Ah… stroke rehab. My most recent placement was mostly involving outpatient stroke rehab, and it was a bit of a roller coaster ride. It was in an international setting, and the patients were often 10 months, or even 2 years post stroke. The poor collusion between the physiotherapy department and the doctors there pretty much means that often stroke patients do not get referred for rehab until a long time after their stroke.
For anyone who has done any stroke rehab, you’d know that this can be really frustrating, as the early phase of rehab is so critical to a patient’s outcome. Not only this, but in the time that they are not being rehabbed, they are learning poor patterns of movement, and these are getting reinforced over and over. Its exactly this kind of thing that makes rehab of these patients so challenging, and frustrating.
There were a few patients that myself and the other student were assigned to treat regularly throughout the placement. Some of these patients were quite old, had had quite a delay between their stroke and receiving rehab, and often did not want to get better. Couple those factors with the language barrier and it made for a very interesting and frustrating clinical experience.
There were days when we’d work really really hard with a patient, and get absolutely no results. There were other days when we’d work really hard and we’d get a good result, and the next time the patient comes in for treatment the results are gone and they are back the way they were. One thing that was particularly frustrating was that some patients would only learn context specific activities. What I mean is that, say for example you are trying to retrain a patients gait, and the main problem they have is improper verticality, so naturally we would do a lot of work on the patients verticality in other positions, assuming that this would carry over to their gait. And often patients would really really improve a lot in their ability to do these verticality exercised in other positions, but once we try them in gait, its clear that there has been absolutely no carry over.
However, most of the patients did improve a little bit over the four week period that we treated them, even if the progress was very slow and a lot of hard work. Has anyone else experienced this?
Friday, December 5, 2008
physios who poorly manage
One thing that I’ve seen a few times throughout my placements is poor practice. This can be a very serious thing sometimes, as obviously it can really affect the outcome for the patient. I remember the first experience I had with this was in third year, I had a musculoskeletal outpatients placement and I was watching one of the physios treat a patient with LBP. The ladies problem was so obviously a postural control disorder/ motor control disorder, yet the physio just gave the patient some random upper limb theraband exercises to do at home. It was pretty obvious that she didn’t really know what she was doing, and that she didn’t really care all that much either.
I found it kind of hard to deal with this. After a lot of thinking I realised that it’s the kind of thing that you cant stop as an individual. The only real thing that you can do is just make sure that you yourself are always striving after best practice and trying to make a big difference with the outcome of patients. What other physios do is not something that you can change. If physios want to be slack, and cant be bothered researching a treatment or doing some problem solving, then there’s nothing that can really be done about it (unless you happen to be one of the supervising physio’s- then you can crack the whip pretty hard).
In my experience outside of clinic, I have an injury that I have seen many physios for, with little improvement in my condition. I tried another new physio the other week, and already I have started to improve. After explaining my previous treatments to this physio, he explained to me that poor physiotherapy management is a very very common thing, especially in private practice. He also said that he was nearly fired from his last job for trying to manage patients correctly.
So my experiences have taught me that I should be wary of relying on other physiotherapists, and that I should always strive for best practice for every patient.
I found it kind of hard to deal with this. After a lot of thinking I realised that it’s the kind of thing that you cant stop as an individual. The only real thing that you can do is just make sure that you yourself are always striving after best practice and trying to make a big difference with the outcome of patients. What other physios do is not something that you can change. If physios want to be slack, and cant be bothered researching a treatment or doing some problem solving, then there’s nothing that can really be done about it (unless you happen to be one of the supervising physio’s- then you can crack the whip pretty hard).
In my experience outside of clinic, I have an injury that I have seen many physios for, with little improvement in my condition. I tried another new physio the other week, and already I have started to improve. After explaining my previous treatments to this physio, he explained to me that poor physiotherapy management is a very very common thing, especially in private practice. He also said that he was nearly fired from his last job for trying to manage patients correctly.
So my experiences have taught me that I should be wary of relying on other physiotherapists, and that I should always strive for best practice for every patient.
patients who dont improve
Over the past few placements I’ve noticed that there are several patients that I see in each placement that do not seem to improve in their condition. It can be quite a frustrating and confusing thing to encounter. I think there are a few reasons for this happening.
