Wednesday, January 31, 2007
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…
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.
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.
Monday, January 29, 2007
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
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?
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?
Sunday, January 28, 2007
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...
Saturday, January 27, 2007
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?
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?
Thursday, January 25, 2007
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???
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.
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
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
Monday, January 22, 2007
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.
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.
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.
Sunday, January 21, 2007
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
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
Saturday, January 20, 2007
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
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
Friday, January 19, 2007
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.
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.
Thursday, January 18, 2007
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?
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?
Wednesday, January 17, 2007
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.
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.
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.
Monday, January 15, 2007
Time Management
Hello all! I appologise for being so late but was having some computer/e-mail issues!
I am currently completing my musculo prac at Curtin and am enjoying my time. An issue that I have had with both this prac as well as my cardio prac was "time management". Now this comment was not always made directly towards me but I feel that it is something that the supervisors and tutors love to tell us to work on. Now, I realise that this is definitely something that we do need to be aware of and that when we graduate and are practicing that we will constantly have to deal with, however, I do not feel that it is the "be all and end all" of being a good physio and that, while we should be aware of it, it should not be one of our main concerns in the first couple weeks of the practicum. I feel that, as students, everything is brand new to us, and while we can't "dilly daddle" and waist people's time that it should be taken into account that we need to get a good grasp on ALL of the information to start. In learning how to establish all of the recently learned new material into clinical practice I feel that it is far mor important to go into greater detail and learn as much as we can about everything. This then allows us to have a good understanding of the issues and what we can and can't miss as a practicing physio (ie; knowing what is the most important assessment, treatment, to do and what can wait till next session due to time constraints).
So, in conclusion, I feel that a student should not be necessarily labeled as "doing well" because they are able to treat more patients and hold to the time contraints, as this may be simply due to them missing out important information! I can definitely say that I, myself, have felt the pressure of time and have most likely missed out on something I probably shouldn't have and have, in fact, being praised for it! If anyone else has anything to add I'd be happy to hear!
Nicole
I am currently completing my musculo prac at Curtin and am enjoying my time. An issue that I have had with both this prac as well as my cardio prac was "time management". Now this comment was not always made directly towards me but I feel that it is something that the supervisors and tutors love to tell us to work on. Now, I realise that this is definitely something that we do need to be aware of and that when we graduate and are practicing that we will constantly have to deal with, however, I do not feel that it is the "be all and end all" of being a good physio and that, while we should be aware of it, it should not be one of our main concerns in the first couple weeks of the practicum. I feel that, as students, everything is brand new to us, and while we can't "dilly daddle" and waist people's time that it should be taken into account that we need to get a good grasp on ALL of the information to start. In learning how to establish all of the recently learned new material into clinical practice I feel that it is far mor important to go into greater detail and learn as much as we can about everything. This then allows us to have a good understanding of the issues and what we can and can't miss as a practicing physio (ie; knowing what is the most important assessment, treatment, to do and what can wait till next session due to time constraints).
So, in conclusion, I feel that a student should not be necessarily labeled as "doing well" because they are able to treat more patients and hold to the time contraints, as this may be simply due to them missing out important information! I can definitely say that I, myself, have felt the pressure of time and have most likely missed out on something I probably shouldn't have and have, in fact, being praised for it! If anyone else has anything to add I'd be happy to hear!
Nicole
Postherpetic Neuralgia
At my orthopedic outpatients placement I’ve recently treated a patient who presented with postherpetic neuralgia with pain in her cervical region and associated headache.
As I was not familiar with the syndrome, I’ve sourced some information about it on the internet (www.mayoclinic.com, accessed 14/01/2007):
Postherpetic neuralgia is a painful condition affecting the nerve fibers and skin. It's a complication of shingles, a second outbreak of the varicella-zoster virus, which initially causes chickenpox. A case of shingles usually heals within a month. But some people continue to feel pain long after the rash and blisters heal. This pain is known as postherpetic neuralgia.
The symptoms of postherpetic neuralgia are generally limited to the area of the skin where the shingles outbreak first occurred. They may include: sharp and jabbing, burning, or deep and aching pain; extreme sensitivity to touch and temperature change; itching and numbness; headaches.
In rare cases, patients might also experience muscle weakness or paralysis — if the nerves involved also control muscle movement.
Treatment for postherpetic neuralgia depends on the type of pain experienced. Possible options include: Lidocaine skin patches, antidepressants, certain anticonvulsants, injected steroids, painkillers, transcutaneous electrical nerve stimulation (TENS), spinal cord or peripheral nerve stimulation.
