Sorry guys, late post, I completely forgot about blogging!
I just wanted to quickly talk about hydrotherapy; a form of treatment prehaps we dont always think about right away. I have just really seen how beneficial hydrotherapy can be this prac and I thiught other people might not have had a chance to do hydro yet this year. I am doing my Rheumatology prac at Shents and I have both in and out pts. For the inpts the hydro is a god-send. I plead, beg, encourage and almost bully these patients into doing exercises and ambulating with me everyday because otherwise some of them do not even get out of bed for meals. They call us the physio terrorists and absolutely hate all land based exercise. BUT if you can manage to get them through the changing into bathers and being wheeled down to the pool they absolutely love it. With the pain relief provided by the warm water and the relief from gravity in the bouyancy of the water you can achieve so much more exercise than you can complete on land!
I give all these patients exercises for strength ROM and fitness and it is just amazing how much more they can achieve. And for these patients, and most of them were at Shents before my placement started and are still inpatients 5 weeks later just this daily exercise i think isso beneficial in preventing deconditoning and a loss of ROM that would definately occur if they were left doing only what they can manage on land.
For outpts too I have found hydro brings big improvements. I have had a few TKRs I have referred to twice or three times weekly hydro classes. Its great for when you have given the pt all the exs they can manage to remember as a HEP and they are a few weeks post and the wound is clean and the stitches out. Especially also for those patients who have adopted an antalgic gait pattern due to years of knee pain- its a great way to retrain even gait without the force of gravity.
Anyway take home message is dont forget hydro as a treatment option, I know I had a bit, we learnt it in second year! There are so many exercises you can make up and it's actually really fun- for the patients and us too!
Tuesday 19 June 2007
Monday 18 June 2007
Compassion
Just to reiterate something we all know...
That whoever the patient and whatever they may have please remember to show some compassion and attempt to not "talk over them" about their condition/symptoms to a supervisor or other health practitioner. This applies to both awake, alert, compus patients and those that are critically ill and sedated (some of the patients that I'm treating at the moment).
There are times when we get so focused on what we need to do to pass a placement or so as not to get told off by a supervisor that we forget that we are in the profession of dealing with people.
There is a book I'm told that is written by a patient who had a head injury and can remember from the acute period when no one thought she would live of medical staff "doing things to her" without ever telling her what it was they were doing, or talking about her to other staff in a manner she felt was inappropriate.
Even if the patient looks asleep and is sedated heavily, I still try very had to remember that sometimes the things I may do to them (eg. suctioning) is really not pleasant and that they need reassurance and even just a simple explanation of what's happening. Obviously they can't be involved in the treatment session but at least talk to them...maybe I look like a fool to everyone else talking to my sedated patients but I hate to think if our roles were reversed and it was me on that bed. Hopefully someone would talk to me before doing anything and not just do it (for once the Nike ad is wrong).
That whoever the patient and whatever they may have please remember to show some compassion and attempt to not "talk over them" about their condition/symptoms to a supervisor or other health practitioner. This applies to both awake, alert, compus patients and those that are critically ill and sedated (some of the patients that I'm treating at the moment).
There are times when we get so focused on what we need to do to pass a placement or so as not to get told off by a supervisor that we forget that we are in the profession of dealing with people.
There is a book I'm told that is written by a patient who had a head injury and can remember from the acute period when no one thought she would live of medical staff "doing things to her" without ever telling her what it was they were doing, or talking about her to other staff in a manner she felt was inappropriate.
Even if the patient looks asleep and is sedated heavily, I still try very had to remember that sometimes the things I may do to them (eg. suctioning) is really not pleasant and that they need reassurance and even just a simple explanation of what's happening. Obviously they can't be involved in the treatment session but at least talk to them...maybe I look like a fool to everyone else talking to my sedated patients but I hate to think if our roles were reversed and it was me on that bed. Hopefully someone would talk to me before doing anything and not just do it (for once the Nike ad is wrong).
home exercise programs
As part of the community physiotherapy placement, studenta re required to provide 2 patients with home exercise programs (HEP). I was assigned one patients from a Abilities group (post stroke) and one from an aqua class (Parkinsons Patient). For my patient in the abilities group i managed to pull her aside during the walk, and ask her a few simple subjective questions such as why she was attending physio, what her major problems are, has she had any recent falls, etc. I then had to observe her movement and balance whilst conducting the clas to determine which exercises would be most beneficial for her. I then developed a home exercise program based on a very short subjective and objective assesment.
It was really hard!!! As a student you make sure you know a bit more about the patient before giving them exercises to do at home. But in the community setting where you only see the patienst for an hour and in that time need to run the class and do home exercise programs, its challenging. So this week i get a chance to revise the program with her and see how she went, fingers crossed it works. There needs to be some form of assesment procedure lined out and documented for these patients to make it more reliable and indiviual.
It was really hard!!! As a student you make sure you know a bit more about the patient before giving them exercises to do at home. But in the community setting where you only see the patienst for an hour and in that time need to run the class and do home exercise programs, its challenging. So this week i get a chance to revise the program with her and see how she went, fingers crossed it works. There needs to be some form of assesment procedure lined out and documented for these patients to make it more reliable and indiviual.
Sunday 17 June 2007
Run in with doctor
Hi everyone,
I have a mutlitrauma pt with a PMH of significant LBP, for which he was receiving weekly chiro Rx, as well as an unstable # of s1/s2 SPs. Needles to say the pt had++ pain (8/10) on rest and as a result we were not able to move him. On request of nsg staff, I was asked to talk to the prof of multitrauma. I explained to him the pts PMH and that his pain was impacting severly on PT Rx as well as that he was only on panadol ond oxycodone.
The doctor then abused me in front of the pt and 5 other doctors. He told me that this was not his problem and that the pt was obvioulsy not in that much pain as he hadn't said anything regarding it to him. He also stated that a little bit of pain was not a problem for the pt and said that my Mx was obviously not good enough otherwise the pt would not be in pain. He then suggested that I do mobilisations of the pts spine. This continued for 10 minutes or so.
