Many of our fellow students have told me stories about their dealings with other health care professionals, in particular the arrogance and condescending attitudes of those in the medical profession. Granted, not all doctors are like this (the doctors on my current prac are marvellous), but it reminded me of the dealings I had with one particular doctor a few months ago.
I was on a general surgical ward for my cardio placement and was sent to another ward to see a patient with pneumonia. I had tried to see this lady for 3 days but to no avail as she had gone for dialysis twice and for a biopsy the other day. This time I was determined! I spoke with one of the doctors treating her prior to starting my Rx as they had tried to put a cannula in her foot, and I had planned to ambulate her. The doctor informed me it was fine, and they were finished with her so I could go ahead. About 10 minutes into my treatment, another doctor came in, demanding that I stop my treatment so he could try re-inserting the cannula. I firmly but politely said to him that I was in the middle of treatment and that I would be finished shortly. The doctor persisted, basically saying that his treatment was more important than what I was doing so I had to get out of the way. My reply was that I had been trying to see this lady for 3 days, and that the condition her chest was in was so bad that if I did not intervene, there was a high chance her condition would deteriorate. I also stated that if the doctor would give me 10 more minutes to try some breathing exercises and ambulation, then she was free for his procedure. Much to my surprise, he left me to it, and I was able to complete an effective treatment for my patient. At no point was I rude or condescending to him, I just stated my case.
What I learnt from this experience is that whether as students or new grad physiotherapists, we should not allow ourselves to be intimidated into giving up our treatment time just because someone else is rude enough to barge in and expect us to get out of the way. If the patient is booked for a procedure (e.g. CT scan, dialysis, surgical procedure) then by all means that comes first. However in situations such as these, we have every right to stand up for ourselves.
Monday, September 29, 2008
Treating the Bereaved
I am currently on my rural prac where I’ve been seeing patients on an aged care rehab ward. One of my patients was admitted to the ward with lumbar, sacral and rib fractures following a fall at home. These fractures are stable, and my treatment thus far has been mobilising her around the ward with a WZF. As I have been treating her, she has started to tell me bits and pieces about what happened the night of her fall, but also the weeks leading up to it. To cut a long story short, her husband of 62 years had passed away 8 weeks before her fall, and she had cared for him for 3 years before he died. She also said she hadn’t been taking care of herself and wasn’t eating enough because she felt so lonely and grief stricken. She has cried during several Rx sessions with me, and has stated she wishes she’d ‘died with her husband.’ During the Rx session, I’ve asked her about how she had been coping with her loss and about her husband (only if she felt comfortable with it) because I felt that if she could talk about her loss, then maybe it may alleviate some of her pain, but also assist in her compliance with PT Rx.
My concern now is that she has become reliant on me to talk about what has happened, but also she has been asking me advice on issues that I don’t feel qualified about. Her doctors have asked her about taking antidepressants, which she has refused, but she almost constantly asks me whether or not she can be forced into taking them. My reply is always that she should discuss it with her doctor, but she keeps asking me as she says she isn’t comfortable speaking to him.
My current plan for this situation is to speak to my supervisor to see how I could change my tack with the patient without hurting her feelings, and asking whether a referral to a counsellor/ clinical psychologist would be beneficial (mainly to find someone who is qualified and can give her appropriate advice). I also plan on speaking to her doctor about what the patient has been telling me.
I feel as though I’ve bitten off more than I can chew here, as I didn’t expect that my input to her would mean as much as I thought. Has anyone else dealt with a situation like this before?
My concern now is that she has become reliant on me to talk about what has happened, but also she has been asking me advice on issues that I don’t feel qualified about. Her doctors have asked her about taking antidepressants, which she has refused, but she almost constantly asks me whether or not she can be forced into taking them. My reply is always that she should discuss it with her doctor, but she keeps asking me as she says she isn’t comfortable speaking to him.
My current plan for this situation is to speak to my supervisor to see how I could change my tack with the patient without hurting her feelings, and asking whether a referral to a counsellor/ clinical psychologist would be beneficial (mainly to find someone who is qualified and can give her appropriate advice). I also plan on speaking to her doctor about what the patient has been telling me.
I feel as though I’ve bitten off more than I can chew here, as I didn’t expect that my input to her would mean as much as I thought. Has anyone else dealt with a situation like this before?
This blog concerns my orthopaedic prac. The pt involved had a nail inserted into her femur roughly 12/12. The ORIF caused an infection and progressively her pain increased to the point where she was on the strongest pain control able to be tolerated. Of course her body developed tolerance to the analgesia’s and started having no effect on her pain level (or very minimal). The pt had to undergo a 2nd operation and have a bone graft and the nail removed from her femur.
I saw her day 1 post-op this operation. She was reluctant to mobilise as any movement caused her immense pain from the looks of it. She had pain cover prior to PT but the effects as I had mentioned her minimal. Myself and my supervisor managed to convince her that she needed to move today and she attempted to reluctantly. On starting to move from supine to SOEOB she started sobbing uncontrollably and then preceded to cry.
I was taken aback, my supervisor tried to encourage the pt and make her stand up. I had mixed feelings about the pt’s response. I was questioning whether she was being ‘brave’ or ‘dramatic’. My supervisor and I discussed later what had occurred and she gave me some advice on how to manage this patient.
