Differences between supervisors

On my recent cardio placement, I was at a cardiothoracic ward. On the ward there were 2 physiotherapists who are sharing the clinical duties due to the staff shortage. On the ward, we were mainly following one physiotherapist in the morning, and in late afternoon (after 3) we have another physiotherapist to supervise us.

The differences between the supervisors were not as obvious as the start. I was new to the ward, protocols and rules were to be learned and followed. Soon I became more familiar with the ward and patients. I started to think out of the box and noticed the difference between supervisors. All of heart and lung surgery patients have a lot of attachment when they are seen Day 1. SCC and ICC in particular needs to be careful placed before moving patients especially when ambulating. One supervisor on ward hangs the draining bottle on the lowest railing around their shin height while the other one places in the cage just above the cage which would be around the knee height. When I am with different supervisors, I have to adapt to their particular way of positioning of the bottle. I understand the rationale of both positioning, however I didn’t think such a slight difference would matter. Each time I positioned the bottle differing to their preferred method, I was corrected. And with one supervisor it was counted as a “safety” error as well, which seemed very unfair to me. There wasn’t a particular protocol in regarding to positioning of the draining bottle. From what we learned as uni, as long as the bottle was lower than chest it would be draining. Other similar experiences also occurred in regards to if ACBT should be given to patients who are able to clear sputum by themselves effectively and their sputum are of same consistency, colour and amount pre-admission.
I found as a student, such differences are so subtle, however when supervisor makes a big deal out of it, the whole situation becomes a very stressful experience. It feels like to me that the supervisor is just looking over your shoulder to pick out the little ambiguous errors which may be perfectly correct to other physiotherapists. I found it to be an obstacle to the learning experience. It seemed that I have spent time unnecessarily correcting different ways to do a task rather than spending time having more learning experience on Xray or handing over etc.
Has anyone else had similar experience and how could I handled it differently rather than adapting to different methods?

Safety Concerns

Recently on my general surgery patient i had a bit of a dilemma with monitoring a pt in a treatment session. One of my patient's had quite low sats at rest and the medical team had advised me to maintain these at 90-93%. This patient had worked in a oil refinery for 30 years and had regular secretions as well as a past medical history of Parkinson's. I found i recent times when i walked this pagtient and advised him to concentrate on taking deep breaths his sats would improve and maintain 93-94% so i was reluctant to increase his oxygen therapy as the objective was to decrease it to get him discharged. This one particular occasion i noticed that my oxygen cylinder was low and would need replacing after seeing this one patient so i risked using it because i didnt require much oxygen with this patient anyway, on 2l via NP his sats were fine. However this particular time my patient desaturated to 85% but i found it really hard to believe; i know sats monitors can be inaccurate but he had no increased SOB, i had allowed for a rest, and he was having a conversation with me. I wasnt far from his room so i didnt panic and just kept monitoring him making sure subjectively he was not desaturating. Suddenly a physio from the other ward came rushing past me and noticed that this patients sats had dropped. Instead of asking me if this was usual for him she grabbed the oxygen cylinder turned it up to 4l (i had him on 1l with NP) and started rushing around so the patient would get to the chair in his room. The oxygen cylinder had almost run out so it looked really irresponsible on my part. I asked the patient how he felt and he reported that he was feeling fine he felt he did not need the oxygen therapy increased and that the reason why he looked unsteady was because he was trying to take big steps because with his Parkinsons as he starts to adopt the festinating gait pattern. I assessed his sats at rest and they continued to stay at 90% on room air. His sats for the last few days on room air had been at this level . I explained everything to my supervisor after and she felt that if he did not use oxygen therapy at home and we want to send him home, its important to start wheening patient's off oxygen despite the fact that their sats are lower. I know we are taught to be conservative with pt sats, but what are everybody's thoughts on using the oximeter and how accurate it is?

Aren't we a team?

Hi,

This is a scenario which happened to my supervisor on my last placement. There was an elderly lady who was admitted to hospital with pneumonia. She was given IV antibiotics which helped markedly and once her infection was under control the doctors wanted to send her home asap. They asked my supervisor one afternoon just before we finished work whether she thought the lady was safe for d/c on that particular day. My supervisor assessed the pt and reported back to the doctors that she was very unsteady on her feet and was not safe to be sent home where she lived by herself. The doctors said OK and we left for the day.

When we returned the following morning we discovered that the pt had been sent home after we had left. My supervisor was really angry and questioned why the doctor had asked for her to Ax the pt and then ignore her advice.

