Whilst on my neuro placement I have been involved with my peers in supervising patients whilst they participate in the ‘running class’. This service is for people who have aquired a UMN lesion and the participants are quite young, younger then you would expect.
Anyway I have been working with a young lady the last 3 weeks supervising her whilst she engages in the exercises a lot of which involve high level balance ++, mobility ++ and co-ordination. She is obviously scared about performing some of the exercises and I have had to encourage her in regards to trying new exercises and performing some of the other ones without holding on for support (whilst jumping on a mini trampoline) or not staying in the parallel bars.
I have seen her progress and become more confident in her abilities just in this short space of time and it has been really great to see the smile on her face when I tell her how good she is performing.
The other day I was trying to encourage her to perform some bounding type exercises. She started to get all teary eyed and I could see she was scared and disappointed in her self as she didn’t want to try them. She probably just didn’t feel she was ready for such an activity. I reminded her of the gains she had made just recently and the disappointment vanished off her face and the tears were wiped away, to be replaced by a smile. She knew she was improving then.
I feel this experience has highlighted the importance of motivating our patients but also knowing when to back off, I wasn’t going over board with my encouragement I was basing it on what I knew she could do. She didn’t feel she was ready so I wasn’t going to push the issue.
I believe encouragement goes along way and I will always be that kind of therapist because it makes me happy when I see the improvement that has resulted from my intervention (s). She needed further encouragement that day to take the next step and I hope she does with the help of another therapist who can inspire her.
Monday, June 23, 2008
Thursday, June 19, 2008
Discharge?
On my current gerontology placement I was treating a patient with an AKA for a couple of weeks. When I went to see him a couple of days ago, he refused physiotherapy treatment stating that he was being discharged at 730am the next day and had too much to do. I was unaware of this situation as no discharge date had been organised at the prior allied health meeting and no one in the allied health team had discussed the discharge plan with me. I was unprepared for this development and didn't have adequate time to organise a physiotherapy referral or go through a home exercise program (HEP) with the patient.
Initially I tried to persuade the patient that physiotherapy was important and necessary in order to arrange a HEP. However no matter how I tried to encourage and motivate him he was adamant not to come to physiotherapy. Luckily I had already supplied the patient with an exercise booklet and given the patient these exercises to perform in his room. I was thus able to simply discuss what exercises he could continue with from the booklet at home, based on what he was previously doing independently.
Therefore I have learnt that it is very important to check hospital information boards every day in advance as well as patient notes, to discern future patient developments in order to plan and prioritise treatment sessions and discharge planning. I have also realised that sometimes no matter what you say or do, a patient will refuse treatment and that decision must be respected. I have also come to recognise when a patient can be encouraged and when you just have to cut your loses.
Initially I tried to persuade the patient that physiotherapy was important and necessary in order to arrange a HEP. However no matter how I tried to encourage and motivate him he was adamant not to come to physiotherapy. Luckily I had already supplied the patient with an exercise booklet and given the patient these exercises to perform in his room. I was thus able to simply discuss what exercises he could continue with from the booklet at home, based on what he was previously doing independently.
Therefore I have learnt that it is very important to check hospital information boards every day in advance as well as patient notes, to discern future patient developments in order to plan and prioritise treatment sessions and discharge planning. I have also realised that sometimes no matter what you say or do, a patient will refuse treatment and that decision must be respected. I have also come to recognise when a patient can be encouraged and when you just have to cut your loses.
Tuesday, June 17, 2008
The Patient with Schizophrenia
This covers two past placements of mine, one in general medicine and one in an orthopaedics setting.
For those who don't know or haven't seen a patient with schizophrenia before, schizophrenia is a psychiatric condition that is usually characterised by hallucinations, paranoid delusions and/or dysfunctional thinking and mental processes. There are four types, but the most well known is paranoid schizophrenia(I'll refer to it as PS). These patients can experience hallucinations (both visual and auditory) and have paranoid delusions. Knowing this, and seeing some pretty poor portrayals of people who were mentally ill on TV, I was quite nervous about treating such a patient for fear of aggression and violence.
The first patient I saw with this condition had developed PS after years of cannabis abuse. He had been admitted for a BKA after a foot persistent infection secondary to diabetes. With my supervisor, we helped him ambulate with a WZF and treated to prevent a knee flexion contracture. Throughout the entire treatment he was extremely compliant and never became aggressive. I was able to build a good rapport with him, and I felt a bit ashamed that I had immediately expected the worst of him given his condition. I realised that not all patients who had a mental illness were the same, and decided to keep a more open mind about this if I encountered a patient with the same condition again. This was approximately 2 years ago.
Earlier this year I treated a patient who had also had a previous diagnosis of schizophrenia. Armed with the knowledge from my previous patient, I was able to treat this patient without fear or prejudice, and be able to see her as a person, not as a mental illness. As a result, she recovered well from her surgery without any major movement deficits.
What I have learnt from seeing these two patients is that mental illness should not define a patient, and thus in most instances should not change the way you would treat them compared to a person without a mental illness. I also realised that media portrayals of people with serious mental illness can be of a catastrophising nature, and instill fear in the general population by only telling of people who are at the most extreme end of the mental health spectrum. As a result, I am now more open minded about patients with mental health conditions and less likely to flinch when assigned one to treat.
For those who don't know or haven't seen a patient with schizophrenia before, schizophrenia is a psychiatric condition that is usually characterised by hallucinations, paranoid delusions and/or dysfunctional thinking and mental processes. There are four types, but the most well known is paranoid schizophrenia(I'll refer to it as PS). These patients can experience hallucinations (both visual and auditory) and have paranoid delusions. Knowing this, and seeing some pretty poor portrayals of people who were mentally ill on TV, I was quite nervous about treating such a patient for fear of aggression and violence.
The first patient I saw with this condition had developed PS after years of cannabis abuse. He had been admitted for a BKA after a foot persistent infection secondary to diabetes. With my supervisor, we helped him ambulate with a WZF and treated to prevent a knee flexion contracture. Throughout the entire treatment he was extremely compliant and never became aggressive. I was able to build a good rapport with him, and I felt a bit ashamed that I had immediately expected the worst of him given his condition. I realised that not all patients who had a mental illness were the same, and decided to keep a more open mind about this if I encountered a patient with the same condition again. This was approximately 2 years ago.
Earlier this year I treated a patient who had also had a previous diagnosis of schizophrenia. Armed with the knowledge from my previous patient, I was able to treat this patient without fear or prejudice, and be able to see her as a person, not as a mental illness. As a result, she recovered well from her surgery without any major movement deficits.
What I have learnt from seeing these two patients is that mental illness should not define a patient, and thus in most instances should not change the way you would treat them compared to a person without a mental illness. I also realised that media portrayals of people with serious mental illness can be of a catastrophising nature, and instill fear in the general population by only telling of people who are at the most extreme end of the mental health spectrum. As a result, I am now more open minded about patients with mental health conditions and less likely to flinch when assigned one to treat.
Monday, June 16, 2008
Dealing with depressed patients
I have found it very hard to deal with depressed patients. I haven't been around many depressed or suicidal patients and I'm finding it quite daunting. On a previous placement a patient came in with pneumonia. I was reading through her notes before I saw her and she had very extensive mental health history. She had recently been discharged from spending 7 months in a mental health hospital and has a history of self-mutilation.
Before I entered her room I had an idea of what I was walking into, but I was still weary. The patient came across very sad but she wasn't as "depressed" as I thought she would be. During the subjective assessment I found it very hard to get any information from her and she seemed very disinterested. She was very compliant with all aspects of the objective assessment. When I asked her to lift her shirt so I could auscultate I saw many small cuts all over her abdomen and her back. This came as quite a shock to me.
I continued with my treatment as planned and all went well. In these cases I find it's not the treatment that is difficult but the patient and their medical history that make things more complicated. I discussed this with my supervising Physiotherapist and she helped me deal with my own emotions and thoughts when it comes to dealing with difficult patients.
In future cases I have to keep reminding myself that every case is different and to approach each patient with an open mind. I need to only take the information from the patients notes that I need and don't let them cloud my judgements of the patient.