After that experience i was keen to learn about tolerance to pain medication. I saw her subsequently by myself for the next 4 days sometimes x2 daily, iIam happy to say she improved dramatically though would still be in a lot of obvious pain at time. I educated her alot regarding her pain and tried to enforce what we were doing was not harmful and she would benefit from this intervention in the long term. Her trust in me developed and she made progress with each session. I gained alot by working with her and the experience helped me understand from a pt’s perspective the concepts of pain and pain cover. In addition and equally important I found that we as physio’s can really influence our patient’s through education and developing a good rapport with them. If you do this successfully they will trust your judgement and will feel more empowered with each gain they make per session.
I saw her day 1 post-op this operation. She was reluctant to mobilise as any movement caused her immense pain from the looks of it. She had pain cover prior to PT but the effects as I had mentioned her minimal. Myself and my supervisor managed to convince her that she needed to move today and she attempted to reluctantly. On starting to move from supine to SOEOB she started sobbing uncontrollably and then preceded to cry.
I was taken aback, my supervisor tried to encourage the pt and make her stand up. I had mixed feelings about the pt’s response. I was questioning whether she was being ‘brave’ or ‘dramatic’. My supervisor and I discussed later what had occurred and she gave me some advice on how to manage this patient.
After that experience i was keen to learn about tolerance to pain medication. I saw her subsequently by myself for the next 4 days sometimes x2 daily, iIam happy to say she improved dramatically though would still be in a lot of obvious pain at time. I educated her alot regarding her pain and tried to enforce what we were doing was not harmful and she would benefit from this intervention in the long term. Her trust in me developed and she made progress with each session. I gained alot by working with her and the experience helped me understand from a pt’s perspective the concepts of pain and pain cover. In addition and equally important I found that we as physio’s can really influence our patient’s through education and developing a good rapport with them. If you do this successfully they will trust your judgement and will feel more empowered with each gain they make per session.
Monday, September 22, 2008
full on family
Recently, while on my musculoskeletal placement, I was treating a woman who had cervicogenic headaches. I met her in the waiting room for the first time and her husband was with her. I hadn't had a family member attend with a patient in the outpatient clinic before but I didn't think it would be an issue, so I didn't object when he accompanied us in to the cubicle.
From the first minute of the subjective assessment I could tellk that he was quite imposing. As I asked questions, his wife would begin to answer and then he would interupt and answer it instead. He would use comments such as 'what she means is...' or 'what she is trying to say is...' His wife was not of another background or spoke another language, she was Australian, understood me perfectly well and was very capable of answering the questions herself, she just didn't get a chance. I got very frustrated and was so surprised that this man was treating his wife in this way and that she was letting him get away with it. During the objective assessement of her Cx AROM, her husband said "you don't need to test that, she can move her neck perfectly fine, that's not her problem". I was frustrated but also felt confronted by him. I explained that I had to do a full assessment of her neck so that I can work out what may be causing the headaches. As I went through the assessment from then on I was very careful in explaining exactly what I was doing and why. Her husband was still quite pushy during the rest of the assessment and treatment but I felt that becuase I had allowed it to become an issue I couldn't just ask him to leave the cubicle.
The next time I saw the patient, her husband was there with her again. I asked him if he would not mind waiting in the waiting room and he didn't look pleased. I explained that it would be a more effective treatment if I was able to treat his wife alone as we would be able to focus solely on her neck problem, and that I would fill him on on how it went after the treatment session.
Whilst in the cubicle, his wife was much more talketive and seemed to 'come out of her shell' - I was able to do a much better session as she was a lot more relaxed and also was able to gain a much clearer picture of her headaches than I had at the previous session.
This taught me that if an issue arises, to deal with it straight away. I've had family attend while I've treated patients before in other settings and it hasn't been a problem but in this case it was. I've also learnt that communication is the key! Her husband was quite happy to sit and wait after I had explained to him why.
From the first minute of the subjective assessment I could tellk that he was quite imposing. As I asked questions, his wife would begin to answer and then he would interupt and answer it instead. He would use comments such as 'what she means is...' or 'what she is trying to say is...' His wife was not of another background or spoke another language, she was Australian, understood me perfectly well and was very capable of answering the questions herself, she just didn't get a chance. I got very frustrated and was so surprised that this man was treating his wife in this way and that she was letting him get away with it. During the objective assessement of her Cx AROM, her husband said "you don't need to test that, she can move her neck perfectly fine, that's not her problem". I was frustrated but also felt confronted by him. I explained that I had to do a full assessment of her neck so that I can work out what may be causing the headaches. As I went through the assessment from then on I was very careful in explaining exactly what I was doing and why. Her husband was still quite pushy during the rest of the assessment and treatment but I felt that becuase I had allowed it to become an issue I couldn't just ask him to leave the cubicle.
The next time I saw the patient, her husband was there with her again. I asked him if he would not mind waiting in the waiting room and he didn't look pleased. I explained that it would be a more effective treatment if I was able to treat his wife alone as we would be able to focus solely on her neck problem, and that I would fill him on on how it went after the treatment session.
Whilst in the cubicle, his wife was much more talketive and seemed to 'come out of her shell' - I was able to do a much better session as she was a lot more relaxed and also was able to gain a much clearer picture of her headaches than I had at the previous session.
