Lasts weeks prac

During my last weeks prac I was so busy finishing my last SOPIE report, preparing for my cardio presentation, that I had no time to do any PCR preparation. That includes musculoskeletal and neuro subjects.

The good thing that came out of this cardio placement that I feel that I am fully prepared for PCR exam and don’t really need to do any extra work. Although other two subjects definitely need some more revision to do.

Anyway my friends this is a short reflection on my last weeks experience as I have to rush to do my final PCR preparation and catch up on same sleep, as I want to have my brains functioning in full capacity during PCR.

Can’t wait for the graduation dinner to see you all there, and have same time off before our rural placement begins.
Just lastly want to wish you all the best luck for PCR.
See you at graduation dinner!

Discharge Discharge Discharge

I have recently had some big issues in which I have had to advocate for patients and their safety when they are about to be unsafely discharged by the doctors.

This is a very pationate issue for me as I feel that we are there to do a very important job of ensuring that the patients mobility status is safe before they are discharged home (unless there are other options such as rehab). So if this is our job, then how come some of the doctors (all that I have met this week) don't take it seriously!

I have done my best this week (and probably stepped on some toes) to keep a couple patients in (or make other arrangements for them) that I truly felt were a huge falls risk if they were discharged to their home. Not to mention that these patients had a had strokes and both of them were expected to leave two days post stroke!! Even if they were farely minor strokes they had huge balance issues! (not to mention a million other risk factors)

I was beginning to question my judgment on Friday when I was in the middle of advocating for another patient who had been admitted two days ago with a severe exacerbation of MS and complete loss of previously independent ambulation. As I spoke to the resident and she said to me "oh, well it's "ONLY MS" and "it wasen't a stroke" and "she'll get better without physio" ummmmm..................the ward clerk came over to tell me that my patient sho had been discharged against my judgment yesterday was back down in the ED as he was "not coping at home". Ummmmmm, can someone please tell me why I feel so educated??? Where are we saving money here??

p.S. That dosen't include my spelling

Grumpy old nurse

Hello all!

Just wanted to share a run in I had with a nurse this week. First, I'd like to say that until now I have got along really well with most of teh nurses and see it as a definite benefit to work with them on our team.

So I discretely noticed one day, this new nurse, who was treating a couple of my patients. He had left my patient (who has global aphasia and is not cognitively fully there) in his wheelchair by an open door (to the public hallway) completely pantless and exposed. I was trying to find him (the nurse) anyways but when I saw this I rushed to find him. I found him wlaking out of another paients room who was way down the hall!!!! I decided not to say anything but asked him what his plan was with the patient as I was wanting to take him to physio when he was ready. He said he was showereing him and told me to come back in 1/2 hour. I thanked him and went on to my next patient.

The next thing I know, the ward was crazy, patients were being reshceduled left right and center and my schedule for the morning was thrown out the window. This, as I'm sure all you can relate to, is something that happens all the time! So anyways when I went by him in the hall a little later, he rudely asked me if I was going to see the patient. I said "yes, as soon as I could find the other physio as he was a double so it might be a while". He then said "well that's great! I bent my back over to get him ready for you and you;'re not even going to see him now, thanks alot!". I was quite surprised at this! He was obvioulsy in the process of showereing the patient in the first place (as he was half naked) and I really didn't understand how he could yell at me like that.

Anyways, no real moral to the story as I never saw him again. But some people can be so grumpy and try to ruin your day for no good reason. Jeez!!

Nic

Expressive Aphasia, 2nd

As some of you might remember, I put a post up last month about conversing with expressive aphasic patients.
A thank you to those who commented on it. You were absolutely right, the more practice I got in interacting with aphasic patients the more I felt comfortable in finding the right balance between helping them out finding the word or just waiting for the right word to come out. I also found with two of my patients that over the period of my placement I got a lot better in understanding their non verbal language and was able to adequately respond to it.
It has been a great experience and I think I just want to reinforce again that it is very important to take time to listen and make sure that what they say is really what they intend to say.
Edith

Almost Done reflections

It feels incredible for most of us to have completed the three major clinical placements. I got up Friday morning and felt excited for the very first time in a long while. Feelings such as excitement and euphoria have been hiding dormant, suppressed by the stress of living under the microscope for far too long. Now it is onto the PCR for Curtin to find that final straw to break our backs. Sorry, I am just dragging things out here.

I was very happy with my last placement being neural. Of all three placements, I feel neural brings out the most Bobby Flynn in all of us. Cardio made me feel like a technician, musculo is where my interest lies and brought out the pragmatic in me, but neural required that I dig deep and quickly develop astute observational skills and a high degree of touch. I had to really feel for patient’s movements (or lack thereof) and reciprocate further movement such that it would achieve the outcome I wanted, almost like a dance. I found that to be as near an art form as anyone can hope for as a physiotherapist. Overall, it was a positive experience.

A correction is also is order. Earlier, I discussed a couple articles that came to the conclusions Bobath techniques were either less or equivalent in effectiveness compared with motor relearning. After using Steve’s methods to analyse the articles, design flaws marred the researching findings. In short, both studies were unable to adequately ensure one group received true expert Bobath or motor relearning approaches. That teaches me to jump to conclusions too quickly, whether it be out of frustration or not.

Thanks for the interesting forum discussions everyone.

Real Time Ultrasound

On the last day of clinic we got a small going away present. Our tutor took us over to the real time ultra sound lab to give us a demo, and to let us use the machine so that if we encounter one later in our careers we'll know how to use it. It works really well as a feedback tool for TAs multif and pelvic floor, so I it was good that we got to learn how to use it.

Giving supervisors feedback

Being the last week of clinic....I'm sure we've all received feedback on how we've performed. Some of our supervisors may have even asked us for feedback as mine did.....

I personally haven't had a problem with the supervisor on the clinic.....the first week she really spoke very 'patronisingly' to us...to which I took offense...but then realised that's how she speaks to everyone - literally...so then I decided not to care. She also didn't ask us what we've done before or anything like that.....which again I didn't care...but the other student on prac with me did.

I was a little concerned giving her feedback.....as I think SOMETIMES it can be useful....SO when she asked for some feedback I just very politely let her know that with the GEMs it might be an idea to have a brief discussion of what we've done before.....to which she replied when she has had that discussion and people have told her what they've done or what skills they have....they've been 'full of shit' (direct quote). I really appreciated her honesty - and I think it's true that some of us are guilty of thinking we're the bees knees having held certain positions in our previous 'careers' if we got that far. So - just to let you know and also it's a word of warning not to be 'full of shit' as new grads...cos somehow, at sometime...they'll catch you!!

Mads

P.S. I was too scared to tell her she speaks to people in a very patronising manner!! but if she was my student I certainly would have! isn't the power difference great? M

Supportive Supervisors

I just wanted to take this opportunity to reflect on how much a clinical supervisor can positively impact your method of learning. I just finished my most recent placement and could not believe how much I had learned from my clinical tutor. The amount of time and effort she put into each student was beyond the call of duty. She always made time for each of the six students on this placement and never once made any one feel like he or she was interrupting if a question needed to be answered. She was always available and provided an array of excellent resources for the students to consolidate our learning. It was such a refreshing change from the usual “go and learn this” attitude that so often comes across on clinic. My clinical tutor took the time to really help sort things out if we had a question and never made it seem like something was too silly to ask. I think what I learned most though from her on this clinic is to keep feeding my drive to learn and to ask questions from those who are more experienced so I can (as she put it today) “soak up the knowledge”.
Good luck with PCR study and see you at the grad dinner!

