A sensitive issue

I was treating a young patient with MS, who I noticed was incontinent while I was treating them. They seemed unaware of this and I approached my supervisor about this, to ensure I handled this the most discreet and appropriate way. I was told that I should try to hint towards it by offering to take the patient to the toilet, and did so, but she did not catch on. The supervisor then advised me to ignore it (as it was not that obvious, if you get my drift), and hope it was a one off.

At the next treatment the same thing happened. I had to talk to her about it, and I absolutely dreaded it! I started by telling the patient that I did not want her to feel embarrasses or offended by what I was going to say, and then I told her (at the end of or treatment session), as delicately as I could, and asked her if she could look into preventing this, and that I was more then happy to offer a referral or some advice if she would like. No matter how I said it, it was extremely awkward, and I could tell that the patient was very flustered and embarrassed, muttering that they don't normally suffer from incontinence and that it wouldn't happen again.

The patient cancelled their next appointment, and has not re booked as yet. Initially I felt that I should have just ignored it, perhaps wrote a letter to their GP, as they were doing so well with their physio, and I'd hate to think that this incident would prevent them from getting much needed physio treatment. However, I came to the conclusion that I did the right thing (plus my supervisor had asked me to). It would have been unhygienic for me and the patient, and as embarrassing and upsetting as it is, the patient must take responsibility for their disability/health and be respectfull of others that could be affected by them.

Paediatric relationships

I have recently completed my paediatric placement in a hospital on the oncology ward that involved working in both impatient and outpatient setting. The most challenging aspect of this placement was determining the appropriate level of emotional involvement with each patient. As children in this setting generally receive treatment from this department for extended periods of time, both as acute inpatients then ongoing outpatients, they see many allied health staff over their duration of care. I learned that when working with children, it is important to establish their trust and build a friendly relationship with them in order to get compliance with their exercises. On the other hand, I found that once they have your trust it is difficult to not get too emotionally involved. As children need a level of stability in their lives, if they are continually building relationships with hospital staff that are then dissolved once that staff has been rotated it can lead to constant disappointment.
There was one patient on the ward that I found particularly difficult to limit my emotional involvement with - a teenage girl that was diagnosed with an osteogenic sarcoma in her distal femur resulting in an above the knee amputation. Over my four-week placement, she was constantly in between the hospital for chemotherapy and at home recovering. While in hospital, physiotherapy treatment included gait re-training with her prosthesis on the ward. During these sessions, we built a strong relationship based on similarities of interests. At the end of my placement, I found it difficult to notify her that I was leaving, as she was asking me to be her friend on face book and planning to tell me all about an event she was going to on the weekend the next week.
From a professional point of view, I know it is inappropriate to give out any contact details including facebook, and from a personal point of view I didn’t want to delay the goodbye till the very end because it was easier for me to just say goodbye and leave without having to deal with the repercussions. So I decided to notify her on the Thursday that I would be ending my placement on the Friday and was unable to exchange any details due to confidentiality reasons. I was met with some resentment on her behalf and frustration and on Friday she refused to see me. I found this experience very difficult and wonder if I became to emotionally involved at the expense of the patient. If anyone has any comments or ideas on how this situation could have been handled better that would be much appreciated as I do intend on working in the paediatric setting again following gradation and don’t want to repeat this incident if possible. Thankyou.

taking responsibility

During this prac I have noticed that, our supervisor has taken another step back, in terms of independance with time management, and organisation, in comparison to earlier pracs. For example, our supervisor does not expect us to notify her that we have finished our work at the end of the day, in order for us to be able to go home, rather we should just go when we have finished our work. And on another note, it is our resposibility to chase things up if they dont get done, because this is what will be required of us when we graduate. This has reminded me that our time at uni is quickly coming to an end. And we will be out in the professional world soon, with more responsibilities. The lesson I have learnt from such experiences, is that now that we are almost Physiotherapists, we cannot expect to have someone holding our hand, and should show more initiative to get jobs done.

