Little goes and long way

Hello all,

Just wanted to speak about something that I am really enjoying on this prac (Musculo at Curtin). I have recently been treating some fabulous elderly people. They have been coming in with many different problems; knees, shoulder, backs. As a student, it's all still quite new to you and you put so much pressure on yourself to remember everything you possibly can and do everything for them that you possibly can. Now, we all know that this is absolutley impossible to do in one session. So when the patient is about to leave and you feel like you have not fully gotten to the bottom of their problem and have "only done" a little of this and a little of that you don't feel so good. However! This all changes when the patient smiles at you and says "wow that feels much better" or is in such gratutude to you for explaining to them a little bit about there problem or even for giving them a simple home exercise program.

I just wanted to say that this really makes it feel all worth while and that even if you think you don't know enough you know a whole lot more than they do and for that they are so greatful!

Nicole

How to tactfully tell someone to lose weight

At my orthopedic outpatient practical placement I came across a 43 year old woman who has had a right Total Knee Replacement 7 months ago. Her rehabilitation has been going very slow and she’s still walking with one, sometimes two crutches.

When I first assessed her it wasn’t so much her right knee that seemed to be hindering her in her gait so much as the malalignment of her left lower extremity. She’s got a very strong valgus knee and pronation of her foot to the stage where she’s practically weightbearing on her medial malleolus. The patient told me that her left ankle and knee will be up for surgery as soon as possible.

The biggest factor for her joint problems is most likely a result of the patient being heavily overweight.

Being a physiotherapy student and knowing about the relationship of obesity and knee osteoarthritis the first thing I could think of was: this patient needs to lose weight.

So I approached the obvious and suggested the patient would start going to the pool. She could do her knee exercises in the water and at the same time getting a good work out without putting a lot of stress on her joints.

My patient wasn’t too happy about this suggestion and replied she didn’t want to go to the pool with all those skinny people. Well...

From my point of view the only way this patient could do aerobic exercise to help her losing weight would either be in the pool or on an ergometer, which she isn’t willing to do.

How could I motivate her to get out there and tackle her weight? Has anyone come across similar situations and how did you handle it?

Edith

Nursing Staff

One issue that's come up on my clinic this week is what to do when nursing staff aren't doing their job.....quite literally. We had a patient this week who we had booked for 9am....As we were trying to get the ward into a routine, we saw this pt at 9am every day for the 4 mornings we were there. The first morning we had to wait 45 minutes to get the pt as he was still getting ready for the day - showering, shaving etc.....we were quite annoyed but also considerate that the nursing staff can't do everything you wish.....however it was written in both the ward diary, the board and had been discussed with nursing staff the afternoon before. We had also been assured from both the physio staff and the nursing staff that having a pt ready for 9am should not be a problem.

The second day we went in to ask the nursing staff at 8.30 if they would have our pt ready, we were told 'yes, yes ready for 10am' DESPITE it being written again in the diary, on the board, and handed over the day before......and it was the SAME nurse from the day previously, SO our supervisor interrupted the 'getting ready' process and negotiated with our pt to have a shower etc when he got back from physio....which wasn't a problem. Despite the pt being a little upset he hadn't had a shower before physio, he was still happy to come.

The next day, we went in to see how he was going at 8.30ish.....and the pt was still in bed! (same nurse again too). So again, we took the pt to physio, also assisted the nursing staff with transfers etc of him and other pt's in the same room, and took him to the gym. He complained that he did not get a shower the day before due to physio and that he would prefer to have a shower before physio as if he didn't have a shower between 9 and 10 - he simply wouldn't get one for the day....and this was the second day. So....we reassured the pt that the nursing staff would shower him when he got back, and that we would see why he didn't get a shower the day before. You can't really say to someone 'you should have at least received a shower yesterday' and undermine nursing staff.....and you can't simply just say 'oh they must have been really busy' because really - it's a shower!! I was also wondering if I should believe my pt.....he is of considerable age and he is suffering some communication problems.....and I was also concerned that he may have just made it up to try and get out of physio. I didn't want to jump up and down about it if he hadn't received a shower - I was a bit unsure of what to say and do about it - so I decided to wait and see if the problem continued. We liaised with the nursing staff looking after the pt and he reassured us he would be ready by 9 the next day. I also wrote in the 'S' part of our notes that the pt had c/o not receiving a shower the previous day- hoping some kind of response would be in there....to no avail.

The third day.....we went to pick up our pt....he was on the commode....still not showered. So again we helped the nursing staff with transfers....and took the pt to the gym for physio. Not wanting to look like I didn't care, and feeling quite confident that the pt would've received a shower the second day I asked him if he got a shower the day before....to which the answer was no. By looking at the pt's hair and face, it was clear that he hadn't washed his hair (which during he first week was washed every day) and was also not cleanly shaven as per usual as well - so that confirmed it to me that he wasn't receiving a shower, and this pt was not unreliable with anything else. I found myself feeling quite angry that a) this pt's BASIC care was not being carried out and b) it was also contributing to the pt not wanting to attend physio - which it was hard enough trying to get the pt to attend and concentrate.