Bribes

I'm sure that title got your attention. Quick quesiton. Is it standard practice to get a little something for your clinical supervisor after your clinic?
Calvin
ps it's not really a bride cause you give it to them on the last day after your assessment is done.

Musculo Placement Comparison

I'm on my musculo now at the Curtin Clinic, and from what I've been hearing the placement there is quite different from other musculo placements. On our placement we have a 1 hour time slot for ongoing patients and 1.5 hours for new patients. Before we see our patient we have to go through the plan for our subjective and objective assessment with our supervisor. We do our subjective which is about 5-10 mins and have to ask specific questions about their pain (present, since last Rx, aggravating factors, easing factors, time to ease/increase) post Rx effect, and how they coping with their home exercise program. After the subj we pop back out to talk to our supervisor about it, and then discuss what we're going to do on our obj.
The objective consists of AROM (PROM) with P1 P2 R2 and the rest of that good stuff. Then PIVM, PAVM, NTPT, appropriate musc length and any other stuff that may be appropriate (eg neuro testing, specific tests), then an assessment of how they perform their home exercises. After that you pop back out to talk to supervisor, and tell her what you want to do as Rx, and how you want to progress your home exercises. She makes her suggestions, and you use a combination of them and your own (mostly hers) :)
After EVERY Rx you reassess something. If your Rx is left and right PAIVM you reassess after your left and then again after your right. After the Rx you write up their home exs and make a photo copy of it to put in their notes, and you book them in for their next appointment. That pretty much takes 45-60 mins and then you find time to do your notes.
Other than Minh and Nicole (who have had the same placement) does anyone else do anything comparable to that on thier musculo. If heard that some people only have to do 1 paragrapg of notes, and don't have to check in with their supervisor during their Rx, or only have 30 min for Rx.
Enjoy studying for the PCR.
Calvin

Hey people,
Hope everyone’s last week of prac is going well.
This week Ive had 3 new patients all with impingement/frozen shoulder type disorders. The 3 of them each presented in a similar fashion; decreased AROM, pain and weakness. I have found that these presentations are hard to treat and often respond slowly to treatment. However I just wanted to say how surprised I was went I tried using slings and pulleys. They actually work!! Each patient I have used them with have increased both their PROM and AROM significantly during the treatment. Its such a simple concept and I think all to often we over think things. I really thought back in first year, learning those techniques was a waste of time but I have been pleasantly surprised!!! (Aren’t I good finishing on a positive note)
Luv Jess
PS Good luck with PCR and have fun on rural!!!

Surgical Ward

During this week’s prac I was working on the surgical ward, which gave a great opportunity to treat patients after cardiac and various abdominal surgeries. Just want to express how much I have enjoyed working in the surgical ward. I sow a guy day one post cardiac surgery and followed the rehab protocol until he got discharged. It’s amazing that day one post operation we sit them over the edge of the bed and walk them in afternoon.

My supervisor let me to do the whole assessment and treatment on this patient (of course she was present at the time). Anyway was really daunting to begin with as this guy had attachments everywhere.

I took a big breath and started my subjective assessment following an objective assessment and so on. In went really very well, I was really pleased that I remembered all the things we have been taught at uni in terms of how to safely mobilise and treat surgical patients.

It was such a good practice in terms of problem list and also to have a real visual picture what the patients look like day one post operation. I am glad to have this experience, as it wasn’t planned. Now I feel that I am ready to do my cardio PCR.

An interesting neural round at RPH

I wanted to share with you a very positive grand neural round experience. A 30 year old patient had a stroke secondary to violent dancing (and possibly connected with ½ an estacy pill). The exact cause of the stroke was not definite. The distribution of the stroke was vertebral basilar, first affecting the vertebral artery and moving rostrally to the basilar. Thus, her symptoms were initially Wallenberg syndrome (AKA lateral medullary syndrome) developed into locked-in syndrome (medial pontine syndrome). Personally, this is most scary condition I have ever heard of. Suffers are conscious and aware of their surroundings but can only respond by eye movement or blinking. The corticofugal, corticospinal and other extrapyramidal systems have been infracted. Their only response to the outside world is the cold binary language of affirmative or negative. The good news is that she started to slowly recover. It has been roughly 9 months post stroke and she is responding well to physiotherapy. Currently, she is able to transfer with 1X assist, and is mobile on an electric wheelchair. Our supervisor believes she will be able to walk independently one day. The patient attended the round and gave a stirring thank you speech. It was one of those moments I thought it was great to be a physio because we can make vast differences in people’s lives. The ability to have positive effects on others is inspiring. On a slightly negative note, the patient’s speech was cut short because she took too long to do it. One other person (surgeon I presume) made the comment to the presenting registrar that he was ‘speaking to those already converted and believed in rehab, and that promotion material was unnecessary and redundant. He believed time was better spent discussing the challenges of rehab. I was initially surprised and even somewhat disappointed with the comment. But after some thought, I felt there was much truth to what he spoke and that a grand round was perhaps not the best forum for ‘promotion’ of rehabilitation.

Laid back

I thought I’d reflect on a colleague that seems to be very laid back but is not in some respects.
One of the supervisors I have been on placement at would regularly arrive at the workplace a few minutes late and usually it would be 10 to 15 minutes before actually being ready for work. I have no problem with that…what I find rather surprising though is the same person having a go at one of my peers when she came back from her lunch 4 minutes late.
I know that being punctual is a sign of respect towards our patients and is an important issue. What I find a bit frustrating is that there seems to be a double standard…it seems to be ok for some people to be late, but not for others.
Anyway, thought I’d share this experience with you and see what you guys think.
Edith

'The Other Side of the System'

Hi All....

I've had an interesting week this week.....being a family member of someone on a major teaching hospital in Brisbane. My brother had the unfortunate event of being hit by a car late Monday night.....and apart from a open, communited distal femur fracture - is fine.

I have had the frustrating experience of trying to get information from the medical staff looking after him. I decided to phone the hospital on Wednesday as he had surgery on Tuesday regarding his fracture etc etc. SO I got the nurse who was supposedly looking after him.....I told her that I was in Perth, nearly graduated physio etc etc and that I did not have a very clear picture from my parents. Turns out the nurse didn't either - she told me he had an ORIF on his R hip the day before (it's L distal femur) and when I said I'd heard distal femur...she said 'yeah, ORIF'd femur - very informative.....I asked her if she was aware of the plan for treatment as my parents had said it was to be a series of surgeries.....she was very honest and said 'nuh'. I then asked her if she could put me through/give me information as to who were the doctors looking after him.....to which she didn't know if he was under the 'trauma' team or the 'orthopaedic' team....again - very helpful.

I can not tell you how frustrated I was when I got off the phone to this lady...and how hard it was to convince myself that Dylan's getting decent care in Brisbane....even though I've worked on the ward of the 'Perth equivalent' and know that ppl do get good care. It is so upsetting to even myself and as a health professional I suppose I didn't really realise how upset I'd be if something traumatic happened to one of my family......so I have a little more empathy (and time) for family members of patients now!

Anyway, I will call again and hopefully find out some more information!

Madeleine

Treating Referrals

I have had a couple of patients this week that have presented via referral for a specific condition. However upon arrival, they describe an entirely different picture. One patient in particular comes to mind in that she was referred due to Achilles tendinosis but on presentation she stated that it was in fact her shoulder which was her main problem, not her ankle. I asked my supervisor what I should assess since her main complaint was her shoulder pain and not her ankle pain. My supervisor explained to me (and to the patient) that we can only legally treat what we have been referred, otherwise this patient would need to come in a second time (privately) and pay for her shoulder to be assessed.

