughs and camaraderie……..couldn’t get through it without you!!

dystonic-itis....

Have you ever had one of those days where you doubt yourself and ask whether your treatments are effective?

I experienced that today.

This patient I am seeing presents with L dystonic upper limb (which basically means it has a mind of its own) and does not respond to stretches, SIMMs, weight bearing activities, posture correction and to the individuals will. I suppose it is also because this patient has a progressive neurological condition and most likely will ultimately never return to pre-morbid status. Or maybe I don’t know much about management of dystonia, which I will endeavour to read up on.

Another patient has been receiving treatment even before I heard of the profession. This patient has now reached a status where max assist is required for transfers, feeding and sessions consist of maintenance stuff such as stretches etc.

With patients who have progressive neurological conditions, I think it is important not to expect too much out of physio treatment as the ultimate aim is to maintain or improve their QOL and where possible, work on the functional task that they have difficulty with. Having said that, we also need to do the best we can for them and not “leave them in the lurch” and assume that whatever we do will not be of benefit to them. Sometimes, it is all they need to add some spice into their lives.

But when will it be time to stop adding those spices and realize that we can no longer help them?

FIGURE OF SPEACH

This week I have acquired a priceless piece of practice, this being communication!! When ‘communicating’ with each other, it is important to remember there is an aspect of how we present the information at hand. This is because there are many ways to say the same thing. This includes the tone of voice, facial expression, body language and much much more! It is also our duty to provide the patient with information when they request and educate them on their well-being. Just today, my colleague and I were working with our patient. Family was present and even though no particular questions were directed to us in regards to our treatment, my partner explained an exercise, why it was being done and how it was going to help our patient. I found this to be an exceptional form of communicating as well as professional practice. This is done ritually with our patients (the explanation of ‘why’ we do things) but it was good to see the inclusion of the family automatically, without second thought. I do recall learning the importance of family and the necessity of keeping them informed as well. I was most taken by the manor in which the information was presented…very professional yet casual. Because we play a big role as teachers and not just providers, the presentation of information is vital to encourage, convince, commend and partake in our patient’s recovery. I have also been told ‘sometimes we must act’ to really achieve the goals we want. This ‘acting’ is meant to be confident, yet credible at the same time, even if you are not sure. Something I myself, must continue to practice until it becomes second nature.

Wires Crossed

When I stepped behind the curtain there were wires everywhere! It’s not that I wasn’t expecting a lot of attachments, as I had read the patient’s notes and was aware of his case. My mind began to boggle as to where I would begin to untangle the various leads and cords:
Telemetry
O2 with humidification
IDC
ICC basal and apical
Central line
Pacing wires
BP cuff
Sats monitor
Intramuscular line for pain
DVT prophylactic pump
We were planning on helping the patient move from their bed to a chair following a pneumonectomy – so simple I know! I knew that everything had to be on one side of the bed, so I began to arrange things accordingly, but I was slow and hesitant while trying to make sure I didn’t do anything wrong. Everything was going fine, but I haven’t seen DVT pumps before so I asked the accompanying physio (not my supervisor) what I should do? The patient could see I was not completely sure of myself, and it was extremely uncomfortable as the physio gave me a very simple and obvious reason for being able to remove the cuffs. I felt like a complete idiot and it was obvious that the patient thought I didn’t know what I was doing.
I felt like saying to the patient, “don’t let my lack of experience fool you to thinking I have an absence of knowledge”. Any tips to avoid looking dumb in such a situation?
Mike

I found it really hard to write my blog this week. My clinic has been going great and my patients do their exercises and try really hard. They also get really excited when they see little improvements that just encourage them to work harder. I find their enthusiasm infectious.

I have a patient that is really sensitive about her height (she is under 5 feet tall) and she seems to take simple things, such as having to lower the plinth to get her feet flat on the floor, as a short joke. I was warned by my supervisor to be careful with what I say and how I approach her, but I think not knowing would have been better because then I would not be constantly thinking about avoiding offending her. I would never intentially make a negative comment about a patient, but I think by trying to avoid anything that will trigger her anger I am not focusing on her treatment as well as I would like to.

Kristie

Visitors

This week I have been faced with patient’s who have visitors at there bed side when it comes time for their physio session. My initial reaction was “I don’t want to interrupt, I’ll come back later”, especially when you know the patient has been in bed most of the day and very bored. Just when it comes time for physio, they have visitors to bring a little sunshine to their day. This has happened on numerous occasions with one of my patients and we were losing valuable rehab time as the patient would refuse physio if they had visitors. I consulted my supervisor and came up with a solution.
Let the patient know in advance what time you’d like to take them to the gym for physio. If you can make it around the same time each day, even better. That way they can tell visitors to try and come before or after that time.
Suggest the visitors go down to the cafeteria for a bite to eat or a drink and that physio will be done in XX amount of time. Compromise and cut the session slightly shorter if needed.
Highlight the importance of the patients physio in returning to function as soon as possible, to both the patient and the visitors.

I have put these ideas into practice and they have been working well. The patient understands the importance of their rehab and the visitors know which times are best to come in. Overall everyone seems happy and there have been fewer physio vs. visitor timetable clashes!

