looking forward looking back

We do make a difference.

This story comes about with abit of help from my grandads god ol' friend Slim Dusty. hence the title. Recently on spinal there was an old aboriginal man who as well as his paralysis had suffered head injury due to chronic alcoholism. he was brought down to physio every day even though he didnt really want and never said anything, just sat there, did abit on the arm ergonmeter and some arm weight, just sat there with a blank look on his face. there was a particular physio ho was working with him and over the 4 weeks he was there I saw him turn into a happy little chappy who was keen to come to physio, and he even brought down his slim dusty cd's which we pt on for him and he loved. I just wtched this physio and it wasnt what she did with him it was how she was with him. In the end on our final week he got discharged. We all thought he was this shy little man but there was a whole gym full of physio's, patients and their families and he rounded everyone uo and said he wanted to say a speech. he thanked everyone for what they had done for him and said he was really happy with his physio sessions. I was in complete shock he had had the guts to say that, and by doing what he did he made our day as much as we made his.

he was the most gorgeous little man

A mothers perogative

Not sure if thats how you spell perogative, aplogies if not. recently, I had a prac on Spinal and there was an 18 yr old boy who had had a MBA resulting in a complete paralysis at the level of C5. This young chap is very positive and a great person. he also manages to cheer everyone else up on the ward when most of them have alot more function than he does. His mother is also a very lovely lady, but ofcourse wants her son to walk which really isnt possible. This lead to her being abit unrealistic about what he shouls and shouldnt be doing in physio. She made a complaint at his physio for not doing evrything they could to get the most of it which ofcourse resuling in meetings, paperwork and a somewhat hostile relationship with the physio everyday he came down for his 2 hour session. Truth is, the physio was doing as much as they could. this pt only had limited muscle activation and they were working with what they could to achieve strength. the pt has no made much gain function wise in 2-3months but this mother is determined he will wlak although been told otherwise. i learnt that soemtimes you tell mothers the truth but they dont want to hear it until they are ready. you just have to stick to you guns and be realistic.

Supervisor, paternal figure?

Some of you may find this funny, some of you may not.

I had one particular supervisor this year that I cant seem to get rid of. He is following me haha. No, i got along really well with my rural supervisor and he taught me alot, and I decided to use him as my SDP supervisor aswell. he was happy to do it but also more than happy to through abit of "constructive criticism" at me whenever he pleased. the funny thing is is that I actually learnt more about what sort of physio (and person) I want to be through his antics. He highlighted how unorganised I was, and how poor time management skills lead me to having to catch up with him to talk through my SDP while he was at a health conference in perth for just one weekend. Although I got flat out bagged alot, it didnt get me down but rather re0iterated my weaknesses. My problem is, he didnt exactly suggest any wasy to combat these weaknesses. So im left basically with a list of weaknesses and no clue how to fix them. I will just keep plugging away. The funniest bit of all is that I have been up in Darwin for a week, and on my first day here... randomly ran into him... what are the chances?

SDP troubles

I guess its abit late now but just wanted to put out there the importance of communication for SDP. i did mine in Perth buut it was a project up in Broome and dicovered abit late that what I thought I was doing and what they wanted were 2 different things. this left me carrying over with it now, as we speak, i have to tweek the project even though i am well and truly done with it. I corresponded via email mostly and sometimes had to wait a week for a reply. this made it very hard and time concuming. there were also too mmany objectives that added to the complication of it. I guess im trying to say dont bite off more than you can chew, do something small and do it well.

Sorry a bit late!

Hi guys, sorry i thought i had done all of mine, but i realised i was one short.

Importance of confidentiality in rural areas!!!

I found that the people in the rural area were very friendly and i would see a lot of my patients around the town, down at the beach, or at the shops and they were most friendly. However one day i saw a patient and i gave him a wave as is my nature and i was somewhat surprised when they ignorned me. I didn't really take offence just thought that they might not have recognised me. The next time i treated them they were very apologetic but they explained that they were with someone who didn't know about the condition and did not want to explain to them and if they had of spoken to me in the shops their friend would have questioned them so it was easier to ignore me.

It reminded me the importance of patient confidentiality and how important it is in a small town!

cheers

Supervisors

I have had a couple of incidents where patients that I have been treating daily for a couple of weeks have not liked the clinical supervisor and have expressed this dislike to me. I found this a very difficult situation to handle as I did not want to tell the supervisor but I also did not want the patient to feel uncomfortable by bringing this supervisor in to see them, especially when there had been some situations where I though the behaviour of the supervisor was not very appropriate and not in the patients best interest. I realise that patients do have to put up with some things they do not like but when they mention this to me I don’t really want to ignore the situation. I also did not feel that I was in a position to be addressing the situation with the supervisor as I didn’t want to get on their bad side. I found that I would try to avoid taking the supervisor to see these patients but sometimes proved difficult. I think these situations will be easier to handle once we are qualified.

Family Members

I have often considered family members a little bit annoying and a bit of a hindrance to a patient’s treatments. For this reason I used to feel more comfortable treating a patient when family members were not around. However, on my most recent placement in acute neurology I came to see the benefits of involving family members in a patient’s treatment and that it can actually enhance the treatment and the benefit a patient may receive from the session. For example our patient was very reluctant to turn to the left and responded a lot better to using a family member to coax her to look toward that side rather than somebody who she was unfamiliar with. The family members were also useful to prevent the patient from using her (R) UL for tasks that we wanted her to do with her left UL. As this patient often had family members around we educated them on things they can be doing to help with the patient’s recovery and to get follow-on from our treatment when we were not around. I now realise that family members can be a very useful tool for patient’s recovery if they want to be helpful and are educated on how to help out.

Education

Something I’ve observed during my placements this year is that no matter what area you are in – outpatients, rehabilitation or inpatients, there are always home exercise programs that don’t get done and patients that don’t show up to gym sessions or outpatient appointments. Often excuses have been given to me or other students I’m at prac with, that really aren’t worth the air they are spoken with.

Looking back at all the situations I’ve encountered throughout the year, it has given me a couple of opinions. Firstly, there is only so much that we as Physiotherapists can do for a patient. We can do our manual techniques and we can prescribe exercises that will really benefit the patient. However, there are some personality types that just won’t do it. Whether they can see the benefit it will have for them or not is another thought all together. So it got me thinking that perhaps education is an aspect of management which is even more important than I have given it credit for. If I can provide patients with even part of the knowledge I have gained over the years and explain to them why turning up to sessions and doing home exercises is so important, these people might just pay attention and start doing what we ask of them. I have had one supervisor in particular who would spend maybe half of the treatment time educating the patient and he would swear by this method for gaining compliance and positive results. He has even said that his mentor would do the same thing and have exactly the same results with their patients. I definitely think it is something which I will take into consideration for my future and try to employ whenever I have the chance…just to see how it works.

Nearly Physios!

Ive been pretty lucky on my pracs and havent had any run ins with any nurses in any of the wards, but something that happened the other day really bugged me. Every day at about 8ish the coordinator will give us a hand over about all the patients. There are 3 physios on the ward and usually they switch each day who goes to handover. None of the physios had arrived yet and so when it got to 8 oclock I thought as it was my last week there I would use my initiative and go get handover by myself to pass on to the other physios.

When I asked the nurse who was coordinating if I could get a handover she asked me where everyone was. I answered by telling her that they hadnt arrived yet and I would pass it on when they got there. She then questioned me and started going on about her not wanting to have to repeat everything she says to the other physios when they get here. I again answered that it wouldn't be necessary to repeat it as I would pass it on (im thinking by this stage im pretty capable of writing down some information and repeating it to the others). She then replyed that she would prefer to wait till someone else got there.

I was quite angry about it because taking a handover isnt that big a deal and for her to doubt my competence in it was really quite rude. In the end when one of the other physios arrived and I told him the story and he came to get the handover with me. It just shows that even a week from being a proper physio, some nurses will always doubt you and treat you like you dont know what you're doing!

Good luck for PCR everyone!

Problem Solving

On my current neuro placement the majority of nurses have been very helpful and co-operative, however me and another student were having a lot of trouble with the nurses looking after one of our patients who requires a hoist transfer. As we usually have 45 minutes to 1 hour to treat the patients it is of most benefit for the patient to have them in their wheelchair and ready to go when we get there in order to receive the most treatment. Every morning we would speak to the nursing staff and make sure it suits them to have the patient sitting in the wheelchair at a certain time and every day the nurses would agree however the patient would never be ready. The first couple of times we didn’t mind too much because we understand that nurses can be very busy and unexpected things often pop up so we would hoist her into her chair. However, it kept happening and as the would often need to go to the toilet as soon as we sat her up and due to several other issues her treatment was being very compromised. It became very frustrating and I felt sorry for the patient as often we were only able to do 20 minutes of treatment and on some occasions she did not receive treatment.

We tried several strategies including speaking to the nurses a couple of times each day to ensure the patient will be ready, we wrote it on the whiteboard and in the diary the previous day but nothing worked. We ended up speaking to our supervisor about it and she sorted it out for us. Although ideally it would have been great to sort out this issue ourselves this made me realise that sometimes we do still need help from our supervisors or from other staff members. Now the patient is receiving 1 or 2 good length treatment sessions per day and is making good progress.

