Sunday, August 31, 2008
I was faced with a situation on my cardio respiratory placement which quite upset me. I have a patient who is a barietric patient (over 120kg) and had recently had a lap band removed. During the procedure the splenic vessel was nicked (open laparotomy) and the patient lost a lot of blood. Her haemoglobin level had dropped down to 88 and as a result of this the patient had not been out of bed as she was in tremendous pain and extremely light headed. Despite all of this my patient was very eager and somewhat anxious to get out of hospital so she was very compliant with her physio, always willing to ambulate and progress the distance she had walked in the previous session. By the end of the week chest physio was no longer indicated and discharge seemed to be the likely option once all of her attachments had been removed. This one particular day i went to see this patient she voiced to me that today she was unable to do physio as there was not a gown big enough for her. I had noticed the nurses had dressed my patient in one of the smaller gowns that barely covered her. I decided that that was not the case and went searching through linen cupboards, called the ward care assistant, and even called the large linen storage room to locate a larger gown. After 1 hour i still had no luck. I spoke to my supervisor about the matter and she was quite angry. She told me that it was the wards responsibility to have 3 barietric gowns in the linen cupboard and that if my patient was unable to receive physio as a result of this, it would require her to fill out an incident form. It wasnt until 15 mins prior to finishing 2 hours later from my inital request for linen did a gown get brought up to the ward so i quickly fit in as much treatment as i could and explained to my patient the reason for the delay. The patient seemed almost embarrassed that i had searched far and wide for a larger gown for her but was grateful for my efforts. Upon reflecting i thought that it was absolutely not acceptamble that a patient would miss out on physiotherapy which was essential for them due to the hospital being unable to accommodate for them. Has anyone been in a similar situation? What was your reaction and how did you manage the situation?
non verbal communication
Hey,
I had an interesting experience on prac this week which really made me realise how effective non verbal communication can be. My supervisor and I were asked to do an induced sputum on one of the patients on our ward. This patient was a Chinese gentlemen who spoke no english and was also a bit drowsy and confused. The sample was needed asap so we didn't have time to wait for family members or an interpreter to help us out.
When taking an induced sputum sample their is a fairly strict procedure which must be carried out and we thought it was going to be quite challenging to covey to the patient what we wanted him to do without being able to verbally tell him. Adding to this, the procedure needed to be done in a sterilised room with my supervisor and I wearing masks, gowns and gloves which would have been very intimidating for the patient.
Anyway, I was given the task of instructing the patient what to do - wash mouth out with saline solution then empty into cup, then every 5th breath with nebuliser take a deep breath for 20minutes in total, then spit sputum into cup without touching edges. In the end it turned out to be very easy through using hand gestures and demonstration conveying to the patient what we wanted to him to do and make him feel relaxed in the unusual environment.
Has anyone else had an experience on prac where they had to rely on non verbal communication?
I had an interesting experience on prac this week which really made me realise how effective non verbal communication can be. My supervisor and I were asked to do an induced sputum on one of the patients on our ward. This patient was a Chinese gentlemen who spoke no english and was also a bit drowsy and confused. The sample was needed asap so we didn't have time to wait for family members or an interpreter to help us out.
When taking an induced sputum sample their is a fairly strict procedure which must be carried out and we thought it was going to be quite challenging to covey to the patient what we wanted him to do without being able to verbally tell him. Adding to this, the procedure needed to be done in a sterilised room with my supervisor and I wearing masks, gowns and gloves which would have been very intimidating for the patient.
Anyway, I was given the task of instructing the patient what to do - wash mouth out with saline solution then empty into cup, then every 5th breath with nebuliser take a deep breath for 20minutes in total, then spit sputum into cup without touching edges. In the end it turned out to be very easy through using hand gestures and demonstration conveying to the patient what we wanted to him to do and make him feel relaxed in the unusual environment.
Has anyone else had an experience on prac where they had to rely on non verbal communication?
Thursday, August 28, 2008
Suprise talks
I'm on my rural prac at the moment which has been going well. I'm working in community physiotherapy which involves participating in and also running a wide range of exercise classes. The classes cover all different areas such as avoiding falls, exercise for people with chronic lung disease and also more high intensity exercise for older people. I've also been helping with classes for pre-primary children who have developmental delay.
Recently i was confronted with a potentially stressful situation. On my first day i was helping with a class and the supervisor who i had just met suggested that i do a talk in 2 days time. The talk was to be presented to 10-15 patients and on the topic of back care. Although i knew i had experience with presenting information on back care i was still a bit worried at the limited amount of time i had to prepare the talk. I was a also a bit surprised that the supervisor strongly suggested i do the talk without really consulting me about it.
I agreed to do the talk and acted enthusiastically about it but i was a bit worried. I prepared for the talk over the next few days and as it turned out the talk went really well. The patients were very friendly and i got them involved in the presentation which made it more interesting for them. I received good feedback for the talk and my supervisor was impressed not only with my presentation but also with my attitude.
After thinking about the situation later i was pleased with the way i handled it because even though i was taken aback by being asked to do a talk so early on i didnt show that i was stressed about it. I think its good to try and maintain a positive attitude even if you are stressed because a lot of the time things that seem stressfull end up being fine.
Has anyone had a similar experience or does anyone have any thoughts on other ways to handle stressfull situations?
Recently i was confronted with a potentially stressful situation. On my first day i was helping with a class and the supervisor who i had just met suggested that i do a talk in 2 days time. The talk was to be presented to 10-15 patients and on the topic of back care. Although i knew i had experience with presenting information on back care i was still a bit worried at the limited amount of time i had to prepare the talk. I was a also a bit surprised that the supervisor strongly suggested i do the talk without really consulting me about it.