I found this to be a bit of a ethical struggle as the patient presented with her primary pain as something other than her referral and yet we can only treat the referral (leaving her to her own devices for her shoulder pain as she is a pensioner and unable to pay for private physiotherapy services). I’m a little dismayed at the same time as to why the doctor how wrote the referral would not have also referred for the shoulder pain she is complaining of? I can’t imagine her not mentioning it to him as it was the first thing out of her mouth during her subjective exam. I guess as physios we always aim to resolve the patient’s presenting problem, but in the situation where you are not legally allowed to do so, it can become a very frustrating and disappointing experience.

mental health

Hey all,
Reflecting on this week it seems my musculo placement is turning more into a psychiatric practical, something that indeed I feel a little unprepared for. I’ve had 3 patients, just this week, burst into tears during their subjective history. Listening to some of their stories makes the exercise prescription and treatment I am providing seem slightly insignificant in the big scheme of things. I know that the chat I have with them is far more beneficial than any hands on therapy I provide.
Many of these patients have been in the “system” for years, with out clear diagnoses and it seems that they end up at ‘out patient physio’ once doctors can’t figure out what is wrong or how to help them. I have heard countless times that they have been told there is nothing wrong with you. I can only imagine how frustrating this must be for them.
My question to you is how can we help these patients, who clearly do need physio, when they have such major psycho social issues that traditional physiotherapy will be ineffective if we are unable to provide some psychological intervention/support during treatment. And if this is required of us, then why are we not taught strategies to deal with and understand such conditions/disorders at uni???
Do not say refer to social worker/pyscholgist/psychiatrist as this is not going to help me half way through my assessment when a patient has a massive panic attack and is screaming in a fetal position on the floor (which actually happened today!!). Obviously it is unethical to refuse to see a patient until their mental health is under control…
Jess

Perhaps to the dismay of some, I will bring up the topic of Bobath techniques again. Nonetheless, the subject of my reflection is not exactly Bobath itself. I am merely using it as an example. I apologise if it appears I am beating about the bush.

I was searching the literature on the efficacy of Bobath techniques (AKA neurodevelopmental technique) and discovered that there is limited support for its use. A couple recent systematic reviews found nil evidence to support (or refute for that matter) its clinical value. One randomized trial found Bobath to be just as effective as motor learning based neural rehab (I think Carr and Sheppard methods), and another RCT found Bobath to be less effective. My search was by no means exhaustive. I simply typed in ‘Bobath’ under 'search' on the Pedro website. As I have mentioned in my last Blog, my neural placement is heavily Bobath based.

If Bobath is not the gold standard, why is it used as gospel? The issue that I’d like to discuss is how much of our hospital clinical experience is dogma, perpetuated by very experienced practitioners who have specialized in one philosophy of treatment? The use of the word dogma is likely too strong, but I am just trying to illustrate a point. If the clinical experience is based on one school of thought, my concern is that it prevents integration of other possibly effective neural rehabilitation techniques. Maybe the gold standard of neural patient treatment is a combination of motor learning and Bobath methods. However, if we are taught to believe one particular method of treatment is the best, where is the incentive to research new methods or a combination of methods?

I used Bobath as the example, but I think it can be with anything we are taught. It makes me appreciate Anne teaching us an integrated approach. Just a thought!

Good Supervisor

I just want to share the experience that I am currently having during my cardio prac in Fremantle Hospital.

The physio staff and our supervisor is so supportive and friendly, treating us like colleagues, it’s a nice change in comparison to the neuro placement, were I felt inadequate in my knowledge or basically, that’s how my supervisor made me feel.

Anyway it’s funny because I thought that I would enjoy my neuro placement the most, but it turned out the opposite, where is cardio placement I wasn’t that keen on and its turning out the best one. My cardio supervisor is very knowledgeable and the way she explains things it’s so clear and precise. I look forward to our tutorials every week. It’s amazing what a difference it makes when a supervisor is not intimidating, you feel relaxed and able to perform the task so much better.

I suppose I its hard to compare neuro with cardio placement, as they are so different. Cardio, as long as you know ten problems list you are fine, it’s like following the instructions to make a cake. Neuro is not black or white it can also be a little grey. What I can compare is the supervisors and the way they relate to students and sometimes not in the friendliest manner. I thing you guys know what I mean…

Learning opportunity

I’m at my neuro placement at present, which provides me with a great opportunity to learn. To learn how to perform a content based assessment on a patient, to learn how to do a problem based assessment and choose the appropriate treatment option and so on. It’s both challenging and demanding, and at times I would love to have more time to digest all the things that happen throughout the day. And then to be able to go into the next session and do it all better.
What I want to get to actually is, that we had an in-service on a very interesting topic over lunch time last week. It was very well presented and had also a practical aspect about it but all I could think sitting there was…I would love to have a lunch break and digest what I’ve learned this morning rather than being fed more stuff. Do any of you guys sometimes feel we get a ‘learning opportunity’ overload?

Edith

Being Safe

Hello all!

Just wanted to voice something that is quite challenging for me in my neuro prac at the moment. This is the issue of being "too safe" with the patients. I am having a hard time with this as it has been grilled in to us time and time again that if we are unsafe with our patients that we FAIL! SO now that I am being extra cautious with them, ensuring that I am VERY close to them and ready to catch them when need be (especially with the patients who have poor balance- which is most of them) I am struggling to (and getting feedback) to step back and let them find their own center of gravity. I definitely understand that these patients do need to feel this and need to re-establish their equilibrium responses, but there is a fine line, at the moment for me as a student, in "letting them go" and "letting them fall". I am sure this is something that will come easier to me as I get experience but I am finding it very challenging to "let go" of it.

Nicole

'Annoying' Patients

Hi All......

I know we've all had it....but at the moment I'm quite sick of some of the sexual harrassment I've received from patients whilst on clinic.

At the moment, we have one elderly, homeless aboriginal man who is a care awaiting placement - so really....he's not even entitled to receive physio, however as our ward is very quiet....I've been asked to see him regarding his chest care. He does have a mental illness, and he can be quite incoherent at times, has a huge PMH, but has presented with an exacerbation of COPD.

Anyway - I'm not quite comfortable stating exactly what happened with this pt when I saw him yesterday.....but I'm just angry and appalled that there are people like him, that try to take advantage of every system that's out there...then abuse staff! It's not just sexual harrassment he dishes out....he's very verbally abusive, yells the most colourful language at staff...can be really bossy - and just plain rude. I really really try not to judge people who are in hospital and just try to think that their lives have certain circumstances that we probably don't know about and can't possibly understand.....but I can not stand this pt!! I really really do not like his nature and attitude I don't like that our hospital system is forced to take care of people like him.

I feel like it's a bit of a cop out to tell my supervisor that I don't want to see him.....but I'm going to because there's no way I'm going to have contact with this man again.....and I realise that through his actions and perhaps cultural differences....I'm unable to provide optimal physio treatment for this pt. BUT I'm sooooo angry with this man, for thinking that he can just say and do whatever he likes just because he's in hospital.........and I really wish sometimes that we could be 'people' instead of 'professionals' when it comes to pts and I had the nerve to tell some pt's what I think! (it might be in language he understands.....but it might be 'unprofessional' as well :))

Hopefully he gets a placement over the weekend.

