Supervisor availability

I have started an outpatient musculo prac now at the Curtin clinic. Due to the limited number of supervisors compared to students often there is a line up of students wanting to discuss S and O findings with them at the same time. This means often waiting 10-15min before you can talk to them, then disussing for 5 min etc all while the patient is waiting in their cubicle. At first I found this quite annoying on my behalf and I am sure on the patients behalf too, wasting so much time. But looking at the logistics of the clinic and uni etc there isnt really any alternative. So I have been working out what I could do to try to cut down this time wasting. Firstly, I have worked on being absolutely definate in my S and O findings and trying to work out possible causes, diagnoses etc during the Ax and while waiting for the supervisor, so by the time I get to her I am alot quicker, smoother and effective. Secondly, I have worked on my time management with both subjective and objective assessment, to allow anytime I need to track down the supervisor.

Mostly from this I have learnt alot quicker and effective handovers but also quicker evaluation of findings. I am still however finding it quite hard, has anyone had similar circumstances with effective solutions?

Confusion

This one relates to last placement where i was on the wards for half the day and in the outpatient department for the other half.

In the outpatient department there was no specified supervisor that you had to present your subjective/objective findings and/or treatment ideas there were 6 different physios and whoover was available was the one that was to be approached for guidance. It was expected that if you were dealing with a patient then all your assessment findings and clinical reasoning related to that patient should be done with one physio to avoid confusion.

I had a new patient come in and sure enough did my subjective and went out to discuss my findings with one of the available physios. I went back into the cubicle and did my objective and came out again to discuss my findings when i realised the physio i was dealing with had left for a meeting. I was left to deal with one of the other physios who was available at the time.

Once our discussion started they were continually questioning the objective assessment i had been performing and considered it necessary to perform further assessments. All the assessment performed was based on my initial discussion with the first physio who had now left and the new physio seemed to have all these new and different ideas regarding pathology and diagnosis. This was a situation that occured at least every week during my placement where i was made to deal with two physio regarding one patient.

It made the process extremely difficult and frustrating as i realised all physios have subtly different methods and techniques with their assessment. This made the whole process a lot harder then it had to be. When i presented the issue to the supervising physio he simply said thats the way it is and offered no solution to the situation.

It made me realise i pretty much have to make the best of the situation available to me and although it often took longer and was harder it was something i had to deal with whilst on this placement

Depression.......

Hi, my placement now is in musculo.

I had a gentle man who was attending to the hospital for a while with ongoing condition.
On my first assessment on him, he did not present that much pain which had been bothering him for a long time. The only activity that increased the pain (up to 2/10) was SLS in occasion. So the pain was well managed at that stage; however, there were many things needed to be considered besides the original problem. His mental status had been changing regularly due to depression which was one of his considered conditions.

He was aware of this condition and had been trying not to think about it too much; because, it was affecting onto his mind as negatively. As you know this condition, it is hard to be active and motivated in any exercises when someone is depressed in general. He was not an exception and was having struggles to break the cycle. He was trying hard on HEP as much he could as possible, since he had been told many times the importance of regular exercises, these needed to be consistent, and he was very aware of it.

However, I could notice during the Sx that he was having a feeling of guilty not doing well on his HEP as depressed. I understood how he felt regarding exercises and his previous history. I was seeking his interests in any activities during the session, but I felt like I was giving him more pressure as time went by.

Lots of encouragement and education was my intervention mainly on him, but what else I could have done? I was told there was not much we could do in terms of physio point of view. I understand that treating the mental condition is out of our scope; however, I just want to give patients a little of help without increasing their feeling of guilty for next time. Does anyone have any idea to help me out??

A patient with Down Syndrome

I recently was treating a patient with down syndrome on my musculo prac who lives in a home with a few other disabled people. He is relatively independent and they do not have any carers living in this 'share house'. Whilst he attends PT treatemnts every week, no gain is achieved as he has cognitive issues that doesnt allow recall of exercises. His learning disabilities inhibit him from reading instructions and his vision isnt the best either. I found it really hard to treat him as his response to everythuing was 'good' and i couldnt find a simple way to explain the exercises so that he could get it. he was in his thirties aswell so i was very aware not to patronise him. After two treatment sesions and recall of only one of the five exercises he really needed to be doing i decided i would trial something. I took (with his permission) photos of him doing the exercises and made a poster. I found this was helpful and although he still had difficulty with prescription of sets and reps, at least he could get himself into the positions. continuous repetition of the same exercises and showing how he did them in the phots already would have made this system even more efficient, though i had finished that prac and don't know how well it did pan out! a nice alternate to some of our more original HEP ideas!

You only make a mistake once.

picture this..

WEEK 5, Musculo... finally the world's most intense prac comimg to an end. You finally have good hold of the whole process then bang, your world is shut down once again!

I won't lie, I found this prac challenging. Time management.. 2 words that have been so prevalent, usually preceded by a lack of.. as such. So I was cruzing along about to rock up at preac at 1.30 knowng exactly what patients i was having, and feeling like i had done good preparation for them. Bang, rock up to prac at quarter past one, my patients had been scribbled out and i had a "newbie" closely followed by one that required a decent amount of time. As we all know, the "newbies" need some more time for the full Ax, Rx, Re Ax ... little bit scoundrel when your supervisor pulls a stunt whereby you have NO time to prepare, you've been given a condition you hadnt revised and oh, did i mention it was your assement with your curtin clinical tutor.