Before I entered her room I had an idea of what I was walking into, but I was still weary. The patient came across very sad but she wasn't as "depressed" as I thought she would be. During the subjective assessment I found it very hard to get any information from her and she seemed very disinterested. She was very compliant with all aspects of the objective assessment. When I asked her to lift her shirt so I could auscultate I saw many small cuts all over her abdomen and her back. This came as quite a shock to me.
I continued with my treatment as planned and all went well. In these cases I find it's not the treatment that is difficult but the patient and their medical history that make things more complicated. I discussed this with my supervising Physiotherapist and she helped me deal with my own emotions and thoughts when it comes to dealing with difficult patients.
In future cases I have to keep reminding myself that every case is different and to approach each patient with an open mind. I need to only take the information from the patients notes that I need and don't let them cloud my judgements of the patient.
Introduction to patient and family
I had my last placement in an oncology ward. It was a cardio placement so the patients I saw usually had a respiratory issue and was thus admitted to hospital. Among the many patients I saw, there was a particular patient that left an impression on me. This patient was hospitalised because he complained of a recent increase in SOB with a history of lung Ca. He was put on O2 therapy since admission. I saw him the next day and learnt that he desat to low 70s early that morning as he walked to the toilet without a portable O2 tank. The nurses panicked and brought him back to bed immediately and changed his mask from a Hudson mask to a NRB mask. The patient’s family learnt about the situation and was very upset with the nurses. Since that situation, the family have been very wary of the people that come to see the patient. The family demanded everything to be explained to them before any procedure was done or any treatment given out.
As I was just a student, the family was naturally wary of me seeing the patient. Fortunately, my supervisor came with me the first time to see this patient. She introduced me to the patient and his family and explained to them that I would be in-charge of this patient. She also assured them that I would have the required skills to be able to treat the patient and that she as a supervisor would be monitoring what I was doing. I felt that this introduction was good as it helped bridge the gap between the family and us as physio students. I know that although we as physio students have got all the knowledge we require to treat patients, we still have not got enough experience or confidence at times. I appreciated this introduction very much as it helped a lot with both patient and family compliance.
At that point of time, I was thinking to myself: What if my supervisor had not given that introduction and I had to do it myself, would the family be as compliant? Also, I know that I cannot depend on my supervisor to give an introduction each time I am faced with a situation like that as I have to be able to handle it on my own.
After thinking about what happened, I realised that I will have to learn to face both the patients and their families on my own. They may not be confident of my skills and what I have to offer, but I still have to prove to them that I have what it takes! ☺ I have to learn to portray a more confident image and be able to take control of the situation. I apologised on the nurses’ behalf for allowing the patient to go to the toilet earlier that morning without a portable O2. I also told the patient that the next time he needs to go to the toilet, he has to ask for a portable O2. I told the family that I would place a tank of portable O2 beside the patient’s bed so that both the patient and the nurses will not forget to use it the next time the patient gets out of bed.
The family and patient were happy with the arrangement, and I was glad they were not as upset as before. The next time I am faced with such a situation, I guess I would carry on as per normal, give a formal introduction and explain the purpose of my treatment and do my best to help the patient. I believe that a mistake made by a healthcare professional should not be condemned but should be brought up and the mistake should be rectified. Everyone deserves a second chance!
As I was just a student, the family was naturally wary of me seeing the patient. Fortunately, my supervisor came with me the first time to see this patient. She introduced me to the patient and his family and explained to them that I would be in-charge of this patient. She also assured them that I would have the required skills to be able to treat the patient and that she as a supervisor would be monitoring what I was doing. I felt that this introduction was good as it helped bridge the gap between the family and us as physio students. I know that although we as physio students have got all the knowledge we require to treat patients, we still have not got enough experience or confidence at times. I appreciated this introduction very much as it helped a lot with both patient and family compliance.
At that point of time, I was thinking to myself: What if my supervisor had not given that introduction and I had to do it myself, would the family be as compliant? Also, I know that I cannot depend on my supervisor to give an introduction each time I am faced with a situation like that as I have to be able to handle it on my own.
After thinking about what happened, I realised that I will have to learn to face both the patients and their families on my own. They may not be confident of my skills and what I have to offer, but I still have to prove to them that I have what it takes! ☺ I have to learn to portray a more confident image and be able to take control of the situation. I apologised on the nurses’ behalf for allowing the patient to go to the toilet earlier that morning without a portable O2. I also told the patient that the next time he needs to go to the toilet, he has to ask for a portable O2. I told the family that I would place a tank of portable O2 beside the patient’s bed so that both the patient and the nurses will not forget to use it the next time the patient gets out of bed.
The family and patient were happy with the arrangement, and I was glad they were not as upset as before. The next time I am faced with such a situation, I guess I would carry on as per normal, give a formal introduction and explain the purpose of my treatment and do my best to help the patient. I believe that a mistake made by a healthcare professional should not be condemned but should be brought up and the mistake should be rectified. Everyone deserves a second chance!
Cultural differences
I was on a womens health prac recently, where my responsabilities included the ward round (maternity), seeing the occasional ante-natal outpatient and running ante-natal education and post natal exercise classes.
I was not uncommon on the ward for women to have perineal tears and or haemhorroids which required ultra sound. This was one of the treatment techniques that I used on many women, most of whom did not seem too phased by the procedure. Most were happy with a quick education on what it is, it's benefits as well as the procedure. I found that most women did not seem too uncomfortable with this treatment and once they'd had the first treatment, they realised what relief it gave them and began asking for it as we came round!!
I came across on woman however, who was a bit different. She was a very young indian woman who only one year ago had come here from India to meet the man her parents had arranged for her to marry. There had been plenty of women of other cultures who i had treated with the ultrasound - most from Sudan. They needed more information and education and I had to be very mindful of making sure i maintained their decency at all times and made sure doors were closed etc. This Indian woman was different as I do not think she was used to a hospital environment like this one she was in. I know this because I lived for six years in the same town as her in India and I've seen the hospital facilities myself - not too crash hot!!
I made this connection not too long into my first meeting with her. Her mother, who had come all the way from home was with her as well as her husband. She had a large tear to her perineum which was extremely tender and required ultra sound. The aim of seeing her that day was to see if she would accept a treatment.
Even as I entered the room with her family there, she seemed uneasy. I sensed this quite quickly and asked if her husband wouldn't mind stepping out while i spoke to her. She asked if her mother could stay in the room as she was the one who was caring for her and the baby. I told her all about the ultrasound and why it would help. she blatantly refused and said she'd be fine, so I then offered her other advice.
The next day, her pain had not subsided - she was unable to sit, and had a lot of pain with walking and going to the toilet. I could sence she wanted me to do something more but she'd used the ice packs and all the advice i gave. The only thing left was the ultrasound.
I sat down and chatted to her about India and her life here. She relaxed a lot and told me how she's so homesick. That she wants to go back. She doesn't like it here and she didn't want to get married in the first place but it was good for her future as her husband was well off. I felt quite sad for this woman and her situation and tried to be as empathetic as i could. Once we'd chatted, i told her again about the ultra sound. I explained it would not hurt, that she could stop the treatment at any time and ask any questions she wanted. She agreed to the treatment - finally!
She was extremely shy I knew, so I made sure the door was shut, sign up. I also asked my supervisor to be close by incase she did not want me to treat her for some reason. I maintained her decency and dignity the whole way through the treatment. I also talked to her and explained what i was doing while the treatment was going on.
At the end of the treatment she felt a lot better. The next day, she was quite eager to have some more ultrasound as it had allowed her a better sleep etc.
Having a patient who is a bit out of the ordinary highlighted to me our cultural differences and how we have to be respectful, mindful and adapting to their beliefs, customs and cultural differences. It was a very valuable lesson for me and I think all of us as Australia is such a multicultural society and as physio's we need to be able to communicate effectively to people from all over the world.
I was not uncommon on the ward for women to have perineal tears and or haemhorroids which required ultra sound. This was one of the treatment techniques that I used on many women, most of whom did not seem too phased by the procedure. Most were happy with a quick education on what it is, it's benefits as well as the procedure. I found that most women did not seem too uncomfortable with this treatment and once they'd had the first treatment, they realised what relief it gave them and began asking for it as we came round!!