Mads

Hello all,
As you may remember my last blog was about Dug, the guy who wouldn’t share his PMH with me. Thanks to Minh and Nic for your advice, you brought up some important issues that I hadn’t really considered. To keep you up dated Dug came back in today, I decided that I would explore the PMH issue. I was quite firm and clinical in my approach, I avoided “dabbling” around the issue and just simply told him that I was a health professional, all information is confidential and that I wasn’t prepared to treat him if he couldn’t be honest with me. This worked better than I could have hoped for. He told me that he had been diagnosed with schizophrenia 10 years ago and had spent a substantial amount of time since then in grey lands hospital, he has also spent time in prison and has battled depression since he was a child. I think once he told me he relaxed, I guess once that was out in the open he felt that I was more likely to be able to help him. I was very pleased with how the situation ended, I think the lesson to be learnt is to… know clearly what you want and why you want it, be confident about getting it, and respect it once you have it. (guess this can be a metaphor for anything you want in life)
Jess

Trying to be Superman

On my musculo clinic, I've been finding it hard to stick to the time limit for each patient. The main reason for this I think is that as a student I tend to assess everything, adn then in turn try to treat everything I can. Rather than doing the logical thing and assessing what's relevant to the patient's complaint, and then only doing one or two treatments that will have the greatest affect. When I teach tennis I always pick the one thing that I know that if I change it, it will create the greatest change in the persons performance. I guess I need to get over the immature idea that the best thing to do for a patient is treat every problem they present with, and start to think like a physio and now that the best thing to do for any patient is to focus on only a couple things at a time. What are your thoughts my fellow physios?

Energy Boost

Hi Everyone!

I started this week purely exhausted... I slept nearly the entire weekend. I joked with a friend of mine the other day that I woke up late Sunday afternoon after a 2 day nap!! And after speaking to a few people in the course, and reading blogs entitled "mental health" and "brain drain" I am comforted by the notion that I am not alone.

I was afraid that by being completely worn out, I would struggle to get through the week, but today, Wednesday, I had a patient who gave me the strength to go foward. My patient is two months post subscap and supraspinatus full thickness tears and has been limited in her AROM due to pain and her arm feeling "heavy". Unfortunately for me she has so much guarding that determining PROM seemed nearly impossible. Today though we had a breakthrough. I set up some slings and did some hold relax and at the end of the session she actively brought herself from her previously ROM of 95 degrees shoulder abduction to FROM! The look on her face was priceless... she couldn't stop saying "wow"! She could hardly believe that she had the range available in her shoulder to do this on her own, especially because up until now she has not been able to get full range. I think today was the breakthrough we needed to help boost her confidence.

After she left, I realized that this session was exactly what I needed also. This patient gave me the energy I needed because I was so happy to see that I had helped to initiate such a big change. I think in the midst of all the chaos of the last two years, I have nearly lost sight of the big picture and why I decided to become a physiotherapist in the first place. Thanks to this patient, I remember.

Megs

Two very different patients

The patient that I sow this week was a 48year old female who had the last stage of bronchiectasis and was admitted to the hospital due to exacerbation of the COPD. Tis week the doctors told her that there was nothing more they could do in terms of her treatment, as they couldn’t get rid of the bacteria that had invaded her lungs even with the strongest antibiotics.

I was so impressed with her mental strength and her attitude towards life, because if it was me in her situation I don’t think I would cope as well as she does. Every time I would come to her room to do the treatment she would always have a smile on her face and positive attitude towards her intervention. I wish all the patients were like her. Unfortunately is not the case. I have got another patient who is completely opposite to the lady I have just described. He doesn’t want to do anything he just lies in bed and sleeps for hours. Every time I would ask him to get out of bed and go for a walk, he claims is too tired and that I would come back later. Once I managed to get him to show me how he does sit to stand, he claimed that he couldn’t do it. Anyway I had to give him nearly max assist to stand him up. Funny thing was, later that day I was passing his room, when I sow him getting out of bed and walking to the bathroom. He looked that he had no problem in achieving the task. No wonder why hospitals have shortage of beds, because the patients like this man who doesn’t want to help himself to get better and getting discharged sooner.

It’s just amazing how different the patients can be, one who is dying and still trying anything possible to prolong the life and another who is just lazy and lack of motivation to do anything to help himself. As a physio is so frustrating having a patient like this man, when you know you could help him to get better, but without his input its not possible.

Feelings of neurological inadequacy

I started my neuro placement this past week and I found it fairly daunting. From the get go, our clinical supervisor says: “at this clinic, we use integrated techniques, but roughly 90% Bobath based”. Needless to say, I felt unprepared for the placement. From a safety standpoint, I felt fine. I knew I wasn’t about to endanger any of the patients. However, as most students would agree, there is an inherent preoccupation to impress the clinical supervisor with the limited knowledge we have, to ensure that we pass the placement at the end of the day. I was gob-smacked when she mentioned “90% Bobath”. I have only heard of Bobath in passing and essentially have no clue what philosophy or manual techniques it involved. Of course, I tried to read up on some Bobath material during night, but it was tough after a full day of working with neural patients. Some of the concepts were also tough to visualize without a patient in front of you, such as ‘key points of control’.

As much as I thought our neurology courses were taught well, I was quite disappointed with how under prepared I felt during the first week. If Bobath techniques are used so prevalently, shouldn’t we spend more time in class and labs learning and practicing it?

Easily Solved Problems Made Difficult

Hello all,

Yet another note discussing the matter of being burnt out and stressed affecting our performance.

I am in my neuro prac at the moment and had a difficult patient for two days who would say some inappropriate things and make false jugments on some things that I was saying to him. I have over ten year of experience dealing with many difficult people (both mentally ill and "normal" public patrons) and situations. I would like to say that as the supervisor in my old job that I was always quite responsive to these people and could deal with all different kinds of people (ie; ill, angry, panicked, depressed, stupid) and was always quite good at getting them to calm down and resolving (or dissolving) the situation. In this situation, however, I found myself to be very tired and so "over it" that it was too much energy for me to sum up to try and resolve (or deal with) a problem that, I could say, would have been most likely solved by me. Instead, I passed the patient on to my supervisor who passed him on to a male physio.

This would normally bother me as I enjoy a good challenge and like to try solving my own problems before I rely on someone else. But this time I don't care. It's really too bad that I have come to this point in which I am no longer displaying my own personality because I am so burnt out. A shame really....

Nic

Past Medical History

Hi guys,
As I take time to reflect on my first week of musculo prac, one patient stands out in my mind. Let me introduce “Dug”…(obviously not his real name).
Dug was a “newy” and also my very first patient. I collected him from the waiting room and introduced myself, something about him was odd but I couldn’t really put my finger on what. I proceeded to take his subjective history and nothing made sense. He had had a horrible childhood, was covered in scars and burns from various accidents and abuse. I started to feel really sorry for the guy. To give you an idea he had been involved in 7 MBAs, 2 MVAs, 1 dog attack, been thrown into a wall while roller-skating and fallen 3 meters off a ladder in the past 5 years. He had weird symptoms and pain in his shoulders, left elbow, low back, calf, neck and both feet. Pretty much a nightmare case (remember this was my first patient). Then we got to his past medical history and medications. He would not tell me any of his medical history or what meds he’s taking (by this stage I’m pretty certain he has some kind of mental illness). Obviously for physio treatment we have to be sure that there is nothing in our patients PMH that contraindicates our intervention. I found it hard to ask questions about his medical history when he was so adamant to avoid the subject. It’s difficult to extract information about relevant medical history, without him thinking that I thought he had mental illness (he obviously didn’t want me to know this and thought that it was nothing to do with physio). As a health worker I do believe that we need to see the whole picture in order to treat a person, as it was our initial consult I felt it best to not push the subject. I guess I could have asked if he was more comfortable with me discussing the matter with his GP. He’s coming back this week maybe as I build more rapport with him he will feel more comfortable discussing his medical history with me. Dose any have any ideas on how to approach this kind of situation??

