Continence and continence pads

sorry for the late post, I had some "cookie" problem with this site :S

This happened while I was working as a physio assistant last year. I was working in a tertiary hospital rehabilitation ward. The work involved mainly supervise and assisting patients doing exercises and ambulation. One of my patients there was about 80 years old asian lady. She was able to speak and understand English however as it’s not her first language, she wasn’t too fluent and had limited vocabulary. She has no children and her closest relatives are her sister and her family.
She was in the rehab ward, however she’s waiting for available beds at a nursing home (or something similar). Therefore her daily exercise was strengthening exercise and ambulation for purpose of maintenance. She needs minimal assistance to get out of bed, standby supervision with ambulation and mostly independent with all exercises. I was able to ambulate about 40m with no rest in between. She did walk very slowly though. To me she was very shy lady and was often worried that she was causing trouble on other staff.
However, one day she was talking to me about her nights. She expressed to me that the night staff were not very friendly. She needed to go toilet a few times a night, however night staff were slow to respond to her bell. When they were unable to walk to the toilet, and instead gave her a bed pan on her bed. She was very uncomfortable with this arrangement. As a result, she could not sleep well at night. A week later, I walked in as she conversed with her doctor who suggested wearing pads at night. I was shocked to hear this. She was not urinary incontinence. She was physically able to get to toilet. I was not sure if other options had been considered such as commode in the room. As it was my last week there as a physio assistance, I did not chase this issue on. Staff on at night might have been too busy to take her to toilet, I was unable to find out why as I was not familiar with the ward and ward staff. There may well be other issues that I’m not aware of. Nontheless, wearing pads for non-incontinent patients would decrease their dignity and self esteem, and at the same time it would increase the possibilities of having urinary infections.
Now with more experience in the hospital setting, I would have to find out the reason that night staff were unable to walk this patient to toilet and encourage them to ambulate patients more frequently. If there is issue with time constraints, other options such as commodes should be considered before using bed pans or pads.
Has anyone had similar experience as a physio? What other approaches are possible apart from bed commodes that’s time efficient?

Calm down!

I am currently on my musculoskeletal outpatient placement and am seeing a patient for a shoulder problem. She presented to clinic 10 days following a fall onto an outstretched hand. After a subjective assessment it was determined that the severity and irritability of her condition was very mild and so a full objective examination was indicated, with minimal caution required.

Objective examination began with AROM of the shoulder joint. The patient had demonstrated full and pain free shoulder abduction, flexion, external rotation and extension, but experienced extreme pain when returning from extension to neutral. Her pain did not settle for the remainder of the session and further accurate examination was difficult. With help from my supervisor we proposed a diagnosis of glenoid labrum tear (SLAP lesion) and decided to tape to support the shoulder joint for one week to allow the condition to settle before re-assessing.

When the patient returned for taping 3 days later she expressed that the symptoms had decreased significantly and was more than happy to have the tape reapplied for a further few days.

Upon return to the clinic for further assessment she once again noted a significant improvement in symptoms, with only mild pain performing repetitive movements (eg washing dishes or dusting) for more than 15 minutes. We therefore began further physical examination. This time, gentle palpation of her upper trapezius muscle caused severe pain and made the physical examination difficult. My supervisor decided to perform further physical assessment regardless of this – testing for impingement, instability etc. Her pain mid way through this session appeared to be extremely severe. The patient became quite teary and was very reluctant to move her shoulder. She expressed that the pain had spread to her neck and upon closer examination the cervical paravertabrals had significantly increased tone compared to the beginning of the session, with a large visible lump at the proximal attachment of her upper trapezius.

I guess you could say I freaked out. The lump honestly looked and felt like displaced bone and was very painful to palpate. My supervisor had a look but didn’t seem too concerned, and she suggested heat followed by very gentle soft tissue massage which relieved the symptoms significantly.

Afterwards my supervisor spoke to me about how my display of anxiety may have increased the patients already elevated anxiety levels. Looking back on the situation I could see how my reaction may have reinforced the patients perception of their pain being caused by a more sinister pathology.

A similar event happened the next time I saw this patient. This time I new what I had to do. I talked to the patient and explained why she was feeling the pain and that there was indeed no pathology in her neck, but rather that her muscles were trying to protect her shoulder, and in doing so were becoming very tense, causing the pain in her neck. This reassurance alone had a positive impact on her symptoms.

Though it is difficult when faced with new/ confronting situations to hide your concern I now realise that the way we react to certain things can greatly influence a patient. Next time I am faced with a patient like this I will know to take a deep breath and remain calm... for their sake and mine!

Settling for less

Whilst on orthopaedic inpatients placement I came across a situation that disappointed me regarding patient compliance. I was going to see a patient with an ankle injury who simply needed motivation to ambulate. The patient was in her sixties, overweight, had a right ankle splint, and a history of left knee pain. She was weight bearing as tolerated and previously used no walking aids prior to admission. I was informed by another physio that the patient was able to ambulate independently with elbow crutches.

After introductions, when asked to ambulate, the patient was reluctant to get out of bed. The patient was not in pain, however, simply didn’t want to come for a walk. I found this frustrating, but eventually convinced the patient to get up for a walk. What disappointed me more, was that once up, the patient refused to walk with elbow crutches and insisted that if she was to go for a walk that she would only go with a walking frame. This annoyed me as I knew she was capable of using the elbow crutches and that she didn’t use walking aids at home, yet she wouldn’t use the more appropriate aid.

Since the patient made it abundantly clear that no frame meant no walk, after trying my best to convince her to at least try the elbow crutches, I just accepted the situation and ambulated her with the frame. The patient had no problems with the frame and elbow crutches were clearly the more appropriate aid in her situation.

I later found out that since injuring her right ankle, the patient was starting to develop a fear of falling or injuring her left knee that she had a history of pain with. Because of this the patient said that they now felt as though they needed to use the frame so to prevent loosing independence if something were to happen to her left knee. I tried to explain to the patient that elbow crutches were more appropriate for her, especially if she wanted to maintain independence and return to her previous function, however, she simply purchased a frame and no elbow crutches and refused to listen to my advice. This frustrated me as I know that if the patient was to try a little harder with her rehabilitation that she would be far better off than simply settling for the easy option and expecting everything to take care of itself.

Later on in my placement I started to notice when patients would refuse treatment or make up childish excuses to get out of a treatment session. It made me start to think, and upon further reflection I realised that as long as they are properly informed, there is no point in getting frustrated and angry with a patient if they are stubborn and refuse treatment, or if they don’t push themselves for the best, simply settling for an easier option. If they know the benefits of treatment, and negative effects of poor rehabilitation, and you have tried your best to persuade them into undertaking treatment and trying their best, then they can make their own choice if they want to do it or not. And if they don’t want to, then our time is better spent on other patients who are more motivated. Through this experience now when I am in a similar situation instead of getting frustrated and angry, I accept the patient’s choice and concentrate my energy on treating patients who are willing to participate in treatment.

