In pt Rx utilising the pts HEP

My placement at the moment is cardio at Charlies and the other day I was assessing and treating a newly admitted patient who had an exacerbation of Bronchiectasis. So i completed my subjective and objective thoroughly before heading out to speak to my supervisor. During the subjective I went into great detail about the pts home program of secretion clearance as apparently all Bronchiectatic pts have a very thorough and detailed home program aimed at clearing secretions independently on a daily basis in a bid to prevent exacerbations and infections and ultimately keep them out of hospitals.

The pt explained to me about the time, positions, duration and other activities she does during this program. She reported she had a neb half hr prior, then completed 10minutes in each sidelying plus percussions as she felt fit at 2pm each afternoon. She completed ACBT's in these positions. During my discussion with my supervisor we were discussing problem lists and treatment options for this lady and since one of her [problems was impaired airway clearance then an obvious treatment was ACBT's to clear secretions heard on auscultation.

So when i returned to the patient to complete the airway clearance techniques I suggested using the tilting of the bed to adopt a head down tilt position to optimise the use of gravity to assist drainage. However, the pt was very apprehensive of this as she has been doing her home program for years now and does not like changing it one bit. I tried explaining to her the advantages of using the head down positions but she did not want to give in and refused to change her program.

So to avoid a confrontation I gave in and simply assisted her through her program as she does at home. Upon completion I was speaking to my supervisor and she was telling me how a lot of these sort of patients can sometimes be pretty stubborn as they have dealt with their condition for years and feel they can handle it independently. So when they come into hospital and there are nurses and doctors doing a million things do them they can get a bit apprehensive towards other people that try and change something of theirs which they feel they can do thoroughly on their own. So they kind of feel its the only way they can keep their independence!

So when visiting her next day I sat down prior to treatment and revisited the benefits of the different positions and told her that this is simply an extension to her program and that its not me changing her program because she cant do it successfully anymore (which she saw it as). SHe took this fairly well and that session went smoothly and produced possibly a bit more sputum than normal which was good as she sore immediate effects. So from there she can incorporate that into her HEP and can maintain her independence.

Listen to what your body is telling you!

My most recent placement was a women's health placement which meant I was lucky enough to view a birth. This was an experience I was very excited about from the beginning of the placement and each day I would journey up to labour and birthing area to write down my pager number and hope to hear from them during the day. After missing a couple of births by a minute or two, when sent a page asking me to come to the birthing suite I raced down in order to not miss this experience again. I was introduced to the couple in the room by the midwife and was asked to stand or sit somewhere in the room where I could see what was going on but wouldn't be in the way. The patient had had an epidural and was pushing with the help of the midwife who was giving her any sensory feedback she could via pressure on the perineum. After racing to get to the room I had suddenly stopped and began to feel a little dizzy but I was so determined not to miss the birth that I thought I coulkd overcome this by concentrating on my breathing and trying to encourage venous return with ankle pumps and toe wiggling. Unfortunately none of this worked and before I knew it I found myself lying on the floor with a very sore head and an unfamiliar voice talking to me trying to wake me up. Yes...that's right, embarrassignly I had passed out in a room while a poor woman was going through arguably the most pain she would ever have to endure. I felt terrible for causing such a fuss on a day that was so important for this couple and couldn't stand the fact that between contractions she was asking me how my head was feeling!
There are many situations that may be similar to this that we come across as students and further down the line in our career where we are confronted with images or situations which make us feel a little unwell. I learnt from this situation it is important to listen to what your body is saying rather than pushing through the symptoms for selfish reasons, such as furthering our knowledge. More opportunities will arise and this is important to keep in mind when assessing how far you are willing to go to experience something amazing such as viewing a birth or a surgery.

The help of a translator

My first placement of the year was a musculoskeletal placement. I encountered patients from many different backgrounds, one of these being a lady who spoke very little English. The reason for her appointments was rehabilitation for her ankle which she had broken and she seemed to be progressing quite well, however her main complaint each time she visited me was of a sore back. As she was a public patient and refered to us for her ankle her back was not something we were supposed to be treating unless it was related to her ankle but all things that it seemed may be causing the back pain if it was as a result of her ankle, such as incorrect use of her crutches or longs periods of uneven weight distribution through both feet, had been rectified and advice given. the pain still did not cease. I was finding it difficult to take a proper subjective of her back pain, especially finding out aggravating activities and if the advice we had given had made any difference.
One day the lady brought her daughter in to sit in on the appointment and help with anything that she did not undertstand. We spent the entire hour appointment talking and a lot was revealed. It turned out that the lady had been continuing to do all of the housework and not letting her children help despite having difficulty getting into comfortable positions to do the work due to her ankle. She told me it was always after doing the housework that she found the pain was at its worst. I provided education on the need for active rest even though it was a few months post-surgery and the need for her to allow her children to help her with any duties she was having troulbe with or were aggravating her back.
Having the daughter come in to translate (and provide a little background information!) saved a lot of time in treating a problem that could have been fixed by eliminating or reducing some activities from her day. To begin with I felt bad that this lady had not received any hands on treatment from me and that the entire session had been spent talking, but then i realised the lady left appearing more happy and confident than she had from any of the previous treatment sessions.
This experience made me realise that many patients may not realise that an activity they are doing is doing them any harm, or aggravating an injury and therefore may not ever raise the issue witht hte therapist. It highlighted for me that in future a very thorough subjective assessment should always be performed, especially if one has already been taken and the cause of the problem does not seem to have been revealed.
It also made me think about the value of a translator. Although they are not available in all cases, I felt as though in this case it may have been very difficult to have ever ascertained the cause of the back pain without one.