This taught me that if an issue arises, to deal with it straight away. I've had family attend while I've treated patients before in other settings and it hasn't been a problem but in this case it was. I've also learnt that communication is the key! Her husband was quite happy to sit and wait after I had explained to him why.
Cognitive deficit, part II
This blog refers to the same patient as in "Cognitive Impairment, Part I".
Another issue I faced with the stroke patient with cognitive impariments was managing his wife's attendance and contribution to treatment sessions. I had taken note of the fact that social work had reported in the notes that the patient's wife had been particularly distressed by her husband's current condition. I felt it would be nice for her to feel included in the treatment sessions to see the tasks he was performing well with and also to see the areas in which he was improving. She was appreciative of the invitation to attend the physio sessions and it became part of her daily routine to join us.
This did not pose too much of a problem to begin with. When I started to attempt to get my patient to perform more abstract tasks such as weight shift, however, his wife would want to try to explain the task to her husband when he wasn't responding to my instructions. Although occasionally her instructions did gain a better response than mine, for the most part this became a big distraction for my patient and caused more confusion.
Eventually, during a treatment session with my patient I had to explain to his wife that it was taking all of his concentration to maintain focus on me and what I am asking him to do, and that although sometimes her explanations helped it then took some time to get his concentration back to me. She seemed a little hurt by this to begin with but I spoke to her once I had finished treatment and she said she understood and thought it was very reasonable.
In the future, if such a situation arose I would rectify the issue as soon as it became an issue, rather than waiting until the middle of a treatment session which is already a rather stressful situation. Or otherwise mention it to begin with when inviting the family member to the physio session.
Another issue I faced with the stroke patient with cognitive impariments was managing his wife's attendance and contribution to treatment sessions. I had taken note of the fact that social work had reported in the notes that the patient's wife had been particularly distressed by her husband's current condition. I felt it would be nice for her to feel included in the treatment sessions to see the tasks he was performing well with and also to see the areas in which he was improving. She was appreciative of the invitation to attend the physio sessions and it became part of her daily routine to join us.
This did not pose too much of a problem to begin with. When I started to attempt to get my patient to perform more abstract tasks such as weight shift, however, his wife would want to try to explain the task to her husband when he wasn't responding to my instructions. Although occasionally her instructions did gain a better response than mine, for the most part this became a big distraction for my patient and caused more confusion.
Eventually, during a treatment session with my patient I had to explain to his wife that it was taking all of his concentration to maintain focus on me and what I am asking him to do, and that although sometimes her explanations helped it then took some time to get his concentration back to me. She seemed a little hurt by this to begin with but I spoke to her once I had finished treatment and she said she understood and thought it was very reasonable.
In the future, if such a situation arose I would rectify the issue as soon as it became an issue, rather than waiting until the middle of a treatment session which is already a rather stressful situation. Or otherwise mention it to begin with when inviting the family member to the physio session.
Cognitive deficit, part I
Earlier on this semester I had a patient on my neuro placement who had had a stroke which affected his cognitive function. He displayed ideational apraxia, decreased concentration, (L) side neglect, perseveration with complex tasks and tasks that had been explained in an abstract way and many other behavious that made treatment a bit of a challenge. He was also regularly not orientated to person, place or time, although as the days went by he started to remember that I was a "very well trained physiotherapist"! (His words, not mine!)
The initial sessions with him were a bit of a disaster due to my lack of experience with such a patient. I had no idea how to communicate to him what I wanted him to do without causing him a huge amount of confusion.What seemed a simple idea to me was actually abstract and complicated for him. What would have been perfectly reasonable to expect from any other of my patient's was cognitively too high level for him. Due to this difficulty with communication he appeared to be a 2 moderate to maximum assist for STS, T/Fs and bed mobility and ambulating was out of the question.
After discussing the difficulty I was having with him with my supervisor, it was suggested to me to make every activity with him a functional one with a purpose and all instructions short and concise. For example, when explaining to him I wanted him to move from the wheelchair to the plinth, instead of giving a longwinded explanation about how I wanted him to do so, I would simply tell him to move from the chair to the bed. I would watch to see what he could do and if he started to have difficulty I would break the task down but explain only one part at a time, allow him to perform that, then explain the next part of the task.
To my astonishment, this patientwas actually quite capable to performing most tasks with stand by assistance or 1 minimal assistance. Ambulating was a two person job due to his tendency to push to the left but otherwise he had the strength and (most of) the coordination required to walk about 100m.
The experience with this patient was invaluable to me. I feel like it is something that an explanation can be helpful but nothing helps as much as experiencing it first hand and seeing how changing your communication slightly can make the biggest difference. I feel as though due to this experience I am now more well-equipped to deal with patients with cognitive deficits and it be a more enjoyable and rewarding experience in the future.
This also showed me the importance of not being afraid to ask questions in difficult scenarios!
The initial sessions with him were a bit of a disaster due to my lack of experience with such a patient. I had no idea how to communicate to him what I wanted him to do without causing him a huge amount of confusion.What seemed a simple idea to me was actually abstract and complicated for him. What would have been perfectly reasonable to expect from any other of my patient's was cognitively too high level for him. Due to this difficulty with communication he appeared to be a 2 moderate to maximum assist for STS, T/Fs and bed mobility and ambulating was out of the question.
