Life...

On my last cardio prac I saw a whole variety of pts with the majority being COPD pts many of whom were still smoking!

I did however have the opportunity to meet a CF pt. He was in his mid 20’s and was well aware of the fact that his only had a hand full of years to life. Yet he was so full of life and said he enjoyed living life everyday like it may be his last! He said he’d learnt how to cope with his condition from a young age and was pretty compliant with his management of CF. Meeting him helped me understand CF much better and get an insight about how he coped with his condition.

This situation got me thinking and made me realise just how valuable life is and how ungrateful some pts are with respect to their conditions and how they manage them. It makes you want to show these patients who have been choosing to harm themselves for years with smoking, drugs and drinking just how to value their lives. It’s like no matter how much to tell a pt that smoking is a bad habit and it does you more harm and good sometimes it just goes in one ear and comes out the other! Educating pts is something we have a great influence over. I guess if we keep on drilling the message into the pts we encounter somewhere along the line it will make a difference and make them realise that life is precious............

D/C issues

During the first week of my cardio prac I was given a pt that had come with an increasing SOB and AF from a rehab home. The thing about the pt was that he was just D/C from the ward 2 days ago to this rehab facility and was there for further rehab. The first time around he had come in with an infective exacerbation of COPD.

The first time I got him up for a walk he was only able to ambulate 30m and required 2 rests because of his increased SOB. The doctors wanted to D/C this pt soon as that felt like he was medically stable. They requested for the PT to do a 6MWT and with the test this pt was able to ambulate only 40m in 6 mins. It took him a good 4 mins to recover from his SOB. From his prior 6MWT results he amb 165m.

With this info in hand I had a chat to my supervisor and we deemed him unfit for D/C home. However every other health professional dealing with him had all written in his notes that he was safe for D/C home! With a chat to the doctors it was decided to send him back to the rehab home as he still required intensive rehab before going home as he lived by himself, had stairs in his house and was independent prior to admission. Once all the arrangements were made this pt was D/C to the rehab home.

I believe it is important to discuss the pts situation with the doctors and the medical team during the ward meetings. Even though everyone else is deeming this pt safe for discharge with the information we have we know that this pt will be a risk to himself if he does not receive further rehabilitation. It all about team work and working hand in hand with the other professionals as each one of us specialise in our own areas. It is always about the patients care and safety.

Learning never stops!

I believe in all our pracs it has become evident about this continued pursuit of learning as a physio. At practically all my placements there was a continuing education class or a presentation of some sort by the physios at the practice or externally employed individuals or sometimes the students were made to make a presentation on a topic’s. I myself had to do at least 5 different presentations at different stages of my pracs. With each presentation I did, I found myself understanding the topics I choose much better and sometimes it got me thinking about the different pts I had dealt with and how it may be applicable to them with the way i approach and handle them. It also developed my public speaking skills and made me more confident in presenting my topics. I found these sessions enriching as topics being presented usually lead to discussions where everyone was asked for their opinions and suggestions. It was a good consolidation of knowledge especially since sometimes there were senior physios’ around who could assist highlighting key issues especially with their wealth of experience in the field. This easy and open channel of a learning environment definitely creates an all rounded enriching experience.

It’s really nice to see this continuing evolution of our knowledge especially since uni has just finished.

Male PT’s Vs female pt!

In my Singapore “rural” prac I had a 14year old female pt who’d come in with a referral for an ongoing knee pain for the last 6 mts following a volleyball game and also for general strengthening program. At the time of my initial assessment I had my pt, her mother and my male PT supervisor sitting in the same area with me. As I began to question my pt I began to get the feeling that she didn’t really want to be at physio and gave me one word answers. So it was really difficult to identify what the problem might be and I must admit it did frustrate me a little! My supervisor also tried asking questions pertaining to her injury but she was still pretty uncommunicative. So it was decided that I go straight into an objective assessment. While doing all my knee assessments I didn’t really find anything wrong with the knee other than the fact she tended to tense up at times!. I felt like I was going nowhere with her so I asked my supervisor to have a go and see if I was missing any important info out!. The minute he put his hands on her she tensed up so much it was interesting to notice!. I was just wondering what was wrong with this girl and felt like I was wasting time treating her as she didn’t seem any bit interested to be here. But my supervisor on the other hand picked up this signal and immediately asked her if she was uncomfortable with him assessing her and if she would prefer a female physio with her next assessment. The patient immediately said yes! So it was decided that we would just get her walking on the treadmill and her next appointment will be with a female PT who would conduct a more detailed assessment. My supervisor left the room with the pt’s mother and I continued to monitor the pt while she was on the treadmill. I began to generally chat to her and to my amusement she began chatting to me so easily and opening up more about her injury! I took all the info she subjectively gave me and documented it in her notes so as the next therapist could have a brief handover.

From this prac I have learnt that we should pick up behaviour patterns of pts while we are assessing them, and it may demonstrate what they are feeling at that particular time hence influencing my approach to treating them. As a physio we should not undermine ourselves and look at possible factors that may also influence the outcome of treatment. We are all about team effort and if we ever have a situation like this be open and seek help from other physio’s as they may be able to assist with any problems.

NO such things as recipes with Rx

It was my cardio inpatient prac and I was given this pt who’d come in a few weeks prior for a lung biopsy and was back in hospital with an infective exacerbation of COPD. The results of the biopsy also confirmed the Dx of Lung Cancer.

From my initial encounter with her to the last day of my prac her health just kept deteriorating. It was like everyday I went in to see her something new had developed overnight. I found her to be my most challenging patient during this prac. There were some days when I’d go in to see her and she would be unable to do anything as just sitting up in bed made her feel so breathless. So my treatment with her on those days were just calming her down and trying to make her feel comfortable. Her SpO2 was 81% on 15L via HFNP. She was supposed to be on BiPap but she just was not tolerating this very well. By the end of 2weeks she just kept on getting more hypercapnic, no sport of intervention was helping her. At a family meeting it was decided she was to be kept comfortable meaning she was to be given morphine whenever she wanted and was considered palliative.

From this experience it brought to my attention that each patient is different and there are no ‘recipes’ or set treatments that you carry out with them. The condition in which the patient is in on a day by day basis varies and new conditions may arise and treatment for these conditions must be carried out. It is important to pay attention to the treatments rendered to these patients so as to facilitate their recovery to the best of our capabilities.

O2 therapy

O2 therapy..... I always thought of it as something that was prescribed by the doctors and would remain as it was till they decided was was ideal for the patient.
I had a pt that’d come in with as Exacerbation of COPD increased cough, sputum production and SOB over the last 3/7. At the ED department his SpO2 levels were 83% on RA therefore he was given O2 of 3L via NP and thereafter his SpO2 was 90%. Doctors wanted his sats to remain 90% and above. Once he was brought onto the ward in his notes it stated he was to be on 2L O2 on exertion and 1L O2 at rest.

