bacterial menigitis

im currently on a rural placement in far north WA. a 15 year old aboriginal boy form halls creek was transfered to darwin by air med (NT version of RFDS) with an acute case of bacterial meningitis. He was extreemly unwell and not expected to live.

He pulled through and has now been transfered back to our dept to continue neuro rehab following the infection. He is currently walking independantly and his major problems are cognitive, fine motor and sensory defecits. So far Rx has included working with the OT to improve fine motor skills and work on improving proprioception (UL affected greater than lower limb).

The department is working together to improve his function so he is able to return home to halls creek ASAP. This patient shows severe developmental delays (ie. he cant write his name and doesnt know if he is left or right handed). We are currently trying to determine whether these problems were pre or post infection. On consulting with his teachers, It appears that there may have been a degree of developmental delay and substance abuse prior to the infection.

For physiotherapy, this patient is very challenging.He has a very short attention span and rarely engages with the staff. He will walk out a treatment session mid Rx once he is bored. We have tried to make activities more functional and interesting with short sessions as often as possible (yet up here resources are very stretched!!). He is very motivated but fails to succeed and he is getting very frustrated (as are we!!!)

On the weekend he was allowed to return to halls creek for the weekend (with the physio) and return via bus on Monday. It is now tuesday and we have seen no site of him. As they live rurally with no phone, we have to get the aboriginal social workers to go bush and track them down.

SO not only are we dealing with an extreemly rare condition in a young boy who doent want to be in hospital and has decided to go walk about. How do we get maximal results and keep this kid interested so he can improve?????

Paediatric placement stirs the heart strings

I've been really touched by the patients I've seen this last week at PMH. I'm on the oncology ward and dealing with a wide spectrum of cancers and ages and good/bad prognosis. Almost every kid has brought a tear to my eye, but their strength of character is amazing during these difficult times and has a direct relationship with the attitude of family and doctors and all support staff.

Of course there are hard times but when I see kids who have to be in isolation for a month following stem cell transplant and are limited to a 5mx5m area I just don't know how they cope...

Its also great to see the kid who has been really unwell all week and sleeping most of it, finally smile as he starts to get over the chemotherapy.

It has really brought to light the psychosocial aspect of treatment, and each week a team of ~15 staff from every health field meet to talk only about the psychosocial care of these kids. The medical team are amazing and every aspect of their care is well thought out and discussed as a team... here's a great example of a medical/alloed health team.

patient with dimentia

In my rural prac, i had a patient who needs transfer assessment for discharge. She has early stage dimentia. She is 1xminimum assistant supine to SOEB.I thought that a bed rail will be benefitial for her transfer at home sinceshe lives alone. However, she refused it and stated that she can 'grabeon something' to sit up on the edge of bed at home like a walking frame.I told her that it is not safe and she said 'I will grabe on something else'. I told her that (according to her son) she has nothing at hometo help with bed transfer. Then she said she will grabe her frame. I I dont think I am going to win this case because she will just simply goon and on around the circle with me.Anysuggestion here?

To walk or not to walk...

One of the hardest things I’ve found on my Cardio prac so far is finding the balance between leaving patients alone, and trying to help them. I understand the importance of rest for these patients, some of whom are quite unwell, as well as the benefits of getting them up and moving to prevent further complications. Many patients, especially those of the older generation have the belief that as they are unwell they should stay in bed. In the last week I have spent most of my time chatting to these patients and ‘coming back later’ to check if they are ready yet to go for a walk. It works at the moment, but I realise as a new graduate and beyond, I will not have the luxury of that much time. The best way I’ve found to get around this problem is to compromise with a shorter treatment time. It also seems to be a lot easier once you have built up rapport with the patient (I had a win on Friday with a patient who previously wasn’t keen to ambulate!). If anyone has any other suggestions I would be most grateful.

How Embarrassment!