I came across on woman however, who was a bit different. She was a very young indian woman who only one year ago had come here from India to meet the man her parents had arranged for her to marry. There had been plenty of women of other cultures who i had treated with the ultrasound - most from Sudan. They needed more information and education and I had to be very mindful of making sure i maintained their decency at all times and made sure doors were closed etc. This Indian woman was different as I do not think she was used to a hospital environment like this one she was in. I know this because I lived for six years in the same town as her in India and I've seen the hospital facilities myself - not too crash hot!!
I made this connection not too long into my first meeting with her. Her mother, who had come all the way from home was with her as well as her husband. She had a large tear to her perineum which was extremely tender and required ultra sound. The aim of seeing her that day was to see if she would accept a treatment.
Even as I entered the room with her family there, she seemed uneasy. I sensed this quite quickly and asked if her husband wouldn't mind stepping out while i spoke to her. She asked if her mother could stay in the room as she was the one who was caring for her and the baby. I told her all about the ultrasound and why it would help. she blatantly refused and said she'd be fine, so I then offered her other advice.
The next day, her pain had not subsided - she was unable to sit, and had a lot of pain with walking and going to the toilet. I could sence she wanted me to do something more but she'd used the ice packs and all the advice i gave. The only thing left was the ultrasound.
I sat down and chatted to her about India and her life here. She relaxed a lot and told me how she's so homesick. That she wants to go back. She doesn't like it here and she didn't want to get married in the first place but it was good for her future as her husband was well off. I felt quite sad for this woman and her situation and tried to be as empathetic as i could. Once we'd chatted, i told her again about the ultra sound. I explained it would not hurt, that she could stop the treatment at any time and ask any questions she wanted. She agreed to the treatment - finally!
She was extremely shy I knew, so I made sure the door was shut, sign up. I also asked my supervisor to be close by incase she did not want me to treat her for some reason. I maintained her decency and dignity the whole way through the treatment. I also talked to her and explained what i was doing while the treatment was going on.
At the end of the treatment she felt a lot better. The next day, she was quite eager to have some more ultrasound as it had allowed her a better sleep etc.
Having a patient who is a bit out of the ordinary highlighted to me our cultural differences and how we have to be respectful, mindful and adapting to their beliefs, customs and cultural differences. It was a very valuable lesson for me and I think all of us as Australia is such a multicultural society and as physio's we need to be able to communicate effectively to people from all over the world.
Not Scared about Death
Recently I was involved with a an exercise class that had a couple of patients with CF. They were in their late twenties and so knew that they probably only had another five or so years left. I have been told by others that CF kids (and adults) are an amazing bunch but I guess you don't realise until you meet them. These two were so happy and friendly and enjoying every bit of life as if it was their last. They were not bitter abut their disease, however they had learnt to live with it and they were still asking me questions about how how to improve themselves even though they had been living with the disease for nearly thirty years.
The situation made me realise just how valuable life is and ungrateful some patients are. It makes you want to show these patients who have been choosing to harm themselves for years and years with smoking, drinking, drugs, ect just how to value your life.
The experience gave me a new understanding of the condition and the attitude CF sufferers have towards life.
In future I will approach a similar situation with a great deal of more knowledge and understanding about living with Cf and will also have that understanding to pass on to other less cooperative patients.
The situation made me realise just how valuable life is and ungrateful some patients are. It makes you want to show these patients who have been choosing to harm themselves for years and years with smoking, drinking, drugs, ect just how to value your life.
The experience gave me a new understanding of the condition and the attitude CF sufferers have towards life.
In future I will approach a similar situation with a great deal of more knowledge and understanding about living with Cf and will also have that understanding to pass on to other less cooperative patients.
Allodynic tendencies. Ouch!!
I am currently on a neuro outpatient placement and treated a patient last week, 1 month post-stroke. When I commenced treatment I started with SIMMS of the lats and pecs. The patient was grimacing from time-to-time whilst I performed these techniques. I asked if everything was ok?, etc, am I hurting you? She would reply that it was a bit sore, so I would reduce my contact in all aspects. She also did the same when I came to tactile stimulation of the hand. I was using various instruments which I thought would not evoke those responses. From the start of this behaviour I would encourage the patient to relax, breath deeply and slowly and while she took this advice on board she still would get slightly upset every-so-often.
I knew their wasn’t much more I could do rather than provide inadequate treatment if I couldn’t continue. She just appeared to have allodynic tendencies. What I noticed about the treatment session was that she could tolerate the techniques so that at least made me feel like I wasn’t hurting her and it was not sustainable pain, i.e. it disappeared as soon as I stopped or reduce the intensity of contact. This was an interesting experience working with this patient. Before this I had no idea what these patients would present like and how they would react to treatment they perceive generates a level of pain to themselves.
I guess every patient will be different in this regard, though you could almost assume that for rehabilitation to occur for a patient such as this we need to get our hands on them and make them feel as calm and comfortable as possible.
In the future I will perhaps get similar patients to rate their pain (0-10) if I perceive they display the same tendencies. That way I can ignore the lower levels, after briefing them regarding this, but back-off the technique on the perceived higher levels they respond with. What are some strategies that you have used in this kind of situation?
I knew their wasn’t much more I could do rather than provide inadequate treatment if I couldn’t continue. She just appeared to have allodynic tendencies. What I noticed about the treatment session was that she could tolerate the techniques so that at least made me feel like I wasn’t hurting her and it was not sustainable pain, i.e. it disappeared as soon as I stopped or reduce the intensity of contact. This was an interesting experience working with this patient. Before this I had no idea what these patients would present like and how they would react to treatment they perceive generates a level of pain to themselves.
I guess every patient will be different in this regard, though you could almost assume that for rehabilitation to occur for a patient such as this we need to get our hands on them and make them feel as calm and comfortable as possible.
In the future I will perhaps get similar patients to rate their pain (0-10) if I perceive they display the same tendencies. That way I can ignore the lower levels, after briefing them regarding this, but back-off the technique on the perceived higher levels they respond with. What are some strategies that you have used in this kind of situation?
Sulking Children
On my current paeds placement one of my roles is to run 2 groups throughout the week, one an OT/PT combined pre-primary group and another a year 1 PT group. The combined PP group usually consists of the PT doing the warm up, OT following with one of their activities, a PT obstacle course or rotating through various stations, another OT activity and then a PT game at the end like a race of some sort or dodgeball etc before a cool down.
Now with our final activity there can only be one winner in dodgeball but to cater for this so the children don’t feel as if there losers if they don’t win we usually play a few games and make sure each child wins. However, there is one child in the group who can not tolerate losing well at all. In fact whenever he loses in this dodgeball game he runs to his mum and starts crying and screaming and refuses to take part in the rest of the group.
So my supervisor and I have tried a few things to try and get around this which include always letting him win the first game of dodge so hopefully if he wins that one he wont care if he doesn’t win the latter ones. This didn’t work either, even though he had previously won a game it didn’t matter he still went off to his mum in his customary manner when he lost the second game.
We have tried playing games where there is no winner but all the other children in the group absolutely love these games at the end of the group. They all whinge and scream if we don’t play dodge, in fact one day they actually started a little chant to try and get us to play. So we spoke about this and agreed it is unfair to deprive the rest of the class of something they love that makes them feel good (as most of these kids never win anything anywhere else).
So on Friday my supervisor and I agreed to have a bit of a think about it over the weekend about another strategy we could try implement for this weeks group to try and get around this sulky child. So my idea is that im going to try and sit him down at the start of the class and try explaining to him that it isn’t possible for one person to win everything and that children need to share with each other and if you do happen to lose then sulking is no way to go about. I will then try and get his mother to reinforce this at home. Does anyone have any other ideas
Now with our final activity there can only be one winner in dodgeball but to cater for this so the children don’t feel as if there losers if they don’t win we usually play a few games and make sure each child wins. However, there is one child in the group who can not tolerate losing well at all. In fact whenever he loses in this dodgeball game he runs to his mum and starts crying and screaming and refuses to take part in the rest of the group.
So my supervisor and I have tried a few things to try and get around this which include always letting him win the first game of dodge so hopefully if he wins that one he wont care if he doesn’t win the latter ones. This didn’t work either, even though he had previously won a game it didn’t matter he still went off to his mum in his customary manner when he lost the second game.