After discussing the difficulty I was having with him with my supervisor, it was suggested to me to make every activity with him a functional one with a purpose and all instructions short and concise. For example, when explaining to him I wanted him to move from the wheelchair to the plinth, instead of giving a longwinded explanation about how I wanted him to do so, I would simply tell him to move from the chair to the bed. I would watch to see what he could do and if he started to have difficulty I would break the task down but explain only one part at a time, allow him to perform that, then explain the next part of the task.
To my astonishment, this patientwas actually quite capable to performing most tasks with stand by assistance or 1 minimal assistance. Ambulating was a two person job due to his tendency to push to the left but otherwise he had the strength and (most of) the coordination required to walk about 100m.
The experience with this patient was invaluable to me. I feel like it is something that an explanation can be helpful but nothing helps as much as experiencing it first hand and seeing how changing your communication slightly can make the biggest difference. I feel as though due to this experience I am now more well-equipped to deal with patients with cognitive deficits and it be a more enjoyable and rewarding experience in the future.
This also showed me the importance of not being afraid to ask questions in difficult scenarios!
Wednesday, September 17, 2008
Angry Oldies
I was recently asked to assess a very old man who had been admitted to the ward with an exacerbation of his COPD. He also had a background of cardiac conditions. When I approached the patient he was resting in bed and was originally quite happy to have a chat with me. However, as the subjective Ax progressed the patient became increasingly frustrated. I finally convinced him to ambulate with me and he managed about 10m with his W.S before he turned around and headed back to his room. When I asked him why he had turned around he snapped at me and said "here, why don't you try walking for me." I know, it didn't really make sense but as the patient was obviously quite angry I decided to leave him alone until the next day.
When I walked into the patients room the next day he said "oh not this bl**** sh** again." As the patient was lying in bed again I decided there was no way I was going to let him push me away so easily. So I asked him why he didn't want me to help him. I think that stumped him and he realised that I was truly only trying to help. He then stated that he felt ill and wanted to rest. When I asked him why he felt ill he calmly replied that he had a crushing central chest pain that he had never had before. I then alerted the NS and the appropriate management was initiated.
This made me realise that you really can't afford to let patients dictate the way they want to be treated and when they want to be treated. Being in hospital is not an enjoyable time and I think they just have to realise that they are there to get better and its our job to do that, no matter how annoying.
In future I won't be easily persuaded to leave a patient and just treat them later. Although this might help build a better rapport, it may not be giving that patient the most optimal treatment.
What do you think?
When I walked into the patients room the next day he said "oh not this bl**** sh** again." As the patient was lying in bed again I decided there was no way I was going to let him push me away so easily. So I asked him why he didn't want me to help him. I think that stumped him and he realised that I was truly only trying to help. He then stated that he felt ill and wanted to rest. When I asked him why he felt ill he calmly replied that he had a crushing central chest pain that he had never had before. I then alerted the NS and the appropriate management was initiated.
This made me realise that you really can't afford to let patients dictate the way they want to be treated and when they want to be treated. Being in hospital is not an enjoyable time and I think they just have to realise that they are there to get better and its our job to do that, no matter how annoying.
In future I won't be easily persuaded to leave a patient and just treat them later. Although this might help build a better rapport, it may not be giving that patient the most optimal treatment.
What do you think?
Fibromyalgia
During my last placement I was referred a ?fibromyalgia patient from a rheumatologist. The referral just asked me provide the patient with a gentle exercise program. I wasn't 100% sure what to expect when the patient walked through the door and to my surprise it was one of the nursing assistants from the hospital. The patient seemed perfectly healthy and it wasn't until I questioned her further that I found she was anything but. She complained of pain and weakness all throughout her lower limbs and stated that she had recently had 3 weeks off work as she just couldn't walk around anymore. She told me that her rheumatolgist had prescribed her with NSAIDS which enabled her to walk again but by the end of her working day she just collapses and finds it too hard to walk around anymore.
On objective exam the patient was found to be TOP all through her LL's and to have reduced muscle strength throughout. Everything else was normal including neural testing. I was unsure of what I could do for the patient because if I gave her a strengthening program I feared it would impede her ability to work. Therefore I suggested some light exercise in a hydrotherapy pool and she agreed that this sounded like a good idea. I told her to try it every 2-3 days and then come and see me again in 2/52 to monitor her progress.
The situation made me feel helpless in a way as there was nothing we learnt at uni that could help this type of patient and I don't even know if there is anything to help.
Does anybody else have any suggestions or experiences with such a patient that they could share with me?
Depending on how she responds to this treatment I think I would take a similar course in future.
On objective exam the patient was found to be TOP all through her LL's and to have reduced muscle strength throughout. Everything else was normal including neural testing. I was unsure of what I could do for the patient because if I gave her a strengthening program I feared it would impede her ability to work. Therefore I suggested some light exercise in a hydrotherapy pool and she agreed that this sounded like a good idea. I told her to try it every 2-3 days and then come and see me again in 2/52 to monitor her progress.
The situation made me feel helpless in a way as there was nothing we learnt at uni that could help this type of patient and I don't even know if there is anything to help.
Does anybody else have any suggestions or experiences with such a patient that they could share with me?
Depending on how she responds to this treatment I think I would take a similar course in future.
