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