Zak’s back……..Well my latest little source of reflection is trying to think of ways to improve my liaising with the nursing staff on my ward. Now, having done a nursing degree and then our other physio pracs I have never ever had any problems with nursing staff or building a good rapport and working relationship. However, this prac is proving to be slightly challenging in this department, not that they are not nice people because I’m sure they are but it seems that they see physio as one big inconvenience to their schedules. Now I understand our ward is particularly heavy with most patients requiring full assistance with their ADL’s which therefore requires a lot of time and effort from the nursing staff. To try to enable things to run smoothly there is a system in place where we write up on the board physio times for our patients and then also in the ward diary, as well as checking this is ok with the patient’s individual nurse…….a process which is quite arduous but supposedly time saving and effective. I have one patient with one of my colleagues who is particularly heavy and often reluctant for physio so she requires a good amount of time to have an effective treatment session. Every morning this week we have gone through the above process, even putting it in the diary the day before so there’s plenty of notice but each day she has still been in bed when we have gone to collect her for physio. My frustration factor was off the richter scale one day, just because we had made every effort to even help the nursing staff get her ready but it just seemed like there was very little appreciation of these people’s need for physio……..even though, apart from their general care, is the best thing for them and the only thing that’s going to possibly get them better and back to as functional a life as possible!!!

PUSHING THE LIMITS!!!

Week two and still battling the DOMS. Sorry Leah, can’t afford a gym, using milk jugs of sand at the mo!! This week I have definitely picked up some new techniques to conserve my back..?? But who knows what else may be compensating!!

My concern this week is the expectancy of the patient. This week I started treating a new neuro patient who is very dysphasic and dyspraxic. This alone makes it hard to treat them because comprehension of the task at hand varies. I can see in their eyes they have quite the personality and understand the necessity of rehab to get better. The length of ‘quality’ time I have to achieve a successful treatment is MAX ~ 20 minutes [not including the transfer to the wheel chair (10min) and transport to the physio gym (5min)] before the patient starts to ‘turn-off’ and loose interest. I find that reasonable! On occasion the secession may not show a huge change (note being this is acute stage neuro) but I chalk that up to the patients mood, fatigue, time of day and people present. At one secession this week I could tell my patient had had enough and I was preparing to return them to their room. My supervisor wanted to see them do a bit more work. My patient continued but by the end of another 10min they were quite annoyed and tired. The session was productive and an improvement seen but my patient was cranky. My patient doesn’t seem to care too much for physio now, but I work my charm to encourage them on the benefit! Could I be too lenient or naive to where I ‘give-in’ (cutting a secession short) which may be hindering the patient?? I don’t want to ‘push their limits’ and loose their respect or motivation to get better?? UGH! Or is there a happy medium?

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.

The Power of Encouragement/Motivation

Hey there friends and colleagues, hope you’ve all had a friendly and inviting first week of clinic. I’m currently at Charlies in neurology with 3 other lovely people. One thing that has become particularly evident to me over the last week is the incredibly important role of encouragement and movitation in dealing and communicating successfully with patients in this area. I understand that this is necessary with patients in all areas but for many of the patients on my ward, their worlds have been totally turned upside down and they have gone from active, independent individuals looking after others, to completely dependent on people for their most basic needs. As you can image (although, I’m not sure we fully can unless you’ve experienced it), this is very depressing and degrading and many patients lose hope. One of my patients was a very independent and active lady before her stroke in December, and now she cannot stand independently, her speech is dysarthric and she is at the mercy of others for all her ADL’s. In working with her she is often expressing that there’s no point in trying and that she doesn’t care anymore which poses an additional challenge to her rehab. I have been amazed at the difference some genuine encouragement and positive reinforcement has made with her. You can see in her face the flicker of hope when you say how well she’s doing and she asks, “Really?” The role of motivator cannot be underestimated when working with patients, and I guess in general the degree of impairment tends to correlate with the level of encouragement/motivation needed to an extent. So go for it guys!!

DOMS

After week one on my neuro prac I have found myself in a world of hurt! I find myself as a fairly fit individual but recently am struggling with very sore muscles and aching joints! My musculo prac had nothing on this one where acute stoke patients, big and small, require a MAX effort to attain any position. It has always been warned that one needs to be somewhat strong to work as a physio.

What I have found is there is huge spectrum of hand placements, transfers and tricks of the trade to ‘safely’ move and treat these sorts of patients. I share a larger, max assist patient with one other individual on my clinic. It is very difficult to feel safe with the patient when all my muscles begin to shake and I start to sweat profusely. I have found it very beneficial to get tutored on the ‘field’ way of handling patients in this situation though I am still uncertain as to my comfort level with theses patients.

Our curriculum has done a good job of giving us a ‘base’ to start from. The difference is, practicing on each other is very different from the real thing and modifications are needed to really get the desired effect!! Currently we have utilised tutorials by our clinical supervisors to demonstrate facilitation, transfers, reeducation etc. as is done in practice. Techniques become quite modified and there are noted changes with those clinicians with years of experience. I still feel the need to become more confident to ‘modify the mold’ of what I was taught and what is used. I guess it comes down to what works for you as an individual but I do want to assure my patient is safe! Has anyone else found that tweaking some of the lessons learned has helped or hindered confidence with transferring/treating a patient?