The pt was trying to negotiate with us to come at 9.30 as the nurse simply didn't have time to get him ready, and continued as to how the nurse was quite rude and rough with his hemi sided shoulder....which we had also witnessed. So...my action was to reassure the pt that he was getting a shower with the OT assessment following physio (he was really worried about not having a shower - this was day 3 and his family were coming in to take him out to lunch), and that we would discuss with the nursing coordinator and tell them that he was not receiving a shower. We also had to reassure the patient that he was supposed to receive a shower each day while he is in hospital.

I carefully approached the subject with my supervisor- not wanting to look like a 'dobber'....and just said....that our 9am pt was complaining of not having a shower for a couple of days....due to attending physio at this time....She immediately asked me if it was the particular nurse involved....and then made it very easy and clear that she would discuss it further with the nursing coordinator as she also had some other issues to raise regarding that nurse. SO...in the end - I didn't have to discuss staff performance with the nursing coordinator (which was a bit of a relief I must admit), and the pt has since been practicing showering with OT each day. The supervisor also reassured me quite adamantly that it should NOT be a problem that a pt is ready for 9am.

One thing that has surprised me, is that our role is not only as 'physio' to provide treatment etc, but we also are required to be an advocate for our pt's in particular scenarios.......So I learnt that it is more than acceptable to stand up for your pt's in this kind of situation - despite being students and it is actually the 110% right thing to do!

Mads

Death

Thought that title would catch your eyes :)
On my cardio clinic we're dealing with a lot of people that are coming in with exacerbation of COPD, and stuff like end stage emphysema. So pretty much people that are really not well. A problem that I've been finding a bit hard to deal with is being in there with a patient and clearing their chest or what have you and knowing or at least feeling that your looking at a person that is on their way out. Or even worse patients that keep saying how they hope they don't wake up in the morning or that they wish they could die. Kinda hard to encourage someone that wants to be dead or someone that looks like they'll be dead in a matter of days.
A pt Claire and I went in to see the other day. Looked at his notes, he had a bad liver prognosis, but it didn't look too bad. So we go in with our happy faces on to get him up and out of bed. We get in there and he says 'I'm sure physio is good for you. But after just being told that there is nothing more they can do for you, and that you have 3 cancers eating away at your body, I don't feel like doing anything please.'
I think that physios by nature are very caring people who truly care about the what happens to their patients. Much like any other health care professional who's not in it for the money :)
So I guess my question is how do you do you present that caring side even when the patient is on their way out?
Ps 1 of my patients died today. Not while I was seeing him though. And another one who took for a walk liked like he was on his last leg when he sat down for a break, and was shaking and crying and not looking in a good way.

Building Rapport

Two weeks into my placement now I am beginning to feel more at ease and have noticed an increase in confidence in my role as a cardiothoracic physiotherapist. In previous placements, I have always been given positive feedback about my ability to build rapport with patients. Even today, I had my midway assessment and both my clinical tutor and my supervisor commented on this as one of my strengths. The problem is, I have one patient who for the life of me I can’t seem to get onside. We’ll call him Mr. C.

Mr. C has been a patient on my ward for two weeks now, and I have tried everything I can think of to get him to participate in physio sessions. Every morning I walk into his room, smile and ask him how he is doing, and suggest I help him get ready and get him out of bed to go for a walk (to progress his mobility). And every morning, I get the same response: “Not today, maybe tomorrow”. After a few days of this, I thought to myself perhaps he’s just not a morning person. So after lunch I tried the same approach but got the same response… maybe tomorrow.

After a week of not being able to ambulate Mr. C (who by the way, was keen to ambulate with any of the nurses… but only to the toilet and back), I figured it was time for some drastic measures. I coordinated with the nurse and after she had ambulated Mr. C to the toilet she came and got me so that I could ambulate him once he had finished. When Mr. C called out to the nurse that he was done in the toilet and ready to go back to bed I opened the door and saw the look on his face when he saw me and said “Oh, it’s you… not today, maybe tomorrow”. He made me go get the nurse instead.

So far progressing Mr C’s ambulation has been Mission Impossible!

I understand that it’s not just me, as Mr C has been refusing physio input from my supervisor as well. It is very difficult and frustrating however, as unless his mobility is progressed to his pre-admission status he will be unable to return home. My supervisor is a recent new grad and she too is out of ideas on how we can get Mr C on side with us for his treatment.

Does anyone else have any suggestions?