I just glared at him for the whole time, even though I wanted to do much more....
Just wondering if anyone else would have stood up to the doctor, given that we are studetns and all?
I have a mutlitrauma pt with a PMH of significant LBP, for which he was receiving weekly chiro Rx, as well as an unstable # of s1/s2 SPs. Needles to say the pt had++ pain (8/10) on rest and as a result we were not able to move him. On request of nsg staff, I was asked to talk to the prof of multitrauma. I explained to him the pts PMH and that his pain was impacting severly on PT Rx as well as that he was only on panadol ond oxycodone.
The doctor then abused me in front of the pt and 5 other doctors. He told me that this was not his problem and that the pt was obvioulsy not in that much pain as he hadn't said anything regarding it to him. He also stated that a little bit of pain was not a problem for the pt and said that my Mx was obviously not good enough otherwise the pt would not be in pain. He then suggested that I do mobilisations of the pts spine. This continued for 10 minutes or so.
I just glared at him for the whole time, even though I wanted to do much more....
Just wondering if anyone else would have stood up to the doctor, given that we are studetns and all?
Communicating to pts
Hi All,
I've been wondering lately, we talk to our pts during treatment sessions, and we find out information about them, and as we continue to treat them (particularly in an outpt setting) we also talk about ourselves and our lives. But how much information is too much information? I know that generally most of us use our common sense and don't talk about private stuff and on the other hand it is impt to create rapport with a pt, but where do you draw the line? Does it differ between pts? I know that I generally talk about all sorts of stuff, such as uni stuff, talking about my family, what I did on the weekend etc. But what about sharing something that is more personal, such as religious beliefs? Are you even allowed to talk about that, or is it considered unethical? I was just wondering what everyone else thought about it? And if anyone has been in a situation where they have might have said a little too much (about anything), or heard a little too much from a pt?
I've been wondering lately, we talk to our pts during treatment sessions, and we find out information about them, and as we continue to treat them (particularly in an outpt setting) we also talk about ourselves and our lives. But how much information is too much information? I know that generally most of us use our common sense and don't talk about private stuff and on the other hand it is impt to create rapport with a pt, but where do you draw the line? Does it differ between pts? I know that I generally talk about all sorts of stuff, such as uni stuff, talking about my family, what I did on the weekend etc. But what about sharing something that is more personal, such as religious beliefs? Are you even allowed to talk about that, or is it considered unethical? I was just wondering what everyone else thought about it? And if anyone has been in a situation where they have might have said a little too much (about anything), or heard a little too much from a pt?
Diagnosis, PD?
Earlier in this placement I came across a patient who presented to me for balance retraining, following several recent falls. Whilst taking his subjective assessment he mentioned that one of his falls came about when he went for a walk, realised he was very far from his car and it was getting late so he started running. When he came close to his car he was unable to stop running, which lead to his fall. On other occasions he noted that it was difficult for him to start walking. He put this down to OA of his foot, and thought nothing more of these symptoms, in fact, had I not asked about his feet, or for details of previous falls he probably wouldn’t have mentioned it at all! Objectively he presented with festinating gait, as well as great difficulty with turning, and rolling. On further assessment cogwheel rigidity was noted. When questioned about these symptoms the patient was unable to tell me how long they had been going on, but they were not new, and it was in the vicinity of ‘years’. I was rather shocked that no one had picked up these symptoms previously, and that the patient hadn’t questioned it. I assumed that as it seems natural for us to question such symptoms the rest of the population should question it too, how soon we forget!
He is to see his doctor soon; as such I need to write a letter to the GP. Is it improper for me to spell out what I think the diagnosis might be? Should I just write the hard facts of what was noted subjective and objectively?
He is to see his doctor soon; as such I need to write a letter to the GP. Is it improper for me to spell out what I think the diagnosis might be? Should I just write the hard facts of what was noted subjective and objectively?
Saturday 16 June 2007
Supervisor Vs CCT
On my last placement I found that my facility supervisor and Curtin clinical tutor had different expectations of what was required of me when assessing and treating a patient. My facility supervisor was also a senior physio of the ward and therefore did not have a lot of time to be supervising my assessment and treatment of every patient. From what she had seen she was very happy and often gained feedback from the new grads to see how I was progressing. My CCT however was very specific in what she wanted but this was not realized until I gained my feedback from my mid placement assessment. My CCT was not impressed with my ‘grasp’ on the patient (an incomplete paraplegic) and where I was going with his treatment. My patient had acquired shingles 2 weeks prior and therefore was unable to leave the room and attend the physio gym, therefore my instructions from my supervisor was to provide him with regular passive stretches and general strengthening exercises. I followed through with this treatment as well as working on his sitting balance (which I used as my main assessment and treatment for my mid placement assessment). My CCT was very concerned with the progress of this patient and said (during my feedback) that his room now had to become ‘his own gym’ and therefore practice facilitated rolling and transfers in and out of a wheel chair within the room. My CCT had said that she had faith in me for her not to have to come back to provide extra help for me in week 4 and said that she would hope for a much better standard in my final assessment (week 5). I discussed this feedback with my facility supervisor and she said she had a different view to the CCT and not to be too concerned, however this still made my final assessment quite a nervy one as I did not know if I was to do what I had been doing for 5 weeks or Ax and Rx as what I thought my CCT expected. What would you do in a similar situation?
Tuesday 12 June 2007
issue on debates
Being at prac, I have the chance to approach many physios (who are not my supervisors) and many of whom are friendly enough to talk with you about the treatment technique they used etc... As a physio student, I already have my opinion on what techniques are superior than others. So when some other physio saying opposite opinions to mine, I really feel I want to defense my opinion but being a student (and someone from chinese background) I dont really feel comfortable to challange someone who are much older than me and had heaps of experience in their area. So I just smiled it off-but I felt bad because I betrayed my heros (creators of those techniques) in my heart. So shall I just stand out for my heros or shall I just stay quiet as usual? Shall I start showing my character now or shall I hide it until I am out :-) any thought will be appreciated.