I was to do an initial assessment with this pt and from his subjective found out that he had been prescribed with domiciliary O2 about a year and a half before but this has since been ceased 6 mts ago by his GP.He reports his COPD is well managed and he is usually pretty active and only of the last weeks has been unwell and thus this admission. After completing my subject and object assessment with this pt decided that his main problems were impaired airway clearance, impaired gas exchange, decreased ex tolerance and dyspnoea.

I decided to begin by taking him for a walk on O2 to help mobilise his secreations, increase his tidal vol and improve the gas exchange. Just as I was about to carry out my treatment, I was caught off guard when my supervisor asked me if I wanted to modify my treatment. Dumbfounded, I had no reply. Upon probing from my supervisor, she suggested thinking about discharge planning and looking at things as a big picture. If the patient come into hospital without home O2, we need to be thinking about sending home either without home O2 or if there is a need for them to be receiving home O2.

Therefore it was brought to my attention that it’s a great idea to ambulate him on RA and see how he maintains his sats on exertion. From this experience, it is evident that as a physio, it is important to carry out a sound assessment looking at things not just related to physio but as a whole with other health care professionals. We should look into other factors as they affect the patient and knowing the history of the patient takes us a long way as it enables us to get them back into their ‘normal’ standard of living which in turn improves their quality of life resulting in less hospital admissions.

supervisors make u or break u!

I believe at each prac your supervisor either brings out the best in you or is out to break you. I must say I have been pretty lucky to have gotton really good supervisors that really motivate you and guide you when need be and are also really open and pretty approachable. I however did have one supervisor that was someone who was just too difficult to communicate with. She seemed to have this set way of how she wanted things to be done and completely hounded for little bits of information.
She had this look that somehow made me feel really small. She wanted me to rattle off handovers of all my pts without looking at any piece of paper, I found this really difficult not just having to remember information of the patients but also verbalising it. It was like every time she came up to me to ask me things I’d get this massive mental block and feel stuck. My mind would go blank. She kept telling me that if I did not get good at this I would not make it through this prac and I was determined to be competent!

I voiced this out to my CCT and was in dire need of help because I felt I should not have to become incompetent in this prac because I was unable to give good handovers without looking at any notes! So with my encouraging CCT we came up with a “cheat card” it had basic heading just so I could begin to visualise and think systematically. I put this “system” into place and I must say it really helped me to think systematically because I was a bit of a scatter brain. It just put lots more information into perspective and helped me verbalise this information to my supervisor much better.

I did make it through this prac but I must say however it is pretty difficult to develop skills on a prac if you have a supervisor who is pretty harsh and overwhelming! I also got some advice from a fellow student who said every time she had an overwhelming moment with her supervisor she took a step back from the situation and built a “glass wall” around her so she felt safe and was able to think much better. I did try this out and well it worked sometimes but not every time. Overall it was a great learning experience for me and I did get much better at it by the end of the prac!

Cerebral Palsy

Whilst on my rural prac I began treating a young 9yo boy with cerebral palsy who had been referred for calf stretches post botox therapy. The boy's medical file revealed that his mother died two years ago from cancer and that his father was no longer part of his life so he and his older brother live with their grandmother. The boy had also been bullied at school because of his R) calf spasticity. I wasnt sure what to expect when meeting this boy, seeing as he had been through so much!

On our initial treatment it was found that he had icreased tone of R) plantar flexors and hamstrings. Even though he needed to wear an AFO at all times and had an abnormal gait pattern, he was fully independant with all tasks and even played soccer at school. I found treating this young boy very interesting as he had such a good attitude after everything he had been with. He was very compliant with all treatment and was wanting to start playing AFL in the next year.

The treatment was focussed on finding interesting ways to motiviate the patient to perform his stretches at home. I did this by making him a stretches book where he could check off each stretch each time he did them. We also tried to make the treatments related to sports, I taught taught his grandma how to strap his ankle before games as he didn't wear his AFO. Treating this patient was a lesson to me on how patients are able to overcome so much and not let it affect their treatment. Has anyone else had any patients who have surprised them with how much they can acheive?

Non compliant patient

One aspect of prac that I have found very difficult to align with theory is the concept of patient consent. Throughout our early years this is one of the most important things we learn to first explain everything to the patient and then gain consent. The physical experience of this when on an acute ward where you are seeing patients 1-2 days post abdominal or orthopedic surgery is that they really dont want to move at all. Although most patients are recieving pain relief everyone responds differently and have different pain threshold levels. Although some patients are quite compliant when you come to walk them, some patients outright refuse. When you first encounter these patients your first reaction is to say 'ok, I guess I can't force them' however your supervisors seem to have a totally different idea and its 'get these patients up at all costs'. Alot of the time it hardly feels like you have patient consent and have used every trick in the book to get them up. After spending more time on prac I have been able to take a more logical approach to motivating these patients within a reasonable time frame... i.e if they dont want to get up because of pain ensure they have enough pain releif, if they are nauseas discuss with medical staff to see if they are able to receive anti-emetics, if they are dizzy check bp etc.

One patient on a surgical ward was 1/52 post abdominal surgery and had been documented as being ++ non compliant with other staff. When I went to see her for the first time I spent 15 minutes trying to convince her to walk and when I finally did she only walked half the distance she had the day before with my supervisor. When I reported back to my supervisor, she thought this was totally unacceptable as her notes had read that the patient must mobilise. My explanation was that this was my first encounter with the patient and didn't know what to expect. My supervisor said that if this patient had a different physio everyday and they took at least one session to know how to deal with her then she wouldnt move at all, which was fair enough. My next session with the patient was a double treatment with the ward OT, as expected the patient declined treatment, the problem was that I was trying to convince her to walk, because my supervisor expected no less, and the OT was looking at me saying " well its really her decision, we can't force her", in the end we managed to make her walk the same distance as the day before. I wonder if anyone else has dealt with an experience like this and what they have found helps in motivating patients?

Observed Treatment

Whilst on my rural prac, part of my duties involved treating patients in an outpatient clinic. One of these patients was a 45yo male who had fallen and shattered his head of humerous and as such had needed a reverse shoulder replacement. He had been referred to physiotherapy for increase in ROM and strength. As the patient was unable to drive himself to treatment his wife brought him, and sat in on the sessions. This was my first experience treating a patient with a family member watching. While most of the treatment consisted of A/AROM excercises and massage/passive lengthening of overactive, I did feel a little self conscious having someone else watching the session. The patients wife was very involved in his recovery and would watch what I was doing intently and try to copy when she went home.

