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..?