Home visits

I recently completed a paedeatric clinical placement that provided me with opportunities to experience different treatment environments. Treatment involved using the facilities at the centre I was located at, home visits for clients and also group classes at an external venue. Most of the treatment/assessment sessions occured at clients houses, and this was a change for me given that all placements to date have been inpatient settings. As a result, my day would consist of arriving at the centre and then going on arranged visits to the clients and their families. Between visits on a single day time would then be devoted to travel and also planning for treatment sessions. This type of placement was a big change for me due to having only completed inpatient placements, and I did feel slightly lost initially. I found I struggled to occupy myself during the time between visits, and was not using the time constructively. It was only after the first week had passed that I began to realise how important the time between visits was, as I began to appreciate the importance of these treament sessions. The facility I was attending used the family centred practice model, and the role of the therapists was more of an educated advisors then therapists, as the family were primary therapists. As a result, the one hour or so treatment sessions each family recieved every few weeks needed to be as effective as possible. This required a diversion from the treatment I was used to, as education of the parents was far more important than any treatment benefits the child attained over that one hour. As a result, treatment planning became extremely important, as did prioritising treatment goals for each sessions. I learnt to split my treatment goals and interventions between therapists, for instance, while at school the client was to focus on activities that would address impairment A, while at home strategies were in place to address impairment B. This taught me in a short period of time how important treatment planning was, and also how it is vital to refine the content of your treatment sessions so that any advice offered is understood. Following this I managed to make much more effective use of my planning time at the facility, which was assisted by communication with other therapists (speech therapy, OT) in order to reinforce our individual goals and also decrease any confusion we may be causing the client. Unfortunately, given that the placement was only 4 weeks in duration, I was unable to see if any great changes had occured, and I am unaware of how effectively the strategies put in place were followed in the clients different environments

Gero

I am currently doing a gerontology placement. Last week, myself and another student saw a 76y/o patient who was referred due to decreased balance. During the session, we planned to do a reassessment of his calf swelling, review his HEP and work on balance exercises. During the treatment session, this patient would joke and comment on different things. However, in this case, it was important for the therapist not to take heart what was said, as the patient had a tendency to push the boundaries sometimes.

After we had finish on the treatment plan, the patient commented on the fact that he had brought his 4WW into therapy that day. He was asked by the previous student to bring his 4WW on the next treatment session. However, this was not documented in the notes. Therefore, we were not certain as to what was needed from the 4WW. The patient became angry as he had to bring his 4WW along. (He usually uses a walking stick, only using a 4WW for long distances). He also said that it was a lot of trouble for him to transport his 4WW to therapy. Throughout this time, he was complaining and using stronger language. My supervisor could not recall why the previous student had asked for the 4WW. She then decided to teach the patient how to safely use the 4WW up/down a curb. My supervisor had to first calm the patient by explaining the reasons as to why it was important for him to bring his 4WW to therapy that day. After much persuasion, the patient settled and was happy to learn.

I can avoid a similar situation in future, if I document accurately each treatment session (the treatment done for that session, a plan for the next session and ax/reax). On reflection, I can learn from what my supervisor said to the patient in order to calm and persuade him. She kept a calm voice throughout the reasoning process, and was patient when explaining.

Referrals

On my current musculo prac, I had a 58 year old male patient who suffered right Webber C ankle # post ORIF about 12 months ago. He has now developed plantarfasciitis in his right foot and his current main problems involve reduced dorsiflexion, tight calf muscles and ongoing pain in his right ankle and sole when walking. The last physio treatment sessions basically involve soft tissue massage, calf muscles stretching exercises, tapping and advices regarding orthotics However, improvements have not been made and benefits from physiotherapy have seemed to be plateaued.

After discussing with my supervisor, we decided to refer him back to orthopaedics and podiatry as well. There is no problem referring this patient straight to podiatry, however, in order to refer him back to orthopaedics, we need to write a letter to his GP to get his GP to refer him back to orthopaedics, in other words, we can only refer him to orthopaedics via his GP. After discussing with the patient, he did not seem to understand why we can’t refer him straight to orthopaedics, so he does not have to make another appointment with his GP. I was not very familiar with the hospital referral system so I had my supervisor to further explain to him and the patient finally agreed. My supervisor then told me that the hospital referral system is sometimes quite unintelligent and inconvenient for us (physiotherapy) and there is not much we can do except just following the rules. On reflection, I not only need to know how to treat the patient but also how to refer patients to other professionals and be aware of the protocol with different methods of referrals before discussing with the patients and also in the future when working in public sectors.

The simplicity yet difficulty of facilitating movement

I am on a neuro placement and one of my patients suffered a R sided basal ganglia stroke about one year ago. He is independent in his tranfers and bed mobility and able to ambulate with a walking stick and an AFO and stand by assistance and has signifcant perceptual and cognitive impairments. I found this patient hard as initially he did not seem to respond to my verbal and tactile feedback, although he is to be motivated and tries very hard to perform the exercises and movements I ask him to do.

