the over zealous pt

I have decided that even worse than the non-compliant pt is the over zealous pt! I have a patient at the moment who is only 4 / 52 post major joint replacement and has decided he no longer needs to stick to the surgeons post op precautions. He never reports any pain and thinks he is completely fine. He basically told me on my initial Ax that he feels its time to push on, he wants help to do it properly but if I didn’t help him he would move on with his programme anyway! I have done education +++ I have explained healing times, insurance companies and why you cant drive, the possibility of dislocation etc. He says he understands it but then says things like “you have to understand I am a lot younger and I need a higher level of function for my job so I can’t wait”. I got the feeling he had no respect for me and considered my education irrelevant.

The only thing that has actually helped is I got him in a hydro class and really pushed the strength and high level balance within the limits of his post op orders. By the end of the class he seemed to understand he can still do high level strengthening within the restricted range, he was feeling a little pain and could appreciate that he had worked hard and achieved a fair bit without having to push through the surgeon’s restrictions. It worked quite well too because the water prevented him from taking to much weight through the limb or being at risk of a fall. I felt like I was back in control of the Rx session and he was actually listening to me. I think, I hope, now he will take my advice regarding post-op orders a little more seriously too.

Tummy Time

Hi all,

I'm on my paeds prac at the moment, and I'm seeing lots of babies with torticollis, plagiocephaly and preferential head turn (so that assignment we did last year has come in really handy). From seeing quite a few of these infants, it really does highlight the importance of knowing what "normal" is, but also keeping in mind that "normal" has a huge range. There are so many different factors that might be affecting the infant, that we don't really consider. For example, playing in the prone position (or tummy time) is encouraged ++++++. However, I saw one baby that was incredibly chubby, and reportedly didn't like "tummy time", which wasn't that surprising because it wasn't a really easy position for him to be in because of his chubbiness. So, to encourage tummy time, we suggested that the baby could be held in the prone position by the mother when standing, with one leg up on a chair and the baby resting on the leg (because he was heavy). It really highlights that we need to look at the overall picture when we are assessing, because something that we might not have learnt about or expect may be affecting the patient, and we need to be able to give treatment that will actually help fix the problem, and consider that there are random things that will hinder the treatment, and we need to work around it, and not just give a prescribed treatment for every patient that we see who has the same problem.

Physiotherapists (or just actors?)

I've just begun my women's health prac and have realised how invaluable our body language/non verbal skills can be, especially when trying to teach a new mum about pelvic floor exercises when English is not her first language. The hospital has a good resource file of pamphlets in languages other than English, but despite reading these pamphlets most mums look at me blankly afterwards.

I've thoroughly enjoyed miming and using my hands to teach these ladies pelvic floor exercises, as have the nursing and medical staff who walk past the room and seen my performance too!

Central Key Point

Whilst on neuro prac, one of my patients, who presented with a stoke had a complicating kyphosis, which meant that her ‘normal’ O2 sats were around 86%, it was also hard to correct her postural alignment, as ‘normal’ for her was obviously different to true ‘normal’. One technique we learned during the prac was central key point - a facilitation technique to enhance posture. We tried this technique on our patient to see if we could change the posture, or if it were fixed. After a few days, with two sessions a day we thought a noticeable change in posture was evident; however we were looking for it and decided an objective measure would be in order. The patient also reported a decrease in breathlessness. After checking her O2 sats again we came up with a reading of 96%!!! We were unable to believe it, however sure enough, after several readings it was clarified that her sats had were at a raised level. We couldn’t be certain that it was only to do with the central key point, however we believe it did have at least something to do with it. Which just goes to show that there is a cross over in all areas of physio!

This technique also proved to be very useful for most stoke patients in enhancing posture (forward and contralaterally), it is a fantastic technique which i highly recommend for use across the spectrum.

Patient Outings

A patient I have been treating throughout my prac. requested a day visit on the weekend to a family members home. She was able to transfer sit to stand independently, however still required help for step around transfers (2 x min assist in physio – due to weakness of left LL). She gave us a weeks notice, and after chatting to our supervisor we decided that given medical clearance and her family being able to transfer her, she would be able to go. We arranged a wheelchair and a bed pan with OT, as well as a time with the family to teach chair to car transfers.

We thought that a slide board transfer was the best and safest way to go, and easiest for family members; however on seeing the car, and the massive gap between chair and car seat, had to change to a step around transfer. After demonstrating the technique to our patient’s daughter, and having her practice on us, she tried to transfer her mother. The technique worked transferring to the car, however coming out of the car the transfer was towards the hemiplegic side. A three person transfer was then required – as one person had to hold the unsteady wheelchair and one to place the foot. The daughter was unable to bend her knees to complete the transfer, so risked injuring herself and the whole thing just didn’t look quite right.

