Being Observant

Recently, on my Neurology placement, I encountered a situation which I would like to share with you. I had been given a new patient, and had not been able to do much with him for the first week of his admission as he was rest in bed. When I did get to see him, he was quite fatigued, as he had had extremely poor sleep due to 11/10 headaches.
I went in to see him in the morning during my final week, as I had hoped to see him for some Physiotherapy during the day. I noticed immediately on walking into his room, that his communcation was different. He almost looked as thoug he was in a different conscoius state- he took a long time to reply to my questions, and when he did, barely opened his eyes to make contact with me, and struggled to keep his eyes open.
I checked his med charts, and his nursing obs, and noticed that he had increased pain meds overnight which may have contributed to his present state, although his latest meds were given multiple hours previously. The patients nrusing obs were within his normal limits.
I immediately went to the nursing staff, and informed them of what I had seen with this patient, to ask if they had also noticed a change. The nurse came in to observe the patient, and the patient was well oriented to time, person and place. The nurse also acknowledged a change in his communicative state, and the medical staff were immediately contacted for a review.
Satisfied with this, I went to look in the medical notes, and noticed that the Reg had not recorded changes noted from my observation of the patients most recent CT scan. I immediately contacted the Reg, to ask if this patient was still fine to treat Physiotherapy wise, considering the new developments with the CT scan. The Reg, noted this, and stated it was fine – she must have failed to update this in her note-taking.
I did not manage to get this particular patient into Physiotherapy that day, and as the placement is now over, I do not know what happened further in this patient’s case, however, I did learn from this expereince.
One lesson is to always be very observant of your patients, as often we are the first ones who notice not only improvements, but also deteriorations in our patient’s status. The second point is the importance of the Multi-disciplinary team, and communicating effectively with all members for the well-being of the patient. Thirdly, don’t be scared to challenge or question Doctor’s from time to time,in a professional manner, as everybody makes mistakes. I will bring these lessons learnt into my future clinical practice.

Dealing with Patient Mortality

On my cardiopulmonary placement, I was faced with many emotional experiences. In particular, one comes to mind. I had been treating this one particular patient for three weeks, and he was approaching discharge. From his history, he was very unwell, and was an inpatient for multiple months.
He had a very supportive family, in particular his son, who I had met on multiple occasions. I had given this patients son education regarding his father’s progress, as well as his oxygen therapy, and just idle chit-chat also.
In my final week, I noticed on the Monday that this patient of mine was not on the list. I heard a loud response from another Physiotherapist, who had been treating this patient before myself, stating that she can’t believe he had passed away. I immediately felt quite overwhelmed for a moment, having realised that my patient had passed away. I was later told that this patient was getting discharged over the weekend, was all packed and ready to go waiting in his chair for transport, and had a heart attack and passed away in his chair while waiting for his car to arrive.
The question that this experience brought to me, was how do we and other health professionals deal with the loss of a patient-particulary when it is someone seen regularly, for instance twice every day? What I found interesting is how everything keeps going as though nothing happened- the staff don’t have a choice.
I realised the importance of having a supportive family/friend environment to come home to post work, to be able to deal with these strong emotional responses that come from working in these high intensity areas. It is also extremely importan to be confident in your own abilities, to be able to say that you did all you could to return this patient to home, or greater functional independence to improve their QOL, to not hold blame for when patients don’t make it home.
I also realise that it is not optimal to get too close to patients-although sometimes it is difficult not to. Having completed this placement, it was in fact my favourite, and most rewarding. It challenged me, and I was able to meet the challenge, through experiences like the one described.

Supervision Clashes

On my rural placement, I was given the option of inpatients or outpatients at the Hospital. I chose outpatients after much debate J and with this, was given a new graduate from Notre Dame as my placement supervisor. I had proceeded through three weeks of inpatients with not only my direct supervisor up on the ward, but with other Physiotherapists that were on the ward also .
At my mid-placement assessment, I was given no negative feedback regarding my current performance, and was told to continue building on my skills to run the ward more independently for the last two weeks.
When some of the other Physiotherapists came up to visit me on the ward, they had no problems with my performance. As it was my first inpatient experience, it was all new to me. On top of this, I had not yet done my cardiopulmonary nor my neuro placment, so I therefore, was reviewing much information over the placment to bring myself up to speed. However, as I wasn’t recieving any negative feedback, I figured my performance was fine, and I just continued to improve and build on my confidence each day.
In my final week, the overseeing Supervisor, from outpatines decided he wanted to come up to the ward and see how I was performing. He informed me later that day that he was not impressed by the way I was handling the ward. He was dissatisfied with my note-taking, and my confidence in dealing with patients. He informed me if I didn’t improve I would potentially require additional development. I was obviously upset, as this was the first time I was informed that my performance was not adequate. I felt I could run then ward indepently, and was doing a fair job.
By the end of the placement, I recieved a competent grade, and the overseeing Supervisor apologised to me as he felt they had not been able to get the best out of me from the placement, and he was upset as he felt they had not done me justice with the supervision/learning I was given.
What I learnt from this experience was to find out from the very beginning of my placements what my exact expectations were, as I recieved mixed messages from different Physiotherapists on this clinic. Also, I learnt that not every Physiotherapist practices in the same way. The overseeing Supervisor was extremely abrupt in his communication with patients, and very much took the philosophy that Physiotherapists were the big, bad guys who got patients up, and we have to use our voice and presence to get in there and do what we have to do. He took my quieter method of communicating with patients as a lack of confidence and ability, when in fact, it is simply a different communication style, which can still be equally effective.
He also stated that my notes were a weakness that I needed to work hard on, although my notes have been my one extreme strength throughout the rest of my ward placments. Whether this has to do with my rural experience, or simply being told clearer how the notes were to be done, I am not sure.
Overall, I believe that many communication styles can be effective in achieving the same result, and also, even in looking to the future when beginning employment, to understand from day one the specific requirements that are needed to be successful at a paticular position, particularly in running a ward independently.