Preparing For Treatment

Im on a neurosurg ward and ive found that it can be a little difficult at times to work with the patients, as im used to working with people who dont have any cognitive issues. As it is an acute ward with traumatic head injury patients, my eyes have really been opened to the cognitive/behavioural problems these patients have.

One of the biggest ways ive found it impacts my treatment is trying to get the patients attention to begin with, and then trying to maintain their attention and find a task that interests them. Most of the patients have been all over the place in terms of attention spans and the slightest thing will seem to distract them. One particular patient will pretty much not stop talking! He will repeat everything you say over and over again and call me all sorts of names (not rude ones just different girls names, eg, tara, lisa, jessica, kate). So for him trying to get him to be quiet and listen for even a minute is a real struggle!

The other struggle is trying to find a task that interests him and keep him interested in it for more than one repetition. Ive learnt that the key to tackling this is to be really really overprepared for all your treatments! As long as you have heaps of treatment ideas to choose from you can keep switching from one to the other to keep the patient interested. If you persist with something the patient clearly isnt interested in it can make them quite aggressive. and if you cant think of anything to do next the patient will get distracted again.

So the moral of the story is always have lots of treatment ideas to choose from so you never run out!

Unreliable patients

My current placement is set up so that some patients from the ward will come to the physio gym for 1-on-1 rehabilitation. The patients who can mobilise independently will make their way to the gym at the appropriate time. I’m currently having an issue with one particular patient of mine. When I speak to him during the session he always mentions how keen he is to stay in physio so he can get strong again and get back to walking. However, the week just gone he came to gym once and the week before that it was 3 times out of a possible 5. Sometimes he complains that he didn’t get his shower so he didn’t come down, other times he just disappears from the ward.

Each time we talk about getting strong again, I mention that he needs to be coming everyday. I have tried numerous approaches to get him to the gym; when I run into him on the ward I remind him about the time for his gym session, I’ve spoken to his nursing staff to get his dressings done earlier and I’ve even tried taking a blunt approach and telling him he needs to come otherwise he’s wasting both mine & his time. It has been quite frustrating because it leaves me with no-one to treat for 2 hours unless I take over someone else’s patient. I just feel that he is a grown man and that I shouldn’t have to spend 30 minutes of my treatment time waiting for him and then having to go and look for…but I often have to and maybe that’s the only way with some people (which seems ridiculous).

RED FLAGS ARE IMPORTANT

ok, so this didnt happen to my patient under my care, and gladly so otherwise one might not be able to forgive herself. the moral of the story, when in doubt get all the investigations you see fit, don't put them off til tomorrow because it could be the difference between walking and never walking again.

An elderly gentleman, from the country presented to his local GP with a URTI and a thoracolu,mbar mass causing him back pain. the GP did perform blood test and infection was found andtreated prophylactically with a course of oral antibiotics. The doctor referred the gentleman to the chiropracter for his vertebral mass. the pt new no better and attended the chiropracter 2-3 times who 'smashed' his back and left him in excruciating pain... eventually the pain got worse and worse and the patient was admitted to hospital with pain and paraesthesia of the LL. what the heck happened? the patient had an infection in his spine (potentially started by a flu) he suffered discitis and septicemia where he nearly died, spent 5 weeks in the delerium ward and now has permanent bruising of his spinal cord (do you think smashing his back helped this?) he was rushed up to perth and AB's continued and he was diagnsed a T9 incomplete paraplegia. He will never walk again due to permanent damage to LL proprioception area in his spinal cord despite his muscle function returning adequately. This will place a huge burden on his wife, who couldnt understand why he went in with an infection and now he is like he is.

Thia is just one example of not picking up early warning signs and how if he had of got scans done earlier, would he have referred to a chiro? (i wouldnt of), would this patient still be walking? has anyone else heard asimilar story?

I have come to learn (its only taken me the whole year) that accurate assessments are so important to potential and prognosis of a patient. Recently another student and I were handed a patient to work with on our spinal prac. We were to work with this patient together. This patient had been put on the list of patients who are seen daily by the PTA for general stretching, strengthening, and some form of cardio regime that was strucutred, didn't particulalry need supervision nor was it all that patient specific. I have a few issues here which I will talk about in subsequent blogs (so stay tuned) but for now we are talking about assessment. MMT, tone, ROM, sensation and whatever else you see fit are the general areas of assessment. By now, i, and no doubt all of us, feel pretty confdent in our abilities to assess. we are aware to look out for 'compensatory strategies' or 'trick movements' but beingtold that and having it smack bang in front of your face is two entirely different things. Lets take sensation. For us this included light touch, sharp blunt, and propriocepton. on inital examination we had discovered this paatient to have altered sensation throughout bilateral limbs and altered proprioception, nil sharp/blunt. it turns out he had no propioception, very little snsation and these are two MASSIVE points in whether this patient will stand/walk again and we missedit, so had everyone else including doctors, registra's, other physios. how does this happen? good question, just note that whwnever we assess a patient, to them it can feel like a est, so they want to give us the correct asnwers, therefore him guessing, or saying what he though we wanted to hear, changed the results we were getting and as a result, we thought he was more able than he acutally was.

Jumpy patients

Occasionally I have had patients post surgery who are overly confident in their abilities post surgery. The type of patient who as your explaining what you want to do during your treatment session and they have already begun swinging their legs over the side of the bed. As we know they may not be functioning at 100% due to the surgery and medications and thus need to take it slow but still try to do everything before you are prepared. On a recent prac I had one of these patients with my supervisor. However on this occasion it was complicated by the fact that the patient weighed 160kg. He was 5/7 post (R) THR and had been transferred from another hospital to my ward. He reported that he had been up since the surgery in the previous hospital but we had not seen him up as yet. As he was so large he required large efforts to move around in the bed and sit over the edge which often looked very unstable. We tried to explain to him that although he was confident in his abilities we needed to be in good positions and didnt want him just jumping up before he was in a good position either. However he continued to ignore our advice and would try to stand and then walk without our prompting. It was a difficult situation and we particularly worried with the patient as we would not have been able to prevent him from falling and there was not a hoist in the hospital that would have been able to help him up. In the end there was no troubles but my supervisor got quite worked up by the whole situation and again emphasised to him why she had been so strick with him and to not rush what he was doing.

i did not get to see the patient again but it was eye opening

Neuro Superviser

Ive found that ive had a bit of a problem with my neuro superviser in regards to how much she expects from me. Shes been working in neuro for 25 years and when I had my mid placement i'd had only a week and a half of experience in neuro. Shes very vague with her questioning and most of the time before I got a chance to answer she'd jump in and reel off all these things. When we were with the patient she told me to take the lead but then she jumped in and took over. so this left me feeling pretty insecure because I didnt know if she was taking over because shes just like that or if I was doing something completely wrong and she took over cos she thought I didnt know what I was doing. So for the rest of the treatment session I was really unsure of who was supposed to be in control because there were certain things I wanted to do but it was very clear that she wanted to do different things.

I guess im not really sure if she expects me know everything she was talking about or whether she was just bringing it to my attention and trying to teach me because she has so much experience. To top it all off I had my assessment on wednesday and she told me she would come back in friday when she was seeing another student to give me my feedback. So I spent 2 days stressing over it! When we finally went through my feedback I asked her what her expectations of me were, and she said that by the end of the placement I should be working at the same level as a new grad because essentially thats what I would be. She also said that she understood that she will talk and talk for ages if she gets the chance and that she cant help but jump in because shes a clinician and a lot of neuro supervisers are like that. She admitted that sometimes she does get a little caught up because she forgets that shes not the one taking in all the information so she does tend to overload people at times.

This made me feel a lot more comfortable and hopefully next time she comes in I will feel a little more confident in what I am doing knowing that if she cuts in its not necessarily because im doing something wrong, its more that when she sees a learning experience she will take advantage of it. Fingers crossed I dont fail my very last prac!!!

Communicating With Neuro Patients

Im currently on a neurosurg ward and have found it a little difficult to communicate with a lot of the patients. Seeings as though its my last prac, im used to having patients being able to communicate effectively with me and tell me what is wrong and how they feel. Unfortunately on this ward, many of the patients arent able to verbally communicate, and their non-verbal signs are usually quite hard to understand.

Ive found this quite challenging because it can be quite frustrating when you dont know what they are trying to tell you, and I feel like a bit of an idiot constantly talking to someone who doesnt talk back. And because I dont know how much they can understand I have to use really really simple language.

I can only imagine how frustrating it must be for the patient when no one can understand you. I hope the language im using doesnt come out too patronising for the patient as the last thing I would want to do is insult them!

Rx links to Fx

I am currently in a facility which is providing rehabilitation for people with a permanent disability. While treating one of my patients throughout the week I’ve noticed that there are times when he is really tuned into what I want him to do and does it well, and there are times when he just seems not too care. Reflecting on this over the week I have come to realise that the times he is focussed on what I want him to do is when it is something directly related to his big goal for rehabilitation – walking.

This has made me think a bit harder about how much education for this patient is required. I could be doing a bridging exercise or an exercise in 2 point kneeling which I know will carry over to his ability to walk well. However, the patient doesn’t actually realise this. I have also started to do more of what the patient wants to do (which is often walking practice) given that I get the best out of him when he knows the treatment is directly linked to helping him walk.

