When to refer a patient on...

I've just been on my rural prac at a private practice. When working at a private practice in the country you never know what kinds of patients are going to walk through the door and you have to be prepared for anything. You also have to be prepared to know when you can not help the patient and need to refer them onto other health care professionals.

A patient came to the practice complaining of left hip pain and lower back pain. This patient was known to the physiotherapist and has a history of intravenous drug use. When assessing the patient her presentation didn't quite add up and she was in allot of pain. As a student physiotherapist I would have kept trying to assess and treat her, but my supervising physio decided to refer her to a doctor. The next morning she was rushed to the hospital in extreme pain and was diagnosed with an infection in her hip joint. After she was admitted into hospital we had no further contact with the patient.

Experience would play a huge role in deciding whether a patient needs to be referred onto another health professional. This case has really helped me understand what all our lectures mean when they say when the "presentation doesn't add up". In this case the presentation didn't add up and it was essential that we referred her onto see the doctor.

I feel that this experienced has helped gain essential knowledge to help me make these difficult decisions in the future.

Importance of time management

I am currently on my rural placement, predominantly a musculoskeletal outpatient placement. I am finding it difficult to adhere to my supervisor's time-frames allocated to subjective (5-7 mins), objective (10 mins) and notes (5 mins) for an initial assessment.

My time management is an area of weakness for me and I am very grateful to have a supervisor who will help me overcome this problem. However I tend to need lots of time to think things through or need to write things down in order come up with a problem list and treatment plan. Just slow with my clinical reasoning I guess :p I feel that these time constraints are preventing me from furthering my learning as I'm tending to rush and I fear I will miss out important assessment areas.

So far I have addressed my time management issue the usual way: by being ultra prepared for my patients, i.e. planning what special questions that need to be asked for the patient's presenting complaint, evaluating possible assessments and treatments that need to be conducted and pre writing as much of my notes as I can. I have also tried to be more directive with my questions during the subjective.

Does anyone have any handy hints for improving time management, besides what I am currently doing?

My supervisor has also instructed me to cut off my patients if they begin to discuss irrelevant information during a subjective. While I appreciate that this is required for time management with some patients whom continue to talk, I don't feel comfortable doing this routinely as I feel it may come across as unsympathetic to a patient. Should I discuss my feelings with my supervisor if the issue is raised again so he understands my point of view, or should I just keep the feedback in mind and continue to conduct my subjective, modifying the flow of conversation as appropriate for each patient?

Non-compliant pts

I have just started my neuro prac and was given a 73 year old pt to assess and treat who had bilateral foot drop. From the notes I gathered that this has been an ongoing condition for as long as both the patient and his family could remember. They simply said he has had it for what seems like forever and he simply deals with it during everyday life. Though the scary thing is this elderly man lives alone in a house and both he and his family report he has constant falls (sometimes up to 3 per day) that are due to him tripping over. They said this has been happening as long as they can remember but they seem to not worry about it.

This man has been admitted to hospital several times prior to this due to a more serious fall and throughout all the admissions there has never been a confirmed diagnosis of the cause of this bilateral foot drop. Treatment in previous admissions has included balance exercises, ambulation practice focusing on getting a high leg lift during swing phase. There has also been several attempts at moulding this man AFO's to prevent this foot drop but with no luck. The reason there has been no luck is that this mans compliance is extremely low! There has been several types of AFO's made specifically fitted for this man and all have been turned down.

The reasons that this man gives for not using them varies including too hard to don/doff, uncomfortable, annoying etc. Other PT's have tried all sorts of things to attempt to encourage more use of the AFO's including outlining the importance of them along with possible consequences if they arent worn, using the family to put across the above message and a few other things.

So during this admission they tried another sort of AFO and we taught the man how to don/doff them and even he admitted they were simply to put on/off so hopefully that has erased that problem and again have tried to push the message of how important they are in preventing him falling. At the moment while hes in hospital he seems to be pretty compliant with them saying there comfortable and he understand the importance of them and that he will use them but the PT reports that he says this every time he comes in and yet never uses them at home and she is convinced this is simply going to happen again.

Though now he has recovered from the fall and he has his AFOs and is walking well in hoispital it has come for him to be discharged. And although we wish for the best from all reports he is simply going to go home, not use them and continue having frequent falls. So i was wondering if anyone has experienced a similiar encounter and what strategies other than the standard ones they have used to try and get patients to maintain compliance when discharged.