In some cases, treatment of postherpetic neuralgia brings complete pain relief. But most people still experience some pain, and a few don't receive any relief. Although some people must live with postherpetic neuralgia the rest of their lives, most people can expect the condition to gradually disappear during the first three months. For about 10 percent to 20 percent of people with postherpetic neuralgia, the pain may persist for a year or more.
The patient I’ve treated mainly presented with pain on active movement and ↓AROM into SF bilaterally and extension. On assessment her upper trapezius on both sides had trigger points reproducing her pain locally and referred (headache), and the insertion of splenius capitis and semispinalis capitis at the occiput were tender and reproduced her pain. On PPIVM’s I found normal movement. I was unable to assess PAIVM’s due to tissue tenderness.
I therefore decided to treat her muscular symptoms, performing STM and very light trigger point release as the patient was still very tender to touch. My reasoning behind is that due to the hypersensitivity of the nerve, the muscle had reacted into local spasm, creating a trigger point. A contributing factor for her muscle soreness could be pain provoked posture, making her lift her shoulders because her neck had been so sore for a while.
Has any one had a similar case where a patient presented with muscular soreness due to neuralgia and how did you treat it? Any other ideas, suggestions or comments…
Thanks,
Edith
Sunday, January 14, 2007
The first neuro patient
I am currently taking neuro placement at the Royal Perth Hospital Shenton Park Campus.
The first patient I saw was a lady who had LMCA stroke and was attending the neuro outpatient department for ongoing rehabilitation. Reading her transfer summary I have noticed that previous physiotherapist was working mainly on this ladies UL function. When I met the lady for the first time I observed that she had quite and advanced pregnancy and her gait was very compensated to the point that I thought that she is quite unsteady and at risk of falling.
During my subjective examination, I asked her what were her main concerns were.
She pointed out to me to her R UL, as she couldn’t talk due to receptive aphasia. All the questions had to be with answers being yes or no. So my first treatment consisted mainly with the exercises of her R UL as she requested and also I followed what was in her transfer summary of her exercise program. On her second visit I decided to do an assessment to revaluate her impairments and prioritise the problem list for her ongoing rehabilitation.
During the assessment of the ladies gait I noticed that she had inadequate weight shift on the affected side and she looked very unsteady. My instant thought was that I needed to change her program in terms of working more on postural control and improving her gait pattern, rather that just working on her R UL function.
My dilemma was how would I tell this lady to change her program as she was quite determined what she wanted, that is to improve her UL function. Seeing her for the second time I wanted first to gain the patients trust and build a better rapport to gain her compliance of the rehabilitation.
I decided to explain the reason for my decision. First, by doing the Berg Balance reassessment and 10 min walk test would show her and me a good outcome measure, that is results probably indicating that she hasn’t improved since her last assessment. Secondly explaining how balance changes with pregnancy in normal people and that being affected by the stroke balance will be affected even more puts her at risk of losing balance, which may harm her and the babie. This may increase her awareness and therefore compliance.
What do you think colleagues of my plan when dealing with this patient?
The first patient I saw was a lady who had LMCA stroke and was attending the neuro outpatient department for ongoing rehabilitation. Reading her transfer summary I have noticed that previous physiotherapist was working mainly on this ladies UL function. When I met the lady for the first time I observed that she had quite and advanced pregnancy and her gait was very compensated to the point that I thought that she is quite unsteady and at risk of falling.
During my subjective examination, I asked her what were her main concerns were.
She pointed out to me to her R UL, as she couldn’t talk due to receptive aphasia. All the questions had to be with answers being yes or no. So my first treatment consisted mainly with the exercises of her R UL as she requested and also I followed what was in her transfer summary of her exercise program. On her second visit I decided to do an assessment to revaluate her impairments and prioritise the problem list for her ongoing rehabilitation.
During the assessment of the ladies gait I noticed that she had inadequate weight shift on the affected side and she looked very unsteady. My instant thought was that I needed to change her program in terms of working more on postural control and improving her gait pattern, rather that just working on her R UL function.
My dilemma was how would I tell this lady to change her program as she was quite determined what she wanted, that is to improve her UL function. Seeing her for the second time I wanted first to gain the patients trust and build a better rapport to gain her compliance of the rehabilitation.