Initially I tried to explain to the patient what and why he needed to do certain movements (example; equal weightbearing through LL when STS) and guided him through the taskes, continuely verbally telling him he needed to shift his weight over to his affected (L) leg. I then tried to physically get him to weight bear more through his (L) leg, by gently pushing him over to the (L) and blocking his leg from moving forwarads when he stood up. Eventually, he did do it the way I wanted him to, but as soon as I took my hands off him he reverted back to his old pattern of movement.

At his next treatment session I decided to try another approach: trick him into having to weightbear through that left leg. I decided to break down the STS task, concentrating on the initial trunk flexion and raising the pelvis just of the bed. I put a fitball just to the left of the patient (with a sandbag in front of it to stop it rolling away) and asked him to roll the ball forwads and slightly left (with his R arm) and 1/4 stand (at the same time ensureing that the patient was not rotating though the trunk, by making sure the ball wasn't too far away). It worked, with his (L) leg becoming active and visibly increasing its weightbearing. He then was able to STS with more weightbearing through his (L) without me having to remind him or put my hands on, which I was very pleased with.

This made me realise that as physios we can sometimes actually give our patients to much feedback, particulary if dealing with patients with sensory, perceptual and/or coginive impairments. I have found, pariculary with neuro patients, that if you can set up/modify the envoriment for them, they actually perform a task much better on their own, i.e. make their treatment/exercises functional. So, next time a patient is not acheiving what I am aiming for, despite all my best efforts, I will take a step back and look at how I can make the task more functional for the patient.

Differing Supervisor Opinions

I am currently on my gerontology prac and had my 1st day of Curtin CLinical Tutor being present. Whilst performing timed balance tests, I was noted that if it is obvious that a patient is capable of achieving up to 2 mins of static balance, it wasnt necessary to time for the full 2 mins, as this may take a long time to complete the assessments.
Later on in the day I was being observed by the facility tutor, and did not time the patient in static standing for the full time period and was told that there was no point doing the test if it wasnt standardised each time it was done, and that I needed to time the full length of time.
I actually agreed with her, however I did not mention to her that the other clinical tutor had told me otherwise.

Perhaps this was not a wise thing, however, I did not want to seem as though I was contradicting her, especially because I actually agreed with her. So in that sense I think I did the right thing by not bringing up what the other supervisor said.
The next time the Curtin clinical tutor is present however, perhaps it would be a good idea to let her know what the facility tutor suggested about consistency, to avoid further problems.

The Family

This patient that was involved was an elderly patient who sustained multiple pelvic fractures during a fall, the fracture was quite severe and this patient was experiencing excruciating pain even after 4/52 post fracture. This patient was admitted to the hospital for rehab and her pain levels were still really high she is unable to do a lot of tasks. It is almost a pain-avoidance behaviour. She came from a low care facility and the plan currently is for her to go to high care. Her family is very supportive and comes to visit her everyday. The incident that happened was that some staff was telling this patient the pain was in her head and the family felt it was inappropriate and they had no right to say that (which I agree with) and the family wrote a complaint letter to the hospital. A family meeting was held a few days ago regarding this issue. The patient, family members, Social Worker, OT, Physio, and the Doctor was present at this meeting. The family requested to stop physio because of the pain levels but primary concern was the pain levels – it is still very unbearable after 4/52 but the doctor explained this # is very serious and it will take up to 3/12 for the pain to go away. The family also asked if there’s anything doctors can do to further investigate the pain – doctor ended up requesting a CT scan to check the alignment of the bones. With reassurance and effort every staff put in , the family members were satisfied with the outcome of this meeting – the result was to request a CT scan for a piece of mind, continue physio, up the pain medication and for the family to record any names of staff who tell the patient “the pain is in the head” or any similar scenarios and it will be dealt with. From this case, I have learnt that one person’s injury can affect everyone in the family. The family is concerned we must keep the patient as well as the family up to date with progress and also I have learnt that we must respect the patient in every way (and also the family members)– we can’t tell the patient the pain is in your head ! I was not the physio treating this patient at the time but if I was the physio treating, I will ensure there’s adequate pain relief and allow plenty of time for the patient (as pain slows her function – takes her a long time to get up an walking), also I will communicate with the family members in this case to see what time is best for them as this is quite a close knit family it would be good if the family members can give some encouragement.

