Nursing Home Patients

During this year across placements in the hospitals and my personal experiences I have been disheartened to observe the attitude of many nurses and allied health professionals to the nursing home residents in the hospital setting. What was most apparent was the view that all we needed to do was get them back to a level of function so the nursing home would take them back and do that as quickly as possible with as little input as possible. With respect part of this attitude has developed because of the shortage of nursing and allied health staff within the hospital system and the large caseload they have to cover.
I believe that physiotherapist have the training to offer the elderly population a great deal that would improve their quality of life as they enter the twilight years. Yet these skills that we have are not being utilised by the nursing homes or low care facilities and those that do employ a physiotherapist are using them basically to do mobility assessments for the clients care plan.
Obviously there are multiple factors surrounding this issue, the pay scales in the care facilities do not encourage physiotherapist to work in this area, the allocation of funding within the nursing home - carer v physiotherapist to suggest just a few.
I hope that if I work in the hospital environment I will be able to manage my time efficiently to enable quality time to be spent with some of these elderly clients.

confused patients

My last placement was a gerontology placement where a lot of my patients had dementia and were confused. I found this hard initially as it is important with demented patients to make the exercises very functional so they comply and do them correctly.

One lady I had loved sitting in a chair. So instead of doing ten sit to stands (which she didnt understand the point of) I would set up 2 chairs (10m apart) and get her to walk to the chair and sit down, then she would see another chair 10m away and I'd ask her to go sit on that chair. She didn't remember that we had just sat down on one chair so she would be happy to do this exercise up to 20 times in one session.

Making an exercise functional for the specific patient is very useful in dealing with demented patients I have found. Otherwise if they don't understand what you want from them they are likely to by uncompliant or even aggressive.

the boring part of physio

on my last prac I was doing gerontology. I found that all I was doing was walking patients and doing basic exercise programs for them. As they were very elderly there was no high level exercise or anything too challanging. after the second week I found this to be be very mundane and boring. most of the patients didn't like exercising and as a result hated coming to physio, making my job vey hard. They would often be very difficult with me come physio time, and I would spend a good part of the session persuading them to come down and exercise and the benifits of exercise. After a while this became wearing on my enthusiasm for physio as a profession. I feel that we are too over qualified for a lot of the things that we do in the hospital system, and that we receive little respect from patients themselves.
I voiced this opinion to some of my peers and many were in aggreeance with this belief. I also spoke to my friend who is a physio and she said that it is just one field of physio, and that it is important to try other parts of physio before making a judgement based on my experience on prac as a whole.

I think it is important to ensure we don't become disheartened by the profession if we have one bad experience on prac, and to continue to stive to find an area that you find exciting and challanging. In the future I will remember this advice and try to maintian my positive attitude in all situations.

Paediatrics

On a paediatric placement earlier this semester under the supervision of my CCT I was assessing a 18 month year old boy who had been referred by a Child Health Nurse for delayed motor development. The mother indicated that she was aware something was not right but appeared to be looking to us for reassurance that this was not serious. Unfortunately as I progressed with my assessment it became more and more apparent to me that this child had a significant motor delay and was probably diplegic. At this stage the mother had not had any input from a paediatrician. At the conclusion on my assessment the CCT checked a few things and then asked the mother to excuse us while we discussed my findings in private. I voiced my concerns to the tutor and she concurred with my diagnosis and offered to explain to the parent. I accepted her offer and was interested to watch her approach to the parent. She confirmed with the parent that the mother was correct to be concerned about the child's problems and that she would like to refer the child to a paediatrician for further assessment. She did not jump in and tell the parent that she suspected the child had cerebral palsy. She addressed a number of areas where the child was having difficulties and offered therapy for these. She indicated to the parent that it was likely that the child would require ongoing therapy. Having the opportunity to listen to an experienced clinician deliver such news was a valuable learning experience. It clearly defined the role of the physio in these circumstances and I feel that if I am placed in a similar situation I will feel more comfortable and able to deliver such news in an caring and considered manner.

Consent is important!

Recently on my cardipumonary placement I was treating a patient in NSU (nursing specialty unit) with my supivisor. The patient had been admitted followig exacerbation of COPD, but had mets and lung ca, with the doctors deeming him pallitive. They had requested chest physio to decrease his WOB and anxiety.
I began to explain breathing startegies when the patient became quite distressed explaining he had not slept well and just had a sleeping med so would prefer to comply with physio in the afternoon. I agreed, though my supivisor interrupted and insisted- due to her heavy case load that we would treat him now. The patient declined treatment due to fatigue and resp distress, yet my supivisor persisted. I was hestitant as a student to interrupt, yet I felt she had breached the pts rights.
I looked on the treatment sessio with the pt becoming increasingly distressed, and finally left the room feeling the supiviso had crossed the line.
On reflection I should have interrupted for the pts sake, but as a student felt I was in no position to do so. In the future I will always remember that above all- the patients consent is important as well as a legality.

Treating the foot to cure the knee

I was treating a patient on my rural placement with chronic lateral knee pain (~ 6mths). The patient had hurt their knee going down some stairs and, being a fit person, decided to leave the injury to get better on its own. When the patient had finally decided to see the physio, they had a lot of wasting of their VMO and calf’s and his main complaint was pain when sitting with their knee flexed for long periods of time.

The patient had been seeing the previous PT student for 3 weeks, who had prescribed VMO strengthening exercises and applied McOnnells (med glide) taping, as well as STM of the ITB. The patient said that these treatments had offered him relief so for the first session with him I continued with the same treatments, and progressed his VMO exercise. Each week I concentrated on his VMO exercises (my theory was that his VMO had become so decondisioned that he needed some time to build its strength before his pain would improve). By the second time I saw the patient they had good length of ITB, good VMO activation, but their symptoms had not improved one bit. I was stumped and asked my supervisor for some guidance.

I explained to my supervisor all that I had done and was asked if I had checked what the patient’s hip and foot posture is like. I had analysed it when the patient was standing still and it looked normal. The supervisor advised me to have a look at those joints while the patient is walking. I did so and realised that the patient had poor control of pronation of the affected side foot. I then looked at his gasrtoc-soleus length and found that it was decreased significantly, and he mentioned that he had a Achilles rupture then surgical repair year ago. I addressed this by taping the foot to prevent over pronation and giving the patient a calf stretch program and the patient said instantly he no longer felt a pull in his knee.

The patient had not reported walking as causing his pain, and only once I had put the tape on his foot that he realise that he had a ‘pull’ of his knee when walking. Hence why I did not look at his walking. This taught me how important it is to analyse motor control during walking in a patient who has lower limb symptoms, even though that may not be the aggravating symptom. The body is a kinetic chain and an alteration in motor control at one point can effect other parts in the chain, particularly if it is injured. This experience made more observant of all my other patient’s movement patterns and actually helped me find things that were not obvious to the condition/symptoms the patient had presented with.

Cerebellar impairment following alcoholism

On my rural placement I was treating an alcoholic patient with moderate cerebellar impairment. I have realised that rehabilitating a patient with a cerebellar impairment is challenging in itself and is even more challenging when the patient is an alcoholic.

The patient was relatively young, early 50s and was admitted to hospital for frequent falls due to impaired balance, ataxia and peripheral sensory loss. This patient denied that they drank too much and was keen to get home as soon as they were ‘better’. It was obvious that this patient also had some cognitive deficits, with their denial of their drinking problem and also memory loss and they were also in alcohol withdrawal.

I had come up with a treatment plan, for his ataxia and impaired balance, but found it very difficult to implement due to these cognitive impairments. During the treatment sessions the patient was very agitated and verbally aggressive, and I became quite impatient with him and each time I went back to my supervisor and told him that the patient was not cooperating and that I felt I was not getting anywhere with them. My supervisor joined me for the next treatment session and managed to actually get an effective treatment session out of the patient.

I realised after watching my supervisor treat the patient were I was going wrong. My supervisor’s demeanour was sympathetic to the patient and my supervisor also attempted to make everyday conversation. I realised that I did not, I was in fact just telling the patient what to do and not building repoire. The next time I was due to treat this patient I read his notes and there was a new social worker entry, highlighting the events that had lead to the patient’s drinking problem. These events were extremely sad and I immediately realised I was judging this patient for being an alcoholic. When I went to treat the patient I changed my demeanour to being sympathetic, to explaining what and why they were receiving physio and during treatment I spoke to the patient about thing other then the treatment session and we even managed to have a laugh together.

This experience has taught me that I still have preconceived stereotypes that I need to deal with, and how much these can actually effect patient progress. I have learnt to leave my preconceived judgements out of my treatment sessions and have learnt how to build repoire with a type of patient that I have never had the experience to do so with. This will make me a better physio as I can be confident that I can help different types of patients even if I may not support or accept their personal decisions.

Dyspnea: A variable symptom

On my rural placement I encountered a number of respiratory patients with varying levels of dyspnea and hypoxia/desaturation. It is well known that dyspnea is not necessarily related to saturation levels, but it was interesting to see such differences between patient’s symptoms, functional levels and saturation levels.