Taking charge

Recently, on my paediatric placement i encountered a difficult situation which involved finding the balance between being friendly and performing an effective treatment. The situation arose when i was seeing a boy on a school visit. I had seen this boy for 2 half hour sessions a week for 3 weeks and we had developed a fairly good rapport. The previous treatment sessions had run reasonably smoothly, however the boy could be difficult as he has a short attention span and can not normally tolerate more than half an hour of treatment.

The boy has a diagnosis of developmental delay and especially has difficulty with arm movements crossing the midline. Treatment has consisted of practicing various arm movements such as windmills, swimming strokes, throwing and catching. The boy is generally a nice kid but he can be a bit cheeky and its important to stay in control. For the treatment session to be effective the boy needs to understand that you're the boss and not just his friend.

On this particular day it was the boy's birthday and he was turning 9. I started off the session wishing the boy happy birthday asking him what presents he got. After this i told him we still had work to do and that we better get started. Things were going fine until the boy became frustrated trying things that he wasnt very good at and then gave up. The boy said that it was his birthday and that he shouldnt have to do anything hard on his birthday. I told him that we still needed to practice even though it was his birthday.

I was trying to be firm but i still came across as being friendly. We ended up fininshing the session after not much longer as the boy was struggling to stay focused on what we were trying to do. It was taking a lot of bargaining and convincing to get the boy to do anything so i thought it was best that we left it there for the day. After the session my supervisor said that overall it was good but that i needed to be more firm with the boy and take charge.

I thought about the session later that day and realised that even though its good to be friendly, its more important to achieve an effective treatment session. Most of the time its possible to do that in a friendly way, but occasionally you need to be cruel to be kind. Consistently getting the best out of the treatment sessions is always going to be better in the long term. Does anyone else have any ideas, or any suggestions for what you can say to stay in control and take charge?

Taking classes..

Hi everyone,

I was faced with having to lead part of a post-natal fitness class this week..It would have been fine, however, as I had not attended the class before, my Supervisor told me I was not expected to present anything - just participate : ) However, the Physio taking the class had different ideas!

Sure enough, the Supervisor got everyone's attention towards the end of the class, and told them that 'Angela will be taking you now for the rest of the session'.

I haven't been in this situation on this placement before, however, I managed to take the ladies through to the end of the class, and actually quite enjoyed it..Everything I taught them I have already been implementing on my post-natal treatment up on the wards, it is just different when you are standing up in front of a whole bunch of eager patients..

I am really glad this physio did this - although not impressed at the time..It highlighted what I did know, and also gave me the confidence in knowing that I can lead a group effectively.

If this situation presents itself in the future, I will not hesitate to take the challenge on board. We are faced with so many challenges through prac, but I know I have already improved so much from them. The situation has also highlighted that I, and we all have the knowledge, and the skills, we just need to believe that we do...

; )

Mental Illness

On my current placement I am treating a young man whom through a self harming incident attempted to, and succeeded, in emotionally hurting their family. This patient has a long history of mental illness in addition to a poor relationship with their family. As a result of their injuries they will be in hospital for a significant period of time and will suffer from the consequences of the burns for the rest of their life. Reading the patients history (ie social problems, problems with the law, drug history) prior to them being admitted to the ward I pictured the patients family as being ‘typically dysfunctional’ ie unemployed parents, drop out children, heavy drinkers etc. However when I met the family I was surprised at how ‘normal’ they were. This immediately made me realise that we should never ‘categorise’ patients before we meet them.

Keeping this in mind I went in with the physio to see the patient for the first time. As they had only just recently been extubated they were on a ‘cocktail’ of medications and were quite drowsy and ‘out of it’. That day we had no problems treating the patient and there was no hint of the behavioural problems highlighted in their notes. The next day however and for the days to come the patient was very verbal – lots of swearing etc – and did not want physio as it was painful. As with all of these types of patients we provided lots of education explaining why physio was necessary etc.

The patient was causing numerous problems for the nursing staff by being verbally aggressive, non-compliant etc. This resulted in a ‘companion’ or full time nurse being stationed in the patient’s room to prevent them from self harming again. Last week comments made by the patient became very inappropriate toward myself asking personal questions etc. At the time I just ignored these and when we had left the room my supervisor said that was the right thing to do and they explained the patient is trying to go beyond a ‘professional relationship’ so that they will be able to manipulate myself in the future. I thought about this and it made a lot of sense as I had witnessed the patient saying some horrible things to their family – again trying to hurt them emotionally. For this sort of patient I realised you have to be very distant and professional as due to their mental illness they have an altered sense of what is appropriate and lack inhibition or a sense of embarrassment/shame in what they will say to you.

Unfortunately whilst it is good to build rapport with patients as it allows them to trust you, you must adapt the way in which you relate to every patient. For patients that suffer from mental illness you must be very clear and outline in black and white what you will accept them saying during a treatment session and what is not allowed. For the above patient a behaviour contract has been written up with the aid of the clinical psychologist. Whilst this has not stopped their inappropriate behaviour there is now a structured and consistent method to deal with the situations which will hopefully improve the patient’s behaviour. I also reflected on how difficult this must be for the family, not only from the guilt they must feel, but also that no matter what sort of upbringing someone may have mental illness when uncontrolled can have devastating consequences for all. This is my first encounter with self harm and a family involved, if anyone has had any patients in a similar situation and has any strategies to deal with inappropriate language prior to a behavioural contract being drawn up please feel free to share them, as it was very awkward at times treating this patient. Thanks.

Over- Enthusiastic Clients

On my current community placement im faced with the situation where rather than being uncompliant and reluctant to engage in physiotherapy most of my clients push themselves beyond their limits. I was faced with a situation in the last week where i actually had to force my client to stop.

Community pulmonary rehab and cardio respiratory classes are incorporated into my program of classes to take in the week. Recently over the last 2 weeks one of my clients from my cardio respiratory class has shown to have an increased heart rate and lower than usual saturation at rest. On initial inspection the clients sats were 90% so i continued to ask the client if they had rushed to the class from the car, if they were not feeling the best with the cold weather this week, or if they had physically exerted themselves more than usual. The client simply responded that they were fine felt slightly breathless and were keen to begin their self paced 20 minute walk. I kept watchful eye on this client who i reiterated to "take things easy" however after several laps of walking they were quite reluctant to stop. At the eighth lap i stood in the path of this client and held out the oximeter to take a reading, the client had desaturated to 78-80% so i advised them to sit down until their saturations reached 90% before they could proceed. After 3-4 mins the client had recovered and then continued to walk of which i watched them closely and made them rest. At the end of the walk the client seemed so disapointed that they had walked 7 less laps than usual. Myself and my supervising physio then went on to explain to the client that if we had not stopped them they could have desaturated to a dangerous level and that we have to intervene to ensure the client is exercising safely. The client tried to justify that despite showing signs of breathlessness they only felt very slight breathlessness and for the rest of the class the client remained distant and very unengaged in the rest of the program.I decided to reason with the client that both themself and the physio play part in deciding what are realistic goals for them in the class and if their safety is in jeopardy it is our roles as physios to intervene and modify. After some reasoning the client seemed more comfortable with modifying their workload and actually thanked me at the end of the class for giving a full explanation as to why i wanted them to stop.