We have tried playing games where there is no winner but all the other children in the group absolutely love these games at the end of the group. They all whinge and scream if we don’t play dodge, in fact one day they actually started a little chant to try and get us to play. So we spoke about this and agreed it is unfair to deprive the rest of the class of something they love that makes them feel good (as most of these kids never win anything anywhere else).
So on Friday my supervisor and I agreed to have a bit of a think about it over the weekend about another strategy we could try implement for this weeks group to try and get around this sulky child. So my idea is that im going to try and sit him down at the start of the class and try explaining to him that it isn’t possible for one person to win everything and that children need to share with each other and if you do happen to lose then sulking is no way to go about. I will then try and get his mother to reinforce this at home. Does anyone have any other ideas
Saturday, June 14, 2008
unfriendly staff
Sorry I haven't posted for a couple of weeks, I couldnt figure how to log back on to the site. I am slightly technologically incapable.
My previous placement was a cardio placement in a surgical ward. I had been asked to see a patient who had an operation that many patients that I had seen had had. It was a fairly straight forward procedure and patient and previously with such patients the aim had been to get the patient at least standing out of bed and ideally walking on day 1 post-op.
I spoke to his nurse and she informed me that the doctors had told her thismorning not to walk him and if i wished to do so I would need to contact them first. I could not see any reason in the notes to not walk him but I tried to get in touch with the RMO. as luck would have it the paging system was not working that day so I was unable to get in touch with them. I asked my supervisor and she looked through the notes and said she was quite happy for me to walk him if I was unable to contact the RMO.
After walking him, the nurse who I had previously talked to about him asked if I had managed to get in touch with the RMO and when I told her I hadn't, she took a very condescending tone with me adn went on to explain that it was very irresponsible of me to do so. I tried to explain that I had spoken to my supervisor and that she had said it was alright and also tried to explain the reasons we saw it to be suitable to walk him but she continued to tell me off, as a mother would tell off a child. I spoke to my supervisor and she spoke to the nurse to explain the situation adn everything got sorted out.
I learnt from this situation that if being questioned on why you have done something by a staff member other than your supervisor, giving your opinions or trying to explain why you did something is not always a great way to handle it. In future, I would think a little more abouit my response, and perhaps a simple "My supervisor gave me the OK, maybe you could talk to her about it" would be more suitable!
My previous placement was a cardio placement in a surgical ward. I had been asked to see a patient who had an operation that many patients that I had seen had had. It was a fairly straight forward procedure and patient and previously with such patients the aim had been to get the patient at least standing out of bed and ideally walking on day 1 post-op.
I spoke to his nurse and she informed me that the doctors had told her thismorning not to walk him and if i wished to do so I would need to contact them first. I could not see any reason in the notes to not walk him but I tried to get in touch with the RMO. as luck would have it the paging system was not working that day so I was unable to get in touch with them. I asked my supervisor and she looked through the notes and said she was quite happy for me to walk him if I was unable to contact the RMO.
After walking him, the nurse who I had previously talked to about him asked if I had managed to get in touch with the RMO and when I told her I hadn't, she took a very condescending tone with me adn went on to explain that it was very irresponsible of me to do so. I tried to explain that I had spoken to my supervisor and that she had said it was alright and also tried to explain the reasons we saw it to be suitable to walk him but she continued to tell me off, as a mother would tell off a child. I spoke to my supervisor and she spoke to the nurse to explain the situation adn everything got sorted out.
I learnt from this situation that if being questioned on why you have done something by a staff member other than your supervisor, giving your opinions or trying to explain why you did something is not always a great way to handle it. In future, I would think a little more abouit my response, and perhaps a simple "My supervisor gave me the OK, maybe you could talk to her about it" would be more suitable!
Thursday, June 12, 2008
Another uncooperative patient!
Hi everyone- apologies for the late entry!
This is another from my ortho in-patients prac. When my supervisor gave me a handover of this particular patient, he was described to me as a male post TKR in his late 60's, an ex-Naval officer with a tendency to be extremely stubborn, uncooperative with Rx and impulsive. At one point he walked across the gym with one crutch and began using the weight machine, even though he was never shown how to use it! I came to the conclusion early that he may be difficult to keep to task.
This patient was particularly difficult to educate in the use of his elbow crutches. When moving from STS, he constantly put the crutches on his arms, placed them out to the side and put his weight through them to stand. Each time I corrected him, he begrudgingly did as I instructed whilst muttering under his breath. He later told me that he had used crutches before, he knew what he was doing and didn't like being told what to do. I explained the reasons why he needed to use the technique I was showing him, but he was convinced he was right. The final time I saw him, he told me 'Don't treat me like a child' and refused to attend the PT gym.
Even though I had treated difficult patients before, I had never encountered a patient like this gentleman. I asked my supervisor what I should do, as I felt I had done absolutely everything I could think of. His reply was to document every detail about the Rx or attempted Rx that I had done, because if this patient had an accident, he was much more likely to blame me than himself and to take legal action against me and the hospital. Otherwise he said I had done the right thing, and there was not much more I could do as the pt was being discharged that day and all other Ax was completed.
Looking back on this, I feel that I did do everything I could to assist this patient and went to great lengths to build a rapport with him in order to make the Rx easier for both of us. However, his attitude toward me did not help. I have realised that there are some patients that are so stubborn that they will not be willing to see the physio point of view, even when their point of view is taken into consideration. In future, I think that I should spend more time in educating the pt, whether it be through demonstration or explanation, so that I know I have shown the safest way to move/ambulate etc.
Has anyone else had a patient as stubborn as this one?
This is another from my ortho in-patients prac. When my supervisor gave me a handover of this particular patient, he was described to me as a male post TKR in his late 60's, an ex-Naval officer with a tendency to be extremely stubborn, uncooperative with Rx and impulsive. At one point he walked across the gym with one crutch and began using the weight machine, even though he was never shown how to use it! I came to the conclusion early that he may be difficult to keep to task.
This patient was particularly difficult to educate in the use of his elbow crutches. When moving from STS, he constantly put the crutches on his arms, placed them out to the side and put his weight through them to stand. Each time I corrected him, he begrudgingly did as I instructed whilst muttering under his breath. He later told me that he had used crutches before, he knew what he was doing and didn't like being told what to do. I explained the reasons why he needed to use the technique I was showing him, but he was convinced he was right. The final time I saw him, he told me 'Don't treat me like a child' and refused to attend the PT gym.
Even though I had treated difficult patients before, I had never encountered a patient like this gentleman. I asked my supervisor what I should do, as I felt I had done absolutely everything I could think of. His reply was to document every detail about the Rx or attempted Rx that I had done, because if this patient had an accident, he was much more likely to blame me than himself and to take legal action against me and the hospital. Otherwise he said I had done the right thing, and there was not much more I could do as the pt was being discharged that day and all other Ax was completed.
Looking back on this, I feel that I did do everything I could to assist this patient and went to great lengths to build a rapport with him in order to make the Rx easier for both of us. However, his attitude toward me did not help. I have realised that there are some patients that are so stubborn that they will not be willing to see the physio point of view, even when their point of view is taken into consideration. In future, I think that I should spend more time in educating the pt, whether it be through demonstration or explanation, so that I know I have shown the safest way to move/ambulate etc.
Has anyone else had a patient as stubborn as this one?
Tuesday, June 10, 2008
un-cooperative patient
Recently on a prac at ICU I had a patient who was post CABG and was awaiting a bed on the ward. There is a set clinical pathway for these patients which is followed quite stricktly. As there was no ward bed avaliable, the patient stayed five days in ICU instead of the norman one day.
I was assigned to this patient and went to speak to him about his rehab once his sedation had worn off. I thought I'd explain the pathway to him and as I did he seemed to become agitated. He interupted and said that there was no way that he was getting out of bed today or tomorrow or any day and that he needed rest.
I have had this problem before with patients, I'm sure we all have, but I've never found it this difficult to motivate one. Usually some positive encouragement and distraction did the trick. I realised the first thing I needed to do was educate him on why he needs to get out of bed and the benefit it would have on his health. He was a farmer and seemed to take everything I said in - as he realised he had to get back to his old self so that he could get back to the farm. This first day I was able to get him sitting out of bed in a big recliner chair.