I am going to compare three patients, and propose reasons for each of their individual dyspnea levels. The first patient is relatively young (50s) and had COPD, and was in hospital with an infective acute exacerbation. Normally the patient is independent (I) with al his ADLs and self care, and has an unlimited exercise tolerance. This patient desaturated to 82%-86% on RA after ~ 50m of ambulation, and his Borg SOB scale score 8/10. The second patient was in their late 60s, also had COPD, and was in with a non infective exacerbation. Normally this patient was I with all ADLs and self care, and was able to ambulate around the shopping centre without rests (aprox 20min). This patient desaturated to 72% on RA after ~10m of ambulation and had a Borg scale score of 0-1/10. The third patient was also in their late 60s, had COPD and was recently diagnosed with late stage lung cancer. They were on home 3-4L O2 via NP, normally I with ADLs and self care, and ambulated indoors and outdoor with a 4WW, her exercise tolerance was ~5min before needing to sit down and have a rest, due to SOB. This patient desaturated to 64% on 4L O2 via NP after ~5m ambulation. Their Borg scale score was 10/10.

The first patients acute SOBOE was most likely a result of a perfusion limitation, on top of already increased WOB (¯ complience of lungs due to their COPD). Normally the patient manages well, but they now have a V/Q mismatch due to the secretions from the chest infection blocking his bronchioles, and his WOB has now increased more then his ventilatory muscles are able to cope with. The second patients drop in saturations were most likely a result of her COPD progressing i.e. more lung tissue damage and also damage to the pulmonary capillaries. The patient did not experience an increase in SOB with the drop in their saturations, most likely due to a good level of physical function as well as seeming to have a relaxed and positive attitude which would influence the patients subjective experience of dyspnea. The third patient had a cancerous tumour nearly blocking off her left main bronchus. This would produce a substantial amount of airway resistance, which requires increased respiratory muscle WOB, plus her already increased WOB due to her end stage COPD.

It is important to know the cause of a patient’s desaturation, and possible contributing pathophysiological basis off their dyspnea, as this will direct whether physio treatment is required. Knowing the possible cause of the SOB will also guide whether the patient requires long term education about pacing themselves, ways to manage any anxiety related to the SOB, and positions of ease and potentially pulmonary rehab. The first patient was treated with ACBTs + percs + vibes+ shakes to clear secretions which helped to normalise his saturations and his SOB resolved. The second patient was prescribed domiciliary O2 and PT Rx was not indicated, the third required surgery to remove the tumour, and PT aimed to monitor her saturations, exercise tolerance and educate the patient about positions of ease and pacing her activities.

Dealing with demented patients

I was on my rural placement and had a patient with dementia. I haven’t had much experience with demented patients and I found communicating with the patient and hence trying to assess their mobility a bit of a challenge.

I approached the patient as any other, by introducing my self and giving a brief explanation of why I was seeing the patient. The patient was very pleasant and for each question I asked they would answer yes, for example ‘Would you like to come for a walk? Even though the patient had agreed to come for a walk, they did not initiate it, i.e. they did not stand up. I then asked them ‘Can you stand up?’, and offcourse the patient said yes, but did not stand up. I then remembered some dementia tips that we had learnt at uni; short commands, trying to avoid questions or choices as this can tend to confuse patients with dementia. So told the patient ‘stand up’, and held their hand and put my hand on their back to give them some tactile cuing as to what I wanted them to do. The patient stood up, and I said ‘lets go for a walk’, and after a few repetitions the patient started to walk.

After this first encounter I began to think of ways that would have been more effective with a demented patient. For me, I worry that the patient may be more lucid then I may pre conceive, and I feel like I should always start talking to the patient as if they are cognitively unimpaired. This is ok to start off with, as you can gage how impaired the patient is and hence change your communication style accordingly. I got thrown with this patient, as when they answered my questions, they were followed by an appropriate comment (eg. Q: ‘Would you like to come for a walk?’ , A:‘Oh yes, that would be lovely’.) I had dealt with a demented patient before and they would answer similarly and then get up and walk with me. However, it was obvious straight away that this patient would not initiate movement with these questions. I should have changed my communication approach with this patient to be more task oriented (eg. Lets go walk down to the tea room to have some tea.) Instead of telling the patient to do one mobility task at a time, I would have been able to assess them all just by giving her a reason to get out of bed and walk. I will apply this technique next time I encounter a demented patient.

Pain

My patient was a 25 year old involved in single vehicle MVA high speed rollover as a restrained front seat passenger at the end of July. He received extensive head and facial injuries including enucleated R eye, base of skull and cranial vault #, multiple facial #, sub dural and sub arachnoid haemorrhage with associated oedema and craniectomy , large degloving injuring of R face, 3mm anterior displaced odontoid peg # C2, avulsion # of C1 anterior arch and bilateral undisplaced #'s throught posterior arch C1. over the next 12 weeks he underwent multiple operations including skin graft and was eventually transferred to a rehab ward.
Upon initial assessment he required 3x max A for supine to sit, sit to supine, STS and 4 x max A to ambulate ~4m. He was displaying very strong pusher tendencies.He had chedoke McMaster grade 4 for foot, arm, leg, and hand and grade 2 for postural control (surprisingly low given his level of voluntary control
In just 4 weeks as the pusher tendencies dampened down he progressed to 1x min assist for ambulation and Independent for supine - sit - supine and STS. While the improved balance can be attributed to the reduction in pushing the other functional tasks rapid improvement was due to a reduction in pain and anxiety about moving the neck. As a result his postural control improved to a grade 5 in just a few weeks.
I was really surprised at how quickly this patient improved in 4 weeks of rehab given the extensive injury and surgery lists. Each patient like this that we see improves our knowledge and skill base for future clients.

Helping People who think they don't want your help

During my recent placement in a rehab ward with clients with a TBI there was a client (who was not given to either student to treat) who exhibited significant frontal lobe behaviours that made treatment extremely challenging. Signficant receptive and expressive dysphasia made communication really difficult and he continuously yelled (all day not just during treatment) and was very unhappy to changes. During this time a new physio ( a graduate) was allocated to him and made me realise that in a very short space of time it could be us in this situation and how would we handle this client. After two days of unsuccessful treatment sessions one of the other physios suggested that for a number of days the physio should just take him for a walk (in his wheelchair ) in the grounds and try to establish some sort of relationship with this client. Often this client would come to physio and actually do nothing because no one could get him to settle. I think this client more than any other I have seen this year has indicated the importance of building a relationship based on trust with the client and the importance of incidental physio that you can build in to whatever you can get the client to do.

way too early d/c

During my ~second week of this last placement, I came across an incident where the Dr. d/c the patient with no follow up physio when we think she shouldn't be. The patient can only ambulate around 10m before fatiguing when she was previously fit. Her chest was still wheezing on auscultation and just simply doesn't look well enough to go home just yet. Before we could get to the Dr about this matter, the pt was d/c already. I think the dr/interns should have communicated with us first about the patient and the suitability for d/c before they make decisions. Around 2 days later, the patient apparently went to ED with SOB. This has not happened before to me, I think with this ward I was on, there was a tendency for dr to dc patients when they 'think' they are well enough and won't bother asking the other members of the team. It was still early for me to pick this matter up so I think I would have made it clear if patients were not ready for d/c if this was to happen again (maybe by writing in the notes? and approach the dr directly) This incident came pretty quickly and if we didn't read the notes, we wouldn't know the patient was being d/c.

Boss for a day

For one day I was in charge of running the whole ward(my supervisor was off sick) so literally in charge. There were other physios around in another ward who I can page if I needed help but I was the only "physio" on my ward. I had to be really prepared, print off the handover sheet, get the handovers from the coordinator, prioritise my pt list and write up the plan for PTA, write up progress notes and to get through my pt load efficiently so I make time for am tea and go home in time =). It was really fun, the fact that I was able to handle it pretty well. As I was there for 3 weeks and a half before this happened I already got a good grip of how things run in the ward. The nurses also had to come to me when they had questions about the patients and I was able to answer their questions with no hesitation and with confidence. The only thing I had trouble with was reading pages from the pager...it was the first time I used it and when it beeped I didn't know how to handle it haha

Patient Independent or not?

I recently treated a 72 year old lady who had dynamic hip screw done on her (L) hip post-fractured NOF from a mechanical fall. She was then transferred to rehab ward under the DRAC team. During the first session, I progressed her ambulation with a gutter frame to a wheel Zimmer frame. While using a WZF for the first time, the patient was ambulating slow but considerably steady. And before writing her notes, I noticed that she was ambulating with WZF to the toilet without supervision and she told me that she had been to the toilet with the frame four times by herself. I also felt that the patient was safe using the frame so I stated in the medical notes that she was independent mobilizing with a WZF. On the next day, I found out the patient had a fall in the middle of the night while mobilising to the toilet, resulting in severe hip pain and was awaiting for bone scan. My supervisor asked me if I thought the patient was safe ambulating with a WZF and I supported myself with the fact that the patient was ambulating independently to the toilet four times during the day. My supervisor then said even though the patient felt safe, I should have written in the notes that standby assist was required as it was her first day using a WZF in order to protect ourselves from being blamed for accident. On reflection, even though the patient was blamed for not calling the nurse at midnight, just to be on the safe side, I should probably have given the patient more sessions to practice walking with a frame despite the patient appeared to be safe and independent before stating the patient was independent mobilising with WZF in the medical notes.