Accurate Ax

On this new prac I have received a patient that I was told to treat without an initial assessment. I have since been able to assess this patient and have continued treatment based around increasing muscle strength and progression toward walking with bilateral crutches. His condition is basically non-resolving so what he has got now in terms of strength is what he will effectively remain with, give or take some small increases.
After manual muscle testing I graded 1 key muscle in particular as a grade 2 bilaterally. I then saw this patient with my supervisor (1 week later) who also performed the test again and found one side to be a 2 and one side to be a 0, meaning that my goals for function needed to be adjusted and so too my treatment plans (thanks to the local muscles tricking me).

I have always thought of accurate assessment o be important to guide treatment, but this has emphasised that fact. Had I not had the supervisor look at this patient, assessment I could well have spent 4 weeks trying to strengthen a muscle which isn’t innervated and working toward a function they may never have achieved This has emphasised the importance of careful and accurate. Definitely something to keep in the back of my mind now.

Nurse

As with all hospital-based placements my current placement requires a lot of communication with nurses. On the first day myself and another student spoke to the nurse looking after the two patients we had been allocated to organize a convenient time to see these patients. We had been told that this is especially important on this ward. I approached the nurse in what I thought was a friendly manner and addressed her as her name was written on the board. She walked off and said to the other nurse ‘I just shouldn’t answer that should I?’ I thought she must have had a problem with the way that I had addressed her but she was annoyed that I had pronounced her name wrong. She then corrected me and informed us that her name was spelt wrong on the board. I didn’t think that this was a huge issue but apparently to her it was. We tried to organise a time to see the patient but she was not being helpful at all. This just really annoyed me and demonstrated to me that even though we may try and do everything right there are some nurses that are still not going to be helpful and do not like us.

Massage

On a recent musculoskeletal placement I had a patient who presented with neck and shoulder pain. On assessment she was found to have poor posture with a lot of associated trigger points and tight muscles. I treated this patient with STM, trigger point release and a lot of postural education and training. She LOVED the ‘classic massage’ and was not so impressed with the postural education. I explained to her throughout the treatment that her pain is caused by her poor posture and that if she addresses the postural issues and does the exercises I prescribe to her the muscles will not be so tight and sore. By the end of the treatment I thought she understood and she was performing the exercises well.

The next time I saw her she had forgotten the exercises and said she had not done any of them and requested for me to do some ‘classic massage’ saying that was all she needed. This annoyed me a bit especially after I had spent so much time explaining posture to her at the previous session. The next time she came in exactly the same thing happened. This time I had a quick discussion with my supervisor and they told me not to do any massage and to advise the patient that we are going to provide physiotherapy which consists of what we determine is most appropriate for them on the day and may or may not include massage. I was told to tell the patient if she wants massage to seek a massage therapist. She decided to continue treatment and did not request massage again.

This patient reminded me that a lot of people present to physio expecting just to receive massage and I realise that for these patients it is important to explain that physiotherapy will only include massage if it is the most indicated treatment based on the assessment.

Unmotivated patient

I am currently treating a very difficult patient as a musculo outpatient. Before i saw him for the first time my supervisor had spoken to me about him, informing me he was a challenging case who he had treated in the past. He presented with (R) sided neck pain with associated migranes, as well as pain in between his shoulder blades, which he reports 'comes on every year about this time' and he cannot think of a possible cause. On objective assessment he has a hypermobile neck through out and he consistently self manipulates it which has led to an instablilty problem. He also has very tight rhomboids and the pain between his shoudler blades comes on when he retracts his scapula together. He seems to have some pyschosocial issues as he had not worked for the previous 2 years due to chronic LBP. Initially i released his tight rhomboids and tried to give him some DNF exercises to increase his stability in his neck, but he does not do his exercises. I then tried to strengthen serratus and stretch his rhomboids out but again poor compliance has left me in the same place i started after 4 weeks. When my supervisor asked me what i was hoping to do with him in my last treatment session i thought in my head im hoping for a DNA as i just can't think of what else to try with this patient. In the previous 2 years when he has been treated he has just rung physio reporting he is better now and i find myself hoping that this happens this time, and i realise this is a bad attitude to take but i am all out ideas of how to get him to take responsibilty for his rehabilitation. Does anyone have any good techniques they use?

Falls

I recently treated an in pt who had been admitted with bruising and cuts to her hand following a fall the previous evening. She had been cleared of any fractures or tendon damage and was due to be discharged. As she had been admitted for a fall i thought to do a falls assessment on her to check if she would be appropriate for a falls class which is available at the hospital. I discovered that this was her first fall in 5 years and 5 years ago she had been falling regularly and then done a physio balance which had keep her balanced for those next 5 years until now. her berg balance score was 46, making her a relatively low risk pt (mainly losing marks on single leg stance and tandem stance), and she reported that she is confident with her balance and doesn't think she will fall again as she uses a stick and a 4WW at home, therefore i was thinking maybe she would be ok with a few home exercises for her balance would be suffice. On further questioning i was asking her regarding going shopping and she said her daughter usually takes her, but she probably won't go anymore. Asking her as to why, she said because of her balance. So even tho she said she was confident that she wouldn't fall, part of the reason was because she was going to cut back on what she was doing. So this changed my thinking from a HEP back to the class as we want to keep these pt's as independant as possible and doing the things they enjoy doing, rather than just being safe and cutting out the things they enjoy and the class not only improves their balance but also their confidence. I suppose what i'm getting at is that I'm glad i completed a full in depth subjective as if i had of rushed through the berg and gone by the score she managed i may have not given her the best possible treatment.
Until next time, -a.

Hand overs

On my musculoskeletal prac I was having a few new patients but also having a lot of patients who had been treated by previous students. I found that i much prefered having new patients as that way i knew everything about them as I had been at all of their treatment sessions. However obviously where ever we work we are going to have patients who are handed over to us and I realised the importance of good note writing and hand overs. I had a previous student who had particularly bad notes and after reading them I constantly felt I didn't have a clear enough picture of the patient to plan a treatment, which meant I was wasting time when they first arrived re-doing unnecessary subjective questions. However reviewing some of my own notes i realised that I would write some things that would jog my memory as to what they were moving like but would not provide adequate information to someone else reading them. So I have tried harder to make my notes as informative as possible as it not only is harder to treat for the next physio it also reflexs badly on you as a clinicain

Home O2...how much for you?

While on my rural placement we had a patient who the Doctors had decided needed home oxygen. We saw this in his notes, so decided it would be helpful to do a 6 minute walk test to assess how many litres the patient would require with his home O2. However when we went to visit the patient he was packing up to go home as he had been discharged by one of the nurses. We asked him about the plans for his home oxygen and he said it had been organised that someone was going to drop it off to his farm but he had no idea as how to use and what strength to use it on. We called to inquire as to who would be dropping it off and discovered they would be giving him a run down as to how to use it, but they were not sure as to what setting he was to have it on either. Being a bloke the most likely thing he would do is 'crank it up' to the max airflow as he hadn't been told any different. As we know this could have severe consequences in a chronic COPD patients who rely on the hypoxic drive to breathe.

Furthermore we discovered that this patient had not being properly d/c and the nurse who said he could go had not spoken with anyone else and the patient had left without his presciption for medications.

Overall i think this situation highlights the importance of communication between all of the Allied health team, to firstly ensure that this man is properly d/c and additionally so that he has had appropriate evaluation of the need for home O2 and what parametres he would require to get the optimal benefit and have no negative effects.

Safety

During my rural placement I attended a home visit with an occupational therapist to see an elderly man who had been referred for a mobility assessment. He has two daughters who act as his carers, one of whom had been to the hospital the previous day to get a wheeled zimmer frame for this man as he was having trouble getting around with his walking stick. The frame had been provided by a physiotherapist, without seeing this patient therefore had not been adjusted correctly and he had not received any instruction on how to use it. To complicate the matter he does not speak English and his daughters speak very minimal amounts of English.

This man was using his frame very poorly, he had it a long way in front of him and was bending over from his back and hips to make an almost 90 degree angle with his legs and back with his arms outstretched a long way in front. The frame was also too tall for him. I was horrified at the technique as it was extremely unsafe. I adjusted the height of the frame for him and taught him the correct technique to use it which was difficult due to the language barrier however we managed to get there eventually. From this experience I realise that it is always essential to see the patient before giving them any equipment. Initially I thought most patients would have enough of an idea to use the equipment well enough for it to be a safer option than having no aids however, following this incident I realise that provision of equipment without assessment can create more of a hazard than actually being helpful for the patient.

Different treatment

On a recent clinical placement I was saw a Malaysian patient in outpatient setting who presented 2 weeks post TKR. On initial assessment I was surprised to see how little movement he had in the knee, especially seeing as the range had decreased by over 20 degrees since his discharge from hospital. I asked if he had been doing his exercises and he claimed to have been doing them everyday and was able to demonstrate them adequately so I believed him. I worked hard to get more movement in the knee and by the end of treatment there was a large improvement. Then he admitted that he had not been doing his exercises at home because there was nobody to do it for him. I found this fairly annoying as I knew all the exercises he was meant to be doing did not require an extra person. I spent a few minutes going through the exercises with the patient and showing him he can do them all by himself and also explained why it is important to get the knee moving. I spoke to my supervisor and she said this was not uncommon for their culture.