This is a story of an event which just so happened to occur today. My student partner and I were to ambulate an 80 y.o. man via zimmer frame, 2 days post op after an anterior resection of his bowel. As this was both our first cardio prac and we had minimal experience ambulating patients with multiple attachments, this proved more difficult than first thought. After taking time to plan our treatment area and positioning for each of the attachments (IDC, epidural, hemivac, nasogastric tube, nasal prongs) we began assisting our patient with ambulation. After a few meters he had began to speed up so we asked him to slow down, but by this stage he was now complaining that his attachments were beginning to pull. As he was unsteady on his feet, my partner and I found it difficult to both move the stand and portable oxygen, whilst guarding the patient at the same time. We decided to turn around and return him to bed but upon return his nasogastric tube had become loose and became removed as he leant forward on his zimmer frame. Despite having an understandably grumpy patient on our hands, we then had to inform the nurse, and as expected this did not go down well at all. This was a lesson learnt the hard way that we will never forget. Moral of the story, always carry tape and safety pins with you on a surgical ward! You will need these to pin the various attachments to the patient’s gown.

Developmental Delay?

There are many paediatric community settings in Singapore, most of these are accellerated learning programs. Its interesting though that even though the child is not delayed in any sense, the parents would send their child for 'extra practice' so their child would out shine the rest. These programs are so intense ranging from 2yr old to 16yrs old, I find my self incompetent at year 9 maths, because it was acturally calculus!

So this leads me to the question, what is cognitive developmental delay? If the expectations are so high on every child, the poor soul would get a scholding if he/she was unable to perform algebra at 12. This is the norm for a singaporean child. Incredibly scary, but these children are incredibly smart. So what if the child doesn't meet the norm? Well, they are classified as 'developmentally delayed'. The fact that they start to learn what we learnt at yr 1 when they're 2yrs old, it's not that hard for them to perform complicated equations at 12 or 13 etc. In this case, the children who are really developmentally delayed ( western classification) are handicapped and the ones that are slow to learn(but really a normal child who's just better in certain areas than others) are delvelopmentally delayed. I feel so sorry for these children, because I don't think they know what is 'play' or 'fun'.

upset patients

Hey guys, I think I missed last week I can't find a fourth post so here is another one.

Do you remember that OSPE we had for Penny's class where the patient was an actor and had a breakdown in the middle of treatment. I think that was a good assignment because it made you think way back in second year that the patients are actually people and can do unexpected things- a very valuable lesson as it turns out.

This last week I have had 2 patients (both I had been seeing reguarly for shoulder pain) cry during treatment sessions about things completely unrelated to physio or their injury. I have to say although that exam in 2nd year terrified me the situation didn't throw me at all in real life.

With both patients I chatted to them about what they were crying about, applied a heat pack for a while and gave them a gentle ST release (indicated through previus Ax in both cases). In terms of progressing their treatment all I did was to check their HEP exs and encouraged gentle stretching of UT and Cx mobility exs to ease tension.

In both cases my supervisor was perfectly happy. He agreed it would have been inapprpriate to push them further under the circumstances (both patients had pretty substantial things to be crying about by anyone's standards). I was comforatable I had made the right decision because having seen both patients for a while I had built up rapport with them. However I was concerned that since my supervisor didn't know the patients he might not have been happy with me doing so little hands on treatment. So I was pleased he agreed with my line of treatment.

Chronic pain patient

Wow these patients seem to be following me from prac to prac. This particular chronic pain patient is 2 years post MVA and had recieved a full year of passive PT (mobs and ST massage) and chiropractis treatment at the expense of the insurance company- this improved her pain and dizziness markedly. She then came to the hospital I was at and the previous student did a further 5/52 of passive Rx which also improved her pain.

I then came along- luckily on that day accompanied by my CCT who advised me to go completely hands off. At the end of the first Rx session where I gave her deep neck flexor exs, postural correction, mobility exs, stretching and heat application as well as education ++++ she turned to me and said so no physio today then? Clearly the message hadn't got through. I then explained that PT= exercises not just passive treatment. She was most unhappy with this and I thought she might DNA after that.

She didn't, she kept coming back which was great, but every Rx session reported incraeased pain (usually 10/10 or more) dizziness, nausea etc. Now I know that passive treatments are not the answer for these patients and I have done exercise programmes instead for heaps of patients but it gets so much harder when someone else has already given them the passive treatment, and even worse when it has worked.I think if I hadn't had my CCT pushing me to stick to my Rx choice I would have given in and at least tried both. I suppose both might work too with some patients but the student before had given the patient one HEP exs an UT stretch and she couldn't even remember that- she was just so fixated on the hands on treatment she couldnt even combine it with active exs and my CCT thought it was best to just leave passive treatment for a period of time.

