Wednesday, November 26, 2008
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.
Friday, November 21, 2008
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.
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.
Sunday, November 16, 2008
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.
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.
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.
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.
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.
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.
Saturday, November 15, 2008
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
Thursday, November 13, 2008
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.
Wednesday, November 12, 2008
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.
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.
Monday, November 10, 2008
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.
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.
Sunday, November 9, 2008
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,
Saturday, November 8, 2008
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.
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.
Thursday, November 6, 2008
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.
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.
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.
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.
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.
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.
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.
Monday, November 3, 2008
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.
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.
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