The next time that I saw this patient his range had again reduced and once again he said that there was nobody at home to do it for him so he had not been doing his exercises. Usually I would think that we need to do everything we can for a patient and I would have gone in and once again used manual techniques to encourage improved range. However, on advice from my supervisor I did minimal ‘hands on’ techniques and instead made the patient do the exercises on his own with my guidance. There was a fair amount of improvement by the end of the session and I gave him a very detailed home exercise program to do. I did not get to see this patient again but I hope that his changed his attitude. This situation made me realise that our treatment needs to be adjusted to the patient and what is better for one patient may not be as good for another despite having the same presentation.

Prioritizing treatment

While at my recent neuro prac I was treating some patients who were functioning at a high level but still had some large deficits and as a result had developed some problematic compensations. One patient in particular was very motivated to progress and was getting quite frustrated with his perceived 'lack of progress' and didnt quite understand why we had him doing so much trnk exercises when it was his leg that he felt to be affecting his walking. This patient was still using an AFO and had quite a pronounced limp while walking. He had also developed trunk compensations and circumduction of the leg to get the foot clearance he needed. In hospital this patient had gotten up and started walking very early on a pulpit frame which seemed to be the reason for his pronounced compensations. This highlighted to me how important proper physiotherapy is in these early stages in decreasing the development of compensations. It was very hard for the patient to understand though as he felt that he was just being held back. I found I often have the view of progressing the patient to the hardest task possible (such as walking for this patient) thinking that this is what is going to make him best in the long run. But looking at this patient over the few weeks that i treated him I realised how important it is that you work on all of the trunk and movement control exercises in order to be able to them progress to walking with the appropriate tools in order to walk AFFECTIVELY rather than just safely. I spent alot of time trying to explain this to the patient and found that it also cleared out my own thoughts. It has changed how I will prioritize treatment and how I progress in the future.

Too Much Physio

On my rural prac I had a patient who had a bowel resection. I saw the patient on day 1 and he had evidence of mild lower lobe collapse (as is expected), his cough was weak but limited by pain and his SpO2 were excellent. When I got the patient up, he was completely independent and looked strong on his feet so I encouraged him to ambulate to the tea room etc.

The instructions from the doctor were apparently for "chest physio" 3x per day (even though the nurses who did the referral couldn't read what he had written). I thought that this was complete overkill since he was going well for day 1 and I also have seen patients with even bigger surgery getting only 1x per day physio when in Perth and did just fine. So I had only seen him once on day one and after the weekend there was a meassage left from the doctor who was irrate that his patient had not got 3x per day chest physio over the weekend. I then saw the patient 3 times on the next day to keep the peace. After that I commented that he was fine, so I stopped seeing him because he didnt need to be seen.

This whole situation made me fairly angry that I was forced to see this patient 3x per day when he didnt need to be just to please that one doctor. I could have easily spent that time with the stroke patients who actually needed more than I could give them in one session. The point i am trying to make is that I think we need to use our clinical judegement and be prepared to stand by that, even if it means upsetting someone because there are other patients that need our services as much as anyone else.

Pushing Kids

My last placement was in paediatrics and although I my clinical area was orthopaedics, I was also fortunate enough to treat a plastics patient with an extensive de-gloving injury to their posterior calf and thigh pre- grafting. My main feedback that was given at the end of my placement was that I didn’t push the child enough during my therapy sessions.

I have taken this on board completely, but I also found it interesting as this was my first ever plastics patient that I was treating and since it is such a specialised area, which is covered by relatively few lectures with minimal clinical application, I just found it hard to apply what I had learnt in uni to my patient because I basically felt unprepared or ill- equipped in my knowledge base in this area to provide a treatment expected of that as a PT working in this area.

It was a minor criticism but still, if I had another patient with similar presentation I think I would still be in the same position just due to my/ our sheer lack of clinical experience. Has anyone else experienced a similar situation in which expectations seemed relatively greater than what you had initially expected, especially if you have had to take on cases that are very unfamiliar to you, and what have you done to manage this situation?

I think I could have managed the situation better by talking more with my supervisors about how I felt treating this patient, and that I didn’t feel completely confident running the show with such a specialised case.

Family Issues

On my last prac I encountered quite a few situations in which the families of patients had conflicting views about their management. I was on a respiratory medical ward and one 87 year old patient was admitted with end stage type 2 respiratory failure, secondary to COPD. I had assessed her but at the time there was no role for physiotherapy, so was just keeping an eye on her in case her condition changed. When the patient was first admitted she was extremely confused, and wasnt communicating with staff at all. Her family had brought her in after noticing a deterioration in her condition over the last few weeks. The patient was not for resucitation.

The medical staff had put her on bipap, however, she was not tolerating it well. She would become extremely agitated and try to pull the mask off herself. At times the only way the bipap could be kept on was when there were family members there who would restrain the patients arms so she could not pull it off. During periods when she was not on bipap she was also agitated and after a couple of hours off it, she would be gasping for air. The daughters of the patient seemed to be divided by how they thought their mother should be managed. Medical staff had enformed them that the only thing keeping her alive was the bipap but after a one week trial it hadnt seemed to make any improvements in her condition. They expressed that sedating the patient to keep the bipap on was a cruel measure. One daughter wanted to continue with the bipap and the other daughter wanted to end the bipap due to the fact that her mother really wasnt tolerating the bipap and she hadnt made any sort of recovery.

After extensive family meetings it was finally decided that the bipap would not be continued, and only comfort measures would be used. I can imagine that this would have been an extremely difficult decision to make but at the end of the day I think they have done what is in the best interest of the patient.

More language difficulties

On my last prac I was on a respiratory medical ward and I encountered many situations where communication was extremely difficulty due to the patient speaking very limited or no english. One particular situation was a patient who was actually part of the surgical team, but had been outlied to our ward. She was a 30 year old lady who was from sudan and spoke basically no english as her primary language was sudanese. She was 20 weeks pregnant and had presented for abdominal pain. At first they thought it was appedicitis so she went in for an appendectomy. Whilst in surgery they found an ovarian cyst which was drained. I saw the patient post op day 2. My superviser had attempted to see her post op day 1 and was unable to get her out of bed as she appeared to be in a lot of pain and communication was difficult. Unfortunately the hospital was unable to organise an interpreter and there were no family members present at the time who could translate.

When I saw the patient she looked like she was in a lot of pain and was indicating that she was. She had a PCA in situ so the medical team were querying why she was in so much pain as it was a relatively small procedure with a small incision. When I tried to tell her we needed to get her out of bed for a walk she was protesting. Due to the fact that she didnt understand english it was hard to explain to her the reason for wanting to get her up. In the end we were able to stand her out of bed for a few minutes but she was not able to take any steps.

During our treatment, the surgical team came into her room to assess her. One of the doctors went to observe her wound and instead of trying to preserve her modesty because she wasnt wearing any underwear, simply lifted up her gown and invited some of the other doctors to also observe.

I really felt for this lady as she looked absolutely petrified. I tried to think how I would feel if i was in her situation. She was 20 weeks pregnant, had surgery which she didnt even know what they had done, was in extreme amounts of pain and strange people are trying to get her out of bed. And to top it all off the medical staff came around and made no attempt to keep her covered. I was very shocked at how rude and disrespectful the medical staff were, as it wouldnt have taken much to simply use a towel to cover her.

Communication

I have been treating one sweet lady who suffered right hemiparesis from stroke. This lady had severe CVA which affects her very much physically and cognitively. She has been more than one month being in a hospital and her conscious level fluctuates up and down day by day. However, her alertness was getting a little longer, but not much, toward the end of 4th week of my placement there.

She has severe dysphasia, so communication was very limited with her throughout all treatments. She was able to express one or two wards when she was alert, but repetitively. However, the pain location was always right and very specific parts of her body.

One day of my final week, she was lying in bed and appeared having pain when I went to her room for PT Rx. When she was asked where the pain was and she stated ‘whole body’. As I mentioned earlier that she always gave me the specific pain location and never been 'whole body', so it was kind of odd to me and seemed having difficulty in breathing. I went out of her room and looked for her nurse but he was in tea break. I was asked by other nurses what I needed and I explained to them the situation. One of the nurses laughed at me and said the patient could not say that, and thought I was making up. First of all, I’ve never made up the story regarding patient’s condition. Second of all, the patient is capable to communicate regarding her pain and more than the nurse thinks.

Fortunately, the registrar heard the situation what I was explaining to those nurses at the corridor in front of a patient’s room where the registrar was in. He went to her room and apparently she was found having a chest pain and required ECG twice on the day.

I have learnt how important the communication with medical team members is from this episode which could be easily missed out. Even tiny changes might be a life threatening on patient so it is always good to inform nurses or/and the doctor the unusual condition if in doubt, before it is too late.

language difficulties

I recently did an initial assessment on a patient who had had a recent head injury and was now getting rehab. This man was of Ethiopian descent but had lived in Australia for quite a few years. During my assessment I found it quite hard to get the patient to follow my commands. Even simple activites like shrugging the shoulders we difficult despite demonstration. At first I thought that there might be some problems with his understanding of english so therefore proceeded with alot of demonstration and simple instructions but there were still difficulties. This man also performed quitepoorly on pronation/supination testing which got me thinking that his issue may be more dyspraxia/dysphasia in nature. This was later backed up by his notes which said that he used to speak mostly english at home wih his family and was quite fluent. I have been continually treating this patient and have ad to be very careful with what I ask him to do, how I ask him and the time I give him to respond. This is the first patient I have had to treat with such high levels of cognitive disability and it has been qute a challenge. No matter how much you learn in uni, it is not until you actually come across a patient that you can truely learn how to deal with them. I feel that I have improved my communicaiton with him and can now get more effective treatments done. It is all about slowing down, having simple demonstrations as well as getting our hands on to guide them into the right postion more and trying different directions if the first way is not working. SOmetimes no matter how much you slow your talking, it just isnt going to get across to them, try another way.