Has anyone had similar experiences where other members of the multi-disciplinary team do not listen to others input?

Parents

On my rural placement i have been helping out with development groups for kids of kindy and pre-primary age. The kids generally dont have a specific diagnosis apart from being developmentally delayed. The groups consist of doing fun activities which help to build muscle strength, improve balance, improve motor planning, improve fine motor skills and reach gross motor developmental milestones.

Generally the kids are referred by their teachers because they are either struggling with schoolwork or are having problems developmentally or socially. A lot of the time it seems that the kids dont have much wrong with them, however it still would be hard for them to fit in at school. I feel sorry for the kids because i know how hard it is to fit in at school even when you can do everything that the other kids can do. I can only imagine how hard it is to fit in when there are certain things that you cant do but everyone else can do. The other thing thats sad about the situation is that a lot of the time the parents are to blame for the kids being developmentally delayed. Whether its because of abuse, neglect or whatever, unfortunately a lot of the kids i've worked with have fallen into this category.

Recently there was a situation where after working with one of the kids their parent came in to pick them up and seemed quite annoyed. I was pretty sure the parent wasnt annoyed at me but still i felt sorry for the kid that now had to put up with a parent in a bad mood. I had really enjoyed working with this kid and i felt that the child was responding well to being part of the development groups. The parent just grabbed their kid and then left straight away without checking with us how there kid was going. I know the parent must have a lot of things going on that would be occupying their mind but i really felt the parent should take more of an interest in their kid. I felt like saying something to the parent but i knew it wasn't my place to. I talked to my supervisor about it and they said unfortunately we can't tell a parent to take more of an interest in their kid.

I thought about the situation a bit more and even though i think i made the right decision not to say anything to the parent i was annoyed that it was the poor kid that was going to suffer developmentally. Has anyone else experienced a similar situation? Has anyone found a way to get through to parents who maybe arent doing their job as good as they should be?

Poor Patient Management

I have a patient who i have been involved with treating over the last three weeks of my general surgery placement who has been poorly managed by surgeons and has had to undergo intensive rehab to regain as much functional mobility as possible. He is currently mobilising with a barietric WZF roughly 30m with 1 x standby assist, independant with bed mobility and requires 1 x assist with transfers.

Mr GM is a 44 year old man who intially went to a private hospital to have a gastric banding surgery performed at the time he was 150kg. Unfortunately the operation was not successful as the lap band had perforated the stomach. Post op complications often occur with this surgery, roughly 25% lap band surgeries have post op complications. As a result Mr GM developed sepsis and was transfered to ICU spending a month there then to a high dependency unit prior to admission on the ward. During his time in ICU Mr GM developed a fibular nerve neuropathy of which now he has limited sensation in his left foot. He has been mobilising with the physio everyday on the wards using an arjo sling to assist with transfers and to act as a support whilst retraining gait. Even though progress has been slow, this patient has been extremely determined and in the span of 3 weeks has gone from being completely dependant on the sling to being able to STS independantly, roll in bed independantly and mobilise with S/B assist and WZF. We have been extremely proud of this patient considering all of the barriers which have stood in place of him making progress.

In a team meeting i was really upset when i heard how the surgeons spoke of this patient. It was as though he was a hinderence and they didnt care about the progress of his rehab. I witnessed my supervisor get into a minor argument with these surgeons on the patient's ongoing progress and hopeful discharge in the next two weeks. They were not interested in his need for a specialized brace for his foot. If a patient is under 120kg they are eligible to receive rehab from the rehab hospitals such as OPH. Basically the surgery team wanted to lie about his weight (report he was under 120kg when he is 144kg) and move him on his way. Has anyone else experienced something similar when the medical team are reluctant to even deal with a patient and try "handball the problem" to someone else. I know this is a major generalisation to make but it really upset me that this patient's efforts nor the PT's were recognised.

loosing credibility

Hey,

Last week on prac I had an embarrasing scenario happen to me. I was asked by my supervisor to do a chest check on an elderly patient who had dementia and was reportedly very confused. When I went in to see this lady she was trying to walk out of her single room whilst still having her nasal prongs on which were attached to the wall- essentially coming very close to falling over. I managed to get her to sit down in a chair and started my Ax. When I was part way through auscultating my pt stood up and started trying to rush out the door. I tried to calm her down and blocked her path and she started yelling out "Go away! Go away!" at the top of her voice.