As far as i was concerned i could have a cry about it, or i could just get along and do the best i could. Admittedly, not the smoothest Ax, and treatment ever but sufficiant. i quickly go stuck into my next patient only to be told 30 minutes into the session that there was a gentleman that had been waiting for me for an hour and a half!!

initial reaction, panic! how on earth did i book another patient in today, the already pear-shaped day! second move, quickly rap things up with patient number two, apologise to patient number three and look as if i was calm . Luckily pt number 3 was the world's nicest man and he didnt mind at all, i felt terrible but i can guarantee i will check and double check with bookings from now on.. I learnt to always allow myself enough time, and to make sure you do things properly, ie. write in the appointment book and on the card that you hand to the patient.

At the end of the day, i was upset but i didnt dwell on it because i learnt something valuable form it so i concur its not always a bad thing to make a mistake

Gynaecomastia

This is a sign / symptom where the male gets inflammation in their mammory glands and essentially there breast tissue develops like a female, some even lactate. It is ususally due to an imbalance of hormones and is usually a sign of something more severe going in lymph nodes, particuarly in the liver. I recently had a young 27 year old male patient with this problem and had to do chest physio on him. Normally, when a male patient, i would get them to take off there top so i can get in and auscultate accurately. In trying to preserve his dignity i just did posterior segments and was abit airy fairy abit where i put my stehtoscope. Afterwards i thought... was it really preserving his dignity, or was it my own... was i scared of my reaction to something i hadnt seen before, and didnt know what sort of reaction i should have to it.. which leads me to think can you question a patient about it if this is the first time you are seeing them, or is that rude. I chose not to, but i found myself really intrigued about how it presented and how he noticed it.

curiosity didnt kill the cat in this instance

Aphasia

Hey guys I have really been struggling all placement to find something to write about… anyway here’s another.

We had a few pts on the ward while I was on neuro placement who presented with either receptive aphasia and or global aphasia’s. Apart from demonstrating what you would like them to do, familiar verbal cues with short sharp commands and guidance throughout the task does anyone have any other sneaky treatment ideas that may come in handy when treating such patients???

The thing I found hardest when treating these patients is that you have no idea of knowing what they are hearing or understanding and/or not understanding and how to change what you are doing to help them understand the task better. Is it just something that will come in time with practice or with some resolution of the impairment?

I have learnt that you need to be really creative when it comes to neuro and to be able to think outside the square especially with these patients, just to keep it interesting to that your patients continue to be compliant.

And Trudi, I will place an extra 2 responses on the next round, as I have been the only one posting over the break and there really isn’t much more to reply to in many of the other posts.

not convinced...

Has anybody else had this experience, when they propose to their supervisor what they think is wrong with the pt, and then get shut down, but then 2 weeks later you were able to prove them that you were right all along???

I know we don’t have very much clinical experience but I had this patient, this is my neuro prac by the way, who has a persistent flexed posture resulting in your classic crouching gait (go back to Connie’s notes if you’re not sure, by the way those notes are pure gold on pathological gait). We tested tone, we tested ms length. Tone testing was unremarkable, and with ms length there was a definite decrease in hip flexor length, and generalised hamstring shortening. The patient was generally very tight and found it very hard to let go during passive movement which didn’t help. We got him into prone still persistent hip flexion (13degs on left and 11 on the right)…. We spoke to his wife and she had mentioned that he had always walked very bent over…. I then proposed to my supervisor that he probably has a hip flexion contracture…. Bad move…

The supervisor made a point after this to mention to all the students that we all needed to start thinking more on the neuro side of things because when you are studying neuro it’s not like musculo. To be honest I wasn’t convinced and whilst talking about the pt during my mid placement I presented all the facts once again to prove my point and then the supervisor finally came around…

The moral of the story I think is, DON’T forget about all your musculo and cardio and anything that you can use to help problem solve through some tricky cases. Because a lot of the time many of these patients will have pre morbid postures and habits that you will be unaware of and a lot of the time the patient will be unaware that they were doing it also, and if they are not able to be solved with a neuro brain maybe a musculo side to it might help.

Communication

One thing that has really opened my eyes in the last week of prac has to do with communication. I’m on my neuro placement and I think that sometimes my patients just don’t understand what we are asking them to do but what I’ve learnt is that you actually need to give your patients enough time to allow for mental processing of the task to occur and then see what they can do. As they already have a neurological insult, the thought process is already going to take a little longer. Whether its part of the task or the whole thing, they may just surprise you in what they can do. And this is patients that may not necessarily have any language or perceptual problems.

This should be taken into consideration also when you are dealing with patients that have English as a second language as even if they do not understand English completely, the parts they know take time to process and translate.

So the thing I have learnt is to let your patients have enough time to organise their thoughts before we rule out that they are unable to do a certain task, due to any of the above reasons, because they may just surprise you and then that makes your job that little bit easier if you don’t have to assist them with something that they actually can do quite independently.