This experience made a few things more apparent to me. Often we deal with uncompliant patients who refuse our services but often we will encounter clients who will work themselves to the limit just to please us. Despite subjectively a client reports they are ok, not experiencing pain etc often just by being more observant its apparent that the client is not comfortable in which we must modify what they do. In many of my classes i have had to modify my whole class plan just by observing the majority of the class not being able to cope but still allowing those who can to continue with a progression. I was wondering if anyone had some more suggestions for strategies to deal with the over enthusiastic patient......

Appearing Confident

Hey bloggers,

A few weeks ago when I first began my current prac, I had a bit of an experience with one of the patients and my supervisor. The patient was a post surgical patient, and it was the first surgical patient that I had seen since being on the prac. Up until then it had all pretty much been COPD exacerbations, which aren’t really all that challenging. As a result I was a touch nervous. My supervisor accompanied me for assistance during treatment but asked me to lead the treatment.

Everything was going well until I sat the patient up. Being a surgical patient he had a lot of post-op attachments, including, of course, an arterial line. And, lo and behold, when he sat up the arterial line came loose. Blood began leaking out everywhere, we quickly put pressure over the area and eventually stopped the flow, however, for the rest of the treatment session I was a little bit shakey, I guess I kind of lost a bit of confidence after the arterial line came loose. After the treatment session, my supervisor informed me that my lack of confidence toward the end of the treatment session was obvious, and that I should be careful to always appear confident in front of patients.

I’ve had other experiences since then that have really reinforced that advice for me. I’ve noticed that patients will feel insecure if I am not confident in a trying situation, and will also tend to lose respect for me professionally. This then makes them less compliant within treatment sessions, and especially with exercise programs. Not only this, but it can affect their perception of the entire physiotherapy profession. Added to this, a lack of confidence will lead to other members of the health profession to lose respect for me and also lose faith in any interventions that I may implement. This may make them less compliant or willing to aid physiotherapy interventions within the scope of their involvement, making it harder for me to do what I have to do.

Ultimately I should aim to overcome any lack of confidence because I realize that if I am not confident, usually there is a legitimate reason (i.e. lack of theoretical knowledge, inadequate backround knowledge of the patient from the integrated notes, inadequate planning of treatment and of eventualities that may occur) and that these reasons need to be addressed in order for me to firstly gain confidence, but also to ultimately become a better health care professional

Home issues

I am on a paediatric placement at the moment which has been a really good experience. I feel that i've learnt a lot because of all the extra duties that we have to do in paeds that are not taught at uni. These include developing a rapport with kids, interacting with school teachers, attending home visits and interacting with parents. The paediatric setting i am working in is very 'family centred'. This means that the parents always need to be informed of what therapy their child is receiving and also how they can be involved and therefore continue the therapy at home. Its therefore important to develop a rappot with the parents aswell as you come into contact with them either through phone calls, home visits or when they're dropping their kids off at school.

This all sounds good in theory but a lot of the time it can be difficult. There are often home issues going on with the family and physiotherapy is generally not a priority at that time. The home issues are at the forefront of the family's mind and it often impacts negatively on the child. This can result in the child being withdrawn at school, demanding attention or even just missing school all together. I encountered one of these home issues recently when attending a school visit and completing an assessment on a child. I had already seen this child two weeks earlier and he had been an enthusiastic and happy kid. the second time i saw the child things were different. He was still generally cooperative but i could tell that something was wrong. I asked the boy how school was going and he told me that he hadn't been to school for a few days. He then said that his parents had split up and then got back together within the last few days. I was a bit suprised how open the boy was with this information and i wasnt quite sure what to say. I responded with "oh ok" and then my supervisor said "thats no good" to the boy. I felt sorry for the boy but i wasnt sure how to comfort him because he didnt seem that upset about the situation. We moved on and the rest of the assessment went fine

I was thinking about the situation all through the assessment and when we got in the car to leave the school i asked my supervisor if i could have responded better. She said i didnt say anything wrong but maybe saying something else to comfort the boy might have been good. I explained to my supervisor that i think its difficult to know what to say because everyone deals with hard situations differently. I also think there is a big difference between how adults deal with something and how kids deal with something.

I think next time i'll say something else like "are you ok with the situation" or "if you need anyone talk to then you can talk to me" to help comfort the person. Does anyone have any other suggestions of what i could i say in this situation or has anyone had any similar situations?

Verbal aggression

My current placement is my third placement, and it is also the first one that I encountered this issue. My current placement is neurology, most of my patients suffered from stroke.
Most of my patients are very nice and fairly easy to build rapport with. However, it is not uncommon for some of the patients to get frustrated, depressed or even upset during treatment.
One of my patients is in her 50s, she had a dense right MCA about one year ago. She is able to ambulate with standby assistance with a walking stick. She has inattention to her L side. She has minimal if any recovery of her L hand. From the supervisor, notes from previous student, all stated that she didn’t cope with the fact she had a stroke very well and have unrealistic goals etc. So I had the impression that she’s hard to get along with and wouldn’t be very cooperative with treatment.

The first a couple session didn’t go too well as she was worried I won’t be able to catch her if she falls. Therefore she was extremely reluctant to shift weight onto the weak leg. However in the last two weeks she had been fairly pleasant, cooperative and humorous at times and has more confidence in herself and me. She is a heavy smoker as well. Each time she comes for treatment, there’s always a smell of smoke, which I didn’t like but I didn’t say anything. At the last treatment, while I was taking her down to the gym, she complained that she hadn’t had a cigarette for a few hours and she wasn’t in a good mood. So I tried to comfort her a little bit. During the treatment, she was still cooperative. However, with my repeated instructions, she became a bit agitated that she wasn’t able to do perfectly as asked, and I tried to encouraging her, saying to her her walking has improved from the first time I seen her. Soon after she started to use more aggresive words in her sentences like bloody. She wasn’t using it against anyone, just letting her frustration out about her slow recovery. She said it in a pretty loud voice. All outpatients receive treatment in the gym with no curtain or anything to separate; I’m not sure how many other patients heard that if there’s any (as everyone’s chatting around). As I have never in this situation, I wasn’t sure what to do yet. Then she said the f-word and before I could react to it, my supervisor came around and lightly asked her if she’s in a bad mood. She replied that she wasn’t feeling well because of lack of smoke. However she apologized, and stopped using those words. So in hindsight, when she started to be verbally aggressive, I should have calmed her down a little bit, or even reminder her that there are other patients in the gym receiving treatment. If my supervisor didn’t come out and I didn’t do anything, the verbal aggression may be offending other people in the gym. I guess the mortal of the story is to be more aware of patient’s mood and psychological condition and take appropriate action as early as possible.
Anyone else had similar experiences? And any other suggestions if patients start to be verbally aggressive?

Feedback to Patients

My musculoskeletal outpatients placement was my first prac for this year and during that placement I discovered a skill that I was not very good at. My tutor brought to my attention that during objective assessment of an ongoing patient I would simply do the assessment and write my findings into the notes without saying anything about the objective findings to the patient.