Tuesday, September 16, 2008
Liaising with OTs
On my last placement I was referred a patient from an OT working in the hospital close by to our department. The patient was an athlete and was working towards returning to his sport for a tournament, thus I organised to see him more regularly than my other patients to give him the best chance. The patient also required telehealth conferences to allow specialists in Perth to review the progress of his treatment. Initially the OT sent an email to my supervisor, which I was asked to read, regarding a telehealth conference and told my supervisor that she thought this patient shouldn't be seen by a student but by a qualified physiotherapist, my supervisor disagreed and I continued to treat the patient.
As I proceeded to treat the patient he told me that the OT was upset that my supervisor was trying to limit the time I spent with him and that the OT overall didn't like my supervisor and his patient approach. At the time I highlighted the fact that I wished not to get involved into the politics of the staff and that I wished not to be involved in their dispute. I continued to reinforce the OTs advice and HEP options which were on par with mine and a couple of times tried to find the OT to discuss the patient yet didn't have much success.
I was told by my supervisor that I was being too conservative with the patient, and adjusted as appropriate producing adverse effects. The patient then informed me that the OT was displeased at this and had discussed it with my supervisor. The OT then discussed the issue with me and we agreed on the treatment approach. I discussed this with my supervisor and the situation was resolved. Sometime later I was pulled aside by my supervisor who informed me that he was told by another physiotherapist that I "didn't like" the OT. To which I informed him that I didn't know the OT well enough to come to that decision and that I hadn't said anything of the sort to the patient or any other staff. I also discussed organising a time to talk to the OT to state that they had been misinformed, yet my supervisor thought the situation was best left as it was.
Through interaction with all parties involved, the impression I received was that the OT was displeased with my treatment and that my supervisor and the OT didn't hold each-other in high esteem. I realise this may have made me feel inadequate and slightly intimidated by the OT. Thus as I reflect on the situation I think my views for each member of staff involved and the entire situation may have been portrayed non-verbally or through my verbal expression to the patient. Thus contributing to the feedback that was portrayed back to the OT.
In the future I believe that the OT and I should have taken the time to discuss any issues that arose to a further extent with each other instead of obtaining information through the patient. I think I should have been more vigilant with organising meetings with the OT and firmly told the patient that I have great respect and approval for the work of all members of our AHT. I should also have been more conscious of my non-verbal, to prevent the patient from misinterpreting my point of view. When I was asked to provide feedback for the hospital at my final assessment, I informed my supervisor that multidisciplinary meetings may work well and help to prevent any further incidences between staff, to which they replied it was an issue currently being reviewed.
Has anyone had a similar confrontation with another staff member and come up with good strategies?
As I proceeded to treat the patient he told me that the OT was upset that my supervisor was trying to limit the time I spent with him and that the OT overall didn't like my supervisor and his patient approach. At the time I highlighted the fact that I wished not to get involved into the politics of the staff and that I wished not to be involved in their dispute. I continued to reinforce the OTs advice and HEP options which were on par with mine and a couple of times tried to find the OT to discuss the patient yet didn't have much success.
I was told by my supervisor that I was being too conservative with the patient, and adjusted as appropriate producing adverse effects. The patient then informed me that the OT was displeased at this and had discussed it with my supervisor. The OT then discussed the issue with me and we agreed on the treatment approach. I discussed this with my supervisor and the situation was resolved. Sometime later I was pulled aside by my supervisor who informed me that he was told by another physiotherapist that I "didn't like" the OT. To which I informed him that I didn't know the OT well enough to come to that decision and that I hadn't said anything of the sort to the patient or any other staff. I also discussed organising a time to talk to the OT to state that they had been misinformed, yet my supervisor thought the situation was best left as it was.
Through interaction with all parties involved, the impression I received was that the OT was displeased with my treatment and that my supervisor and the OT didn't hold each-other in high esteem. I realise this may have made me feel inadequate and slightly intimidated by the OT. Thus as I reflect on the situation I think my views for each member of staff involved and the entire situation may have been portrayed non-verbally or through my verbal expression to the patient. Thus contributing to the feedback that was portrayed back to the OT.
In the future I believe that the OT and I should have taken the time to discuss any issues that arose to a further extent with each other instead of obtaining information through the patient. I think I should have been more vigilant with organising meetings with the OT and firmly told the patient that I have great respect and approval for the work of all members of our AHT. I should also have been more conscious of my non-verbal, to prevent the patient from misinterpreting my point of view. When I was asked to provide feedback for the hospital at my final assessment, I informed my supervisor that multidisciplinary meetings may work well and help to prevent any further incidences between staff, to which they replied it was an issue currently being reviewed.
Has anyone had a similar confrontation with another staff member and come up with good strategies?
Monday, September 15, 2008
Patients That Dont Listen
I have just finished my neuro prac and in my final week I had a patient who had just recently had a stroke. Now the patient initially had grade 1 muscle strength globally down one lower limb and grade 2s in his upper limb. Now over the next few days recvoery began to occur quite rapidly in his arm and within 3-4 days it was pretty much back to grade 5 msucle strength. Now since his staic and dynamic sitting balance was perfect our goal of treatment was to fascilitate standing balance and eventually get him back to walking.
Now we began working on his static standing balance using a wheeled zimmer frame for him to hold onto. He was balancing ok in this position but when we tried to correct alignment so to make him have even weightbearing you could see that as we put him more across to his hemi side the more weight he put through his arms. So to finish this sesion we tried to do little weight shift exercises to get him taking small steps on the spot. Doing this exercise every time he needed to put weight through his hemi limb he simply took all of his weight through his arms. However, the fact that he was now standing and to him seemed like he was walking he was pretty happy and just wanted to do mroe and more and even wanted to go for a walk but we had to hold him back and stop him from doing this as he wasnt ready.
