During my musculoskeletal placement, I was assigned a patient with chronic low back pain who also suffered from severe depression and obstructive sleep apnoea. I was aware of the “yellow flags” involved initially yet I still found it difficult to treat this patient as the previous home program put into place was not being followed. The patient simply stated he did not have the motivation to do basic exercise and ADLs as he was not sleeping well because he found his CPAP mask uncomfortable.
Throughout the number of times I saw this patient, I was required to basically do the same treatment each time which involved a management approach consisting of patient education and constant reinforcement of the home program/CPAP. Until the patient became compliant with his home program I was schooled not do perform manual therapy to prevent the patient becoming dependant on physiotherapy to “fix” his back pain. After a couple of treatment sessions I began to become frustrated with the patient’s depressive state, wanting to tell him to just snap out of it and realise what his life has to offer! I felt that whatever I did was inconsequential as he was not going to comply anyway. However I decided at the time that regardless of compliance, if I was inwardly irritated and bored, the patient would sense this and lose what motivation and hope he had. I realised that he needed me to be supportive and not lose faith in him as he had in himself, in order to achieve any progress. I decided to set him small one or two achievable goals each week, which he responded quite well to. I also constantly tried to encourage him and highlight the small gains he achieved.
I have realised from this encounter that treating the whole person is important and that some patients need much more empathy and patience than others. It is also crucial as a physiotherapist, to be able to put your personal feelings aside and consider what approach is best for the patient.
Monday, May 26, 2008
Confronting Death
I have just completed a clinical placement in an Intensive Care Setting. On my second day there, a patient was admitted from theatre and I was assigned to treat her with my supervisor. This patient, in their 60's was the victim of domestic voilence and had recieved blunt head trauma and consequently surgery. I walked into the room and was confronted by a patient who had so many facial injuries and head trauma that I didn't even think they looked human. Having read the notes and knowing the backgroud, I still didn't know what to expect when walking into the room. I was shocked and I kept my distance from the patient - I think I felt quite nervous about treating someone so badly injured.
The supervisor helped me a lot with this patient on the first treatment, and then I treated the patient twice a day from then on with supervisor help and feedback when i needed it. At the end of the second day, the patient began to deteriorate quite quickly, the ICP was gradually increasing and there was nothing more the team could do. I was told that Physio treatment would continue as normal. I had treated this patient on my own for a day and i found it very challenging as it was terrible to know that someone could have done this to another person. I tried to maintaing profesionalism and not allow my personal feelings and thoughts out. I felt great sadness and helplessness that i couldn't do anything more. When I arrived the next day, my patient was having a brainstem scan as they thought they may have coned overnight. The patient came back to ICU and it was confirmed that she had died although she was kept on a ventilator for organ procurement.
I was assigned to treat her that afternoon. I performed MHI and suctioning on the patient knowing that they had died and this was the huge challenge that I faced. I felt overwhelmed during the treatment, but I tried to keep it as 'normal' as possible, talking to the patient like I had on previous treatments. I think I did that more for myself than anyone. That night when I got home I had a huge range of emotions from sadness for the patient and their family, to anger towards the person who had done such a thing, and helplessness at us not being able to save her.
Looking back on it now, and having not had to deal with death before, I think I coped quite well.
I talked to my family about it as well as my peers on prac with me. I also let some of my emotions out once I had left the hospital. I realise that everyone did all they could to save her and that it was an aweful tragedy. I suppose it gave me another perspective, seeing this patient in the flesh and the struggle they went through, instead of on the evening news. When I think about that I feel glad that I was able to help in some way.
I think it's important to 'keep work at work' like they say, but for issues like this you need to let your feelings out to a certain extent. I was wondering if anyone has to deal with a death on placement and how you coped.
The supervisor helped me a lot with this patient on the first treatment, and then I treated the patient twice a day from then on with supervisor help and feedback when i needed it. At the end of the second day, the patient began to deteriorate quite quickly, the ICP was gradually increasing and there was nothing more the team could do. I was told that Physio treatment would continue as normal. I had treated this patient on my own for a day and i found it very challenging as it was terrible to know that someone could have done this to another person. I tried to maintaing profesionalism and not allow my personal feelings and thoughts out. I felt great sadness and helplessness that i couldn't do anything more. When I arrived the next day, my patient was having a brainstem scan as they thought they may have coned overnight. The patient came back to ICU and it was confirmed that she had died although she was kept on a ventilator for organ procurement.