Ultimately this was a positive situation, with the patient being very dilligent with his exercises and having great support from his wife. It was however difficult to feel comfortable having someone looking over your shoulder. As treatments progressed I tried to involve the patient's wife as much as I could, by explaining aspects of treatment that she could do herself at home, even adapting my treatments so they could be done at home more. While no real issues occurred with this patient I found it to be an experience that I had to adapt to and will hopefully prepare me for other patients who have a very involved family.

End of life

I've just finished my placement in geriatrics. As you can imagine, most of the these patients are 80yo+ and with quite end-stage of their conditions. I was treating this 89yo gentleman who has end-stage lung cancer. The doctors have told him that the prognosis is not good. The patient had planned to enter High-Level Care upto discharge from hospital and that is where he will be enjoying the rest of his life.

This gentleman was really nice . Friendly and approachable. I went to see him to ask him to walk so he could maintain his mobility and some muscle strength. He has severe SOB upto walking just 10m and desats to 82% on 4L oxygen. It was pretty bad.

On this particular day i went in to get him to walk and do his exercises. He says to me "Kenny, why should i bother continue doing it anymore?" I didn't really know what to say. Replied with the typical physio response "Maintain your mobility and muscle strength" i extended by saying "Even though you may not think it'll help, IF you ever stop walking, at least you can still have some muscle strength to assist nurses in transfers." My point was, even though his life was ending, he shouldn't be giving up, it will make a lot of difference for people who will be transferring you.

I've known this patient quite well during my prac. He has already planned where he is going after hospital and his funeral and his finances etc. He has told me that "i've enjoyed my life, Kenny" and i guess that's all you can ask for. So, to some extent i agree with him on why bother to continue walking/exercising. He is happy with his life and is happy to go. I think we can only do the best we can. If he chooses not to walk on that particular day, i won't push him.

I think it's important to be understanding of the patient. Think about life from their perspective. Physio treatment doesn't always have to be mobilising or exercising. By just talking to your patient can be treatment in itself. It'll only help to build rapport with the patient. My supervisor agrees.

Pelvic Floor exercises

on my musculo prac i was treating a 30 yo man from the middle east for LBP. he spoke and understood very little english but with mimicking i got him to remove his shirt for me. at first he was a bit uncomfortable in front of me and let me feel his muscle tone, PAIVM and PPIVMs. as the ax/rx session wore on and it got increasingly difficult to find out what caused his pain, where etc... i could feel we were both getting frustrated with the lack of understanding. the asssessment took ages as i had to pantomime out questions and he had to say yes or no. after a long assessment he was diagnosed with non specific low back pain with a hypomobile segment l3/l4 and +++ poor motor control. he had no lumbopelvic dissociation and +++ decreased lumbar lordosis. i treated the hypomobile segment and then i approached the problem of teaching pelvic floor to someone who did not speak english. i gave him a sheet explaining what the pelvic floor was incase his english reading capability was better than his speaking. i tried to explain slowly that his tummy muscles were weak and we needed to strengthen them to help his back. his face of shock when i put my fingers on his TrA to palpate his contraction told me that he had not quite understood and he got quite demonstrative saying that he had no leaking or problem there. i left the session at that for the first day, wrote down some HEP with pictures for him and told him to research the PF and we'd go over it next time. does anyone have any advice on how to approach the situation differently, cuase im not sure how i should have done it differently. i think a) by having a female physio b) being shirtless for a good half an hour and c) me palpating his TrA was too much for the first session, so maybe i should have done less the first time around! the patient's next appointment fell out of my placement time so i booked his appointment with a male physio student was coming after me, hopefully he'd have more success with the patient than i did.

Learning from the nurses

I have been learning throughout the year a few good pointers frpm not only the qualified physios we work for but the nurses as well. These valuable tips will be very handy after we graduate and enter the workforce.

Simple things on the wards like operating a patients pca when alarms are sounding, maintaining an IV, learning about different drugs and there effects, learning to take away a slidesheet from under a patient without moving them and being a 2nd or 3rd helper in many treatment sessions has given me now found respect for what they do.

I have also found that its a two way street/ Educating not only the patinets, but the nurses about simple things such as same transfers and how we conduct mobility Ax menas they have an understanding and an appreciation of what we do.

What I have found is that whenever a nurse needs a spare hand for a role, transfer or to get something for them on the ward, i'm always happy to do it, especially if they have been helping you treating your patients and giving valuable subjective and objective measures for each or your treatment sessions. My recent ortho inpatinets clinic highlighted this as there was a terrific group pf nurses who ran the ward, to me some times it seemed like chaos, but to them, ordered chaos.

If I ever end up working on a ward in the near future, one of my main goals is to be friendly with the other allied health team members, especially the nurses. Everything runs a lot smoother with them on your side.

Has anyone had the priviledge to work with a good group of allied health professionals on their clinics this year?

the wonderful world off hand gestures

I managed to complete a 20 min treatment session on my orthipatient placement recently without een saying more than 10 words. The patient was a 99 year old asian lady who only new 4 english words. Yes, No, Food and Water. I thought this was going to be a tough one!

The patient was a day 1 hip replacement and I was suppose to do a chest treatment and teach bed exercises. Things such as as mimicking taking big deep breaths in and out through my mouth meant i could do a chest Ax with my stethescope. PLus getting the patient to hold at the end of each deep breath in became her deep breathing ex's.

UL and LL ex's were also taught via me performing the exercise and pointing to the patient and saying "yes" to her. This eventually got better and they patient finally understood what was expected of her. If this situation ever come up again, strategies such as gesturing the ex's via imitating them can always be used in a situation where the patient doesn't understand english. it worked for me.

Anyone had a similar ecperience?

Frustrating patients

I've just finished a ortho inpatients prac where I was able to treat patients from teenagers topatients well into there 90's. One particular patient became very frustrating to deal with and i just about lost it.

He was a 17 year old male, just about to graduate from high school and he broke his hip whilst skateboarding. He spent a week on the wards just so the swelling could go down around hip so they could operate. Whilst being in hospital, year 12 finished for him and he missed his graduation. The operation finally came and went and he was eventually told to weight bear through his injured hip. Knowing he needed to ambulate with crutches on the stairs, he kept pushing my supervisor and my self to do it, despite almost falling numerous times ambulating on the wards with crutches. After telling him he had to stay in hospital for one more day. Out came the tears, swear words etc - venting his frustration at staff.

I could see his point of view, the last thing you want to be doing for graduation is sitting in hospital but her his own safety and well being, one more night was needed. The next day he was eventually discharged home. Hopefully the extra night in hospital prevented him from having another fall and ending up back in hospital. I actually used the strategy of telling the patient that some one on the ward had discharged themselves 2 weeks ago against medical advice and she came back re dislocating her hip after having a fall cause she was unstable on crutches - despite this never happening. The pateint did quiet down a little eventually seeing that we were keeping him overnight for his own interests. If this situation was to present itself again, I may use the same strategy, only if all other avenues had been used up.