I agreed to do the talk and acted enthusiastically about it but i was a bit worried. I prepared for the talk over the next few days and as it turned out the talk went really well. The patients were very friendly and i got them involved in the presentation which made it more interesting for them. I received good feedback for the talk and my supervisor was impressed not only with my presentation but also with my attitude.
After thinking about the situation later i was pleased with the way i handled it because even though i was taken aback by being asked to do a talk so early on i didnt show that i was stressed about it. I think its good to try and maintain a positive attitude even if you are stressed because a lot of the time things that seem stressfull end up being fine.
Has anyone had a similar experience or does anyone have any thoughts on other ways to handle stressfull situations?
Monday, August 25, 2008
Carer Issues
Recently on my cardio general surgery placement i was presented with an 85 year old gentleman who had not had any previous surgery so goals of physiotherapy have been aimed at gaining as much independant function as possible. He presented to ED post fall and reported had had four falls in four days. He is legally blind, has lung cancer, mild dementia, COPD and CRF. Initially he was admitted with a suspected hip fracture but post examination revealed no fractures. Currently doctors are querying a gastrointestinal bleed or metastasis of his cancer causing him to have low haemoglobin levels thereby explaining why he has been falling. At home he has a carer whom assists with most ADLS and ambulates independantly however needing standby assistance when in new environments.
For treatment of this gentlemen as chest physio has not been indicated my focus has been on mobility and encouraging him to be as independant as possible with bed mobility, STS, and ambulation.
On this particular occasion his carer was present during the treatment session. I thought this would be handy as a second pair of hands wouldnt go astray when trying to manage all of his attachments. Also with his carer present i could demonstrate the best ways of assisting the patient with movement as the carer had reported that her job was getting "too difficult" because this patient's condition was deteriorating and he has slowly become less mobile requiring more assistance.
Throughout the treatment session i found it very difficult to gain control of the situation. I was trying to encourage the patient to move as indepednantly as possible and then his carer would intervene grabbing hold of his arm and lifting him out of bed. I would reiterate that it was important for this patient to do as much as possible so he could be discharged home and the carer still persisted to ignore me. I decided to get this patient up for a walk and despite he was quite capable of standing independantly the carer grabbed his arm and pulled him up. To prevent the carer anymore from intervening i told the patient that his carer would direct the IV pole when going for a walk down the ward and i would just provide some manual support around his waist to direct him which direction to steer the wheeled zimmer frame. I noticed the patient was quite independant with this and only needed prompting because he is legally blind and gets uncomfortable with unknown surroundings. I then thanked the carer, wrapped up the session and went to write up his notes.
As i left his room i really started to think about how the carer's approach towards managing this patient was in fact preventing him from becoming more independant. Now top of my priority list with ths patient is to provide the carer with education on appropriate manual handling so this patient can be as independant as possible and the carer can prevent any injuries from the physical exertion of her current ways. Maybe i should have been more firm and assertive with this carer but i did not want to discourage her from participating in the treatment session and being involved in this patient's discharge plan. Any thoughts?
For treatment of this gentlemen as chest physio has not been indicated my focus has been on mobility and encouraging him to be as independant as possible with bed mobility, STS, and ambulation.
On this particular occasion his carer was present during the treatment session. I thought this would be handy as a second pair of hands wouldnt go astray when trying to manage all of his attachments. Also with his carer present i could demonstrate the best ways of assisting the patient with movement as the carer had reported that her job was getting "too difficult" because this patient's condition was deteriorating and he has slowly become less mobile requiring more assistance.
Throughout the treatment session i found it very difficult to gain control of the situation. I was trying to encourage the patient to move as indepednantly as possible and then his carer would intervene grabbing hold of his arm and lifting him out of bed. I would reiterate that it was important for this patient to do as much as possible so he could be discharged home and the carer still persisted to ignore me. I decided to get this patient up for a walk and despite he was quite capable of standing independantly the carer grabbed his arm and pulled him up. To prevent the carer anymore from intervening i told the patient that his carer would direct the IV pole when going for a walk down the ward and i would just provide some manual support around his waist to direct him which direction to steer the wheeled zimmer frame. I noticed the patient was quite independant with this and only needed prompting because he is legally blind and gets uncomfortable with unknown surroundings. I then thanked the carer, wrapped up the session and went to write up his notes.
As i left his room i really started to think about how the carer's approach towards managing this patient was in fact preventing him from becoming more independant. Now top of my priority list with ths patient is to provide the carer with education on appropriate manual handling so this patient can be as independant as possible and the carer can prevent any injuries from the physical exertion of her current ways. Maybe i should have been more firm and assertive with this carer but i did not want to discourage her from participating in the treatment session and being involved in this patient's discharge plan. Any thoughts?
Clinical Pathway
In my recent cardiopulmonary placement, I spent most of my time on the cardiothoracic ward. Patients included heart surgery patient, lung surgery and general medical patients.
For patients who underwent heart surgery, there is a pathway of their treatment, for all aspects of their medical needs and also allied health treatment. For a typical physiotherapy treatment, treatment initially includes chest review and progress mobility as appropriate. A normal recovery would indicate patient is able to sit out of bed and stand on Day1, ambulate on Day2 – Day 4 and a stair test (2 flights of stairs) as a final discharge test on Day 5. For respiratory part of recovery, treatment included SMIs or ACBT for patients with productive coughs. For most of my heart surgery patients, they have followed this recovery process. It is a lot easier with a pathway, it is a lot easier to progress their mobility. On the other hand, it is also a lot easier to just do a routine treatment, instead of targeting their particular impairment/problems, which I was sort of doing in the first two weeks of my placement.