A situation occurred where a patient was limited with their range of motion into dorsiflexion and when I saw them a week after treatment, on reassessment they had gained somewhere between 5-10 degrees (I can’t recall the exact amount) of dorsiflexion. I simply just noted this in the notes and carried on with the session. My tutor was watching over me and mentioned afterwards that this was a great improvement in range and I was not giving the patient any feedback during objective assessment.

I think I am reasonably good at giving feedback whilst instructing a patient how to do an exercise or assessment correctly, however, I realised that I wasn’t really giving enough feedback regarding the results of objective assessments. And ultimately, a patient is often likely to be more concerned with whether or not what they are doing each week is having a positive effect, rather than if they are doing it the right way. This is also beneficial in compliance with HEP, as a patient is more likely to do their exercises if they are told that they are making a difference. I think I give feedback during subjective reassessment fairly well, as it is often unconsciously brought up when asking patients questions such as “is your pain the same, better, or worse?”, however I hadn’t realised that I wasn’t doing it enough for objective measures. My tutor mentioned that I give good feedback during objective re-assessment after a treatment session, but that it is also important to give feedback to the patient at the beginning of the session to reassure them that your treatment and their HEP is beneficial.

I made a point of telling a patient if they had any objective improvements at the beginning of each session for the rest of my placement. My tutor mentioned I had improved well in this matter and I also noticed that by mentioning if a patient had for example improved their ROM, that they were more compliant throughout the rest of the session and also with their HEP until I saw them next. I now approach similar situations with more effective communication regarding this feedback. My current placement is orthopaedic inpatients, and I have noticed that I am now communicating this feedback automatically with my patients. Through this experience I will now approach this situation in the future with greater care for the patient and for appropriate feedback to them, and hopefully this may also apply to other students reading.

Amazing experience : )

Hi fellow Bloggers,

I am currently in Women's Health, and fortunately have had the opportunity to see a Caesarean Section birth. I was extremely apprehensive in the hours before the operation, however, it was definitely something I wanted to see.
It is quite a brutal procedure really, and the strangest thing I found was that on one side of the curtain the patient is fully awake, but is completely oblivious to the deep incisions, and trauma that her body is enduring on the other side.
What is important to understand, for people who aren't interested in Women's Health, is the amount of tissue and muscle that must be cut, before the baby is expelled. In addition to this, the epidural insertion is quite a procedure in itself. Often the pain described by women that I have seen post-natally that comes from the suturing of the abdominal incision is greater than the pain experienced by natural, vaginal deliveries. (Post-natally of course!).
The entire caesarian process took a lot longer than I initially anticipated, and was very different to what I had pictured it to be. The majority of the time was spent on suturing all the different layers of muscle, and other tissue back together (It was half-way through this process that the excitement wore off and I needed to leave the room for fear of passing out!).
I have learnt from this experience how best to relate to post CS patients in a more intimate way as I know the extent of the surgery they have recently endured. When patient's complain of pain over their incision site, as well as pain in their back where the epidural was inserted, I can certainly understand why. It brought home the importance of the education I have been giving up on the ward, in relation to the simple procedures like getting in and out of bed in the correct manner to avoid placing strain over the incision site. Additional education such as avoiding lifting anything heavier than the patient's baby, avoiding heavy housework like vacuuming, avoiding heavy exercise or walking uphill, and even avoiding driving for the first 6 - 12/52 following the CS becomes so important.
The experience has definitely assisted me in being able to deliver better Physiotherapy treatment to this patient group, in a post-natal setting, not only for the remainder of this placement, but also for the future.

Ange.

Feedback...feedback and more feedback

Half of the joy of being a student is getting feedback from our supervising physiotherapists so inevitably we can better our performance and for the future make ourselves better clinicians. On my community placement you visit several venues to take classes which are specialised depending on the diagnoses of the cliental and at each venue a different physiotherapist acts as your supervisor. So in a week you are assessed by several physiotherapists whom all give you feedback. In a sense this can be quite advantageous as each physio seems to pick up a different strength and weakness in your performance and give you confidence in your abilities and suggestions for improvement, however when the feedback you receive conflicts itself it isvery confusing in establishing areas for improvement. This became particularly tough for me last week.
In my week i take 3 abilities classes at different venues with different physiotherapists. All of the clients whom are prescribed this program present with very similar diagnoses; in summary these clients required exercise which focuses on balance and retraining functional tasks also incorporating strength training and aerobic exercises. As last week was my mid placement assessment every physio had a discussion with me about my performance. By mid week i was particularly confident in myself as all physios really liked my class plans and the feedback i had received was fairly consistent, my curtin tutor included. So i decided to keep the same class plan i had maintained in my first 2 abilities classes for my third abilites class which was to be on friday morning.
After teaching this class i felt particularly confident as the two physios who had watched me in the week both liked my class plan and really liked how the exercises precription was very appropriate to the population i was dealing with. However when speaking to my friday supervisor all that positive feedback i had received prior seemed to have went down the gurgler. My friday supervisor really did not like my class plan and thought it lacked creativity (which i was told was my strong point) and did not focus on the client's problems. She felt i did not show as much personality in the class and that after seeing all of my preparation she felt a bit let down.
I really could not understand this...i had used this class plan twice and both physios prior had loved it... why was this physio giving me a hard time....I was quite frustrated because how was i to make sense of this feedback to improve?
I think this situation brings to light the importance of evaluating our performance on a more global scale than isolating how we treated someone, or how we performed to one separate occasion. I think what i learnt over the last week about evaluating my own performance was to pay more close attention to consistent feedback than feedback from one separate occasion. I think this can be applicable to any prac...in 4/5 weeks you receive lots and lots of feedback and to try better every single attribute just leaves you chasing your own tail and losing sight on a global scale of what can be improved and what "weaknesses" can be bettered with the more clinical experience you have. A culmination of so many external factors can contribute to why you did not perform your best on the day.The next time i take this class rather than completely renovating my class plan i have collaborated feedback from all my supervisors and picked three things i want to show i have imrpoved on... Has anyone else had a confliction in feedback from supervising physios that effected your own self evaluation....and if so what did you do to gain a fuller picture of your abilities? Rach

Last minute changes

Originally my 3rd placement was meant to be in Perth, however it got cancelled due to unforeseen circumstances (supervisors going on holidays). I was informed of this midway through my 2nd placement. It was a bit annoying not knowing where i was going next but i could understand that there is nothing the uni can do when placements are cancelled. At the end of my 2nd placement i was told that my 3rd placement would be in Mandurah and Rockingham.
I wasnt looking forward to all the travel but as the placement was in the physio field i had wanted i didnt mind too much. I was also told i had an induction for the placement but i wasnt informed at what time.

It was the week off the next week and i went to Kalbarri on a holiday that had been planned for 3 months. Unfortunately a lot of the holiday was spent emailing a few different people as i was trying to find out when my induction was and every time i emailed one person they told me i needed to email someone else. Eventually i found out that my induction was to start at 9am on the friday and that it was compulsory. This was a problem for me as i had arranged to drive back on the friday and therefore i wouldnt be back until late friday arvo. I was also going to be travelling with someone so unfortunately it wasnt just me that the sudden change of plans was going to affect.

