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.
Being Observant
Recently, on my Neurology placement, I encountered a situation which I would like to share with you. I had been given a new patient, and had not been able to do much with him for the first week of his admission as he was rest in bed. When I did get to see him, he was quite fatigued, as he had had extremely poor sleep due to 11/10 headaches.
I went in to see him in the morning during my final week, as I had hoped to see him for some Physiotherapy during the day. I noticed immediately on walking into his room, that his communcation was different. He almost looked as thoug he was in a different conscoius state- he took a long time to reply to my questions, and when he did, barely opened his eyes to make contact with me, and struggled to keep his eyes open.
I checked his med charts, and his nursing obs, and noticed that he had increased pain meds overnight which may have contributed to his present state, although his latest meds were given multiple hours previously. The patients nrusing obs were within his normal limits.
I immediately went to the nursing staff, and informed them of what I had seen with this patient, to ask if they had also noticed a change. The nurse came in to observe the patient, and the patient was well oriented to time, person and place. The nurse also acknowledged a change in his communicative state, and the medical staff were immediately contacted for a review.
Satisfied with this, I went to look in the medical notes, and noticed that the Reg had not recorded changes noted from my observation of the patients most recent CT scan. I immediately contacted the Reg, to ask if this patient was still fine to treat Physiotherapy wise, considering the new developments with the CT scan. The Reg, noted this, and stated it was fine – she must have failed to update this in her note-taking.
I did not manage to get this particular patient into Physiotherapy that day, and as the placement is now over, I do not know what happened further in this patient’s case, however, I did learn from this expereince.
One lesson is to always be very observant of your patients, as often we are the first ones who notice not only improvements, but also deteriorations in our patient’s status. The second point is the importance of the Multi-disciplinary team, and communicating effectively with all members for the well-being of the patient. Thirdly, don’t be scared to challenge or question Doctor’s from time to time,in a professional manner, as everybody makes mistakes. I will bring these lessons learnt into my future clinical practice.
I went in to see him in the morning during my final week, as I had hoped to see him for some Physiotherapy during the day. I noticed immediately on walking into his room, that his communcation was different. He almost looked as thoug he was in a different conscoius state- he took a long time to reply to my questions, and when he did, barely opened his eyes to make contact with me, and struggled to keep his eyes open.
I checked his med charts, and his nursing obs, and noticed that he had increased pain meds overnight which may have contributed to his present state, although his latest meds were given multiple hours previously. The patients nrusing obs were within his normal limits.
I immediately went to the nursing staff, and informed them of what I had seen with this patient, to ask if they had also noticed a change. The nurse came in to observe the patient, and the patient was well oriented to time, person and place. The nurse also acknowledged a change in his communicative state, and the medical staff were immediately contacted for a review.
Satisfied with this, I went to look in the medical notes, and noticed that the Reg had not recorded changes noted from my observation of the patients most recent CT scan. I immediately contacted the Reg, to ask if this patient was still fine to treat Physiotherapy wise, considering the new developments with the CT scan. The Reg, noted this, and stated it was fine – she must have failed to update this in her note-taking.
I did not manage to get this particular patient into Physiotherapy that day, and as the placement is now over, I do not know what happened further in this patient’s case, however, I did learn from this expereince.
One lesson is to always be very observant of your patients, as often we are the first ones who notice not only improvements, but also deteriorations in our patient’s status. The second point is the importance of the Multi-disciplinary team, and communicating effectively with all members for the well-being of the patient. Thirdly, don’t be scared to challenge or question Doctor’s from time to time,in a professional manner, as everybody makes mistakes. I will bring these lessons learnt into my future clinical practice.
Dealing with Patient Mortality
On my cardiopulmonary placement, I was faced with many emotional experiences. In particular, one comes to mind. I had been treating this one particular patient for three weeks, and he was approaching discharge. From his history, he was very unwell, and was an inpatient for multiple months.
He had a very supportive family, in particular his son, who I had met on multiple occasions. I had given this patients son education regarding his father’s progress, as well as his oxygen therapy, and just idle chit-chat also.
In my final week, I noticed on the Monday that this patient of mine was not on the list. I heard a loud response from another Physiotherapist, who had been treating this patient before myself, stating that she can’t believe he had passed away. I immediately felt quite overwhelmed for a moment, having realised that my patient had passed away. I was later told that this patient was getting discharged over the weekend, was all packed and ready to go waiting in his chair for transport, and had a heart attack and passed away in his chair while waiting for his car to arrive.
The question that this experience brought to me, was how do we and other health professionals deal with the loss of a patient-particulary when it is someone seen regularly, for instance twice every day? What I found interesting is how everything keeps going as though nothing happened- the staff don’t have a choice.
I realised the importance of having a supportive family/friend environment to come home to post work, to be able to deal with these strong emotional responses that come from working in these high intensity areas. It is also extremely importan to be confident in your own abilities, to be able to say that you did all you could to return this patient to home, or greater functional independence to improve their QOL, to not hold blame for when patients don’t make it home.
I also realise that it is not optimal to get too close to patients-although sometimes it is difficult not to. Having completed this placement, it was in fact my favourite, and most rewarding. It challenged me, and I was able to meet the challenge, through experiences like the one described.
He had a very supportive family, in particular his son, who I had met on multiple occasions. I had given this patients son education regarding his father’s progress, as well as his oxygen therapy, and just idle chit-chat also.
In my final week, I noticed on the Monday that this patient of mine was not on the list. I heard a loud response from another Physiotherapist, who had been treating this patient before myself, stating that she can’t believe he had passed away. I immediately felt quite overwhelmed for a moment, having realised that my patient had passed away. I was later told that this patient was getting discharged over the weekend, was all packed and ready to go waiting in his chair for transport, and had a heart attack and passed away in his chair while waiting for his car to arrive.
The question that this experience brought to me, was how do we and other health professionals deal with the loss of a patient-particulary when it is someone seen regularly, for instance twice every day? What I found interesting is how everything keeps going as though nothing happened- the staff don’t have a choice.
I realised the importance of having a supportive family/friend environment to come home to post work, to be able to deal with these strong emotional responses that come from working in these high intensity areas. It is also extremely importan to be confident in your own abilities, to be able to say that you did all you could to return this patient to home, or greater functional independence to improve their QOL, to not hold blame for when patients don’t make it home.
I also realise that it is not optimal to get too close to patients-although sometimes it is difficult not to. Having completed this placement, it was in fact my favourite, and most rewarding. It challenged me, and I was able to meet the challenge, through experiences like the one described.
Supervision Clashes
On my rural placement, I was given the option of inpatients or outpatients at the Hospital. I chose outpatients after much debate J and with this, was given a new graduate from Notre Dame as my placement supervisor. I had proceeded through three weeks of inpatients with not only my direct supervisor up on the ward, but with other Physiotherapists that were on the ward also .
At my mid-placement assessment, I was given no negative feedback regarding my current performance, and was told to continue building on my skills to run the ward more independently for the last two weeks.
When some of the other Physiotherapists came up to visit me on the ward, they had no problems with my performance. As it was my first inpatient experience, it was all new to me. On top of this, I had not yet done my cardiopulmonary nor my neuro placment, so I therefore, was reviewing much information over the placment to bring myself up to speed. However, as I wasn’t recieving any negative feedback, I figured my performance was fine, and I just continued to improve and build on my confidence each day.
In my final week, the overseeing Supervisor, from outpatines decided he wanted to come up to the ward and see how I was performing. He informed me later that day that he was not impressed by the way I was handling the ward. He was dissatisfied with my note-taking, and my confidence in dealing with patients. He informed me if I didn’t improve I would potentially require additional development. I was obviously upset, as this was the first time I was informed that my performance was not adequate. I felt I could run then ward indepently, and was doing a fair job.
By the end of the placement, I recieved a competent grade, and the overseeing Supervisor apologised to me as he felt they had not been able to get the best out of me from the placement, and he was upset as he felt they had not done me justice with the supervision/learning I was given.
What I learnt from this experience was to find out from the very beginning of my placements what my exact expectations were, as I recieved mixed messages from different Physiotherapists on this clinic. Also, I learnt that not every Physiotherapist practices in the same way. The overseeing Supervisor was extremely abrupt in his communication with patients, and very much took the philosophy that Physiotherapists were the big, bad guys who got patients up, and we have to use our voice and presence to get in there and do what we have to do. He took my quieter method of communicating with patients as a lack of confidence and ability, when in fact, it is simply a different communication style, which can still be equally effective.
He also stated that my notes were a weakness that I needed to work hard on, although my notes have been my one extreme strength throughout the rest of my ward placments. Whether this has to do with my rural experience, or simply being told clearer how the notes were to be done, I am not sure.
Overall, I believe that many communication styles can be effective in achieving the same result, and also, even in looking to the future when beginning employment, to understand from day one the specific requirements that are needed to be successful at a paticular position, particularly in running a ward independently.
At my mid-placement assessment, I was given no negative feedback regarding my current performance, and was told to continue building on my skills to run the ward more independently for the last two weeks.
When some of the other Physiotherapists came up to visit me on the ward, they had no problems with my performance. As it was my first inpatient experience, it was all new to me. On top of this, I had not yet done my cardiopulmonary nor my neuro placment, so I therefore, was reviewing much information over the placment to bring myself up to speed. However, as I wasn’t recieving any negative feedback, I figured my performance was fine, and I just continued to improve and build on my confidence each day.
In my final week, the overseeing Supervisor, from outpatines decided he wanted to come up to the ward and see how I was performing. He informed me later that day that he was not impressed by the way I was handling the ward. He was dissatisfied with my note-taking, and my confidence in dealing with patients. He informed me if I didn’t improve I would potentially require additional development. I was obviously upset, as this was the first time I was informed that my performance was not adequate. I felt I could run then ward indepently, and was doing a fair job.
By the end of the placement, I recieved a competent grade, and the overseeing Supervisor apologised to me as he felt they had not been able to get the best out of me from the placement, and he was upset as he felt they had not done me justice with the supervision/learning I was given.
What I learnt from this experience was to find out from the very beginning of my placements what my exact expectations were, as I recieved mixed messages from different Physiotherapists on this clinic. Also, I learnt that not every Physiotherapist practices in the same way. The overseeing Supervisor was extremely abrupt in his communication with patients, and very much took the philosophy that Physiotherapists were the big, bad guys who got patients up, and we have to use our voice and presence to get in there and do what we have to do. He took my quieter method of communicating with patients as a lack of confidence and ability, when in fact, it is simply a different communication style, which can still be equally effective.
He also stated that my notes were a weakness that I needed to work hard on, although my notes have been my one extreme strength throughout the rest of my ward placments. Whether this has to do with my rural experience, or simply being told clearer how the notes were to be done, I am not sure.
Overall, I believe that many communication styles can be effective in achieving the same result, and also, even in looking to the future when beginning employment, to understand from day one the specific requirements that are needed to be successful at a paticular position, particularly in running a ward independently.
A Chronic Pain
Firstly, I apologise for the delay in posting these blogging entries. I would like to share a clinical experience I had on my rural placement. I was told that I could participate in a programme that was being run for patients suffering from chronic pain. I was very interested in the opportunity to learn something new clinically so took the opportunity. My main role was to take the patients for a prescribed exercise class, and also partcipate in other activites carried out by other health professionals.
I learnt fairly quickly, as did the other patients and staff that there was one particular patient who was going to be a little difficult. He was very abrupt throughout the presentations that were given by the other health professionals, and would bring a large shopping bag filled with his X-rays everywhere he would go, perhaps in an effort to prove his pain was in fact real. He did little to no physical activity, and had the belief that he did not want to do any physical activity that caused him pain as he did not want to end up in a wheelchair.
I took a number of the exercise classes held for this chronic pain group over the two weeks that the programme was running. I noticed that this patient was distracting the other patients, who were highly motivated through the comments he was making and his lack of motivation. I tried my best to encourage him with his exercises, and to perform them properly, including the proper sets and reps.
One particular exercise involved walking for ten minutes. It was the second last session, and the patient in question had never before completed the ten minutes without a rest. This one time, it was around fifteen seconds before the ten minutes was up, and he had not yet had a rest. I was encouraging him to keep going, and that he had achieved much, and as I was doing this, I was standing in front of one of the chairs in the corridor that the patients could use to rest. This patient became infuriated with this unintentional gesture, and stormed inside the Physiotherapy Department to take a seat inside.
The following time I caught up with this group, the patient pulled me aside and wanted to speak with me. He had some literature that he wanted to inform me about his diabetes, and proceeded to tell me that he feels I pick on him, and that I think I know what is best for him, because I think I have much knowledge, when he doesn’t want to end up in a wheelchair because of me. I tried to explain to him that I am only trying to help him, and never meant to upset him or pick on him. This conversation went on for quite a while, and after the incident, I became quite upset by it.
The following day when I saw this patient by accident, he apologised to me about the things he had said, and that he realises that I was trying to help him, but that I have to realise that you can’t help everyone. He also wished me the best of luck.
What I learnt from this experience is to never single people out, even if it is unintentional. Also to be aware of the large significance of psychosocial issues in relation to chronic pain. Possibly the biggest lesson I learnt from the patient himself is that yes, you cannot help everyone, particularly with chronic pain, the patients need to want to help themselves. They need to want to change-we can’t do that process for them. Through all the presentations from not only Physiotherapists about the importance of physical activity, but Anaesthesiologists, Dieticians, Clinical Physchologists and the like, nothing could alter this patients view on his pain, however I did learn a valuable lesson from this experience, and really wish this patient all the best in finding a solution to his chronic pain.
I learnt fairly quickly, as did the other patients and staff that there was one particular patient who was going to be a little difficult. He was very abrupt throughout the presentations that were given by the other health professionals, and would bring a large shopping bag filled with his X-rays everywhere he would go, perhaps in an effort to prove his pain was in fact real. He did little to no physical activity, and had the belief that he did not want to do any physical activity that caused him pain as he did not want to end up in a wheelchair.
I took a number of the exercise classes held for this chronic pain group over the two weeks that the programme was running. I noticed that this patient was distracting the other patients, who were highly motivated through the comments he was making and his lack of motivation. I tried my best to encourage him with his exercises, and to perform them properly, including the proper sets and reps.
