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.