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?

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?

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?

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.

smoking cessation and lung cancer

Hi Everyone,

This week I started my respiratory prac on an Oncology Ward. So far I have been surprised at the number of patients who continue to smoke after being diagnosed with lung cancer. I did some research on the internet and found out that quitting cigarette smoking after being diagnosed with lung cancer increases not only your life expectancy but also quality of life by slowing the disease progression. I have tried explaining this to one of my patients, a 70 year old gentlemen, but he states that he has been smoking since 10 years old so “dosn’t see the point in stopping now”. In a way I can see his point because to him it may relax him and trying to quit at his stage may actually decrease his quality of life through the withdrawl symptoms and making him more stressed and anxious. Then again, a stuctured quit program would probably lessen the withdrawls, and the temporary hardship will result in a longer, better quality life. I'm a bit torn as to how far to pursue the issue with him and thought I would put forward the question in regards to what everyone feels a physiotherapist role is in smoking cessation. Do we simply educate the patient on the benefits of quitting and respect their decision or should we be more active and refer them to smoking programs, education sessions etc

Thanks for your ideas :)
Alicia

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.