One particular exercise involved walking for ten minutes. It was the second last session, and the patient in question had never before completed the ten minutes without a rest. This one time, it was around fifteen seconds before the ten minutes was up, and he had not yet had a rest. I was encouraging him to keep going, and that he had achieved much, and as I was doing this, I was standing in front of one of the chairs in the corridor that the patients could use to rest. This patient became infuriated with this unintentional gesture, and stormed inside the Physiotherapy Department to take a seat inside.
The following time I caught up with this group, the patient pulled me aside and wanted to speak with me. He had some literature that he wanted to inform me about his diabetes, and proceeded to tell me that he feels I pick on him, and that I think I know what is best for him, because I think I have much knowledge, when he doesn’t want to end up in a wheelchair because of me. I tried to explain to him that I am only trying to help him, and never meant to upset him or pick on him. This conversation went on for quite a while, and after the incident, I became quite upset by it.
The following day when I saw this patient by accident, he apologised to me about the things he had said, and that he realises that I was trying to help him, but that I have to realise that you can’t help everyone. He also wished me the best of luck.
What I learnt from this experience is to never single people out, even if it is unintentional. Also to be aware of the large significance of psychosocial issues in relation to chronic pain. Possibly the biggest lesson I learnt from the patient himself is that yes, you cannot help everyone, particularly with chronic pain, the patients need to want to help themselves. They need to want to change-we can’t do that process for them. Through all the presentations from not only Physiotherapists about the importance of physical activity, but Anaesthesiologists, Dieticians, Clinical Physchologists and the like, nothing could alter this patients view on his pain, however I did learn a valuable lesson from this experience, and really wish this patient all the best in finding a solution to his chronic pain.
Monday, November 24, 2008
Maintaining profesionalism even when you dont like patients
This is something that I experienced primarily on the Burns placement. There were a only a few patients, thankfully, that I experienced this with. What I basically experienced was having to treat patients that I really didn’t like as people. It’s really quite hard, and it takes quite a bit more maturity than I realized to maintain professionalism in these situations.
The first patient that I experienced this with was not of Australian descent. When I met him for the first time in his ward room, I was startled by the number of family members that had come to visit him. I was a bit in awe, and I was thinking- ‘what a lucky guy to have so much loving family’. However, in the space of a few minutes I witnessed this patient be extremely rude and abusive toward both his wife and daughter, who were completely submissive. I quickly realized that there must be some cultural laws within his family that were different than in Australia. Still, I could not help but dislike the man for his words and actions.
I was surprised at how difficult it became for me to treat him after that. During the assessment and treatment, I couldn’t seem to forget his previous actions toward his seemingly innocent family, and I felt a definite sense of reluctance in helping the man with his problem. Eventually I just tried to visualize fixing the problem rather than fixing him.
The second patient was a young teenage male, who had a history of drug abuse and minor criminal activity. His current history relating to his incident was that he had gotten into an argument with his parents, and then deliberately set himself on fire. His father had had to throw him into their swimming pool to put him out. During his subsequent admission to the burns unit, he had been very abusive towards the staff and had eventually absconded/been kicked out of the ward. The period where I was treating him was several months after this, during his outpatient rehabilitation program.
During my treatment of him I witnessed him do several things that made me dislike him as a person. He very rarely showed up for his treatments as an outpatient, and when he did, it was obvious that his impairments were really quite serious, and it was also obvious that he had not been managing his condition. He would often arrive late to treatments, often still inebriated from the previous nights activities, and during treatments he would make several inappropriate comments towards any female staff in the vicinity. He would often lie to the health professionals involved in his rehab about other treatments he had received, and about his home management. Only upon contacting his family directly did it become apparent that he had been lying to both them and the health care team. In short, he was wasting his time, our time, and his families time. When he did attend treatments, I knew that any treatment that I would do would essentially be a waste of time if he didn’t change his self management (which was not at all likely to occur). On top of this, I really didn’t like him as a person. I got around this by switching off my emotions during the treatment and simply treating the problems, and not worrying about the person.
Im not sure if the way that I manage patients that I don’t really like is the right way to manage people, so if anyone has any suggestions or had similar experiences please let me know.
The first patient that I experienced this with was not of Australian descent. When I met him for the first time in his ward room, I was startled by the number of family members that had come to visit him. I was a bit in awe, and I was thinking- ‘what a lucky guy to have so much loving family’. However, in the space of a few minutes I witnessed this patient be extremely rude and abusive toward both his wife and daughter, who were completely submissive. I quickly realized that there must be some cultural laws within his family that were different than in Australia. Still, I could not help but dislike the man for his words and actions.
I was surprised at how difficult it became for me to treat him after that. During the assessment and treatment, I couldn’t seem to forget his previous actions toward his seemingly innocent family, and I felt a definite sense of reluctance in helping the man with his problem. Eventually I just tried to visualize fixing the problem rather than fixing him.
The second patient was a young teenage male, who had a history of drug abuse and minor criminal activity. His current history relating to his incident was that he had gotten into an argument with his parents, and then deliberately set himself on fire. His father had had to throw him into their swimming pool to put him out. During his subsequent admission to the burns unit, he had been very abusive towards the staff and had eventually absconded/been kicked out of the ward. The period where I was treating him was several months after this, during his outpatient rehabilitation program.
During my treatment of him I witnessed him do several things that made me dislike him as a person. He very rarely showed up for his treatments as an outpatient, and when he did, it was obvious that his impairments were really quite serious, and it was also obvious that he had not been managing his condition. He would often arrive late to treatments, often still inebriated from the previous nights activities, and during treatments he would make several inappropriate comments towards any female staff in the vicinity. He would often lie to the health professionals involved in his rehab about other treatments he had received, and about his home management. Only upon contacting his family directly did it become apparent that he had been lying to both them and the health care team. In short, he was wasting his time, our time, and his families time. When he did attend treatments, I knew that any treatment that I would do would essentially be a waste of time if he didn’t change his self management (which was not at all likely to occur). On top of this, I really didn’t like him as a person. I got around this by switching off my emotions during the treatment and simply treating the problems, and not worrying about the person.
Im not sure if the way that I manage patients that I don’t really like is the right way to manage people, so if anyone has any suggestions or had similar experiences please let me know.
Being Judgemental
I’ve encountered several many patients out on clinic that I really wonder about them and the decisions that they make. They make these decisions which put them in these situations, such as hospital, and it seems like they’re getting all the right advice from people; their families; the health professionals; and other patients. But despite all this they seem to continue to get themselves into the same situations again and again, and sometimes it can be frustrating as a health care professional. I guess this is because there are patients that we feel deserve our time and energy much more than the people who seem to be willingly putting themselves in hospital; there are other people who are in hospital because of factors beyond their control. I guess it feels a bit unfair, distributing resources toward those who obviously do not appreciate it.
This is something that I have experienced across many different practicuums, in particular though; cardiopulmonary, burns, and neurosurgery. In my cardiopulmonary prac, people in this category were usually people who had COPD caused by smoking, and were still smoking. They often were people who had been admitted many times over the previous years for excacerbations of their deteriorating and chronic condition, and were well known around the ward by the staff. Each time they are admitted they are a little bit worse, and each time they are given the same good advice: stop smoking. Which they don’t take. As a physio, sometimes it feels like we care more about their condition then they themselves do.
Burns and neurosurgery usually involved patients who had been involved in some kind of drug abuse or violent behavior. One teenager in burns had a history of elicit drug use, had had a fight with his parents, and deliberately set himself on fire during his argument with his parents. Another teenager I met in neurosurgery had climbed on top of his girlfriends car during an argument, she drove off and he fell off the car and cracked his skull on the pavement. There are many other histories of patients that I encountered that involved similar tales of drugs and violence. And most of these patients seem completely unrepentant after the incident. They receive guidance from social workers, and are presumably offered all the knowledge and means to make the necessary changes in their lives, but they don’t. it’s these patients that I feel don’t deserve the treatment.
The fact is though, these patients are still entitled to treatment, even if they are completely responsible for their condition, unrepentant, and even likely to something similar again. The decision has been passed down that these people should still receive treatment- though I have to say I don’t completely understand it, it is not a health professionals place to define policy.
Has anyone else experienced similar thoughts?
This is something that I have experienced across many different practicuums, in particular though; cardiopulmonary, burns, and neurosurgery. In my cardiopulmonary prac, people in this category were usually people who had COPD caused by smoking, and were still smoking. They often were people who had been admitted many times over the previous years for excacerbations of their deteriorating and chronic condition, and were well known around the ward by the staff. Each time they are admitted they are a little bit worse, and each time they are given the same good advice: stop smoking. Which they don’t take. As a physio, sometimes it feels like we care more about their condition then they themselves do.
Burns and neurosurgery usually involved patients who had been involved in some kind of drug abuse or violent behavior. One teenager in burns had a history of elicit drug use, had had a fight with his parents, and deliberately set himself on fire during his argument with his parents. Another teenager I met in neurosurgery had climbed on top of his girlfriends car during an argument, she drove off and he fell off the car and cracked his skull on the pavement. There are many other histories of patients that I encountered that involved similar tales of drugs and violence. And most of these patients seem completely unrepentant after the incident. They receive guidance from social workers, and are presumably offered all the knowledge and means to make the necessary changes in their lives, but they don’t. it’s these patients that I feel don’t deserve the treatment.
The fact is though, these patients are still entitled to treatment, even if they are completely responsible for their condition, unrepentant, and even likely to something similar again. The decision has been passed down that these people should still receive treatment- though I have to say I don’t completely understand it, it is not a health professionals place to define policy.
Has anyone else experienced similar thoughts?
Monday, November 17, 2008
Everyone can hear you!
Whatever happened to patient confidentiality. I was recently on my neuro placement and was shocked at the amount of times that I heard personal health details being discussed in an inappropriate setting.
I refer to one situation where a patient was in a four bed room and suffering from haemorrhoids. A doctor went in to review the patient, drew the curtain and started the examination with “so *Frank, how are the haemorrhoids feeling?” with an unnecessary loud volume. I know that often a shared public hospital room is a difficult environment to maintain patient confidentiality but if I was the one with haemorrhoids and my doctor had just announced this fact to the entire room (patients and visitors) I would NOT be impressed.
Of course, as a student, I didn’t feel like it was my place to say anything to the doctor but it really made me realise how important it is to use appropriate communication strategies when discussing what may be embarrassing issues.
I also tried to think about it from another point of view. Often people find it difficult to discuss these types of issues with medical staff as they may carry a certain stigma. Do you think that making it obvious/ discussing freely in this environment would “normalise” the situation and encourage people to think of these conditions as just another impairment, making them more comfortable to discuss them with health professionals?
I don’t think I’ll be changing my view on this situation as I still stand by the fact that what is private to you should be kept private…but what do you think?
I refer to one situation where a patient was in a four bed room and suffering from haemorrhoids. A doctor went in to review the patient, drew the curtain and started the examination with “so *Frank, how are the haemorrhoids feeling?” with an unnecessary loud volume. I know that often a shared public hospital room is a difficult environment to maintain patient confidentiality but if I was the one with haemorrhoids and my doctor had just announced this fact to the entire room (patients and visitors) I would NOT be impressed.
Of course, as a student, I didn’t feel like it was my place to say anything to the doctor but it really made me realise how important it is to use appropriate communication strategies when discussing what may be embarrassing issues.
I also tried to think about it from another point of view. Often people find it difficult to discuss these types of issues with medical staff as they may carry a certain stigma. Do you think that making it obvious/ discussing freely in this environment would “normalise” the situation and encourage people to think of these conditions as just another impairment, making them more comfortable to discuss them with health professionals?
I don’t think I’ll be changing my view on this situation as I still stand by the fact that what is private to you should be kept private…but what do you think?
Present?...For me?
I’ve just completed my neuro placement on an acute neurology ward where I received several small gifts from patients families for the work I/we did with their loved ones. The gifts ranged from cards and chocolates to a necklace.
I discussed with other students on the prac how they felt about this situation. Was it appropriate/ inappropriate to accept the gifts? Did we really deserve them just for doing our job? The general consensus was that we probably didn’t deserve them but it was nice to receive acknowledgement for what we had done, and it was appropriate to accept these small gifts.
One thing however which really pleasantly surprised me was that one of the students received a present from a patients partner which was to acknowledge the efforts of the entire ward but the card was in fact addressed to the “student and rest of the team” (of course they used the students name!). I think sometimes we forget how much of an impact we have on these peoples lives, especially in the setting of acute stroke where huge functional gains can be made from effective physiotherapy treatment, and trust and relationships are formed between the patient and therapist.
It was as if this patient saw the physio as the most important part of the multi-disciplinary team for their condition and time in hospital. I think it’s a nice reminder of the value of physiotherapy and that we really can impact so heavily and positively on a patients life.
We should all feel proud to receive a gift for the time, heart and effort we put into improving the quality of life of others.
I discussed with other students on the prac how they felt about this situation. Was it appropriate/ inappropriate to accept the gifts? Did we really deserve them just for doing our job? The general consensus was that we probably didn’t deserve them but it was nice to receive acknowledgement for what we had done, and it was appropriate to accept these small gifts.
One thing however which really pleasantly surprised me was that one of the students received a present from a patients partner which was to acknowledge the efforts of the entire ward but the card was in fact addressed to the “student and rest of the team” (of course they used the students name!). I think sometimes we forget how much of an impact we have on these peoples lives, especially in the setting of acute stroke where huge functional gains can be made from effective physiotherapy treatment, and trust and relationships are formed between the patient and therapist.
It was as if this patient saw the physio as the most important part of the multi-disciplinary team for their condition and time in hospital. I think it’s a nice reminder of the value of physiotherapy and that we really can impact so heavily and positively on a patients life.
We should all feel proud to receive a gift for the time, heart and effort we put into improving the quality of life of others.
Workers' Compensation
While I was on my rural outpatient placement (public sector), I had a patient who has worker’s compensation. It wasn’t until then I realized how little I know about the procedure of worker’s compensation.
The lady was a currently patient of my supervising physiotherapy for her wrist pain. I was asked to do an initial assessment and treatment for her LBP. During her subjective assessment, she reported that a heavy object had fallen onto her back while she was bent over to pick up things on the floor at her work place. She has been taken to ED and her Xray finding was NAD. Therefore she was covered by worker’s compensation. It wasn’t till then that I realize I don’t really know anything about how to deal with this type of situation. I only vaguely remember work’s comp patients are general seen by private physio and there is some paper work involved. Also the patients tend to recover slower due to diminished motivation. I have no idea what I need to do in a public setting. I asked my supervisor on that day who has been graduated for about 2 years. I was advised to get her company’s details. During my treatment with this lady, my supervisor rang the senior physiotherapist for further advice. After my treatment, the patient requested a brief summary for her doctor who will be organizing the worker’s comp insurance. So I wrote a summary of the assessment findings, possible structures involved, treatment delivered and future plan. As it was my last week of the placement, she was handballed to the supervising physiotherapist to be review the week after.