Has anyone had to handle a frustraing patient like this?

pending employment:

My last placement was a geriatric placement and after completing six other pracs, I felt that this one would probably be quite easy and would give me lots of free time to study for PCR. On the first day my supervisor told me I was to perform a full stroke assessment on lady 3/52 post R) MCA infarct. I suddenly realised that even though I had completed a neuro placement, being an outpatient placement I hadnt completed a full assessment in just one session before. I also realised that alot of the knowledge I had gained on that placement ( which was in Febuary) had been pushed to the back of my mind as I made my way through the various other placements this year. Although initially I was quite freaked out, I slowly realised how lucky I was to get this placement and have the oppurtunity to practise a full stroke assessment before going out into the real world. This also made me think about all the possible areas that I may not have experienced throughout this year of prac. Although we do so much throughout the year there are so many areas of physiotherapy and many that we may end up working in with no prior experience. I also feel that the most important skill that we take from this year may be the ability to adapt to new environments and quickly assess the most important skill needed in each area. I also realised the importance of making the most of each oppurtinity we are given this year and learning as much as we can before going out to work as we wont have someone checking up on us all the time.

Geriatric Discharge

On my recent geriatric placement, as with most placements, a major role of physiotherapy was to organise and plan a safe discharge destination. For many of the patients on this ward, physical ability and functional status were not the only aspects that needed to be considered. One patient in particular I met as a readmission. She had been initially admitted to this rehab hospital with a history of small subdural bleeds with had affected her balance and motor control mildly. She was rehabilitated on her first visit and discharged home performing all functions independantly and ambulating nil aids upwards of 200m. Unfortunatly after a week of being home alone it became clear to her family that she was not coping and seemed very confused. She had begun doing things such as putting sheets in the fridge and forgetting where she had put her keys, locking herself in the house. Eventually the patient had a fall and was readmitted



On readmission I carried out her initial assessment, finding that she had very high function and her main impariments were decreased saving reactions when responding to external forces and decreased quads strength on the r) ( grade 4). After the inital assessment the patient was ambulating independantly on the ward and performing all ADL's independantly. Unfortunatly, in light of her failed discharge and possible perceptual problems, discharge home was not looking to be a feasible option and hostel discharge was the most likely outcome. Once this was decided, the issues was discussed with the patient, she was not enthusistic, however she did understand the situation. Unfortunatly, while awaiting placement the patient developed dual incontinence, secondary to bowel loading. While this was incredibly embarrasing for the patient, who is very independant, it also meant she was not suitable for discharge to hostel and instead would have to go to a nursing home.

I finished my placement before the patient was discharged and as such I do not know the outcome of this situation, however I feel that if this patient does end up in a nursing home then it is a very unfortunate ending. She is very independant and would feel very out of place in a nursing home. Unfortunately there is so many variables when it comes to discharging a patient and sometimes the safest option is not always the nicest option for the patient. I felt looking after this patient helped me develop and understanding of the sensitive issues we face when plannign discharges for our patienst and being aware of all aspects of their care.

Time management

Throughout all of our pracs, time management has been a large part of our practical learning and not always something we are prepared for. On my recent cardio placement I found this was a problem not only on the prac but at home as well. Having completed my rural prac I had only a weekend before I started my next prac for cardio. While I was on this prac I was required to complete a rural report due ten days after finishing, complete my self directed proposal also due on the same day, and prepare for my groups seminar, which was to be presented on the second monday of the cardio prac. As well this I was trying to prepare for PCR sessions, write blogs, soapiers and complete worksheets for prac. I found that having all of these things to do, although they were acheivable if I worked on them a bit each night, really affected my performance on prac. Not only was I not able to study for cardio, I wasnt really getting a chance to relax and destress once I went home. It was also quite discouraging to think that I wasnt able to get the most out of the experience as after all we only have 4/5 weeks of supervision in each speciality before we are out there by ourselves. After speaking to other students I have found that throughout this year many of us have felt overwhelmed by the amount of extra work required of us, and how often its not the actual work that is a problem but the timing of deadlines, organising group meetings and the inability to focus on the placements we are on. These situations are also not something we have much control over as we cannot choose when we are doing each prac, or when it is our time to present either seminars or journal club. I feel that this has had quite a large impact on my prac experience and whilst teaching me important coping strategies and ensuring I communicated well with my supervisors, I still felt dissapointed that I couldnt get mroe out of the prac.

unexpected outcomes

Whilst recently on a geriatric placement I was asked to assess a 90yr old lady who was admitted 1/52 post fall. She has fractured a small part of her greater trochanter, had originally been sent home by her GP however was not able to cope with the pain and as such was admitted to this secondary hospital for rehab. On initial assessment it was found that the patient had decreased exercise tolerance with SOBOE and reduced dynamic standing balance. She was also very anxious and displaying signs of expressive aphasia, which was contributing alot to her anxiety. Discussion with her daughter revealed that the expressive aphasia had developed about a month ago and had been written off as a hiccup in the aging process by her GP, the patient also had a very limited exercise tolerance and rarely walked further than within her home. The daughter mentioned that her anxiety was most likely being caused by being surrounded by so many people when she was used to being by herself so much.

The second session was conducted at 8-30 am the next day and her obs had not yet been taken. The session was carried out in her room so as not to overwhelm her and finished off by walking her to the dining room. Although she continued to feel SOB she was able to walk further than the day before with no other adverse signs throughout the walk. At this stage the doctors were planning a CT to investigate the expressive aphasia.

On return to prac after the weekend I was informed that on the sunday the patient had been transferred to RPH and then had died. This information was extremely shocking as the patient had only been admitted for a small fracture. My supervisor was also shocked and apparantly the patient had simply collapsed while being transferred on sunday, after that we have no information on what happened. The disturbing thing about this patient was how unexpected her death was and how suddenly it happened. This was also the first time a patient of mine has died. Even though my treatment was unlikely to have influenced what happened, you still can't help but wonder if there was something else you should have picked up. It was also a really important warning that no matter who the patient is, you can't just assume that their case will be completely straightforward.