Mental Health

Hi guys,

I wanted to raise the issue this week of our sanity!!!
I'm hearing more and more of fellow collegues (not unlike myself) feeling VERY stressed and some are wondering about burn out and depression. I think that a lot of us are facing some huge issues in the next couple of months, one hurdle is the PCR, some of our colleagues are moving home to Canada, and quite frankly, a HUGE change is ahead for all of us.....

Personally I absolutely hate change most of the time....the worry of getting a job is starting to get to me.....and I feel like I have pretty much no time and really can't be quite bothered to get my resume out yet....I'm wondering things like....what differentiates us as new grads? we've done the same physio degree.....apparently grades don't matter....clinic performance is marked as competent/not competent....and I'm thinking it wouldn't be as professional to include our clinic reports in our resume etc...so I kind of feel like I'm going to have to be plain lucky to get a job! Surely the 'selectors' for interviews wouldn't be able to remember if we've been on placement in their hospital and be able to ask appropriate people about you.

So what do you guys think?? and what are you doing about it?

Madeleine

Subjective History

Hi Everyone… Hope the new clinics are going well.

I just started my musculo outpatient, and had a new patient referral the other day. It was my second new patient that I have had on this prac (the first having gone relatively smoothly), so I was confident that I would be able to handle this patient who I knew was referred for left ankle/heel pain.

This patient was more complex than I had originally anticipated, mostly because she had an extensive history of bilateral, hip, knee and ankle pain. I tried to steer the subjective history so that we could mainly concentrate on her presenting problem, her left ankle. But with every question, her answers became more and more off the course. So in the end, a 90 minute first assessment turned out to be a two hour appointment.

I tried everything from asking more direct, closed typed questions to almost leading questions. Nothing worked. Has anyone had this problem? I’m not sure how to deal with it for future. She was a very lovely lady and I didn’t want to be rude and interrupt while she told me about all other issues (pain in her knees, hips…), but at the same time, I couldn’t seem to find the right way to word the questions to avoid her going off topic.

Any advice would be greatly appreciated!

Expressive Aphasia

On my neuro outpatient placement I came across a few people with expressive aphasia. Needless to say that a conversation doesn't take place in the usual way. Most of the patients I have seen are only able to say one or two words at a time and a lot of the times it seems like they are saying a word related to the one they want to say but just do not quite hit it. So it usually takes them about three trials before they can say the one word.
I find it very hard not to put words in their mouth by guessing what they want to say but just be patient and waiting for the right word to come out. Another challenging aspect of communication with those type of patients I find is not to give up (patient or physiotherapist) trying to talk and listen because it is important what they have to say.
I think it is imperative to find the right balance with helping them out with the word they are looking for without being patronising or impatient. Who knows, I might improve my ability to communicate with aphasic patients over the next three weeks. And I hope that the times where I have to say:"I am sorry, but I can not understand what you are saying" are becoming less frequent.
Edith

Well done so far

Hi Team Physio,
I wanted to put up a post to let you know how well you have been doing in engaging in this process. I have had a brief scan through the posts and there has been a wide range of topics that you have explored as a group with some good reflection on difficult issues encountered on the placement. Many of the posts share some fairly in depth observations from clinics. Where an issue has been raised and opened for discussion it would be great for you to consider putting up some follow up reflections later in the placement as to how the scenario may have changed through the clinical placement and what you feel you have learnt or changed through the process of reflecting on that issue.

A reminder that you might want to consider writing your post in a word document, saving it and then cutting and pasting into the Blog. It will save you time if you have technical difficulties in posting your message.

Keep up the good work
PG

Bottom of the Food Chain

During the third week of my clinic something came up with my Curtin tutor that I thought I'd share. We were seeing a patient that we had seen the previous week. This patient had been in for three weeks, with infective exacerbation COPD, and was coughing up copious amounts of stuff ranging from pink to dark green, and always very runny and always lots of it with little trying to get it up. I had developed a bit of a rapport with her doctors as I was concerned with how much she was always producing. Anywho the week before when the Curtin tutor came in we got sample, cause that was the pink day, and we got in touch with te doctor and he said do a sample. Later that week (second week) when I was by myself, the sputum changed and I saw the doctor in the hall so I told him what we found and asked if they wanted a sample. He said "No that's ok, we have enough samples. Thanks". (very polite doctor)
So fast forward to third week when the Curtin tutor comes in. After we see the lady she says for me to get a sample. So I went to look up the doctors pager number to ask him if he wanted it, because in the hospital you have to get a doctor to fill out the sample request form. As I'm looking for it she says to just the sample then we'll get the form filled. So got the sample, and then she's says "Is the doctor here?" He wasn't so she says for me to just get another doctor to fill out the request form. (this is somewhat common, but still within being legal) Now at this point I felt uncomfortable getting this sample kinda behind the doctors back when I knew he wouldn't want it done. And the doctor I asked to fill out the form did so very unwillingly, and asked a million questions. Anywho after she left I was worried that when the results came back and the doctor found out that I had gone ahead and sent the sample off kinda behind his back that he may take offense. Because in all honesty it isn't my decision to send off samples and its kinda like second guessing what he's doing.
I guess by saying all that I was just wondering what do you do when the tutor who is there only a fraction of the time pushes for something you dont think should be done. Like this other time that she had me page two interns about 5 times each in a space of 10 mins, to find out if we could get a patient up. I knew that calling them was important but if they could they would have returned the call. Come to find out the phone I was paging from didnt really work so I couldnt receive the returned calls on it. I just felt like the annoying student physio. Anywho later my fellow physios. Sorry this one is a bit all over the place.

Cerebellar stroke with negative tests rezults

During this week neuro prac I had a new patient to assess. This man presented to NOP following a bilateral cerebellar infarct, three months ago. His referral letter stated to provide ongoing rehabilitation for this patient’s decreased balance.

My assessment included 6MWT, 10 meter WT, Bergs Balance, proprioreception, cerebellar testing. During his 6MWT he had a classical cerebellar signs. Ataxic gait with fixed trunk, wide BOS, decreased stride length. He did look very unstable.

When I started doing cerebellar testing to my surprise all the test, including finger nose test, heel shin, asthenia, rebound phenomenon, toe tapping were negative. The proprioreception was also adequate. I was very puzzled, as I thought this patient who had cerebellar stroke would ultimately have these tests positive? Then I thought, may be may testing skills weren’t precise, so I asked my supervisor to come and help me out as I couldn’t understand why the tests came out negative.

My supervisor did exactly the same tests as I did and they also came out negative.
Then my supervisor told me that this patient may had some vestibular implications.

That day my treatment with this patient consisted of increasing the patient’s postural tone by using the exercises on trampoline, walking around obstacles, fitball exercises. After 25 min of the treatment patient became ill and started vomiting. Well I thought that next treatment session should definitely include same vestibular testing, and get a better idea what was wrong with this patient to enable us to give him the most appropriate intervention.

I thought would be a good idea to share with you guys my experience with this patient, as didn’t know that patient presented with cerebellar stroke can have negative cerebellar tests. Cha, neuro is definitely isn’t as simple as I thought……

From one place to the next

I’ve really enjoyed my placement in musculo outpatients at charlies. It was in this last week that I realised that I was getting a grasp of everything, knowing the patients and being in the middle of rehabilitating them. I would have loved to stay on for another couple weeks, to progress with these patients and getting them ready for discharge.

But, as you all know, our time was up and the next placement is starting today. A new place in a different area with a new supervisor in a new team of physiotherapists (neuro outpatients). And I feel like I am starting from scratch again. Getting to know the workplace, the colleagues, the supervisor, the senior physiotherapists and of course the patients.