As we were finishing for the morning, the physio revealed that even it is a public sector (free for locals with or without referrals), we still need to bill the company because it is a worker’s compensation case. The cost will be a lot higher than private physios, the bill would be at least $500+ from the access of the service. For a usual case, the patient will be referred to private physio immediately, however this patient was a little more complicated as she has been accessing public physiotherapy treatment for her painful wrist.
I do not recall we covering anything about worker’s compensation at uni, ( I do have a terrible memory though). Does anyone have any experience with this type of scenario? Or have any suggestions/advices?
The lady was a currently patient of my supervising physiotherapy for her wrist pain. I was asked to do an initial assessment and treatment for her LBP. During her subjective assessment, she reported that a heavy object had fallen onto her back while she was bent over to pick up things on the floor at her work place. She has been taken to ED and her Xray finding was NAD. Therefore she was covered by worker’s compensation. It wasn’t till then that I realize I don’t really know anything about how to deal with this type of situation. I only vaguely remember work’s comp patients are general seen by private physio and there is some paper work involved. Also the patients tend to recover slower due to diminished motivation. I have no idea what I need to do in a public setting. I asked my supervisor on that day who has been graduated for about 2 years. I was advised to get her company’s details. During my treatment with this lady, my supervisor rang the senior physiotherapist for further advice. After my treatment, the patient requested a brief summary for her doctor who will be organizing the worker’s comp insurance. So I wrote a summary of the assessment findings, possible structures involved, treatment delivered and future plan. As it was my last week of the placement, she was handballed to the supervising physiotherapist to be review the week after.
As we were finishing for the morning, the physio revealed that even it is a public sector (free for locals with or without referrals), we still need to bill the company because it is a worker’s compensation case. The cost will be a lot higher than private physios, the bill would be at least $500+ from the access of the service. For a usual case, the patient will be referred to private physio immediately, however this patient was a little more complicated as she has been accessing public physiotherapy treatment for her painful wrist.
I do not recall we covering anything about worker’s compensation at uni, ( I do have a terrible memory though). Does anyone have any experience with this type of scenario? Or have any suggestions/advices?
Supervise this
Throughout most of my placements I have felt as though I have been given very good support from my clinical supervisors. There was one prac, however, that I feel as though the supervisor did not spend adequate time supervising the students.
As a student I expect that a supervisor will be there to give you some support you may need. Especially in the early part of the placement. By the end of the placement I expect supervisors to step back and let the students take on most (if not all) of the work when it comes to dealing with patients. Sure, if there is something that a supervisor could demonstrate from her experience that we are not aware of then that is good for our learning.
I have found most of my supervisors good in this way. There was one though who barely saw me with any patients. My CCT saw me assess and treat more patients than my FCT, and my CCT was only there for a couple hours a week. The FCT was clearly taking on too many duties and did not have the time to adequately supervise students. She was covering someone else and had other people from her area to help with any problems that the students may have had. We were pretty much left to run part of the ward by ourselves.
Now this didn’t bother me in that I think it is good to be independent as once we graduate we will be expected to work like this, so I was not too concerned about this. And to be honest the supervisor did spend a bit of her time going over mini tutorials and things with us. However, she criticised me on several things. My CCT had actually been very happy with several of the things that my FCT criticised. I felt that she really did not have an adequate representation of my ability when making some of those comments. Some of the feedback was good early in the placement when she spent more time with us students, however, in the second half of the placement she spent very little time with us and had not had the opportunity to see the students develop their skills and work on their weaknesses. Yet she still gave the same feedback at the end of the placement.
I have always been a big advocate for constructive feedback. I feel it is one of the best ways to learn. Since my experience on this placement I have come to take some feedback with a grain of salt, and see things from a more global perspective, rather looking at all the different feedback I have received throughout the year. In the future I wont take things to heart from somebody who hasn’t seen enough of my abilities to make a valid comment about me.
As a student I expect that a supervisor will be there to give you some support you may need. Especially in the early part of the placement. By the end of the placement I expect supervisors to step back and let the students take on most (if not all) of the work when it comes to dealing with patients. Sure, if there is something that a supervisor could demonstrate from her experience that we are not aware of then that is good for our learning.
I have found most of my supervisors good in this way. There was one though who barely saw me with any patients. My CCT saw me assess and treat more patients than my FCT, and my CCT was only there for a couple hours a week. The FCT was clearly taking on too many duties and did not have the time to adequately supervise students. She was covering someone else and had other people from her area to help with any problems that the students may have had. We were pretty much left to run part of the ward by ourselves.
Now this didn’t bother me in that I think it is good to be independent as once we graduate we will be expected to work like this, so I was not too concerned about this. And to be honest the supervisor did spend a bit of her time going over mini tutorials and things with us. However, she criticised me on several things. My CCT had actually been very happy with several of the things that my FCT criticised. I felt that she really did not have an adequate representation of my ability when making some of those comments. Some of the feedback was good early in the placement when she spent more time with us students, however, in the second half of the placement she spent very little time with us and had not had the opportunity to see the students develop their skills and work on their weaknesses. Yet she still gave the same feedback at the end of the placement.
I have always been a big advocate for constructive feedback. I feel it is one of the best ways to learn. Since my experience on this placement I have come to take some feedback with a grain of salt, and see things from a more global perspective, rather looking at all the different feedback I have received throughout the year. In the future I wont take things to heart from somebody who hasn’t seen enough of my abilities to make a valid comment about me.
Cheers for the heads up
This blog is another one relating to my experiences in Cambodia. I was at the CSC for 2 and a half weeks. For the last week that I was there, the one physio at the centre did not come to work for the first half of the day. He is in his 5th year of studying medicine and was on clinical placement at another facility during the mornings of that last week I was there.
I felt pretty confident by this point so I wasn’t too intimidated, although it was pretty hard work trying to treat patients for most of the day when they spoke a completely different language to you. Although it would have been nice for the physio to have mentioned to me on the Friday that he wouldn’t be there at all on the Monday. That was a bit intimidating at first not knowing that he wasn’t going to be there, but no big deal.
I did get a lot of help form some of the IT staff, who came and helped to translate when I needed it. One example is a young girl who I had removed her cast after having lengthening to her calf, who was going home and needed to be given an HEP of stretches and some general education. I don’t think I would have been able to do this successfully without the help from the IT staff who translated for me. As I mentioned in a previous post, we did learn several Khmer words and phrases (such as; where is the pain, copy this/do this, a little more, relax, sit, stand, contract/press against, slow down, have a rest) which were extremely helpful when I did not have anyone who could translate for me. Non-verbal communication was also a huge part of treating these patients due to the language barrier.
To be honest, it turned out very well for the CSC that a physio student was there for some of the time while their physio wasn’t there because if he wasn’t able to be at work, then the work simply would not have gotten done. Most of the patients would not have done any stretches or exercise without someone telling them to several times throughout the day. No one would have assessed patients pre-op, windows would not have been cut into casts, and casts would not have been removed. So while being under a bit of stress, it was still very rewarding to know that you are actually making a difference. I also learned a huge amount about non-verbal communication, treating patients who cannot speak English, improvising, and working independently in not necessarily the best of conditions. I feel these experiences have already made me a better clinician, and will help me in many clinical situations in the future.
I felt pretty confident by this point so I wasn’t too intimidated, although it was pretty hard work trying to treat patients for most of the day when they spoke a completely different language to you. Although it would have been nice for the physio to have mentioned to me on the Friday that he wouldn’t be there at all on the Monday. That was a bit intimidating at first not knowing that he wasn’t going to be there, but no big deal.
I did get a lot of help form some of the IT staff, who came and helped to translate when I needed it. One example is a young girl who I had removed her cast after having lengthening to her calf, who was going home and needed to be given an HEP of stretches and some general education. I don’t think I would have been able to do this successfully without the help from the IT staff who translated for me. As I mentioned in a previous post, we did learn several Khmer words and phrases (such as; where is the pain, copy this/do this, a little more, relax, sit, stand, contract/press against, slow down, have a rest) which were extremely helpful when I did not have anyone who could translate for me. Non-verbal communication was also a huge part of treating these patients due to the language barrier.
To be honest, it turned out very well for the CSC that a physio student was there for some of the time while their physio wasn’t there because if he wasn’t able to be at work, then the work simply would not have gotten done. Most of the patients would not have done any stretches or exercise without someone telling them to several times throughout the day. No one would have assessed patients pre-op, windows would not have been cut into casts, and casts would not have been removed. So while being under a bit of stress, it was still very rewarding to know that you are actually making a difference. I also learned a huge amount about non-verbal communication, treating patients who cannot speak English, improvising, and working independently in not necessarily the best of conditions. I feel these experiences have already made me a better clinician, and will help me in many clinical situations in the future.
Experiences abroad
As I have mentioned in previous blogs, I spent 2 and a half weeks while in Cambodia working at the Children’s Surgical Centre, part of Kien Khleang National Rehabilitation Centre. If you haven’t already, check out their website at www.csc.org
This was one of the greatest experiences in my life. I got to see some really amazing things while I was there and these things really helped put things into perspective and I would like to share some of these in this blog.
Firstly, check out the website to see what this place is about. Basically while I was there I was working with the one physio there and treating all the post-op patients on the two wards, as well as assessing some pre-surgical patients. Now when I say wards, they are pretty much two rooms with several beds (pretty much just a piece of plywood on a steel frame) and as many patients as they could fit (plus their family members) piled in like sardines. There would maybe be 20 patients in each room that would be no bigger the size of the library lecture theatre where we had most of our seminars this semester. It was extremely overcrowded, pretty filthy, and stinking bloody hot. There was not an awful lot in terms of medical supplies either (well by our standards). There is also a small consultation room maybe 5m by 10m. This got really crowded at times. The surgical theatre is about the same size as the ward, maybe a little smaller. There are three surgical beds set up, and at any given time, up to three surgeries being performed within this close proximity.
This is probably one of the best facilities available in Cambodia. Especially to the Khmers as it provides completely free consultations, surgery, and short term rehabilitation (they don’t have to bribe anyone at all!). I was able to walk into surgery basically whenever I wanted to. I was able to get as close as I wanted, take pictures or videos as long as I didn’t get in the way of the surgeons. Pretty amazing stuff. There are teams of surgeons that come from around the world to volunteer there time and skills most of the year round. This is the brilliant thing about this facility. It is encouraging self-sustainability through empowering the Cambodia people to continually learn and practice surgical techniques. This is unlike a lot of organisations and charities in Cambodia and I would assume other third world countries.
I was able to see and treat a range of patients, lots of these having conditions that just simply would not be seen in Australia. The major thing I saw was fractures. Most of these occurred from motorbike accidents, the occasional one from falling out of a tree or farming. Now these were not acute fractures like we see in Australia. These were all anything from 6 months to 6 years post fracture. Health care is not necessarily free in Cambodia. Everyone who sees you, you must bribe if you want any treatment. One of the reasons people don’t go to see a doctor when they break their leg. Other reasons are lack of transport, qualified medical staff, or facilities. So they might go and see a traditional Khmer healer. They might rub some herbs on your broken leg and off you go on your merry way.
So there were lots and lots of patients in ilizarov frames (which were all reused many many times). Another condition I got to witness that is unheard of in Australia was acid burns. This is very horrific, and a form of torture. I saw a lady who had her scalp avulsed and lost one of her eyes from an acid burn. There were many children who had burns when they were younger from various sources, and had formed contractures and secondary bony deformities requiring extensive surgery. These secondary deformities are simply unheard of in Australia. This was truly an incredible thing to witness first hand. Yet I don’t think I heard a single Khmer complain once about their ailments once.
Other conditions were; quadriceplasties, THR, a young girl with an osteogenic sarcoma of her mandibular (this was terminal, the tumor was about the size of her head), subluxed wrists and patella, meningoencephalocoele, and club feet. I viewed several surgeries including; eye surgery, external fixations, skin grafts, amputations, an exploration of an elbow (the patient turned out to have fracture off his lateral epicondyle. His arm was fixed in 900 to give him some function), and many others.
So a lot of these patients required post-op physiotherapy. I was also involved with pre-surgical consultations. The surgical team would often send a patient for pre-surgical assessment of for example ROM. I was also involved with assessing the odd child with poliomyelitis. One really enjoyable thing I got to do was remove or cut windows into several young children’s casts that they had after external fixation was removed. This was pretty challenging as the children were all rather intimidated by a strange white man coming after them with this old noisy rather large saw. No matter how many times I tried to explain to them in Khmer that there would be no pain (we learned some basic Khmer words and phrases while we were there), the kids were often crying and screaming. Not to mention that this was performed outside due to the mess it caused, in stinking hot and humid conditions to an audience of about 20 or 30 other patients and family that gathered around to see what was going on. A great experience.
So there you have it, a brief summary of my experiences while at the CSC. I encourage you all to volunteer some of your time, knowledge, and skills internationally in a country that is far worse off than ours as it truly is one of the most rewarding things you can do. This experience has completely changed my perspective on lots of things in life, not just physiotherapy. It has certainly changed my approach for many clinical situations in the future, given me many ideas for treatment and management with little or no equipment or resources, as well as putting several things into perspective (standard of health care, facilities, qualified allied health staff, level of knowledge and skills of allied health staff, medical conditions and complications, and probably most of all how others can suffer through great adversity and simply deal with it without complaint).
This was one of the greatest experiences in my life. I got to see some really amazing things while I was there and these things really helped put things into perspective and I would like to share some of these in this blog.
Firstly, check out the website to see what this place is about. Basically while I was there I was working with the one physio there and treating all the post-op patients on the two wards, as well as assessing some pre-surgical patients. Now when I say wards, they are pretty much two rooms with several beds (pretty much just a piece of plywood on a steel frame) and as many patients as they could fit (plus their family members) piled in like sardines. There would maybe be 20 patients in each room that would be no bigger the size of the library lecture theatre where we had most of our seminars this semester. It was extremely overcrowded, pretty filthy, and stinking bloody hot. There was not an awful lot in terms of medical supplies either (well by our standards). There is also a small consultation room maybe 5m by 10m. This got really crowded at times. The surgical theatre is about the same size as the ward, maybe a little smaller. There are three surgical beds set up, and at any given time, up to three surgeries being performed within this close proximity.
