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.