Firstly, there are patients whose conditions are of the deteriorating type (it’s not really these that I’m talking about though). For example, multiple sclerosis patients tend to steadily decline, as with patients who have motor neuron disease.
Secondly, patient compliance with HEP’s is a very large issue. One lady in particular springs to mind when I think of this. It was on my musculoskeletal outpatients practicum that I treated her, and it was a long-term (like 2 years) injury. The unfortunate thing is that she had a stack of notes the size of gray’s anatomy, and it would’ve taken a long time to go through them. As such, I decided to do a full assessment, and treat her based on my assessment rather than what the last student had done. My treatment basically consisted of shoulder muscle strengthening exercise and scapula retraining, most of which was to be done at home, daily. Unfortunately, the patient had a very set idea about what worked for her (pretty much just massage) and did not comply with the HEP that I gave her. This is probably a reason why she did not improve. And there are several other patients that I have seen with this same problem.
A third reason that patients sometimes do not improve, is that sometimes they just don’t want to get better. I encountered this mainly on my international prac. Over there (Malaysia) the family network is very strong, and younger members of the family really look after the older members. This is good in a way, but not so good in other ways. While its always good to have the support, it can lead to the patient becoming very dependent and even relying solely on the family. Some patients are perfectly happy to be waited on hand and foot by their families and not have to do a thing for themselves, and as a result do not comply with their rehab, and so don’t get better. These are just some the reasons why patients often don’t improve, im sure there are probably more. Does anyone else know of any?
Firstly, there are patients whose conditions are of the deteriorating type (it’s not really these that I’m talking about though). For example, multiple sclerosis patients tend to steadily decline, as with patients who have motor neuron disease.
Secondly, patient compliance with HEP’s is a very large issue. One lady in particular springs to mind when I think of this. It was on my musculoskeletal outpatients practicum that I treated her, and it was a long-term (like 2 years) injury. The unfortunate thing is that she had a stack of notes the size of gray’s anatomy, and it would’ve taken a long time to go through them. As such, I decided to do a full assessment, and treat her based on my assessment rather than what the last student had done. My treatment basically consisted of shoulder muscle strengthening exercise and scapula retraining, most of which was to be done at home, daily. Unfortunately, the patient had a very set idea about what worked for her (pretty much just massage) and did not comply with the HEP that I gave her. This is probably a reason why she did not improve. And there are several other patients that I have seen with this same problem.
A third reason that patients sometimes do not improve, is that sometimes they just don’t want to get better. I encountered this mainly on my international prac. Over there (Malaysia) the family network is very strong, and younger members of the family really look after the older members. This is good in a way, but not so good in other ways. While its always good to have the support, it can lead to the patient becoming very dependent and even relying solely on the family. Some patients are perfectly happy to be waited on hand and foot by their families and not have to do a thing for themselves, and as a result do not comply with their rehab, and so don’t get better. These are just some the reasons why patients often don’t improve, im sure there are probably more. Does anyone else know of any?
Thursday, November 27, 2008
Important Lessons
On my cardiopulmonary placement, I had an Indigenous woman, who had been re-admitted multiple times for exacerbations of bronchiectasis. I was allocated this patient, and prior to going to treat this patient for the first time, my Supervisor warned me that she would be difficult, and to not take offence to comments that she may make.
By the end of the placement, this patient was one of the most enjoyable patients that I treated. At first, this patient was quite abrupt, and not interested in Physiotherapy. However, I would not leave until my patient had her treatment, and eventually, she would realise the importance of clearing her secretions, and assist me with this.
A key point I want to make is how important it is, I feel, to persist with patients, and not to give up, especially if you have recieved pre-concieved ideas about how they will behave.
Before I treated this patient every day, I would often just chat, and the patient's compliance with Physio improved dramatically.
With Indigenous Australians, family, and home is extremely important to them, and we would talk about this often, and relate it back to treatment and the importance of self-management.
The key lessons I learnt fron this patient was the importance of persistence, and communication with all patients. The importance of family, and home to all patients. The need to be tolerant and understanding of the differences between cultures to enable effective treatment.
By the end of the placement, this patient was one of the most enjoyable patients that I treated. At first, this patient was quite abrupt, and not interested in Physiotherapy. However, I would not leave until my patient had her treatment, and eventually, she would realise the importance of clearing her secretions, and assist me with this.