Higher function stroke rehab.

Physios are heavily involved in the acute and functionally impaired stroke rehab. Oviously the end stage functional ability will depend on the extent of the stroke and how much a person recovers, all maximised by PT (i.e not all stroke patients will return to high level function) depends on the patient. There is however a number of patients which do return to high levels of function, usually fairly young, previously fit and healthy people. This begs the questions; What is available out there to help them maintain their fitness and function, as well as being social and having the fun that is associated with being physically active? There are no gyms or sporting clubs out there that cater to a higher level stroke patient.

On my neuro placement I encountered a new and still small program which catered for these kinds of higher function stroke patients. Patients were pushed to do higher level and resisted strength training, sometimes on gym equipment, plyometeric training and running retraining (indoors and outdoors). Research was being conducted on the efficicacy of this programme, with great results.

This experience made me realise firstly, how many young people are actually affected by stroke, and secondly how little there is out there for these kind of patients in terms of increasing their quality of life and preventing future CV events (these people are obviously at risk of having another CV event, with this risk increasing if they remain inactive and unfit and regular exercise is one of the best ways to lower this risk and stay fit and healthy).

It also made me think about how much to push a patient. Some of these patients initially thought that they would never be able to run or exercise again but with peristance, modifications and supervision acheived amazing results. These patients will need to continue this for the rest of their lives, as they will always have their impairments and increased risk of CV event.

I also applied this to other PT subjects, for example musculo. When we have acheived pain free function a patient is discharged. A lot of the time though, the patient comes back (especially neck and back pain patients). To me these patients have a permanent impairment(This is not really based on evidence, just my own observations, that 0nce you hurt yourself that structure/joint is never quite the same and one time or another will casue you a problem). Hence emphasis on long term specific/therapeutic exercise is needed i.e Shoulder rehab group, chronic neck pain group ect. classes run by PT's. Just like running fitness groups for higher function stroke patients, or COPD patients can reduce the cost and strain on the health care system, so to can running classes for recurrent musculo conditions reduce surgeries, medication use, disability pensions, and reduce the likleyhood of a PT developing OA of their hands.

Allied Health

During this placement I have been treating a client who deteriorated rapidly two days post elective embolization for an AVM. ( R sided weakness, expressive and receptive dysphasia, vomiting and drowsiness). During our treatment sessions her expressive dysphasia is obvious and she has difficulty in communicating as she is unable to find the right word. What I did not realise until I attended her speech session with her was the extent of her speech dyspraxia. The speech therapist gave her choices and then needed to repeat the words six to seven times before the client was able to say the word, this included the names of her children !!.
I have attended many,many, many !!! sessions of speech therapy with my children but still found this single session very informative. Knowing the methods being used to aid her communication during the speech session has allowed me to use the same techniques with her during physio. I hope everyone has taken the opportunity during their placements when offered to attend sessions with other allied health specialists.

Physio POV

I recently treated a 50 year old lady who had bilateral total knee replacements and was discharged to home within a week with only 65 degrees active flexion in both her knees. I spoke to her surgeon regarding her progression post-surgery hoping to prolong her stay in hospital in order to gain a bit more flexion in both her knees and that I would like to keep her for a few more days as she would definitely benefit from further rehab at hospital. However, the surgeon said to me that the ranges in both her knees were important, but it was also important to assess her ability to go up and down the stairs with crutches. Being a physio student, I did not really know how to respond to the surgeon in a better way as I thought I have made myself clear that her current main problem was reduced active range in both her knees. I then approached my supervisor and I was glad that my supervisor stood by my side and agreed that it would be difficult for the patient to continue to gain more range if she was discharged with 65 degrees active flexion in her knees (most surgeons aim for at least 90 degrees active flexion post-TKR at D/C). My supervisor took measurements again on the next day and her knee ranges were still the same. He then spoke to the surgeon and stated his concerns however the surgeon did not feel that it was a big problem and insisted to discharge the patient. My supervisor then told me that we had at least communicated with the surgeon and if that was what the surgeon wanted, we had to follow the plan. He then told me that it would be important to record in the medical notes that “PT spoken to surgeon re: patient’s reduced ROM and surgeon happy to D/C” for medico-legal purposes. I learnt that PT point of view can be easily neglected when discharging a patient and there is not much we can do when the decision is made. I however then arranged an outpatient physio appointment for the patient to receive further physio as soon as possible, hopefully to help improve her knees functions. I also educated the patient thoroughly to make sure that she understands her current main problems and that she needed to work harder without PT supervision and a CPM machine at home.

Following a recipe

Currently on my cardiopulmonary placement, I had the opportunity to treat a patient in ICU with APO, cardiovascular instability and obesity (BMI  of 43). The patient had been in ICU for over two weeks, and has remained fairly unstable over this period. He has CPAP via a trachy, constant production of sputum that he is unable to clear independently and maintains O2 sats of 94% on O2 therapy. His BP fluctuates throughout the day and with t/f.

When I went to assess this patient, auks findings revealed insp and exp wheeze in the upper lobes, and quiet bibasally. The chest Xray confirmed L lobe pneumonia. He had decreased chest expansion bibasally and the NSG where regularly s/o 2-3 plugs M2P1 secretions. Prior to assessment, I read the patients noted to investigate past physio treatment he has received while on ICU. Over the two weeks, he received the same PT treatment bidaily: TEE’s, +/- vibes, active movement (10 ul and 10LL exs) followed by a s/o.

To me, this treatment sounded fine- TEE’s to increase FRC and Vt, vibes to aid in shearing secretions active movement to encourage increase in exp flow. All aimed at improving gas exchange, air way clearance and reduced lung vol. But the more I thought about this repetitive treatment, I began to think how effective 4*4 deep breaths and 20 active movements twice a day could really be for a patient this debilitated?? If the nursing staff are already suctioning, wouldn’t it be more beneficial to encourage active movement and set goals with a more functional outcome ie passive movements program to active assisted to active?

This experience taught me that it is important to understand the rationale behind treatment techniques and to not just follow a recipe when treating patients in an acute setting. Functional goals are just as important for the critically unwell as those in other stages of recovery, 

being flexible

Over the last 3 weeks, I have treated a patient who is awaiting news about whether he will recieve a double lung transplant, due to his severe bronchiectasis.
He has been asked by the physios running the exercise class for the advanced lung team to participate in the classes which run daily from 1-2pm. This class time is during our normal lunch hour, and they wanted me to bring the patient down at that time. This meant that for most of the week I had to have lunch on my own and lunch was often cut short.

I also was told that i would just be helping out in the class, but it turned out that I was to just take my patient through his paces, the the physios taking the class did not observe him during the hour he was there. The thing that was a little frustrating was that besides loosing lunch time for almost the whole week. All the exercises i did down in the PT dept could have been completed up on the ward gym during regular ward treating times and I could have just reported back his progress to the physios downstairs as I was doing without having to take him down 9 stories during my lunch break

Now enough whinging, I realise that a change of environment may be beneficial for this patient, and being a student you should just do a you are told. but even as a qualified physio, we need to be flexible sometimes to accommodate different programs. On the up side the patient displayed improved extol and the physios were grateful for me taking the patient down each day. Perhaps if I believe exercising up on the ward and reporting progress later in the day was a better idea, than I could voice that idea to see if it woulf have the same outcome.

how much will an elderly patient improve?

I am on a prac where I am mainly trying to improve deconditioned elderly patients strength, balance and endurance. We try to get the best possible outcome so we know whether to send them to high care, low care or home. I struggle when to know when they have reached their full potential, as my view is most old people are pretty weak, unsteady and not exactly marathon runners and compared to a lot of other elderly people in the community they seem relatively similar (in terms of acceptable level of functioning).
What I would accept as normal for an 86yr old is different to what experienced physios on the ward accept. I find it hard to know when to determine that physio is no longer helping. I have addressed this problem by reviewing the inpatient notes (particularly the social worker notes) on the patients previous mobility status. I try to aim to get them at least up to this point and if they are very slow to improve then make the decision that they are in fact deteriorating and therefore would benefit from higher level of care upon discharge. I have also found the old notes (previous admission notes) very helpful, as they state the reason for admission (i.e. admitted 3 times last year all related to falls), and therefore can direct my treatment and discharge planning accordingly.

hospital or physio equipment?

At my cardio placement at the moment, I have been required to take one of my patients down 6 stories to the physio department to partake in exercises because he is awaiting news on whether he is going to have a double lung transplant. This requires me to take him down in a wheelchair with his O2 as he will get too SOB and desaturate if he walks that far. For the last 2 weeks I have used the wheelchairs on the ward because they have a slot to place mobile O2 and they were the only wheelchairs i was aware of on the ward. This week a lady who had the key to unlock the wheelchairs (who i believe was either a orderly of a cleaner) joked at first that they should "charge us rent" for us to use the wheelchairs as we had our own and these wheelchairs were for them. She showed me this "physio" wheelchair, but i noticed that it did not have a place to put O2 and therefore was not suitable. I mentioned this to her, but she still pressed the fact that the other wheelchairs were for her use.