Bad news

In the last week, I sat in on a combined treatment session with my supervisor, the OT and a OT student. The patient was a 4 month old baby who was brought in by his mum due to poor head control. During the initial treatment session, my supervisor noticed that the poor head control was not the conventional floppy/weak. Instead, he was unable to keep his head in a good position due to an excessive extensor reflex. In addition, he had a strong ATNR. The OT and my supervisor decided to review the child in 2 weeks, so that the child was able to “grow a little more”.

On the next treatment session, the child still presented the same. That session was mainly an objective assessment. The senior physio was called in for a second opinion. But, by then, the child was tired and started crying. The physio had to quickly complete the assessment. The senior physio then tried to explain she found, but was unable to as the child was still crying. The staff then decided to have a discussion so that the mother could calm and feed the child.

My supervisor and the OT had to discuss the findings and discuss treatment options with the mother. It did not look good for the child as he was still holding onto the extensor reflex. This inhibited him from functioning normally as a 4 month old. He was unable to tolerate prone, and could not use his hands in supine, and sometimes seemed not to be able to respond to sounds. However, he responded appropriately if someone talked to him face to face.

This was a difficult situation as the mum was already feeling anxious as her child was crying and there were too many people in the room. Furthermore, the whole group had to leave the room to discuss, which probably added to her anxiety level.

On reflection, I suppose the situation could have been handled better if there were less people in the room during the treatment session (ie no students). It also made me think about how I would approach the subject of breaking bad news to family, esp in the area of paeds. I suppose this would come with experience. I did not sit in with the physio when she had to tell the bad news, as it was not appropriate. So, if I happened to come across a similar situation, I would most likely have to excuse myself after the assessment if the situation permits. This would allow me time to collate my thoughts before speaking to the family. If not, I would probably explain the assessment findings to the mother while doing the assessment so that she is involved in the treatment session.

If you are feeling lost.....

On my current neuro prac, I bumped into my previous female supervisor who I used to work with in my third year 3 weeks Cardio prac. She graduated from Curtin University with an Honours degree about 2 years ago. I remember when we were working on oncology ward last year, she told me that she did not enjoy working as a physio at all since she graduated and she would quit her job beginning of this year. I was therefore very surprised to see her last week working in neuro inpatient ward at XXX hospital. She told me that she changed her mind after working in this ward. In fact, she loves her job at the moment. She mentioned that her current working environment is different than other working places that she experienced before. She is currently more motivated working with the patients in this ward and receives a lot of support from her colleagues/senior physios. She is also intending to specialize in this field.

I had an unpleasant experience doing my Cardio prac early this year and I am sure other students have had the same experience or worse, and I learnt from my previous supervisor’s experience that: it took her about 2 years to realize what she wants to do in her physiotherapy profession, we as students therefore should not decide our future career pathways purely based on our clinical experience that we obtained this year (of course, unless you have already found what you enjoy doing). We should continue to explore after we graduate. Another supervisor of mine once told me that it is normal to feel stress to work as a fresh graduate physio and it is therefore very important to choose a place where we can receive a lot of support from our colleagues/seniors. I hope this very small piece of information helps people who are a bit lost or confused out there. Good luck!

Patient's Personal Relationships

On my current neurology placement, I have a 17 y.o girl who was diagnosed with multiple sclerosis. Following 3 months deterioration in her functional status, she received a 4-weeks intensive rehabilitation in neurology inpatient ward and she is currently attending neurology outpatient 2x per week. When I was reading her notes, I found a long letter written by her parents concerning her uncontrolled behaviour: drinking and drugs, vulnerability to men, foul language, fear for her to become pregnant & suicidal thoughts and report having no control over her. I managed to build good rapport with her and she reports that she usually spends the weekends at night clubs and getting drunk, and there was one occasion that she ended up in a hotel with 3 male strangers. She is currently on contraceptive pills and is aware that alcohol consumption can make her condition worse. During my last physio session with this patient, she was telling me her relationships with guys again, however this time involves a 36 yo male patient who is also attending neurology outpatient. The stories that she told me were absolutely unusual and very inappropriate such as receiving his naked pictures via mobile phone. Initially, I was not sure if I should be discussing this matter with my supervisor (a male supervisor) as I did not want my patient to lose trust in me. I however approached a female senior physiotherapist for advices regarding this matter and she insisted that I should discuss with my supervisor. My supervisor then told me that it was very important for me to inform him any forms of potential harms that my patient may experience especially due to her vulnerable behaviour as we can help to avoid unpleasant incidents to happen. My supervisor then spoke to her clinical psychologist who then dealt with this problem. My supervisor also told me that if I did not feel comfortable knowing too much about my patient’s personal relationships, I should inform my patient that I cannot guarantee that I will not be telling anyone her stories. It is then up to her if she wants to keep telling me her personal stories. I agreed with my supervisor and said that to my patient which then made me feel much more comfortable when treating her.