Hi all. Hope everyone enjoyed their holidays. It is weird to not see all of you every day :)

I'm doing Neuro Outpatients at Shenton Park. So far it is really good. It is a student run clinic and we each have a list of patients that we have taken over from the last set of students in December.

So far everything is running smoothly. My most challenging aspect so far is dealing with a patient that speaks virtually no english. She is a left hemi that needs both gait retraining and upper limb function retraining. I find that I have to use my hands more than my mouth and I need to have very concise instructions, if any (if you know me then you know that it is really hard for me not to be chatty). The hardest part is giving her a HEP because I cannot seem to get her to understand what I want her to do and how many times. I can get her to do what I want if I guide her, but not by herself. She is content to let me move her appendages, but cannot repeat the actions on her own. I finally got her to lift her toes for IC, but not she is almost lunging instead of striding. Any thoughts?

Hi everyone!. At the moment I am on a neuro placement at RPH Shenton Park in the out-patients department. Patients come in to us after they have been discharged from the ward on a twice weekly basis. "Reflecting" back on our whole studies in neuro, we have been taught how to do various assessments ie tone, cerebellar, cranial nerves etc but I am now having trouble putting these into perspective in an outpatient setting. When a patient is in the ward, you are seeing them daily and testing absolutely everything you can think of progressively throughout their stay in hospital ie you test everything. In an outpatient setting, patients have all recovered to some extent (enough to be discharged) and all come in with a wide variety of issues. Consequently, I had absolutely no idea which assessments were necessary and which were an absolute waste of time ie I had no idea where to start when a new patient arrived! Was I supposed to test vision? Was I supposed to test cranial nerves? Did I need to check sensation? Our supervisor knows each patient as she has treated each one previously on the ward so can pick her assessment up from where she left off. She states in an outpatient setting she never checks sensation, or perceptual deficits as the main goal is to improve motor function. Apparantly it is not time efficient to test everything. Hmm. I saw no other way to resolve this problem then simply to ask? Our supervisor gave us the answers (which was lucky as this is our assessment). I feel I know how to do things, but not necessarily when to do things in an outpatients setting. Reflecting back on our studies, perhaps it would have benefited me now if I had clarified which assessments were relevant in an outpatient setting, other than motor function.

jitter bugs

I always get the jitters when I see patients for the first time.

And this is because I get anxious about focusing too much on the assessment and the whole procedure that I forget to look at the big picture. Is this known as focusing on the trees and forgetting the forest? Hmm.

One good example is when I was assessing a patient with multiple sclerosis (MS), I followed the assessment form and thought that I had assessed enough and analysed it well. But when my supervisor came and saw the patient move from a position of supine to crook lying, she immediately saw something that I had completely missed out. My patient had a very subtle trunk ataxia. She went on to explain that some MS patients may seem to have no/little ataxia because they fixate the movement through the global muscles. In addition, if we work on getting them to stop the fixation, the ataxia will become more apparent and as a result, patients may think we are doing them more harm than good. Contrary to popular belief, enabling them to stop the fixation will allow us to work on their postural muscles and thus, improve their ambulation.

Being a student with no experience in neurology, I feel it is important we analyse our assessments (therefore we do a SOAPIER) and get the supervisor to go through it (important to do at least one) so from there, we know if we are on the right track and can build up on our skills.

I think it all boils down to how well individual observation skills are (that’s why we are students and trying to get more experience to train it). Apart from observing patients movements and analysing it, knowing common movement patterns are pertinent too.

Is there any other way to improve observation skills?

Learning Styles

I’m interested to know how different people prefer learning whilst on their placements. I have been on placements which have involved the majority of my learning and practice solo and have also been grouped with other students. At present I am part of a wonderful group of 4 people which I believe is enriching my learning experience. Working with a fellow classmate enables us to bounce ideas off each other and fill in each others learning gaps. Even if we are working with separate patients but are in the same work space (i.e. the physio gym) we are able to confer briefly if questions arise or ideas need clarification. Personally I am happy to help others where I can and in turn am grateful to receive help in my time of need. I think both styles of learning have there place, but perhaps initially being paired together gives me more confidence and sets me up to handle things individually as time on placement progresses…..what do you guys think??

Powers of observation

Hi guys!

Hope you have all had a fantastic break and are ready to take on the final few months.

I am currently in Cardiothoracics at SCGH. While treating a patient today, I was in need of an extra chair. There were no spare chairs in the room, and I had noticed chairs in the corridor that the patients used to rest on during their walks. I hurried out of the room and grabbed a high back chair by the arms pulled up. To my dismay the chair stayed where it was and I was left holding the arms - the chair was tied to the wall!

Hmm, seems I need to work on those powers of observation. Ok, my next blog promises to be more clinical but I learnt to pay more attention to the environment that I work in.

Mike