I decided to explain the reason for my decision. First, by doing the Berg Balance reassessment and 10 min walk test would show her and me a good outcome measure, that is results probably indicating that she hasn’t improved since her last assessment. Secondly explaining how balance changes with pregnancy in normal people and that being affected by the stroke balance will be affected even more puts her at risk of losing balance, which may harm her and the babie. This may increase her awareness and therefore compliance.
What do you think colleagues of my plan when dealing with this patient?
Saturday, January 13, 2007
Angel Transfers
Dear All,
I am currently completeing a neuro inpatient clinic on an acute ward. One thing we've had to learn to do thus far is an 'Angel' transfer. For those of you that are unaware - it is a maximal dependent transfer - with students 1 at the front of the patient and one behind controlling the pelvis. It can go to say that the person at the front has a bit more work to do. Anyway, the idea is that you take the patient's weight with them leaning on you, ensure that you've got their weight, and you kind of rock forwards and to the direction you are going in, then unaware to the patient, you transfer them. Nursing staff do not do this transfer due to the 'no lift' policy and this transfer is classified as a lift.
We have been seeing a patient who had a large L MCA infarct on the 6/1/07, and was allowed up on Wednesday. Thursday we took the pt to the gym and were shown the transfer. Our supervisor wanted us to perform it ourselves getting the pt from the plinth back into her chair, and almost unfortunately I was the student in front. This pt would weigh approx 100kg......my weight: approx 55kg. I was quietly anxious regarding transfering such a large pt in this style, however completed the transfer with minimal difficulty, however I felt as though I put in maximal effort.
Then on Friday, I had to transfer the pt from her bed (complete with Nimbus mattress) to her wheelchair. By the end of the week I also had quite considerable DOMS in both my ULs and LLs, not to mention trunk, abs....ok everywhere - I'm the sorest I've ever been, so I was a little anxious to say the least. The pt's room was full of pepole and I didn't want to have to spend a lot of time doing the transfer, and needless to say - the transfer didn't go as well....I almost overshot the wheelchair and pushed my weight too far backwards....so although the pt ended up in her chair....I nearly ended up on the floor! I was quite embarrassed to say the least, and have learnt my lesson in that - when preparing for the transfer to TAKE YOUR TIME and not go until you are really sure you've got the pt exactly where you need them. I was also really worried that the pt had lost confidence with me.....so when we got down to the gym, despite being asked by my supervisor if I would like her to do the transfer, I did another 2 - with no hiccups. BUT I am still quite sore to say the least. So....I have restored my pt's confidence in me (I hope) and my confidence in myself....however I'm wondering when and how you decide that a pt is either too big for your body size and therefore it's unsafe for you to manually transfer them whilst they are completely dependent? I have also been thinking about the culture of physiotherapists....we seem to have this belief that we can manually transfer anyone, no-one is too big for us if we have the correct technique - but is that really true?? What about all of the 'workplace safety policies' - do they not apply to us? AND, if you do decide NOT to manually transfer a pt - do you look incompetent or like you have a lack of confidence to your supervisors?
Mads
I am currently completeing a neuro inpatient clinic on an acute ward. One thing we've had to learn to do thus far is an 'Angel' transfer. For those of you that are unaware - it is a maximal dependent transfer - with students 1 at the front of the patient and one behind controlling the pelvis. It can go to say that the person at the front has a bit more work to do. Anyway, the idea is that you take the patient's weight with them leaning on you, ensure that you've got their weight, and you kind of rock forwards and to the direction you are going in, then unaware to the patient, you transfer them. Nursing staff do not do this transfer due to the 'no lift' policy and this transfer is classified as a lift.
We have been seeing a patient who had a large L MCA infarct on the 6/1/07, and was allowed up on Wednesday. Thursday we took the pt to the gym and were shown the transfer. Our supervisor wanted us to perform it ourselves getting the pt from the plinth back into her chair, and almost unfortunately I was the student in front. This pt would weigh approx 100kg......my weight: approx 55kg. I was quietly anxious regarding transfering such a large pt in this style, however completed the transfer with minimal difficulty, however I felt as though I put in maximal effort.