However my clinical tutor and supervisor reminded me that though there is a pathway, we still need to identify their individual physiotherapy problems, identify their previous functional level and know especially what is normal for them and set a goal for them to discharge. This way is particularly more helpful when a patient is off pathway due to delay in their recovery process. There were a few patients who were delayed due to their medical stability and as well as pre-admission status. The pathway needs to be altered to suit their needs. For example, if they were unable to perform the stair test, and have minimum exposure to stairs, then they would still be fine to go home if they were able to do a few steps in the physio gym. There were a few patients of mine actually had to perform the steps in the gym on after Day 6 instead of the full stair test. Moreover, prioritizing their problems is important to maximise their recovery. Some of my patients were limited in ambulation. However it can be contributed by a few factors such as shortness of breath due to reduced lung volume, impair gas exchange etc, due to muscular wasting as they were delayed and deconditioned, or pain which can be a big factor if it’s poorly managed. Furthermore, patient can perform better than the pathway. Some of my patients even walked on Day1.
I have previously been to an orthopaedic inpatient setting where they also uses the pathway. I have realized that the pathway is there to assist the treatment, however we do need to see beyond the pathway and set individual plan and tailor treatment to individual patients. Thus not limiting patient’s recovery to the pathway as well as promoting fastest recovery to patient with delayed recovery.
For patients who underwent heart surgery, there is a pathway of their treatment, for all aspects of their medical needs and also allied health treatment. For a typical physiotherapy treatment, treatment initially includes chest review and progress mobility as appropriate. A normal recovery would indicate patient is able to sit out of bed and stand on Day1, ambulate on Day2 – Day 4 and a stair test (2 flights of stairs) as a final discharge test on Day 5. For respiratory part of recovery, treatment included SMIs or ACBT for patients with productive coughs. For most of my heart surgery patients, they have followed this recovery process. It is a lot easier with a pathway, it is a lot easier to progress their mobility. On the other hand, it is also a lot easier to just do a routine treatment, instead of targeting their particular impairment/problems, which I was sort of doing in the first two weeks of my placement.
However my clinical tutor and supervisor reminded me that though there is a pathway, we still need to identify their individual physiotherapy problems, identify their previous functional level and know especially what is normal for them and set a goal for them to discharge. This way is particularly more helpful when a patient is off pathway due to delay in their recovery process. There were a few patients who were delayed due to their medical stability and as well as pre-admission status. The pathway needs to be altered to suit their needs. For example, if they were unable to perform the stair test, and have minimum exposure to stairs, then they would still be fine to go home if they were able to do a few steps in the physio gym. There were a few patients of mine actually had to perform the steps in the gym on after Day 6 instead of the full stair test. Moreover, prioritizing their problems is important to maximise their recovery. Some of my patients were limited in ambulation. However it can be contributed by a few factors such as shortness of breath due to reduced lung volume, impair gas exchange etc, due to muscular wasting as they were delayed and deconditioned, or pain which can be a big factor if it’s poorly managed. Furthermore, patient can perform better than the pathway. Some of my patients even walked on Day1.
I have previously been to an orthopaedic inpatient setting where they also uses the pathway. I have realized that the pathway is there to assist the treatment, however we do need to see beyond the pathway and set individual plan and tailor treatment to individual patients. Thus not limiting patient’s recovery to the pathway as well as promoting fastest recovery to patient with delayed recovery.
Sunday, August 24, 2008
smoking cessation and lung cancer
Hi Everyone,
Thanks for your ideas :)
Alicia
Wednesday, August 20, 2008
Playgroup
Throughout my rural placement each week I attended a playgroup organised by the senior paediatric occupational therapist. Each of the families invited to join the playgroup had a child or children with a physical, neurological and/or social disability. The common feature amongst these parents (besides their children) was that each had avoided social situations such as mother’s groups, playgroups etc due to their child. The senior OT felt that these parents were missing out on an important social and support network thus decided to set the group up. The aim of this group was to create an environment where the children could play with their parents, without it being ‘therapy’ (which is what a lot of the parents did – any quality time they spent with their child was doing ‘exercises’ etc and not bonding) and also to provide a forum where the parents could talk amongst each other, swap ideas etc as all parents do in the playgroups.
It took a couple of weeks for the parents to get to know one another and start forming friendships, which is when the swapping of ideas and sharing tips began to occur. As a therapist this was great as it is exactly what we had hoped would happen, however a few problems arose which we had not foreseen. A number of the children were developmentally delayed and had been provided specialised equipment from the hospital to assist them. This equipment was provided for that child alone as it addressed their specific needs. Two of the parents at the group were talking amongst themselves close to the group of therapists about a ‘standing frame’ that one of their children had been using. The mother of the child whom it had been given to was telling the other mother that they don’t use it, but they would give it to them to try with their child (whom had a completely different pathology and thus different needs/requirements).
This provided us with a dilemma which we talked about whilst this conversation was occurring. On the one hand we didn’t want to interrupt their conversation, as it would highlight the fact we were listening in, thus undermining the whole aim of the program (that it isn’t about therapist intervention). However, on the other hand, the child whom has been provided with the equipment required it to improve their standing – thus we needed to reiterate that to their mother. In addition it’s an expensive piece of equipment belonging to the hospital and needs to be kept track of ie it doesn’t belong to that mother; therefore she does not have the authority to ‘lend it out’. Whilst it was great the mothers were talking and swapping ideas and tactics that had worked for them it wasn’t the sort of conservation the playgroup was aimed at. It was appropriate for the parents to share what sorts of therapy their child has been receiving, what wasn’t appropriate was that specialised equipment provided by the hospital was being loaned out by parents. Those types of issues needed to be discussed between the parents and the therapists
The course of action decided was not to approach the parents at that point, continue to let them discuss ideas etc as we didn’t want to jeapordise that for in the future, and also to maintain the fact that the playgroup wasn’t ‘therapy’, we were there only to set it up, the parents were to take over from us. Instead the OT would speak to the mother at her next appointment and review the child and what equipment they still require from the hospital – and if they didn’t require it ask them to bring it in. The following week this occurred, and the mother confessed that they weren’t using that particular piece of equipment as the child couldn’t tolerate it. The frame was brought back to the hospital and the parents given different strategies to improve their child’s development.