Pts that have given up!

I have just finished my prac on a resp ward at a major hospital and in my last week working on this ward I got allocated a new pt who came in with an exacerbation of his COPD. On initial assessment I found that his chest problem wasnt actually too bad and was going to be managed quite quickly with various meds and his exacerbation would be resolved. On examination of his social history I found out that he lives with his wife who is his main carer and that he has been wheelchair bound for that past 3 years. He needs assistance from his wife or silverchain which he gets 5x/week to transfer between chairs, beds and toilets. 2/52 prior to admission the pt had a fall and suffered a fracture of one of the bones in his foot and so his foot was in a PofP. I might also mention that he is an older Italian man with a very stroong accent so communicating with him isnt the easiest.

So after the first few sessions of treating his chest it began to clear up and was no longer a problem so the priorities from a PT point of view was to ensure he was back to his pre-admission mobility levels, which involved practicing transfers to/from chairs/beds and toilets. So practicing these trasnfers involved assisting sit-stand and then stand by assist with him using a 4WW then small steps around so that he rotated 90degrees so he was in line with the wheelchair. The fact that he is deconditioned along with his fractured foot makes this transfer quite a difficult task for him.

After practicing 3 transfers he began to get a little tired and upon sitting down he started venting to me that the best thing for him was
"for the doctors to give him a needle full of something that would make him never wake up" and saying " I wish I had a gun to I could kill myself".

So as he was saying comments like this and saying how he was pointless and just a hassle to his wife and he was better off dead I kind of got stuck for words as I didn't know how to reply. So I kind of said things along the line of how he was wrong and that he could improve and still had a point in life and how his wife would never want him to die. But the fact that this man is Italian and communicating was so difficult it was hard for him to actually understand what I was saying and so it didn't really come across that well.

I'm sure that this happens quite often in hospital with pts with chronic conditions and simply want to be dead than for their life to drag out. SO I was wondering if anyone else has experienced this sort of situation and how they handled it and what sort of things they said to the patient.

Pts that have given up!

difficult kids

I've been on my peads placement for the last 3 weeks and I recently had an supivisor assesment with a child with CP. This child was seven yrs old and also had charge syndrome. This meant the child was deaf, blind and non verbal. She has an interpreter who works with her. She also doesn't like to be handled by strangers and has just started receiving growth hormone injections in her legs and thus doesn't handle anyone touching her legs.
This was my first client who I'd encountered problems with, but coupled with being nervous about the assessment, I was in for a tough time!
Initially I observer her in positions, but when I tried to test her tone and ROM in her legs she started to get very distressed. I moved to her UL's instead but still she didn't want me anywhere near her. No amount of toys or distractions could take her mind off me!
I realised that I'd need the help of the interpreter. I explained what I wanted her to do and then she tested the ROM in the childs legs whilst I measured. She was then able to get the client to move into different positions so that I could observe her movements and postures. Whilst she was doing this I tried to play as much as I could with the child to build some trust. In the end I was able to do a little treatment session with her myself.
I was unsure whether what I'd done in the session was ok seeing that I had not physically assessed her tone and ROM. It also made me realise how important the interpreter and carers are in the childs life and also how we can use their help and expertise in our treatment sessions. Once I recieved my feedback, I realised I'd done the right thing. I think me treatment would not have been very effective otherwise. I was wondering if anyone has had problems like this with clients and whether you've had to do that before or whether you employed another strategy?