A key point I want to make is how important it is, I feel, to persist with patients, and not to give up, especially if you have recieved pre-concieved ideas about how they will behave.
Before I treated this patient every day, I would often just chat, and the patient's compliance with Physio improved dramatically.
With Indigenous Australians, family, and home is extremely important to them, and we would talk about this often, and relate it back to treatment and the importance of self-management.
The key lessons I learnt fron this patient was the importance of persistence, and communication with all patients. The importance of family, and home to all patients. The need to be tolerant and understanding of the differences between cultures to enable effective treatment.
Wednesday, November 26, 2008
Palliative Care
I would like to share an experience from my rural placement. It is in regards to a palliative patient who was on the ward list. The patient was extremely emaciated, was nearly completely blind, and had severe respiratory disease. He had threatened nursing staff, and was clearly losing his will to live.
On this particular day, my overseeing Supervisor was up on the ward with me. We went in to see this patient, who was clearly distressed and absolutely did not want to get out of bed. I initially introduced myself and attempted to persuade him to do some chest exercises, however he was completely disinterested. When I mentioned getting up, just to sit on the edge of the bed, he swore at me, and as much as I wanted to get this patient to move, I knew I had to respect his wish for me to go, and leave him be.
However, my Supervisor was not at all happy with my performance. He had his turn to get this patient out of bed. He used his bellowing voice to tell the patient that the Doctor’s had requested he get up. After much distress from the patient, he angrily got up out of bed to the toilet. He was clearly very distressed with having to do this, and I felt a little upset for the patient as well as he was not happy.
The point I am trying to make is at what point with a palliative patient do you leave your professional hat at the door, and respect the patients wish to be left alone? Is our role more to improve their quality of life in these later stages, rather than attempt to 'treat'. Has anybody encountered this instance over their clinical practice?
I was told by my Supervisor that I was too soft, and needed to work harder to get these patients out of bed. I have to say I disagree when it comes to palliative care. I did learn through this experience that there are different approaches to treating the same patient, and we all have to respect the different ways in which we practice.
I would be interested to hear how others would have dealt with this situation, and what approach others would have undertaken.
Thankyou!
On this particular day, my overseeing Supervisor was up on the ward with me. We went in to see this patient, who was clearly distressed and absolutely did not want to get out of bed. I initially introduced myself and attempted to persuade him to do some chest exercises, however he was completely disinterested. When I mentioned getting up, just to sit on the edge of the bed, he swore at me, and as much as I wanted to get this patient to move, I knew I had to respect his wish for me to go, and leave him be.
However, my Supervisor was not at all happy with my performance. He had his turn to get this patient out of bed. He used his bellowing voice to tell the patient that the Doctor’s had requested he get up. After much distress from the patient, he angrily got up out of bed to the toilet. He was clearly very distressed with having to do this, and I felt a little upset for the patient as well as he was not happy.
The point I am trying to make is at what point with a palliative patient do you leave your professional hat at the door, and respect the patients wish to be left alone? Is our role more to improve their quality of life in these later stages, rather than attempt to 'treat'. Has anybody encountered this instance over their clinical practice?
I was told by my Supervisor that I was too soft, and needed to work harder to get these patients out of bed. I have to say I disagree when it comes to palliative care. I did learn through this experience that there are different approaches to treating the same patient, and we all have to respect the different ways in which we practice.
I would be interested to hear how others would have dealt with this situation, and what approach others would have undertaken.
Thankyou!
Tuesday, November 25, 2008
Nurses
On a recent placement, it required much communication with the nursing staff, particularly in the mornings. This was due to the fact that the patients required higher level care, and therefore, it was courteous to let the NS know appropriate times so they could organise their schedules also.
One particular morning, one of the nurses was extremely rude to us as students. She was upset that her name was spelt wrong on the board and was mispronounced by us, and therefore stated that she should not help us out with our patients. Later we found out that she was covering shifts for a sick nurse who had gone home.
Another nurse questioned me checking the obs chart, and writing down the obs, stating that I should not be writing them, as I did not take them myself. I had been present in the room when she was taking all the obs, and I found this particularly rude, and condescending, however I laughed it off as best I could.
Another instance was when a nurse was asked if a particular time would be appropriate for a patient, as she proceeded to go into the patient’s room and ask if the ‘students’ could see him this morning. I felt this was putting a low priority on the important physiotherapy service we were needing to provide to this patient.