This is probably one of the best facilities available in Cambodia. Especially to the Khmers as it provides completely free consultations, surgery, and short term rehabilitation (they don’t have to bribe anyone at all!). I was able to walk into surgery basically whenever I wanted to. I was able to get as close as I wanted, take pictures or videos as long as I didn’t get in the way of the surgeons. Pretty amazing stuff. There are teams of surgeons that come from around the world to volunteer there time and skills most of the year round. This is the brilliant thing about this facility. It is encouraging self-sustainability through empowering the Cambodia people to continually learn and practice surgical techniques. This is unlike a lot of organisations and charities in Cambodia and I would assume other third world countries.
I was able to see and treat a range of patients, lots of these having conditions that just simply would not be seen in Australia. The major thing I saw was fractures. Most of these occurred from motorbike accidents, the occasional one from falling out of a tree or farming. Now these were not acute fractures like we see in Australia. These were all anything from 6 months to 6 years post fracture. Health care is not necessarily free in Cambodia. Everyone who sees you, you must bribe if you want any treatment. One of the reasons people don’t go to see a doctor when they break their leg. Other reasons are lack of transport, qualified medical staff, or facilities. So they might go and see a traditional Khmer healer. They might rub some herbs on your broken leg and off you go on your merry way.
So there were lots and lots of patients in ilizarov frames (which were all reused many many times). Another condition I got to witness that is unheard of in Australia was acid burns. This is very horrific, and a form of torture. I saw a lady who had her scalp avulsed and lost one of her eyes from an acid burn. There were many children who had burns when they were younger from various sources, and had formed contractures and secondary bony deformities requiring extensive surgery. These secondary deformities are simply unheard of in Australia. This was truly an incredible thing to witness first hand. Yet I don’t think I heard a single Khmer complain once about their ailments once.
Other conditions were; quadriceplasties, THR, a young girl with an osteogenic sarcoma of her mandibular (this was terminal, the tumor was about the size of her head), subluxed wrists and patella, meningoencephalocoele, and club feet. I viewed several surgeries including; eye surgery, external fixations, skin grafts, amputations, an exploration of an elbow (the patient turned out to have fracture off his lateral epicondyle. His arm was fixed in 900 to give him some function), and many others.
So a lot of these patients required post-op physiotherapy. I was also involved with pre-surgical consultations. The surgical team would often send a patient for pre-surgical assessment of for example ROM. I was also involved with assessing the odd child with poliomyelitis. One really enjoyable thing I got to do was remove or cut windows into several young children’s casts that they had after external fixation was removed. This was pretty challenging as the children were all rather intimidated by a strange white man coming after them with this old noisy rather large saw. No matter how many times I tried to explain to them in Khmer that there would be no pain (we learned some basic Khmer words and phrases while we were there), the kids were often crying and screaming. Not to mention that this was performed outside due to the mess it caused, in stinking hot and humid conditions to an audience of about 20 or 30 other patients and family that gathered around to see what was going on. A great experience.
So there you have it, a brief summary of my experiences while at the CSC. I encourage you all to volunteer some of your time, knowledge, and skills internationally in a country that is far worse off than ours as it truly is one of the most rewarding things you can do. This experience has completely changed my perspective on lots of things in life, not just physiotherapy. It has certainly changed my approach for many clinical situations in the future, given me many ideas for treatment and management with little or no equipment or resources, as well as putting several things into perspective (standard of health care, facilities, qualified allied health staff, level of knowledge and skills of allied health staff, medical conditions and complications, and probably most of all how others can suffer through great adversity and simply deal with it without complaint).
Sensitive grounds
I was in a situation a couple of weeks ago with a patient who had no idea of the severity of the condition her child had. I was on my paediatric placement and the baby had been referred for plagiocephaly, but also for severe gross motor delay. These weren’t her main problems unfortunately. The child had a diagnosis of Wolf-Hirschhorn syndrome. Both my supervisor and I were not familiar with this condition. The syndrome is caused by a chromosomal abnormality. The common characteristics are; severe to profound mental retardation, microcephaly, seizures, heart defects, hypertonia, cranial asymmetry and various other facial abnormalities. There is an estimated mortality rate of 34% in the first 2 years, but this rate is underestimated due to many affected children dying without being diagnosed. It is a rather serious condition.
The mother of the child is of foreign decent. She does not speak very good English. The father is Australian, however, works during the week and is finds it difficult to get time off work for his child’s medical appointments. The mother usually goes to the appointments and relays what she gathered from them to her husband. The child has been seen by various allied health staff and the diagnosis has been explained to the parents.
However, I am not sure the diagnosis has been explained well enough to the parents. Either that or the mother is in a bit of denial about the severity of her child’s condition. She came to the initial assessment with her baby and had information written on a sheet that mentioned some of her problems, such as heart defect, microcephaly, poor brain development, low muscle tone, and several other things. The mother seemed aware that her baby had these things, but was surprised to hear that her gross motor development was extremely delayed.
This baby was around 3 months old, and my supervisor said that a newborn baby has more tone than this baby had. The child had pretty much no control of its head, poor social interaction – would not focus vision at all throughout the session, extremely low tone, and severe delay in gross motor skills. The prognosis is very poor.
The mother had the impression that her baby was just small, and this was relatively normal and she would catch up with her development soon. I don’t think she had any idea of the severity of the syndrome and that if her baby survives the next few years, she will be severely impaired.
It was very difficult to try to inform the mother that the child has a very poor prognosis and will never be what she sees as normal. We tried to get her to bring her husband the following session two weeks later but he was unable to attend. We informed her of a few things regarding her baby’s condition throughout both sessions, yet it still seemed as though she was not aware of the impact that these would have on her child’s life.
I was very hard trying to inform someone that their baby had such a terrible prognosis. I think the mother may have been in a bit of denial regarding the diagnosis and that may have been affecting her views. I’m not sure how well it was explained to her previously, but I feel as though eventually she did come to terms from a gross motor perspective that her baby would not be very good.
I hope I am not in a similar situation many times again as it was very depressing and difficult to deal with, however, as hard as it may be for me or someone else to tell a parent of a condition like this, it is no where near as hard as hearing it. I do feel now that if you have to deliver bad news if you go about it in a sensitive way, parents (or patients), while obviously depressed are still grateful that you spent the time to discuss with them and help with any questions they may have had.
The mother of the child is of foreign decent. She does not speak very good English. The father is Australian, however, works during the week and is finds it difficult to get time off work for his child’s medical appointments. The mother usually goes to the appointments and relays what she gathered from them to her husband. The child has been seen by various allied health staff and the diagnosis has been explained to the parents.
However, I am not sure the diagnosis has been explained well enough to the parents. Either that or the mother is in a bit of denial about the severity of her child’s condition. She came to the initial assessment with her baby and had information written on a sheet that mentioned some of her problems, such as heart defect, microcephaly, poor brain development, low muscle tone, and several other things. The mother seemed aware that her baby had these things, but was surprised to hear that her gross motor development was extremely delayed.
This baby was around 3 months old, and my supervisor said that a newborn baby has more tone than this baby had. The child had pretty much no control of its head, poor social interaction – would not focus vision at all throughout the session, extremely low tone, and severe delay in gross motor skills. The prognosis is very poor.
The mother had the impression that her baby was just small, and this was relatively normal and she would catch up with her development soon. I don’t think she had any idea of the severity of the syndrome and that if her baby survives the next few years, she will be severely impaired.
It was very difficult to try to inform the mother that the child has a very poor prognosis and will never be what she sees as normal. We tried to get her to bring her husband the following session two weeks later but he was unable to attend. We informed her of a few things regarding her baby’s condition throughout both sessions, yet it still seemed as though she was not aware of the impact that these would have on her child’s life.
I was very hard trying to inform someone that their baby had such a terrible prognosis. I think the mother may have been in a bit of denial regarding the diagnosis and that may have been affecting her views. I’m not sure how well it was explained to her previously, but I feel as though eventually she did come to terms from a gross motor perspective that her baby would not be very good.
I hope I am not in a similar situation many times again as it was very depressing and difficult to deal with, however, as hard as it may be for me or someone else to tell a parent of a condition like this, it is no where near as hard as hearing it. I do feel now that if you have to deliver bad news if you go about it in a sensitive way, parents (or patients), while obviously depressed are still grateful that you spent the time to discuss with them and help with any questions they may have had.
Sunday, November 16, 2008
On my current prac I was asked by the nursing co-ordinator to see a patient who was complaining of pain in their (L) UL following a fall. When I saw the patient they stated that it was not pain in their arm that was bothering them, it was that ‘their arm didn’t work’ anymore. The patient reported they had had a fall at home and that ‘they thought’ this was when their (L) UL lost its function. The patient had nil activation and voluntary control around their (L) shoulder, FROM at the elbow, wrist and hand – but significantly weaker compared to the (R) and altered/diminished sensation of their entire (L) palm. Looking at the posture of the UL it did not present like any traumatic injury I had seen, instead it looked very similar to the UL presentation of some CVA patients I had treated. As I was unsure I paged my supervisor who examined the patient and agreed the presentation indicated a neurological event. Adding to this the more we questioned the patient we identified they had a facial droop and had had a period of time where they couldn’t quite remember the events clearly, and it was around the time they fell and these symptoms first presented.
I documented these findings in the notes and began to retrain the function of this patient’s UL (reach, pincher grip, grasp etc). The following day the consultant documented that this patient had torn their RC and ordered an US for that afternoon for confirmation. That same morning the registrar approached me and stated they felt that this was not a RC tear and would like to investigate the possibility of a neurological incident further, but were unable to do so at this stage until the RC tear was ruled out. The US revealed no inflammation of the RC or evidence of an acute injury, it did reveal a tear of subscapularis, but was reported as being due to degerenerative changes (the patient was in their late 80’s). Despite this the consultant wrote for physio to treat the patient’s RC injury. Whilst this didn’t affect my treatment – as I continued retraining reach etc as this was the patient s main functional limitation (nil pain, swelling etc) I did overhear the consultant and registrar having several 'arguments/discussions' in the doctor’s office regarding this particular patient. When I was asked to provide feedback about the patient’s progress etc it was extremely awkward as all the assessment findings and progress the patient had been making indicated a neurological event and not the RC pathology the consultant had diagnosed. In the end a series of neurological investigations were ordered and it was revealed that the patient had had a minor stroke.
I wasn’t sure if the situation was an indication of some negative politics or power play occurring between the consultant and registrar but it did reveal a key issue for me. In the hospital setting as physios we often read the patients notes (prior to seeing them) get the diagnosis and then from there meet the patient and treat them accordingly. In 9/10 this would be appropriate (assuming that you still are doing a clinical examination etc) but this incident really made me realise that when you are treating a patient and their diagnosis doesn't seem to fit with their presentation and response to PT Rx make sure you follow it up. While as physios we don’t have the training and skills as a doctor for diagnosing conditions we do have a fairly good understanding and ability to recognise clinical signs and symptoms of a variety of conditions. Thus this particular situation showed me that we constantly need to be using this skill and analysing if the patient is responding to the PT Rx as they should be, and if they’re not considering the possibility that something else may be going on, and should be followed up. In this scenario the registrar’s actions meant that the patient was entitled to and received a variety of services (which with a RC injury they would not have received) when they were D/C which will hopefully ensure they regain as much function in their UL as possible.
I documented these findings in the notes and began to retrain the function of this patient’s UL (reach, pincher grip, grasp etc). The following day the consultant documented that this patient had torn their RC and ordered an US for that afternoon for confirmation. That same morning the registrar approached me and stated they felt that this was not a RC tear and would like to investigate the possibility of a neurological incident further, but were unable to do so at this stage until the RC tear was ruled out. The US revealed no inflammation of the RC or evidence of an acute injury, it did reveal a tear of subscapularis, but was reported as being due to degerenerative changes (the patient was in their late 80’s). Despite this the consultant wrote for physio to treat the patient’s RC injury. Whilst this didn’t affect my treatment – as I continued retraining reach etc as this was the patient s main functional limitation (nil pain, swelling etc) I did overhear the consultant and registrar having several 'arguments/discussions' in the doctor’s office regarding this particular patient. When I was asked to provide feedback about the patient’s progress etc it was extremely awkward as all the assessment findings and progress the patient had been making indicated a neurological event and not the RC pathology the consultant had diagnosed. In the end a series of neurological investigations were ordered and it was revealed that the patient had had a minor stroke.
I wasn’t sure if the situation was an indication of some negative politics or power play occurring between the consultant and registrar but it did reveal a key issue for me. In the hospital setting as physios we often read the patients notes (prior to seeing them) get the diagnosis and then from there meet the patient and treat them accordingly. In 9/10 this would be appropriate (assuming that you still are doing a clinical examination etc) but this incident really made me realise that when you are treating a patient and their diagnosis doesn't seem to fit with their presentation and response to PT Rx make sure you follow it up. While as physios we don’t have the training and skills as a doctor for diagnosing conditions we do have a fairly good understanding and ability to recognise clinical signs and symptoms of a variety of conditions. Thus this particular situation showed me that we constantly need to be using this skill and analysing if the patient is responding to the PT Rx as they should be, and if they’re not considering the possibility that something else may be going on, and should be followed up. In this scenario the registrar’s actions meant that the patient was entitled to and received a variety of services (which with a RC injury they would not have received) when they were D/C which will hopefully ensure they regain as much function in their UL as possible.
Professional Communication
During my recent rural placement my supervisor asked me on several occassions to ring my patient's GP and talk to them about various issues. This included updating them on my pt's progress, alerting them to any new symptoms the patient presented with or getting a more thorough medical Hx when things didn't seem right.
Initially I felt a bit nervous contacting the GPs as on my previous musculo outpatients prac we had only communicated with them via writing. However my supervisor stated to me that its really important to keep the communication lines open as this results in better care for the pt and also presents a good image to the GPs in terms of our proffession.
I was worried that the GPs would think I was wasting their time talking to them; however they generally were very happy to discuss their patients and by the end of my prac I felt I'd built a good rapport with the them.
This highlighted to me the importance of professional communication in terms of promoting our service as physiotherapists and, although at the time I was hesitant, in retrospect I am glad I had the opportunity to practice this whilst on prac.