A Chronic Pain

Firstly, I apologise for the delay in posting these blogging entries. I would like to share a clinical experience I had on my rural placement. I was told that I could participate in a programme that was being run for patients suffering from chronic pain. I was very interested in the opportunity to learn something new clinically so took the opportunity. My main role was to take the patients for a prescribed exercise class, and also partcipate in other activites carried out by other health professionals.
I learnt fairly quickly, as did the other patients and staff that there was one particular patient who was going to be a little difficult. He was very abrupt throughout the presentations that were given by the other health professionals, and would bring a large shopping bag filled with his X-rays everywhere he would go, perhaps in an effort to prove his pain was in fact real. He did little to no physical activity, and had the belief that he did not want to do any physical activity that caused him pain as he did not want to end up in a wheelchair.
I took a number of the exercise classes held for this chronic pain group over the two weeks that the programme was running. I noticed that this patient was distracting the other patients, who were highly motivated through the comments he was making and his lack of motivation. I tried my best to encourage him with his exercises, and to perform them properly, including the proper sets and reps.
One particular exercise involved walking for ten minutes. It was the second last session, and the patient in question had never before completed the ten minutes without a rest. This one time, it was around fifteen seconds before the ten minutes was up, and he had not yet had a rest. I was encouraging him to keep going, and that he had achieved much, and as I was doing this, I was standing in front of one of the chairs in the corridor that the patients could use to rest. This patient became infuriated with this unintentional gesture, and stormed inside the Physiotherapy Department to take a seat inside.
The following time I caught up with this group, the patient pulled me aside and wanted to speak with me. He had some literature that he wanted to inform me about his diabetes, and proceeded to tell me that he feels I pick on him, and that I think I know what is best for him, because I think I have much knowledge, when he doesn’t want to end up in a wheelchair because of me. I tried to explain to him that I am only trying to help him, and never meant to upset him or pick on him. This conversation went on for quite a while, and after the incident, I became quite upset by it.
The following day when I saw this patient by accident, he apologised to me about the things he had said, and that he realises that I was trying to help him, but that I have to realise that you can’t help everyone. He also wished me the best of luck.
What I learnt from this experience is to never single people out, even if it is unintentional. Also to be aware of the large significance of psychosocial issues in relation to chronic pain. Possibly the biggest lesson I learnt from the patient himself is that yes, you cannot help everyone, particularly with chronic pain, the patients need to want to help themselves. They need to want to change-we can’t do that process for them. Through all the presentations from not only Physiotherapists about the importance of physical activity, but Anaesthesiologists, Dieticians, Clinical Physchologists and the like, nothing could alter this patients view on his pain, however I did learn a valuable lesson from this experience, and really wish this patient all the best in finding a solution to his chronic pain.