I found out a few numbers of people i could call to let them know my situation as i thought once i explained myself to someone at the facility they would understand and i wouldnt have to cut short my holiday. I also had a feeling that the orientation would be fairly irrelevant to me so it seemed a shame to have to come back early for it. I spoke to a few people at the facility and after failing to politely reason with them i accepted the decision and drove back thursday. Unfortunately the orientation was a waste of time and i was really annoyed that my holiday had been shortened because of it.

I got over it fairly quickly and I have really enjoyed my placement so far. The only reason i am talking about it is because the issue was raised with me by my supervisor at my mid placement assessment. My feedback was generally really positive but my supervisor said she had to mention the fact that me being reluctant to drive back early for orientation gave a bad first impression and showed a poor attitude. She said it wouldnt be written on my feedback form because what she had seen of me had been good, but she felt she had to mention the fact that trying to get out of orientation was a bad start. I explained the whole situation to her and although she could see my side of it, she still stood by what she had said.

I felt that i had been unfairly treated because even though i didnt think i had done much wrong, i had given a bad first impression. I understand that uni is my first priority and it annoyed me that because of this situation it was made to look like i wasnt entirely committed to uni. I didnt think it was fair to be told that we had a week off and then for that to be interfered with by an unnecessary orientation.

I was wondering if anyone had any ideas of how i could have handled this situation better? Was i in the wrong, or was it more a case of unfortunate circumstances?

Personality Issues

I am currently treating a patient whom sustained FT burns to their UL, back and lateral aspect on their trunk. As the patient had a number of risk factors including obesity and diabetes they had extensive surgery 1/7 after being admitted to debride the dead tissue and have SSG’s over a substantial area of the burn. Following surgery the patient was admitted to ICU for a period of time as they had not responded well to the operation. When the patient returned to the ward they were given the all clear to begin UL exercises and ambulation ASAP (as their health was deteriorating rapidly from being in ICU and bed rest). Unfortunately the patient was not compliant with physiotherapy. Whenever the physiotherapist and I went in to treat the patient they constantly asked for us to come back later ‘at 4 o’clock’ and ‘I’ll be alright’. After some education of the importance of moving etc the patient would comply to some treatment. As the week progressed it became apparent that the patient was not moving their arm at all when we weren’t in their room standing over them and watching them do their exercises. This lead to the UL becoming v swollen and more painful – limiting their ability to regain function.

The physiotherapist and I spoke to the nursing staff and they mentioned that the patient was quite confused (they were pulling out their IDC and NGT every single night) and would not do anything for them self. In addition to being confused the nursing staff suspected that due to the patients background and culture they had not cared for them self before they were injured – also apparent with their health. I reflected on this and realised that it was going to be difficult to engage this patient in their treatment due to their personality and background. I thought of a few ways to overcome this including more education, speaking with the family, taping exercises to their wall as a constant reminder etc. A number of physios on the ward were involved in treating this patient at different times, and due to good communication everyone knew the patients history and tried to be consistent with their education and exercises. No matter whom was in the room with the patient treating them the patient constantly requested a later Rx session and stated ‘I’ll be alright’. Unfortunately due to the nature of their burn and the associated risk factors they had this patient was not going to be alright.

Following the ward round on Monday the patients UL and now LL was significantly more swollen than the previous Friday. It was apparent that even with week end physio the patient had not moved this UL at all and still appeared to be confused and unmotivated. I found this frustrating as by knowing the long term implications of this sort of injury if they continued to play a passive role in their rehabilitation it was unlikely they would use this UL again. For this sort of injury 2x daily physiotherapy will not prevent the loss of function – thus even by ensuring the patient does their exercises at least 2x a day it will not be enough. In addition if the patient is non-compliant during the sessions as well then they are almost guaranteed to lose some degree of function. This has reinforced my belief that sometimes all we can do as therapists is place the tools in the patient’s hands. We can ensure they do their exercises properly with us and provide them with all the education and resources they may need. What we can’t do is ensure they are doing their stretches etc every hour, and making lifestyle changes to optimise the healing process. Unfortunately as with the above patient factors such as culture, personality etc can work against us, and it may be difficult to treat the patient effectively. For the above patient (as their confusion is declining)what I am hoping is that with 2x daily physio teamed with repetitive ongoing education (in particular with the family present) they may begin to take some responsibility and ownership in their rehabilitation to try and first regain their lost function – and then maintain it.

Facebook?

In orientation to my paediatric placement my supervisor had brought to my attention the fact that some of the patients I may come across, would be quite close to my age, and to be careful with personal boundaries.

On this paediatric placement I was treating a patient who was practically a young adult. He had been admitted to the facility sometime before I began there, and remained an inpatient for my entire placement. I treated him twice a day for up to 2 hours each session, practically everyday whilst I was there and, as could be expected, we became quite close.

By the final week of my placement I began to realise how much we had influenced each other. In terms of his physical progress he had come so far since the first time I saw him as a result of the rehabilitation we had been performing. For me, especially being on my first placement for Y4, it was really great to see that physiotherapy can be really effective and make a difference and that we really can have a positive influence on the patients we deal with. I was quite sad saying goodbye to him on my last day and his family gave me a card thanking me for everything I had done for their son.

Towards the end of the placement he asked if I was on “Facebook” and suggested that we find each other, so that I would be able to monitor his progress. I didn’t know what to say. I knew that he meant it purely for the reason he had stated and nothing else, and I’d love to see how he is going with his rehab now, but I wasn’t sure if it was appropriate. I tried to avoid the situation stating that I did have Facebook but that he’d have to find me, knowing that I could decline if necessary.

Being a “people person” is a major part of why I chose to pursue a career in physiotherapy. I am and will always be a firm believer in establishing rapport/ relationships (with boundaries – obviously) with my patients as I feel it facilitates communication and an “open environment” whereby the patient feels free to share their problems with you, no matter how personal they may be. But where do you draw the line? What do I do if he does find me on Facebook?

visitors

Recently I have been on a placement working on an inpatient ward at a hospital. The patients are of course allowed visitors during working hours, and, as a result I find myself often walking in to a ward room filled with the patients family and friends. Im sure everyone has been through this. Sometimes it can be very hard to perform a treatment when there are friends and family members present. Most often, family members realize that it would be better if they went for a walk or something, and are pretty good about making themselves scarce, although occasionally this is not the case. Some family members will actually try and participate in the treatment session, often when they are not needed or wanted. It seems to me to be a bit of a grey area as to what we are to do in these situations.
Sometimes visitors have come a long way and really put themselves out to come and see the patient. Sometimes they only have a small amount of time to see the patient before they have to go. And of course, the patient usually is very eager to spend time with any visitors. Patients can often get quite depressed in hospital and therefore the time they spend with their visitors can mean a lot to them. For these reasons I can sympathise with patients and the visitors wanting some time alone.
On the other hand, we have a job to do, and a caseload. Our treatments can be extremely important to the patients’ recovery and strongly affect their length of stay at the hospital. This really is the reason that they are in hospital- so they can receive professional health care. So this is the dilemma.
Different physios seem to have different opinions on this. Some will ask the visitors to leave outright (though politely). Others will allow visitors to participate in a treatment session even if they are not needed, and are even impeding the treatment. I wanted to ask everyone what their opinions and experiences are with this issue, and please give me some suggestions, if you have any, for the future.
Thanks, posted by simon

Social Status?