When I walked in the next morning he saw me and groaned "not you again!" I knew I'd have a difficult day. I started be talking to him about things that were totally unrelated - his family, hobbies, farm etc. This seemed to calm him and lower his initial anxiety. His nurse who he'd come to know quite well joined in on the conversation which livened things up some more. I had already educated him and wanted to get him up walking. He tried everything to resist, even offering me money if I would go away! I assured him that he would be fine and there would be two Physio's with him the whole time. He finally agreed to walk as long as everytime he did, he could have a cup of tea - Something we were only too willing to do after the negotiating we'd been through. As he stood up I thought to increase motivation I'd let him feel like he had more control of the situation. I explained the oxymeter and as it rested in front of him on the trolley, he read the numbers out to me as he walker. I also showed him the oxygen cylender and allowed him to put on his nasal prongs himself, that type of thing. A lot of encouragement and a cup of tea later and he was happy. Each day became easier as he realised his capabilities and the need for cups of tea diminished too. By the end of the fifth day he was walking laps of ICU and was feeling really good.
I felt this patient was challenging as I had to try lots of different techniques to increase his motivation. I think a major hindrance was the fact he was in ICU where all the other patients around him were on ventilators and he didn't have that interaction that he'd have on a ward. I think he was bored, and just needed a bit of encouragement and support to get him going again. I've also learnt that the biggest motivator seems to be belief in oneself and if we as physios can impart that belief in our patients we'd have a much easier time when it comes to rehab.
I was assigned to this patient and went to speak to him about his rehab once his sedation had worn off. I thought I'd explain the pathway to him and as I did he seemed to become agitated. He interupted and said that there was no way that he was getting out of bed today or tomorrow or any day and that he needed rest.
I have had this problem before with patients, I'm sure we all have, but I've never found it this difficult to motivate one. Usually some positive encouragement and distraction did the trick. I realised the first thing I needed to do was educate him on why he needs to get out of bed and the benefit it would have on his health. He was a farmer and seemed to take everything I said in - as he realised he had to get back to his old self so that he could get back to the farm. This first day I was able to get him sitting out of bed in a big recliner chair.
When I walked in the next morning he saw me and groaned "not you again!" I knew I'd have a difficult day. I started be talking to him about things that were totally unrelated - his family, hobbies, farm etc. This seemed to calm him and lower his initial anxiety. His nurse who he'd come to know quite well joined in on the conversation which livened things up some more. I had already educated him and wanted to get him up walking. He tried everything to resist, even offering me money if I would go away! I assured him that he would be fine and there would be two Physio's with him the whole time. He finally agreed to walk as long as everytime he did, he could have a cup of tea - Something we were only too willing to do after the negotiating we'd been through. As he stood up I thought to increase motivation I'd let him feel like he had more control of the situation. I explained the oxymeter and as it rested in front of him on the trolley, he read the numbers out to me as he walker. I also showed him the oxygen cylender and allowed him to put on his nasal prongs himself, that type of thing. A lot of encouragement and a cup of tea later and he was happy. Each day became easier as he realised his capabilities and the need for cups of tea diminished too. By the end of the fifth day he was walking laps of ICU and was feeling really good.
I felt this patient was challenging as I had to try lots of different techniques to increase his motivation. I think a major hindrance was the fact he was in ICU where all the other patients around him were on ventilators and he didn't have that interaction that he'd have on a ward. I think he was bored, and just needed a bit of encouragement and support to get him going again. I've also learnt that the biggest motivator seems to be belief in oneself and if we as physios can impart that belief in our patients we'd have a much easier time when it comes to rehab.
Monday, June 9, 2008
Liaising with the Allied Health Team
Currently while at my gerontology placement a new patient was transferred to our ward that had recently had another AKA on the same leg. Before seeing the patient for the first time for a mobility assessment I checked with the nursing staff if it was convenient for them if I assessed him in the afternoon and generally obtained some background information about the patient. The nursing staff informed me that he had been a very difficult patient over the course of the day, only wanting to stay in bed. He had not been compliant with showering, eating lunch in the dining room and wasn’t assisting the nurses with transfers when he had previously been independent before his second surgery.
Talking to the nursing staff made me realise that I may have trouble with patient compliance and I was not sure if I could persuade him to get up and out of bed. Realising that the no nonsense approach the nurses had employed had failed with this patient I decided that being more sympathetic and encouraging may have a greater effect. Consequently I didn’t have any trouble with patient compliance and was able to convince the patient that getting up and OOB was for his own benefit.
Thus I have learnt that it is very important to talk to the nursing staff or any member of the medical team as they often retain crucial information that can be invaluable or guide your patient approach.
Talking to the nursing staff made me realise that I may have trouble with patient compliance and I was not sure if I could persuade him to get up and out of bed. Realising that the no nonsense approach the nurses had employed had failed with this patient I decided that being more sympathetic and encouraging may have a greater effect. Consequently I didn’t have any trouble with patient compliance and was able to convince the patient that getting up and OOB was for his own benefit.
Thus I have learnt that it is very important to talk to the nursing staff or any member of the medical team as they often retain crucial information that can be invaluable or guide your patient approach.
On my current placement majority of my patients have chronic pain. When you are not constantly in pain it is very hard to understand what your patients are going through. Many of the patients still come in looking for a "quick fix" and unfortunately that is not possible and the most likely result is that they are probably never going to be able to live pain-free. I am finding this very hard to explain to my patients. I am also finding it very difficult to treat these patients because most of the more traditional therapies have already been tried and failed.
There is a chronic pain program currently running at my placement. It consists of a small group of patients suffering from chronic pain conditions who attend lectures, group meetings and gym sessions over a 3 week period. The program is aimed to help the patients deal with their conditions and the pain that goes with them.
I attend a lecture with the patients today, it was very interesting to listen to the patients and hear how everyday activities are so difficult for them to complete and how their pain impacts so severely on their lives. The lecture today was about "Pacing". I learnt some interesting points that will definitely help me when treating chronic pain patients in the future. They advised the patients to all keep diaries and to plan and prioritise all their activities. By doing this they can make sure they do only one heavy activity a day, schedule their breaks and generally feel in control of their lives and their pain.
I found this very interesting and will be educating any of my patients in the future who have a chronic pain condition about this. We as physiotherapists can also utilise the diary to prescribe their exercise programs. This will assist with compliancy and give the patients control over their own programs.
There is a chronic pain program currently running at my placement. It consists of a small group of patients suffering from chronic pain conditions who attend lectures, group meetings and gym sessions over a 3 week period. The program is aimed to help the patients deal with their conditions and the pain that goes with them.
I attend a lecture with the patients today, it was very interesting to listen to the patients and hear how everyday activities are so difficult for them to complete and how their pain impacts so severely on their lives. The lecture today was about "Pacing". I learnt some interesting points that will definitely help me when treating chronic pain patients in the future. They advised the patients to all keep diaries and to plan and prioritise all their activities. By doing this they can make sure they do only one heavy activity a day, schedule their breaks and generally feel in control of their lives and their pain.
I found this very interesting and will be educating any of my patients in the future who have a chronic pain condition about this. We as physiotherapists can also utilise the diary to prescribe their exercise programs. This will assist with compliancy and give the patients control over their own programs.
Learning to overcome Death
In my last placement, I was assigned to an oncology ward. One of my duties there was to hold an exercise class for the patients’ daily. Most of the patients were there for chemotherapy and were due for discharge after their treatment. What we were trying to help them do was to maintain their activity level and keep them going through exercise. I met with a particular patient and she was recovering well after her chemotherapy. Her only goal before discharge was to be able to climb a couple of steps as that was the only obstacle she had at home. Everything seemed to be going smoothly and was due for discharge but things started to change…
She started to complain of nausea and was not able to get out of bed. Her health deteriorated very quickly and was soon bed-bound. She did not even have the strength to sit up in bed for her meals. She had to be fed through an NGT. Sadly, she departed from this world within a span of one week.