Maintaining profesionalism even when you dont like patients

This is something that I experienced primarily on the Burns placement. There were a only a few patients, thankfully, that I experienced this with. What I basically experienced was having to treat patients that I really didn’t like as people. It’s really quite hard, and it takes quite a bit more maturity than I realized to maintain professionalism in these situations.
The first patient that I experienced this with was not of Australian descent. When I met him for the first time in his ward room, I was startled by the number of family members that had come to visit him. I was a bit in awe, and I was thinking- ‘what a lucky guy to have so much loving family’. However, in the space of a few minutes I witnessed this patient be extremely rude and abusive toward both his wife and daughter, who were completely submissive. I quickly realized that there must be some cultural laws within his family that were different than in Australia. Still, I could not help but dislike the man for his words and actions.
I was surprised at how difficult it became for me to treat him after that. During the assessment and treatment, I couldn’t seem to forget his previous actions toward his seemingly innocent family, and I felt a definite sense of reluctance in helping the man with his problem. Eventually I just tried to visualize fixing the problem rather than fixing him.
The second patient was a young teenage male, who had a history of drug abuse and minor criminal activity. His current history relating to his incident was that he had gotten into an argument with his parents, and then deliberately set himself on fire. His father had had to throw him into their swimming pool to put him out. During his subsequent admission to the burns unit, he had been very abusive towards the staff and had eventually absconded/been kicked out of the ward. The period where I was treating him was several months after this, during his outpatient rehabilitation program.
During my treatment of him I witnessed him do several things that made me dislike him as a person. He very rarely showed up for his treatments as an outpatient, and when he did, it was obvious that his impairments were really quite serious, and it was also obvious that he had not been managing his condition. He would often arrive late to treatments, often still inebriated from the previous nights activities, and during treatments he would make several inappropriate comments towards any female staff in the vicinity. He would often lie to the health professionals involved in his rehab about other treatments he had received, and about his home management. Only upon contacting his family directly did it become apparent that he had been lying to both them and the health care team. In short, he was wasting his time, our time, and his families time. When he did attend treatments, I knew that any treatment that I would do would essentially be a waste of time if he didn’t change his self management (which was not at all likely to occur). On top of this, I really didn’t like him as a person. I got around this by switching off my emotions during the treatment and simply treating the problems, and not worrying about the person.
Im not sure if the way that I manage patients that I don’t really like is the right way to manage people, so if anyone has any suggestions or had similar experiences please let me know.

Being Judgemental

I’ve encountered several many patients out on clinic that I really wonder about them and the decisions that they make. They make these decisions which put them in these situations, such as hospital, and it seems like they’re getting all the right advice from people; their families; the health professionals; and other patients. But despite all this they seem to continue to get themselves into the same situations again and again, and sometimes it can be frustrating as a health care professional. I guess this is because there are patients that we feel deserve our time and energy much more than the people who seem to be willingly putting themselves in hospital; there are other people who are in hospital because of factors beyond their control. I guess it feels a bit unfair, distributing resources toward those who obviously do not appreciate it.
This is something that I have experienced across many different practicuums, in particular though; cardiopulmonary, burns, and neurosurgery. In my cardiopulmonary prac, people in this category were usually people who had COPD caused by smoking, and were still smoking. They often were people who had been admitted many times over the previous years for excacerbations of their deteriorating and chronic condition, and were well known around the ward by the staff. Each time they are admitted they are a little bit worse, and each time they are given the same good advice: stop smoking. Which they don’t take. As a physio, sometimes it feels like we care more about their condition then they themselves do.
Burns and neurosurgery usually involved patients who had been involved in some kind of drug abuse or violent behavior. One teenager in burns had a history of elicit drug use, had had a fight with his parents, and deliberately set himself on fire during his argument with his parents. Another teenager I met in neurosurgery had climbed on top of his girlfriends car during an argument, she drove off and he fell off the car and cracked his skull on the pavement. There are many other histories of patients that I encountered that involved similar tales of drugs and violence. And most of these patients seem completely unrepentant after the incident. They receive guidance from social workers, and are presumably offered all the knowledge and means to make the necessary changes in their lives, but they don’t. it’s these patients that I feel don’t deserve the treatment.
The fact is though, these patients are still entitled to treatment, even if they are completely responsible for their condition, unrepentant, and even likely to something similar again. The decision has been passed down that these people should still receive treatment- though I have to say I don’t completely understand it, it is not a health professionals place to define policy.

Has anyone else experienced similar thoughts?

Everyone can hear you!

Whatever happened to patient confidentiality. I was recently on my neuro placement and was shocked at the amount of times that I heard personal health details being discussed in an inappropriate setting.

I refer to one situation where a patient was in a four bed room and suffering from haemorrhoids. A doctor went in to review the patient, drew the curtain and started the examination with “so *Frank, how are the haemorrhoids feeling?” with an unnecessary loud volume. I know that often a shared public hospital room is a difficult environment to maintain patient confidentiality but if I was the one with haemorrhoids and my doctor had just announced this fact to the entire room (patients and visitors) I would NOT be impressed.

Of course, as a student, I didn’t feel like it was my place to say anything to the doctor but it really made me realise how important it is to use appropriate communication strategies when discussing what may be embarrassing issues.

I also tried to think about it from another point of view. Often people find it difficult to discuss these types of issues with medical staff as they may carry a certain stigma. Do you think that making it obvious/ discussing freely in this environment would “normalise” the situation and encourage people to think of these conditions as just another impairment, making them more comfortable to discuss them with health professionals?

I don’t think I’ll be changing my view on this situation as I still stand by the fact that what is private to you should be kept private…but what do you think?