Pubic #'s

whilst on my community prac, we visited a 60 yo lady who had a bilateral sup/inf rami # and was discharged from hospital the day before. the other curtin physio was going to ax and rx the patient and the supervisor and i were observing. the pt had a high respiratory rate and was breathless when we arrived and seemed unable to catch her breathe which she reported as very unusal for her. she tired very quickly during the strength and balance assessment and had an irritating cough which she reported caused her mild chest pain. as the session progressed the patient reported feeling well, so we decided to finish off the session with some bed exercises. the patient lay down in the bed and started feeling really sick, she asked us to cal the ambulance and as our supervisor was making the call she started fitting and foaming at the mouth, she was completely un-responsive. as the fitting stopped she slowly started to follow commands and seemed to be improving. we put her in the recovery position which caused a lot of pain from her pelvis and my supervisor asked the other student to wait outside for the ambulance. the ambulance seemed to take forever to get there, it actually took about 15 minutes and the patient kept dozing off and my supervisor and i tried to keep her talking. when the ambulance arrived, the patient seemed much better and the paramedics weren't worried, they attached her to an ecg to check her heartrate which looked normal and they put her on oxygen. one of the paramedics went back out to the ambulance to bring a chair inside to wheel her out to the ambulance. the other paramedic was on the phone when the patient started fitting on the bed again and the ECG monitor flat lined, the paramedic got us to help take her off the bed onto the floor and we started trying to resuss her. when the other paramedic came in they had to use the defib three times before getting a trace. as the patient was so unstable, our supervisor had to go in the ambulance and continue helping with CPR on the way to the hospital. we got a phone call later that afternoon saying that the patient had suffered a massive bilateral PE and passed away, i got a bit upset and we called the hospital back to get a bit more information only to be told that the patient had had a massive bilateral PE but was still alive in ICU. the patient did end up surviving and was discharged home a couple weeks later, only to have her initial physio visit post discharge as my final assessment! needless to say i probably went overboard asking how she was feeling throughout the session! what i learnt from this experience is that even though a patient has been deemed safe for discharge, you still have to monitor them carefully throughout treatment. i now know that - SOB, rapid brathing pattern, chest pain and cough are all signs of a PEand PE's are most common in pubic #'s.

Discharged patients

i did a community prac with another physio student and we would visit patients houses to ensure that they were safe post DC in their houses. our role was to carry on their rehab and depending on their functioning level either refer them on to outpatients or community physio. often we were the first ones to visit a patient after DC and it was amazing to see that most of the patients sent home were unsafe in their homes. they were frequently sent home with inappropriate equipment, especially walking frames. in hospital frames are very easy to use and doorways are wider and they have huge showers/toilets but in the home envionment, frames proved to be particularly hazardous to elderly patients as they had small units and the frames were unable to go into the bathrooms, toilets and some doorways. patients would leave the frames in the lounge and furniture walk to try get to their destination. another thing we found out on this prac was that homes can be particularly hazardous for falls , so many of the patients we visited who'd had # NOFs had small rugs lying around and electrical cords from heaters, tvs etc... lying across doorways which are hazardous to more falls. what this prac made me realise was that when prescribing the safest walking aid, its not just important to look at the patient's mobility, its also important to ensure that the walking aid is functional for the patients environment so that they can use it in all situations. education about falling hazards such as removing little rugs, using electrical tape to tape down cords is also useful information that could be provided to patients prior to discharge. we drove a hospital car which was full of frames of various width as 9/10 times the prescribed aid had to be changed. it was an eye opening prac because when you're working in the hospital you feel like you are discharging the patient with all the necessary means to keep them safe, when truthfully at times its quite inappropriate. when working in an inpatient setting now, i try use this new insight to be as pratical as possible for the patient.

Page Page Page

I was going to amb this 76 yo pt, but recently he has been complaining of (L) calf pain. So the Dr. have requested for a scan to rule out any DVT. So i checked with the nursing staff and she wasn't sure of the results. I went to page the registra in charge. No reply. I page again 2 minutes later.Waited...and waited.... for another 5 miunutes, no reply. I left the phone and went to treat my other patients. I went back after treating another patient and paged again. No response. And then again. No response. Thought i'd paged one more time (for good luck). He replied!! Woohoo!

I introduced myself and asked about the patient. He went ballistic on the phone saying that i don't have to page him 3 times (well the 3rd time worked :p )then i went on to explain to him that i paged him earlier and i got no response. At this time he was even more angry that i have in total paged him 5 times. He said that he replied my earlier page straight away (which he didn't). He was really quite rude and said he hadn't look at the results and will do when he's free. Fair enough i thought. And then i said, if he could let me know that will be great, because i'd like to get him up walking after 3 days of not walking. He rudely replied "i make the calls here, not you!" At this point, i realised there was no point talking further. I said thank you and hang up.

Some doctors can be quite rude and abrupt sometimes. This is not the first time i've had difficulties with doctors. They often invade halfway into your treatment and just talk to the patient you're treating without acknowledging or apologising.

I spoke to my supervisor and he said, if next time the registra doesn't reply a page, try the resident, or even a doctor from another team may know. But he said doctors can sometimes be quite rude, especially when they're under a lot of stress with many patients. Next time i will try the approach.

Fluctuation.

I know i've already done a post on dementia, but because every patient presents differently, i thought i'd write about this particular patient and the encounter i had with him. I am currently on a geriatrics ward in Freo.

He is a 74yo gentleman who came into hosptial with dehydration/fall. We is quite a tall gentleman, and at first his dementia seems quite mild. He was alert, cooperative and oriented. He also seemed quite a good historian, making sense of all the questions i'd asked him about his mobility and exercise pre-admin. i then assessed his mobility. He was generally 1x min (A) with t/f and amb with WZF. So i went ahead and completed his mobility chart. And that was day one.

Day two, i went to see him for some ambulatory exercise. He managed to get up with min (A) and amb to the toilet (about 20m). He needed a loo stop. Now this is where things went abit funny. He refused to get up from the commode. After 15mins of talking and rationalising the reason why he needed to get up and return to his room, all he yelled out was "Just leave me alone!" I tried to get him up with some facilitation, getting him to move his bottom, lean forward, etc. He got up halfway, screamed out! and then trioed to sit down. I had blocked his knee and pushed on his ischial tub. so he couldn't. We were kinda stuck, beacuse i knew if he sat, it'll be really hard to get him back up again. However, i lost the battle. He forced himself to sit, and just yelled "why can't you leave me alone!". I replied "well, you're sitting in a commode, you're in the toilet, and you don't have a pad on." At this time i managed to flag down the ward PT and get him to help. We tried a 2x (A) STS with no luck. He just refused. We eventually just wheeled him back and basically t/f him into the bed with 2x max (A).

now, the thing is. the day before, he was fine! i would even say standby (A). And he was fine walking to the toilet. But for some reason, he just wouldn't go back. i reasoned and reasoned with no luck. I had a chat to my supervisor and he said people dementia can often change their mood quite quickly. He said there was not much you can do at that point, apart from just wheeling him back, otherwise you could be stuck with him for 1hour (and you've got the whole ward to look after).