After a chat with the supervisor we decided the transfer just wasn’t safe enough, and recommended a wheelchair taxi. Understandably the family was very disappointed as they felt that it was safe, so we requested they came in again the next day for the senior physio to assess the transfer. The next day the family said after some thought they agreed with us and had booked the taxi… however unbeknownst to us a bed had become available at another rehab hospital, and our patient was to be transferred there that afternoon. The other hospital then said that she would most probably not be able to go on day leave… and it just goes to show the best laid plans…

So advise for similar situations would be to go with an instinct feeling, and not get caught up in family emotion, at least we knew that there weren’t going to be two patients coming back to hospital, not just one!

Physio on a ward

My first true ward experience has been on a neuro ward, and I must say it’s adds a whole new dimension to the word challenging. It’s not only your’s and your patient’s timetable you have to work around, but all the medical and other AH staff as well. One particular day comes to mind as particularly ‘dynamic’. After arranging our day in the morning, around patients appointments, each other’s timetables (as we worked in pairs for some patients), as well as clearing times with nursing staff, it seemed that none of our plans were going to work out. Even after helping nursing staff to get our patients ready, we were all running behind, and eventually were unable to see many of our patients that morning. The afternoon seemed to run a little smoother, except when I got to one of my patients who had been up and took a few steps in her room (but still remained a hoist transfer on the ward) the day before. I started to assess her more formally – including going through the Stroke Assessment form, and realized she had deteriorated quite a lot. Before I was able to test ‘muscle strength’ her nurse came in and asked if she could be taken to the toilet. I did not want to get the patient up again before doing some sort of muscle and voluntary control assessment, and so proceeded to do this. The nurse came in again two minutes later and told me that it was rather urgent that the patient went to the toilet, and told me to walk her. Eventually I did get the patient up (with 2 by min assistance), however found her gait was VERY slow. It took us 15 mins to walk about a meter. Eventually another nurse came in to help us, but left shortly after stating she would be back soon.

To cut a long story short, the other physio student helping me had to go, and I was left with the patient to take her and stay with her in the toilet, and get her back to bed again. It was an awkward situation, one which I believe I was unable to effectively do on my own – or even with the help of another physio student. By the time I got her back to bed, my session was over and the patient missed out on effective treatment for the whole day. The next day, the same nurse came in at the beginning of my session again and requested I do the same thing – despite me having written her as a definite hoist transfer on the ward. This time I asked for her help, however she said I only needed two people (myself and the other physio student), so I merely asked her to watch while I demonstrated the patients complete inability to carry out the task. She then requested that we hoist the patient to the commode and take her to the toilet. I did not know how to use it, nor feel safe operating it, so she said she’d show us and leave us to it….

To cut an even longer story short, the nurse helped us to carry out the hoist transfer and stayed with the patient this time, however begrudgingly. Soon after I informed my supervisor as it was more than a one off occurrence, and my patient was missing out on treatment time due to the situation. My question: Is it right to say no when a nurse asks you to toilet a patient in the above outlined situation?

Patient Compliance

In the clinic I am in at the moment, I had one lady with post muscle tear and fracture of the shoulder who is 2 months down the track in terms of rehabilitation, but her active range was shocking on examination. When I asked her if it was possible to take her shirt off so I could palpate the area and the effected mm groups while she moves and access her shoulder passively, she replied 'if I have to take my clothes off, I'm never going to come in again'. This lady was also refered by the doctors to begin hydrotherapy. I couldn't imagine anything worse for this lady, if she was so uncomfortable removing her top, let alone wearing bathers in a group of 8 others. This lady self discharged herself when really she was not appropriate for discharge. I wanted to give this lady a call to convince her that she really needed physiotherapy but I'm not sure whether it's appropriate or not. Any suggestions?

Disclosure?

On my neuro prac I treated a man from day one post stoke who presented with comparatively very mild symptoms. That is mild weakness in the LL and UL on one side, slight sensation loss LL > UL in that side, and once the doctors deemed him medically stable, mild gait deviations. He asked me on a number of occasions if people were as bad as him, if they had as many problems as he did. I tried to assure him that he was getting better each day, and just how good his strength was (within a few days, L = R). However I’m not sure he actually believed me, as ‘better’ is a relative term. I realized that I couldn’t say just how dependent my other patients were, nor how good he was in comparison. I was wondering if anyone had come across a similar situation, in which you just want to say: ‘You’re actually really, really good compared to most other patients!’

In the end I was able to take my patient to the gym, and other much more dependent, non ambulant patients happened to be in the gym at the same time. I think he got the message, and then said to me just how lucky he was.