Monday 11 June 2007
Frontal lobe behaviours
I have been treating a young pt who is currently displaying sometimes inappropriate frontal lobe bahaviours, secondary to a MVA. Whilst I get along with him really well and tend to brush over his poor behaviour, some staff members do not like his behaviour at all and are quite rude to him. In their defence, I can totally understand how the pts behaviour could be deemed offensive. But, this made me think if pts have little idea/control over what they are saying when they are agitated, is it really right to yell at them. On the other hand, if you casually tell them off (my approach), are they not going to realise that their behaviour is not on and therefore continue to act inappropriately towards people?. Any thoughts?
Forgetfull patient
I have a bit of an interesting patient. She was 2/52 post TKR when she first came to outpt PT with a d/c knee AROM reported at 8° to 80° with no quads lag and an extensive pre-op falls history. Unfortunately this lady had suffered post op dementia and had no recollection of having any PT or being taught any exercises. At first assessment in outpts she had an knee range AROM of 16° extn to 65° flxn with a quads lag of 5°. She returned early the next week after falling onto her operated knee with an active range of 20° to 45° and a huge increase in swelling. Her GP examined the knee and said there was no damage to the replacement but in the meantime she hadnt done her exercises. She returned again today after having 2 more falls over the weekend with an active knee range of 10° to 72° .
When asked to demonstrate her exercises she couldnt remember any. All the falls she has had have been because she can't slow down on her crutches and twice she fell when she wasn't using them. Today she came to the appointment with only one crutch because she forgot the other one! I have demonstrated all the exercises, drawn pictures and given written instructions but even immediately after doing the exercises she cant follow the written/drawn HEP. I have given her a grid to tick when she has done her exercises but I don't know this will help. So I have booked her in for hydrotherapy and PT 3x a week. But what I am not sure of is how much improvement I can expect. Realistically I can only do her exercises with her maybe 2 sets of 10 reps 3x a week...will this be enough to make a difference? what else can I do?
When asked to demonstrate her exercises she couldnt remember any. All the falls she has had have been because she can't slow down on her crutches and twice she fell when she wasn't using them. Today she came to the appointment with only one crutch because she forgot the other one! I have demonstrated all the exercises, drawn pictures and given written instructions but even immediately after doing the exercises she cant follow the written/drawn HEP. I have given her a grid to tick when she has done her exercises but I don't know this will help. So I have booked her in for hydrotherapy and PT 3x a week. But what I am not sure of is how much improvement I can expect. Realistically I can only do her exercises with her maybe 2 sets of 10 reps 3x a week...will this be enough to make a difference? what else can I do?
Being positive
I'm on my neuro placement at the moment, doing outpatients. One of my pts is a 30 yo female who suffered a bilateral pontine stroke a couple of years ago. She presents with "locked in syndrome", where she is fully functionaing and aware cognitively, but she is unable to execute mvts. she communicates via a lightwriter, where she types in words, and it speaks them for her. Last week, we got her on the tilt table to stretch her calves and do some trunk work. While she was on the tilt table she started laughing. I had no idea what could she could be laughing about, so I asker her, and she typed back, "I farted". For the next five minutes she was laughing uncontrollably. I couldn't do anything except wait until she had calmed down.
I can't imagine how hard it must be to be "locked in". She is extremely bright and cheerful, and always motivated. I think that we can learn a lot from our pts, we think that it is hard being a student, but how much harder is it for them? If they can be bright and cheerful, then we should be more than able to be positive, after all, it is only til the end of the year. And, of course, no matter what happens to you, farting will always be amusing.
I can't imagine how hard it must be to be "locked in". She is extremely bright and cheerful, and always motivated. I think that we can learn a lot from our pts, we think that it is hard being a student, but how much harder is it for them? If they can be bright and cheerful, then we should be more than able to be positive, after all, it is only til the end of the year. And, of course, no matter what happens to you, farting will always be amusing.
Clinical Supervisors
I guess all of you have already read Nicki's outcry on her clinical supervisor. I thought I would just add a tiny bit on. The 3rd week was feedback week. The facility I am currently in has 6 different physios working and their shifts are organised as 3 day shifts 3 night shifts and 3 days off. As a result of this I get to work with a range of different physios, which is great at times, but not when it comes to assessments.
We have competencies to complete in Cardiopulm, they're bagging, suctioning and positioning. Hand outs were given for us to read and a relevant tute was conducted the next morning.This only lasted for the 1st week and then order was disrupted because of the increasing no. of patients which is understandable.
But the issue is when you have been working with the same physio for 3 days and on the 4th day another physio comes onto the shift who has no idea about you. They have a totally different style to the previous physio and who also needs to assess you on that day...the assessment just simply doesn't flow...and you end up with a disscussion of what have you been doing for the past 3 days. I've exaggerated things a little, but I get all worked up about not completing something I know well enough to do well in.
By the end of the second week I was given a mixed impression of what's expected of me. So I went to talk to the senior in the area who is also one of my supervisors, and luckily she said that I was going fine. Really?????
We have competencies to complete in Cardiopulm, they're bagging, suctioning and positioning. Hand outs were given for us to read and a relevant tute was conducted the next morning.This only lasted for the 1st week and then order was disrupted because of the increasing no. of patients which is understandable.
But the issue is when you have been working with the same physio for 3 days and on the 4th day another physio comes onto the shift who has no idea about you. They have a totally different style to the previous physio and who also needs to assess you on that day...the assessment just simply doesn't flow...and you end up with a disscussion of what have you been doing for the past 3 days. I've exaggerated things a little, but I get all worked up about not completing something I know well enough to do well in.
By the end of the second week I was given a mixed impression of what's expected of me. So I went to talk to the senior in the area who is also one of my supervisors, and luckily she said that I was going fine. Really?????
Sunday 10 June 2007
Thinking towards the future
I'm putting this out to the group to hopefully settle my own concerns in regards to the fact that I have no (absolutely zero) ideas of where I see myself working as a physio next year. I know that we are only in prac number three, but I guess I felt that by now I would have some clarity as to where in the scheme of things I fit, and where I can best put my skills to use.