In the end the outcome was positive for all, the parents still maintained that support network, the mother now had effective strategies for their child and the hospitals expensive piece of equipment wasn’t ‘lost’. It made me think that the manner in which we deal with various problems that arise is dependent upon the context and situation in which they occur. The outcome of the above scenario could have ended in numerous different ways, with the parents feeling like they were constantly ‘being watched’ at the play group if we had intervened there and then or if we had stepped back completely then numerous pieces of hospital equipment could be lost and the children not receiving appropriate intervention. I will now always carefully consider all the options and their implications when dealing with an issue that arises in the health system.
It took a couple of weeks for the parents to get to know one another and start forming friendships, which is when the swapping of ideas and sharing tips began to occur. As a therapist this was great as it is exactly what we had hoped would happen, however a few problems arose which we had not foreseen. A number of the children were developmentally delayed and had been provided specialised equipment from the hospital to assist them. This equipment was provided for that child alone as it addressed their specific needs. Two of the parents at the group were talking amongst themselves close to the group of therapists about a ‘standing frame’ that one of their children had been using. The mother of the child whom it had been given to was telling the other mother that they don’t use it, but they would give it to them to try with their child (whom had a completely different pathology and thus different needs/requirements).
This provided us with a dilemma which we talked about whilst this conversation was occurring. On the one hand we didn’t want to interrupt their conversation, as it would highlight the fact we were listening in, thus undermining the whole aim of the program (that it isn’t about therapist intervention). However, on the other hand, the child whom has been provided with the equipment required it to improve their standing – thus we needed to reiterate that to their mother. In addition it’s an expensive piece of equipment belonging to the hospital and needs to be kept track of ie it doesn’t belong to that mother; therefore she does not have the authority to ‘lend it out’. Whilst it was great the mothers were talking and swapping ideas and tactics that had worked for them it wasn’t the sort of conservation the playgroup was aimed at. It was appropriate for the parents to share what sorts of therapy their child has been receiving, what wasn’t appropriate was that specialised equipment provided by the hospital was being loaned out by parents. Those types of issues needed to be discussed between the parents and the therapists
The course of action decided was not to approach the parents at that point, continue to let them discuss ideas etc as we didn’t want to jeapordise that for in the future, and also to maintain the fact that the playgroup wasn’t ‘therapy’, we were there only to set it up, the parents were to take over from us. Instead the OT would speak to the mother at her next appointment and review the child and what equipment they still require from the hospital – and if they didn’t require it ask them to bring it in. The following week this occurred, and the mother confessed that they weren’t using that particular piece of equipment as the child couldn’t tolerate it. The frame was brought back to the hospital and the parents given different strategies to improve their child’s development.
In the end the outcome was positive for all, the parents still maintained that support network, the mother now had effective strategies for their child and the hospitals expensive piece of equipment wasn’t ‘lost’. It made me think that the manner in which we deal with various problems that arise is dependent upon the context and situation in which they occur. The outcome of the above scenario could have ended in numerous different ways, with the parents feeling like they were constantly ‘being watched’ at the play group if we had intervened there and then or if we had stepped back completely then numerous pieces of hospital equipment could be lost and the children not receiving appropriate intervention. I will now always carefully consider all the options and their implications when dealing with an issue that arises in the health system.
Monday, August 18, 2008
Positive Support Reaction
On my neuro placement i encountered a problem with a patient with a postive support reaction which proved to effect my treatment tremendously.
I was treating a patient who had a Right Middle Cerebral Artery infarct (TACS) on 17/06/07. Patient's main presenting complaint is left hemiparesis, left shoulder pain, inattentiveness to the left side and poor initiation of movement, motor planning and loses concentration easily. Current treatment has consisted of dynamic standing balance exs, sit to stand practice, dynamic standing balance exs and gait reeducation. The pt's progress for the last six months has been up and down with little carryover treatment session to session. Since discharge from ward 2 on 07/03/08 pts Berg Balance score has decreased from 32 to 19 0n 06/08/08.
I was really keen to treat this patient and had planned a whole treatment session with every intention to work as hard as i could to progress this patient. My treatment plan included bilateral lower limb stretches, bilateral foot mobilisations, sitting balance a-p and lateral pelvic dissociations, dynamic standing balance exs and progression to gait ed. Unfortunately little had been said in the notes that this patient had a strong positive support reaction (abnormal tone response when patients push foot against surface foot deviates into plantar flexion and inversion).
Treatment was going well until i moved from sit to stand without the pt's shoes off. The pt became distresssed and was telling me that she could not stand on her foot and that it was hurting.... In response i sat the patient down and did some SIMMS on gastroc/soleus however this proved to have little effect. I became really frustrated and called my supervisor for assistance. When my supervisor attended to the problem he advised me that there was no hope in continuing my treatment in the direction i wanted. The best plan for now was to get the patient on the tilt table to at least get a gastroc/soleus stretch, once the pt has the strong PSR it is very difficult to dampen.
I felt hopeless as i had not achieved my treatment goals in this session and did not get a true indication of what this patient was capable of. In response to my distress my supervisor showed me a good technique of hip perching in which you encourage the pt to perch their unaffected limb on the bed, raise the bed height until the patient has no contact with ground, slowly encourage pt to find affected foot and control the position of the foot.
The next week i saw the patient i tried this technique and it proved to be successful. I managed to achieve a lot in my session and really progressed the patient. Also because i had more confident in myself and the patient felt more comfortable with me and as a result was more confident in weightbearing on her affected side.
