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.
Friday, September 26, 2008
Wednesday, September 24, 2008
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.
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.
Friday, September 19, 2008
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.
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.
Thursday, September 18, 2008
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.
Tuesday, September 16, 2008
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.
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.
Monday, September 15, 2008
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.
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.
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.
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.
Saturday, September 13, 2008
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.
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.
Monday, September 8, 2008
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.
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.
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.
Sunday, September 7, 2008
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.
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.
Saturday, September 6, 2008
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.
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.
Friday, September 5, 2008
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?
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?
Thursday, September 4, 2008
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).
Tuesday, September 2, 2008
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.
Monday, September 1, 2008
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.
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.
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.
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