I was assigned to treat her that afternoon. I performed MHI and suctioning on the patient knowing that they had died and this was the huge challenge that I faced. I felt overwhelmed during the treatment, but I tried to keep it as 'normal' as possible, talking to the patient like I had on previous treatments. I think I did that more for myself than anyone. That night when I got home I had a huge range of emotions from sadness for the patient and their family, to anger towards the person who had done such a thing, and helplessness at us not being able to save her.
Looking back on it now, and having not had to deal with death before, I think I coped quite well.
I talked to my family about it as well as my peers on prac with me. I also let some of my emotions out once I had left the hospital. I realise that everyone did all they could to save her and that it was an aweful tragedy. I suppose it gave me another perspective, seeing this patient in the flesh and the struggle they went through, instead of on the evening news. When I think about that I feel glad that I was able to help in some way.
I think it's important to 'keep work at work' like they say, but for issues like this you need to let your feelings out to a certain extent. I was wondering if anyone has to deal with a death on placement and how you coped.
Substance Abuse
In my current prac I am involved with pulmonary rehabilitation. As you would suspect most of the patients that I see are quite elderly and have smoked for most of their lives. There are however the minority of patients who have not smoked and are just unlucky enough to suffer from a pulmonary condition. Many of these patients would benefit from a lung transplant, however it is extremely hard to get on the transplant list let alone be lucky enough to get the transplant.
One of the patients that I see is a middle aged woman who requires a lung transplant to prolong her life. She appears to have very different values to myself, she is very loud and upfront and has many opinions that she insists on expressing. She does not spend time on her physical appearance and she doesn’t refrain from using coarse language around anyone. She openly talks about her many, many years of substance abuse and even told me that she used to drive her kids around whilst intoxicated.
I find her slightly confronting and have to try and maintain a professional image whilst communicating with her. She tells me that she is about to be placed on the transplant list if she can add a further 1Kg of weight to her tiny frame. This angers me as I believe there are far more deserving patients who would benefit from a transplant. I have to try and curb my personal feelings and still treat her as any other patient but I find this difficult and wonder if anyone else has any ideas about how to manage the situation.
I will continue to approach this sort of situation with a professional mind set and forget about the causes of a patient’s illness, and rather focus on the person that presents at the time.
One of the patients that I see is a middle aged woman who requires a lung transplant to prolong her life. She appears to have very different values to myself, she is very loud and upfront and has many opinions that she insists on expressing. She does not spend time on her physical appearance and she doesn’t refrain from using coarse language around anyone. She openly talks about her many, many years of substance abuse and even told me that she used to drive her kids around whilst intoxicated.
I find her slightly confronting and have to try and maintain a professional image whilst communicating with her. She tells me that she is about to be placed on the transplant list if she can add a further 1Kg of weight to her tiny frame. This angers me as I believe there are far more deserving patients who would benefit from a transplant. I have to try and curb my personal feelings and still treat her as any other patient but I find this difficult and wonder if anyone else has any ideas about how to manage the situation.
I will continue to approach this sort of situation with a professional mind set and forget about the causes of a patient’s illness, and rather focus on the person that presents at the time.
Counselling???
I am currently undertaking my neurology outpatients (NOP) placement and last week met all my patients for the 5 week duration I will be in attendance there. One patient sustained a CVA in November 07 and has been attending NOP’s now for 16 weeks. Prior to meeting this patient I was informed by my supervisor that he would be referred onwards to ‘Community Physiotherapy’ or a similar organisation after my tenure with him.
The supervisor told the patient soon after we met and it was obvious from this the patient was upset and immediately anxious about what the future held for him in terms of rehab. The patient has since expressed his concerns to me during the 2 Rx sessions he has attended. It seems apparent to me however that it is the obligation and the social aspects of his physio appointments that are more important to him. This can be backed up by his less than enthusiastic approach to his HEP.