Flexibility and Creativity

The thing that I have learnt most at my paeds placement is to be flexible when dealing with patients. This differs greatly from the other placements that I have experienced, such as musculo inpatients/outpatients and cardio. With these placements, I usually am able to follow a certain format that I plan out before seeing the patient. For example, for musuclo outpatients, I plan out the objective assessment so that it follows a pattern (testing in standing --> sit --> supine -->prone).
Since the previous blog, I have had a couple of other patients. Most of them are young infants with motor delay and toddlers/young children with intoeing. During the treatment session, I have had to combine both objective and treatment together. This was a shock at first, especially with a new type of condition, but with practice I will be more proficient at this.
I have also realised that it was difficult to follow a carefully thought out plan during the treatment sessions. I have not had one treatment session that went according to plan. Most of the time, I would need to use my powers of observation to assess and structure the treatment session around what the child happens to do. This means taking the oportunity to work with the child wherever his attention is focused on. In future, I would need to work on my creativity skills and being able to pull out a treatment session easily in any clinical situation. But at the same time, still working on formulating a plan as it helps me understand and prepare for each case.

Treatment Strategies/Techniques

On my current neurology placement, I had a stroke patient with left hemiplegia who was not responding well to exercises involving weight shifting to his affected side in standing. The patient would either do it incorrectly or pushing really hard with his good leg refusing to move and reported fear of falling and I was aware of “pusher syndrome” in this patient. In order to make him feel safer, I had the patient stood next to a high plinth and I stood on the other side, holding around his pelvis with both of my hands helping him to weight shift to his affected side but it did not work. I then changed my position to the front sitting on a stool with my hands around his pelvis with a high plinth at the patient’s back hoping to make him feel safer but the patient was still not doing what I wanted him to do.

I became frustrated at myself because 20 minutes of the treatment session wasted on trying to get this patient to weight shift. I then seek help from my supervisor. My supervisor treated him exactly how I did, however managed to get him to weight shift with only few attempts. I immediately realized the difference between our treatments was that my supervisor provided really good & strong grips, with short & precise commands and the patient trusted him more and therefore responded better. And the next time when I saw this patient, I reassured the patient that I will not let him fall, and made him feel more supported (to trust me more) by performing the exercises in parallel bars with me sitting in front and a chair behind him. I also tried not to explain too much what I wanted him to do and relied more on my hands (strong grips) and legs to give the patient input to move the way I wanted him to move, and the patient responded much better.

Paeds

I am currently on a paeds placement. After 2 weeks of observation, I was given my first patient, a 5 year old who was referred after sustaining a supracondylar fracture. The instructions on the referral were to do only active movements.

What I found challenging was the coordination of the subjective examination with the patient and her dad, mum and mum’s partner. In addition, my supervisor was also sitting in for that session.

After the introduction, I began by directing all my subjective questions to my patient. I asked about the pain and its severity (using the kid’s version of the VAS). All I got was a blank look. After a couple of tries, I decided to direct the question to her parents and guardian. While talking to her parents and guardian, the patient became a little restless (I only took a few seconds!). Talking to her parents and guardian was also tricky, as all 3 were talking at the same time.

From this I realized that I needed to improve on my multi-tasking skills. I needed to be able to listen to the information from the parents/guardians and also the patients’. From that, I need to filter the given information and decide on what’s relevant and what’s not. Secondly, I needed to be more flexible with conducting a treatment session esp in paeds. I could have performed my subjective and objective exam concurrently. In this case, keeping the child occupied while I directed the subjective questions to her parents and guardian. Or I could direct my questions to my patient first. If the patient does no answer or gives an inappropriate question, I will direct the question to the parents/guardian. Lastly, I need to give the patient time to “warm up” to me. I realized that this patient was quite shy at first, but once I started on a couple of games (secretly disguised as exercises) she was quite keen on participating.