Multiple Supervisors

During my current placement I have 3 supervisors who I am under the supervision of throughout the course of the day. I know that many students have complained about having several supervisors in which they were unsure about who is their main one and who will be doing their assessment. From most of the feedback that I have heard from students who have had multiple supervisors, I have found that the majority of the feedback has generally been quite negative.

I on the other hand, on almost all of my placements have been under the supervision of more than one therapist and to be honest I find that it has truly been more beneficial to have lots of different treatment ideas and approaches to the same or similar patients than that of a single therapist. I feel that I have gained a better knowledge in particular in my current placement, by learning several ways to do the same thing especially as I’m sure most have you have found out that some techniques or approaches do not work for all patients, even if they do have the same conditions as each and every patient is an individual in their own right.

So I think it is important to take advantage of all the supervisors advice and ideas on assessment and treatment of patients, because when we get out into the real world on our own, we will not have our colleagues to fall back on for ideas all the time and this year is supposed to be our biggest opportunity to learn as much as possible from all our supervisors who have contributed so much to our learning already.

Supervisors

On one of my previous pracs had a supervisor who i thought made my time at this placement more difficult and stressful then i felt it needed to be.

There was 4 students on the prac and we initially met this supervisor for our orientation and the supervisor was continually referring to our assessment and how we could potentially fail the prac. After the meeting the students chatted and felt that it was a pretty intimidating start to such a placement but didn't think much of it.

For the preceeding 2 weeks the supervisor was sitting in our treatment sessions for at least 2 hours every day and continually questioning and critisising us throughout our time at the placement. It was very intimidating and made my time at the placement pretty stressful. In comparison to other supervisors i have had this one was very intense. Others have been extremely helpful but less intense and i felt these are the placements i have learnt most from as i have had an oppurtunity to work with the supervisor and independently and learn from there.

All my supervisors have been different but i have definetely found those who are less confronting have been the ones i have actually learnt most from and done the best whilst at these placements. Hopefully i can get through the last few pracs with whatever supervisors i get.

Confused patients

I have a patient on my caseload who is my first really confused patient. She has a #NOF and has been in hospital about 1 week. This lady is a real handful, she will not move out of bed at all. Initially this was because of pain, but now she has become very stubborn and will not move for anyone. The physio and myself will go into her room about 2-3 times per day and spend anywhere from 10-20 minutes trying to convince or "trick" her to get up, but she wont budge and despite our best efforts she is now developing a chest infection.

I consider myself a rather patient person, but this lady has been very trying. It is a difficult situation because I know she needs to mobilise to get out of hospital and not end up in a nursing home. But we need to have some form of consent to be able to help her with this. When we try a 2x max assist but she fights it and screams for us to stop every time despite us giving her all the advice and education we can. Its dissapointing to think that she could have been back at home already had she not developed this confusion and that there isnt a lot more that I can do to help her, even with all of her physio-relevant impairments...but i guess that happens sometimes.

Inappropriate patients

This was in relation to a new patient on the ward that i was assessing

Initially on our ward which mainly deals with acute strokes a general subjective, obs/CV and mobility/balance assessment is performed prior to commencing more formal neuro assessment and treatment. On this occassion my supervisor had chosen to come into the patients room with me and another student who were assessing this gentleman. Cognitively he appreaed normal but slightly drowsy and we decided to look at his mobility in bed which was max assist and decided to assess his sitting balance. We assisted him to SOEB with close guarding and the other student kneeled in front to stabilise him and commence assessing static/dyamic sitting balance. At this point the patient decided to make an extremely inappropriate comment which caught us all by surprise. Instead of paying attention to it the supervisor, other student and myself chose to ignore/laugh it off and continue with the session.

It made me realise that sometimes like many other professions we are placed in comprimising situation that need to be dealt with professionally. If we had reacted the situation could have become uncomfortable and potentially confrontational. The supervisor said everyone involved had done the right thing and handled the situation appropriately. In regards to similar situations in the future i would most probably do the same thing as light was not made of his comments and the session continued without incident.

Draw a line for discharge

Have you guys ever had experience to make a decision for your patient to be safe for discharge? It is happening to me with a couple of my patients.

A gentle man who suffers right hemiparesis from stroke. He is quite capable in terms of physically, however his balance is still questionable. In addition, he has right neglect, dyspraxia, dysphasia, spatial disorder, big problems in proprioception and sensation, and is impulsive as well. He walks with supervision on even surface, but he requires constant verbal cues for right foot clearance, right side awareness, and motor planning. As a result of these problems, the right side of his body hit everywhere like doorways, trolleys, W/C, and stools etc that he was totally unaware of hitting. He is easily to stumble over anything as you can imagine. And he cuts a corner or turns himself very quickly due to impulsive, so he is easily to lose his balance as he does so.

He also has problems on his right hand which is his dominant side. Because of his sensory problem and dyspraxia, he quite often puts his right hand onto a hot meal without any attempting of picking up fork/spoon/knife according to his family. One day, it happened three times within 1 min in front of me while I was talking to his family in his room. That happened really quick because of impulsive and nothing we could do to stop him from that. He was aware it was wrong, because he wiped his right hand right away, but he did it twice after that. Fortunately the meal was warm and not hot. However he has burning marks on his fingers from previous repetitions. This is another episode from his family. He grabbed knife by holding the blade side instead of holding proper way. There are some minor areas that I still concern regarding safety issue on him.

Now, isn’t that enough to be concerned his safety issue? I know some of his issue would not be necessary to be recovered before discharge and might not be happened for long period of time or will not be ever. Maybe I am too cautious regarding safety issue.

He has been seeing by his doctor and nurses that walking around without any problems with his family in corridor. Well, most of the corridors at the hospital are wide enough with even surface and do not have lots of equipments around, thus easy for him to manoeuvre I would think. Plus, they have not seen him turning or stumble yet, so his doctor was wondering why physio was holding him back to be discharged.

I explained to his doctor why I did not feel safe for discharge, however I have got impression that his doctor was still unclear why. I just can’t work it out where I should draw the line to be safe for discharge. He will be able to get some help from community services, and I know his wife will help him as needed because she is very supportive, but she can’t be babysitting him 24 hrs a day. He might be fine (I hope) at home, but what if something happen to him?
Do you guys have any suggestions for me?

Dramatic Accidents

I was treating a day 1 THR with another therapist the other day. When talking to her while laying in bed apart from some pain everything was fine, all instructions understood and she was keen to get up and moving. Once standing up and a few metres away from the bed she was a bit quiet and i noticed her skin going plae. At that time she fainted and collapsed onto my knee luckily I was at arms reach of a chair and we placed her down into it. I was asked to get oxygen for her and as i turned to get it, she passed out completely, slipped through the grasp of the physio, off the chair and proceeded to dislocate her hip.
Obviously I found this somewhat of a frightening situation to be in with my first THR patient. This situation had never happened to me with a surgical patient before. In reflection perhaps it was the best thing to happen to me as a student. It has really reinforced the importance of monitoring the whole of the patient very closely after surgery and I find I am being more vigilant about it now. If i hadnt seen her face go pale, I might have dropped her - resulting in a fail for my clinic and probably a bad reputation in the hospital. Hopefully I wont have to experience this for a long time to come! (the patient is now doing fine you'll be glad to hear).

assessment of voluntary movement

I am currently at the head injuries ward at Shenton Park and was asked last week to do an indepth SOAPIER on one of my patients. Within this SOAPIER you need to explain the patients movement patterns fo all limbs. This patient presented as a left hemi (LL>UL) and with some dyspraxia of all limbs. Due to the limited movement of this patient Gowland was not appropriate for assessment. My supervisor therefore showed me another way to assess voluntary movement in a 1, 2, or 3 joint control format in varying positions. This isnt a really easy way to assessment the movement but after some practice it seems the best way to explain exactly what the patient can do, in what range and what type of movement. I was suprised that we didnt actually learn how to do this form of assessment in uni. I know it is pretty specific to head injuries etc but itis also just a good way to get your head around exactly what needs to be worked on and what the impairments etc are. Has anyone come across this particular assessment or similar assessments that they thought we should have been taught. I found that I felt quite unequipped to perform an effective assessment on this patient with what I was taught at uni.

Private vs. Public

My last placement was women’s health and during my time there I had a conversation with my Curtin supervisor about private and public patients. As I was on placement in a public hospital and my supervisor worked elsewhere in a private hospital, she made the comment that often we see patients in the private sector more enthusiastic to learn what a women’s health physio has to educate them on, more so following childbirth, than in the public sector, as patients in the private sector had to pay for the service to see a physio.