Initially I felt a bit nervous contacting the GPs as on my previous musculo outpatients prac we had only communicated with them via writing. However my supervisor stated to me that its really important to keep the communication lines open as this results in better care for the pt and also presents a good image to the GPs in terms of our proffession.
I was worried that the GPs would think I was wasting their time talking to them; however they generally were very happy to discuss their patients and by the end of my prac I felt I'd built a good rapport with the them.
This highlighted to me the importance of professional communication in terms of promoting our service as physiotherapists and, although at the time I was hesitant, in retrospect I am glad I had the opportunity to practice this whilst on prac.
Saturday, November 15, 2008
Bad Bad Boys
My paediatric placement was really enjoyable. I saw mostly young babies with plagiocephaly, developmental delay, and some older kids with DCD. Most of my patients (and their parents) were all really nice. The majority of the kids were well behaved. The occasional baby would be tired or hungry and get easily upset, but that wasn’t the worst thing to deal with. About half way through my prac I had to treat a really difficult child.
Throughout the prac there were the occasional older children who would have short attention spans or not be able to follow many complex commands, but I soon developed strategies to deal with that. There was one child, however, that I struggled to deal with. I think he was about 4 or 5 years old. He had delayed gross motor skills and poor core strength and functional balance. But worse of all he was extremely bad behaved.
This kid was simply uncontrollable. He was bouncing off the balls, wouldn’t follow the simplest of commands, and if you got close to him he would slap, punch, kick, or headbutt you. Towards the end of the session he even started forming a big mouthful of spit and threatened to spit at me and my supervisor. I know exactly what I wanted to do with this kid, however, I don’t think it would’ve gone down too well with my supervisor. So I had to use more politically correct strategies to deal with this little bundle of joy.
I did actually feel sorry for this kid though. The child came from a very difficult family situation. His father wasn’t really around, and his mother worked away most of the time. He lived with his grandfather, who didn’t pay a huge amount of attention to him. The grandfather would bring him to the appointments, but sit outside during the session not interested what was going on with his grandson.
My supervisor was really helpful. She has many years experience and knew how to deal with this kid. I tried my best, but I don’t think I was very effective. My supervisor later said that when a child is like that you can only do your best and sometimes you cannot avoid it and their bad behaviour may cause a session to simply not be very productive. It is not your fault if you are in that situation and you do your best to overcome it.
I was glad to be put in that situation because I learned a lot from trying to deal with it, as well as seeing my supervisor pulling out some tricks from her years of experience. One thing she did for example, was to bend down to his level, grab hold of his shoulder with one hand and point her finger with the other, stare him down with her face right next to his and speak to him in a strong voice. I seriously thought that she was going to get spat on. But it worked. He did what she said when she did that. This was one of the only commands he actually listened to throughout the session. I gained several ideas from this experience that I will be sure to use in the future when I am in similar situations. Has anyone else been in a similar situation while on paeds or any other placement? If so, were there any strategies you used or learnt?
Throughout the prac there were the occasional older children who would have short attention spans or not be able to follow many complex commands, but I soon developed strategies to deal with that. There was one child, however, that I struggled to deal with. I think he was about 4 or 5 years old. He had delayed gross motor skills and poor core strength and functional balance. But worse of all he was extremely bad behaved.
This kid was simply uncontrollable. He was bouncing off the balls, wouldn’t follow the simplest of commands, and if you got close to him he would slap, punch, kick, or headbutt you. Towards the end of the session he even started forming a big mouthful of spit and threatened to spit at me and my supervisor. I know exactly what I wanted to do with this kid, however, I don’t think it would’ve gone down too well with my supervisor. So I had to use more politically correct strategies to deal with this little bundle of joy.
I did actually feel sorry for this kid though. The child came from a very difficult family situation. His father wasn’t really around, and his mother worked away most of the time. He lived with his grandfather, who didn’t pay a huge amount of attention to him. The grandfather would bring him to the appointments, but sit outside during the session not interested what was going on with his grandson.
My supervisor was really helpful. She has many years experience and knew how to deal with this kid. I tried my best, but I don’t think I was very effective. My supervisor later said that when a child is like that you can only do your best and sometimes you cannot avoid it and their bad behaviour may cause a session to simply not be very productive. It is not your fault if you are in that situation and you do your best to overcome it.
I was glad to be put in that situation because I learned a lot from trying to deal with it, as well as seeing my supervisor pulling out some tricks from her years of experience. One thing she did for example, was to bend down to his level, grab hold of his shoulder with one hand and point her finger with the other, stare him down with her face right next to his and speak to him in a strong voice. I seriously thought that she was going to get spat on. But it worked. He did what she said when she did that. This was one of the only commands he actually listened to throughout the session. I gained several ideas from this experience that I will be sure to use in the future when I am in similar situations. Has anyone else been in a similar situation while on paeds or any other placement? If so, were there any strategies you used or learnt?
The real world
As we are all soon to graduate and start working in the real world I thought I’d blog about a situation that recently happened to me outside of prac relating to our physiotherapy experience.
I’m sure we’ve all had family and friends ask us to ‘have a look at this’, or ‘fix this for me’, or even the dreaded ‘oh so you’re a physio, so you’d be able to give me a massage’, but have any of us really seen any real life situations where our physiotherapy knowledge has helped us in the real world outside of prac?
I am currently on my paediatric placement and one of the common things that we see and treat is babies with plagiocephaly. Outside of studying I work in a small independent bottle shop. A lady walked in last week with a young baby in her arms. I commented on her baby and asked if he was roughly around 4-5 months old. She said ‘yes he is actually 4 and a half months old, do you have kids yourself?’
I found this slightly amusing, but explained to her that I don’t have kids, but the reason I had a good idea of her sons age was because I am a physiotherapy student and currently undertaking a paediatric clinical placement. She went on to ask what sort of conditions would paediatric physios treat. I couldn’t help but notice from across the counter that her son had quite a significant left sided plagiocephaly. I wasn’t quite sure what to say as I didn’t want to mention her son’s head as an example of what we see and treat and offend her.
So I played it cool and said that where I am working we mostly see children who are delayed in gross motor skills and so on. As the conversation went on I gathered the impression that she would actually appreciate the information if I mentioned her son’s head shape and not take any offence. So I went on to describe how we also treat plagiocephalies.
At that point I mentioned that her sons head is slightly asymmetrical and he actually has a mild left sided plagiocephaly. His mother seemed slightly surprised that she hadn’t noticed this, but I reassured her that often mothers don’t notice, it is usually the child health nurse or someone else who brings it to their attention. I went on to describe the condition and quickly assess the child and give the mother some information about what she could do to hopefully help with his head shape.
Meanwhile my boss at the liquor store didn’t mind me doing this and not working per se. He probably thought that engaging the customer like that would be good for business or something. Anyway I digress. The baby had FROM, good strength and the mother didn’t notice any preference to the left side. I gave her the same information that I would someone who I saw on prac in the same situation. I also made it clear that if she had any concerns or questions she should follow them up with the appropriate medical persons.
When I saw the child from across the counter, I felt almost obligated to at least mention to the mother what I had observed. In the end, I’m glad I did and said what I said. In the future when I am in a similar situation I wont feel hesitant to use my knowledge and skills to help others (but at the same time, I’m not going to go out deliberately prying into people looking for problems). Has anybody else been in a situation outside of prac where their physio knowledge made them notice something about someone that they felt obligated to mention to them?
I’m sure we’ve all had family and friends ask us to ‘have a look at this’, or ‘fix this for me’, or even the dreaded ‘oh so you’re a physio, so you’d be able to give me a massage’, but have any of us really seen any real life situations where our physiotherapy knowledge has helped us in the real world outside of prac?
I am currently on my paediatric placement and one of the common things that we see and treat is babies with plagiocephaly. Outside of studying I work in a small independent bottle shop. A lady walked in last week with a young baby in her arms. I commented on her baby and asked if he was roughly around 4-5 months old. She said ‘yes he is actually 4 and a half months old, do you have kids yourself?’
I found this slightly amusing, but explained to her that I don’t have kids, but the reason I had a good idea of her sons age was because I am a physiotherapy student and currently undertaking a paediatric clinical placement. She went on to ask what sort of conditions would paediatric physios treat. I couldn’t help but notice from across the counter that her son had quite a significant left sided plagiocephaly. I wasn’t quite sure what to say as I didn’t want to mention her son’s head as an example of what we see and treat and offend her.
So I played it cool and said that where I am working we mostly see children who are delayed in gross motor skills and so on. As the conversation went on I gathered the impression that she would actually appreciate the information if I mentioned her son’s head shape and not take any offence. So I went on to describe how we also treat plagiocephalies.
At that point I mentioned that her sons head is slightly asymmetrical and he actually has a mild left sided plagiocephaly. His mother seemed slightly surprised that she hadn’t noticed this, but I reassured her that often mothers don’t notice, it is usually the child health nurse or someone else who brings it to their attention. I went on to describe the condition and quickly assess the child and give the mother some information about what she could do to hopefully help with his head shape.
Meanwhile my boss at the liquor store didn’t mind me doing this and not working per se. He probably thought that engaging the customer like that would be good for business or something. Anyway I digress. The baby had FROM, good strength and the mother didn’t notice any preference to the left side. I gave her the same information that I would someone who I saw on prac in the same situation. I also made it clear that if she had any concerns or questions she should follow them up with the appropriate medical persons.
When I saw the child from across the counter, I felt almost obligated to at least mention to the mother what I had observed. In the end, I’m glad I did and said what I said. In the future when I am in a similar situation I wont feel hesitant to use my knowledge and skills to help others (but at the same time, I’m not going to go out deliberately prying into people looking for problems). Has anybody else been in a situation outside of prac where their physio knowledge made them notice something about someone that they felt obligated to mention to them?
Differences in health care
Many people, and I’m sure we have also at times, complain about our health care system here in Australia. Amy recently made a fantastic blog about her experiences in Cambodia. I too shared these experiences and am extremely grateful to have had the opportunity to, and encourage anyone to go to another country less fortunate than ours. I could talk for hours about all the amazing things that myself and the other students that went saw while we were there, but I will just describe one particular experience that really stood out to me.
I spent two and a half weeks at a place called Kien Khleang National Rehabilitation Centre, specifically at the Children’s Surgical Centre. Check out their website at www.csc.org , it really is a remarkable place. They truly do amazing things for the Khmer people.
Some background information on the place;
- it’s a small facility located on the outskirts of Phnom Penh
- Kien Khleang has several small facilities
- Veterans International (a rehab centre)
- Children’s Surgical Centre
- A leprosy clinic
- the CSC basically performs consultations, surgery, and some ongoing treatment free of charge for any local Khmers. Just check out the website to save time me explaining.
There is only one physiotherapist who works there so he is pretty busy, especially considering he deals with some pretty interesting post-op patients. He speaks fairly good English, as do most of Khmer staff working there, although nearly all the patients do not.
While I was there I treated a young girl who was roughly 9 years old. She had had a quadriceplasty on her left leg. That was pretty interesting, but not the most interesting thing about her. Her right leg had a subluxed patella. I have no idea how long this had been for, but judging by the muscle shortening and movement patterns that she had adopted, we assumed it had been like this for a reasonable length of time. I was curious why the surgeons had done nothing to address this. Ath (pronounced Art), the physio at the centre, told me that the priority was surgical intervention for her quadricep contracture and that maybe in a few months when she returns (if she returns) for a follow-up assessment, the surgeons may consider to relocate her patella.
This was somewhat of a shock to see. I saw some amazing injuries and surgeries while I was there that simply would not occur in Australia. This situation just would not occur here in Australia. If someone presented to a clinic with a subluxed patella, they would most likely be either sedated or given pain relief and have the patella relocated. In Australia it would be absurd to let a patient walk around with a subluxed patella for months or even years. But the Cambodian people simply deal with it. And its not just subluxed patellas either, they will not receive treatment for fractures, tumors, and many others. This is for many reasons, such as lack of money, transport, facilities, qualified medical staff and many more. But the point is that they have it pretty hard, as do many other third world countries, yet they live through adversity and do not complain about it. Which leads me to my main point.
Here in Australia we serious take an awful lot of things for granted. For one, our health care system. It would have to be up there as one of the better health care systems in the world, yet we constantly complain about it. Of course there are many things that we could do to improve it, but really is that the point. Since my experiences in Cambodia, when I hear people complain over insignificant petty things regarding our health care system I think to myself just shut up and look at some other peoples situations and be thankful that you have what you have got, because it really isn’t that bad.
This situation, along with many other experiences in Cambodia has really helped me put things into perspective regarding our and other health care systems. It may make me more frustrated with some of the whinging patients I may encounter, but at least when I think I have it tough I can think back to some people I got to see who had it really tough, and not complain about my situation. I hope others reading can gain this message and think about it when they approach similar situations in the future.
I spent two and a half weeks at a place called Kien Khleang National Rehabilitation Centre, specifically at the Children’s Surgical Centre. Check out their website at www.csc.org , it really is a remarkable place. They truly do amazing things for the Khmer people.
Some background information on the place;
- it’s a small facility located on the outskirts of Phnom Penh
- Kien Khleang has several small facilities
- Veterans International (a rehab centre)
- Children’s Surgical Centre
- A leprosy clinic
- the CSC basically performs consultations, surgery, and some ongoing treatment free of charge for any local Khmers. Just check out the website to save time me explaining.
There is only one physiotherapist who works there so he is pretty busy, especially considering he deals with some pretty interesting post-op patients. He speaks fairly good English, as do most of Khmer staff working there, although nearly all the patients do not.
While I was there I treated a young girl who was roughly 9 years old. She had had a quadriceplasty on her left leg. That was pretty interesting, but not the most interesting thing about her. Her right leg had a subluxed patella. I have no idea how long this had been for, but judging by the muscle shortening and movement patterns that she had adopted, we assumed it had been like this for a reasonable length of time. I was curious why the surgeons had done nothing to address this. Ath (pronounced Art), the physio at the centre, told me that the priority was surgical intervention for her quadricep contracture and that maybe in a few months when she returns (if she returns) for a follow-up assessment, the surgeons may consider to relocate her patella.