Is there anyone else that is as lost as me, and lacks direction? With the busy-ness of this year I'm afraid I've lost motivation and drive...who can inspire me?
Is there anyone else that is as lost as me, and lacks direction? With the busy-ness of this year I'm afraid I've lost motivation and drive...who can inspire me?
Tutor trouble
On one particular clinic this year I found myself in a world of difficult situations. The clinic started off with me having absolutely no clue what was expected of me or what treatment sessions should entail. I found that the tutor gave us little to no guidance, even when asked and we were made to feel that we just SHOULD know what was meant to happen, what to assess and how to treat. On one particular occasion during a treatment session the tutor came rushing over to where I was giving an exercise to my patient and said that what I was doing was wrong and I should be doing it another way (a minor adjustment, and what I was doing was not unsafe). The patient, her friend, the other students and one of their patients were in the room and within earshot. I explained to the tutor why I was doing the treatment, but I was told it was still wrong, so rather than push the issue further then and there I did what had been suggested. Needless to say I was extremely embarrassed and for the rest of the session, which I completed in the same room with the same people, I was completely thrown. The issue was much further compounded (details of which need not be told here) when I went to talk to the tutor afterwards.
I understand that my exercise wasn’t perfect, and that it could have been that little bit better, but if a patient is unable to do one exercise, we can make it easier. My question, for the most, part is: When is it ok to make your own mistakes in order to learn better?
I understand that my exercise wasn’t perfect, and that it could have been that little bit better, but if a patient is unable to do one exercise, we can make it easier. My question, for the most, part is: When is it ok to make your own mistakes in order to learn better?
Saturday 9 June 2007
Letter to GP
I am treating a guy with medial anlke pain-I need to write a letter to his GP, who referred him to our clinic for 'strengthening ex program' as he recommanded, that this guy has hardly make any progression and I need to rule out the possibility of stress fracture. I find it awkward to write to the GP because I dont want to make him think I am telling him what to do, however, I need to know if he has a stress fracture so I can alter my treatment plan for him... Has anyone of you had the same problem?
Simon
Simon
Boundaries?
On my last placement at PMH, i was treating an 8 year olf aboriginal girl from up north. She was admitted for a tune up after getting a ripper chest infection. The patient has regularily attended the hospital and the physio's who know her, carry her around on their backs as a bit of fun to inprove compliance with physio. During treatment, she also liked to make "santa masks" with the bubbles created during physio. When i met her, you could see her head crawling with knitts. She had been recieving treatment for them but had yet to be cured. I made the decision that i was not happy to carry this child and was not happy to have bubbles put on my face.
Is this unfair? I would not carry any other child older than 2 or 3. I would also not allow anyone to place bubbles on my face, yet she seemed to be an acception with the physio's. At first she was not happy that i wouldnt carry her or allow santa masks but i made up another game to keep her occupied and having fun instead of being carried. I allowed her to put bubbles on my arms instead as i was "allergic on my face". She was ok with this as were the other physio's. As students, are we expected to follow the lead of the tutors in such a case or can we make rules of our own!!
Is this unfair? I would not carry any other child older than 2 or 3. I would also not allow anyone to place bubbles on my face, yet she seemed to be an acception with the physio's. At first she was not happy that i wouldnt carry her or allow santa masks but i made up another game to keep her occupied and having fun instead of being carried. I allowed her to put bubbles on my arms instead as i was "allergic on my face". She was ok with this as were the other physio's. As students, are we expected to follow the lead of the tutors in such a case or can we make rules of our own!!
Friday 8 June 2007
Home Exercises
As I’m sure most of you who have completed or are completing their musculo prac may find it quite difficult to get your patients to complete their home exercises on a regular basis. On a number of occasions already I have had to explain to my patients the importance of home exercises. One example springs to mind, a young female with bilateral trochanteric bursitis. Her pain is 0/10 at rest and only comes on after approx 3km of running. I have seen her for 3 sessions now with me and had been coming for 3 sessions prior yet has seen now improvement in the distance she can run before the onset of pain or the severity of pain (6/10). Treatment in the clinic has consisted of ITB and priformis release and ultrasound. Both seem to improve muscle length but this improvement does not seem to be maintained by the next time I see her. She has poor pelvic control (increased lateral pelvic tilt) during running, so I have given her a number of glut med ex’s to improve her glut med control and endurance and hopefully pelvic control. I found it difficult to find an effective way to stretch the ITB however she has now found a useful technique which she adapted from her body balance class. I have advised her to rest from long distance running as much as possible and have warned her about the importance of daily prolonged ITB stretching and ongoing glut med and TA exercises. I have suggested to her to record a dairy of her exercises over the week so that I can monitor whether she is really doing as much as I have recommended. I trust that she will not lie, but I am still concerned that she may still not be seeing the importance of her exercises. Does anyone have any suggestions to increase the compliance of patients with home exercises?
Tuesday 5 June 2007
Doctors vs Physios
I always knew there is a hierarchy in the hospital between the doctors and the rest of the medical team and we work together and come to a consensus and to seek the best treatment available to each patient. So what happens when this consensus is not reached?
This was the situation I was in today. I’m into my 3rd week in ICU at SCGH. I have the basics of the running orders in ICU, which is a nurse per bed 24/7, 3 physios on day shift and 1 on night shift. 2 residents and 4 registrars (from 6 different registrars) rotate between shifts and 3 consultants who conduct regular ward rounds. Therefore calculating the amount of time spent with each patient, on the top of the chart are the nurses, then the physios, residents, registrars and the very least the consultants.
The problem arose when the physios and the registrar had a different opinion on weaning( ↓ ventilatory support) of a patient. A gentleman who had a craniectomy 20 days ago, who then developed Type II respiratory failure was finally awake, stable but having difficulties weaning, due to CNS disturbance :. ↓ respiratory drive. The patient was currently ventilated on high flow ventilation (the part where Kate said it was not in exams. This ventilation provides high jet of O2 which is entrained with medical air to a % of O2 desired for the patient and it provide PEEP and prevent collapse of the airways on expiration) of 8L with Sat 98%. On SIMV the patient was on minimal support which indicates that the patient was able to tolerate Bi PAP in the evenings which is a form of non-invasive ventilation that could also be provided in the respiratory wards.