Whereas in the public sector, well in the facility I was at, we got a blanket referral to see all the patients on the ward and if there were any patients with specific complications needing intervention then we would of course see them for that particular complication. In the beginning I thought that this was quite an over generalisation, but as the weeks went by it became more and more clear those patients who were of a higher socio-economic status in the public hospital were more inclined to take on board the information provided and ask questions and consciously practice the exercises because they could clearly see the benefit of doing it correctly, than those who presented with relative disinterest to the topic of conversation. I know that women’s health is the nicest topic of conversation or education however it is so much more important to try and somehow develop rapport with those disinterested patients to help even bring to their attention some health issues that they may never had heard of or cared about previously because they are the ones, more often than not, who are at a greater risk of women’s health issues later on in life.

From that placement I think I most importantly learnt how to read patients non verbal communication signs better than most of my other placements, and those patients who were interested obviously gained the most out of the education session, but it’s a reminder that we can not forget about the other relatively disinterested patients, in all areas of physio, because these are the patients that actually have the most to gain even out of a simple 10 minute education session.

Importance of Passive Movements

I'm currently on my cardio placement and in the ward that i'm on there is a high dependency unit, which is mainly used as a step down from ICU or for patients who are ventilated. One of the patients there is a 37 year old man who has motor neuron disease. He was diagnosed only 18 months ago but it has very rapidly progressed. He is now completely chair/bed bound, a full hoist transfer, and has had a permanent nasogastric tube inserted as he has pretty much lost his swallowing. I was asked to see him by my superviser for some upper and lower limb passive movements and muscle stretches.

As I am on my cardio prac I thought that doing passive movements and muscle stretches is a little bit of a waste of time, but of course I will do what i'm told! The patient has lost a lot of his ability to project and articulate words and as a result is very difficult to understand. From the conversation I was able to have with him and his family he had told me how much the passive movements and muscle stretches actually do make a difference to him. He had said that they really do make him so much more comfortable and he feels so much better after having them done. As he has been told that he only has 6-8 weeks to live, he was extremely grateful for us taking the time out to do this for him.

This experience has just shown that something that we find a little tedious and somewhat unneccessary can actually make a really big difference to someones life. So even though we dont think we're doing much, a patient is very appreciative of it as it may do a lot to increase their comfort and, in this case, his quality of life for the time he has left. This has definately given me a different perspective to doing simple passive movements as a treatment.

How much pain is too much?

I have a patient whi is 4/52 post carapl tunnel release and jus tin the pat 1/52 or so, her pain has increased to the point where she only has to lightly touch herhypothenar eminance or palmer aspect of her writs and it can shoot terrible terrible pains. is this normal, i felt too inexperienced to advise her whether she needed further review fom her surgeon or just to reassure this that this is normal and thoug movement is painful, it will do no harm, and the pain should start to resolve with regaining of function. I havent seen many carpal tunnels, and certainly arent an expert on hand therapy, am i missing something. She has gone backto work full time caring for a boy with CP which involves alot of manual handling so i gave her a splint just to provide protection, keep wher wrist inneutral and remind her not to use it too much really. It was great for the first week but her symptoms seemed to have worsen since she has been coming to see me. Am i stirring her symptoms up by too much gentle mobilisation. I am a little stumped and would appreciate any advice, or comments by those who have seen similar presentations.

I have liased witht he OT's who have lots of experience in the area, and they seem to think im doing all the right things, but my query is given the surgeon doesnt visit very often and only takes priority cases when he does, should i refer back for an opinion on this excessive pain, or keep going the way i am?

communicating with aboriginal patients

Hey guys,

Thought I might share with you some specifically remote experiences i have had that i have found challenging. I know we did a section at uni on indigenous health adn have designed various programs "culturally sensitive" for various assignments, but it is not until you get out and make a few mistakes that those lectures etc. kick in!

A fair few of my patients are indegenous and my best advice... your subjective and objective ax is NOT the priority. For practitioners to establish rapport with our patients we are taught how important body language, eye contact and communication. Well i tried it and failed miserably, a thorough history is important, but sometimes you dont have to retrieve it so formally, or even in one session. In fact, the most success i had was talking about the footy, looking at the gorund, having a play with the affected areas and discovering patellofemoral symptoms. Specifics abou pain, mechanism of injury, past history of similar things, aggravaitng factors were just not attainable, and holding their attention was short. Also, management through exercise was what i wanted to achieve, but i have discovered promoting this striaght up with education ++ is too much and I was more successful with hands on manual therapy and as they got to know me, then introduce simple exercises (one at a time) was amore successful approach.

Does anyone else have any advice about cultural sensitivity? do you agree/disagree with my approach?

Physio Vs Nurse

Hey gang, hope prac is going well

In my placements so far i have been lucky enough to be working with very friendly,helpful and knowledgable nurses. On placement at the moment i had my first bad experience with a nurse.

A dependent patient was to be hoisted from their recliner chair into bed following a PT session. Another physio student and I returned the patient to the room and we saw the nurse was busy so we volunteered to hoist the patient back into bed. It was something that i have not come across in my previous placements or been exposed to at uni but at placement we had a brief introduction to hoists and how to use them. Therefore, we proceeded to place the material underneath the patient and then hoist the patient back into bed. When we placed her down the patient was slightly off centre in the bed and the nurse stormed over and proceeded to abuse both of us for the transfer and address us in a derogatory manner. She labelled us "bad physios" and "not to let physios do a nurses job"and was confrontational for the rest of the week.

My initial reaction was one of anger as i thought we had done quite well for something that was essentially new to both of us as the patient was hoisted safely back to bed but just needed some simple realignment. Thus, my instinct in this case was to become confrontational as i felt there was no need for her to criticise us.
Taking a deep breath i did what i needed to do to realign the patient and then once she was stable left the room without saying anything to the nurse. I knew the right thing to do was to maintain a professional demeanour as becoming confrontational would only ignite the situtation and not be of benefit to anyone involved.

This type of situtation is something i have learnt a lot from. I know now that if something similar happens in the future the best way is to maintain your cool and deal with the situation at hand.

Questions in subjective

I had two patients with Parkinson's disease in this week in different days at my placement. Both of them were females and I and another student had to conduct subjective, objective, and treatment to these ladies.

I am sure you already have experienced how important the relationship is which built between your patient and you during the subjective and that would affect onto your treatment. In truth, I had been having difficulty conducting subjective in most of my placements, but these PD patients made me realized more so than any other patients.

I know I don’t use the phrases that most English speakers use. I have tried to learn and use them, but the words seemed not to come out my mouth easily. Plus many phrases are still new to me.

During subjective with first PD patient, I was asked what I meant by her many times. As the subjective went along, I could tell the patient got frustrated by my questions. Then another student took over from the middle of subjective. As you can guess, the subject part went well smoothly. When it came to the objective, the patient looked at another student all the time and I have got the impression that I was not there. Which was understandable, but I felt I was useless at the same time. Another student and the patient, of course, were having a good conversation in following sessions, but not happening to me. The same thing happened again with the second PD patient.

At this stage, I kind of reluctant to see these patients as I know what is coming. I keep trying to have normal conversation with them, but the answers are always going to the different direction. To listen to the conversation what the patient and another student have makes me to compare myself more. I just want to know how I can make the questions easy to understand in general. Does anyone have any idea or suggestions? I just need to have some strategies I could use for future patients.

aggressive patients

In my new placement at ward 1 Shenton Park we often have to deal with patients that have altered cognition and behavioural problems as a result of their head injury. A patient that I was asked to help out in the gym was known to have issues with aggression and being instructed what to do and didnt often actually turn up for his sessions. I tried to help him with starting his exercises but it became quite clear that he didnt feel he needed help and resented being told what to do. I decided to step back and let him do what he wanted and was going to come back later. On returning I found him doing some exercises that he should not be due to a recent clavicle fracture. I therefore tried to explain that he should not be doing this exercise due to this but was continuely cut off by the patient whose answer to everything was that someone told him he couldnt do it so he was going to anyway. This patient did not like females telling him what to do and would do everything that he was told he should not. As I continued to try to reason with him he got more worked up and was not doing any exercises. At this point I decided to walk away from the situation and let the supervisor try to further talk to the patient. It was finally the male physio assistant that got through more to the patient but he still left the gym withthe same attitude and not really acheiving much withthe situation.

Looking back at this I dont think I handled the situation veyr well but I also don't know what I could have done differently to try to make it more effective. The patient clearly did not respect me or anything I had to say and his long standing attitude was unchanging. Does anyone have any circumstances where they have had to deal with similar patients or any ideas on what I could have done?

Helpful Advice

Hi everyone,
I recently had my rural prac and I was given some good advice from my supervisor that I thought I might share with you all.

I was in outpatients one afternoon when the patient I was expecting didn't turn up. So my supervisor told me I could sit in on her new patient who was due in about 5 minutes. She told me it was a stroke patient and asked me to perform the subjective and objective assessment. Seeings as though I havent had my neuro prac yet, I had a mini freak-out as I realised I had no idea what to do!

I spoke to my supervisor about the fact that I wasn't confident with neuro which was when she gave me the advice which was that if you are in this sort of setting and I patient comes in with a condition that you know very little or nothing about, or arent overly confident in that area, it is best to simply ask the patient what their problem is. If you look at the patient from a hollistic and more functional approach, and find out what they are having trouble with, and what they would like out of physio (goals and expectations), you can use this to guide your treatment. Therefore, you dont need to always do a specific assessment, but guide your assessment and treatment by the patients problems.