This made me a little annoyed, as I was using the wheelchair for a patient, to recieve treatment and she was making this more difficult.

I am not sure how I could have made this a better situation, as previous orderlies holding the key have not had an issue with us using these wheelchairs. Perhaps, by explaining that I will return the wheelchair within an hour and the need for this particulat type of wheel chair will help.

aggressive patients with dementia

I am currently on my gerontology placement and am finding some of the more demented patients very difficult. Some are very aggressive and call me names and swear at me when trying to get them to do anything. For example I was asked by my supervisor to do a mobility assessment on an elderly lady. I introduced myself and made niceties etc to develop rapport, then simply asked her to come to the gym with me for “a look at how you are managing”. She told me she was managing fine and if I didn’t believe her to call her husband. I then decided to compromise and do a simplified assessment in her room. I asked her if she could roll to her side. She then became very aggressive and told me to “bugger off”. I asked her to sit over the edge of the bed and she told me to “go to hell” and “get out of here I’m sick of the sight of you”.
None of the physio’s have been able to get her to comply and do any physiotherapy. I have tried to trick her into doing exercise or assessment. I told her I didn’t think she could sit over bed and walk and that I thought she was fibbing. She then did these tasks to prove to me (very abusively) that she could do them. I’m not really sure if this is ethical, but I was able to get the task done and in doing so determined her level of mobility. I was wondering if anyone has any strategies that they find helpful.

sterile suctioning

While I was on my cardio placement it was routine to suction patients, due to the nature of the placement. My supervisor was very pedantic (understandably) about the sterility of our technique. We were instructed to double glove on the hand that was to touch the catheter and NOTHING else was to touch the catheter or the glove touching the catheter.

I became quit efficient with this technique and could perform it with confidence towards the end of my placement. I did, however witness on a number of occasions poor technique by nursing staff. They did not double glove and they would often clean the mouth with the catheter that had just been removed from a pneumonic airway. I found this very discerning considering we physios take the utmost precautions to be sterile to prevent further infection and complications.

I didn’t report and confront the nursing staff on their technique and question whether I should have? I think in the future if I witness this again I will simply (tactfully) educate nursing staff on correct technique and emphasise infection control. I feel as a student it is a touchy issue, when trying to approach qualified staff about the effectiveness and appropriateness of their job.

the proffesional vs personal barrier

I am on a placement where I see my patients twice daily. I have been seeing this one old man for several weeks now and have development good rapport with him. He reminds me very much of one of my elderly relatives so that has made me quite fond of him. I feel very sorry for him because he tells me all the time that he loves his elderly wife so much and wishes he could see her more. This is however hard as she cannot drive and their only son works far away.
One day he was quiet during our physio session and seemed generally depressed. I asked him if he was alright and he became teary. He told me it was his 60th wedding anniversary that day and he wished he could see his wife. He then told me all the details of his wedding day and how much his wife means to him. I felt so sorry for him that I was almost in tears myself, silly as it may seem! As it was my half day I offered to go and collect his wife from home and bring her in to see him. I asked my supervisor if this was alright and she was very hesitant. I then decided it was best not to because I think this would be crossing the barrier between professional and personal. I told my patient that it was against hospital policy that I collect his wife, and he understood.
In the future I hope to be able to handle the situation better and not get so emotionally tied to patients personal problems.

unmotivated patients

I am currently on my gerontology placement, which for the most has been enjoyable. I am finding it difficult however to motivate patients to exercise. The common excuses are “I’m too tired, after lunch, I’ve just had a shower, I’m waiting for a cup of tea” etc etc. As most of the patients have some form of dementia it is difficult to reason with them rationally on the benefits of exercise etc. Initially I tried to explain why I need them to do exercise and physio, but this was unsuccessful as patients would look at me confused and simply tell me to “go to hell, bugger off or they’ve had enough”.

I found this to be quite disheartening, seeing as I was only doing it for their benefit and not for my own amusement. I’ve now learned I need to speak to them with some form of understanding of they wants and try to meet these. Such as bringing them a cup of tea after physio if they are about to miss the tea trolley due to physio. I have found this to be rather more successful but I still get a few patients who simply try to fit me into their routine rather than the other way around.

Inapropriate patient

On my neurology placement I had an experience with a very inappropriate male patient. He was a new patient, so I did not have any warning about potenial inapropopriate behaviour. I was very shocked to say the least and think that I did not handle the situation in the best way.

The patient was elderly with a history of right CVA (LACS)and intially seemed a very pleasant and refrained person. I began my subjective amd after a little while the patient began to make subtley inappropraite comments. I ignored them and continued with my assessment. They continued and grew more uncomfortable as the asssement continued but I chose to stick it out, trying not to let it phase me.

I then came to the objective part of the assessment, and this is were things got really inappropriate and I felt very uncomfortable. I reached my wits end when the patient touched me on the buttocks: I was no longer uncomfortable, I was angry. However I remained calm, and told him, as politlelty but sternly, that if he continued with his inappropriate comments or if he touched me like that again, I would stop the assessment and never treat him again. This had the effect I hoped, with the patient behaving for the rest of the assessment. By the end of the treatment I really felt like we had build a repoire and that what had happened previously was behind us. I chose not to tell my supervisor, as I didn't see the need.

The patient cancelled his appointment and I felt compelled to tell my supervisor what had happened. My supervisor said not to worry about it, and left it at that, which suprised me (I was lucky to have a pretty cruisey supervisor me thinks). But I started to think about how I could have handled the situation better, particularly as a student, especilly since this was the second time a patient had cancelled, seemigly due to what, or how, I had said. I really should have excused myself and went to my supervisor with what had just occured. The supervisor could have then come out to assist me, making it look like he was helping me ect.

I am a pretty honost and straight forward person, and am realiseing that maybe I need to learn to be more discreet when handeling situations like this, to seek more advice from my supervisors, instead of trying to handle things I have no experinece with myself. In future I will consult with my supervisor about touchy situations instead of trying to deal with them myself.

HELP!!!!!!!!!

On my current rural prac, I have been seeing patients on my own without supervision and I only work with the physios/"supervisors" when they need a second hand to stand patients up. I have been working with a fresh graduate physio from N**** D*** who graduated just a couple months ago in the same ward for the past two weeks. She is very nice and friendly but I have been feeling very anxious and unsafe for the patients when watching her treatments. During the first session with a patient with congestive cardiac failure (CCF), we checked his observation chart: increased respiratory rate 26 breaths/min, otherwise stable. The patient was on 2L O2 nasal prong so prior to seeing this patient, I suggested to grab an oximeter but she told me not to worry about monitoring his O2 sats. Besides not monitoring the patient’s oxygen level, she did not monitor/palpate the patient’s pulse rate or ask for constant feedback if the patient feels okay. On top of that, she kept pushing the patient to do his upper limb exercises in the chair even when the patient became to look more distressed and his breathing rate was obviously increasing which really worried me while watching her treating this CCF patient. She then got me to help her to stand this patient up, and I was so worried that we would make him feel worse (e.g. cardiac arrest). We failed to stand him anyway and the physiotherapist ended the treatment.

When seeing the second patient who sustained a full rotator cuff tear and needed 2-person assist with standing as well, her patient handling was worrying me again. She basically was grabbing and pulling the patient’s injured arm while trying to stand her up. The patient was swearing and then refused to stand. So we put her back to bed and I felt really bad and sorry for the patient. The main lesson I learnt: the importance of regular monitoring and putting patient safety first while carrying out treatments. I have thought of approaching one of the senior physiotherapists to discuss this matter but given that this is my last prac, I do not want to create potential problems/conflicts for her/me as I will still be working with her for the next two weeks. Can anyone please give me some good ideas on how to solve this problem if the same situation happens again that put patient’s safety at risk? Any advices or suggestions will be much appreciated.

pain pain pain...