Has anyone else in the neuro field experienced any major barriers affecting treatment? How did you respond and what strategies did you implement to overcome these?
I was treating a patient who had a Right Middle Cerebral Artery infarct (TACS) on 17/06/07. Patient's main presenting complaint is left hemiparesis, left shoulder pain, inattentiveness to the left side and poor initiation of movement, motor planning and loses concentration easily. Current treatment has consisted of dynamic standing balance exs, sit to stand practice, dynamic standing balance exs and gait reeducation. The pt's progress for the last six months has been up and down with little carryover treatment session to session. Since discharge from ward 2 on 07/03/08 pts Berg Balance score has decreased from 32 to 19 0n 06/08/08.
I was really keen to treat this patient and had planned a whole treatment session with every intention to work as hard as i could to progress this patient. My treatment plan included bilateral lower limb stretches, bilateral foot mobilisations, sitting balance a-p and lateral pelvic dissociations, dynamic standing balance exs and progression to gait ed. Unfortunately little had been said in the notes that this patient had a strong positive support reaction (abnormal tone response when patients push foot against surface foot deviates into plantar flexion and inversion).
Treatment was going well until i moved from sit to stand without the pt's shoes off. The pt became distresssed and was telling me that she could not stand on her foot and that it was hurting.... In response i sat the patient down and did some SIMMS on gastroc/soleus however this proved to have little effect. I became really frustrated and called my supervisor for assistance. When my supervisor attended to the problem he advised me that there was no hope in continuing my treatment in the direction i wanted. The best plan for now was to get the patient on the tilt table to at least get a gastroc/soleus stretch, once the pt has the strong PSR it is very difficult to dampen.
I felt hopeless as i had not achieved my treatment goals in this session and did not get a true indication of what this patient was capable of. In response to my distress my supervisor showed me a good technique of hip perching in which you encourage the pt to perch their unaffected limb on the bed, raise the bed height until the patient has no contact with ground, slowly encourage pt to find affected foot and control the position of the foot.
The next week i saw the patient i tried this technique and it proved to be successful. I managed to achieve a lot in my session and really progressed the patient. Also because i had more confident in myself and the patient felt more comfortable with me and as a result was more confident in weightbearing on her affected side.
Has anyone else in the neuro field experienced any major barriers affecting treatment? How did you respond and what strategies did you implement to overcome these?
Friday, August 15, 2008
Diagnosis v. Non-diagnosis
Last week I attended a pediatric team meeting with the pediatricians, nursing staff and allied health workers. Also present was a team from the community disability services. During the meeting all children on the caseload were discussed in terms of their progress, services required and any referrals or assessments that needed to be done or were booked for in Perth. What I found interesting was the difference for financial and other service support provided for those children with a diagnosis compared to those without.
Two children were brought up at the meeting whom both had developmental delay and inappropriate behavioral/social skills. Both children attended a local kindergarten and were disruptive in their class – basically making life difficult for their teachers! Each child had been referred by their pediatrician to PMH for an autism assessment however only one came back with the diagnosis.
The child with the diagnosis had been provided with a therapy assistant to visit them once a week in class to work on their gross and fine motor skills, in addition at school they had a full time aid with them. For the other child, whom didn’t have a diagnosis none of these services have been provided despite the similarities between their presentations. In the last month this child’s behavior has become increasingly disruptive and has eventuated to the situation whereby the mother of this child has been told by the teacher that unless the child’s behavior improves by the end of the week they will be expelled from school (keep in mind this is kindergarten). In addition the child has also been ‘expelled’ from the daycare centre they attend.
For the mother of the child without a diagnosis life is extremely difficult at the moment as she is no longer able to work, yet cannot receive any financial support from centerlink or the disability services. Furthermore she doesn’t have access to the services the child with a diagnosis has to provide her with methods to improve her child’s behavior etc. When these children were being discussed I thought it seemed extremely unfair as one child was being provided with more and more assistance, whilst the other received nothing. When the disability service team was asked by the allied health workers what they could do for this child they replied nothing, until they get a diagnosis.
After the meeting I reflected on the caseload of children I was currently seeing. A number of them had a specific diagnosis and were given aid support at school etc, however a number of the children didn’t quite fit into any box – yet clearly ‘something wasn’t quite right’, and they would benefit from similar services. To me it seems there is a gap in the health system and large numbers of children are at a disadvantage as they don’t have access to the services they require to develop appropriate motor and social skills. It made me think of the percentage of adults now in the community that ‘don’t quite fit in’ and have inappropriate social skills etc. They may have been children such as these that were lost in the system and didn’t receive possibly some very basic treatment which may have taught them the necessary life skills.
At this stage all we can do is identify children at the various schools, kindergartens etc and ask their teacher’s/parents to refer them to a pediatrician, hoping they will get a diagnosis so they will eligible for the various services. I'm not sure as a therapist what we can do once the child has been for an assessment and it has come back negative. For me that has been the most frustrating part of working in paeds, as so many children present with signs and symptoms for multiple pathologies - but don't present with enough to obtain the diagnosis. Instead these children become labelled with developmental delay or delayed social skills, with only limmited access to services.
Two children were brought up at the meeting whom both had developmental delay and inappropriate behavioral/social skills. Both children attended a local kindergarten and were disruptive in their class – basically making life difficult for their teachers! Each child had been referred by their pediatrician to PMH for an autism assessment however only one came back with the diagnosis.
The child with the diagnosis had been provided with a therapy assistant to visit them once a week in class to work on their gross and fine motor skills, in addition at school they had a full time aid with them. For the other child, whom didn’t have a diagnosis none of these services have been provided despite the similarities between their presentations. In the last month this child’s behavior has become increasingly disruptive and has eventuated to the situation whereby the mother of this child has been told by the teacher that unless the child’s behavior improves by the end of the week they will be expelled from school (keep in mind this is kindergarten). In addition the child has also been ‘expelled’ from the daycare centre they attend.
