HEP

On my Musculo placement, I was treating a 78 y/o male who presented with low back pain (L>R) and L lateral thigh pain. He was diagnosed with L4/L5 hypomobility and an associated left L4 nerve irritation and was treated with a L rotation in R sidelying PPIVM and a reverse lateral flexion in R sidelying. He responded extremely well to this treatment over 4 treatment sessions. His low back pain decreased from 7 to 2/10 at rest, and experiences only occasional leg pain.

However, the trouble I had with this patient was that he did not seem to understand his HEP! On the first treatment session, I gave the patient lumbar rotation in crook lying (within pain limits). During the follow up session, he came in with an absolutely different exercise. On that session, I spent a considerable amount of time explaining the importance of his HEP and how it will impact on this progress made during the treatment sessions. In addition to this, I also decided to explain in greater detail the pathology of his back pain and how the physio treatment is helping him. (with spine models and pictures). At the end of the session, I wrote out the HEP on a piece of paper (with the usual instructions, stick man drawings, and warnings).

The following session, this patient was able to perform this exercise but was still making a couple of mistakes. For example, going into too much range aggravating his leg symptoms. So, I had to constantly remind and correct his exercises. This is main reason why I only gave him that one home exercise.

On reflection, I realized that I should have spent more time on the initial session explaining the pathology and back ground to his condition and why physio helps. I suppose this comes with experience as I felt I was more focused on thinking about the subjective questioning and the components of the objective exam than actually thinking ahead and explaining relevant findings to the patient. In future, I will strive to explain the patient’s condition as thoroughly and precise as I am able to (given the situation) during the initial treatment session. And I will also write out the HEP or use one of the available HEP handouts with any patient.

Neuro Outpatients

During my previous placements, I was able to apply most of the techniques/skills that we learnt at university however in my current Neuro Outpatients placement, I have not been able to practice what we were taught at uni including basic skills to transfer patients. This is simply because my supervisor uses a more integrated approach (Bobath etc) and most of his skills are very different from what we learnt. During the first week of prac, I was very overwhelmed with all the new treatment techniques and handling skills that my supervisor has demonstrated and became confused in choosing the appropriate approach, not knowing if I should apply what I have learnt at uni or what my supervisor has taught in a day. In most occasions, I had to choose what my supervisor preferred.

In order to solve my confusion, I approached my supervisor to find out more about his expectations in this placement and I was told that most importantly I must be able to rationalize my treatment choices/techniques, four-week placement will be too short for me to learn everything and a lot of it will really come with experience. I should also choose a treatment approach that I feel most comfortable with as long as I make sure the patient is safe. Constant evaluation is also necessary. Knowing my supervisor’s expectations has helped me to know where to focus in order to pass this placement. In this placement, I think I will only be able to practice what my supervisor preferred. Even though I really hope to practice the skills that we learnt at uni on “real” patients, this placement will definitely be a good opportunity for me to learn more different approaches/skills that were not taught at uni and to have more options to choose what is best for myself and my patients.

Oxygen Therapy

One aspect I have found extremely frustrating and have had difficulty in getting answers about is oxygen therapy during ambulation. Despite us being taught to check the charts and that O2 is a drug and will (I don't think so!!) be charted it rarely is. Not only is is not charted, the patients status can change quite rapidly post surgery and the nursing notes do not often reveal the level of O2 therapy the patient is on during any particular shift. So I can have a client who yesterday was 98% on 2L O2 via NP during ambulation and when I next see him he is SOOB and hasn't had O2 on all morning and is 98% on room air. Do I walk him on O2 or not?
Take for example two of my current patients - at rest both have SpO2 98% on room air and both desaturate with ambulation however
Patient A drops to about 92% and then stabilises no further intervention/O2 therapy required but
Patient B drops to about 92 %, but if he stops walking rises to 94% if he sits he immediately returns to 98% but if I allow him to continue walking he continues to desaturate (we have reached 77%) and I have had to bump up the O2 to 6L via Hudson mask for him to stabilise at 92%.
When I have asked for help in trying to decide if/when I need to use O2 during ambulation and more importantly when it is safe to try without O2 the only answers I get seem to imply that it is all about clinical judgement- something that comes with experience. Lets hope this develops quickly in these situation which seem a little too much like trial and error!
What I have learnt or had reinforced during these 4 weeks
that I am quite conservative in nature (and I don't always trust oximeters)
to be prepared to back my own clinical judgement ( I think I might be developing some!)
and to keep asking for advice again and again and again until you get what you need.

Communication Again!

During this cardio placement I had to treat a Croatian woman with acute renal failure who required chest care for a very moist chest. This lady had very limited English. Having introduced myself and briefly explained why I was there and that I wanted her our of bed she immediately attempted to get up. However her nasogastric bag was pinned to the sheets and as she rolled to her side the nasogastric tube detached from the bag and sprayed bile across the sheets and the patient (missed me!!). Thankfully it separated at a safety release point rather than her nose!!
I reassured her that everything was OK and her lovely nurse assisted in cleaning her up and changed the sheets.

I quickly realised during the remainder of the session that she was impulsive in her movements and I had to ensure that everything was in place and that I was ready before I attempted to explain what I wanted her to do because as soon as she thought she understood what I wanted she would move.

What did I learn from this incident
1) it is better to pin bags to the patient's gown rather than the sheets so that it goes with them when they move! and
2) the necessity of very clear specific short instructions particularly with patients for whom English is not their preferred language.