I have another surgical patient who has undergone a major abdominal surgery. I was again the “physio” to mobilize her day 1 post op. This patient has an altered understanding of her post op recovery – she thinks that it was ‘too early’ to mobilize so soon after surgery and she is very dominant in nature. On day 1 post op, her pain was not very well controlled and she was very irritated when we asked her to SOEB at least. She reports subjectively 10/10 pain at rest (using PCA which was not helping at all), however, she was able to talk to us with no cringe in the face, and was able to move her legs freely but was not compliant at all to what we wanted her to do. So, day 1 post op we only managed to give advice/education about breathing ex and circulatory exercises and did a chest assessment with her lying supine. When we returned the next day, her pain was better controlled but she was still reporting high levels of pain but was more compliant this time. She was able to ambulate 1xSB assist with no aids and just needed assistance with pushing the pole with all the attachments on it. She then made comments about not having enough sleep and we shouldn’t make her to this so soon after surgery and asked us not to interrupt her when she is ‘asleep’. I think if she had a better preop (if she had any) education about her operation and recovery period, her attitude will be better and more compliant. What I did was mostly liaising with her a good time to visit and really explaining myself to why we need to mobilize and not to allow the patient to dominant over us !! This patient is progressing really well compared to other patients I’ve seen and she does feel better after moving around, it just takes a bit of convincing and explaining.

cultural issues

I have got a surgical patient who is Aboriginal. I was responsible to see him day 1 post op for chest physio and mobility review. The main issue that have arise from this situation is the patient’s attitude towards females and dignity issues. I went to see him with my supervisor one day and talked him through what we will do for that day which include getting him out of bed and go for a walk. He only had a gown on at that time, he didn’t sound very comfortable talking to us (2 females) and requested to put some pants on, when we offered to help he declined the offer and said “I’ll like to have some dignity please”. We told him that we will help put his legs through the pants and he can do up the pants by himself with the sheets covering – this worked out well. On the other occasions, he also made comments such as “ I wish I was in a full male ward” and I felt that he was not very comfortable for me to treat him. However, he is a compliant patient and is progressing well after surgery. With this patient, I think it is important for us to understand their culture and not to take comments personally and to communicate with the patient and provide reassurance when needed.

Working towards Independence

Currently on my last placement for fourth year, my goal is to work towards independence on a hospital ward to increase my confidence following graduation.
Prior to commencing this placement, a fellow student and I discussed our goals and expectations of this final placement with our supervisor who happened to be a new grad themselves. We both agreed that the main goal of this placement is to be able to run a ward, including obtaining ward lists in the am, identifying then prioritising the patients to be seen then carrying out the treatments.
In the first week of placement, the supervisor delegated all the suitable patients, which was fine as we were getting used to how things worked on this particular ward and at this hospital in terms of discharge, allied health teams and caseload expectations. This week we both asked for an opportunity to increase our input as to how the patients were divided and to increase our case load as last week was fairly light and not pushing us as much as we wanted. The supervisor agreed, but for the past four days he has continued to print off the lists in the am, give us four- five patients to be seen for that day and simply leave the patients notes for him to read over at the end of the day.
Both the other student and I have discussed the current situation and are trying to decide how to approach our supervisor about it. We understand that as a new grad he is not as experienced as a supervisor and doesn’t want to seem as though he is a dumping a workload on us, but at the same time he is treating us like a supervisor would have at the start of this year.
We have decided to address the situation by asking if we could have increased input in the am with handovers and practising dividing up and prioritising patients, which he can over see and make any changes he feels necessary. Hopefully next week we can ask for an increase in case load, depending on how he feels. Ultimately it would be most beneficial to our learning if we could simply practise these independent tasks, then get immediate feedback. If any one has been in a similar interest and would like to provide insight into how to ask for greater independence that would be appreciated.

Limited Communication

I am currently completing my final practical placement in an international facility, working primarily in a neurological setting but also other areas as the opportunity arises. I have found there to be challenges that are somewhat unique here, as a result of both cultural and language barriers. For instance, the younger population are taught three langauges, with English being one of them. However as most of the neuro patients are older, this is not the case in the vast majority of the patients with English being very uncommon. It has been possible to get by using the few words that I have learnt of the native language, or with the aide of staff and family members (who regularly sit in and watch the treatmet, something you need to adjust to). I have found that this is an environment where the need for non verbal communication is greatly stressed. Given that neurological patients can present with impaired cognition, confusion or forms of dysphasia, it has not been so different to my earlier neurological placement. Facilitation with hands on contact is still extremely effective, as is the select use of specific words so as not to confuse the patients. The patients affect also becomes extremely important, as without a translator, some verbal communication is not as meaningful as the way it is said, or the patients non verbal cues.
Admittedly, it is much harder to communicate with patients who speak differing languages, as you cannot specifically ask for certain symptoms, hence it would be a nightmare in Musculo, but I have not found that the language barrier has been to hard to cross with neurologicla patients.

New Grad Supervisors

We are now in our last 4 weeks of prac and many of us will currently have supervisors that have either graduated in the last 6 months or in the last 1-2 months.
I personally have found this amusing, despite the fact that they have passed one more exam than we have, it feels a little strange having supervisors, that are new to the workforce. I do think that we all can learn from anyone and everyone, but when the supervisor has had very little more experience than yourself, there will certainly be limitations to this.

I am not complaining at all, as my supervisor, is a lovely and knowledgable person from a fantastic tertiary institution!! who am enjoying working with. I certainly dont find it hard to learn from her, but because she has only been at this ward for 2 weeks longer than we have, there are areas that we both have to try and figure out. This has been achieved with questions being raised and recolecting from past prac experiences (the only experiences we have to look back on in terms of hospital experience).

Learning from Mistake

On my current rural and remote prac, I was treating a 78 year old man who came in with sore (L) foot secondary to gout with an extensive history of cardiac diseases. At rest, his heart beat was irregular 40-77bpm and oxygen saturation was 97% on room air. During ambulation, his oxygen saturation dropped to 79% on room air post-60 metres, and recovers to 94% in 2 minutes. I then raised this problem to the patient’s consultant during a team meeting. The consultant initially stated that the problem might have been caused by the oximeter but I insisted that I had checked both his hands temperature and swapped between pt’s fingers/hands to confirm the finding. The consultant then decided to have a chest x-ray done on the pt and asked me to re-assess the patient again, and if his O2 sats continues to drop to 80% on RA, they will perform an ABGs test. I consulted my supervisor regarding this patient and my supervisor was willing to see this pt with me. On re-assessment, the same thing happened again and my supervisor explained that it was normally perfusion problem when O2 sats dropped below 80% and I should try using ear probe instead of finger probe. We had to go to the paeds ward to borrow an ear probe oximeter and on reassessment, the patient’s oxygen sats turned out to be fine, maintaining 94% on RA throughout ambulation. On reflection, I should have thought of this problem and tried using ear probe in the first place. I should have checked all possible causes that can lead to dropping of O2 sats and not to forget the use of other equipments even though they are often not provided in the ward in order to justify & confirm my assessment findings before discussing with the consultant or other health professionals to avoid confusion.

Effectiveness of Treatment

I am currently on my cardiopulmonary placement, and had my first experience with a patient in ICU. The patient was a 77 y.o female, BIBA to ED 6/7 ago with a 3 month history of nausea and vomiting. A CXR revealed a L pulmonary effusion and empyema, and she underwent a thoracotomy the following day. She had received physiotherapy treatment for the past four days, but had not yet mobilised.
Her main problems include: reduced lung vol, impaired airway clearance, pain and impaired gas exchange.
On assessment, she had poor chest expansion bibasal with L>R, ausc revealed no B/S L lower lobe and poor b/s L upper lobe. The CXR taken that day showed a worsening of the L lung effusion, and the patients ABG’s were a concern with PaCO2 at 60mmhg. Overall the patient’s general condition was deteriorating.
The PT that treated her the day before expressed the goal of mobilising the pt with a hoist to assist with secretion clearance and improve gas exchange, but following the assessment in the am, I decided not to sit the patient OOB as she was quite unstable.
Treatment then consisted of deep breathing ex’s, upper limb exercises and repositioning. On evaluation, ausc findings revealed no change, her cough was still moist and non productive as her deep breaths were impaired by her increasing confused state and pain.
I saw this patient with my tutor, who encouraged me to rationalise my treatment choices and provide justification of my actions prior to treatment. She then agreed with my plan. The main problem of this scenario was my doubt as to the effectiveness of my treatment in a situation like this. I understand that the treatment options have sound theory as to why they work, yet I question how effective the implementation of these techniques where to the patient. The evaluation post treatment revealed no change in her respiratory status, despite my tutor deeming my treatment as competent.If any one would like to comment on other possible treatment options, or what they would have done in the situation that would be much appreciated.

Bipolar Patient

I am currently doing my cardio prac, and was required to do a 6MWT on a patient who was being treated by the psychiatrist for his bipolar condition. The notes suggested that he was a non-compliant patient, who could be difficult to talk to at times, but when I went to see him , he initially presented as a friendly man. Following doing a subjective and nearly finishing his objective assessment, I then explained to him, the process on the 6MWT and then we went out to the corridor to complete the test. We started the test (using a 25 metre track) and we walked a couple of laps, before he said what u want me to keep going? I replied yes we still have to walk for just under 6 more minutes, and said he was doing well. After completing the test, he said that I had only told him to walk 25 metres and never said that he had to walk 6 minutes and that I should tell him next time, otherwise he expected only walk 25 metres.

I thought for a second, because I had explicitly told him what he was going to do, but to avoid confrontation in front of other patients, I said i am sorry and should explain myself better.

I dont think i behaved badly following the 6MWT, however to make sure that I am not at fault, it would be good to have pt's such as this to repeat back to you the procedure, to make sure they fully understood what was required.