For the mother of the child without a diagnosis life is extremely difficult at the moment as she is no longer able to work, yet cannot receive any financial support from centerlink or the disability services. Furthermore she doesn’t have access to the services the child with a diagnosis has to provide her with methods to improve her child’s behavior etc. When these children were being discussed I thought it seemed extremely unfair as one child was being provided with more and more assistance, whilst the other received nothing. When the disability service team was asked by the allied health workers what they could do for this child they replied nothing, until they get a diagnosis.
After the meeting I reflected on the caseload of children I was currently seeing. A number of them had a specific diagnosis and were given aid support at school etc, however a number of the children didn’t quite fit into any box – yet clearly ‘something wasn’t quite right’, and they would benefit from similar services. To me it seems there is a gap in the health system and large numbers of children are at a disadvantage as they don’t have access to the services they require to develop appropriate motor and social skills. It made me think of the percentage of adults now in the community that ‘don’t quite fit in’ and have inappropriate social skills etc. They may have been children such as these that were lost in the system and didn’t receive possibly some very basic treatment which may have taught them the necessary life skills.
At this stage all we can do is identify children at the various schools, kindergartens etc and ask their teacher’s/parents to refer them to a pediatrician, hoping they will get a diagnosis so they will eligible for the various services. I'm not sure as a therapist what we can do once the child has been for an assessment and it has come back negative. For me that has been the most frustrating part of working in paeds, as so many children present with signs and symptoms for multiple pathologies - but don't present with enough to obtain the diagnosis. Instead these children become labelled with developmental delay or delayed social skills, with only limmited access to services.
Monday, August 11, 2008
Inappropriate Patient Behaviour
On my neuro placement i have encountered a patient who is incredibly difficult and would like to share my experience with her in hope of some advice to handle this particular patient in the next upcoming week
This particular patient had a bilateral pontine infarct almost 2 years ago and has had intensive physiotherapy rehabilitation since. She is 31 years old, wheelchair bound and requires 1 x moderate assist to transfer from chair to bed. She has increased extensor tone in her LL, decreased muscle length globally in LL esp PF, and has no functional use of her L UL. Her balance in sitting is poor as she does not have the trunk control and muscle activation to adopt good posture and alignment. Aims of treatment have been to maintain muscle length in her LLs, improve functional staus of the L UL, and improve the efficency of her transfers. This is particularly important as her carers are finding it difficult to transfer her.
The first two weeks of treating this patient have been fine as my supervisor has provided me with lots of support as this patient generally is very uncompliant unless encouraged by physios who have had a lot to do with her in the past. So last week was the first time i independantly treated this patient. Until then we have got along just fine, i actually was surprised to read in her notes that this patient dislikes students and has "behavioural problems."
To begin with the patient was half an hour late and seemed not to care, she generally is absent for at least one of her PT sessions a week and frankly has made no progress for quite some time. As we began treatment i could see a change in the patient's response to me being on my own. She complained about her streches being to extensive and had the nerve to ask me.." are u sick? coz you look like absolute s@#* today" of course i was shocked by this and remained professional replying that i had a lot on atm and was really tired. She then continues to say " Yeah and when your ass starts looking fat in those pants i wont be afraid to tell you." Again i remained professional and laughed off that comment. As we continued with the treatment i thought id challenge the patient to increase her muscle endurance with reciprocal knee bends on the tilt table, we progressed to 2 x 10 resps and asked the patient if she could do 2 more. The response i received was "NO!" I then continued to bargain with the patient assuring her that this was for her benefit and again i received," What part of NO dont you understand, the N or the O?" By this stage i had had enough of being completely disrespected that i remained professional and finished the treatment session whilst the patient smuggly drove away in her wheel chair.
This situation has demonstrated to me that sometimes you need to be firm and more assertive with patients who are difficult. How this patient treated me was completely inappropriate and rather than taking control of the situation and demanding more respect i let the patient walk all over me. Now looking back at this experience i think i would approach the situation differently by subjectively questioning the patient on whether something had upset her that day, ask her to be more punctual in the future, and if she does not want to continue with PT that she best say so now so her treatment timeslot be taken up by someone else. Also i think i would explain to her that students obviously do not have the experience and knowledge base of other more experieced senior physios who have treated her in the past. We are just learning so inevitably at times we will take longer to do things and make more mistakes.
Any thoughts??
This particular patient had a bilateral pontine infarct almost 2 years ago and has had intensive physiotherapy rehabilitation since. She is 31 years old, wheelchair bound and requires 1 x moderate assist to transfer from chair to bed. She has increased extensor tone in her LL, decreased muscle length globally in LL esp PF, and has no functional use of her L UL. Her balance in sitting is poor as she does not have the trunk control and muscle activation to adopt good posture and alignment. Aims of treatment have been to maintain muscle length in her LLs, improve functional staus of the L UL, and improve the efficency of her transfers. This is particularly important as her carers are finding it difficult to transfer her.
The first two weeks of treating this patient have been fine as my supervisor has provided me with lots of support as this patient generally is very uncompliant unless encouraged by physios who have had a lot to do with her in the past. So last week was the first time i independantly treated this patient. Until then we have got along just fine, i actually was surprised to read in her notes that this patient dislikes students and has "behavioural problems."