When the registrar came on in the afternoon, he decided that the O2 levels provided by the high flow was inadequate ( Sats of 98% ?) and should be increased and also the patient can be on it for longer. BiPAP was also not necessary, and the patient should be ventilated with SIMV at night and off to the ward with high flow tomorrow. The registrar contraindicated what the physios where planning to do and when questioned, the registrar said that he would like to see Mr…work his respiratory mm harder and have a better night sleep. This may not be the best option to go as the patient fatigues easily and from the doctors orders it looked like that the patient was set up to fail as both the nurses and physios knew that Mr… will not tolerate long periods of high flow. So the million dollar question is do we challenge what the doc’s orders and if so, how? Or do we follow the doc’s orders and fail the attempt to wean the patient?
This was the situation I was in today. I’m into my 3rd week in ICU at SCGH. I have the basics of the running orders in ICU, which is a nurse per bed 24/7, 3 physios on day shift and 1 on night shift. 2 residents and 4 registrars (from 6 different registrars) rotate between shifts and 3 consultants who conduct regular ward rounds. Therefore calculating the amount of time spent with each patient, on the top of the chart are the nurses, then the physios, residents, registrars and the very least the consultants.
The problem arose when the physios and the registrar had a different opinion on weaning( ↓ ventilatory support) of a patient. A gentleman who had a craniectomy 20 days ago, who then developed Type II respiratory failure was finally awake, stable but having difficulties weaning, due to CNS disturbance :. ↓ respiratory drive. The patient was currently ventilated on high flow ventilation (the part where Kate said it was not in exams. This ventilation provides high jet of O2 which is entrained with medical air to a % of O2 desired for the patient and it provide PEEP and prevent collapse of the airways on expiration) of 8L with Sat 98%. On SIMV the patient was on minimal support which indicates that the patient was able to tolerate Bi PAP in the evenings which is a form of non-invasive ventilation that could also be provided in the respiratory wards.
When the registrar came on in the afternoon, he decided that the O2 levels provided by the high flow was inadequate ( Sats of 98% ?) and should be increased and also the patient can be on it for longer. BiPAP was also not necessary, and the patient should be ventilated with SIMV at night and off to the ward with high flow tomorrow. The registrar contraindicated what the physios where planning to do and when questioned, the registrar said that he would like to see Mr…work his respiratory mm harder and have a better night sleep. This may not be the best option to go as the patient fatigues easily and from the doctors orders it looked like that the patient was set up to fail as both the nurses and physios knew that Mr… will not tolerate long periods of high flow. So the million dollar question is do we challenge what the doc’s orders and if so, how? Or do we follow the doc’s orders and fail the attempt to wean the patient?
Confronting Issues
Currently I'm on prac in ICU and we were asked to assess a patient who had attempted suicide. Reading through the patient notes, I struggled to comprehend how and why someone could do that to themselves as I have never been faced with a situation where anyone close has ever attempted to or committed suicide. Hoping, hoping was I that they would not yet be awake as I'm not sure I could cope assessing someone who had tried to do this to themself, although I do recognise that it is a call for help and and a psychological condition.
Fortunately they were not awake at the time, but were being weaned off sedation and likely to wake up at any time. Later in the day the physios were asked to extubate the patient. Watching from closeby, the first thing I heard this patient say was "what happened?" No one could or would acknowledge his question and I choked up and almost cried and have been holding onto this since. Some patients certainly stick in your mind for years later, and I know this one definitely will.
Fortunately they were not awake at the time, but were being weaned off sedation and likely to wake up at any time. Later in the day the physios were asked to extubate the patient. Watching from closeby, the first thing I heard this patient say was "what happened?" No one could or would acknowledge his question and I choked up and almost cried and have been holding onto this since. Some patients certainly stick in your mind for years later, and I know this one definitely will.
Monday 4 June 2007
Communication
Hi All,
At the moment I'm on my neuro placement. One of my pts has expressive aphasia. During our treatment sessions, I'm finding it difficult to understand what he tries to tell me. He doesn't talk very often, but when he does usually I have no idea what he is saying (except when he swears, which is perfectly clear and understandable). Sometimes I try to pretend I know what he's saying, but he knows that I don't understand. But when I do try to understand and he has to repeat himself several times, he gets a bit frustrated, and I also get frustrated. Does anyone have any ideas?
At the moment I'm on my neuro placement. One of my pts has expressive aphasia. During our treatment sessions, I'm finding it difficult to understand what he tries to tell me. He doesn't talk very often, but when he does usually I have no idea what he is saying (except when he swears, which is perfectly clear and understandable). Sometimes I try to pretend I know what he's saying, but he knows that I don't understand. But when I do try to understand and he has to repeat himself several times, he gets a bit frustrated, and I also get frustrated. Does anyone have any ideas?
Role for PTA and Carers in community physio
Community physio has a wide range of programs designed to keep the elderly population in the community active, mobile and out of hospital. Abilities classes are targeted for neurological patients and classes can have a range of patients from parkinsons, to stroke, to dementia. Some of these classes are high level function, concentating on imporving blaance, muscle strength and ambulatory function under supervision. Others are low level function and consist of high falls risk patients that need help to maintain a baseline level of transfers and balance to stay out of nursing homes.
One class i am currently attending is a very low level balance group. The class consists of 8-12 patients with a high involvement of dementia as well as one patient (only in her 50's) with cerebellar ataxia. There are 5 patients in the group who require close standby assistance or use of a chair or aid to keep balance. The patients are situated around the room in an oval shape and the majority of the exercises are performed in sitting. It is however, vital to incorporate a balance component and lower limb strengthening in standing so that these people can remain mobile.
On Friday, the physio and i, we were busy trying to ensure that all patients were safe in the activities. One patients, with dementia, forgets that she is unable to stand unassisted, so in commencing standing exercises, she jumps from her chair and tries to walk around her chair. The physio has to be there straight away to stop her and prevent her from falling. 4 other patients in the same group need chairs in front of them for stability and cannot walk around their chairs to do so. The phsyio must move chairs aroudn the room everytme the group stand up.