I think it is a great chance for us to see so many different areas of physiotherapy in such a short time but at the same time I find it challenging to switch over in such short intervals and start all over again…

Edith

Brain Drain

A patient came in the other day and sapped all the strength out of me by the time she left. It was an outpatient musculoskeletal placement. She had a seven year history of lower back and bilateral hip pain and was on a disability pension. She also reported of a right-sided intermittent sciatica. Her attitude was not necessarily poor or negative. Rather, it was a nonchalant ‘been there, done that’ kind of attitude. She reports that she has tried physio in the past, but with limited or no success. She was quite frank in stating that she presented to our clinic because her GP had referred her. Going through the subjective with her was like pulling teeth. She was vague and inconsistent. For example, she had great difficulty with determining pain intensity levels. At times, her resting pain levels went higher than her aggravated pain levels. When directed to the inconsistency, she simply shrugged.

Hell, I simply wanted to shrug her off too. Of course, I did not… because we are professionals and our game face always needs to be turned on. As any good physio would, I wanted to help, but felt rather helpless. The patient was a chronic pain sufferer, so I thought about going through educating her on hurt versus harm, mechanisms of pain sensitization and what needs to be done to break the pain cycle. Towards, the end of the treatment session with her, I tried to encourage her to increase physical activity and how it was important to not let pain prevent her from doing the things she loved. I am not convinced at all that I got through to her. She politely agreed with all that I had to say,
By the end of it all, I felt utterly drained. Worse of all, I felt that this patient’s blasé attitude affected me to the point where it spilled over to the next patient. It would be great if all the patients that walked through the door were motivated individuals striving to take good care of themselves. Nonetheless, this is far from reality. I have heard of physios being burnt out from the accumulation of negative karma. My question and comment is how do you shield yourself from this? To be a good physio who demonstrates genuine concern for his or patients, putting up a false front would throw good rapport out the window. Do you simply put on a fake optimistic happy face? How do prevent patients from draining your vitality?

Knowing it all

I have really enjoyed this musculo prac and thank god for that really because it's what I thought I'd enjoy. It's amazing how much I have learnt and was able to consolidate, but at the same time you feel like there is so much more that you still don't know. This thought tends to freak you out a bit... However! I have come to a very important conclusion this week as an almost new grad! It's what you do know and the fact that you know what you don't know and that you know that you will know it...eventually. If that makes any sense. So, what I'm trying to get across on this Sunday night before I have another week of energy draining learning and consolidating is that we must have faith in ourselves and know that no one knows it all and that soon we'll know some more.

Nic

Saying Goodbye to Patients

On my neuro prac, we have had one patient in particular who has really taken to us.....She is only 46 and had a major stroke just before our clinic started, so we were the first to see her, and her and her husband have made jokes about adopting us, have bought us chocolate (despite us saying thanks, but you don't need to etc etc), and have just been so nice to us and appreciative of our help that saying goodbye to them was actually quite hard......I felt bad as they haven't had good experiences with the hospital in some areas, and we've been what they've called the only consistent positive thing in her therapy!

It has been a really positive experience to work with this pt as she has made quite large gains quite quickly with us, and although she is a heavy pt, the work we've put in has really paid off for her.....I really hope it continues!

Anyway I won't ramble either - I'm too exhausted from clinic and this week has had too much assessment time in it to write anymore!!!

Mads

Too Sick To Stay?

The past few days I've been feeling a bit crook. So I took Tuesday off as I was throwing up Monday nite, and felt like shit on Tuesday (can I shit on this blog?). I went in today, which was Wednesday as I had my final Curtin assessment and a presentation to do. I still felt like lets say crap, and I wasn't all there, but I really thought I was well enought to not miss clinic. Well anyway in my less than normal state I missed some stuff in the notes that I shouldn't have. So my question is, as a student how do we tell when to draw the line on feeling well enough to go in to clinics, without giving the physios you work with (who you are trying to impress) the impression that you are just not toughing it out?

Stop fighting

Hey guys,
Hope you are enjoying your last week of prac…Today I came across situation that I never imagined having to deal with as a physiotherapist.
Two of my patients share a room. They are both over 80 and on first impression appear as 2 sweet, polite and nice old ladies. I have been treating them both for the last 4 days; they have similar diagnoses and are often happily chatting away when I come to treat them.
However this morning as I approached their room I heard not the chatter of old women but instead yelling and cursing. I rushed in concerned that an unwanted guest had entered the room but found only them. When I asked what had happened, I got an array of answers, from both women at the same time, none of which really making much sense.
Unsure of how to calm either woman down, I excused myself and went and spoke with the nurse, apparently they had been at it all morning. The nurse had said their was an incident involving one lady walking in on the other women while she was on the toilet without knocking, and then there was a dispute about the air conditioner, and something about a lost comb followed up with a somebody ignoring the other one. The nurse was feed up with them.
I went back into the room, by this stage one lady was crying and the other was “bitching” on the phone to her daughter. I seriously felt like I was back in year 8!! I tried to get the crying lady to come to the gym with me, I thought at least this way the two of them could get some distance. She blatantly refused any physio saying she was too upset to do any exercises.
So I tried another angle, asking her if she would just come for a walk with me and tell me her side of the story. Surprisingly this worked, which was good because I got her ambulating without her realising she was doing physio. She told me what had happened and how she did not want to be fighting with her room mate. I think they had just been spending too much time in close proximity to each other. In the end they both agreed to stop the bickering and to use their energy to get well rather that fight. As I left the room I realised providing treatment to a patient is only a part of the role of a physio, you must also be able to deal with whatever day to day issues arise. Sometimes to actually provide treatment to your patients you must first solve another problem. This situation just shows how “script” or wrote-learnt physiotherapy would never work in the real world. You have to be flexible and ready to face whatever situations present themselves to you everyday. I think that this is what makes physio (like all health professions) such a fantastic field as two patients are never the same…

Patience and Compliance

I had a patient this week who is being discharged post CABGx3. I was going over discharge planning with him yesterday which included a referral to his local cardiac rehabilitation facility for follow-up classes, and a generalized home exercise program for him to follow in the interim.

It is not uncommon for patients post heart surgery to be full of questions and be generally quite anxious about going home, leaving the security blanket of the hospital staff behind. But this patient was different.

I explained to him that part of his program would include some graduated cardiovascular exercise in order to increase his exercise tolerance post surgery. In the hospital prepared booklet, it gives examples for this such as either walking or cycling on a stationary bike. My patient immediately developed a huge grin as he had just bought a bicycle prior to his admission. I explained to him though that it was not ideal to use at this time (over the stationary bike) as he would be putting too much force through his upper limbs, and that the steering of the bike could cause sheering forces across his sternum (another big no-no post op!). My patient wasn’t happy about this and became quite argumentative, demanding further answers as to why he should not be allowed to use his bike on discharge. Then, somehow (I’m not really sure how it got to this point as I was a little flustered), he got onto the topic that he should be allowed to go swimming in the ocean as soon as he is discharged. Again, I explained about how no pushing or pulling is allowed through the upper limbs (even the resistance of water) and that even freestyle stroke can produce sheering forces across his chest. I gave him the option to do some water walking/running in a hydro pool once his incision had healed, but according to my patient, this would just not do! My patient was not going to be satisfied until I would agree with his point of view….

After nearly 30 minutes of going through the do’s and don’t’s of his HEP (a task that normally takes less than 10 minutes), I was extremely flustered and was starting to lose patience. How can this man, who has just had his sternum cut open, his heart stopped, and had multiple arterial grafts want to put himself at risk for delayed or worse yet, non healing? How can he want to put himself at risk for returning to hospital when he’s already been in hospital for nearly 3 weeks recovering after his second… yes, SECOND CABG surgery?!