I was devastated. Never did I expect life to be so fragile. Things changed too quickly. My supervisor was really helping me to face the reality of people coming and going in this particular ward. It is really sad, but we still have to go on. There are many more patients out there that require our help and we should not let our emotions get the better of us. We have to be compassionate but also strong when we face such situations.
Is life really so fragile that it can change the destiny of a patient in just a couple of days? Through this situation, I learnt to cope with patients who suffer from terminal illnesses. I learnt to prepare myself for the worse but hope for the best for the patient. I will not give up on patients that seem to be deteriorating but continue to help them feel better. But I am also aware of my limits and the amount of help I can offer to the patient.
Thus, I believe I will be able to take things in stride and move on when faced with such situations in future. I hope to be able to compose myself, accept the situation professionally and look forward to helping more patients.
She started to complain of nausea and was not able to get out of bed. Her health deteriorated very quickly and was soon bed-bound. She did not even have the strength to sit up in bed for her meals. She had to be fed through an NGT. Sadly, she departed from this world within a span of one week.
I was devastated. Never did I expect life to be so fragile. Things changed too quickly. My supervisor was really helping me to face the reality of people coming and going in this particular ward. It is really sad, but we still have to go on. There are many more patients out there that require our help and we should not let our emotions get the better of us. We have to be compassionate but also strong when we face such situations.
Is life really so fragile that it can change the destiny of a patient in just a couple of days? Through this situation, I learnt to cope with patients who suffer from terminal illnesses. I learnt to prepare myself for the worse but hope for the best for the patient. I will not give up on patients that seem to be deteriorating but continue to help them feel better. But I am also aware of my limits and the amount of help I can offer to the patient.
Thus, I believe I will be able to take things in stride and move on when faced with such situations in future. I hope to be able to compose myself, accept the situation professionally and look forward to helping more patients.
Sunday, June 8, 2008
Talking Ax and Rx allowed works!!
While on my paeds placement I have treated a large variety of different conditions in children of various ages. As you know with paeds doing a session is pretty full on as we have to take into consideration where the child is in regards to their development. So no matter what condition we are assessing we are also focusing on what the child can functionally do and then trying to picture in our heads if this is normal for his age along with the task of trying to analyse what we have found subjectively and objectively in our assessment so we can plan our treatment.
Now in my time so far I have found to incorporate doing the assessment, analysing the assessment along with assessing the childs development to be pretty full on and have found myself constantly needing pauses so i can have a chance to stop and organise my thoughts in my head and plan where to go from there. I told this to my supervisor and she suggested that I really concentrate on talking allowed my assessment to the parent of the child. So i did and for example when i was assessing a toe walker i did exactly that.
During the subjective as the mother reported things I would say ok this is normal while this is isnt etc etc.. and by saying this aloud it made the whole analysis of the childs development so much easier as I was analysing it as I went instead of having everything the mother had said in my head at once trying to organise my thoughts while she continued to tell me new things.
During the objective as I analysed tone. mm length, strength, posture, alignment etc I would explain to the mother each of my findings as I went so I would say "this ROM is normal while this is a bit lower than we expect, can you see how is knee has this sort of angle and this causes this foot position which causes this and this etc etc". Again doing this made evertyhing so much more clear in my head as I was figuring it out as I explained it to the mother.
So not only does it help me with my assessment and treatment it also helps to improve the relationship we have with the mother as according to my supervisor apparently a lot of students tend to find it a bit difficult to work with the child along with the mother and instead tend to deal entirely with the child first and then at the end of the session simply just overload the parent with everything you have found today and everything you did with the child and this leads to a reduced knowledge of the session on the mothers behalf!!!
So in conclusion talking and explainingthe assessment and treatment aloud to the parents or 3rd party while doing it works absolute wonders for the relationship you have with the parents and also to improve the flow of the session and reduce the number and length of the dreaded silent moments which we use to gather and organise our thoughts.
Now in my time so far I have found to incorporate doing the assessment, analysing the assessment along with assessing the childs development to be pretty full on and have found myself constantly needing pauses so i can have a chance to stop and organise my thoughts in my head and plan where to go from there. I told this to my supervisor and she suggested that I really concentrate on talking allowed my assessment to the parent of the child. So i did and for example when i was assessing a toe walker i did exactly that.
During the subjective as the mother reported things I would say ok this is normal while this is isnt etc etc.. and by saying this aloud it made the whole analysis of the childs development so much easier as I was analysing it as I went instead of having everything the mother had said in my head at once trying to organise my thoughts while she continued to tell me new things.
During the objective as I analysed tone. mm length, strength, posture, alignment etc I would explain to the mother each of my findings as I went so I would say "this ROM is normal while this is a bit lower than we expect, can you see how is knee has this sort of angle and this causes this foot position which causes this and this etc etc". Again doing this made evertyhing so much more clear in my head as I was figuring it out as I explained it to the mother.
So not only does it help me with my assessment and treatment it also helps to improve the relationship we have with the mother as according to my supervisor apparently a lot of students tend to find it a bit difficult to work with the child along with the mother and instead tend to deal entirely with the child first and then at the end of the session simply just overload the parent with everything you have found today and everything you did with the child and this leads to a reduced knowledge of the session on the mothers behalf!!!
So in conclusion talking and explainingthe assessment and treatment aloud to the parents or 3rd party while doing it works absolute wonders for the relationship you have with the parents and also to improve the flow of the session and reduce the number and length of the dreaded silent moments which we use to gather and organise our thoughts.
Desat
Recently I was asked to treat a patient who was admitted to hospital with an infective exacerbation of COPD (emphysema.) When I saw the patient, he had been in hospital for 4 days and his infection had cleared up. He had a non productive cough and his chest was clear. The main problem that he had was his oxygen saturation. This was maintained in the low 90's with one litre of oxygen via NP and hovered around the high 80's on RA. With ambulation the patient desaturated markedly and within 3 minutes of walking (approx 80m) his SpO2 was 79%. If I was by myself I would have not allowed his sats to drop so low however I was with my supervisor at the time so she instructed me to keep going. The patient was also getting quite frustrated as he wanted to go home and continue work and he couldn't understand why he wasn't being discharged when he felt like normal.
I was slightly anxious in allowing a patient to desat by so much and I was forced to explain to the patient why we could not let him go home with such a low oxygen saturation. I had to explain that is heart would be working far too hard with oxygen levels that low, but also had to keep in mind that he felt as though it was always that low. This made me feel uncomfortable and I could only suggest to the patient that hopefully his oxygen levels would continue to increase as his body bought the infection.
When the patient's sats dropped to 79% he only felt slightly short of breath which made me wonder how you would know if a patient was desaturating by that much if you weren't in a situation where you had an oximeter on hand.
This situation has made me realise how easy it is for a patient to desaturate after having a lung infection and I will definitely ere on the side of caution when dealing with these patients in the future.
I was slightly anxious in allowing a patient to desat by so much and I was forced to explain to the patient why we could not let him go home with such a low oxygen saturation. I had to explain that is heart would be working far too hard with oxygen levels that low, but also had to keep in mind that he felt as though it was always that low. This made me feel uncomfortable and I could only suggest to the patient that hopefully his oxygen levels would continue to increase as his body bought the infection.
When the patient's sats dropped to 79% he only felt slightly short of breath which made me wonder how you would know if a patient was desaturating by that much if you weren't in a situation where you had an oximeter on hand.
This situation has made me realise how easy it is for a patient to desaturate after having a lung infection and I will definitely ere on the side of caution when dealing with these patients in the future.
Wednesday, June 4, 2008
Distractions do work!!!
I was on an Ortho inpatient placement earlier this year, mainly treating patients who had just had major joint replacements. My patient was a lady in her 70's who just had a TKR, and had a past medical history of arthritis and 2 CABG's ~ 20 years previously. Whenever I brought her to the rehab gym, she was always very stressed and worried that the exercise she was going to do would cause her lots of pain (as she felt pain on movement in bed) but also place so much strain on her heart that she might have a heart attack. Every exercise she completed she did with her hands gripping the edge of the bed and a look of constant fear in the eyes. She also became quite aggressive in her manner towards me, and cried as she wanted to go home.