I was sitting in amazement watching the physio run this class. She had to be watchful of every patients movement and was unable to stand near all the patients that needed assistance. In order for these people to remain in the community, the classes are vital for function. Yet when so many patients are a high falls risk, the physio has a huge responsibility. So my question is.... is there a role for PTA's or carers to provide assistance in such classes to increase the class outcome and safety of patients and physiotherapist.
One class i am currently attending is a very low level balance group. The class consists of 8-12 patients with a high involvement of dementia as well as one patient (only in her 50's) with cerebellar ataxia. There are 5 patients in the group who require close standby assistance or use of a chair or aid to keep balance. The patients are situated around the room in an oval shape and the majority of the exercises are performed in sitting. It is however, vital to incorporate a balance component and lower limb strengthening in standing so that these people can remain mobile.
On Friday, the physio and i, we were busy trying to ensure that all patients were safe in the activities. One patients, with dementia, forgets that she is unable to stand unassisted, so in commencing standing exercises, she jumps from her chair and tries to walk around her chair. The physio has to be there straight away to stop her and prevent her from falling. 4 other patients in the same group need chairs in front of them for stability and cannot walk around their chairs to do so. The phsyio must move chairs aroudn the room everytme the group stand up.
I was sitting in amazement watching the physio run this class. She had to be watchful of every patients movement and was unable to stand near all the patients that needed assistance. In order for these people to remain in the community, the classes are vital for function. Yet when so many patients are a high falls risk, the physio has a huge responsibility. So my question is.... is there a role for PTA's or carers to provide assistance in such classes to increase the class outcome and safety of patients and physiotherapist.
Prognosis
I was on my last placement on the spinal unit at Shenton Park with Flic and we couldn’t help but become attached with one of our more memorable patients, a Down’s Syndrome male with incomplete tetraplegia (J.T.). The story of this lovable larrikin is complex, however to put it simply, he should not be an tetraplegic. His widowed mother, who is probably in her late 60s, is very protective of her son and has looked after him all his life. Six months prior, J.T. was ambulating independently, however due to his cognitive deficit he was highly dependent on his mother for many ADL’s (e.g. cooking, cleaning, driving). During the following six months the mother had noticed a slow decline in her son’s motor function. At first she had thought that he was just becoming lazy, however movement in his legs had declined so rapidly that he soon required a wheelchair. At this point he was admitted to SJGH where CT-scan revealed spinal canal stenosis from C3-5 causing compression of the spinal cord. This required surgery in which the stenosed segments were decompressed and vertebral segments were fused from C3-5 to maintain stability. Recovery following surgery began well, with J.T. regaining partial motor function in his legs however this recovery took a turn for the worse when he was allowed to sit to 90deg in a SOMI brace. J.T.’s lower limb recovery had begun to plateau and he had noticable loss of his (R) hand intrinsic muscle function and his triceps had weakened to G3+ bilaterally. Muscle charting and sensory assessment was difficult with J.T. due to his cognitive disability, however over the period we had assessed him (5 weeks) he had made minor improvements to his tricep strength however a noticable improvement to his (R) intrinsic hand function. Although his light touch and sharp blunt discrimination of his lower limbs was partially present, it seemed that the chances of J.T. regaining full motor recovery of his LLs to be very slim.
J.T.’s overbearing mother was very concerned with his progress at the spinal gym and had attributed his lack of (R) hand activity to him being ‘lazy’. It was obvious that the severity of J.T.’s condition and his prognosis had not been explained to his mother, who without any assistance at home would struggle to look after her son independently. She seemed to be quite concerned that her child had been put under the responsibilities of two students, and attributed his slow progression to the fact that we were not ‘working him hard enough’. There were often times were we had both felt that the seriousness of her son’s condition needed to be explained to her, however as students we did not feel it was our place. We had asked on numerous occasions for her to speak with the surgeon and consultant regarding J.T.’s prognosis, however both these doctor’s seemed too hard to track down and no one was willing to take the responsibility of explaining her son’s situation. This continued for a month while we were at Shenton Park, and this was not the only case where a prognostic meeting had been missed. It seemed (from other cases) that some of the consultants were very good at ‘beating around the bush’ and even if a prognostic meeting was to be held, many family members left the meeting feeling confused or as if they had been given false hope. What would you do in this situation if a close family member of a patient had been left in the dark for so long?
J.T.’s overbearing mother was very concerned with his progress at the spinal gym and had attributed his lack of (R) hand activity to him being ‘lazy’. It was obvious that the severity of J.T.’s condition and his prognosis had not been explained to his mother, who without any assistance at home would struggle to look after her son independently. She seemed to be quite concerned that her child had been put under the responsibilities of two students, and attributed his slow progression to the fact that we were not ‘working him hard enough’. There were often times were we had both felt that the seriousness of her son’s condition needed to be explained to her, however as students we did not feel it was our place. We had asked on numerous occasions for her to speak with the surgeon and consultant regarding J.T.’s prognosis, however both these doctor’s seemed too hard to track down and no one was willing to take the responsibility of explaining her son’s situation. This continued for a month while we were at Shenton Park, and this was not the only case where a prognostic meeting had been missed. It seemed (from other cases) that some of the consultants were very good at ‘beating around the bush’ and even if a prognostic meeting was to be held, many family members left the meeting feeling confused or as if they had been given false hope. What would you do in this situation if a close family member of a patient had been left in the dark for so long?
Pain Relief
On my Muscol prac, my very first patient on my very first day was a new patient with a Doctors referral including the following things: pt has RA, ?OA of the knee, ?McConnels as X-ray shows evidence of maltracking patella, “however I feel this is not the whole story!”
I went about trying to find what the whole story may be. Subjectively she did not have a very positive opinion of physiotherapy, and being her first session, and my first patient the session took a while due to having to report to my supervisor several times.