This was somewhat of a shock to see. I saw some amazing injuries and surgeries while I was there that simply would not occur in Australia. This situation just would not occur here in Australia. If someone presented to a clinic with a subluxed patella, they would most likely be either sedated or given pain relief and have the patella relocated. In Australia it would be absurd to let a patient walk around with a subluxed patella for months or even years. But the Cambodian people simply deal with it. And its not just subluxed patellas either, they will not receive treatment for fractures, tumors, and many others. This is for many reasons, such as lack of money, transport, facilities, qualified medical staff and many more. But the point is that they have it pretty hard, as do many other third world countries, yet they live through adversity and do not complain about it. Which leads me to my main point.
Here in Australia we serious take an awful lot of things for granted. For one, our health care system. It would have to be up there as one of the better health care systems in the world, yet we constantly complain about it. Of course there are many things that we could do to improve it, but really is that the point. Since my experiences in Cambodia, when I hear people complain over insignificant petty things regarding our health care system I think to myself just shut up and look at some other peoples situations and be thankful that you have what you have got, because it really isn’t that bad.
This situation, along with many other experiences in Cambodia has really helped me put things into perspective regarding our and other health care systems. It may make me more frustrated with some of the whinging patients I may encounter, but at least when I think I have it tough I can think back to some people I got to see who had it really tough, and not complain about my situation. I hope others reading can gain this message and think about it when they approach similar situations in the future.
Political Correctness
Whilst on international placement in Cambodia part of our role as students was facilitating a group of local Khmer physiotherapists that were studying a two week course – advanced certificate in musculoskeletal physiotherapy. This was a group of maybe 20 qualified Cambodian physiotherapists. Their physiotherapy course is obviously a lot different from what we have learned here in Australia. Their level of understanding is no where near that of what we have obtained from our years studying, but that is a whole other issue. The course was basically set up and run through a Singapore hospital or the Singaporean government as far as I know. There was a Singaporean physio (with post grad qualifications) who presented topics on the elbow, wrist, and hand, and Michelle, who we all know, who presented topics on the shoulder. Which brings me to issue I wish to discuss.
I honestly feel as though I could have done a better job in presenting the topics. It was blatantly clear once this lady started talking that she hadn’t put a lot of thought into what she was doing. Firstly the whole series of lectures were poorly structured. Secondly, and of more concern was the content of what she was delivering. She aimed her lectures at far too high a level of knowledge for the Khmer physios. It was obvious that they were struggling with what she was saying, yet she continued to cover topics as if she was lecturing back home. Also apart from the content being too challenging for the students, she also discussed completely irrelevant information that simply confused them. It was extremely frustrating watching this and not being able to do anything, watching the students struggle and take little in. The whole thing could have been far more effective for all if she thought a little more about what she was doing before, or even during the lectures.
The next frustrating thing was the fact that when she was delivering the lectures she simply rambled on at great lengths before pausing for the translator to translate. The poor bloke was struggling to recall and translate everything that she was saying, she was aware of this as he made it abundantly clear through not and his body language, but also as he was constantly having to ask her to repeat parts of what she had said. Yet she did not change her lecturing techniques.
But wait there’s more. Apart from confusing the hell out of the students, the ones who actually did follow what was going on soon found themselves pondering because every now and then this lady, a post-grad I’ll reiterate, contradicted herself or made blatant fundamental errors in what she was saying.
Okay, sorry for the rant but it was extremely frustrating for me. But here is the worst part. The students got a practical exam at the end of the course. This was kind of loosely, very loosely similar to our ospes. The question this lady had written stated something along the lines of – the patient has grade 2 dorsiflexors, demonstrate 1 exercise to increase dorsiflexor strength. That question was at an appropriate level for the students..but not really for the examiner. When the students, and I mean every one of them, came out and started to do a strengthening exercise for a person with a grade 2 dorsiflexor, she confused the hell out of them and said it was wrong and made them try to do a grade 3 exercise for the patient.
Now the students all knew different grade 2 and 3 exercises that they could have done, but as the question said to do a grade 2 exercise, when the examiner tried to get them to do a grade 3 exercise (without calling it a grade 3 – she tried to get them to figure it out) they all just drew blanks. I was acting as patient and it was obvious that they all knew what she intended to examine, however, her communication with them was so poor that no one understood what she was asking of them. Thus they all ran out of time and all the students failed and had to resit the prac. They all finally passed but not after much unnecessary confusion.
The other two students and I discussed with Michelle this ladies communication and lecture skills, as well as her level of knowledge. What were we to do in this situation? Given the situation, that we were invited there by the Singaporeans, it was a rather sensitive issue, and we really couldn’t say much to this lady without offending her. We could subtly drop hints but that was about it. Other than that all we could do was try to clear up any confusion the students had. They would often ask us questions during breaks or prac times and we gladly helped, and with some common sense communication strategies the students understood what they wanted to know.
Michelle restructured her information to ‘correct’ a few things from the previous lecturer in a subtle way. Watching Michelle lecture was great. She was truly professional and well prepared. She structured her content well and aimed it at the appropriate level for the Khmers. Not to mention, it was pretty good to see her talk slowly during a lecture! The students without a doubt learnt far more from Michelle’s couple of days than from the other lady.
So what did I learn from this? Firstly, how lucky we are to have the opportunity to learn what we learn studying at Curtin. Secondly, how good our lecturers actually are. And thirdly, how important it is to use good communication when talking to people with little or no English. It certainly helped me in the way I approached the next couple of weeks working in a children’s surgical centre. Has anyone else been in a similar situation where someone ‘superior’ to them went about things the wrong way, or was clearly wrong yet political correctness meant that you couldn’t do or say anything about it? Or does anyone have any thoughts or tips on my situation?
I honestly feel as though I could have done a better job in presenting the topics. It was blatantly clear once this lady started talking that she hadn’t put a lot of thought into what she was doing. Firstly the whole series of lectures were poorly structured. Secondly, and of more concern was the content of what she was delivering. She aimed her lectures at far too high a level of knowledge for the Khmer physios. It was obvious that they were struggling with what she was saying, yet she continued to cover topics as if she was lecturing back home. Also apart from the content being too challenging for the students, she also discussed completely irrelevant information that simply confused them. It was extremely frustrating watching this and not being able to do anything, watching the students struggle and take little in. The whole thing could have been far more effective for all if she thought a little more about what she was doing before, or even during the lectures.
The next frustrating thing was the fact that when she was delivering the lectures she simply rambled on at great lengths before pausing for the translator to translate. The poor bloke was struggling to recall and translate everything that she was saying, she was aware of this as he made it abundantly clear through not and his body language, but also as he was constantly having to ask her to repeat parts of what she had said. Yet she did not change her lecturing techniques.
But wait there’s more. Apart from confusing the hell out of the students, the ones who actually did follow what was going on soon found themselves pondering because every now and then this lady, a post-grad I’ll reiterate, contradicted herself or made blatant fundamental errors in what she was saying.
Okay, sorry for the rant but it was extremely frustrating for me. But here is the worst part. The students got a practical exam at the end of the course. This was kind of loosely, very loosely similar to our ospes. The question this lady had written stated something along the lines of – the patient has grade 2 dorsiflexors, demonstrate 1 exercise to increase dorsiflexor strength. That question was at an appropriate level for the students..but not really for the examiner. When the students, and I mean every one of them, came out and started to do a strengthening exercise for a person with a grade 2 dorsiflexor, she confused the hell out of them and said it was wrong and made them try to do a grade 3 exercise for the patient.
Now the students all knew different grade 2 and 3 exercises that they could have done, but as the question said to do a grade 2 exercise, when the examiner tried to get them to do a grade 3 exercise (without calling it a grade 3 – she tried to get them to figure it out) they all just drew blanks. I was acting as patient and it was obvious that they all knew what she intended to examine, however, her communication with them was so poor that no one understood what she was asking of them. Thus they all ran out of time and all the students failed and had to resit the prac. They all finally passed but not after much unnecessary confusion.
The other two students and I discussed with Michelle this ladies communication and lecture skills, as well as her level of knowledge. What were we to do in this situation? Given the situation, that we were invited there by the Singaporeans, it was a rather sensitive issue, and we really couldn’t say much to this lady without offending her. We could subtly drop hints but that was about it. Other than that all we could do was try to clear up any confusion the students had. They would often ask us questions during breaks or prac times and we gladly helped, and with some common sense communication strategies the students understood what they wanted to know.
Michelle restructured her information to ‘correct’ a few things from the previous lecturer in a subtle way. Watching Michelle lecture was great. She was truly professional and well prepared. She structured her content well and aimed it at the appropriate level for the Khmers. Not to mention, it was pretty good to see her talk slowly during a lecture! The students without a doubt learnt far more from Michelle’s couple of days than from the other lady.
So what did I learn from this? Firstly, how lucky we are to have the opportunity to learn what we learn studying at Curtin. Secondly, how good our lecturers actually are. And thirdly, how important it is to use good communication when talking to people with little or no English. It certainly helped me in the way I approached the next couple of weeks working in a children’s surgical centre. Has anyone else been in a similar situation where someone ‘superior’ to them went about things the wrong way, or was clearly wrong yet political correctness meant that you couldn’t do or say anything about it? Or does anyone have any thoughts or tips on my situation?
Patient Self Mx
During my last placement I was seeing a lady as an outpatient with chronic non specific LBP with a strong motor control aspect involved. Treatment was mainly focused on increasing her local muscle system activation with a core stability program. However, this patient self-admittedly was not doing any of her HEP, so essentially the only time she was working on her TA and multifidus activation was during her therapy sessions (ie. half an hour a week). I tried several times explaining to this patient the need to regularly be doing her exercises and that only doing exercises during Rx time with me would not be adequate to increase the stability of her back and reduce her symptoms. However, this patient continued not doing her HEP and would always make excuses like "I'm too busy" or "I forgot". After speaking to my supervisor we discharged her and referred her to the hospital hydrotherapy group. My supervisor stated it was a waste of our time, which is a resource, if the patient is not going to be compliant with Rx.
This got me thinking... in a public system discharging a pt not compliant with Rx makes sense in that it allows another person on the wait list to receive treatment...however, in a private setting, where the patient is paying and their isn't neccessarily a wait list, do you think it is unethical to continuing seeing this patient as they will not receive long term benefits if they do not start to self manage?
This got me thinking... in a public system discharging a pt not compliant with Rx makes sense in that it allows another person on the wait list to receive treatment...however, in a private setting, where the patient is paying and their isn't neccessarily a wait list, do you think it is unethical to continuing seeing this patient as they will not receive long term benefits if they do not start to self manage?
Friday, November 14, 2008
Refer for imaging
This week during my rural placement in outpatient department, I had a 13 years old girl coming for new assessment. She has had bilateral knee pain for 2 years, with right knee worse than the left. She has seen her GP previously and was thought to have growing pain. On recent visit to GP, PF pain syndrome was considered as there was pain to inferior to patella, and hence was referred to see a physio for further opinion and management.
During my subjective assessment, all symptoms and signs almost fit with PFJ problem. Her aggravating factor included running, long distance running and squatting. Her pain came on spontaneous and slowly getting worse over the 2 years. She also mentioned that she used to jump onto her knees a lot with her brother when she was younger for one year. However, it was long before onset of her knee pain. Her objective assessment did not help me clear things up at all. Her alignment was good and no apparent swelling or atrophy. She was TOP all around the patella area, no particular spots are worse and also TOP in muscle bulks of squats, hamstring and adductors. In AROM, She was slightly short of full flexion limited by pain. Her patellar glides are all painful, most painful and tight medially. Pain with resisted knee flexion, extension, hip flexion and adduction. She is able to do full squats however very painful. McConnell did not ease pain with resisted knee extension. I was very confused with what her diagnosis could be. So I called in my supervisor to help me with this particular patient. And he re-assessed a few objective signs and also unable to pinpoint the structure involved. Fortunately, her mother booked a xray for her the day after. So I asked her to come back after the xray. I gave her hot packs and HEP of stretches, strengthening ex’s, hot packs and also tubigrip for support.
The day after, they came back with the x-ray. She almost is having an avulsion fracture of tibial tuberosity of her R knee, and also similar problem but better with her L knee. Therefore I happily diagnosed her with bilateral Osgood-Oshlatters. However, if the mother has not yet planned to do the X-ray, I wonder if I would immediately ask her to get a xray of the knee. With her history of no trauma, insidious onset and no clear pain pattern, I may not have referred her to x-ray immediately. This occasion will be an alarm bell for me. If there’s possible yellow flags, it would be safer to get a x-ray to clear. Has anyone else had similar experience or other comments?
During my subjective assessment, all symptoms and signs almost fit with PFJ problem. Her aggravating factor included running, long distance running and squatting. Her pain came on spontaneous and slowly getting worse over the 2 years. She also mentioned that she used to jump onto her knees a lot with her brother when she was younger for one year. However, it was long before onset of her knee pain. Her objective assessment did not help me clear things up at all. Her alignment was good and no apparent swelling or atrophy. She was TOP all around the patella area, no particular spots are worse and also TOP in muscle bulks of squats, hamstring and adductors. In AROM, She was slightly short of full flexion limited by pain. Her patellar glides are all painful, most painful and tight medially. Pain with resisted knee flexion, extension, hip flexion and adduction. She is able to do full squats however very painful. McConnell did not ease pain with resisted knee extension. I was very confused with what her diagnosis could be. So I called in my supervisor to help me with this particular patient. And he re-assessed a few objective signs and also unable to pinpoint the structure involved. Fortunately, her mother booked a xray for her the day after. So I asked her to come back after the xray. I gave her hot packs and HEP of stretches, strengthening ex’s, hot packs and also tubigrip for support.
The day after, they came back with the x-ray. She almost is having an avulsion fracture of tibial tuberosity of her R knee, and also similar problem but better with her L knee. Therefore I happily diagnosed her with bilateral Osgood-Oshlatters. However, if the mother has not yet planned to do the X-ray, I wonder if I would immediately ask her to get a xray of the knee. With her history of no trauma, insidious onset and no clear pain pattern, I may not have referred her to x-ray immediately. This occasion will be an alarm bell for me. If there’s possible yellow flags, it would be safer to get a x-ray to clear. Has anyone else had similar experience or other comments?
