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?
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