I am by no means in this blog trying to say that nurses are not doing a fantastic job – they go over and above what they are required to do. I think that is the point I am trying to make is that they are required to do more than is possible, and as a result, the quality of care cannot always be there. If someone calls in sick, they are run off their feet. I do believe however, their must be a mutual respect and understanding for what both professions do for patients, so we can work together to achieve optimal patient results.
These valuable lessons I think we can all bring into our future clinical practice, as it is easy to moan about how some nurses treat us, however we need to be aware of their position as well, and vice versa.
One particular morning, one of the nurses was extremely rude to us as students. She was upset that her name was spelt wrong on the board and was mispronounced by us, and therefore stated that she should not help us out with our patients. Later we found out that she was covering shifts for a sick nurse who had gone home.
Another nurse questioned me checking the obs chart, and writing down the obs, stating that I should not be writing them, as I did not take them myself. I had been present in the room when she was taking all the obs, and I found this particularly rude, and condescending, however I laughed it off as best I could.
Another instance was when a nurse was asked if a particular time would be appropriate for a patient, as she proceeded to go into the patient’s room and ask if the ‘students’ could see him this morning. I felt this was putting a low priority on the important physiotherapy service we were needing to provide to this patient.
I am by no means in this blog trying to say that nurses are not doing a fantastic job – they go over and above what they are required to do. I think that is the point I am trying to make is that they are required to do more than is possible, and as a result, the quality of care cannot always be there. If someone calls in sick, they are run off their feet. I do believe however, their must be a mutual respect and understanding for what both professions do for patients, so we can work together to achieve optimal patient results.
These valuable lessons I think we can all bring into our future clinical practice, as it is easy to moan about how some nurses treat us, however we need to be aware of their position as well, and vice versa.
Some gains vs Nursing Home
This next entry is also regarding my neurology placement. One of our patients was a severley affected right MCA.
When we took this patient on, he had been an inpatient for at lest three months, and had achieved small gains in this time. He had severe left, unilateral neglect, very poor trunk control, and a severe left hemiparesis, along with many other impairments.
By the end of the placement, the patients neglect, head and trunk control had improved significantly, and he had attained close to independent sitting balance. In consulting with the multi-disciplinary team, the patient had also made marked advances with both occupational and speech therapy.
The problem was in regards to his discharge. The medical team were pushing to place the patient in a nursing home, and the therapists wanted to keep the patient in the ward to continue making significant gains. Going home was not a viable option, as the patient had most extended family in Singapore, and his elferely wife would simply not be able to cope.
By the end of the placement, the decision had been made to place the patient in a nursing home for his continuing care. This was upsetting in a way, as we could clearly see the gains he had made, and at one point, had even been able to stand the patient (although it was with 3xmax assist!).
I guess what was learnt from this was to never give up on a patient, as he was able to make remarkable gains whilst we were treating him. It is also important to consider discharge from the very beginning of treatment, to have a clear goal of where the treatment is heading. It is also important to be the pateints advocate as well, and to try to do the best for their well-being, even if at the end of the day, you lose.
When we took this patient on, he had been an inpatient for at lest three months, and had achieved small gains in this time. He had severe left, unilateral neglect, very poor trunk control, and a severe left hemiparesis, along with many other impairments.
By the end of the placement, the patients neglect, head and trunk control had improved significantly, and he had attained close to independent sitting balance. In consulting with the multi-disciplinary team, the patient had also made marked advances with both occupational and speech therapy.
The problem was in regards to his discharge. The medical team were pushing to place the patient in a nursing home, and the therapists wanted to keep the patient in the ward to continue making significant gains. Going home was not a viable option, as the patient had most extended family in Singapore, and his elferely wife would simply not be able to cope.
By the end of the placement, the decision had been made to place the patient in a nursing home for his continuing care. This was upsetting in a way, as we could clearly see the gains he had made, and at one point, had even been able to stand the patient (although it was with 3xmax assist!).
I guess what was learnt from this was to never give up on a patient, as he was able to make remarkable gains whilst we were treating him. It is also important to consider discharge from the very beginning of treatment, to have a clear goal of where the treatment is heading. It is also important to be the pateints advocate as well, and to try to do the best for their well-being, even if at the end of the day, you lose.
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