Comprehensive treatment

In the final week of my musculoskeletal prac i found myself recieving patients who were presenting with slightly more vaired conditions. While I still recieved the same number of back pain and knee pain patients, I also managed to see shoulders and upper limb injuries, which I had no experience with. However, given that my approach to treating patients had changed considerably since the first week, I did not find my inexperience with shoulders to be a barrier to effective treatment. Over the past three weeks I had found myself incorporating information learned from units such as Musc 352 and epa, even though I initially would no have expected it given the patient referrals. For instance it took me a week to remember that I could use the available TENS machine to manage the pain of my patient who had developed sensitisation problems, and this allowed me to optimise the treatment session time as pain was no longer a limiting factor to his active movement and range.
The same could be said of using Hold relax when trying to gain additional range in patients who had developed tight hamstrings due to a stooped gait due to low back pain.
While none of this is rocket science, I did noetheless find it difficult to recall, and feel that my treatments became considerably more comprehensive as a result of me applying the knowledge that I had learned in all 4 years, not just 3rd year. Admittedly I should ahve revised more prior to beginning the placement, but I found it easier to revise things that I thought would impace directly on the patients condition in my opinion. I think tahat I have learned as a result of this that the treatment modalities that we have at our disposal are much more comprehsnive then I had initially thought. Wether it be providing our own form of pain relief or having more of an impact with patient education, the units that recieved less of an emphasis (psych, EPA, movt science) can all prove effective in managing a patient if we choose to apply them, and this can result in more comprehensive treatment.

rural cardio

On my rural prac, I came across a few cardio patients, all of whom presented differently with similar pathology (COPD) which allowed me to see the great variation in severity of the disease impacting on the patient’s QOL. They were all generally bright in personality and motivated so compliance was not a problem. What I found interesting was that the readings from oximeters, Ausculations etc does not always correlate with the patient’s presentation.

Patient 1: elderly lady, very keen for exercise however has low exercise tolerance. SOB limits her ambulation distance which was around 10m. SpO2 would below 85% but the patient will need a reminder to take a break and would only report she’s tired once we stop.

Patient 2: relatively younger patient in 50s, on O2 therapy, SpO2 would desat on RA to below 80% dramatically. She could walk a long distance given she had O2 on. TEE and SMI worked very well with getting improved gas exchange with this lady.

Patient 3: this patient was more severe, had a lung reduction surgery on O2 24/7. Only able to ambulate around 10m (housebound) normally. Ambulation limited by severe SOB.

From working with these cardio patients, I found that the oximeter we use to monitor SpO2 was helpful for us to decide when to give pt’s rests or terminate the treatment but most importantly getting subjective feedback and monitoring the pt’s face was very important also. I also found that these patients were very compliant and would keep walking even if their Sats are low, so it is important for us to prompt them when this happens.

I have not yet done my cardio placement but I think the cardio patients I saw on my rural prac will be helpful when I actually see cardio patients for 4 weeks!!

patient education

From my Musc OP placement, I found that patients often come to the clinic with a minimal understanding of their condition and I found patient education played a big role as part of the management for the patients. I realised building rapport with them first is also very important to get their trust and confidence to what we are telling them. Also, helping them with understanding the problem, the anatomy and telling them “why” we are doing specific things were important as well. I had a patient with post RCR repair, on the road to end of recovery, had minimal functional limitations and the only thing he is complaining about is getting pain at end abduction, ER (sort of reaching backwards)- impingement position. I had to tell him that that was normal and explained the anatomy of the shoulder and how the scapula is invovled with shoulder movement. This got more compliance from the patient to do the scapula setting exercises (and to do them properly!) and I believe the patient had a greater knowledge of how he can get better. It was great to see the patient was happy with my explanation and I must say I found it a little challenging to explain it in easy terms so he can understand what I was saying(about the Scapulohumeral rhythm). I think I did well with explaination and patient education and I believe this is an important aspect of treatment. The patient was discharged around 3 sessions after.

Timeframe

As I approach the tail end of my Musculo prac, I have now been exposed not only to patients who are new admissions, but also a number of patients who I have seen a number of times and as a result been able to monitor their improvement. This has provided me with an insight into the nature of the patients conditions, their response to treatment and also allowed me a better understanding of what intervention works and for what condition. It has made me appreciate how frustrating it must be for some of the patients who have waited over 8 weeks in order to receive treatment for an injury, and have had the carry on with the pain and associated painkillers for weeks, and then receive some sort of recovery in a short period of time. While the change would be great for the patient, one has reported that he was annoyed that it took 8 weeks to get treatment, as he felt that he had spent the last 8 weeks in pain unnecessarily. From that perspective he has lost 8 weeks through his pain limiting his activity. Admittedly this has been an unusual comment from the patients, and he has been the first and only to state such (he is also one of the more acute cases, and is quite young with previously high levels of activity). For many of the more chronic conditions, patients have been attending physiotherapy for months on end, and as a result this has not been much of an issue.
However, considering the patients comments about the length of time between injury and treatment, I have thought about possible alternatives to waiting. It would not have been possible to treat the patient much earlier for the clinic, as the physios already have an extensive list of patients, and I believe my patient would have had to wait longer if it had not been for me being on placement. I suppose the alternatives I could think of for the patient would have been consulting a private practice (not sure how that works with medicare/private health insurance). I am not sure what other options are available for patients who are on wait lists for OPpt, but I am aware that the wait of 8 weeks for a sports injury is not as bad as waiting 1 year for an appointment with an orthopaedic surgeon. I am aware of how and why a patient may be disgruntled at waiting 8 weeks for treatment, but I think it depends more on the patient and their outlook then any intervention by myself.

Referrals to OPD

I'm now just over halfway through my out patient placement, and have seen quite a variety in how patients present and how their referral describes them. Given that the department sees a large number of patients referred from orthoapedic clinics, there is in some cases quite a large waiting time. For those who need post op reviews or exercise prescription, or referrals to hydrotherapy, some have been seen within 2 weeks of the referral. However, in the cases of non surgical and non trauma patients, the referrals have been in some cases more then 8 weeks ago. An example of this is a patient who suffered a dislocation of their patella. As this patient had certain equipment available (knee brace, crutches) through a friend, they were reviewed at the clinic and advised to rest the knee, being referred onto physiotherapy. However, with so many weeks beteen the referral and availability of treatment, the presentation of the patient can vary significantly. In the case of the patient who was more proactive, their condition was generally better, with less pain and better range of motion. However, in another case I saw, there had been next to no activity of the knee since the ortho clinic (the patient's ADL's did not call for high levels of activity). As a result the patient presented with almost unchanged pain levels, had not attempted to maintain any range (now very pain and resistance limited) and had a degree of sensitisation around the knee. Hence, the referral asking for review of a patient who was 8 weeks post patella disloaction was significantly different to the presentation of the patient at the clinic.
However, having spent some time in the orthopaedic clinic while on prac, I have resigned myself to the fact that it is the most effective system. Each consultation with the Orthopaedic surgeon and the physiotherapist (if present) lasts around 15 minutes, which does not provide any opportunity to give any more advice other then symptom control (rest, ice, heat packs etc). The surgeon and the physio simply don't have the time to go into any sort of treatment recommendations, and as a result, the longer the waitlist for the patient, the greater possible variance in their presentation. If anyone has experience similiar situations and wanted to voice their opinion that would be swell.

bad handwriting on inpatient notes

I am currently on my cardio placement at ICU. Before we treat pts we must read all the inpatient and admission notes to get a timeline of events that have happend while the pt has been in hospital. I found this to be very hard as I find it extremely difficult to read the handwriting. It is very time consuming and on a number of occasions I have missed critical information which is essential background knowledge to keep in mide when treating a cardio patient. for example if I was to see suction a pt and they had high blood pressure it is not so much a worry if the pt has a history of HTN as this is his "normal" BP.
On a number of occasions my supervisor has corrected me when I have missed these points. In the future I will try to be more particular with my note reading and ensure I haven't missed any important points by asking the nurse in charge how the pt has been going etc.

sorry its short but I really didn't have much to write!

conflict with nursing staff

I am currently on my cardio prac, in the intensive care unit. Most of the treatment for each patient involves suctioning and manual hyperinflation. In order to perform MHI you must squeeze a bag that has a resouvoire of O2 into the pts lungs. The bag holds 2L, and the amount that you squeeze the bag determines the tidal volume delivered to the pt. I was instructed by my supervisor to deliver a tidal volume of 1L, so squeeze half the bag basically.
The nurse that was looking after my patient I found to be very nosy and intrusive (considering I was being closely supervised by the physio in charge at the time). He told me to go easy on the MHI and that I was delivering too great a tidal volume and that I would hurt the pt. I then proceeded to lower the tidal volume even though I knew I was supposed to give a 1L amount of O2, as I was intimidated by the nurse.
My supervisor then interrupted him and said that I was supposed to give a 1L tidal volume in order to re-inflate the areas of atelectasis and help with secretion clearance. The nurse then backed down and left the room. My supervisor then told me I my technique was correct.

In the future if I know I am correct (and especially if I have been given direct orders from my supervisor) I will be more assertive to allied health staff. I feel that as I am a student my opinions/knowledge are inferior to actual members of staff, but I will work on being more confident in what I have to say/offer. In the future I will try to tell the nurse diplomatically the rationale behind my treatment if it is questioned, and hopefully this will help the ignorant nurse understand the technique better and have confidence in my skills.