A nurse nearby came in to see what was happening and asked the patient if she was trying to go to the bathroom which the pt replied she was. The nurse then guided the pt back into her room and to her bathroom. I felt embarrased that I hadn't asked the patient this simple question but at the time was so flustered with not wanting the pt to walk out the room and trip that I didn't really think clearly. The nurse involved was really nice about the whole thing but I felt like I have lost my credibility in front of her as she had to come in and take over.

Has anyone had similar challenging experiences with pts with dementia?

It’s not so bad

I recently completed my rural international placement in a third world country. The aim of this blog is to try to help you understand how fortunate we really are.

Working in the health system in Western Australia you hear many complaints. Extreme waiting periods in emergency departments, waitlists for elective surgery, over crowded hospital wards, short staffing issues…the list goes on. Here’s a short recount of a gentleman on my rural placement to put things into perspective.

A 50 yr old gentleman presents to the rehabilitation clinic with pain in his right leg. He had fractured the mid shaft of his tib/fib at age 21, falling off the roof of a house he was constructing. At the time of the accident he presented to the “emergency department” of a public hospital in his capital city, where health care is “free” (though you have to bribe the nurses, doctors, physios etc if you actually want to receive some form of intervention). The initial “treatment” was to “open it up to reduce infection” (not quite sure of the reasoning behind this). After a few days stay in hospital when his emergency funds had run out a doctor informed him that he would require surgery to have it internally fixated. Obviously he could not afford this. He was sent home to his province, still with a fractured tib/fib, no advice, no walking aids, no splint/ cast, no analgesia, no follow up appointment.

He continued to work as a labourer on a construction site, often carrying heavy bags of concrete – FWB! He saw a “traditional Khmer healer” for a treatment called “coining”. This is basically where they rub, very firmly, a copper coin across the skin until it is red raw and bleeding. It may have helped with the pain (think back to Max’s pain theories) but it certainly did not help to reunite his fracture.

29 years down the track he now has a painful psuedoarthrosis mid way between his ankle and knee, an ankle that will not plantarflex or dorsiflex more than 5° out of pantagrade, globally decreased muscle strength in his lower limb and patellofemoral pain.

If you presented to RPH/ SCGH emergency with a fracture such as this, you could wait anywhere up to 24 hours to be seen/ treated but:
· Pain would be managed medically – during your hospital stay and for a necessary amount of time after
· The fracture would be managed appropriately – surgically or conservatively
· Walking aids would be supplied
· Outpatient follow up appointments would be made with doctors and physiotherapists
· It would be free of charge – no need to bribe the health care professionals.

Complications may arise but will be dealt with accordingly. At least you know in 29 years time it won’t still be broken.

We all take our public health system for granted and of course it could always be improved, but think about this story next time you hear someone whinging about it….it’s not so bad after all.

Patient feedback

Recently on my rural placement i was taking an exercise class aimed at seniors. The class aims to get seniors to keep moving and doing exercise and is called 'Stay on your feet'. I was asked to take the class as it would be a good experience for me. I was looking forward to running the class as i hadnt instructed a class on my own before. At uni we had taken a class in groups but it was a lot different being on your own.

The main problem was that i didnt know the exercises that the group usually performed. The exercises were like an aerobics class and were surprising complicated as there were lots of steps to learn. I felt bad for the patients as it was going to be difficult for them to follow what i was doing because i didnt know the proper steps. My supervisor said it didnt matter what steps i did as long as they were safe. This reassured me somewhat but i still wanted to run the class as close to normal as possible.

I instructed the class and it seemed to go well but i felt i was doing some exercises for too long as they were the only ones i knew. Afterwards most of the patients said they enjoyed the class and didnt mind that i didnt know the proper steps. However, one of the patients was critical of my instructing and said that i was out of time and should of known the exercises. I told her i would work on it but because i hadnt done this kind of thing before it may take a while.

I was a bit annoyed that the patient had criticised me because i thought i had done pretty well considering it was my first attempt. However, i took the advice on board and worked on my timing. I started to notice how the music was always four beats and so i had to match the steps to the music. I worked on my timing and the next week the class went a lot better. To top it off the same patient who had criticised me the week before then congratulated me on my improvement.