Physio Meetings

Hi all,

Last week I attended a meeting with my supervisor for Paediatric Development Physios in WA. They have this meeting once every two months, and quite often they develop tools and assessment forms for the common conditions that they see. It was really interesting to see how a group of physios interact in a meeting situation. At this particular meeting, they were asked to develop a list of the common conditions they see and the assessment and treatment tools they use so they could pass this information on to people who refer kids to them (eg community health nurses). What was interesting is that even though they all worked in the same area, the variety of kids they saw was quite amazing. Some would only accept kids under a certain age, and some would see more of one type than another. It really showed me how diverse a particular area can be, as well as when you are a physio, you do have some choice of who you want to see in some situations. It is also really good to see that even though there is diversity, there is also unity between physios, and that when people work as a team, they can provide incredibly useful information. This group of physios was also a kind of support network, which is really good, because in this area, you are mainly working in a facility where there are only 1 or 2 physios, so having a support network would be really beneficial.

Business vs Healthcare

For all of you out there who have heard the different levels of medial treatment that different classes of people receive in hospitals in Singapore well, here it goes. Class C- no air conditioning and patient pays for all costs including blueys :. these patients bring everything and they share a room with 8 people. Class B2 has no air conditioning, where as Class B1 has but patient still pays for everything, 4-6 people share 1 room depending on your luck. Class A has 2 beds per room, some items are government subsidised. Class A1 which are presidential suites and the best rooms that hospitals provide is ~45 square metres with huge plasma, dining room, ensuite, bar and views overlooking the ocean.

In terms of Physiotherapy treatment...as the patients needs to pay for everything, physios don't really have a part for the C and B2 classes because most patients don't want to waste money to see a physio! These wards are run by junior doctors with a registra over looking . As we move up the ranks to A class, these patients are looked after by only consultants and these patients are extremely demanding. Some patients will request that the physio to come on sunday or after dinner because it suites their timetable.

In terms of the treatment provided, the consultant's knowledge and experience will definately be more superior than that of junior doctors. The fact that most Class A or A1 patients are referred by the doctor for physio when they don't need it, yet some of the C class patients will really benefit from our treatment but is unable to afford it really frustrates me. I queried the staff in the hospital and they all say that it's just the way it is. If they don't provide top quality treatment for the upper class, they'll make a loss, and if they provide too much for the lower class, the hospital will also make a loss. What a sad medical system when there are more than 30 hospitals in such a small country with 85 % being private hospitals...is this business or healthcare?

Exercise and Pregnancy

I amazed at the number of ladies I've seen over the past 4 weeks who seem to have decided that its just too hard to exercise anymore once their bump gets a little too big. There is a strong correlation (observed by me) between ladies who have difficulties (pubic symphysis pain, SIJ pain, leg pain) through their pregnancy and don't exercise.

Maybe its because they're having difficulties that they don't exercise (I don't know), or that they were never one to exercise in the first place. But having observed a birth, I can fully appreciate now the amount of energy required to get through the experience and the fitter you are the better. Speaking to all the ladies who have had 'dream' labours - quick, and with nil complications were all very active right up until labour first began...

Let it be a lesson to all us females, and to males: don't let your partner get away with being too lazy during the pregnancy!!

Expectations

Hi all,

This week with my Clinical Tutor I was seeing a 13 month old boy who was referred because he wasn't sitting much independently and wasn't yet 4 pt crawling. He also had been diagnosed with a seizure disorder approx 6 months before, and is on medication for it. I (and my tutor) were expecting to see a kid who was not really moving much, possibly low tone. However, this was absolutely not the case. The child we saw was very active, he was 4 pt crawling (the referral was a month old, and in that month he had started 4 pt crawling). He went exploring all over the room, and quickly moved his attention from one thing to the next. Both my tutor and I were astounded at the difference between what we expected and what we saw. What I learnt from this is that even with a detailed referral, you cannot predict what a child or any other pt will be like. Sure, it's good to have an idea of what could be wrong with the pt in order to direct your attention to certain features that could affect assessment and treatment, but it is really important to keep an open mind and expect the unexpected!

Proven: ultrasound works...I saw it!

Not wanting to undermine the research or make you believe that I never thought ultrsaound worked as we listened to our EPA 252 lectures, rather, I just hadn't realised the scope of its use.