Pain

I have recently begun my Musculo Outpatient placement, and have received patients who present with a number of complaints. The majority of the new admissions appear to be post op follow ups, or referred from orthopaedic clinics, which has allowed me to see some variety in diagnosis and presentation. However, many of the current patients at the practice are chronic pain patients who have been presenting for an extended period of time. While I personally have not been assigned any of these chronic pain patients, I have assisted or observed the assessments of the supervisors. Some of these patients have presented with pain that has lasted for over 20 years, and in some cases the patient has had the pain longer then they haven't. The majority of patients appear to have acquired the pains through work related accidents or injuries, with some as a result of trauma. What I have noticed through the observation of the senior physiotherapists is that the treatment for the pain patients appears to involve very little intervention. For the most part advice and education on self management play a far more significant role then any sort of manipulation. I was informed that the reason for this is due to the psycho-social yellow flags that we observe for during an assessment. The supervisor informed me the applying an intervention such as mobilisations or manipulations for a chronic pain patient is much less effective then self management and education in terms of patient outcomes. Promoting self management decreases the chance of the patient becoming dependant on intervention to function, and also is more likely to allow the patient to remain independant. I have also learnt that with chronic pain patients their response to treatment is as dependant on their physical state as their psychological state. The supervisors have told me that the patients who manage their pain the best are the realists, who acknowledge they will always have pain regardless of treatment. It is the patients who expect a miracle cure who then cease treatment when they don't get the results they expected, which in turn directly impacts their quality of life. Even though I am only a week into my current placement, I feel that I have a greater appreciation of the impact of a clients outlook on their condition, as well as the psychological state, especially when dealing with an issue such as chronic pain.

Discussing Discharge

Over the past four weeks on rural placement I found it difficult to discuss the option of discharge with a few patients, as they where not willing to cease treatment despite being relatively asymptomatic. One patient in particular, a 68 year old male with right low back pain and right lower limb pain/weakness with the medical diagnosis of L3/4 facet joint degeneration and mild disk extrusion, received treatment for the discussed twice weekly, for four weeks. This time period was discussed at the commencement of treatment and agreed upon if he was relatively asymptomatic after this period.
At this rural placement, like a majority of rural facilities, there is quite a large waiting list so it is important that if the patients have progressed to discharge then they no longer receive weekly treatment. But over the period of the four weeks I came to know the patient quite well, and he would bring me wooden pens he made at his wood work shop and express his appreciation at having some one to talk to because he was quite lonely. His treatment included PAIVMS, trigger point therapy of glut’s and Q.L, heat pack application and HEP. After the four weeks his pain was significantly decreased to WNL and he no longer experienced the radiating leg pain.
On the conclusion of the final treatment, he refused to accept discharge and expressed interest in ongoing treatment. So I discussed with him his underlying pathology, and how we have progressed as far as I can help, which he said he understood, but he wanted to keep coming in because it gave him something to look forward to.
After much discussion, he agreed that discharge was necessary, though I did find it quite difficult to be forceful in this situation. My supervisor confirmed that my actions were correct, though I still feel a little bad having to discharge him on that note.If any one has experienced similar patients and can share how they dealt with their refusal for discharge I would appreciate it.

CVA on TIA

On my last placement I was treating a man coming in for a mild TIA which only affected his Right LL (weakness and sensory disturbances) and balance due to R LL weakness. I was treating him for around 4 days for his balance (high level) and some strengthening exercises for his R LL and also weight shifting exercises onto Right to increase WB on R and knee control in R. All was going well and he was ambulating independently around the ward on his WZF. One morning when I went in I couldn’t find the notes for this patient, apparently he was admitted for ED for having another stroke. The physiotherapist was comforting me and told me the patient may be alright – its just that the ward does not have a doctor present all the time, at least when he’s in ED a doctor can attend to him in case something happens. So 2 days after ED, the patient returned to the ward, I had to do his assessment again from the start because he has a new condition now (pt was diagnosed with bilateral cerebellar CVA). It was really interesting to see this - he had severe ballistic movements which frustrates him. It was quite sad to see this to happen especially when you already built rapport with the patient and they are progressing really well. The next few days, I was one of the 2 therapists treating this patient ( we had to have 2 full assist to help him from supine to SOEB otherwise his UL and LL will start to ‘fling’). From there rehab continues…the patient gets quite anxious and frustrated with his uncontrollable flinging movements and our job was to reassure him and get him to relax. From this experience, I believe I can handle emotions better in future if this is to happen again, we must understand the aetiology behind conditions (in this case – previous stroke is a cause for subsequent strokes) and since we can’t stop strokes from happening again, we must be professional and treat as necessary. We can also talk to our supervisors about the experience and I’m sure they will give us some ‘counselling’ of some sort if needed.

difficult patient

On my musculoskeletal placement, I had a patient who came in with knee pain. However, due to an intellectual disability, she was not able to specifically tell me about her pain or its history. All I got out from the subjective exam, was that there was pain all over the knee. When I asked a question to clarify, she always said “yes it hurts” or “yes that makes the knee hurt” etc. Basically, everything I suggested seemed to make her pain worse…

During the objective exam, everything I did made the pain worse and she did seem to like the idea that I was touching her knee. I was getting quite frustrated as I had no idea how I could help her, especially if the patient was not giving any hints!! Her carer started talking to the patient about what they would do after physio, that seemed to make the patient less interested about her knee. I was then able to do PAM’s on the knee, and palpate! Following the example of the carer, I started chatting to the patient about her interest and at the same time getting her to do some of the objective exam (AROM, fx tasks etc). She was more cooperative with physio and did not seem too caught up with her knee pain.

In future, if I do get a similar patient, I am able to handle the situation better. I will not focus the patient’s attention on their pain. Instead, I will use distraction while performing the objective exam. In these situations, an objective exam would give me more information than a subjective exam.

Ongoing education

Finishing my paediatric placement, I found that paediatric physiotherapy despite being given a focus over the years of study, does not receive the same amount of teaching time or content as the other streams of physiotherapy (Musculo, cardio etc). Whilst on my paediatric placement I found that the education I have received has made me competent, but it is still extremely limited in the face of actual patient loads. There were conditions that I saw that admittedly are quite rare, yet I had not even heard them mentioned in the context of physiotherapy, and as a result I have spent time looking into the conditions and appropriate treatment or management techniques. It was not expected of me to be aware of these conditions, and the placement provided me with the resources that they had available in order to gain a better understanding. However the facility I was attending had fantastic resources which benefitted me greatly. I was lucky enough to be on placement while a general meeting for all of the departments physiotherapist's was being held, and as a result I attended. The meeting involved information about continuing ed being held independently, as well as some workshops such as basic Makaton (a sign language). In addition to this, equipment was discussed as well as treatment techniques such as serial casting and dynamic taping. This proved to be a great opportunity for me, as I could practice the techniques and also receive input from the physiotherapists who had applied these techniques in the past. Some of the physiotherapists were new grads on their first year out, and their opinions reinforced mine. They both had felt competent when leaving uni, but due to the education provided at the facility they believed they were much more effective in treating patients, and a lot more comfortable with their knowledge base.
While all of the placements I have been on have provided some sort of education program, I believe that my Paediatric and ICU placement have provided the most input. Admittedly I felt less confident before both of these placements, which may have been a factor in my appreciation of the education. These placements both helped me to appreciate the importance of utilising the facilities at any new work environment, and also to keep an active interest in professional development and education. Given that some of the staff I have met have worked in the same Field since graduation, the content they were taught at uni would be vastly different to what is current literature now.

Dementia 3

Two other clients have also increased my knowledge and understanding of working with clients with dementia. The clients I have referred to in previous blogs were both unaware of where they were. However two clients did know they were in hospital and both were desperate to get out.
The first client had a superior pubic rami fracture but was mobilising with WZF. She had declined physio on a number of occasions but as I walked past her room she called out to me and implored me to help her out of bed. As I wanted her to walk I agreed and assisted her out of bed and she indicated that she wanted to go for a walk. As her gait became more unsteady I asked her to turn around and head back to her room but all she wanted to do was find the exit. I told her we had to go back the other way and when we got to her room she was very upset with me and not easily pacified even with the information that the plan was for her to go home the following day. I found out after that she had previously absconded off the ward and got lost on a locked ward!!
The second client also repeatedly refused physio until I advised her that the doctors had asked me to assess her and would not allow her to go home until that had been done. She then did everything I asked but I felt like I had forced her into consenting and she was merely going through the motions.
When working with patients with dementia I think you need to be quite direct. I have found that asking them to do something usually resulted in them saying no; but telling them that this is what they were going to do usually resulted in compliance - as if they needed instructions to be given to initiate anything.
I think it is also necessary for the physio to be mindful and aware of the fluctuating moods and functional abilities of these clients and be very flexible in their approach and treatments.
I feel more confident of dealing with patients with dementia following these experiences.