I have tried to rely the importance of finishing this 5 weeks with me as a NOP with a commitment to his HEP to gain as much as he can so he is better prepared to undertake future rehab. He also mentions, at least three times per session, how much he will miss attending PT Rx because of the above reasons. I have tried to re-assure him that he won’t be left with no options at the end of his NOP programme and new social opportunities will eventuate with further rehab.
I understand the holistic aspects of our position a little clearer now. Most people value what we do for them immensely and are appreciative of us helping them re-gain function and the like. We need to acknowledge this but we also need our patients to gain ownership of their functional limitations and utilise their HEP. We are also required to counsel patients as I have learnt from this experience. This I will continue, with this patient, for the following 4 weeks and perhaps this may be as important as the Rx session(s).
The supervisor told the patient soon after we met and it was obvious from this the patient was upset and immediately anxious about what the future held for him in terms of rehab. The patient has since expressed his concerns to me during the 2 Rx sessions he has attended. It seems apparent to me however that it is the obligation and the social aspects of his physio appointments that are more important to him. This can be backed up by his less than enthusiastic approach to his HEP.
I have tried to rely the importance of finishing this 5 weeks with me as a NOP with a commitment to his HEP to gain as much as he can so he is better prepared to undertake future rehab. He also mentions, at least three times per session, how much he will miss attending PT Rx because of the above reasons. I have tried to re-assure him that he won’t be left with no options at the end of his NOP programme and new social opportunities will eventuate with further rehab.
I understand the holistic aspects of our position a little clearer now. Most people value what we do for them immensely and are appreciative of us helping them re-gain function and the like. We need to acknowledge this but we also need our patients to gain ownership of their functional limitations and utilise their HEP. We are also required to counsel patients as I have learnt from this experience. This I will continue, with this patient, for the following 4 weeks and perhaps this may be as important as the Rx session(s).
Sunday, May 25, 2008
The patient with social issues
During my neurology inpatient placement, I was assigned to treat a patient with a left sided stroke who also had a very long past medical history which included chronic behavioural problems. This patient was very difficult to engage generally, but was particularly difficult when his wife was in the room. On every occasion she was present during one of his treatments, he was more intent on abusing her and yelling obscenities at her than listening to what I was asking of him.
The last occasion I saw both of them together his wife asked me if he was allowed a certain type of food. I spoke with his speech therapist who said he could not have it, and I explained to the patient and his wife that it was because of his swallowing and feeding difficulties that he wasn’t allowed to. He then proceeded to tell his wife to bring it in ‘one piece at a time’ so no one would notice, and she refused. He proceeded to verbally abuse her in front of me, causing her to become very upset and leave.
This was not the first time that this had happened. Previous times when he had spoken to her or about her like this I asked him what did he hope to achieve by speaking to her in this way, and was it really necessary. I also spoke to my supervisor to see what I should do in the future and I was told it would be best to ignore it or ask his wife to leave the physio sessions. I had attempted these but the patient was very persistent in his ridicule of his wife, whether or not she was there. I found the situation quite distressing because I felt he was behaving very inappropriately, but felt unable to tell him without becoming argumentative.
I was wondering if anyone else had encountered a situation similar to this, and what your thoughts were.
The last occasion I saw both of them together his wife asked me if he was allowed a certain type of food. I spoke with his speech therapist who said he could not have it, and I explained to the patient and his wife that it was because of his swallowing and feeding difficulties that he wasn’t allowed to. He then proceeded to tell his wife to bring it in ‘one piece at a time’ so no one would notice, and she refused. He proceeded to verbally abuse her in front of me, causing her to become very upset and leave.
This was not the first time that this had happened. Previous times when he had spoken to her or about her like this I asked him what did he hope to achieve by speaking to her in this way, and was it really necessary. I also spoke to my supervisor to see what I should do in the future and I was told it would be best to ignore it or ask his wife to leave the physio sessions. I had attempted these but the patient was very persistent in his ridicule of his wife, whether or not she was there. I found the situation quite distressing because I felt he was behaving very inappropriately, but felt unable to tell him without becoming argumentative.