Hi,

I would like to ask an opinion about an incident that comes to mind regarding 'communication'. It was on my first placement, and I was asked to do a full subjective report on an elderly lady who had a fractured NOF. In liasing with the team earlier in the day, there was confusion as to the social status of this particular patient. Determining this information from any patient was critical in determining where to head for discharge (eg. home or LDU etc..).
So, when it came time for me to see this particular patient, I had this in mind. I was also told this patient was quite temperamental, and had upset quite a few nurses, but I thought I could handle that!
I made my way into her room, and it was quite obvious from her expression that she wasn't impressed with my cheerful disposition. I proceeded to ask the usual subjective questions, and was finding it quite difficult to build a fair rapport with this lady. I turned my attention to flowers that were on her bedside table, and after I had commented on them, I asked if they were from a friend. she replied with "Yes, I have heaps of friends thankyou." I then stayed on the same line of the conversation, and asked if she was married, or had been married in the past. She took great offence to this question, and commented that I was being very nosy. She was not compliant from then on with any of my questioning, and was not willing to come for a walk with me, or do any work in the PT gym. I was a little disappointed after I left her room, that my questioning had stirred her up, and I had not been able to complete my assessment, or do any treatment for her that day.
Has anybody else been in a similar situation, and not known how to deal with asking more personal questions relating to social status?Or does anybody have any tips on how I could have handled the situation better, or asked in a more tactful way?
I am aware that on gerentology placements, there are a lot of co-morbidities going on, but what do people think?
Ange.

Did I put my foot in it?

Hi everyone,

I thought I would comment on a situation I encountered on my last placement. It was on a ortho-gerentology rehab ward, in which daily fitness classes were held for selected patients. These patients were allocated every morning in the PT meeting, and the groups were run primarily by the wards PTA.
One of the other PT's wanted one of her patients, diagnosed with Parkinson's Disease, to participate in the group. When the PTA heard of this, he was disgusted, and demanded that the patient be removed from the group, or else he would not be a part of it, and that "The Physios's would have to run it themselves." I didn't really know what to make of this comment, thought it was a little uncalled for, and continued with the daily caseload.
When it came time to bring all the patient's into the training room ready for the group, I walked this patient to the group, with his PT. When we approached the room, the PTA came out, stood in front of us, and demanded that we take the patient back to his room, where the PT calmy replied that she wanted the patient to be involved in the class. The PTA then proceeded to comment further, to "take him back as he had walked far enough", and that "he does not want demented patients' in his group", or else I would have to run the group myself.
Eventually, the patient participated in the class, as the PT insisted, and I sat in the group to observe and help out. I was really disgusted and upset by what the PTA had said, particularly as it was directly in front of the patient, and very demeaning for him.
After the class, I felt I had to comment to the PT's on my opinion regarding the PTA's actions, and the fact the the patient had probably, honestly been the best performer in the group!
I noticed after this incident, that although the patient was encouraged to attend the group each day, he refused to attend, preferring to sit in his room.
I guess my question is, should I have gone higher with this, and got a formal complaint made for the PTA, or did I handle it best by just concurring with my supervisor's? Is there more that other people would have done in this situation, or perhaps does anybody agree that he wasn't a suitable particpant and that the PT got it wrong? Has anyone had a similar experience?
What I took away from this was that it is no justification for demeaning patients in this way, but it does happen. It has brought home the importance of respecting patient's rights and dignity, no matter what their diagnosis. It is our responsibilty as health professionals to monitor what goes on, and to act accordingly, and in hindsight, I should have spoken up even more, and made sure that the PTA knew that his behaviour was unacceptable.
In the future, I would have handled the situation in a similar way, however, if I was a qualified Physio, I would definitely have spoken directly to the PTA following the incident to air my thoughts, and gone to the Head of the Department to forward a formal complaint.

Ange.

Physio or Social Worker?

On my paediatric placement I was treating a child with complex social issues regarding parental custody, and both mother and father had strict, limited visitation rights. I was told that the patient would not comply with/ participate in physiotherapy when either of the parents were present. However on this particular afternoon I had no choice but to treat the patient whilst the parents were there, as the rest of my patients were occupied with other tests/ treatment sessions.

I soon discovered that what I was told was quite far from the truth on this occasion. Mum got very involved in the treatment session (it was a cardio placement so treatment involved bubble PEP and other bubble blowing/ popping games) and provided lots of encouragement for her child to participate. I’d never had a more productive treatment session, or had such good compliance from this patient!

I felt that it was wrong that the parents only had limited visitation rights, when all I had seen was that they were great parents. Other members of staff (including physiotherapists, nursing staff and dieticians) seemed to have only negative things to say about the parents which appeared to be based mostly on “hear-say”.

I knew that previous events were the reason for DCD being involved, and for the limited visitation, but I wanted to tell someone that they’d got it all wrong, but I felt it was beyond my “authority” to question it. Also, I knew that things wouldn’t change based on one good session with the parents present. So I documented in the notes that the parents were present and “compliance +++++” and that the patient appeared to be in extremely good spirits on that particular occasion. I also made a point to try and treat the patient whilst the parents were there so I could see if it was a once off – which it wasn’t. However, when I subtly mentioned how fantastic the child was whilst the parents were visiting, staff seemed to be shocked, as if it wasn’t possible.

The patient was in hospital for almost three weeks and despite what I had seen and documented nothing was changed.

I feel I did everything within my power to communicate what I was seeing without crossing the line, or treading on toes, but do you think I should have taken further action? I know we’re not social workers but at what point does it become our responsibility to cross that line? I can’t comment on the history of this case and I’m sure there were reasons for the rules in place but I am of the understanding that people change and deserve the right for a second chance.

Any thoughts…suggestions?

Patient compliance with home exercise program

My first placement was an outpatient musculoskeletal placement. Due to the nature of this placement, the treatment consistent mostly of hand on treatment and home exercise program to retain or even improve the effect gained from hands on treatment.
One of my patients has PFJ problem, and has been having treatment from this clinic for over one year. She is a amateur dancer and a part time dance instructor, she dances for upto a few hours a night, and on average 3 nights a week. The longest dance session I recalled was 5 hours. She often experiences pain on her right knee which is the leg she spins on, usually after 2 hours of dances. The pain level was averaging 5/10. The pain persists for the whole night until the morning after. On objective assessment, she has mod tightness in medial glide of her right patella, slight reduced muscle bulk of VMO on the right, reduced muscle length of TFL and calf muscles bilaterally, reduced muscle strength of glut med, and also flat and inverted feet
From handover summary, she has a home exercise program which includes mini squats, calf stretches, TFL stretch and clam shell exercises.