Wednesday, November 12, 2008
Unreliable Handovers
Sorry this is so close to the last one! Have had some trouble connecting to the net this week. During a recent placement I was given a handover for a patient on a ward I was unfamiliar with by the ward physio. The handover the physio gave me was given to them by the nursing co-ordinator for that shift – in both instances neither had actually met the patient. Included in this handover was the following, patients ages, PC, brief HPC, PMH and brief social situation. From this handover it appeared that this patient was relatively straightforward and required a mobility assessment and possibly chest physio. With this handover I allocated a certain amount of time to see the patient and went to the ward to treat them. As with all patients I read through their notes prior to seeing them and very quickly identified a number of significant events that were not present in the handover;
1. Patient had been in ICU for a period of time requiring ventilation
2. Patient had had a recent code blue on the ward (when ambulating)
3. Currently the patient was in ARF and not medically stable
4. Doctors on the ward round that morning had indicated in the notes that the patient was to be RIB for the next 2-3/7 thus not appropriate for PT
After reading through the notes I realised how important it is not just to take the information given by others prior to seeing a patient without having investigating their history yourself. While some of this information probably should have been included in the handovers the nursing co-ordinator and physio are by no means at fault (as they didn't know the patients full history either) but it really highlighted to me that you need to have a fairly good understanding as to the patient’s background prior to seeing them. In this case it was very obvious after reading the notes and was re affirmed by my supervisor that this patient was not appropriate for PT Rx. When you’re busy on the ward and don’t have much time to read through the notes it can be easy to just go by the handovers you receive (I have definitely been guilty of that!), but this particular patient has shown me that without reading their notes I could have potentially caused a medical emergency for this already acutely ill patient just by taking a shortcut. Thus even though it may take an extra few minutes you don't have, find the time to read through the notes as it may save your patients life!
1. Patient had been in ICU for a period of time requiring ventilation
2. Patient had had a recent code blue on the ward (when ambulating)
3. Currently the patient was in ARF and not medically stable
4. Doctors on the ward round that morning had indicated in the notes that the patient was to be RIB for the next 2-3/7 thus not appropriate for PT
After reading through the notes I realised how important it is not just to take the information given by others prior to seeing a patient without having investigating their history yourself. While some of this information probably should have been included in the handovers the nursing co-ordinator and physio are by no means at fault (as they didn't know the patients full history either) but it really highlighted to me that you need to have a fairly good understanding as to the patient’s background prior to seeing them. In this case it was very obvious after reading the notes and was re affirmed by my supervisor that this patient was not appropriate for PT Rx. When you’re busy on the ward and don’t have much time to read through the notes it can be easy to just go by the handovers you receive (I have definitely been guilty of that!), but this particular patient has shown me that without reading their notes I could have potentially caused a medical emergency for this already acutely ill patient just by taking a shortcut. Thus even though it may take an extra few minutes you don't have, find the time to read through the notes as it may save your patients life!
Family Issues
I recently treated a patient who was admitted to hospital following a fall and sustaining a hairline fracture of the pubic ramus and ischium. This patient had a history of falls and in the past had been given a 4WW to use at home when ambulating with the hope of preventing/reducing the chance of them falling again. Unfortunately this patient ‘only occasionally’ used the 4WW, as they did not feel they required it. Additionally this patient had had a previous neurological event leaving them with a fairly significant long standing ataxic gait pattern which contributed to their impaired standing balance (which we could not address). Once the patient’s pain was Mx by the medical team we were asked to assess the patient’s mobility and determine whether they were safe to D/C. Following this Ax it was clear that the patient was still a falls risk – however this would not change with a couple more days as an inpatient receiving physiotherapy. After educating the patient on the importance of using their 4WW we referred to the patient to the falls clinic and wrote in the notes that the patient despite a falls risk was safe to be D/C. This was when the family issues began.
Prior to the medical team stating the patient was to be D/C the patient’s family had had no involvement nor voiced any concerns about the patient returning home. The day the patient was to be D/C their son announced that they (patient) could not go home as they were at risk of falling etc. Modifications were already in place at the home, services/assistance organised and the patient ambulated safely with a 4WW. Despite this the family maintained that the patient was not going to be safe at home, however the family had not made any alternative living arrangements or suggestions. Simply put the family wanted the hospital staff to organise these alterative arrangements and not take any responsibility. However, the medical team did not agree with the families concerns thus were not prepared (or couldn’t) arrange for these new ‘living arrangements’. Thus a ‘stand off’ occurred on the ward with the family refusing to take the patient home, and the medical team not providing any alternatives. While I had little involvement in this scenario it made me see the importance of a family meeting prior to D/C a patient. No such meeting had occurred in this scenario and what I found particularly difficult with this case was that the family didn’t appear to want to be involved in the process they just wanted ‘the problem’ sorted out for them.
If a family meeting had occurred all these issues could have been discussed with each of the medical team and allied health team present. From a physio POV there was no reason why the patient couldn’t return home as they could ambulate safely – should they chose to use their 4WW and they were part of a falls program. For these reasons (and that they were independent for all ADL’s) the medical team could not refer them for a rehabilitation program or in a nursing home/hostel etc, despite the family wishes. Unfortunately it was a tricky situation which I’m sure occurs all the time as although the patient may still be a falls risk, the reasons for them being at risk of falling is with the patient not complying with medical advice. In the end what the team had to do was explain to the family that this patient wasn’t going to ‘get better’ and by putting them in care (apart from them not meeting the criteria) it doesn’t mean that will not fall. In the end the family accepted this and took the patient home but it was a very awkward situation, especially for the patient who just wanted to get home. On reflection it would have been better to have got the family involved sooner, but as they had voiced no concerns (and had been spoken to by the staff) there had been no indication that this would happen. What I learnt from this situation was to always involve the family in the decision making process or at the very least keep them informed along the way in order to avoided such conflicts.
Prior to the medical team stating the patient was to be D/C the patient’s family had had no involvement nor voiced any concerns about the patient returning home. The day the patient was to be D/C their son announced that they (patient) could not go home as they were at risk of falling etc. Modifications were already in place at the home, services/assistance organised and the patient ambulated safely with a 4WW. Despite this the family maintained that the patient was not going to be safe at home, however the family had not made any alternative living arrangements or suggestions. Simply put the family wanted the hospital staff to organise these alterative arrangements and not take any responsibility. However, the medical team did not agree with the families concerns thus were not prepared (or couldn’t) arrange for these new ‘living arrangements’. Thus a ‘stand off’ occurred on the ward with the family refusing to take the patient home, and the medical team not providing any alternatives. While I had little involvement in this scenario it made me see the importance of a family meeting prior to D/C a patient. No such meeting had occurred in this scenario and what I found particularly difficult with this case was that the family didn’t appear to want to be involved in the process they just wanted ‘the problem’ sorted out for them.
If a family meeting had occurred all these issues could have been discussed with each of the medical team and allied health team present. From a physio POV there was no reason why the patient couldn’t return home as they could ambulate safely – should they chose to use their 4WW and they were part of a falls program. For these reasons (and that they were independent for all ADL’s) the medical team could not refer them for a rehabilitation program or in a nursing home/hostel etc, despite the family wishes. Unfortunately it was a tricky situation which I’m sure occurs all the time as although the patient may still be a falls risk, the reasons for them being at risk of falling is with the patient not complying with medical advice. In the end what the team had to do was explain to the family that this patient wasn’t going to ‘get better’ and by putting them in care (apart from them not meeting the criteria) it doesn’t mean that will not fall. In the end the family accepted this and took the patient home but it was a very awkward situation, especially for the patient who just wanted to get home. On reflection it would have been better to have got the family involved sooner, but as they had voiced no concerns (and had been spoken to by the staff) there had been no indication that this would happen. What I learnt from this situation was to always involve the family in the decision making process or at the very least keep them informed along the way in order to avoided such conflicts.
Monday, November 10, 2008
Respect
hey
On my community physiotherapy placement at the moment i've had to take a lot of different group exercise classes. This has meant that i have had to use clear communication and instruct people (all above the age 60 years) while still being polite and maintaining my professionalism.
The trickiest thing so far has been able to gain the respect of the clients, so that they will listen, but also having a friendly and happy attitude so they will enjoy the class and continue to listen. This is a similar situation that occurs on all pracs. No matter what placement you always have to gain respect from the patient but also develop rapport. However it is more important to do this in group classes because instead of having only one patient's attention you need to gain 20 patients attention at once. You only have to have one or two patients who don't respect you to disrupt a whole class.
While i was taking a class a few days ago i was instructing the clients in some strengthening exercises. There were a few murmurs coming from one old lady. She was complaining saying the exercise was hurting her knees a little bit. She didn't appear to be in any great trouble. Everyone else was getting on with the exercise without complaints and she was making a bit of a kafuffle.
I explained to the lady nicely how the exercise would help and to continue doing the exercise if she could manage it, i also gave her a slightly easy abridged version of the exercise she could adopt. She responded by saying she had "old knees" and that if i had her knees i wouldn't be able to do the exercise either. I then overheard her say to the person next to her ..."he'd be all of 17!" Referring to the fact that it must be simple for me with my young knees.
I didn't take too much notice of her comment at the time but later on i've started thinking about this. Even though i had tried so hard to gain respect from the class, it was obvious that one of the class members still didn't take me seriously because of the age she thought i was. The main worry about this that i have is i will be 24 years old in 2 months and also as an imminent new grad stepping out into the physiotherapy workforce i want to be able to be able to have my patients respect me and be taken seriously, even with the older generation clients.
Has anyone else experienced anything similar to this situation? Any thoughts on this? Hopefully by continuing to gain rapport with patients and maintaining a positive and professional attitude i will be taken seriously over time.
On my community physiotherapy placement at the moment i've had to take a lot of different group exercise classes. This has meant that i have had to use clear communication and instruct people (all above the age 60 years) while still being polite and maintaining my professionalism.
The trickiest thing so far has been able to gain the respect of the clients, so that they will listen, but also having a friendly and happy attitude so they will enjoy the class and continue to listen. This is a similar situation that occurs on all pracs. No matter what placement you always have to gain respect from the patient but also develop rapport. However it is more important to do this in group classes because instead of having only one patient's attention you need to gain 20 patients attention at once. You only have to have one or two patients who don't respect you to disrupt a whole class.
While i was taking a class a few days ago i was instructing the clients in some strengthening exercises. There were a few murmurs coming from one old lady. She was complaining saying the exercise was hurting her knees a little bit. She didn't appear to be in any great trouble. Everyone else was getting on with the exercise without complaints and she was making a bit of a kafuffle.
I explained to the lady nicely how the exercise would help and to continue doing the exercise if she could manage it, i also gave her a slightly easy abridged version of the exercise she could adopt. She responded by saying she had "old knees" and that if i had her knees i wouldn't be able to do the exercise either. I then overheard her say to the person next to her ..."he'd be all of 17!" Referring to the fact that it must be simple for me with my young knees.
I didn't take too much notice of her comment at the time but later on i've started thinking about this. Even though i had tried so hard to gain respect from the class, it was obvious that one of the class members still didn't take me seriously because of the age she thought i was. The main worry about this that i have is i will be 24 years old in 2 months and also as an imminent new grad stepping out into the physiotherapy workforce i want to be able to be able to have my patients respect me and be taken seriously, even with the older generation clients.
Has anyone else experienced anything similar to this situation? Any thoughts on this? Hopefully by continuing to gain rapport with patients and maintaining a positive and professional attitude i will be taken seriously over time.
Me?...an educator?
I recently wrote a blog about being supervised by new graduate physiotherapists with little clinical experience and questioned the value of what they have to offer a fourth year physio student, compared to the value of a highly experienced, highly skilled clinician.
However, since that placement I've had the opportunity to be in a facility working with second and third year physiotherapy students. I found that most of them felt more comfortable coming to me with any queries as opposed to the facility physio's. This was most likely becuase they didn't want to appear stupid in front of their assessors. It suprised me that I was actually able to offer them information to fill the gaps in their knowledge (obviously I didn't have ALL the answers!).
I guess what I'm trying to say is that, despite the fact that we only have 4-5 weeks experience in various fields of physiotherapy, we do have some clinical experience, and that experience is really quite valuable. I was initially a little anxious about the possibility of having to supervise students as a new graduate physio (not to mention being anxious about independently treating real patients!) but have realised that we can make a contribution to their education.
I'm sure you all remember being a first year physiotherapy student, seeing the fourth years (enviously) and thinking "wow, they must know everything!". We are now those fourth years and whilst we don't have all the answers, remember that the first years look up to us for a reason. After all we have earned (or will have earned) a physiotherapy degree for a reason!
However, since that placement I've had the opportunity to be in a facility working with second and third year physiotherapy students. I found that most of them felt more comfortable coming to me with any queries as opposed to the facility physio's. This was most likely becuase they didn't want to appear stupid in front of their assessors. It suprised me that I was actually able to offer them information to fill the gaps in their knowledge (obviously I didn't have ALL the answers!).
I guess what I'm trying to say is that, despite the fact that we only have 4-5 weeks experience in various fields of physiotherapy, we do have some clinical experience, and that experience is really quite valuable. I was initially a little anxious about the possibility of having to supervise students as a new graduate physio (not to mention being anxious about independently treating real patients!) but have realised that we can make a contribution to their education.
I'm sure you all remember being a first year physiotherapy student, seeing the fourth years (enviously) and thinking "wow, they must know everything!". We are now those fourth years and whilst we don't have all the answers, remember that the first years look up to us for a reason. After all we have earned (or will have earned) a physiotherapy degree for a reason!
Taking things for granted
Hey everyone,
I wanted to talk about a thought provoking conversation that I had with someone a couple days ago. I was on my placement in the area of community physiotherapy and i was chatting to one of the clients.
The client is 70 yrs old and has been attending the pulmonary rehab class for 4 years. He has a diagnosis of COPD and asymptomatic IHD. The objectives of the class are to improve the clients cardiovascular endurance, balance, strength and functional independence. The class starts by getting the clients to go for a 20 minute walk by doing laps of the building.
Anyway, i was walking with this client and i asked him what he used to work as. He said he did lots of different jobs and finds it quite boring at home now that he's retired. I felt a bit sorry for the client because he missed working and didnt seem to have a lot going on at the moment.
It really got me thinking, because as much as this year has been a struggle, at least we've had something to do. I think it would be worse to be stuck at home doing nothing, even though we may not have enjoyed some of the placements we've been on.
What does everyone else think, has anyone had a similar experience with a client/patient? I really hope this client finds a passion/hobby so he isnt bored and can enjoy his life. Also i think i might be a bit more grateful in the future to have something to do rather just complain adn take things for granted.
I wanted to talk about a thought provoking conversation that I had with someone a couple days ago. I was on my placement in the area of community physiotherapy and i was chatting to one of the clients.