I was wondering if anyone else had encountered a situation similar to this, and what your thoughts were.
How to handle difficult babies
I am currently doing my paediatric placement at a child development centre. Here one of the main areas focused on is the assessment and treatment of Plagiocephalies. When a child presents with this condition they are usually around the age of 4-5 months and the assessment consists of observing the baby in supine, prone, sidelying and sitting postures. To do this there is quite a bit of handling and facilitating of the baby to move between these positions. We also have to assess active and passive neck ROM. So as you can see there is quite a bit of hands on with the baby. Now most of the babies I have seen so far have tolerated being handled by me and the PT quite well until I came across a 4/12 baby whose mother reports that her baby does not tolerate strangers very well at all and tends to “lose it” when first handled by a new person. Now as most of you might know when a baby decides to throw a fit it takes a fair while to settle them back down if even at all.
So after the subjective I gave picking the baby up a go and just as the mother said the baby did absolutely lose it and so after my failed attempts to calm her down I had to give her back to her mother so she could settle her. After a few minutes when she had settled the PT tried but also failed to keep her calm while handling her and again had to pass her back to her mother. So since it looked like only the mother was going to be able to handle the baby today the PT looked at me and challenged me to come up with a solution to still complete the objective assessment without handling the bub.
First of all I tried simply talking the mother through what I wanted to do but after the first few tests it was clear she didn’t really understand what I wanted of her and so the aim of the test wasn’t being achieved. Now I was back to square one. The next thing I tried was a went and found a doll and so I sat opposite the mother and demonstrated exactly what I wanted her to do and explained the aim of the activity. This seemed to work very well and allowed me to complete the assessment enough as to determine the extent of the problem and then prescribe management strategies.
When reviewing the session my supervisor said that what I did was very acceptable and she commended me on the way I handled my first screaming baby.
So I was wondering if anyone else has had to deal with babies who don’t tolerate being handled by strangers very well and if so how and what did they do to get around it and complete a successful session.
So after the subjective I gave picking the baby up a go and just as the mother said the baby did absolutely lose it and so after my failed attempts to calm her down I had to give her back to her mother so she could settle her. After a few minutes when she had settled the PT tried but also failed to keep her calm while handling her and again had to pass her back to her mother. So since it looked like only the mother was going to be able to handle the baby today the PT looked at me and challenged me to come up with a solution to still complete the objective assessment without handling the bub.
First of all I tried simply talking the mother through what I wanted to do but after the first few tests it was clear she didn’t really understand what I wanted of her and so the aim of the test wasn’t being achieved. Now I was back to square one. The next thing I tried was a went and found a doll and so I sat opposite the mother and demonstrated exactly what I wanted her to do and explained the aim of the activity. This seemed to work very well and allowed me to complete the assessment enough as to determine the extent of the problem and then prescribe management strategies.
When reviewing the session my supervisor said that what I did was very acceptable and she commended me on the way I handled my first screaming baby.
So I was wondering if anyone else has had to deal with babies who don’t tolerate being handled by strangers very well and if so how and what did they do to get around it and complete a successful session.
Patient expectations
I am currently on my musculoskeletal placement. During the last week I observed many of the senoir physiotherapists at work and tried to absorb all the knowledge I could!! During this last week I observed one of the senior physiotherapists treating a 34 year old women following a left total hip replacement. This patient was born with a left hip dysplagia. She was only diagnosed at 5 years old, following the local GP watching her run in a sports carnival. She then received 4 surgeries in the next 3 years to correct her dysplagia. She has lived a normal active life since then and is mother of two young children. In the last 8 - 10 years her left hip has become increasingly more painful. She is very young to be receiving a total hip replacement, but due to her history she was advised by her orthopaedic surgeon to have the hip replacement. The aim of the hip replacement was to decrease her pain and increase her activity.