I'd tried techniques such as ice to reduce her pain and ensured she'd taken her medication prior to her treatment, but still the pain for her was massive. It finally clicked for me that it wasn't her pain, it was her anxiety throughout the treatment that was causing her problems. So, every time I treated her, I talked to her about what her hobbies were, what jobs she'd had etc. in order to distract her from her pain but also to develop a rapport with her. Much to my surprise, it worked! The more we talked to one another, the less her pain and the better quality treatment I was able to give her.
What I learnt form this is that the symptoms that the patient experiences may not necessarily be through injury or surgery, rather the personality or anxiety that the patient has. It was an eye-opener for me, and further reinforced the principle that you treat the WHOLE patient, not just the presenting complaint.
I'd tried techniques such as ice to reduce her pain and ensured she'd taken her medication prior to her treatment, but still the pain for her was massive. It finally clicked for me that it wasn't her pain, it was her anxiety throughout the treatment that was causing her problems. So, every time I treated her, I talked to her about what her hobbies were, what jobs she'd had etc. in order to distract her from her pain but also to develop a rapport with her. Much to my surprise, it worked! The more we talked to one another, the less her pain and the better quality treatment I was able to give her.
What I learnt form this is that the symptoms that the patient experiences may not necessarily be through injury or surgery, rather the personality or anxiety that the patient has. It was an eye-opener for me, and further reinforced the principle that you treat the WHOLE patient, not just the presenting complaint.
Tuesday, June 3, 2008
Don't come near me!
I am currently on my elective placement at King Edward's doing Women's Health. As I'm sure you all can imagine, this can be quite a confronting area to work in and the need to develop trust with your patients is very important as in many cases treatment involves performing ultrasound on perineums and haemorrhoids. The shock of performing such treatments subsides quite quickly as you kind of need to just get on with things however, it is not quite so easy for all patients.
Recently, one of my patients had been readmitted due to an area of hardness, perhaps a haematoma, developing around a scar that had resulted from the repair of a 3rd degree tear of her perineum. It was very uncomfortable and tender for the patient and she had been referred to the physios for ultrasound.
The first time I visited her, her boyfriend and his mother were there and she asked if I could come back later. Due to my busy schedule that day this was not an option. She then asked if it could wait until the next day and I explained it was important that the she received treatment as soon as was possible. Her visitors were happy to leave the room once I had reassured them that it wouldn't take longer than 15 minutes.
Once they had left, my patient was still very reluctant to have ultrasound. She was asking me all sorts of questions such as "Will I have to have a needle?" and "will tis be at all painful?". I realised that a large reason for her reluctance to allow me to ultrasound was that I had provided her with very little explanation of what it was that I was going to be doing and how it would help her condition. A lot of patients readily accept that the physios know what they are doing and why they are doing it, which I had gotten used to. It is surprising really, considering the intrusive nature of the treatment. This was the first patient I had come across who had needed a reasonably in-depth explanation of the reason ultrasound would help.
Once I had provided this explanation, she was a little more willing to have the treatment but continued to ask questions throughout the treatment about how long it would take for it to have an effect and still seemed a bit skeptical.
At the end of the treatment she said it felt a little better and the following day she couldn't kick her visitors out quick enough when I arrived.
This was a valuable experience for me as it has reminded me that not all patients are so trusting of health professionals and require a little more explanation than "It's Sarah the physio here, I have been told you need some ultrasound for you perineum tear. It will help!". I am happy with how I dealt with the situation in terms of being understanding of the patient's need to have more information provided and this helped me develop really good with a patient that wasn't necessarily an easy patient to develop good rapport with!
Patient and family frustration
I was on my neurology placement recently working on a stroke rehabilitation ward. One of the patients I was assigned to treat was an elderly man who had a brainstem stroke a few weeks back. He was an extremely patient patient, especially seeing it was my first day and i was a bit unsure of myself! He was my patient for the whole five weeks that I was on placement and the aim of rehab was to get him as strong as possible so that he could cope with surgery to remove some melanomas from his chest wall which was booked for five weeks time.
He did extremely well with rehab, and we built up a strong raport. I also got to know his family quite well over this time and they were present at a lot of the rehab sessions. My patient slowly improved with rehab, and he was very keen and motivated. Over the first three weeks, however, my patient started to change and become more withdrawn and 'down'.
The first time he walked was a happy day for him and his family, and for me as well. However, his progress was slow and wavering. He began to ask why he cant walk as far today as he could yesterday and why his fingers were moving more yesterday than today. He began to get frustrated during rehab sessions and give up a lot earlier than usual. He also stopped eating and his motivation decreased.
I noticed this happening quite early on and so I tried to keep the mood light and keep his spirits up during rehab. Sometimes he would cheer up quite quickly if i took some time to just sit and talk about something totally unrelated. This was easy for me to do as a student as I did not have a full patient load - I doubt it would be as easy if that was not the case. I tried to keep the sessions varied and the environment interesting - even taking him outside for rehab. I found that beginning with something that he was good at was very helpful as it showed him some positive progress that he'd made and then ending on the same note.
I felt a huge sense of empathy towards these patients as I can only imagine how frustrating it must be to go from functioning well to having such a large disability and the huge task of rehab that they face with such courage. I got advice from my supervisor throughout the time and also talked to my peers about ideas that they have. I know that many people have already experienced patient and family frustration in their prac's so I was wondering if anyone has any other strategies to deal with this type of situation.
He did extremely well with rehab, and we built up a strong raport. I also got to know his family quite well over this time and they were present at a lot of the rehab sessions. My patient slowly improved with rehab, and he was very keen and motivated. Over the first three weeks, however, my patient started to change and become more withdrawn and 'down'.
The first time he walked was a happy day for him and his family, and for me as well. However, his progress was slow and wavering. He began to ask why he cant walk as far today as he could yesterday and why his fingers were moving more yesterday than today. He began to get frustrated during rehab sessions and give up a lot earlier than usual. He also stopped eating and his motivation decreased.
I noticed this happening quite early on and so I tried to keep the mood light and keep his spirits up during rehab. Sometimes he would cheer up quite quickly if i took some time to just sit and talk about something totally unrelated. This was easy for me to do as a student as I did not have a full patient load - I doubt it would be as easy if that was not the case. I tried to keep the sessions varied and the environment interesting - even taking him outside for rehab. I found that beginning with something that he was good at was very helpful as it showed him some positive progress that he'd made and then ending on the same note.
I felt a huge sense of empathy towards these patients as I can only imagine how frustrating it must be to go from functioning well to having such a large disability and the huge task of rehab that they face with such courage. I got advice from my supervisor throughout the time and also talked to my peers about ideas that they have. I know that many people have already experienced patient and family frustration in their prac's so I was wondering if anyone has any other strategies to deal with this type of situation.
Monday, June 2, 2008
Difficult patients!!
I had a very interesting patient this last week. He was injured two years ago during his attempted murder. He was shot in the abdomen. This resulted in a severely perforated bowel and a fracture to L3. There was no neurological damage and the patient seems to physically functioning well, but there seem to be many psychological issue involved.
When the patient first arrived he did not react well to the fact that I was a student and was very unhappy about being in a cubicle alone with me. Luckily my Curtin clinical tutor was with me and this put the patient at ease. I continued with the subjective assessment and found it very difficult to get any information out of the patient. the patient seemed very vague and would not make eye contact with me. I finally made it through the subjective and on to the objective. The patient was very unhappy about me seeing him without his top on and didn't want me to touch him. I decided the best treatment for him was to learn to activate his TA and pelvic floor. Through out the teaching process the patient covered his eyes and made painful faces, but said everything was fine.
If I was not a student I think I would have chosen to get a male physiotherapist to treat this patient. Unfortunately he has now been allocated to me. Does anyone have some ideas to help in his future treatment?
When the patient first arrived he did not react well to the fact that I was a student and was very unhappy about being in a cubicle alone with me. Luckily my Curtin clinical tutor was with me and this put the patient at ease. I continued with the subjective assessment and found it very difficult to get any information out of the patient. the patient seemed very vague and would not make eye contact with me. I finally made it through the subjective and on to the objective. The patient was very unhappy about me seeing him without his top on and didn't want me to touch him. I decided the best treatment for him was to learn to activate his TA and pelvic floor. Through out the teaching process the patient covered his eyes and made painful faces, but said everything was fine.