I have learnt from this that as long as you can find out what the patients problems are, and provide an effective treatment based on this, you dont need to be an expert in every area. I think this will help in the future if I am faced with a patient im not sure about.

Overall if you follow what the patient says and improve their perceived problems, they will be happy and satisfied with the treatment you have provided. So pretty much you cant go wrong!!

Impressed

Hi everyone,

Just a note to - again! - let you know I am reading all your posts, and to also let you know that I continue to be more and more impressed with all of them.

Trudi

paeds

I’m doing paediatrics at the moment and the thing I think I mostly find difficult is being able to change my attitude. By this I mean, that I am so used to treating adults for the last 6 months, my supervisor’s are encouraging me to let the barriers down, be silly, make jokes and just have some fun with it all. I think I’m finding it so hard because I still am trying to portray that professional image, whereas with kids, I don’t think it matters as much as it does with our adult population of patients. Kids don’t want to do physio if there is some authoritarian figure trying to tell them to do something, especially if they are in pain. I’m also finding it hard not explaining everything in detail, as kids don’t particularly need to know because they wouldn’t understand, let alone don’t want to know the nitty gritty of why you are doing something. It’s hard I think because it is changing everything we have learned in the last 3 years and putting it completely back to front and upside down and changing all the key things that we have had drummed into us.

Did anybody else have this same issue to any extent, and was there anything that you did to help bring out the inner child in you?

Neuro/Safety

I am on a neurology placement at the moment

A patient i was allocated was an elderly gent who had a CVA following a 70% occlusion of his left ICA. Upon assessment his voluntary control of UL and LL was surprisingly good but there was some associated balance deficits mainly in standing but when it came time to assess his perceptual deficits it was evident he was suffering from expressive aphasia. During his subjective he often became frustrated as he could string sentences together but would be unable to verbalise key words unless i stated them then he would agree or disagree.

We finally got into the gym and from my previous chat with him i had gathered he was understanding me and answering my questions well. We were working on his dynamic sitting balance and other issues and he had performed quite well. When it came time to end the session there was 1 last t/f to perform from plinth to w/c. Once we were in standing i asked him to step towards his right towards the w/c once he had shifted his weight onto his left with close guarding and he proceeded to step in the complete opposite direction comprising his balance and safety. We eventually safely negotiated our way to the w/c. Because of the nature of the stroke i was talking to the Dr/OT and was querying receptive aphasia/ideamotor,ideational apraxia all of which they considered not present in this gentlemen.

This situation showed me that although we sometimes tend to take a person ability to perform certan tasks for granted it pays to underestimate their abilities slightly to ensure safety. I will now monitor my patients closely to ensure tasks are done correctly and safely.

Interpreter

On a recent placement I had a patient who had moved to Australia from Indonesia less than 10 years ago and spoke very good conversational English and therefore I saw her initially with no interpreter. On further questioning I found that although her English initially appeared to be good she struggled with a lot of the questions during the subjective examination. I continued to rephrase the questions and used simple and common terms and managed to get enough information to perform an objective assessment and treatment. Next time I booked her in I also booked an interpreter and asked for ‘Indonesian.’ At the next appointment I attempted to gain further information from the subjective examination although the patient was still having trouble even with the interpreter. I was not sure why I could not get a thorough subjective from the patient.

At the next appointment a different interpreter was used and I was relieved that I was finally able to gain a thorough subjective examination. Following the appointment the patient told me that the interpreter from last week was Malaysian and therefore didn’t speak true Indonesian, which is why she had trouble understanding, whereas this interpreter was from Indonesia and spoke true Indonesian. This made both the patient and myself a lot happier. Really I feel that an Indonesian interpreter should have been booked in for the initial assessment and realise that it is important for gaining as much information from the patient as you can to provide an effective treatment, as well as making the patient feel as comfortable as possible.

L CVA

Hi, my placement now is in neuro.

My patient was suffered from L CVA. This patient did surprisingly well on initial assessment without any major complaint, compare to the result showed on MRI.

As we know the results from MRI and presenting S & S of a patient sometimes do not match, but I was still surprised how capable this patient was physically.

The major problems on this patient were dysphasia (expressive > receptive) and dyspraxia. As we all have learned the strategies to address for dyspraxia/apraxia at uni, I was using some of them such as ‘simple commands/instructions’, ‘visual, tactile & kinesthetic input’ and ‘demonstration’ as much as possible.

In terms of addressing for dysphasia, my patient and I made a rule as ‘thumb up’ for ‘YES’ and ‘thumb down’ for ‘NO’. This patient seemed to understand the simple instructions or commands, but some of the responses from this patient were not clear in my head. It could be from my instruction which made this patient confused, could be from cognitive involvement, or could be decreased concentration by long Ax. I have realized there were many possibilities could contribute to this patient which made me difficult to write a note on this patient.

On the 3rd day, this patient presented having difficulty to grab a cup on R UL. During this patient was performing this task, it seemed easier to hold a cup from top using index finger inside and rest of fingers and thumb were outside. As this patient was asked to hold from side way which we normally do, this patient was capable but having difficulty more than from top. At this stage, this patient started having tears in front of me. Imagine how stressful or frustrate knowing the activities or tasks not be done smoothly or taking longer than used to be. In addition, this patient was unable to express self verbally.

I have explained to this patient that it was not the exactly same situation but I could relate to my experience how frustrate not being able to express self. That explanation made this patient more in tears. I have realized I should not say anything to emphasize this patient’s emotion, but it was too late. I started to encourage this patient on keep trying and practicing to get better. At the end of the session, this patient held my hands say nothing but keep nodding the head. Did it mean this patient understood the reasons for having PT Rx or where this patient was heading to? Hopefully this patient was happy with my explanation on the session.

I have learnt that those patients especially who suffered from stroke need lots of encouragement and important to let them see their improvement in each PT treatment even though it was small.

Time limits

Im on my rural prac at the moment covering the wards at the regional hospital. I have one patient who has an extensive medical history. He was transferred from one of the tertiary hospitals in Perth back to this hospital in his home town. I had treated him twice for his cardiorespiratory impairments, one large component of which is ambulation.

There was one comment that he made which made me think about how we do things as a ward physio. His comment was that we dont spend enough "quality" time with patients, that we have a quota and need to fill it. After some conversastion about what he had said, I went away thinking that perhaps there are occassions that we may not be compassionate enough to patients, especially if we have a large caseload to complete that day. Whilst I understand that we cannot spend an hour with each patient in a ward setting, perhaps an extra 5 minutes here and there with the more deconditioned patients might go some way toward keeping their faith in the profession. The next time I saw the patient, I did this and he seemed to respond a little better to the session - so perhaps there is something in this (or maybe its just this patient).

post treatment soreness

As I was finishing my musculo prac I had to call any patients on my list that I had not seen during my prac to see if they still wanted some treatment or if they could be discharged. One man that I called had been seen once by the previous student about neck pain but had not returned since. I managed to call this patient who upon questioning whether he required more treatment said that he didn’t want to come back because last time he had gone home sorer than he had arrived. I further questioned him as to how he then went for the week after treatment and although the patient was somewhat vague on details he said that his neck had recovered back to normal by the following day but he could not say whether he had felt any better after this.

I therefore explained to him the side effects of post treatment soreness cue to manual techniques and that this was very normal. I suggested that he come in again, get some treatment and see if over the week it did indeed improve his pain levels, ROM etc. If it didn’t help we come try different techniques or again try to same technique but monitor responses over a longer time. I also explained how when dealing with a chronic disorder such as his neck it did take time and a number of sessions to have an effect on the pain and that he should not be looking for a miracle cure that is going to fix everything instantly. Treatment was an ongoing process along with self management to control the pain levels. The patient agreed to come back and try further treatment.

This made me more aware of just how important it is to warm patients of post treatment soreness and how first impressions are so powerful. This patient was willing to dismiss physio as a possible treatment all because he had some increased pain immediately post treatment and was not aware of what this meant. Anyone with similar experiences?

Neck and upper shoulder pain

One out of my five neck and upper shoulder pain patients was very curious why I was focus on postural correction and more on Tx area on the day of this patient’s initial visit.

First of all, English was not this patient’s first language, thus it took more than it should on SE. It was difficult to obtain the correct information from this patient as expected; however, this patient was required huge amount of time on explanation of SE questions. I did not mind taking longer to explaining since I could relate it to myself; however, it needed to be rushed to go through the initial Ax due to I was under pressure with time Mx.

Second, this patient never had any physio Rx before and did not have any information regarding physiotherapy beside massage. That’s quite common in general, and I am capable to educate these people who don’t know much about physio that there are lots of Rx that we can provide and also importance of self-Mx.

What made me more difficult treating this patient was informing this patient to focus in different area where this patient did not complain about. I assume it was not that much of issue if I explained to English speakers, even though my English was not good enough. Letting the non-English speaker understand the simple and basic concept of treating on or dealing with different area was really challenged for me. Obtaining informed consent was even harder due to the patient was still in doubt.

During Rx, I was stopped by this patient many times and told where the actual pain was. I assumed this patient thought I did not understand what this patient’s problem was since I was non-English speaker as well. About the point where the postural education was introduced, this patient got very curious why. That was the last intervention for the day, thus all I could say was ‘just trust me’ to the patient. I was sure the patient was still uncertain. At the end of the session, the patient was emphasized on HEP which included correcting posture.