What i've learnt is, you need to be re-assessing someone's mobility everytime. Err on the side of caution and put down more (A). I mean, i didn't know the first day, because he did not present like that at all. I will continue to monitor his mobility and have noted that his mobility fluctuates.

Communication

Currently I am on my cardiopulmonary prac. I have been alocated this patient -
Mr E is a 68yo man who is one day post distal gastrectomy and gastrojejonostomy for a gastric adenocarcinoma. His PMH consists of - PVD, GORD, appendectomy, asthma, gout, glaucoma. His SHx - live alone, has no friends or family in perth. His nursing obs are WNL, SpO2 99% on 2L O2. He has Iv line, PCA, NGT and 2x V'Vac insitu.

This looks like an every day surgical patient on my ward. The only difference was this patient was congenitally deaf (ie born deaf) and was partially blind. The hospital had organised an interpreter to come to the hospital at a certain time so the doctors and the patient could communicate. The nursing staff were using a white board to communicate instructions and ask questions.

Previously to studying physiotherapy I studied AUSLAN (Australian Sign Language) for 2 years full time. Im a little rusty and I do need practice but still able to communicate with a deaf person using sign language. I also took a course in how to communicate with a deaf-blind person but this patient was not congentially blind so he did not know this language. I found it really helpful to beable to understand sign language and even tho I muddled up a few signs I think the patient was less anxious to get OOB after surgery as he had some way of communicating how he felt without the interpreter there.

Working with a deaf person also showed to me the importance of demonstration. Demonstration is the key to all understanding I believe (unless the pt is blind ofcourse!). It shows the patient exactly what is going to happen and what you want for them. This was a very valuable learning experience.

A family session

On my rural prac, I was introduced to a young 6 year old girl who ahd been referred to physio with gross motor delay, especially for balance and ball throwing activities. One of the things I didnt know is that her parents had just recently been divorced and she spent most of her time during her week going back and forth between her mum and dad's houses.

The first two treatment sessions with my supervisor and the patient's mum didn't really go according to plan as we were unable to get what we wanted out of the session. The fact that the patient kept asking for her daddy also didn't help.

We sat down and talked to her mother and asked if it was at all possible they could negotiate and get her father to come along to the treatment sessions as well.

The 3rd session saw all three of them come along and we got what we wanted out of the session plus a lot more. The fact that both of her parents worked on their differences and both attended a physio session for the sake of their daughter, speaks volumes for parental input for a child's well being and motivation.

If I was ever to come across a situation with a child who had divorced parents and wasn't participating properly at all in sessions, I may again choose to use the same approach. The thing to remember is that not every approach works on a particular paeds patient. As a physio, you have to develop an arsenal of different approaches so hopefully at least one of them can help you out when this particular situation arrives.

A collapsing kid

I'm currently on a ortho inpatient's placement at the moment and had a spinal patient who had a farming accident on a 4 wheeler with her child on the back. Only the mother got seriuosly injured and the child got away with cuts and bruises.

The patient's family came to visit, including the child, and saw that she had a spinal brace and halo on. This scene was too much for the child who was so distressed seeing her mother in that situation that she passed out and collasped in her room. Although not serously injuring herself, its quiet amazing to see how emotional some kids get in the hospital, especially for this child who was in the accident but got away relatively injury free.

If this situation were to ever present itself again, a distressed child seeing their parent in a hospital bed, I would sit down and talk to the kid in laymens terms, explaining what has happened to their parent and answering any questions that they have.

Has anybody come across a similar situation throughout there pracs this year?

Isolated prac

For the first time throughout this prac year i felt completely isolated and on my own when i was on rural prac. my supervisor was there 3 days a week but when whe was there she was in conferences and meetings and from day 1 she told me that she preferred if i worked things out on my own than asking for help. i dont mind independent learning but i find that i work better if i can bounce ideas off people and discuss patients and different ways of treating problems. i was the only physio in the hospital and i was thrown into doing peri US and looking after 20+ patients on the wards in only 4 or less hours as the rest of the tme was spent in outpatients or taking exercise classes. i struggled on this prac because i felt that some of the patients in the hopsital required more than a 20 minute session a day but due to time constraints thats all i could give. i had many patients with chest infections which would have benefited from 2 visits a day, one day i spent nearly 2 hours with the pneumonia patient mentioned in my previous blog so i was unable to see some of the other patients and i wsa informed i needed better time managment skills. there were at least 5 patients who were in hospital for rehab due to strokes and complicated fractures, i found myself so frustrated by the lack of effective treatment i was able to offer these patients who deserved more than a 20 minute rush through exercise plan. i found myself having to go back to the hosptial after i'd finished in outpatients at 5 to write up all 20+ notes as i couldnt afford to take 5 minutes out of the patents treatment sessions. although i did actually love rural prac after i became more confidnet in myself and i did learn alot from the vast number of patients i saw, i still think i could have learnt so much more about different treatment options and conditions if i'd had an interactive supervisor or another student/physio to exchange ideas with. i have a much greater appreciation for team environments than ever before!

Pneumonia patient

whilst on rural prac, a man was admitted to the hosptial in his mid twenties with pneumonia. to complicate the situation the patient had a severe form of cerebral palsy, was unable to communicate, follow instructions and his muscles were so spastic that he was curled into a foetal position so effective positioning for airway clearance was virtually impossible. the family of the patient were desperat for the patient to be transfered to RPH because they had a younger son with CP who had also had pneumonia a few years earlier and ended up spending 3 months in RPH ICU as he got so sick. however, the doctors persuaded the parents to let the son stay for a while to see if the antibiotics helped and sent me a referral for chest physio to "beat the stuff out of his lungs". when i went to see the physio in the morning he was on 12L oxygen via a hudson mask, the oxygen was leaking out the mask into his eyes which were so sore he wouldnt open his eyes anymore. his sats were low 80s and there was no way to increase his oxygen as the hospital has no form of humidified oxygen or NIV. the patient's ches was so full of sputum that you could hear it gurglin in his throat, there were tactile secretions sternally and you could hardly hear air entry in the lungs due to the added sounds of sputum. the patient was too weak to take deep breaths/cough and unable to follow instructions. we tried nebs every half an hour to help loosen the secretions, percussion, vibes, positioning but nothing was improving the patient's condition. the parents were asking me if they should take their son to perth and even though i thought it was the only thing they could do i couldnt say it to them, i documented my findings and spoke to the ward coordinator that i was extremely worried about the patient and that he was getting exhausted due to WOB, the nurse agreed but said it was up to the doctor and he wanted to wait another 24 hours. maybe it was due to my prac in ICU but the only other option of treatment i could think of was a nasopharngeal tube to clear the secretions - this idea was rejected by the nurses in charge and i had noone to back me up. the patient ended up having to be air lifted to RPH as 2 o'clock that morning and is on full ventilator settings in ICU and the doctors have advised the parents to turn off the machine as too much damage has been done. does anyone have any ideas on how i could have treated this patient more effectively or communicated more effectively? my supervisor was not there that day and no other physios either. it was so frustrating knowing that i was being completely ineffective with this patient who needed much more experienced help than i could give and noone would listen to me, the doctor asked me to just "keep banging the crap out of him".