If I was not a student I think I would have chosen to get a male physiotherapist to treat this patient. Unfortunately he has now been allocated to me. Does anyone have some ideas to help in his future treatment?
What do you say when.......
Currently, whilst on my gerontology placement I was performing a subjective assessment on a female patient that was submitted with decreased mobility resulting in concurrent falls. At my placement the aim is to orientate treatment with respect to the patient's goals. When I queried the patient as to her goals she told me that she wanted to go up. Go up where I thought. I made it plain that I didn’t understand and she clarified by stating she wanted to go to heaven. She didn’t want to live independently anymore instead she wished to move into a hostel, specifically into respite care. I initially didn’t know what to say and said something about her hopefully having plenty of time and that with physiotherapy we can ideally increase her balance so that she feels safe to go home again. Since then I have tried to encourage and motivate her and be specific about how each exercise will help her function.
I found it completely different being on a gerontology placement after a musculoskeletal placement, because you have to approach older patients with a completely different perspective. You have to consider their quality of life and previous level of function to a greater extent whereas with outpatients you assumed that a patient was functioning independently and generally enjoying life.
However my question is, how do u reply to that? Should you be encouraging and tell them that they hopefully still have many years to live (depending on the prognosis of the patient) and that they shouldn’t give up, when the patient feels they have already lived their life. Alternatively, do you just respect their wishes and let them remain in that mindset. Has anyone been in this situation before?
Clinical (In)experience
This blog concerns a past placement. It was an ortho outpatients placement and I was treating a man who complained of lateral ankle pain after a incident 6/52 previously. He had a doctor's certificate to cover him from not working and saw me 3 x a week over 3/52. During the time i was treating him I struggled to find out what was exactly wrong with this patient. His ankle was not swollen, nor was their bruising evident however he had the symptom of allodynia if I had ever seen it. Just touching his ankle sometimes would have him flinching in pain. I was open-minded about the situation, clearly lacking the clinical experience I was not about to judge him and therefore continued to treat his symptoms of pain, lack of ROM and reduced weight-bearing. When my Clinical Tutor sat in on a Rx session he told me afterwards that this patient was perhaps not being genuine to me and to himself (or words to that effect). I did not change my attitude to this patient in spite of this synopsis from the tutor.
On my last week at this placement the patient informed me that his Doctor's certificate was due to expire and he was not fit to resume his casual position of employment. My supervisor indicated to me I would need to make a decision on the said patient's request, Was he unfit for work or not? I simply wrote my objective findings and the patients' subjective complaints on the form for the Doctor. I had told my supervisor in confidence I thought their was nothing wrong with this patient's ankle to which he replied "indicate that on the form". I told him I would prefer to report my findings as above.
What would you have done in this situation now and would it be different if you were not a student? For me it may have been different if I was not a student.
On my last week at this placement the patient informed me that his Doctor's certificate was due to expire and he was not fit to resume his casual position of employment. My supervisor indicated to me I would need to make a decision on the said patient's request, Was he unfit for work or not? I simply wrote my objective findings and the patients' subjective complaints on the form for the Doctor. I had told my supervisor in confidence I thought their was nothing wrong with this patient's ankle to which he replied "indicate that on the form". I told him I would prefer to report my findings as above.
What would you have done in this situation now and would it be different if you were not a student? For me it may have been different if I was not a student.
Sunday, June 1, 2008
Unexpected subjective information
I'm on my paeds placement and was seeing a 10yr old girl with fairly severe developmental delay. When assessing these sort of patients it is very important in gaining a detailed history of the child since birth. This includes birth Hx (age, weight, complications etc...), developmental milestones, any injuries/conditions or events that have existed since birth until now.
The child attended with her mother and so I directed the subjective towards her while the child was playing. When I asked the mother about the latter question she began to tell me about how her and her child were victims of domestic violence and had previously been on the run from her ex-husband and still felt scared occasionally. On arrival I noticed how close the mother and daughter was and even when I told the daughter that she could go and play with the toys in the room while I asked the mother a few questions she was still apprehensive in leaving her mother. When I asked the mother she told me how now her daughter is still fairly scared and nervous when she meets new older males as they remind her of her father.
So after my subjective I kind of thought I would dedicate the first half of the session to getting close to the child and trying to make her feel comfortable around me. I did this by playing many games with the child and really joining in with her and making her feel safe around me. On reflection I think this was the correct thing to do based on her history as by the end of the session I believe she was a lot more confident around me and felt safe in my presence. Even though I didnt achieve as much in this initial sesssion as I usually would I booked her in for another session a week later where I plan to complete the assessment and then really get stuck into the treatment.
So what does everyone think about how I handled the situation and if anyone has been in the same situation how did they handle it.
The child attended with her mother and so I directed the subjective towards her while the child was playing. When I asked the mother about the latter question she began to tell me about how her and her child were victims of domestic violence and had previously been on the run from her ex-husband and still felt scared occasionally. On arrival I noticed how close the mother and daughter was and even when I told the daughter that she could go and play with the toys in the room while I asked the mother a few questions she was still apprehensive in leaving her mother. When I asked the mother she told me how now her daughter is still fairly scared and nervous when she meets new older males as they remind her of her father.
So after my subjective I kind of thought I would dedicate the first half of the session to getting close to the child and trying to make her feel comfortable around me. I did this by playing many games with the child and really joining in with her and making her feel safe around me. On reflection I think this was the correct thing to do based on her history as by the end of the session I believe she was a lot more confident around me and felt safe in my presence. Even though I didnt achieve as much in this initial sesssion as I usually would I booked her in for another session a week later where I plan to complete the assessment and then really get stuck into the treatment.
So what does everyone think about how I handled the situation and if anyone has been in the same situation how did they handle it.
Patient's who don't stop talking
Recently I saw a number of outpatient respiratory patients and was only given half an hour to see each of them. I managed my time well, up until my last patient of the morning. This elderly man with COPD obviously had no idea bout two way communication and his dyspnoea definately didn't curb his talking. As he walked in he asked me and my supervisor a question. He said; Three things happen on the 25th April, what are they? I replied with ANZAC day but that was all I could think of. He went on to tell me that I was correct and then to say that the other things are that the baby herring migrate from South Australia, up the WA coast line and something else about olive trees. Unfortunately he wasn't so concise though, taking about fifteen minutes to complete that story. He also went on to inform us on a lot of other subjects and share his childhood memories with us. As if we weren't enjoying his company enough, he started to serenade my supervisor which is when he started turning from a sweet old man to someone who struck us as a little creepy.
The issue that I had however, is that a thirty minute session turned into an hour long session and I struggled to get any information out of this patient at all as every time I asked him something, he turned it into another story. This was starting to anger me a little as I wanted to help this patient but needed his co-operation to do so. I tried to interrupt a few times and I even explained that we didn't have a lot of time but nothing seemed to work. Even at the end of the session, he would not stop talking. I stood up in an attempt to end the session and when that didn't work I walked to the door and opened it. To my amazement, he still didn't stop. Finally I had to tell him that I was sorry but I had to ask him to leave so I could see the other patients.
As you can see I tried many ways to communicate successfully with this patient but nothing I could do seemed to work. I am wondering if anyone else has experienced a similar situation and had any ideas for how to deal with these sort of patients in the future.
In future I think I will identify these sorts of patients earlier and take charge of the conversation with more closed questions.
The issue that I had however, is that a thirty minute session turned into an hour long session and I struggled to get any information out of this patient at all as every time I asked him something, he turned it into another story. This was starting to anger me a little as I wanted to help this patient but needed his co-operation to do so. I tried to interrupt a few times and I even explained that we didn't have a lot of time but nothing seemed to work. Even at the end of the session, he would not stop talking. I stood up in an attempt to end the session and when that didn't work I walked to the door and opened it. To my amazement, he still didn't stop. Finally I had to tell him that I was sorry but I had to ask him to leave so I could see the other patients.
As you can see I tried many ways to communicate successfully with this patient but nothing I could do seemed to work. I am wondering if anyone else has experienced a similar situation and had any ideas for how to deal with these sort of patients in the future.
In future I think I will identify these sorts of patients earlier and take charge of the conversation with more closed questions.
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