Dementia 2

Continuing my learning experiences with patients with dementia.
The physio and I were asked to assess the mobility of a 78 year old lady described as "pleasantly confused".
She was resting in bed and we assessed her ability to move in the bed, go from supine to SOEOB, STS - all achieved independently with supervision including verbal prompts and reminders. Ambulation was with a WZF + 1 min assist with frame + verbal prompts - to take a larger step with her left foot (previous CVA). The physio recorded all this in the notes and included a comment - mobility may fluctuate secondary to dementia.
The next day the physio asked me to take this patient for a walk. On this day the patient needed 2 mod assist to stand from chair, 1 max assist in standing, 2 mod assist with ambulation with WZF + verbal prompts every three to four steps as the patient would just stop and needed to be told to take a step and we just had to wait ( the physio described this as being just like a Parkinson's patient).
This experience enable me to understand very quickly the physio's comment about fluctuating mobility. I will now be aware of this possibility with future clients I assess , particularly when noting mobility recommendations for nursing and other staff.

Dementia 1

Prior to my current placement I have had very little to do with patients with dementia. It has been quite an eventful learning experience.
Obtaining consent can present a challenge with these patients.
After introducing myself and my role as a physio I asked the patient if she would be happy to come for a walk with me. To which she replied - Thank you so much but I can't as I'm going out for tea. Still trying to coax her into walking and with the sun pouring in through the window she responded with "don't be ridiculous, I'm not going for a walk at this time of the night". Then she asked me "what are you going to do?" to which I replied "I'm going to go for a walk with you". The patient stood up and said "thank you , how lovely of you" and proceeded to walk with me.
Can/should I assume implied consent because she chose to walk after I told her too?
I think it would be very easy (due to time pressure/frustration/ lack of patience/ having a bad day) just to walk away and record patient declined to walk but considerable care/attention needs to be taken to make sure that a client with dementia does not miss out on necessary treatment because of issues of consent.

Suprising Age

This week, at my gerontology placement, I conducted a initial assessment of a patient who had been diagnosed with parkinsons disease earlier in the year. She was about 10 years younger than the youngest person I had treated with parkinsons up to this point. I had read in her notes that she was in her 60's, however when I met her, she presented as being still rather youthful. The reason why this was a little more challenging for me was that up to now, my patients with parkinson's disease all had the disease for at least 5 years, and were also considerably older. Therefore with this patient, I was unsure as to how she was feeling about having the disease at a stage in her life, when she was still very active, going for long walks, going to the gym, and very keen on watching sports etc.

Many of the tests we do for initial assessment and annual review, appear to be designed for patients, who are further down the track with the disease, and are struggling with functiona and transfers. So I did feel like the tests might be a little patronising for her. However, she suprised me by being enthusiastic about the assessments, even though she excelled at them, and even remarked on enjoying doing the 6 MWT, as she loves going for walks.

The lesson I learnt from this, was that even though patients seem youthful, and maybe early on in their disease process, they would still like to be thoroughly looked after, as they would not like to have anything go under the radar and not be picked up, with later consequences. It is still important to be tactful however.

Infection Control

Currently on my rural placement, I have been fortunate to experience a situation in which infection control was enforced. On the Monday, a patient presented with constant diahoriah through out the day, and the next day half the ward had loose stools and occasional vomiting. By Wednesday 14 out of the 26 beds on the ward where determined to be positive noro virus.
Through out the week I witness a very efficient display of infection control by the nursing staff and infection control team, with patients being isolated and rooms rearranged to decrease the opportunity of transmission. All staff had a meeting to educate them on appropriate infection control precautions to exercise while on ward including gown, gloves, mask and hand wash between all patients.
As a staff member who had been on ward and exposed to positive patients, I was unable to work on surgical ward to prevent transmission. Although the infection precautions were quite intense, I was very impressed with how the whole situation was handled. By the next week the ward was clear and back to normal, and none of the staff caught the virus.
This experience taught me how important it is to follow precautions and it was a credit to the nursing staff how controlled this episode was. As I have never experienced a similar event, I am now aware of hospital protocols with regards to infectious disease.
If anyone would like to comment on similar previous experiences that was not handled as well that would be appreciated.

Involving patient and family

On my gerontology placement, one of my patients was a 88 y/o male who was referred for falls. He is relatively dependent on his wife for assistance with ADLs. Therefore, usually attends the appointments with his wife. During the treatment sessions, I have noticed that he usually takes ownership of the treatments when his wife is not around. He responds to the exercises when I explain it to him, he also asks questions and seem more responsive. However, when his wife is with him, he seemed to switch off, leaving the wife to learn from the session/clarify things. One instance was when he attended physio, and reported that he had a fall a few days ago. He was rushing to the toilet and had forgotten to take his WZF, so he slipped while turning the corner. His wife had difficulty assisting the patient to get off the floor. The patient also reported difficulty getting off the floor. So, my treatment session for that day, was to teach them how to get the patient up from the floor in case of another fall. Before I did that education, I was giving the patient new exercises for his HEP. During that, his wife was not in the room. The patient was responding well to instructions and seemed genuinely interested. But during the education, I needed to speak to both the patient and his wife. In that time, the patient was just staring into space and did not participate in the session. (I was just demonstrating the procedure with my supervisor, so the patient did not have to get onto the floor).

In future treatment session, I will direct my questions/education to the patient, so that he feels that he is able to take ownership of his treatments. I also felt that the “get off the floor” education was brought across in such a way that it was mainly the wife’s responsibility. In future, I will tailor it in a way that both the wife/partner and the patient play a part in the patient’s treatment/education. Another thing I can do in future sessions, is to ask the wife to wait in the waiting room during sessions. But, involve the wife, if the patient requires a HEP, or education.

Monitoring Symptoms

On my current musculoskeletal outpatient placement, I have been treating a 43 y.o. male patient post right shoulder arthroscopy 3/12 who was previously treated well for his right shoulder ROM and strength which are close to normal now. However no improvements were shown over his last few treatment sessions with me as he reports increased weakness in his right upper limb and worsening symptoms of P&Ns and numbness in his right 5th digit & ulnar border of his forearm. On neurological examinations, he was found to have weak right hand intrinsic muscles, reduced sensation on right upper limb and mild hyporeflexia in his triceps, brachioradialis & pronatus quadratus tendons. NTPT via ulnar nerve was negative and other tests for all possible diagnoses including thoracic outlet syndrome were performed, and no significant findings were detected. I have seen this patient 3 times over the last few weeks and I felt that I have not been helping this patient to improve at all as he continued to complain of worsening of his symptoms each time he came in. After consulting my supervisor, my supervisor re-performed all the tests and results were same. The patient’s symptoms were flared up after double assessments done by me and my supervisor in the last session. After discussing with my supervisor, I was told to only do soft tissue massage on his tender shoulder area to help release pain. In terms of medical referral, my supervisor explained that his symptoms and the results from the neurological exams were not serious enough to get a medical referral. There is not much that we can do in terms of treatment but it is very important to keep monitoring his symptoms and therefore the best management for this patient is to educate him to monitor his symptoms at home and to keep track of his symptoms by re-performing the neurological examinations every time he comes in.

Patient Education

Through out this year, across a majority of the clinical settings, in particular the musculoskeletal environment, I have come across numerous patients frustrated with the lack of explanation they have received from their doctor/source of referral as to their condition. The most recent patient to express their frustration is a 34 year old woman that has been referred for outpatient physiotherapy treatment post excision of the (L) radial head.
This patient was diagnosed with RA two years ago, affecting only her right wrist (which is to be fused when she recovers from this surgery in 6 months) and her left elbow. She reported that the only education received from the surgeon was pre-op, regarding the actual procedure and only briefly addressed the reasons for the op. She received very limited education concerning functional outcome post surgery and the likely prognosis of the surgery. She has presented to the physiotherapy outpatient department, now two weeks on, quite devastated as to her lack of strength and functional use of her L elbow and wrist. She has only just stopped wearing the sling recommended by the surgeon, but with not explanation as to how long it is necessary to wear.
The initial assessment findings included no active ROM of elbow flexors, severely restricted pronation > supination and wrist extension. Finger mobility is also limited due to strength and it feels chronically swollen. Following the physical examination, she simply asked- why can I not lift my L hand to my mouth, brush my hair or write with my left, because I am usually left hand dominated and it is quite hard to cope at the moment. This was the final piece of information I needed to realise this patient has been mistreated in the hospital system, in particular by the medical team. How can she have a piece of bone removed from her dominate hand without any explanation as to the repercussions?
So the initial treatment session was based very heavily on education regarding the operation, why she is experiencing these symptoms and the likely outcome/functional recovery of her L upper limb. I then provided a HEP addressing not only her elbow, but preventative exercises for upper limb mobility following two weeks in a sling and hand exercises. At the conclusion of this session she was quite emotional and expressed her gratitude for the time spent explaining this whole situation. As she is a mother with three children, it made a huge impact on her goal setting and future preparations. From this experience, and the many other similar ones throughout this year, I am beginning to question the patient care pre- and post op within the hospital system. If anyone has an opinion as to who is responsible for this almost negligent case, it would be appreciated.