My treatment with her included STM of TFL and calves, med glides of R patella, and strengthening exercise for glut med and mini squats. And I updated the HEP and give her the exact reps and sets to do a day.
There are some improvements after each treatment, over a few sessions, her med glides were only slightly less than the other side. However her TFL and calves length were only slightly improved. And there’s minimal change with glut med and vmo strength. She has reported pain required longer dancing session to reproduce. From a hands on point of view she has almost plateaued.
However when I ask her about home exercise in every treatment, she always say she’s done a bit, not as much as she should. From what she said, I understand she’s only doing stretches max 3 times a week instead of 3 times a day. And every time I should educate her on how important it is to do the exercises, how it is linked to her pain experiences at dances and that she should take responsibility of her PFJ problem. I also tried to incorporate the exercises into her daily activities, include do a calf stretch on step when need to go up the stairs, do clam shell before getting up and before sleep etc. There’s no change with her motivation to do exercises. If she was a public patient, due to waiting list she could have been discharged and self manage at home.

From what I heard, there are other clients in musculoskeletal outpatients like this. Just turn up for treatment, and only expect hands on treatment to “fix” them and reluctant to do home exercises.

Anyone has patients like this? Do you have any good strategy to improve their motivation? Any input will be helpful.

Legal issues

I'm on a paediatric placement at the moment which is going pretty well. I feel that i'm learning a lot because we're doing stuff that we either didnt really do at uni or stuff that didnt seem to be a priority at uni. This includes scoliosis reviews, serial casting and full assessments of kids including gross motor skills. I also get to decide what to do with the kids in terms of treatment and as long as its working towards their long term goals and is safe then its generally ok. This therefore includes a lot of basketball, football, throwing and catching.

I havent really had any issues that have come up because everyone i work with seems quite nice and we generally work in a more relaxed environment. However, i have thought of a potential issue that i think may need to be addressed as soon as this week. This issue is about whether i should be left alone with the kids. The reason i think its important is because if any of the kids were to accuse me of anything that i didnt do, then i would want a witness there to verify my story. The witness would also need to be someone other than the kids parent as the kids parent would most likely side with their kid.

I have only been alone with a kid for short periods of time during treatment as my supervisor would sometimes duck in and out of the treatment room. This doesnt really worry me as we are at the kids school and my supervisor is there most of the time. However, my supervisor has told me that i might need to do a home visit on my own and this is of some concern to me. I have been told that even though parents are generally really happy to have a male working with their kid, they dont want their kid to be left alone with a male. I am worried that maybe, if for whatever reason the kid or parent didnt like me at a home visit, they may accuse me of doing something innapropriate to the kid. I know this is a very unlikely situation but i thought i better give it some thought in order to prevent the situation from happening.

I am going to discuss with my supervisor what the normal protocol is for students, in particular males, attending home visits to treat kids. I am also going to ask my supervisor whether i am at risk of being accused of something and how do i make sure this doesnt happen, or how do i manage the situation if it does.

Does anyone have any advice for me? What would you do if you were told you needed to treat a kid in their home on your own? Am i being too paranoid? Any suggestions would be good, especially from the guys as i think its fair to say that the accusations are more likely to be directed at a male student than a female student.

Passive Patients

During my musculoskeletal outpatients placement I encountered a ‘passive patient’. By this I mean that the patient came to physiotherapy each week, expecting the therapist to treat her passively, without her actively participating in any aspect of her rehabilitation, and expected to get better by simply the physio ‘fixing’ her problems for her. Granted, passive treatment by a physiotherapist on a patient is very much a part of musculoskeletal physiotherapy, however, it should be used in combination with other mediums of treatment that involve active participation by the patient, thus putting the onus on them for their own rehabilitation.

This patient was in her late 50’s or early 60’s and was nearly 3/12 post MVA. She had various investigations to clear her of any significant pathology, and had simply sustained soft tissue injuries to her ankle and contralateral hip. On assessment her main problems were; decreased dorsiflexion (especially functionally during gait), stiffness of TCJ into dorsiflexion, decreased calf strength and length, and poor balance, gait, and exercise tolerance. I had discussed with my supervisor the situation and we concluded that given she has no significant underlying pathology, her soft tissue injuries should be resolving at this stage, and that her treatment should involve; accessory mobilisation of TCJ, as well as predominately an exercise program to increase her strength, mobility, balance and gait. The patient would present each week with great pain, mainly in her ankle, and would say that she “couldn’t do anything today”. She would state she could only tolerate such treatment as ultrasound, and would refuse to give consent to mobilisations or participate in any active exercise.

I sufficiently explained to the patient her situation and the need for active involvement with exercises for her to get better. Throughout the few weeks I treated her she was very reluctant to do any active treatment and would constantly complain about her high level of pain. I found it difficult to believe she was in so much discomfort, however, after discussing the issue with my supervisor, she made me realise that pain is a subjective thing and people perceive pain differently, and regardless of whether or not a patient is ready to be progressed, you cannot neglect their perception of pain. We also discussed how the psychological impact of the traumatic incident may still be affecting her.

After talking with my supervisor I tried to approach treatment in an assertive way, emphasising the need for active participation, whilst still showing empathy with the patient. By communicating in a more effective way and giving plenty of education regarding her condition, I was able to get the patient to participate in exercises in the gym for a short period of time for the next few sessions that I saw her. She was still reluctant to push herself and presented with significant pain each week, but also acknowledged that she felt better after the physio sessions.

I will approach similar situations in the future knowing that just because I think a patient shouldn’t be in much pain or discomfort given their condition, doesn’t mean that they actually aren’t in any pain or discomfort. I will be more sensitive to their issues and use effective communication to provide the best option of treatment given the situation.

Has anyone else been in a similar situation where either they thought a patient’s perception of pain was ‘over the top’ given their condition, or where a patient would not actively participate in treatment, simply expecting passive therapies by the physiotherapist to ‘fix them’. If so could you please give me some advice as to how you addressed the situation?

Communication concerns

Currently I am on my community physiotherapy placement of which I conduct classes for specialised populations. I’d like to share a difficult situation I encountered in the last week with regards to supervision and communication in a group setting.

I was asked to take parts of an aqua function and balance class at a new leisure centre which had opened just over a month ago. As I had already attended one of the classes and observed the class content of the supervising physiotherapist I felt confident that I would be able to take the warm up, strengthening and flexibility components of the class. So beforehand I had a set plan of exactly how I was going to take the class and the appropriate sequence of exercises I was going to do related to the specific conditions of my clients in the class.

This task proved to be a lot more of a challenge then I had expected. Firstly maintenance repairs were being done in the pool enclosure so I had to compete against noises of drills and workmen. Three clients who had been absent last week attended the class one of which was a non swimmer so they required more individual supervision. The clients were distracted by the noise and at how hot it was, as it was a twenty six degree day and the sun reflected into the hydrotherapy pool room which felt like a sauna. To make the situation even more trying, the leisure centre had put a restriction on the space allocated in the pool for the class roping off half the pool so everyone was quite crowded. I felt really frustrated and agitated and as I began to conduct the class I found it almost impossible to project my voice, maintain the attention of my clients, keep watchful eye on my non swimming clients and modify the exercises I had chosen to accommodate for the new clients. The supervising PT could see my frustration that she took over the class for awhile giving me a chance to reflect on my experiences.