By the third visit, this patient got so much better in posture and Sx. This patient was very happy with the progress and not much c/o pain.

What I have learnt from this was it is sometimes better to leave it less word and let the patient see the improvement first. I thought it worked well on this patient, because this patient was curious what the outcome would be from Rx and self-Mx. Fortunately, I have got enough trust from this patient and this patient was able to see good progress by following HEP what was told to do in such a short period of time.

Aggressive patient

I was recently on placement where i was chalenged by a confrontational patient. The patient had been in the public hospital outpatient system for many years and had continuing chronic LBP that first arose following a flexion/rotation lifting injury and prior to this there had been no major incident of spinal pain of any description. This middle aged man had been in pain since the incident with the only relief coming from acupuncture and upon subjective he appeared depressed, frustrated and even angry at times regarding his condition. Objcctively, it was clear there was elements of central sensitisation occuring with extreme tenderness to light touch over the erector spinae bilaterally and with slight pressure there was an explosive pain response. The supervisor confirmed my suspicions and thought the best way to treat this gentleman was to manage his condition and not perform any manual treatment. As i entered the cubicle i explained what was occuring and how any treatment could exacerbate his condition whereas managing his condition has been proven to be beneficial in such conditions.
He quickly snapped at me that i haven't done anything and verbalised his disapproval at the course of treatment. It took me a good 10-15min to explain in depth how his condition was not improving and how physio applied before he started to appear to trust what i was saying. Following this the patient came to all alloctaed physio sessions and complied with treatment until i left the placement.

This situation initially surprised me as i was being intimidated by the patient and my decision making was being questioned. Only after an extensive explanation did the patient understand why we were doing the things we were. It made me realise these types of chronic patients often need much more verbal input and support to facilitate their treatment/management then acute/sub-acute patients. I will now hopefully be able to identify these types of patients and give succint xplanations as to why hands on therapy is not always indicated as most patients do expect it.

Yellow flags

I had a new patient come in last week due to bilateral medial knee pain after a long winded subjective I managed to uncover that he had also had bilateral arthroscopies on both knees, shoulders and one elbow and ankle, sciatica which he informed me was form his "piriformis syndrome", flat feet for which he had orthotics made for but then he remade for himself because he didnt like the first ones, spondylolythesis in his lower Lx (when xray reports showed only spondlytic changes) but had had rods put in his back which his body had eaten away and his spine was now only held together by 'the glue used with the rods', this knee pain that got worse if he ate chicken treat or was around pesticides, but if he cleansed his liver it got better. It also helped this knee pain to do back/yoga type exercises. He had also made himself a machine that he could use to work on both his back mm and his abdominals. But the main reason he had come in today was to try some US on his knee to see if it helped because he wanted to buy one for himself over the internet.

Now I hope you are thinking exactly what I was, 'ummmmmm where do i start with this one?'. This man obviously had quite alot of yellow flags going off about his beliefs regarding his 'allergic arthritis', his chronic pain and his self diagnoses over the internet but how are you supposed to confront the patient about this. His large stack of Xrays and previous surgeries shows that he has seen many people over many years about his problems. I was left with no choice but to say (after not finding any major signs inobjective assessment) that I did not think that his pain was mechanical in origin and that PT was not indicated, especially not US. But also I found that I was quite drawn in by his story during subjective assessment that it was not until I stood back afterwards that I really put together everything he was saying and realised that this man did have alot of psychological issues along with the physical problems. Other health professionals had obviously also had been sucke din by the story considering all the surgeries that he had managed to get them to do and it seemed that they were all now just 'handballing' him on to other people. I found myself quite unprepared to handle such a patient. Should I try to correct all these long standing views, should I suggest he goes back to his GP to get further help? Does anyone have any ideas or has had any similar cicumstances that they have learnt from?

Family issues

On one of my previous pracs i was in a situation where i was allocated an elderly gentleman to treat. He presented to the department with his wife, son and daughter and i promptly introduced myself as a 4th year physiotherapy student and gave them a brief overview of how our session would include a part where i would be asking some questions (subjective) and doing some assessments (objective) based on his presenting problem then the appropriate treatment.

The family seemed to co-operate intially but just prior to the session starting the son and daughter insisted that a qualified physiotherapist assess and treat their father as they did not want a student as their fathers physio. This took me by surprise and from there i explained how although i am a student a thorough assessment will be performed followed by a discussion with the supervising physiotherapist to ascertain the best course of treatment. I told the family members they could ask questions at any time and even speak to the supervising physio but eventually the elderly gentleman and his family agreed to allow me to treat him and things went well from there.

This situation made me realise as we are students patients often judge us based on this and not our level of skill as a clinician. To overcome such obstacles i feel as though it's important for us to communicate clearly how the patient is going to be assessed thoroughly and treated accordingly based on the decisions of not only myself the student but also the supervising physio during our 4th years as students. Once we are new graduates such situations will most probably not arise as with a qualification comes a certain level of trust from a patient but until then such situations must be dealt with appropriately.

Trigger thumb

I had an opportunity to see a patient who presented ‘trigger thumb’.
On the initial evaluation, this patient presented c/o discomfort when heard the ‘clicking’ sound. Sometimes the thumb got stuck in one position and nothing could be done to release discomfort beside wait till resolved itself. There was no pain association with this condition at all.

In PE, there were no activities or any thumb movements which could possibly bring up the Sx such as ‘clicking’ sound or stuck the thumb in certain position. NAD on other exams, eg. AROM, PROM, PAMs, sensation and no patient’s discomfort at all. Basically I was treating this patient with no S & S of ‘Trigger thumb’ on the day. There was not much physio contribution in terms of intervention according to the literature and books, thus STM, gentle stretching and US were my first choice for this condition.

After each Rx component, clicking the thumb became visible more and more with thumb flexion. By the end of US, the thumb was clicking all the time. At that point, I felt very terrible because all what I did made the patient worse. Before the Rx started this patient was instructed there was limited what we could do to this condition and the Rx may or may not contribute to release the S & S, and this patient understood well. But even so, I did not expect the S & S would get worse.

On the 2nd visit, the patient reported there was still ‘clicking’ sound in occasion, but no ‘stuck in one position’ of the thumb since last Rx. The patient thought the previous Rx did help some and was happy to do the same thing again. I was not 100% sure the previous Rx did help or not, but the patient was happy to proceed the same Rx so the same procedure was conducted.

Again, no S&S pre Rx and S&S was brought up post Rx with every thumb movements. At that stage, I was thinking any of my intervention was some how triggering the ‘trigger thumb’, even though the patient reported it helped some.

I need to come up any other techniques in terms of physio intervention which at least do not increase S&S for this patient’s next visit. Does anyone have any idea? I searched in several books, but no luck.

There is most common Rx used for non-surgical Rx that is corticosteroid injection to the tendon sheath or mid-axial area, but this is not conducted by physio. Taking NSAID is another way to reduce inflammation. If the conventional Rx failed, surgical procedure would be the option to release the narrowed tendon sheath. Percutaneous procedure is getting popular recently, over open-cut procedure, which is releasing A1 pulley and very safe, effective, and quick procedure (takes 15 mins under local anesthesia in Dr’s office) without any complications. Again, this is not done by physio. So anyone has any idea?

Self Mx chronic neck pain

I have a 60 yo patient at the moment who suffers from chronic neck pain and decreased ROM. She has global hypomobility of the Cx spine, tight suboccipitals, scalenes, UT and LS and bad posture. Previously she has had some improvement with Cx PAIVMs Rx along with STM and postural advice. She is currently doing a HEP consisting of gentle AROM, muscle stretches and some postural correction exercises (which she admits she does not do often). During her recent visit she reported that she was no longer getting much pain from the neck but instead the stiffness was more of an issue and she often found the muscles to be quite stiff and painful when she stretched them.

After SE and OE I was left to decide how to progress this patient. My first thought was that I neede to free up some of the PAIVMs with manual treatment but what level and direction would I do as there was global stiffness and pain throughout the whole Cx spine and the pain ws quite central. After talking to my supervisor about my findings and the long term goals of this patient I realised that although I could do some manual treatment today to free up a few of the restricted joints, in the long run, with the extent of arthritic changes within the neck, it would not be of any benefit. Therefore for this patient Rx was more outweighed by Mx for long term affect. Therefore this would include helping teach her to self massage tight muscles to both increase general AROM and help maintain a neutral posture, teach her appropriate stretches for all of the mm that were continually getting tight and most importantly educating her on the importance of a neutral posture and ongoing Mx.

The patient had not been putting as much emphasis on maintaining a neutral posture as she should have been due to both lack of knowledge and the inability to easily get into a neurtal position due to her tht suboccipitals. Therefore it was important to explain the pathophysiology behind her neck pain and how everything linked together. I then booked the patient in to be seen again the next week. I thought that this follow up was important to see if she was becoming affective in self Mx her condition, correct any errors th exercises and posture and reinforce withthe patient the importance of self Mx for the long term treatment of her neck problem.

The patient is yet not come back in at the moment so I do not have any follow up details. I would liek to know however if anyone has any other ideas as to self management techniques or any experiences in which they have had a similar patient, and the relative sucess rate for self Mx of this kind of condition?