For the first time last week I ultrasounded a ladies haemmarhoids that had developed as a result of labour. The patient had tried everything under the sun to manage them, but it was only on a friends advice that she decided to try ultrasound treatment.

The result was remarkable. The gel is quite soothing to the skin, but to my amazement the haemmarhoids softened and literally shrivelled with 10 minutes of treatment to 1/2 to 2/3 of their original size. The results were maintained overnight and on treatment the next day we managed to shrink them again.

Yes, Danielle, I am now a believer, it works!

organised swelling

This is just a note of something a physio on my prac called me in to see on one of his patients because he felt it was of particular interest. The patient was a 78 year old lady post fractured shaft of humerus. She had been immobilised for a six week period finishing 3 weeks prior to my seeing her and had not been referred for physio so had literally just sat with her arm in a collar and cuff for that time. When I saw her she had this huge collection of tissue around her distal humerus, elbow and proximal forearm. She had a significant biceps contracture with 20 degree lack in active and passive extension. I was just amazed at this extra tissue, it wasn't soft and fluid like regular extra articular swelling but it was palpable in the axtra-articular tissue. It was hard but not quite as hard as bone and since the patient has no pain on palpation you could sink quite firmly into it and differentiate it from the neighbouring bones. The fracture site was more proximal but the swelling had just tracked distally and acumulated and organised into this fibrous lump in places protruding up to 4cm from where the skin should have been. The wrist and hand luckily had been spared as the arm was immobilised in elbow flexion with the hand sitting near the contralateral shoulder. The management the physio had undertaken was massage, ultrasound and active extension. The physio felt that over the last 3 weeks this had been successful with a slight softening of areas of the tissue and an increase in elbow extension range. He was however doubtfull that full recovery would be possible. Interesting to see I thought although quite dissapointing that it had occured given that it could have been prevented, or at least decreased, you would think by proper swelling management and movement within restriction during the 6 weeks.

Communication

Working in a paediactric setting in Singapore was very interesting especially in terms of communication. Communication with children of all ages was difficult enough, but in a couple of different languages was even more challenging. Even though most people here speaks english, but it's on all different levels. The hospital I'm working in is a public hospital :. the patients are of a mid-low social-economic background. Their languages range from English, Malay, Mandarin, Hokkien and other dialects but patients usually speaks a mixture of all of the above...and I just get so confused. My tactic was to read body language. I had a 7 yr old boy who presented with spastic diplegia came to clinic and the first question was ' when will it finish?'. About 5 minutes into therapy, I was thinking of all sorts of different ways to motivate the kid to walk up stairs...it was really energy consuming.

Parents and paeds

Hi all,

I'm on my paediatrics prac at the moment. A lot of the stuff that I'm seeing is developmental problems such as delayed development. Something that is different about doing paeds is that the involvement of the parents is very important. I know that it sounds obvious, but without the parent's help and motivation, the outcome will not be the optimal outcome. For example, I saw a 4yr old for the 2nd time this week, and one of his problems was decreased ball skills. When I first saw him, his mum watched what he was doing throughout the treatment session (where one of the things we were working on was ball skills), and at the end of the session my supervisor asked them to practice some throwing and catching at home. The 2nd time I saw him, his ball skills (particularly in catching) had improved dramatically. It was really good to see such an improvement, just in one week. It really did show the importance of the parent, as well as the importance of the parent's paying a bit of attention during the treatment session, which we can do by getting them involved in the treatment session.

Paediatric experience.

Hi everyone, recently I've just started a placement in Singapore in paediatrics. My patients range from neonates to 16 yr olds with a wide variety of conditions such as CP, TEV, DDH, scoliosis, fragile-x, SB etc musculoskeletal issues. The health care system here is very different, each physio only has roughly 1/2hr to see each patient regardless if it's a neuro or ms or cardio problem, they have long working hours 8-5:30 everyday and after hours care. They cram in patients whenever they have the time, very much like a private practice except a whole lot bigger. What striked me the most was the fact that there are a huge population of disabled children in singapore, and a large percentage of these children all attend therapy with a maid ( common for every house hold) instead of there parents. So far in my third day i've only seen 1 child accompanied my her family, but the father refuses to come into the treatment room. I'm not sure whether the parents are traumatised because of there child's condition and that's why they don't want to attend or that they can not be bothered? The child needs a warm and supportive environment especially at this age, is the maid sufficient?