Observing the PT I noticed how well she modified all of her teaching strategies to this challenging situation; she modified exercises so they required less space, she projected her voice well by speaking slowly and using less instruction, she involved the class by asking them questions about stretching to engage their interest, provided progressions for the advanced clients and both the new clients to still be challenged and allocated me to individually supervise the non swimmers. Once I overcome my frustration and by observing this PT I was more effectively able to conduct the rest of my class plan despite the fact that it was a completely different story to what I had planned on paper. After the class my supervising therapist discussed with me how important it is to be flexible with class plans and that in a group setting it is important to not stress and just modify teaching techniques as you would modify a treatment technique on an individual client.

I think it was a good learning experience for me to be faced with a challenging environment. Usually as physiotherapy students we become accustomed to adapting and changing treatment techniques due to a challenging patient and sometimes forget that environmental factors can effect how we conduct ourselves. As a result of this experience I have become more conscious of my treatment environment; do I have enough space, equipment, how best can I instruct a client; am I competing against noise and distraction? And as a result are more flexible with my class plans allowing for these considerations.

Was wondering if anyone has taken any group sessions in any of their pracs and if so were their any environmental barriers or considerations which they had to contend with……what was your strategy to overcome these?
Rach

Difficult Patient

One of my patients was admitted to the ward following an infection of a deep partial thickness burn they sustained to their lower limb. The patient had gone to the ED following their burn however was not admitted as an inpatient. They were referred to the outpatient burns clinic which provides daily dressings (if needed), consultations with the Dr’s, physiotherapy and OT Rx. The patient did not attend the outpatient clinic the next morning as recommended, and a few days later presented to the ED once more, this time with increasing pain levels and an infection. To assist in the wound healing process the patient went to theatre and had a SSG and debridement (clearing away of all the dead tissue etc). Following their surgery they were NWB’ing for 5/7. Once this time frame was up they came to the gym twice a day where their Rx focussed upon stretches (active), mm strengthening exercises and high level balance skills. The patient’s pain was well controlled and they were very compliant for all sessions.

Following the ward round the doctor mentioned to the patient they may be D/C in 2/7 following a review of their SSG. The patient was eager to get home as due to the nature of their job they didn’t have sick leave pay, thus whilst in hospital weren’t able to earn any money. The doctor reviewed the patients SSG in 2/7 time and found a small area had not taken and had turned white. They informed the patient they would review the graft again in 2/7. Understandably the patient did not take the news very well as they had been hoping to go home that day. Following this I approached the patient to go to the gym. The patient stated that they were in a lot of pain and wasn’t able to go that day. I had looked at their chart and knew the patient had had adequate pain medication and suspected that the reason they didn’t want to go was they were disappointed they weren’t going home. I reflected on the reasons why the patient wasn’t keen to participate in physio. The major reason I thought was they had been doing everything the surgeon had asked of them – physio a major component of this –and yet the graft still hadn’t taken so what was the point. After reflecting on this I had a chat to the patient reiterating why it is important to keep exercising (as the rest of the graft wasn’t healed yet) and that by maintaining their fitness and strength they will be able to get back to work much faster. The patient then agreed to come to the gym and was compliant for the next two days.

Two days later the surgeon examined the graft and there had been no change – the rest of the graft was doing well except the small patch was now dead. The surgeon informed the patient that he should start fasting at midnight. The patient looked confused and asked why, to which the surgeon replied he needed to have surgery again and put another small SGG over the dead area. The patient looked very angry at this news and looked away from the surgeon. The surgeon then began to explain why the new SSG was needed however the patient was clearly ignoring him. The surgeon asked if the patient wanted to listen and the patient replied ‘nup’. The surgeon continued to explain why it was necessary and told the patient with the SSG it would taken approx 5 days to heal, otherwise it would take 1/12. I later went and spoke to the patient to see how they were, they informed me they were really angry and they wouldn’t be participating in physio again and there’s no point coming back to try and persuade them as their answer wouldn’t change. I left giving the patient an hour to think and then went back to again try and explain not only the importance of physio, but the reasons why the SSG is necessary – however thy refused to look at me and I left. I wrote in the notes the patient had refused physio that morning and left a note to the afternoon physiotherapist. The next day I was told by the nursing staff that the patient had refused to listen to anyone and had D/C themselves the afternoon before.

It made me realise that we can give the patients all the information/education/options and attempt to steer them towards the optimal Rx however in the end it is their own choice. We aren’t able to make the decision for them even though we know in the long run it is the best option for them. The patient above had already make a poor decision regarding their injury leading to an infection and surgery. Whilst they had not done anything wrong in the Mx of their SSG it still hadn’t taken and required further surgery – which they declined. Knowing that the chances of seeing this patient again on the ward is high due to associated pain and delayed healing of their burn is frustrating as it could have been prevented if the patient had taken our advice. However, it is ultimately up to the patient and the best we can do it attempt to guide them in the optimal direction and provide advice/education as best we can. If anyone has been in a similar situation and has any advice it would be much appreciated.

By simon

Something I’ve been encountering a lot lately, since I am now working with inpatients, is compliance with treatment. The hospital I am currently at, patients have the right to decline treatment. I mean, I guess patients in all hospitals do but at this one we have to document that we obtained consent in the notes. Anyway, I’ve realized that when you see a patient you don’t just ask them straight out “can I do a treatment with you?” because they will almost always say “no, but come back tomorrow, we’ll do it then” or “no, I really don’t feel like it now”. I’ve learned that a fair bit of persuasion and rapport building with the patient before asking for consent plays a pivotal role in getting their consent. This may involve a short chat about the weather, how did they sleep, what was their lunch like, etc. it may also involve highlighting to them the various benefits of physiotherapy intervention for them(in layman’s terms).

I’ve also learned that some patients need a lot more of this pre-treatment banter and persuasion before the question of consent is presented, to gain a positive outcome. Some patients need only the very brief “hi, how you going?” before requesting consent, whilst others I would chat with for a few minutes before asking for consent, and then I would have to persuade them by outlining the various physiological, and even psychological, benefits of the intervention, before they finally consented. From my experience I believe that most patients have got a point at which they can be persuaded to consent, if the therapist is skillful enough in building rapport and persuasion. There do seem to be some though, that will not consent whatever the therapist says.

The reason I bring all this up is that I had a patient on my cardio placement who I was supposed to see for the first time. As I approached the patient, he was shaking his head, and when I began to talk with him, he was very obvious in saying that he did not feel like treatment. I decided not to try and persuade him, I guess maybe because I was too tired to- normally I would have. It was a Friday.

When I returned to the ward on Monday, I was told that the same patient had died over the weekend. That was pretty shocking. I began to wonder- what if I had tried really hard to get him to consent to treatment? Could the treatment intervention have kept him alive? Since then, I’ve been wondering- where exactly should the line be drawn when it comes to trying to obtain patient consent? The patient that I didn’t see on that friday would have taken a lot of time and effort to be persuaded to consent, and when I already had a patient caseload that is overfull it can be hard to justify that much time, just talking, to a single patient.

I would really appreciate any input anyone has on this.