So as you could imagine this man was still a 2 person assist for transfers and ambulation. However, even tho we explained to him several times and tried to make it as clear as possible that he not to stand by himself and definitely not to try walking by himself. When we told him this he said he understood but both my supervisor and I werent convinved that he was going to follow our instructions so mentioned it to all of the other staff on the ward. And before we knew it one of the nurses caught him walking around his room with his frame!! So we went back and re-edcuated him about the dangers of him trying to walk etc. We even took his WZF away but before too long he was caught borrowing his roommates WZF and walking with that. On confrontation he simply gave us excuse after excuse as to why he was walking.
So from here we had him moved to a room closer to the nursing head1/4s so he was closer to the more crowded area. We also kept his WZF out of his room so he couldnt use that. So I was wondering if anyone has had patients like this who are at falls risk and dont obey yours or the doctors instructions about things not to do and if so what strategies you used to get around this problem.
Now we began working on his static standing balance using a wheeled zimmer frame for him to hold onto. He was balancing ok in this position but when we tried to correct alignment so to make him have even weightbearing you could see that as we put him more across to his hemi side the more weight he put through his arms. So to finish this sesion we tried to do little weight shift exercises to get him taking small steps on the spot. Doing this exercise every time he needed to put weight through his hemi limb he simply took all of his weight through his arms. However, the fact that he was now standing and to him seemed like he was walking he was pretty happy and just wanted to do mroe and more and even wanted to go for a walk but we had to hold him back and stop him from doing this as he wasnt ready.
So as you could imagine this man was still a 2 person assist for transfers and ambulation. However, even tho we explained to him several times and tried to make it as clear as possible that he not to stand by himself and definitely not to try walking by himself. When we told him this he said he understood but both my supervisor and I werent convinved that he was going to follow our instructions so mentioned it to all of the other staff on the ward. And before we knew it one of the nurses caught him walking around his room with his frame!! So we went back and re-edcuated him about the dangers of him trying to walk etc. We even took his WZF away but before too long he was caught borrowing his roommates WZF and walking with that. On confrontation he simply gave us excuse after excuse as to why he was walking.
So from here we had him moved to a room closer to the nursing head1/4s so he was closer to the more crowded area. We also kept his WZF out of his room so he couldnt use that. So I was wondering if anyone has had patients like this who are at falls risk and dont obey yours or the doctors instructions about things not to do and if so what strategies you used to get around this problem.
Monday, September 8, 2008
Inappropriate patient
I’m sure many of us have had an expience of some kind with a patient behaving inappropriately at some point in our pracs this year. My first encounter happened recently on my musculoskeletal prac. We were made aware at many times during the year that it does happen, especially to students. I thought I was prepared to deal with it if it was ever to happen. (especially since working in aged care for three years I’ve had my fare share of inappropriate comments and have learnt to deal with them well!!) The patient in question was 35 years old and within the first minute of my sebjective assessment he had told me his expectations of physiotherapy was to take me out to lunch, dinner, then live happily ever after! (WHAT?!!!) I felt incredibly uncomfortable from then on as the comments got more and more inappropriate. I was very concious of not giving him any hint of encouragement throughout the assessment, I became quite closed in my body language, didn’t smile and made my questions as specific as I could (not the best thing to get info out I know!) Once the Subjective examination was over (very relieved) I went to talk to my supervisor. He was in the middle of an assessment himself and so I was only able to alert him to the sleazy patient. I tried to find another student or physio that was free to sit in with me on the session...there was none! I went back in for the objective and the treatment and did that as quickly as I could. I was surprised and a bit frustrated that I didn’t have the guts to say somethig to the patient during the session – I felt quite threathened and uncomfortable because his attitude just took me totally by surprise. After the patyient had left, I told my supervisor. We have organised for him to sit in with me when I see this patient next as we know this will solve the problem. I am still quite nervous and uncomfortable about seeing this patient again but there are no other physios to transfer him over to. I know other people will have had similar experiences...how did you deal with it? I think one of the reasons why I didn’t stand up to him in the first place was the fact that I still feel like a student! (and that I don’t necessarily have the authority of another Physio)
Friday, September 5, 2008
Challenging other professions
i am currently working on my neuro prac at a major hospital and am treating a stroke victim. I have been seeing this patient for about 2 weeks now and rehab seems to be going along nicely with the man now progressing into ambulation practice and retraining. Though the rehab is progressing I believe that his recovery had/has the potential to progress along at a much greater rate as the man is quite severely deaf and usually wears hearing aids which allows him to hear at an almost normal level.
Now when we found out that the man wore hearing aids it took about 3-4 days for someone to actually find them as they were right down the back of his bedside drawer!! However, even though we have them they are still useless as they are out of battery. The man reports that usually there is someone at his nursing home who can organise someones to come out and organise a replacement battery. However, since there is noone that does anything like this at this hospital then it is kind of a toss-up to see who is going to organise a replacement.