motivational frustration

Whilst on my paediatric placement, i have been visiting a sixteen year old girl with CP. I've been visiting her twice weekly for the last three weeks and implimenting her exercise program as well as adding other exercises into our session.
By my second session with her I realised she would need some serious motivation to do her exercises at home. I found out that she loves watching TV, and quite often would spend all evening doing just that. She also told me that her main goal was to be able to stand at her yr 12 ball. Currently, she stands with 1xA but due to her knee flx contractures can't maintain any balance in standing. She is on a waitlist for surgery and needs to be building her strength pro op so that she doesn't lose the progress she's made thus far.
I have been asking her to do her exercises at home two times weekly and to stand in her standing frame for at least 10 mins every night whilst watching home and away. By my second week with her she had been in the frame once and hadn't done any exercises because she forgets.
I talked to my supervisor who knows her quite well, and she told me that the parents are also very relaxed about the exercises, although their main goal for her is her physio management. I realise that as a sixteen yr old girl she should be responsible, but I also think that as a parent they need to be supporting her and perhaps giving her a gentle reminder to do her exercises and standing frame. Her parents and her are aware of the importance of the exercise in order for her to reach her goals.
I've implimented some hopefully motivational techniques to help her remember:
1 - she is sent a text message reminding her to do exercises
2 - I've designed her a new exercise chart - it has her in a ball dress standing next to Loenardo Di Caprio (her ultimete partner!) and a count down of the months left until the ball. She puts stars next to each month when she does exercise at home, and if she reaches a certain number of stars in each month she will receive a reward.
I have two visits left with her and after that she will only receive a visit from the physio once monthly. I've become frustrated because I really want her to do well, but I can only do so much and I'm worried that once I leave, she won't have the support or encouragement as often an she needs. I realise that a the end of the day, I've done all that I can and that her and her family needs to start taking responsability. Anyone have any ideas of other things that may possibly help to motivate her?

Patient-Nurse Confrontation

I am currently working on a respiratory ward in a major hospital. Last week I was treating a patient and one of the things I was doing was taking them for a walk. Now the patient I was with was a private patient even though they were in a public hospital. From what I gathered it is given that if you are a private pt then they kind of get priority to the single rooms with the better views. This patient had been in 2 days and they had been in a nice single room which is whats expected.

So as I said I took this lady for a bit of a walk and we were gone probably 10 minutes and when we returned the nurses had begun moving her things from her single room into a 4 bedroom room. Now as the pt had a respiratory problem they were very short of breath on returning and so was trying to speak to the nurses about what was going on. During this period the pt was getting quite distressed as she was already short of breath from the walk and then was getting stressed out from the nurses moving her stuff and not being able to control the situation.

So I tried to reassure her that everything would get sorted out but in the mean time it was important she got control of her breathing as she was desaturating quite significantly but it didnt seem to bother her as she was more ocncerned with getting her room back.

Once she had regained control of her breathing and her saturation levels had returned to normal she begun to get quite agitated about the nurses simply moving her from room to rom without asking her. the patient begun to turn quite aggressive and turned into a mini-screaming match with the nurses. At this point I kind of started feeling a bit arkward as I didn't know whose side to support. I could see where the pt was coming from but I could also see where the nurses were coming from as they needed the room for a patient who needed to be confined.

So I chose to simply stand back and let the nurse resolve the situation with the patient. In the end the nurse kind of backed down and simply explained the siutation to the patient and in a way got on the side of the patient by saying they agree that its bad the way she was being treated and that she would do everything she could to get her a private room. So if anyone has been in the same sort of situatin could you please let me know what you did or if you have an opinion on how or what I could of done.

When thrown a curveball on prac

So at the moment I am currently doing my cardio at Charlies. So all of the patients we see are usually COPD, Pneumonia, CF or Bronchiectasis. However, there was a patient who came in a few weeks ago before I started with an exacerbation of a previous lung condition. So the doctors treated her for this using AB's and other various medications. One of the medications that they gave this patient has the potential side effect of causing peripheral vasoconstriction which can lead onto peripheral ischaemia.

Since there is no way you can test to see if a patient is at high risk of developing this possible complication then the doctors kind of have to wait and see how they respond. It so happens this patient did develop this complication and developed ischaemia of both hands and feet. Now the only option for them is to have their limbs amputated. So recently the patient has progressed and now the pulmonary condition they came in for has completed gone but now the patient is in hospital awaiting bilateral feet and hand amputations.

Now this has been an issue as since we are working on a cardio ward we are having to treat this patient who doesn't have a pulmonary condition as due to the politics within a hospital no other ward is willing to accept her and so she is remaining on our ward until this resolves. So each day I am having to spend upto half an hour treating this patient doing muscle strenghtening and ROM exercises when I am meant to be completing my cardio placement.

I dont mind all that much that I have to do this but aside from getting a bit of an insight into the politics of the public health system in Perth my supervisor has made me realise that no matter where we end up working once we graduate you cant simply forget everything you have learnt in other areas just because you are working in a different area. One of the abilities of a PT is that we have learnt so much in so many different areas over the last 4 years that we are able to treat patients no matter what they present with or where they present, we have the ability to draw on all of our knowledge from all areas to treat a patient effectively.