Since having the total hip replacement the patient has experienced increased pain in her right hip, knee and lumbar spine. Following the surgery she has also been left with a 1.5cm leg length descrepency (her left leg is now longer than her right.) The patient was refered to the physiotherapy department by her orthopaedic surgeon for treatment for her hip, knee and back pain. The patient was told by the orthopaedic surgeon that she would be receiving lots of physiotherapy treatment and that it should help her. Therefore the patient arrived at the department with very exact ideas of what her physiotherapy treatment should be like.
After the senior physiotherapist had assesed her, the only appropriate treatment for the patient at this time was increasing her active range of motion of her left hip and gait re-education. The gait re-education was to show the patient how she can deal with her leg length descrepency. Once the patients gait was changed her lumbar spine pain reduced. The physiotherapist told the patient that she should continue with her exercises and come back to the physiotherapy department once she had been reviewed by her orthopaedic surgeon in 3 weeks time.
The patient was very dissapointed with this because she thought she would be having multiple physiotherapy sessions per week. The senior physiotherapist took a very motherly approach when reassuring the patient that she was capable to continue with her own rehab at home. Explaining that she was a very clever person, that she was not dumb and could cope on her own. The physiotherapist did suggest that the patient call the physiotherapy department if she needed to talk to her.
I felt that the patient left the treatment session feeling very disapointed and even slightly belittled. Maybe this is my lack of experience shining through, but I'd hate for a patient to leave a treatment session with me feeling that way. With future patients I would like to explain to them more thoroughly why I would not need to see them more often. If the patient is still upset about this I could always see them for a shorter follow up session and use this time to further reassure the patient. I don't know if sending a letter to the patient orthopaedic surgeon would be appropriate, but I would like to send them a letter explaining what treatment I was able to supply and why.
Has anyone experienced in situations when a patients expectations don't match up to the appropriate treatment you used for them?
Since having the total hip replacement the patient has experienced increased pain in her right hip, knee and lumbar spine. Following the surgery she has also been left with a 1.5cm leg length descrepency (her left leg is now longer than her right.) The patient was refered to the physiotherapy department by her orthopaedic surgeon for treatment for her hip, knee and back pain. The patient was told by the orthopaedic surgeon that she would be receiving lots of physiotherapy treatment and that it should help her. Therefore the patient arrived at the department with very exact ideas of what her physiotherapy treatment should be like.
After the senior physiotherapist had assesed her, the only appropriate treatment for the patient at this time was increasing her active range of motion of her left hip and gait re-education. The gait re-education was to show the patient how she can deal with her leg length descrepency. Once the patients gait was changed her lumbar spine pain reduced. The physiotherapist told the patient that she should continue with her exercises and come back to the physiotherapy department once she had been reviewed by her orthopaedic surgeon in 3 weeks time.
The patient was very dissapointed with this because she thought she would be having multiple physiotherapy sessions per week. The senior physiotherapist took a very motherly approach when reassuring the patient that she was capable to continue with her own rehab at home. Explaining that she was a very clever person, that she was not dumb and could cope on her own. The physiotherapist did suggest that the patient call the physiotherapy department if she needed to talk to her.
I felt that the patient left the treatment session feeling very disapointed and even slightly belittled. Maybe this is my lack of experience shining through, but I'd hate for a patient to leave a treatment session with me feeling that way. With future patients I would like to explain to them more thoroughly why I would not need to see them more often. If the patient is still upset about this I could always see them for a shorter follow up session and use this time to further reassure the patient. I don't know if sending a letter to the patient orthopaedic surgeon would be appropriate, but I would like to send them a letter explaining what treatment I was able to supply and why.
Has anyone experienced in situations when a patients expectations don't match up to the appropriate treatment you used for them?
A dilemma - tolerance and professionalism
During one of my placements in a mental health setting, I met with a patient suffering from drug-induced depression. She was pregnant in her third trimester and was complaining of low back pain. The nurses referred her to the physiotherapist for the relief of her back pain. I was assigned to this case. On meeting with her, she was full of complains and started hurling vulgarities at me. I offered to give her a massage that she refused, tried to teach her to correct her posture that she did not want to listen and offered advice on pregnancy but was bluntly shut off as she claimed she knew more than I did because she has had six previous pregnancies.