The patient subjectively reported minimal irritability, so I planned my session accordingly, trying to be thorough. She was rather a large patient, observation revealed apparent genu valgus. Her quadriceps and hamstrings were very weak, and she was in need of VMO strengthening, and taping to help correct the problem of her painful knee. By the end of the session she was starting to report an increase in pain levels, so rather than give an extensive home program on the first session I decided to only give her IRQ exercise (with bias on VMO), and told her we would go into greater detail in the second session. I also suggested taping, but she said she didn’t want it, as she could not go around with taping for the rest of her life, as well as her sensitive skin. Even when I explained the tape would do the job until the muscles were strong enough to take over, and that Fixamol would decrease the likelihood of skin reaction, the patient declined. When asking her when a suitable time for the next appointment would be she replied she was unable to make a second appointment at that time and would have to ring back. She never rang back, nor did she answer letters or calls from the clinic.
From this experience I have learned that future patients presenting in this way primarily want decreased pain. I really should have spent more time educating her on pain relief rather than focusing on VMO, even though I believe that would have helped her in the long term, short term solutions would have meant I could have seen her again to work on the long term problems.
I went about trying to find what the whole story may be. Subjectively she did not have a very positive opinion of physiotherapy, and being her first session, and my first patient the session took a while due to having to report to my supervisor several times.
The patient subjectively reported minimal irritability, so I planned my session accordingly, trying to be thorough. She was rather a large patient, observation revealed apparent genu valgus. Her quadriceps and hamstrings were very weak, and she was in need of VMO strengthening, and taping to help correct the problem of her painful knee. By the end of the session she was starting to report an increase in pain levels, so rather than give an extensive home program on the first session I decided to only give her IRQ exercise (with bias on VMO), and told her we would go into greater detail in the second session. I also suggested taping, but she said she didn’t want it, as she could not go around with taping for the rest of her life, as well as her sensitive skin. Even when I explained the tape would do the job until the muscles were strong enough to take over, and that Fixamol would decrease the likelihood of skin reaction, the patient declined. When asking her when a suitable time for the next appointment would be she replied she was unable to make a second appointment at that time and would have to ring back. She never rang back, nor did she answer letters or calls from the clinic.
From this experience I have learned that future patients presenting in this way primarily want decreased pain. I really should have spent more time educating her on pain relief rather than focusing on VMO, even though I believe that would have helped her in the long term, short term solutions would have meant I could have seen her again to work on the long term problems.
Patients with multiple complaints
I am increasingly finding when I do subjectives on new patients that while they have been referred for PT post knee replacement say they also have pain in the contralateral knee, both shoudlers, an elbow and a big toe. When you ask "from your perspective what is your main concern at the moment?" a lot of the time it's actually "my shoulder pain" or "the fact i cant do the washing" when it was actually the knee they came to see you about. This is where I get stuck.
For the sake of being a wholistic PT I feel you shoudl really be treating all these problems but you cant even properly assess all the different problems let alone treat them in the allocated time. At the place where I am the general sugestion is just treat what they have been referred for and once thats fixed they can come for the other problems if they need. Time constraints wont let you treat everything at once but I would have thought coming to 2 seperate sessions in a week for two different problems could be a solution but that doesnt seem to happen.
I suppose my comment is just that I have really just discovered how complicated these patients are. The rules we are taught at uni for treatment and assessment seem to need modifying more times than they work. I always knew that patients are complicated but I would have thought that at least some patients for example 2 weeks post TKR might be easy.
A lot of the time I query my ability to actually make a difference to the patients' function when short of general advice on rest, activity and the use of heat and cold I am not even able to get around to treating the joint taht gives them the most concern. Has anyone else faced this dilema?
For the sake of being a wholistic PT I feel you shoudl really be treating all these problems but you cant even properly assess all the different problems let alone treat them in the allocated time. At the place where I am the general sugestion is just treat what they have been referred for and once thats fixed they can come for the other problems if they need. Time constraints wont let you treat everything at once but I would have thought coming to 2 seperate sessions in a week for two different problems could be a solution but that doesnt seem to happen.
I suppose my comment is just that I have really just discovered how complicated these patients are. The rules we are taught at uni for treatment and assessment seem to need modifying more times than they work. I always knew that patients are complicated but I would have thought that at least some patients for example 2 weeks post TKR might be easy.
A lot of the time I query my ability to actually make a difference to the patients' function when short of general advice on rest, activity and the use of heat and cold I am not even able to get around to treating the joint taht gives them the most concern. Has anyone else faced this dilema?
Sunday 3 June 2007
Stress #
Sorry about my over-sized last post, trying to keep it short this time:)
I have a patient who presented an graduate onset of shin pain (1-2 cm superior to medial malliolus). He had supinated foot (lack of pronation). He started rugby training (5k running twice a week and games on the weekend) beginning of this year before when he hadnt done any sports for a year. 2 month later, he developed this shin splint, aggrovating factors are walking in the morning, hopping and lots of pain when he wakes up in the morning, soleus stretch (passive DF with knee bent) also aggrevates his pain. Isometric tests around the ankle were all negative. He has very short calf (AROM DF=5 degree). My previous 2 treatment with him hasnt been sucessful (US, STM on Calf and later glide on STJ to increase pronation) since his pain score in functional test stays the same (4-5/10 on hopping). He heel strike when hopping on the symptomatic side. I am thinking about stress # however, looking up in the Sports Med book, the spot (above med malliolus) isnt a popular site for stress #(and this is the reason that my supervisor doesnt think it should be a strees #). Tuning fork or US can provoke symptom if applied on the site of stress #. I remember I applied contiuous US at 1.0Wat/cm on his painful site, he felt fine...so now I dont think it is a stress #. But what do you guys think? how can I treat this guy? any thought will be appreciated!