Then on Friday, I had to transfer the pt from her bed (complete with Nimbus mattress) to her wheelchair. By the end of the week I also had quite considerable DOMS in both my ULs and LLs, not to mention trunk, abs....ok everywhere - I'm the sorest I've ever been, so I was a little anxious to say the least. The pt's room was full of pepole and I didn't want to have to spend a lot of time doing the transfer, and needless to say - the transfer didn't go as well....I almost overshot the wheelchair and pushed my weight too far backwards....so although the pt ended up in her chair....I nearly ended up on the floor! I was quite embarrassed to say the least, and have learnt my lesson in that - when preparing for the transfer to TAKE YOUR TIME and not go until you are really sure you've got the pt exactly where you need them. I was also really worried that the pt had lost confidence with me.....so when we got down to the gym, despite being asked by my supervisor if I would like her to do the transfer, I did another 2 - with no hiccups. BUT I am still quite sore to say the least. So....I have restored my pt's confidence in me (I hope) and my confidence in myself....however I'm wondering when and how you decide that a pt is either too big for your body size and therefore it's unsafe for you to manually transfer them whilst they are completely dependent? I have also been thinking about the culture of physiotherapists....we seem to have this belief that we can manually transfer anyone, no-one is too big for us if we have the correct technique - but is that really true?? What about all of the 'workplace safety policies' - do they not apply to us? AND, if you do decide NOT to manually transfer a pt - do you look incompetent or like you have a lack of confidence to your supervisors?
Mads
Thursday, January 11, 2007
Mingling
Something that I seem to be having a problem with is mixing the physios in the department other than those who I am in direct contact with. At morning tea and lunch the tendency is to just either speak with the physios that I work with on the ward or with other students. I’m not really looking for advice, just more if anyone else is having the same problem, or if I’m just special.
Dealing with different points of view
Like Jess, I have also just begun my cardiopulmonary placement at a major teaching hospital and have been faced with my first clinical dilemma.
I have noticed in many of the patient notes that the consultants have recommended the use of incentive spirometry (IS) post surgery to prevent postoperative pulmonary complications (PPCs). In lecture, we’ve learned that there has been little evidence to prove that IS has clinical benefit over other physiotherapy techniques in preventing PPCs. Having come home this evening and done a search on the Cochrane Collaboration, and explored a variety of search engines, I have not been able to find firm evidence of IS preventing post-op pulmonary complications.
Our research unit tells us that expert opinion has minimal levels of evidence, and that randomized controlled trials are much higher on the hierarchy of the levels of evidence. My question is then, why do doctors continue to prescribe the use of IS post-op if there is little evidence supporting its use?
IS disposable units cost more than $100 each, which can become quite expensive for the hospital if it is being recommended for most post-op cardiothoracic and abdominal surgery patients. How can this cost be justified if the evidence supporting the use of IS is so conflicting? I spoke with my clinical supervisor about what she does in these situations. She wasn’t able to give me a definitive answer, as most of the time it depends on how firmly the consultant believes IS is necessary. Often, she is able to substitute IS with other physiotherapy breathing techniques and exercises.
This conversation with her made me realize how difficult it must be to provide a treatment even though current evidence states that benefits from it have yet to be proven, however you are part of a hierarchy that demands you do it anyway.
I feel I am becoming more aware now of the struggles that we will be faced with upon graduation when we begin working. Over the remaining 12 weeks of clinical placements, one of my goals will be to develop the skills that are necessary for dealing with conflicting evidence and differing points of view. My question to you as students, is how have you dealt with scenarios such as this and what are your thoughts on how to deal with them?
I have noticed in many of the patient notes that the consultants have recommended the use of incentive spirometry (IS) post surgery to prevent postoperative pulmonary complications (PPCs). In lecture, we’ve learned that there has been little evidence to prove that IS has clinical benefit over other physiotherapy techniques in preventing PPCs. Having come home this evening and done a search on the Cochrane Collaboration, and explored a variety of search engines, I have not been able to find firm evidence of IS preventing post-op pulmonary complications.
Our research unit tells us that expert opinion has minimal levels of evidence, and that randomized controlled trials are much higher on the hierarchy of the levels of evidence. My question is then, why do doctors continue to prescribe the use of IS post-op if there is little evidence supporting its use?
IS disposable units cost more than $100 each, which can become quite expensive for the hospital if it is being recommended for most post-op cardiothoracic and abdominal surgery patients. How can this cost be justified if the evidence supporting the use of IS is so conflicting? I spoke with my clinical supervisor about what she does in these situations. She wasn’t able to give me a definitive answer, as most of the time it depends on how firmly the consultant believes IS is necessary. Often, she is able to substitute IS with other physiotherapy breathing techniques and exercises.
This conversation with her made me realize how difficult it must be to provide a treatment even though current evidence states that benefits from it have yet to be proven, however you are part of a hierarchy that demands you do it anyway.