There was no explanation as to why vulgarities were hurled at me because I have not even attempted any form of treatment on her. It was upon coming into the physiotherapy department that could have agitated her. My supervisor tried pacifying her but was shut off by her as well.
Should I ignore her? Should I walk away from her? Or should I continue treatment?
Given the option, I really should have ignored her rendering neither treatment nor advice. However, as a professional I have due diligence to relief her of the back pain that she is complaining off as she has been assigned to my care. This is indeed a dilemma! On reflection, it would be to my advantage to seek advice from a psychologist to better manage my emotions when meeting this type of patients.
In this instance where there was no way I could go near her, it could have been better if I request that she decides what is best for herself. So as not to agitate her further, I would prefer to leave the scene and let her cool down on her own. However, I would observe her from a distance so that she would not harm herself. At the same time, I would try to link up with the nurses to find out whom she can better relate to and work together with that person to gain access into managing her back pain.
There was no explanation as to why vulgarities were hurled at me because I have not even attempted any form of treatment on her. It was upon coming into the physiotherapy department that could have agitated her. My supervisor tried pacifying her but was shut off by her as well.
Should I ignore her? Should I walk away from her? Or should I continue treatment?
Given the option, I really should have ignored her rendering neither treatment nor advice. However, as a professional I have due diligence to relief her of the back pain that she is complaining off as she has been assigned to my care. This is indeed a dilemma! On reflection, it would be to my advantage to seek advice from a psychologist to better manage my emotions when meeting this type of patients.
In this instance where there was no way I could go near her, it could have been better if I request that she decides what is best for herself. So as not to agitate her further, I would prefer to leave the scene and let her cool down on her own. However, I would observe her from a distance so that she would not harm herself. At the same time, I would try to link up with the nurses to find out whom she can better relate to and work together with that person to gain access into managing her back pain.
Saturday, May 24, 2008
Over zealous treatment
My first placement was in a paediatric setting. It was my first time working with neonates in a cardiopulmonany department. I was doing my daily rounds and was assigned to treat a nine month old baby suffering from pneumonia. The aim of the treatment was to try and “clear” the baby’s lungs through percussions/vibrations and suctioning. As it was my intention to achieve the best for the baby, I spent 45 minutes carrying the treatment. My supervisor did not stop me along the way. However, she told me that I could have carried out the treatment in a much shorter time without putting the baby in distress.
As it was only my second week into the placement, I felt quite enthusiastic and was determined to perform a “perfect” treatment. I carried out a full objective assessment on the baby through auscultation and chest expansion. As saturations remained within an acceptable range, I continued with percs/vibs to loosen the secretions, followed by suctioning as there were audible crackles.
Was I wrong to continue with the treatment, or should I have shortened the treatment?
My supervisor commented on my performance and said that I did well. However, due to the age of the patient, too zealous a treatment may not give an optimal outcome. Although the saturations were within an acceptable range, the baby showed signs of distress through nasal flaring, which I did not take note of during the treatment.
Therefore, I learnt from this issue that I should observe the patient holistically instead of looking at only one parameter (ie. Oxygen saturations). In future, when rendering treatment, I should pay more attention to the holistic presentation of the patient and not be too enthusiastic trying to reduce crackles!
As it was only my second week into the placement, I felt quite enthusiastic and was determined to perform a “perfect” treatment. I carried out a full objective assessment on the baby through auscultation and chest expansion. As saturations remained within an acceptable range, I continued with percs/vibs to loosen the secretions, followed by suctioning as there were audible crackles.
Was I wrong to continue with the treatment, or should I have shortened the treatment?
My supervisor commented on my performance and said that I did well. However, due to the age of the patient, too zealous a treatment may not give an optimal outcome. Although the saturations were within an acceptable range, the baby showed signs of distress through nasal flaring, which I did not take note of during the treatment.
Therefore, I learnt from this issue that I should observe the patient holistically instead of looking at only one parameter (ie. Oxygen saturations). In future, when rendering treatment, I should pay more attention to the holistic presentation of the patient and not be too enthusiastic trying to reduce crackles!
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