Simon
I have a patient who presented an graduate onset of shin pain (1-2 cm superior to medial malliolus). He had supinated foot (lack of pronation). He started rugby training (5k running twice a week and games on the weekend) beginning of this year before when he hadnt done any sports for a year. 2 month later, he developed this shin splint, aggrovating factors are walking in the morning, hopping and lots of pain when he wakes up in the morning, soleus stretch (passive DF with knee bent) also aggrevates his pain. Isometric tests around the ankle were all negative. He has very short calf (AROM DF=5 degree). My previous 2 treatment with him hasnt been sucessful (US, STM on Calf and later glide on STJ to increase pronation) since his pain score in functional test stays the same (4-5/10 on hopping). He heel strike when hopping on the symptomatic side. I am thinking about stress # however, looking up in the Sports Med book, the spot (above med malliolus) isnt a popular site for stress #(and this is the reason that my supervisor doesnt think it should be a strees #). Tuning fork or US can provoke symptom if applied on the site of stress #. I remember I applied contiuous US at 1.0Wat/cm on his painful site, he felt fine...so now I dont think it is a stress #. But what do you guys think? how can I treat this guy? any thought will be appreciated!
Simon
Difficulty with tutors (part 2)
I am increasingly finding that my tutors are disagreeing with each other and taking it out via me. For example, I had to write a very extensive SOAPIER report for my facility tutor, to which she claimed lacked in detail ans told me to write "query decreased AROM" for example if unable to fully assess AROM. My CCT then said it contained way too much detail and yelled at me for writing to many "queries". I pointed out that that was what my CCT wanted- apparently not a smart thing to say.....
As highlighted in my previous blog, my F/tutor is not very flexible in regards to me trying techniques on patients (under her supervision). I am finding this a problem ++ because my CCT stated that I need to improve my communication skills and treatment ideas for pts with extensive head injuries. I tried to explain to her my situation (without blamming my FT) and told her that the other physios tend to run treatment sessions. She said that I was obviously not trying hard enough and being interactive enough. I was really really frustrated and upset as I could not fully explain to her the difficulty of being in my position as well as the fact that I am not seeing nearly enough pts to improve or given enough supervision, despite seeking more. The fact that I could not fully explain my situation was partly due to there being no privacy on the ward (my F/tutor was listening to what I was saying) and also because I do not want to seem unprofessional by bad-mouthing my facility tutor to my CCT.
SO, i was wondering if any of you have any ideas in how i could cope more appropriately or improve my communication with both of my tutors in a professional manner,
Thanks,
Nicki
As highlighted in my previous blog, my F/tutor is not very flexible in regards to me trying techniques on patients (under her supervision). I am finding this a problem ++ because my CCT stated that I need to improve my communication skills and treatment ideas for pts with extensive head injuries. I tried to explain to her my situation (without blamming my FT) and told her that the other physios tend to run treatment sessions. She said that I was obviously not trying hard enough and being interactive enough. I was really really frustrated and upset as I could not fully explain to her the difficulty of being in my position as well as the fact that I am not seeing nearly enough pts to improve or given enough supervision, despite seeking more. The fact that I could not fully explain my situation was partly due to there being no privacy on the ward (my F/tutor was listening to what I was saying) and also because I do not want to seem unprofessional by bad-mouthing my facility tutor to my CCT.
SO, i was wondering if any of you have any ideas in how i could cope more appropriately or improve my communication with both of my tutors in a professional manner,
Thanks,
Nicki
Difficulty with tutors.. (part 1)
Hi everyone,
sorry for the late entry (was having toubles setting up the account). Here goes....
My prac has not gone very well from the onset. It started off with my tutor telling me that she "wasn't ready for another student yet" as well as being "too busy to give orientation", which she eventually gave to me last thing on Tueday aftternoon... Furthermore, I am finding it very hard to pretend like i am enjoying myself. I keep asking for more patients to see, despite my tutors refusal to let me see patients who I am not there to treat (half of the pts are neuro on the ward and half are ortho), so am only seeing one pt on my own / day. I also feel like i am not improving, as I see complicated low level patients with 2-3 other physios and tend to take over the sessions. I understand that my ideas may not be the best and may take extra time, but I am never given any le-way to try new things (or any treatment) on patients. This is despite my CCT asking my facility tutor to allow me to become more involved in treatment sessions. I asked if I could just follow my tutor around to see her treatment to try to improve, but she said no.
Furthermore, I am finding it very hard to know what to do and how to go about it, due to my tutor's disorginisation....she turns up late every day, only tells me the days plan at 10am and, is very contradictory. For example, she told me not to write pt notes till the 4th-5th week of placements and then became angry at me for not writing up pt notes during the past week I tried to subtly point out that she told me not to write notes and she became angrier as said she told me to start writing them later on in the placement -- (? maybe i should read minds for a living instead of doing physio)...
Therefore, I propose the question: When I've tried very hard to help, learn and be enthusiastic throughout the placement, how can i improve / pass this placement without actually seeing any patients til im assessed?
sorry for the late entry (was having toubles setting up the account). Here goes....
My prac has not gone very well from the onset. It started off with my tutor telling me that she "wasn't ready for another student yet" as well as being "too busy to give orientation", which she eventually gave to me last thing on Tueday aftternoon... Furthermore, I am finding it very hard to pretend like i am enjoying myself. I keep asking for more patients to see, despite my tutors refusal to let me see patients who I am not there to treat (half of the pts are neuro on the ward and half are ortho), so am only seeing one pt on my own / day. I also feel like i am not improving, as I see complicated low level patients with 2-3 other physios and tend to take over the sessions. I understand that my ideas may not be the best and may take extra time, but I am never given any le-way to try new things (or any treatment) on patients. This is despite my CCT asking my facility tutor to allow me to become more involved in treatment sessions. I asked if I could just follow my tutor around to see her treatment to try to improve, but she said no.
Furthermore, I am finding it very hard to know what to do and how to go about it, due to my tutor's disorginisation....she turns up late every day, only tells me the days plan at 10am and, is very contradictory. For example, she told me not to write pt notes till the 4th-5th week of placements and then became angry at me for not writing up pt notes during the past week I tried to subtly point out that she told me not to write notes and she became angrier as said she told me to start writing them later on in the placement -- (? maybe i should read minds for a living instead of doing physio)...
Therefore, I propose the question: When I've tried very hard to help, learn and be enthusiastic throughout the placement, how can i improve / pass this placement without actually seeing any patients til im assessed?
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