Looking back now, perhaps he’s just a man who needed to have someone tell him he’s right to do whatever he wants, and perhaps he was just giving me a hard time because I wasn’t telling him what he wanted to hear. In the end, I explained to him that all I could do was give him the information to make an informed decision, and these were the guidelines that are set in order to optimize a healthy recovery. He looked at me and said ok, and we left it at that, but I really wonder how compliant he will be once he has left hospital and is out on his own. I have a feeling he won’t be very compliant, and for that I am disappointed.

Has anyone else had a difficult patient like this? I really struggled with this because all I wanted to do was help him get better and back on his feet, and yet he seemed determined to put himself right back in hospital.

PAIN

Hello all!

I am curently in my musculo prac and have been dealing with a very challenging patient- but learning lots from him! A 61 year old male walked in on O2 as he has severe COPD and was in hospital last year with core pulmonale. He first presented with severe Lx pain limitimg all movements and bilateral neural signs ans sympotms down both legs as well as cauda equina S+S. (now don't worry this is all in conjunction with Dr's orders). Oh and did I mention he's severely obese.

SO as you can see he was highly irritable so I was unable to do PAIM's or place him in prone. So I treated him the best I could with some PIVM's (quite challenging for me and I'm not a weak girl!). Then sent him home with some exercises! He came back saying the back pain was getting better (as in a 8/10 instead of a 10/10!) but came with a second referal from the Dr to treat his severe pain in Cx and Tx limiting all movements as well as having bilateral neural S+S in his arms and hands! Sooooo (after another long inital assessment for this problem) I have been treating him each session for all of his spine!

This proves to be a great challenge as a student but also as it it very hard to treat him as position changes are very aggravating. I have learnt a great deal from this patient both in the theory part of it as well as seing him (and his fabulous wife) keep his sense of humour when he clearly has a very LOW QOL! Gives you something to ponder.....

Nic

Evidence based practice

Due to diminishing healthcare dollars and the need to streamline the delivery of healthcare, evidence based practice (EBP) has become the buzz-term of the last decade. Even the medics are subjected to greater scrutiny, resulting in patients being charged for medical certificates (so don’t be sicker than 2 consecutive days on your placements).

The cardiopulmonary component of our program is quite good at bringing to surface EBP issues, such as questioning the effectiveness of chest physio to prevent post-op complications. It appears to me that EBP has been less of an emphasis in the musculoskeletal coursework. At my musculoskeletal placement, soft tissue massage, muscle release, mobilizations and SNAGS are used all the time. Yet there doesn’t seem to be much discussion on the effectiveness of these treatment modalities. For example, we are not taught or encouraged to look up Cochrane reviews for the effectiveness of one treatment modality over another for the shoulder, or the lower back. Do you know what I mean? Maybe it is just assumed that if we could delve into it if we were interested in that area.

The other day, I heard someone demonstrated some Mulligan’s techniques and said there is little clinical reasoning backing it, but it definitely works. On another occasion, I inquired as to the validity of SI motion palpation testing and the response was 'there are little validity to these tests'. My supervisor elaborated that it is used as a part of generating the whole clinical picture. Fair enough, but I think the EBP PT assessment and treatment techniques should be discussed in greater detail. I am beginning to ramble now. My argument is simply that EBP is important and that it should be emphasised in the clinical placements. Is that not what separate us from other quacks in the healthcare industry?

Vague answers

Last week I had a new patient coming in with a shoulder problem (RC pathology and possible impingement).

It took me 2.5 hrs to complete subjective and objective examination and to provide her with some treatment. I was very frustrated, and almost lost my patience.

The reason it took me so long was not because it was a very complicated problem in itself but the fact that the patient answered all my questions very vaguely and she could not cut a story short.

As I wanted to be specific in my assessment and trying to find out exactly when her pain would increase during movement and what it felt like I found my self becoming very angry at the person for not being able to answer a simple question with yes or no. I tried every possible way of asking questions trying to minimize the possible answers but then she would just not answer it but would describe her sensation in her shoulder in one way but then say: Oh, but if I do it again, it feels different.

Now, how can I be specific and chose the most appropriate treatment option if a patient is unable to be just a tiny bit specific in her description?

I decided to treat the signs that I was able to measure objectively, which is decreased GH caudad and AP glides and weak scapular stabilizing muscles. I will not even attempt to ask about subjective asterisks in the next session as it would probably take half of the treatment session to assess these. All I will ask is: has there been a change since the last treatment? And hope for a yes or no answer...

Edith

Hygiene in Physiotherapy

During one of my treatment sessions this week, I had a patient who I have been seeing now for the third week of my prac. She is motivated, fun and friendly person. This week wasn’t the case.

During the session with her, another patient turned up in NOP clinic and began his prescribed exercises on the plinth next to us, so we ended up working on the same double plinth area. I have noticed a sudden change in my patient’s concentration level and quality of her performance. She looked very distracted and uncomfortable. Then she turned towards me and starts pulling all different faces, nonverbally letting me know that the patient next to us stinks and she cannot handle it. To make things more complicated she has an expressive aphasia and all she did was pulling her face in all different directions and squeezing her nose, as the smell coming from him according to her was unbearable. I would have to agree with my patient, as this man was smelly, although I do not agree with the attitude my patient had.

As funny as it may seem, it was quite uncomfortable for me, I had to stay professional and somehow redirect her attention, to prevent from the situation getting out of hands. I thing this poor man picked up on my patient’s body language and what she was trying to say to me. The good thing I suppose was that man didn’t get angry and got in to the fight with my patient. He was just focused on his exercises trying to ignore my patient.

To my luck after fifteen minutes of this uncomfortable situation, another plinth got available and I politely asked my patient to move there. My excuse was, I wanted to set up another exercises for her there, and that over there she would need to have more space for this particular exercise.

I am just wondering if that man was my patient, how I would have dealt with his bad hygiene? Any thoughts or a suggestion guys the best way you would approach someone with a bad hygiene?

Safe for discharge??

Hi everyone,
Here’s an interesting scenario…This morning as I am just about to see my third patient I receive an urgent page “please call transit lounge RE: EMERGENCY mobility assessment, falls risk patient”. I think to myself, this is a little strange; I haven’t been called to the ‘transit lounge’ to do a mobility assessment before.
For those of you who are unaware, the transit lounge is an area in which patient’s that have been discharged, can wait until somebody is available to pick them up. The lounge is designed to free up beds on the ward, allowing new patients move in sooner.
There are certain criteria that a patient must fit before he/she can discharge, one such criteria is that they are safe from a physiotherapy point of view. This was what puzzled me, surely a patient who is a “falls risk” should be seen by physio and Okayed prior to discharge. I rang the nurse in the transit lounge; I asked her why the patient was discharge with PT approval, why I was being asked to assess in the lounge and more importantly what was going to happen if I deemed this patient not safe for discharge??? His bed would have already been taken on the ward; this just really didn’t make any sense!!
So I went down to the transit lounge, supervisor in toe, and we took a look at the patient. Well… he was not safe at all, he was going home to two storey house with his 78 year old wife as his primary and only carer and he was at least twice her size. He had no walking aid and clearly needed one; we fetched a walking stick and gave him rushed lesson on its use. But we didn’t have time/facilities to assess him on stairs (even though his house is 2 stories).
As I left the lounge, I really felt that the hospital system had failed this poor man. I think hospitals have protocols for good reason, something like discharge planning should be done strategically. I think that this man just got rushed through to free up another bed when he really wasn’t ready to be discharged. It placed a lot of stress on my supervisor to have to let this man discharge against her better judgement. I guess the only way to help prevent this sort of thing happening in the future would be ensuring better interdisciplinary communication. Ensuring that everybody is aware of the correct discharge procedures and making sure that they are followed at the correct time. This way if a problem does arise it can be dealt with in a satisfactory manner. Has anyone come across any similar situations???