I think its good to always take constructive criticism on board because it helps us to become better therapists. Has anyone had any similar experiences with patients providing feedback?

physio's managing patients or vice versa

I’ve been encountering a behaviour from some patients that is a little frustrating and a little hard to deal with whilst being on my musculoskeletal outpatient placement; some people coming into the clinic for outpatient physiotherapy have very set ideas about what they expect to get from treatment. I can recall a few patients who were of this type. It seems to happen more with those who have chronic conditions.
Some patients seem to want very specific things from physiotherapy, and if they do not get this they can sometimes get very upset. For example, after carrying out a treatment in fairly normal time (i.e. subjective time 5 mins, objective time 10 mins, treatment time 10 to 15 mins) a patient might complain that they were getting too much assessment and not enough treatment. A patient might also complain that the treatment for them is wrong- they may say after an ultrasound treatment, for example, that “what I need is actually just a really good massage”- that last comment seems to recur a lot.
At first I didn’t really know how to deal with these comments, and I found it a little frustrating. After a bit of thinking I realized that it’s a pretty complicated issue. On one hand, the patient has a condition, which is often chronic, which they will have figured out how to manage it in their own way, which can be helpful for the physiotherapist. We are, after all, big on promoting self management. This downside to this is that a patient’s opinion of their condition is totally subjective: it does not include any objective reasoning. They will talk about their pain and what they think makes it better, and they will often try to sound objective about what they are telling you, but ultimately it is all just subjective.
That where the physio comes in, and I guess this is the other side to the story. Yes, we do want patients with chronic conditions to ‘take the reigns’ of their own conditions, and so we really try and encourage self management- we do this because a patient cannot objectively assess themselves, and they do not have the knowledge of a PT. However, patients with chronic problems still need some PT management, and often we have to ‘take the reigns’ back off them and resteer them in another direction. I understand that this can be very upsetting for the patient- especially those who do not like taking advice. If the changes to their management are quite drastic, then this can also be very upsetting for the patient.
The thing that makes it really hard is this; we want the patient to give up a degree of their autonomy and let themselves be guided by the PT; however, sadly it is true that there are health professionals out there that really might be making a wrong decision with their management choices for a patient, and therefore it is necessary for a patient to always be on guard with health professional management and maintain some degree of autonomity- enough that if they feel they are getting managed in a totally incorrect way, that they will seek another professional.
I guess the bottom line is that, with any questions or queries that patients might have, we make sure that we address them, and keep the patient informed. We should endeavour to explain ourselves and the decisions that we are making as much as possible. That way we can persuade patients to follow their given management plan, whilst also keeping them informed enough so that they do not feel that they have lost their autonomity in managing their condition.

non problematic patients

Whilst on my musculoskeletal outpatient placement, I discovered an interesting phenomenon among several patients. There were several patients who I would be following up on (from the previous student) that seemed to not really have any problem, and yet would still think that they need physiotherapy. I can recall a few patients who had been treated for a condition by the previous student, but upon subjective exam did not appear to have any of their former pain or any functional limitations. And I found myself wondering- what did this patient even come to the clinic for?
The subjective assessments were in particular pretty frustrating. When asking a direct question (e.g. “what is your main problem?”) the patient would answer with a vague and rambling answer where he/she might talk about a few previous injuries that they’d had, or something that they used to have trouble with, which upon further questioning has completely resolved. After ten minutes of subjective assessment you might have only gleaned one functional activity that the patient is getting a little bit of pain with, but which is not really anything that serious.
Objective assessments with people like this are pretty similar to subjective. Patients might report generalized pain throughout their body but nothing that is connected to what they reported in the subjective assessment. By the end of the subjective assessment a problem which could use physiotherapy intervention may have been identified, but it might not have anything to do with what was gleaned from the subjective assessment.
I found that the kind of patients who presented like this were those who were of the more elderly age group, and usually retired. Without trying to infer too much about this group, it seems that they have much more time, and that they see attending physiotherapy as possibly another way to fill their day. Or perhaps they just like the company.
It’s a stark contrast to the majority of patients who attend outpatient physiotherapy. Most are very busy, and often many patients miss or cancel their appointments due to work, family, or other commitments. Most patients are also very straight to the point i.e. “this is my pain, and this is what I’m having trouble doing- fix me”.
These treatments are not really a waste though. As most of these patients are elderly, they were often started on a general program of strengthening and balance, and given a regular walking program, as a maintenance and prevention measure. This can be pivotal in preventing falls and subsequently fractures. I guess the important thing is to identify these patients early so that you don’t tie yourself in knots and waste a lot of time trying to figure out what their problem is. As most patients like this are elderly, we can always give them general geriatric maintenance programs. And I guess we shouldn’t forget to be as friendly and talkative as we can- because one day we are going to be old too.