To begin with the patient was half an hour late and seemed not to care, she generally is absent for at least one of her PT sessions a week and frankly has made no progress for quite some time. As we began treatment i could see a change in the patient's response to me being on my own. She complained about her streches being to extensive and had the nerve to ask me.." are u sick? coz you look like absolute s@#* today" of course i was shocked by this and remained professional replying that i had a lot on atm and was really tired. She then continues to say " Yeah and when your ass starts looking fat in those pants i wont be afraid to tell you." Again i remained professional and laughed off that comment. As we continued with the treatment i thought id challenge the patient to increase her muscle endurance with reciprocal knee bends on the tilt table, we progressed to 2 x 10 resps and asked the patient if she could do 2 more. The response i received was "NO!" I then continued to bargain with the patient assuring her that this was for her benefit and again i received," What part of NO dont you understand, the N or the O?" By this stage i had had enough of being completely disrespected that i remained professional and finished the treatment session whilst the patient smuggly drove away in her wheel chair.
This situation has demonstrated to me that sometimes you need to be firm and more assertive with patients who are difficult. How this patient treated me was completely inappropriate and rather than taking control of the situation and demanding more respect i let the patient walk all over me. Now looking back at this experience i think i would approach the situation differently by subjectively questioning the patient on whether something had upset her that day, ask her to be more punctual in the future, and if she does not want to continue with PT that she best say so now so her treatment timeslot be taken up by someone else. Also i think i would explain to her that students obviously do not have the experience and knowledge base of other more experieced senior physios who have treated her in the past. We are just learning so inevitably at times we will take longer to do things and make more mistakes.
Any thoughts??
Regional Visits
Last week I went on a regional visit with a pediatric occupational therapist, speech pathologist and physiotherapist. Each term this team travels to three remote towns to assess new children referred by teachers, doctors etc and to monitor the progress of those children already on the case load. Following the visit a home exercise program is then sent to the parents of these children as well as a program for the therapy assistant whom works with these children at the school. Due to their location it is not possible to treat these children on a weekly basis due to the cost of traveling etc, thus these twice a term visits are the best way to monitor and ensure these children’s gross motor, fine motor and speech skills develop.
The weeks prior to these visits require an enormous degree of organisation by the therapists. They need to contact the local health centers or schools for rooms to assess the children, contact the parents to let them know when the regional visit are occurring and finally a timetable must be made up in order to allow time to travel between each of the towns (roughly 1-2 hours driving between each). Whilst this is a huge undertaking in itself it is made more difficult by the parents.
Whilst many of these children require the therapist intervention a huge degree of the education must be aimed at the parents to ensure they are compliant with bringing their children to the appointments and then following the HEP provided. One major problem in organising these appointments is getting hold of the parents in the first place. A number of the families live in communities and don’t have their own telephone number (instead it is a community one) making it difficult to speak to the parents in person and not just communicate via messages. The next challenge was to see if the parents brought their children to the appointments.
In one town we were booked to see a child with cerebral palsy (hemiplegia). She required measurements to be taken so that an AFO could be made for her foot and we had brought the necessary equipment to make a splint for her hand. Each of these would assist the child to develop her gross and fine motor skills as well as maintaining the joint positions and preventing deformities of the hands/feet as the child grows. Previously the child had been brought to the majority of her appointments by an ‘uncle’, whom we had spoken to on the phone prior to leaving.
When we reached the local health centre the nurse stated that it was unlikely that the child would be brought in as the entire community they were from was out bush looking for a missing person. Sure enough we waited for over an hour but the child wasn’t brought in. This frustrated me as the child required intervention or else it would impact on the quality of their movement and life. Due to the towns location it would be another 5/52 until the child has the opportunity to be seen again as there are no other services provided in the area until then.
Whilst we were waiting I reflected upon the situation and realized that we had done all we could to contact the family, explain what we would be doing in the session and why it had to be done. Unfortunately for us timing wasn’t in our favour due to the missing person. For this family and the community these events take precedence over everything else, which is something we must respect even if we don’t share that belief. As we were waiting the OT and physio explained to me that this was a common occurrence and that there is no point is getting frustrated etc, we just need to ensure that we provide the family with the best options and services for their children.
It was a great experience going on a regional visit, seeing remote towns and communities. Even though we live in the same country there are vast differences in the cultures and belief systems. As a therapist when providing a service to these areas you just have to do the best you can and fit in with these beliefs and value systems. Whilst its frustrating that we didn’t get to see the child, on the next regional visit the team will once again contact the family, organize an appointment and hopefully no situation will arise in the community to prevent the child from being brought in!!
The weeks prior to these visits require an enormous degree of organisation by the therapists. They need to contact the local health centers or schools for rooms to assess the children, contact the parents to let them know when the regional visit are occurring and finally a timetable must be made up in order to allow time to travel between each of the towns (roughly 1-2 hours driving between each). Whilst this is a huge undertaking in itself it is made more difficult by the parents.
Whilst many of these children require the therapist intervention a huge degree of the education must be aimed at the parents to ensure they are compliant with bringing their children to the appointments and then following the HEP provided. One major problem in organising these appointments is getting hold of the parents in the first place. A number of the families live in communities and don’t have their own telephone number (instead it is a community one) making it difficult to speak to the parents in person and not just communicate via messages. The next challenge was to see if the parents brought their children to the appointments.
In one town we were booked to see a child with cerebral palsy (hemiplegia). She required measurements to be taken so that an AFO could be made for her foot and we had brought the necessary equipment to make a splint for her hand. Each of these would assist the child to develop her gross and fine motor skills as well as maintaining the joint positions and preventing deformities of the hands/feet as the child grows. Previously the child had been brought to the majority of her appointments by an ‘uncle’, whom we had spoken to on the phone prior to leaving.
When we reached the local health centre the nurse stated that it was unlikely that the child would be brought in as the entire community they were from was out bush looking for a missing person. Sure enough we waited for over an hour but the child wasn’t brought in. This frustrated me as the child required intervention or else it would impact on the quality of their movement and life. Due to the towns location it would be another 5/52 until the child has the opportunity to be seen again as there are no other services provided in the area until then.