Outside your comfort zone

I just wanted to share a little story with you about a patient I had recently. I met a man this week in the claudication clinic I was running with my supervisor. He’s an 87 year old man who doesn’t look a day over 65… literally. He’s the most genuine patient I have ever met. Always friendly and keen to do his exercises, and has his wife there every session to watch and cheer him on as he does his treadmill and bike tests.

This week we had an 86 year old woman join the clinic who is very shy and was a little anxious about starting the class with a group full of already established participants. Before starting the class she mentioned to me that she wasn’t sure she could do it since she felt “too old”. I managed to talk her into it and yesterday she showed up in her “tai-chi” exercise clothes complete with a jewel encrusted name badge and ready to exercise. Very cute.

I introduced her to the class on her arrival, and I could tell she was nervous. It reminded me a lot of anytime I start a new venture (for instance a new physio placement). The gentleman in our class took to her immediately and made her feel right at home. By the end of the class she was power walking and cycling like a pro!

At the end of the class she thanked me for introducing her to her “new physio friends, especially that nice young man and his wife”. When I told her she was a year younger than him, she couldn’t believe it. She said to me “I guess I’m not too old after all!”

It made me realize that despite your age there will always be times in your life when you have to start something new that might not initially be within your comfort zone. I know that in a few weeks it will be very overwhelming to start work as a physio new grad, but everyone has been there at one stage or another. This weeks claudication class just reaffirmed how important it is to take the time to help someone who is new get settled in (be it a patient new to physio, or those who start work after you do).

I honestly believe that had it not been for this gentleman, despite all my advice and encouragement my patient would probably not have returned to physio. But because someone in her position (experiencing claudication pain) and her own age showed her she is capable of doing it, she has developed some much needed confidence.

Unmotivated Patients

This week my post is also about patients who simply aren't motivated for rehab.
A pt that I'm currently seeing has had a stroke over a month ago, and is still in the acute neuro ward awaiting a rehab bed. Not to judge anyone, but given this mans social history etc etc he is just loving being in hospital at the moment. No kidding! Before his stroke, he lived quite isolated from friends and relatives in a not very nice environment, didn't go out anywhere to do anything, didn't drive, and didn't cook meals etc etc. He is now in an environment where all of his needs are taken care of, he gets meals, friends and family have come in to visit quite regularly (he can't come to physio in the afternoons due to visitors.....), and he has displayed absolutely no motivation to get out of hospital.

I can not believe the quite manipulative nature of this pt. He has managed to get himself a single room on the ward, not by being out and out rude, but by complaining he can't sleep due to the other patients in the room (who are all on sedatives of a night anyway - don't know what noise they're making?) He manages to stay in bed most of the day until we come and get him up - which the other pt's don't manage to do, he pretends to be asleep when we come in, he will claim either way if he hasn't yet had a shower he can't come to physio, and if he has had a shower in the morning he can't come because he's tired, oh and he can't come in the afternoon due to visitors coming. He also manages to sleep most of the day - or for about 3 hours during the day, then get a sedative at night as he complains he can't sleep!!!

I'm wondering.....if depsite several conversations that physio is a very important aspect of his 'stay' in hospital, and the pt's claims he is trying.....if we can really take up a valuable rehab bed with this pt? Of course I want what is best for this pt, however if he can't display motivation for rehab or any desire to get any better, where physio is only for approx. 1 hour a day, how will he go with intensive rehab?? I am wondering how we're all going to go as physios saying that a pt is not appropriate for rehab really due to psychological motivation?? Not saying that this pt is not suitable....there may be some reason he has regarding his health/home lifestyle that he doesn't want to get back to it...and it also may be a factor accounted for by the stroke, however I'm certainly not comfortable declaring this at this stage....and I'm not quite sure the physios on the ward are either.

Mads

Observational skills

During this week’s prac I have been treating a patient who had transverse myelitis, which is a rare neuroimmunologic disorder affecting CNS. His main impairments were decreased postural control of his abdominals, back extensors, pelvic girdle muscles, decreased muscle activation of his LL hip extensors abductors knee extensors and overactivity of his hip adductor muscles.

My treatment with this patient involved improving the selectivity and control of these muscles. One of the exercises that I was doing with this patient was bridging in crook lying. When observing this patient doing bridging, he looked like he was able to lift his bottom off the plinth, although it wasn’t easy for him. I have also palpated his gluteal muscles and I did feel their activation, so I thought I was on the right track.

My supervisor came up to me and asked me if I noticed that this patient wasn’t doing this exercise properly and if I could identify that it was wrong and correct it as this encourages the wrong movement pattern. I have tried to observe him again and I noticed that he was using his UL quite strongly to push himself up, but what I didn’t notice was that he was also using his back extensors and hip adductors to compensate for the decreased activation of TA, pelvic floor and hip extensor muscle.

In addition she showed me a better handling skill in order to achieve the desired outcome of activating TA, pelvic floor and hip extensor muscles. She broke down bridging in three components, first the activation of TA with posterior tilt, secondly the activation of pelvic floor muscles and thirdly the activation of hip extensor muscles without compensation from back extensors, although the hip adductor muscles were still too overactive with this patient, this was hard to change from the first treatment session.


What I have learned for this simple looking exercise, that how much more is involved in being effective with your treatment, that is your observational skills, handling skills, commands to your patient are paramount in achieving the desired outcome which obviously I was lacking and I guess that will come with more experience.

Is PT for everyone?

Is physio suitable for everyone?

When the Curtin Clinic is not so busy, the students double up on patient visits. I ‘sat in’ on another student the other day, and went through a painful experience. It was obvious the patient did not believe physio was of any benefit and she has not been compliant with her HEP despite claims to the contrary. She was there because the surgeon had wanted her to go through a clinical trial of physio before he would consent to surgical intervention. (Surgeons have been successfully sued in the United States for not offering alternative therapies as a part of seeking informed consent.) The patient was nice enough but her disinterest was clear from the beginning. The treating physio student used soft tissue massage as a part of the management, but it was the first time applied on this patient in the last two months of coming to the clinic. The complaint was longstanding and she had tried extended periods of physio in the past, with limited success.

Physios assume that just because we teach patients what is good for them, they will go ahead and follow our instructions. I feel this is a poor and erroneous assumption. It is equivalent to assuming people will quit smoking because it causes cancer, and or eat less because weight gain is associated with diabetes and heart disease. Physios assume that every person is well motivated to take care of themselves. Sadly, this is not the case. We live in a pill-popping society where everyone is looking for a quick fix. If given a choice of how to get better from a condition, patients would always prefer a one-time passive treatment over an extended regimen of active exercise management. The vast majority of patients are interested getting rid of their pain, not doing exercises.

It pains me to have heard time and time again, people saying “physios haven’t done a thing for me”. Do we simply brush these people off, blaming them for a lack of motivation or refusal to take responsibility for their own health? Or perhaps, our management plans have not taken into consideration patient motivation. Maybe there is something more we could do. I feel we should examine how we can increase patient compliance. Perhaps, we can strike a better balance between passive and active care, or make better exploitation of the placebo effect. I am not certain. Your input would be much appreciated.

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.