As this patient is medically stable then the main reason he is in hospital is for rehab (OT and PT) and so his lack of hearing is severely affecting the communication between us and the patient and it is effecting us the most and so we want to do something about it. However, my supervisor has told me that it should be the doctors or social workers duty to sort this out. Now I have spoken to both parties twice and they both say they are trying to organise something but it has now been close to a week and nothing seems to be happening.
So I'm kind of unsure as to what to do about this issue. I am kind of tempted to simply go to a shop that sells them and buy some my self as I believe allowing this man to hear would almost double the rate of recovery. However, the situation should be managed properly by the doctors or social workers and I am unsure about how to approach the issue with those parties as since I have already asked twice I dont want to seem pushy though I dont want to not do anything as this is not beneficial to the patient and this is also not very professional. So I will have a think over the weekend and try to come up with something for Monday but if anyone has any ideas/suggestions then please feel free to let me know.
Now when we found out that the man wore hearing aids it took about 3-4 days for someone to actually find them as they were right down the back of his bedside drawer!! However, even though we have them they are still useless as they are out of battery. The man reports that usually there is someone at his nursing home who can organise someones to come out and organise a replacement battery. However, since there is noone that does anything like this at this hospital then it is kind of a toss-up to see who is going to organise a replacement.
As this patient is medically stable then the main reason he is in hospital is for rehab (OT and PT) and so his lack of hearing is severely affecting the communication between us and the patient and it is effecting us the most and so we want to do something about it. However, my supervisor has told me that it should be the doctors or social workers duty to sort this out. Now I have spoken to both parties twice and they both say they are trying to organise something but it has now been close to a week and nothing seems to be happening.
So I'm kind of unsure as to what to do about this issue. I am kind of tempted to simply go to a shop that sells them and buy some my self as I believe allowing this man to hear would almost double the rate of recovery. However, the situation should be managed properly by the doctors or social workers and I am unsure about how to approach the issue with those parties as since I have already asked twice I dont want to seem pushy though I dont want to not do anything as this is not beneficial to the patient and this is also not very professional. So I will have a think over the weekend and try to come up with something for Monday but if anyone has any ideas/suggestions then please feel free to let me know.
Monday, September 1, 2008
Complex Patient!
Whilst on my rural placement I had a patient who was referred to outpatient physiotherapy for low back pain. As the initial assessment progressed I was informed that the patient had severe allergies to noise, smell, touch, light, movement, you name it! They told me that they reacted very easily in the form of seizures. The patient stated they had been cleared of epilepsy and after years of extensive medical examinations no definitive diagnosis had been made and doctors were baffled with the patient’s condition. However as the session progressed it was apparent that there were many yellow flags present and I was thus unsure how much of the patient’s condition was medical or psychological.
I begin an objective assessment wherein the patient had frequent bouts of shaking and pain onset. I found that I had to ask the patient’s permission every time I touched them to enquire if they knew if contact on that particular part of their body would cause a seizure. I had to be very clear about my manual contacts and give thorough explanations on what I was doing and why throughout the assessment. Although the patient had underlying mechanical LBP that was applicable to physiotherapy treatment, in retrospect I should have referred the patient straight away once I learned about the extensive “medical” issues.
Thus I have learnt that some patients require more extensive education and explanations throughout assessments and that although some patients have physiotherapy related conditions, overlying medical disorders may need to be dealt with prior to physiotherapy treatment. In the future I will be more definitive about referring patients with medical issues at the onset rather than trying to assess and treat them regardless.
Transfers
I am currently doing my neuro prac at a major hospital and am predominantly working with stroke patients. Last week we had two new stroke patients, both older males who were quite large. So after treating them in bed for the initial stage we decided it would be best to take them down to the gym. Now since they are both really acute strokes the transfers in/out of bed as well as up/down and across the bed all needed assistance.
So the first couple of times I transferred the patients I really found that it was starting to take a toll on my back. Now i was trying to do the technique in the safest way to protect my back but it still seemed to be niggling me. So I asked my supervisor for suggestions as to how she transfers these patients on her own (as shes a smallish lady) and she came in and showed me several alternative ways to move the patients.
Over the next few sessions I trialled several of the different techniques to find which ones suited me more and I found specific techniques which felt as if they were a lot easier on my back. So froom this it really made me think back to when we were learning all the different transfers and how much different it is when you actually get out there and have to move a fully dependent patient. It really made me think about the exact way we got taught the transfers and realised how important each little aspect of the transfer is - from the patients starting position to our feet position.
So upon reflection I guess it is advice to everyone going into a neuro prac or even working in that field next year to really concentrate on perfecting a transfer technique that works for you and that you really practice the whole motto that our safety is priority number one and then the patients. If you are unable to figure out a way to transfer patients without feeling your back is straining then possibly ask for assistance to do a 2 person transfer or to ask more experienced PTs as for alternative suggestions for performing the necessary transfer.
So the first couple of times I transferred the patients I really found that it was starting to take a toll on my back. Now i was trying to do the technique in the safest way to protect my back but it still seemed to be niggling me. So I asked my supervisor for suggestions as to how she transfers these patients on her own (as shes a smallish lady) and she came in and showed me several alternative ways to move the patients.
Over the next few sessions I trialled several of the different techniques to find which ones suited me more and I found specific techniques which felt as if they were a lot easier on my back. So froom this it really made me think back to when we were learning all the different transfers and how much different it is when you actually get out there and have to move a fully dependent patient. It really made me think about the exact way we got taught the transfers and realised how important each little aspect of the transfer is - from the patients starting position to our feet position.