Whilst we were waiting I reflected upon the situation and realized that we had done all we could to contact the family, explain what we would be doing in the session and why it had to be done. Unfortunately for us timing wasn’t in our favour due to the missing person. For this family and the community these events take precedence over everything else, which is something we must respect even if we don’t share that belief. As we were waiting the OT and physio explained to me that this was a common occurrence and that there is no point is getting frustrated etc, we just need to ensure that we provide the family with the best options and services for their children.
It was a great experience going on a regional visit, seeing remote towns and communities. Even though we live in the same country there are vast differences in the cultures and belief systems. As a therapist when providing a service to these areas you just have to do the best you can and fit in with these beliefs and value systems. Whilst its frustrating that we didn’t get to see the child, on the next regional visit the team will once again contact the family, organize an appointment and hopefully no situation will arise in the community to prevent the child from being brought in!!
Sunday, August 3, 2008
Over preparing
I am currently on my neuro outpatients placement and encountered a situation of over prepared- ness. I have been treating patients in 90 min time slots and as i am roughly half way through my placement i have got to a stage where i am quite comfortable with my patients and familar with their current treatment plans, goals and responses to certain treatments. To make myself more efficient i decided for a short while the night before to run through my notes on each patient i would be seeing the following day; i.e. impairements, problem list and my treatment plan for the next session.
One of my patient's i was going to treat was the patient that had been chosen for me to review. Keeping this in mind i had accommodated in my treatment plan enough time to get a thorough assessment of the patient; joint rom, mms length, tone, functional status, sensation and a berg balance ax. I had planned exactly what assessments i was going to do on this patient over the next 5 times i would see her so i had a lot of assessment measures to work with on my soapier report and objective measures i could reax each treatment session to monitor this particular patient's progress.
This particular patient had suffered a right MCA infarct roughly 2 years ago and has had a lengthy rehab regime with her response to treatment being up and down. Functionally the patient can sit with good posture when prompted, has abnormal standing balance and weight bears more through her unaffected side, and can ambulate with 2 x A with a very antalgic gait pattern. Upon reading her notes at times in the last 2 years this patient has progressed to gait retraining then lost motivation so much so that getting from sitting to standing has been a struggle. My intentions for this patient was to get her in standing, work on her standing balance, and functionally carry over this thru to gait re training.
This particular morning the patient was very uncompliant that transfering from her wheelchair was difficult. All i managed to achieve in a 90 min session was some lower limb stretches, foot mobs, and 30 mins on a tilt table. Post session once this patient had left i was so disappointed in myself that i just burst into tears as i felt completely hopeless and felt that the patient also thought i was useless. My supervisor sensed my frustration and pulled me aside. It was very comforting to know that even after 20-30 years of experience in neuro that some days patients have bad days which is by no means a reflection of the therapist's skill. My supervisor then told me that there a certain ways of getting this patient to "do what you want them to do" and that he would be happy in the next session to guide me through my treatment.
I have found that in a lot of placements i have been reluctant to ask my supervisor for help, guidance and feedback on my performance as i have been scared that they may think i am not capable of fullfilling the placement expectations. On this particular occasion my supervisor really put my mind at ease. No question, query or doubt is stupid. Supervisors are there to help us learn and the time to make mistakes is now as students. Now i feel more confident speaking directly to a supervisor specifically on feedback of my performance. Also no matter how prepared you may be, things presented to you on the day can be quite a different story. So rather than being so set in your ways on how you will achieve your treatment goals it is a good idea to be accomodating and consider many external factors.
One of my patient's i was going to treat was the patient that had been chosen for me to review. Keeping this in mind i had accommodated in my treatment plan enough time to get a thorough assessment of the patient; joint rom, mms length, tone, functional status, sensation and a berg balance ax. I had planned exactly what assessments i was going to do on this patient over the next 5 times i would see her so i had a lot of assessment measures to work with on my soapier report and objective measures i could reax each treatment session to monitor this particular patient's progress.
This particular patient had suffered a right MCA infarct roughly 2 years ago and has had a lengthy rehab regime with her response to treatment being up and down. Functionally the patient can sit with good posture when prompted, has abnormal standing balance and weight bears more through her unaffected side, and can ambulate with 2 x A with a very antalgic gait pattern. Upon reading her notes at times in the last 2 years this patient has progressed to gait retraining then lost motivation so much so that getting from sitting to standing has been a struggle. My intentions for this patient was to get her in standing, work on her standing balance, and functionally carry over this thru to gait re training.
This particular morning the patient was very uncompliant that transfering from her wheelchair was difficult. All i managed to achieve in a 90 min session was some lower limb stretches, foot mobs, and 30 mins on a tilt table. Post session once this patient had left i was so disappointed in myself that i just burst into tears as i felt completely hopeless and felt that the patient also thought i was useless. My supervisor sensed my frustration and pulled me aside. It was very comforting to know that even after 20-30 years of experience in neuro that some days patients have bad days which is by no means a reflection of the therapist's skill. My supervisor then told me that there a certain ways of getting this patient to "do what you want them to do" and that he would be happy in the next session to guide me through my treatment.
I have found that in a lot of placements i have been reluctant to ask my supervisor for help, guidance and feedback on my performance as i have been scared that they may think i am not capable of fullfilling the placement expectations. On this particular occasion my supervisor really put my mind at ease. No question, query or doubt is stupid. Supervisors are there to help us learn and the time to make mistakes is now as students. Now i feel more confident speaking directly to a supervisor specifically on feedback of my performance. Also no matter how prepared you may be, things presented to you on the day can be quite a different story. So rather than being so set in your ways on how you will achieve your treatment goals it is a good idea to be accomodating and consider many external factors.
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