ICU patient

during my cardio prac in ICU, i was looking after a patient who'd had a CABG and many complications since the operation including the bypass graft becoming blocked and multiple organ failure. he was ventilated for the first few days in ICU then had a trachi inserted to help maintain the airway and keep him ventilted. he was on a cocktail of drugs of which one was warfarin so the site around his trachi was very oozy and the nurses did not change the dressings as they were hoping that it would eventually clot and by continually changing the dressing, the bleeding increased. the patient improved enough to start to SOOB for a few hours everyday, the patient started off being a slide transfer but as the weeks progressed we progressed to s stand transfer. the transfer required 5 peoples assistance to watch the lines and assist the patient. since it was my patient i'd been in charge of allocating people to the various jobs and positions and controlling the transfer - which had all previously run smoothly. it was my last day of prac, we'd all just been given feedback and it was time to go home. the patient mentioned above was about to be transfered back to bed after a day of SOOB when he wrote a note (as he could not speak due to the trachi) asking if he could please stand up and do the transfer as he was really proud of his progress. one of the other physio students on prac offered to help me so we decided to do it before we left. the nurse was in charge of the lines (ECG, IDC, ventilator tubing, arterial line), 1 orderly was in charge of moving the chair away and the bed in behind the patient, another was assisting the other physio student and i with the patient. the patient stood up and as he stepped across to the bed, the whole trachi tubing came out of his throat, the nurse who was watching the tubing didnt notice and as we sat him down i felt the tubing blowing air down my arm. i panicked, unsure of whether to attempt to put the tubing back into the gaoping hole in his neck as the now had not been ventiltated for nearly a minute. i shouted out for a doctor and luckily bein in ICU there are always doctors around whilst the other physio student tried to get the patient to breathe independently. the doctor came in and decided that the patient should be put on NIV and to see how he went overnight. he said the patient was becoming too dependent on the ventilator and it was time for the patient to "sink or swim" as because they had been trying to wean him off it for a few days and we'd just gone and "skipped a few steps". we had to fill out an AIMS form which was really scary as looking back on what happened, none of us could pin point how, why or when it happened and we had all the bases covered for the transfer so if i had to do it again, i'd do it the same way. this was a horrible way to end a great prac, espacially as i'd not be able to see the outcome for the patient. my supervisor sent me an email saying that the patient was able to maintain his sats on niv and would probably end up leaving hospital a lot earlier than if the incident hadnt occurred. i learnt from this incident that even though there were so many people helping out with the patient and it had been done successfully so many times before, that you cant control everything and things still go wrong - constant vigilance in required when working with patients!

Passing away

it's near the end of our the year and prac is nearly finished. I thought about all my patients that i have treated throughout the year and thought to myself "hmm, i've been so lucky that none of the patients i have treated have passed away (while i was there on prac at least)" I actually said that to my supervisor. He says "hope your record stays clean :) "

You know those moments when you realised you shouldn't of said what you said? Yeah, this was one of those. The next day a pt on the ward had passed away. He was really my pt, i saw him once and at that time he was too unwell to be seen. So i don't think it counts. Anyway, this pt had a CVA and then developed pneumonia and passed away due to resp. reasons.

There were lots of family members present to say goodbye to this man. I've never seen something like this happen. The pt was still inside his room. I was really curious and wanted to see what was happening. Everyone else on the ward continued on with their jobs as normal. I kept walking pass the room and looked inside. I guess it was the kind of curiosity when something happens for the first time, you wanna know what happens, and that was me. i guess i wanted to know what happens after.

The family spent the whole morning there and said their goodbyes, the pt was finally taken away in the afternoon. It is always sad to see such events, and such events are part of life.

I guess what i learnt was i know what happens when a pt passes away.
I keep thinking about the event.

Grabbed the wrong part.

I've been doing my prac in Geriatrics. Recently came across a 75yo Croatian lady. European, and family was brought up quite wealthy. Her diagnosis was a subarachnoid haemorrhage. She has had prolong stay in ICU and have been on the geriatrics ward for about 1 month now. Pre-adm status (according to the family) was (I) amb and all ADLs. This lady didn't speak english at all, luckily she has 7 daughters, and they all rotate to visit her. Basically there was a family member available from 9am - 9pm each day. They were useful for interpreting. Well that's what we all thought.

Now there are 2 main routes for discharges in hospital from geriatrics- Home or Nursing Home. This 75yo lady's current status is 1x(A) with Amb and T/Fs. She is terrified of falling and walks with a really funny posture. She is fully flexed at hips and her weight are on her heels, so basically she is falling backwards most of the time. It normally takes us 15mins just to convince her to walk. The family negotiates with her...... and this patient is a talker. She just keeps talking even when the family is not there and that we don't understand her.

It was one of the first time i saw her and wanted to get her up and walking, so i went in and told her my plan (Daughter interpret) after 15mins of talking, she agrees to go for a TINY walk, not long! I went to assist her stand, she keeps falling back into the chair not shifting her weight onto her feet (due to fear of falling forwards). So i went to place my hand onto her ischial tuberosity to facilitate the movement. She just went OFF! Point her finger at me. I knew she was telling me off for touching her bottom. I went to ask the daughter what she said, and she says "Oh, she is saying how thankful she is to get physio and think you have beautiful eyes" .... my thoughts were "Bullsh*t!" (seriously). This scenario becomes a common occurence, what the pt said was not what it is relayed back to me. That affects treatment greatly. I did gathered there was a cultural difference, that a 75yo european lady would find it offensive for a 24yo male to be touching her bottom. I continue to treat this pt for the next 5 days and couldn't get any gains. She was later transferred to another ward and was treated by a female PT instead and it seems to be working out better.

With this scenario, i've learnt about cultural differences. It can really affect your treatment
-male treating female
-incorrect interpretation. The family is really nice and didn't want to offend me by what the pt has said (i'm sure it was rude). And that affects treatment, because if i didn't read her non-verbal language and continued to facilitate from ischial tuberosity, i would really put her off physio and further offend her.
-family values: sign of disrespect to send your mother to a nursing home, regardless how dependent she may become.