Communication

Hey all,
As I near completion of my second week of cardiopulmonary, I have a story for you about a 60 year old widow, who for privacy, we will call Ted.
Ted arrived on my ward seven days ago, having undergone a MVR one day previous. When I first meet Ted he was a quiet, but pleasant man. He was compliant with physio and our session run without hiccup. We built rapport and I even managed to get the occasionally joke out of him. I noticed that, unlike the majority of our patients, he did not receive many (if any) visitors. I felt sorry that Ted had to undergo this major operation on his own; I knew that he had tragically lost his wife a couple of years ago and that they did not have any children. I tried to pop in or give him a wave as passed by, but with a full case load I couldn’t really afford to spend the time just socialising.
Over the next couple of days I noticed a change in Ted’s behaviour, he didn’t seem very keen to ambulate on the ward nor participate in any exercises, he wasn’t making jokes and nursing staff kept saying how grumpy he was.
I knew he was waiting to hear whether or not he would require a pacemaker. For those of you who are unaware, in order for a person to receive a pacemaker they must first be seen by a cardiologist. The cardiologist must come onto the ward and examine the patient. The problem with this is that it may take days for them to be able to get up onto the ward and see the patient. Often patients wait around for days not knowing when they will be seen. As you may imagine this proves very frustrating for a once active person.
After talking with nursing staff and Ted, I discovered there was a bit of a problem with communication Ted was told five days ago that the cardiologist would be into see him that day, when the specialist did not arrive he was simply told, she’ll be in tomorrow. This cycle continued for the next five days and still today he has not been seen. When I found out this information I spoke to the nursing staff, they said that don’t have control over when the specialists come up and they are told one thing and then something changes and they don’t arrive. I discussed with them that this was distressing Ted, as an elderly single man he likes structure and to know what is going on and when. We decided to go and have a chat with Ted to try and relieve any concerns or frustrations he was having. Once we explained that we really couldn’t be sure when the cardiologist would arrive and that he wasn’t going to be forgotten he seemed to be a little relieved. He also commented that he felt like certain medical staff only ever spoke over him and amongst themselves, he referred to them as the ‘secret society’. We said we would try and find out what was going on and relay the information to him. It was also obvious that part of his hostility was due to the fact that he was just plain bored. I decided to take him down to the gym and get him exercising on the bike and doing some other different exercises just to mix it up a little. He responded well to this, I think the fact that he now felt like we were actually talking to him and were honest about the cardiologist made him feel more at ease and willing to comply with treatment.

VBI

I hope clinic is going well for everyone. I wanted to bring up the topic of vertebral basilar insufficiency. At Curtin Clinic, patients with neck pain are routinely asked for whether they have symptoms of vertebral basilar insufficiency. The checklist of symptoms include a history of any of the following: dizziness, drop attacks, dysarthria, dysphagia, and double vision (the five “D’s”). Other commonly asked symptoms are the presence of unilateral tongue and face paresthesia, ataxia, hemianaesthesia and hemiplegia. I wonder as to the purpose of these screening questions.

Depending on your reference, there is a 1/100000 to 1/1000000 chance of suffering a stroke from cervical manipulations. The stroke usually occurs in the vertebral artery or the PICA, causing a lateral medullary syndrome. Theoretically, spasm of the vertebral artery can occur, causing a possible embolism. This usually occurs at the C1-2 area, where the vertebral artery takes a tortuous course before entering the foramen magnum. Manipulations to this area of the spine can physically stretch the artery and set off arterial spasm, in particular those with congenitally short vertebral arteries. My understanding is that positive responses to these screening questions would contraindicate the use of cervical manipulations. If the VBI screening questions are meant to exclude patients from receiving cervical manipulations, why ask about possible symptoms that can occur secondary to cervical manipulations before they occur?

The logical answer is that the VBI screening questions are not simply meant to identify those who are at higher risk of suffering a stroke from cervical manipulations, but have implications on assessment and treatment techniques. If that is so, what kind of patient besides those who had suffered a vertebrobasilar stroke has symptoms of drop attacks, dysarthria, dysphagia, and double vision? Can a person turn their head to EROM and cause immediate VBI symptoms such as dysarthria? (If they did, would they be able to tell you about it? - THAT IS A JOKE) Dizziness doesn’t really count, since many conditions can result in dizziness, like middle ear infections and Meniere’s disease.

I am sure there are good reasons behind asking these screening questions. Petty (one of our many musculoskeletal texts) referenced Bogduk (1994) for including the VBI questions as a part of a subjective. Bogduk is a big time researcher from the Uni of Newcastle and his work is usually taken as gospel. Nonetheless, Petty did not give the rationale behind using the screening questions. I have not found an answer for it, (actually I haven’t looked too hard). I wanted to bounce the question around this forum to get some ideas before I get some answers (starting with my clinical supervisor, then the article by Bogduk). Thanks.