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.