So upon reflection I guess it is advice to everyone going into a neuro prac or even working in that field next year to really concentrate on perfecting a transfer technique that works for you and that you really practice the whole motto that our safety is priority number one and then the patients. If you are unable to figure out a way to transfer patients without feeling your back is straining then possibly ask for assistance to do a 2 person transfer or to ask more experienced PTs as for alternative suggestions for performing the necessary transfer.
TA's activation
Recently I saw a patient in musculoskeletal outpatients who presented with hip pain and hypomobility and lower back pain. The patient was obese and had had many back problems in the past including a laminectomy. After assessment I concluded that the patient's hip pain was in fact being referred from his motor control impairment of his lumbar spine.
Therefore I decided to manage the patient's condition by teaching him PF and TA activation exercises. However I was unable to palpate a contraction as he had such a large stomach so was unsure whether or not he was doing it correctly.
It made me think whether it was the best treatment that I could provide for this treatment and whether it would actually have an effect on his LBP and hip pain. I also wonder why we try to isolate TA when it never really works in isolation in healthy individuals. Wouldn't we benefit more from strengthening the entire core musculature?
Has anyone had similar patients to this and seen an effect of managing them in this manner?
I am still unsure of how to approach these patients but will continue to manage them in this way until I am shown evidence of a different technique being more effective.
Therefore I decided to manage the patient's condition by teaching him PF and TA activation exercises. However I was unable to palpate a contraction as he had such a large stomach so was unsure whether or not he was doing it correctly.
It made me think whether it was the best treatment that I could provide for this treatment and whether it would actually have an effect on his LBP and hip pain. I also wonder why we try to isolate TA when it never really works in isolation in healthy individuals. Wouldn't we benefit more from strengthening the entire core musculature?
Has anyone had similar patients to this and seen an effect of managing them in this manner?
I am still unsure of how to approach these patients but will continue to manage them in this way until I am shown evidence of a different technique being more effective.
Non compliant patients
I am currently on my rural prac and am therefore fortunate enough to see a number of different conditions. Last week I was asked to assess and treat a patient with an acute exacerbation of COPD. The patient was middle aged and therefore I expected someone that would be very compliant to treatment as they are clearly unwell at such a young age. However after reading through the notes I realised that the patient was still smoking 50 cigarettes per day, not taking any medication and not attending any rehabilitation classes. She was also obese and suffering from type 2 diabetes.
When I assessed the patient I was confronted with someone who had obviously had negative experiences with medical professionals in the past as she was not keen for my help at all. I explained the importance of a thorough assessment and how physiotherapy advice could help her situation so she reluctantly allowed me to continue. After assessing her I realised she had impaired airway clearance, decreased exercise tolerance, airflow limitation and decreased gas exchange. As she was still able to mobilise freely I provided her with an ambulation program, demonstrated the ACBT and suggested she sat out of bed as much as possible. Her response was that she was already walking outside to smoke regularly so didn't need to do any of the other stuff and wouldn't do any of the other stuff. She also told me she would not take any of the medication the doctors had prescribed and that she was not interested in attending pulmonary rehab classes and would smoke till the day she died.
I decided to leave the patient for a day and follow her up the next day as I thought she may have been suffering from nicotine withdrawal and she was still ambulating, all be it for negative reasons. However, on return she was even more adamant that she would not comply with any suggested medical or physio treatment.
This frustrated me as she came to hospital expecting to 'get fixed' but would not allow me to do my job in helping her. I felt as though she was taking up room that someone else would benefit more from occupying. On top of this she was also irritating the other patients in her room and affecting their recovery.
I just wonder if anyone else has any thoughts on these types of patients or any suggestions in gaining their compliance.
In the end their was nothing I could do as she refused treatment but I think I will approach similar patients with much more preparation in future and think of more enticing ways to sell physiotherapy treatment.
When I assessed the patient I was confronted with someone who had obviously had negative experiences with medical professionals in the past as she was not keen for my help at all. I explained the importance of a thorough assessment and how physiotherapy advice could help her situation so she reluctantly allowed me to continue. After assessing her I realised she had impaired airway clearance, decreased exercise tolerance, airflow limitation and decreased gas exchange. As she was still able to mobilise freely I provided her with an ambulation program, demonstrated the ACBT and suggested she sat out of bed as much as possible. Her response was that she was already walking outside to smoke regularly so didn't need to do any of the other stuff and wouldn't do any of the other stuff. She also told me she would not take any of the medication the doctors had prescribed and that she was not interested in attending pulmonary rehab classes and would smoke till the day she died.
I decided to leave the patient for a day and follow her up the next day as I thought she may have been suffering from nicotine withdrawal and she was still ambulating, all be it for negative reasons. However, on return she was even more adamant that she would not comply with any suggested medical or physio treatment.
This frustrated me as she came to hospital expecting to 'get fixed' but would not allow me to do my job in helping her. I felt as though she was taking up room that someone else would benefit more from occupying. On top of this she was also irritating the other patients in her room and affecting their recovery.
I just wonder if anyone else has any thoughts on these types of patients or any suggestions in gaining their compliance.
In the end their was nothing I could do as she refused treatment but I think I will approach similar patients with much more preparation in future and think of more enticing ways to sell physiotherapy treatment.
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