I feel I am becoming more aware now of the struggles that we will be faced with upon graduation when we begin working. Over the remaining 12 weeks of clinical placements, one of my goals will be to develop the skills that are necessary for dealing with conflicting evidence and differing points of view. My question to you as students, is how have you dealt with scenarios such as this and what are your thoughts on how to deal with them?
Wednesday, January 10, 2007
to push or not to push
I am currently completing my cardiopulmonary practical at a major teaching hospital. As my fellow colleagues will be aware a major the role of a physiotherapist in this setting is encouraging the post operative patient to get up out of bed and begin to mobilise.
I have discovered over the past few days that this task can prove difficult. Let us first look at the situation from a patient’s point of view. Imagine you have undergone major surgery just 24 hours ago, you have woken up in a strange place, there are 3 strangers sharing your small room, your head and body ache, you feel nauseous and a little dizzy, there are ear piercing alarms coming from down the corridor plus you have 3 tubes coming out your body and 2 others going in. At least you feel somewhat safe in the comfort of your bed and finally, after an hour of moving around in the bed you have found a comfortable position when…… in walks the PHYSIO and asks you to get up out of bed and go for a walk.
From a physiotherapists point of view we know that it vitally important for our cardiopulmonary patients to sit upright and mobilise out of bed. We understand the physiology of the lungs, how anaesthetic and bed rest compromise the functioning of this organ, how upright position and deep breathing exercises help to reinflate collapsed alveoli and how clearing secretions can reduce chest infections rates. In a perfect world every set of lungs would sit out of bed day one, ambulate and demonstrate good breathing exercises, however as physios we don’t deal with lungs we treat humans!! And sometimes despite the best education and encouragement that you can give the human will just say “no”. So how do we know when to push for what we want and believe in or when to leave the patient be?? I asked this question of a supervisor of mine and she shed some light on the area, you can’t force anyone to do anything they don’t want to do. However the use of good bargaining and persuasion skills do not go astray, education tailored to the individual is an invaluable tool.
Obviously there are also times that call for compassion and clinical judgement for example, some surgeries on my ward are exploratory procedures, if the results come back with widespread inoperable metastasic disease, it would be inappropriate for a physiotherapist to insist that the patient gets up and walks around the ward shortly after they receive the news.
I have noticed a wide range of ways that different physiotherapists tackle this kind of patient, some are very strict and do all but physically pull the patient out of bed; others seem less keen to upset the patient and don’t really attempt too hard to change the patient’s mind. I guess knowing when to push and when not to push a patient will only come with experience…
I have discovered over the past few days that this task can prove difficult. Let us first look at the situation from a patient’s point of view. Imagine you have undergone major surgery just 24 hours ago, you have woken up in a strange place, there are 3 strangers sharing your small room, your head and body ache, you feel nauseous and a little dizzy, there are ear piercing alarms coming from down the corridor plus you have 3 tubes coming out your body and 2 others going in. At least you feel somewhat safe in the comfort of your bed and finally, after an hour of moving around in the bed you have found a comfortable position when…… in walks the PHYSIO and asks you to get up out of bed and go for a walk.
From a physiotherapists point of view we know that it vitally important for our cardiopulmonary patients to sit upright and mobilise out of bed. We understand the physiology of the lungs, how anaesthetic and bed rest compromise the functioning of this organ, how upright position and deep breathing exercises help to reinflate collapsed alveoli and how clearing secretions can reduce chest infections rates. In a perfect world every set of lungs would sit out of bed day one, ambulate and demonstrate good breathing exercises, however as physios we don’t deal with lungs we treat humans!! And sometimes despite the best education and encouragement that you can give the human will just say “no”. So how do we know when to push for what we want and believe in or when to leave the patient be?? I asked this question of a supervisor of mine and she shed some light on the area, you can’t force anyone to do anything they don’t want to do. However the use of good bargaining and persuasion skills do not go astray, education tailored to the individual is an invaluable tool.
Obviously there are also times that call for compassion and clinical judgement for example, some surgeries on my ward are exploratory procedures, if the results come back with widespread inoperable metastasic disease, it would be inappropriate for a physiotherapist to insist that the patient gets up and walks around the ward shortly after they receive the news.
I have noticed a wide range of ways that different physiotherapists tackle this kind of patient, some are very strict and do all but physically pull the patient out of bed; others seem less keen to upset the patient and don’t really attempt too hard to change the patient’s mind. I guess knowing when to push and when not to push a patient will only come with experience…
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