The client is 70 yrs old and has been attending the pulmonary rehab class for 4 years. He has a diagnosis of COPD and asymptomatic IHD. The objectives of the class are to improve the clients cardiovascular endurance, balance, strength and functional independence. The class starts by getting the clients to go for a 20 minute walk by doing laps of the building.
Anyway, i was walking with this client and i asked him what he used to work as. He said he did lots of different jobs and finds it quite boring at home now that he's retired. I felt a bit sorry for the client because he missed working and didnt seem to have a lot going on at the moment.
It really got me thinking, because as much as this year has been a struggle, at least we've had something to do. I think it would be worse to be stuck at home doing nothing, even though we may not have enjoyed some of the placements we've been on.
What does everyone else think, has anyone had a similar experience with a client/patient? I really hope this client finds a passion/hobby so he isnt bored and can enjoy his life. Also i think i might be a bit more grateful in the future to have something to do rather just complain adn take things for granted.
Sunday, November 9, 2008
Indigenous Patients
When we had the people from CUCRH talking to us, I was interested with their talk about how culture differs etc. I listened and took mental notes however they didn’t sink in until I have actually started treating indigenous patients.
My first contact was in my cardio placement with a patient from remote community who had heart bypass surgery who was also my midway assessment patient. When I was told that she would be my patient, my supervisor also reminded me of cultural difference. During her assessment, I remembered from CUCRH talk, I didn’t pursuit for clearer answer when I asked about timeframes and gave up using VAS scale. However as it was my first experience with a patient, I wasn’t too sure when it is appropriate to ask for more details and when to change approach. My CCT then jumped in asking if pain is small or big. I also noticed of eye contact issue that she would sometimes look away and sometimes look into my eyes. Afterward, my supervisor commented that in general my approach with the patient was good. And I have to thank CUCRH for giving us the opportunity to get insight of indigenous culture.
Now at my rural prac, when I was in remote community doing outpatients I had a couple indigenous patients as well. Although they live in around the town, there are still cultural differences. For example sisters are necessary blood related. On the 2nd appointment, neither of them turned up. It was understandable to me, as they may have family affairs which are far more important than appointments and difference time system.
So I just wanted to say it was great that we had some opportunity to learn the basics of aboriginal culture. The CUCRH has helped me a lot during my placement.
My first contact was in my cardio placement with a patient from remote community who had heart bypass surgery who was also my midway assessment patient. When I was told that she would be my patient, my supervisor also reminded me of cultural difference. During her assessment, I remembered from CUCRH talk, I didn’t pursuit for clearer answer when I asked about timeframes and gave up using VAS scale. However as it was my first experience with a patient, I wasn’t too sure when it is appropriate to ask for more details and when to change approach. My CCT then jumped in asking if pain is small or big. I also noticed of eye contact issue that she would sometimes look away and sometimes look into my eyes. Afterward, my supervisor commented that in general my approach with the patient was good. And I have to thank CUCRH for giving us the opportunity to get insight of indigenous culture.
Now at my rural prac, when I was in remote community doing outpatients I had a couple indigenous patients as well. Although they live in around the town, there are still cultural differences. For example sisters are necessary blood related. On the 2nd appointment, neither of them turned up. It was understandable to me, as they may have family affairs which are far more important than appointments and difference time system.
So I just wanted to say it was great that we had some opportunity to learn the basics of aboriginal culture. The CUCRH has helped me a lot during my placement.
Saturday, November 8, 2008
Aboriginal Health Worker
I am currently on my rural placement and part of the allied health team at the hospital is an Aboriginal Health Worker. This man's role is to assist Aboriginal patients adjust to being in hospital, promote health awareness in this population and assist staff with any challenges which may arise when dealing with Aboriginal patients. So far I have found this person to be a great resource, in terms of seeking advice in regards to patients of Indigenous decent and basically just learning from him more about the beliefs and culture of Aboriginal Australians. He also has a great sense of humour and is able to relieve tension which sometimes arises in heated discussions during meetings.
One of my supervisor's patients, who I saw with her on my first day, is an Aboriginal man aged 23, who developed a severly infected knee joint after being speared during tribal punishment. As a non-Indigenous Australian, this seemed quite shocking to me; yet the patient wasn't concerned and had a very relaxed view on the event. After speaking to the Aboriginal Health Worker I learnt that this is a normal part of many Aboriginal tribes and the patient would have known and accepted that this is the consequence of his actions.
When sharing with this man about how valueable his help had been to me during prac, he was suprised to find out I hadn't accessed an Aboriginal Health Worker during my metropolitan practicals? I know there is a group of Aboriginal Health Workers at RPH but I haven't come across them during Allied Health meetings previously.
Has anyone had any experiences with Aboriginal Health Workers in their practicals; particularly metro ones?
One of my supervisor's patients, who I saw with her on my first day, is an Aboriginal man aged 23, who developed a severly infected knee joint after being speared during tribal punishment. As a non-Indigenous Australian, this seemed quite shocking to me; yet the patient wasn't concerned and had a very relaxed view on the event. After speaking to the Aboriginal Health Worker I learnt that this is a normal part of many Aboriginal tribes and the patient would have known and accepted that this is the consequence of his actions.
When sharing with this man about how valueable his help had been to me during prac, he was suprised to find out I hadn't accessed an Aboriginal Health Worker during my metropolitan practicals? I know there is a group of Aboriginal Health Workers at RPH but I haven't come across them during Allied Health meetings previously.
Has anyone had any experiences with Aboriginal Health Workers in their practicals; particularly metro ones?
Tuesday, November 4, 2008
Physiotherapy in remote communities
In my rural placement in Geraldton, once a week I go to a remote community with my supervisor. The town is about 1hour and 15 min away from Geraldton. I heard the town used to be a mining spot, however since the mine closed down, most caucasians have moved to Geraldton. Therefore, most of the residents there are aboriginals and staff from the local school and the community health centre.
During my half day there, I do an exercises class with the elderly and then physiotherapy for outpatients. On my first day there, I had total of 3 patients, and two of them are aboriginal descent. As we were driving back to Geraldton, my supervisor told me that I was very lucky to have two aboriginal patients in one day. He expressed that there are few aboriginal patients who come for physiotherapy treatment. Although the whole idea of driving to this town is to provide free physiotherapy treatment for the whole community which is mostly made up of aboriginals, many of them are not aware of the service available. In other cases, the limitation seemed normal to them to just endure it. For this reason, most of patients who come for outpatient appointment are either teachers from the school or the staff from the community health centre. When he just started, he had very little patients, some days having only 1-2 patients. Up to this point, due to limited staff from the health centre and community he is keeping some patients who could have been discharged with HEP if the clinic’s busier.
Reflecting on what he said, I realized that my second aboriginal patient was referred by doctor to see a physiotherapist. After her treatment, her sister who accompanied actually asked if she can have an appointment too for her own injury. As a rural community, many of aboriginals have more injuries from the outdoor lifestyle as well as the occasional violence.
This service aimed to deliver health service to the local aboriginals. It seems somewhat missing the point when majority of the patients who don’t necessarily need physiotherapy. There is probably nothing I can do about this situation. If there is an appropriate campaign to increase awareness of free health services in the rural aboriginals, It would greatly benefit the locals to promote physiotherapy.
During my half day there, I do an exercises class with the elderly and then physiotherapy for outpatients. On my first day there, I had total of 3 patients, and two of them are aboriginal descent. As we were driving back to Geraldton, my supervisor told me that I was very lucky to have two aboriginal patients in one day. He expressed that there are few aboriginal patients who come for physiotherapy treatment. Although the whole idea of driving to this town is to provide free physiotherapy treatment for the whole community which is mostly made up of aboriginals, many of them are not aware of the service available. In other cases, the limitation seemed normal to them to just endure it. For this reason, most of patients who come for outpatient appointment are either teachers from the school or the staff from the community health centre. When he just started, he had very little patients, some days having only 1-2 patients. Up to this point, due to limited staff from the health centre and community he is keeping some patients who could have been discharged with HEP if the clinic’s busier.
Reflecting on what he said, I realized that my second aboriginal patient was referred by doctor to see a physiotherapist. After her treatment, her sister who accompanied actually asked if she can have an appointment too for her own injury. As a rural community, many of aboriginals have more injuries from the outdoor lifestyle as well as the occasional violence.
This service aimed to deliver health service to the local aboriginals. It seems somewhat missing the point when majority of the patients who don’t necessarily need physiotherapy. There is probably nothing I can do about this situation. If there is an appropriate campaign to increase awareness of free health services in the rural aboriginals, It would greatly benefit the locals to promote physiotherapy.
Monday, November 3, 2008
Praise
Hi
Im on my community placement at the moment which is going pretty well. I've already had a lot of feedback so far because of the large amount of supervisors that i have.
The feedback has all been positive or constructive criticism which has been good.
However, i had an interesting situation last week where a supervisor said that she was really pleased with how i had conducted the class and she said she could "learn a lot from the way i communicate with older patients". I was glad to receive good feedback but i didnt take too much notice of it until later on that night.
I then started thinking thats its not often that a supervisor ever admits that they could learn from a student. I also thought that it was really refreshing to hear an experienced physiotherapist confess to a lowly student that they could in fact learn from them. I believe every student in our year has something to offer and something to teach even experienced physiotherapists. I just wish that everyone would hear this kind of feedback a little more than once a year.
I think its important to recognise that although we are always learning we may also be able to be teaching other people things while were learning from them.
Has anyone had a similar situation? Do people agree with what ive said?
Im on my community placement at the moment which is going pretty well. I've already had a lot of feedback so far because of the large amount of supervisors that i have.
The feedback has all been positive or constructive criticism which has been good.
However, i had an interesting situation last week where a supervisor said that she was really pleased with how i had conducted the class and she said she could "learn a lot from the way i communicate with older patients". I was glad to receive good feedback but i didnt take too much notice of it until later on that night.
I then started thinking thats its not often that a supervisor ever admits that they could learn from a student. I also thought that it was really refreshing to hear an experienced physiotherapist confess to a lowly student that they could in fact learn from them. I believe every student in our year has something to offer and something to teach even experienced physiotherapists. I just wish that everyone would hear this kind of feedback a little more than once a year.
I think its important to recognise that although we are always learning we may also be able to be teaching other people things while were learning from them.
Has anyone had a similar situation? Do people agree with what ive said?
Sunday, November 2, 2008
Dobbed On
I was going to post this situation as a comment to Yang’s “Embarrassment” as the patient situation is quite similar – however this situation sparked some other issues which I thought were worth a blog.
On a general surgery placement I was treating an elderly woman following abdominal surgery. The first time I stood her following removal of her IDC she immediately said she needed to go to the toilet, and within seconds started losing the contents of her bladder. I was with my supervisor at the time and we noted that it was quite a large volume of urine that was expelled. The mess was cleaned up and we didn’t take too much notice of the situation the first time. However, when we saw her on the 2nd day, before getting her up we asked if she needed to go to the toilet to which she said no. However as soon as she stood she again felt the sudden urge to urinate and lost the contents of her bladder – again another large volume. Each time this happened the patient then became quite distressed and refused to ambulate. We realised we needed to do something about it.
I discussed the situation with my supervisor and together decided the best solution at this stage was “timed toileting” and a bladder chart with nursing staff to ensure the patient voids 2 hourly and that volumes of fluid consumed and expelled were measured so that the toilet timing could be altered accordingly. We discussed with the nurse on that shift about starting the 2 hourly voids that day, and documenting this in the nursing care plan.
The next day we again asked if she needed to go to the toilet and again she replied no. However on standing there was a repeat of the previous days episode. We asked the nurse on this shift if the change was documented in the nursing care plan. She said it was not documented and she didn’t know anything about it (despite the fact that we had documented in the physio “plan” in her notes). We requested that she start timed toileting and document in the nursing care plan.
The change was still not documented in the care plan. By this stage we were very concerned about the patient over stretching their bladder and not ambulating as she was too distressed by the episodes of incontinence. We proceeded to discuss the situation with the nursing co-ordinator who promptly updated the nursing care plan and asked for the names of the two nurses who had not done it previously as she would ensure they had a “good talking to”.
I felt slightly bad for the nurses who may have gotten into trouble over the situation, after we effectively “dobbed on them” to the nursing co-ordinator. However I feel that going above their heads to the co-ordinator was the right thing to do for the patients sake. Despite the fact that there were then a few dagger eyes displayed by one of the nurses, after the timed toileting started the patient was up and ambulating and I’d gladly dob on them again if I had to.
On a general surgery placement I was treating an elderly woman following abdominal surgery. The first time I stood her following removal of her IDC she immediately said she needed to go to the toilet, and within seconds started losing the contents of her bladder. I was with my supervisor at the time and we noted that it was quite a large volume of urine that was expelled. The mess was cleaned up and we didn’t take too much notice of the situation the first time. However, when we saw her on the 2nd day, before getting her up we asked if she needed to go to the toilet to which she said no. However as soon as she stood she again felt the sudden urge to urinate and lost the contents of her bladder – again another large volume. Each time this happened the patient then became quite distressed and refused to ambulate. We realised we needed to do something about it.
I discussed the situation with my supervisor and together decided the best solution at this stage was “timed toileting” and a bladder chart with nursing staff to ensure the patient voids 2 hourly and that volumes of fluid consumed and expelled were measured so that the toilet timing could be altered accordingly. We discussed with the nurse on that shift about starting the 2 hourly voids that day, and documenting this in the nursing care plan.
The next day we again asked if she needed to go to the toilet and again she replied no. However on standing there was a repeat of the previous days episode. We asked the nurse on this shift if the change was documented in the nursing care plan. She said it was not documented and she didn’t know anything about it (despite the fact that we had documented in the physio “plan” in her notes). We requested that she start timed toileting and document in the nursing care plan.
The change was still not documented in the care plan. By this stage we were very concerned about the patient over stretching their bladder and not ambulating as she was too distressed by the episodes of incontinence. We proceeded to discuss the situation with the nursing co-ordinator who promptly updated the nursing care plan and asked for the names of the two nurses who had not done it previously as she would ensure they had a “good talking to”.
I felt slightly bad for the nurses who may have gotten into trouble over the situation, after we effectively “dobbed on them” to the nursing co-ordinator. However I feel that going above their heads to the co-ordinator was the right thing to do for the patients sake. Despite the fact that there were then a few dagger eyes displayed by one of the nurses, after the timed toileting started the patient was up and ambulating and I’d gladly dob on them again if I had to.
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