So for next time, identify the signs earlier and try different avenues (ie. PT of the same sex).

a Prac in Singapore

The reason as to why I chose to do my practical in Singapore was because I am a Singaporean and my journey in Australia after four long years is about to come to an end. Thus I decided to have an insight to the world of physiotherapy back home. I was very excited and was looking forward to this experience. Initially i was a little apprehensive about commencing this practical as I had no notion of how the health care system functioned in Singapore having done all my practicals in Perth thus far. This practical was also an experience as it was a paediatrics practical and I have not had the opportunity to work with children before.

Upon arrival at this hospital, I was slightly taken aback at how unfriendly the staff was towards me. It seemed as though everyone was too busy and caught up with their own work. This was a different experience for me as in Perth; most staff are very friendly and accommodative to students. A possibility to this is most certainly the cultural difference as Singaporeans tend to be more conservative. However as time went by they did warm up to me.

Physiotherapy in Singapore is still not well established and as a result, the patients that had come to the physio department sometimes seemed unaware of their purpose and only attended as they were told to do so by a doctor from the hospital. A lot of times educating the patients as to the benefits of physiotherapy seemed essential and important so as to produce a positive effect with the therapy they were to receive.

Working with children has also been very challenging as it is difficult to command a child without a rebellion. Thus the sessions had to be ‘fun’ and at the same time productive. This kept me on my toes as I had to come up with various activities to encourage the children to engage in their rehab. I must admit I thoroughly enjoyed the experience of working with children. It most certainly was very rewarding.

This prac was definitely an interesting and eye-opening experience as it gave me a glimpse at what physiotherapy is like in Singapore. I must say after being in Australia for so long I seem to have needed time adjusting to the way things work in this pseudo westernised country that is still very much preserving traditional school of thought.

First impressions

Currently on my cardiopulmonary prac I was allocated a patient who was admitted to hospital for an open colectomy. She is 49 yo and her past medical history included - gall stone anaemia, lamiectomy, T2DM, ETOH, smoker, chronic back pain, appendicectomy, hysterectomy, (L) uretic stent, bowel perforation, Hep C positive. After reading her notes, I was told NOT to call her Mrs ..... as she become quite hostile and will yell and rant and rave.

When walking into the room I noticed she was aboriginal and all she did was look at me an say "What you want?". My first impression of this patient was that se was going to rant and rave at me (because my aim was to run her up and down the corridor a few times!), completely refuse physio treatment and quite frankly tell me where to go.

I introduce myself and asked her how she was, what was her pain at rest and with movement, had she been coghing etc etc etc. Then I asked her how she would feel about heading up and down the corridor for a change intead of sitting in her room. To my surprise she said that sounded like the best idea she had her all day and off we went.

I have seen this patient a few times now and I think she is a wonderful kind lady who really likes a good gasbag. My first impression were horribly wrong. I have learned from this experience and now have stopped pre-judging patients by their PMH or what the nurses are saying.

Depressed patient

on my neuro prac i was treating a middle aged man who had a debiltating stroke about 5 years earlier, he was a dense left hemi dependent with all transfers and in a wheelchair. he had no motivation during rehab sessions and was very depressed. during one of our sessions he arrived and started talking about how i didnt need to stretch out his left arm today because he no longer needed it. i explained why it was important to maintain the muscle length in his arms and he told me that it was no longer important as he was going to kill himself that night. i didnt know how to react or what to say. i started to flounder my way through reasons why he should not be thinking about suicide but my patient was adamant and had it all planned out, i started to get upset as this topic touched a personal raw spot with me. my supervisor saw that i was starting to get upset and came over and asked how everythinig was going and my patient said that he'd just come in this morning to say goodbye. my supervisor started talking to the patient about his problems at home and ways that we could get him help and people to talk to. my supervisor went to cal the patients wife who reported that he'd takken a knife from the draw last night and had tried to stab himself but she'd walked in on time and managed to take the knife away from him. she had no idea what to do and was exhausted from constantly being on quard with him and was in desperate need of a break. we spent the session talking to the patient about the help that was available to him, respite and positive things he had to look forward to. i felt quite useless in this sitatuation as i felt like i didnt know what to say to the patient and i felt like if somthing did happen when he went home then it would partly be our fault as we knew about it. what i found out that day is that there are so many services out there for patients in this situation. as he was an outpatient we organised suicide watch team for him and they went over that afternoon to see him and called him regularly that day/night and he was able to call them if he felt upset. we organsied a psych consult for him the next morning and a 2 week respite for him and his wife. unfortunately i did not get to see the patient again as he was at respite for the rest of my prac but i learnt in this situation that you cant personally take responisbility for the patient's wellbeing and that there are so many services available for patients in this situation. if i could change anything i did with this patient is how i reacted so emotionally when he was talking about suiciide, even though it touched a raw nerve i think its important to keep personal feelings separate as i found myself i a situation where i needed support as much as my patient did.

Rude neuro patient

one of the patients in my neuro outpatients prac was a 50 year old man who had suffered an right mca a few years ago. his rehabilitation had plateaued and if anything he was digressing. he had no standing balance, dependent with all transfers and chronic shoulder pain. from the start of our rehabilitation sessions he refused to let his wife watch the sessions or for her to be involved in any of his rehab at home such as stretches which were vital to improving his everyday function. he was combative during sessions and very unmotivated. to try and get him more involved with the rehab we set a goal to to work towards in my 4 week prac which was for him to be able to use the toilet independently, with this aim in mind we started our rehab sessions together. the patient was focused during the first few sessions although still refused to let his wife be involved in the rehab process. in my second last week, he came in and rudely told his wife to go and come back in 2 hours and then told me that he was getting a divorce because he couldnt live with her anymore. i took the patient over to the plinth where another patient was waiting for one of the physios with his wife, they had beeen having rehab in the same time slot for years. my patient loudly said to the patient next door how he had no idea how he could have married such an unattractive lady and stayed so long with her. he went on to say that the man's wife looked like a witch and how his life must have been hell married to a woman like her. i was so shocked, i wasnt sure how to react, i immediatley told my patient that that was completely uncalled for and and very rude and that he should apologise to the couple who were very upset at what he'd said. i transfered my patient to the plinth next door to the couple and i apologised for my patients rudeness and then my patient started having a go at me saying how i had no idea what his life had been like since the stroke and i had no right to tell him that he was being rude and to apologise. my patient said that he needed someone to support him in his rehab and not someone to tell him how to behave. the couple's physio arrived and calmed them down and my supervisor heard the commotion and called me over.

we talked about what had happened and i can see that there are many ways i could have handled the situation better. as soon as my patient had been rude to the couple, i should have taken my patient to the other side of the gym instead of transfereing him to the plinth next door to the couple where the insults kept flowing. i could have gone over to the couple then and apologised for my patients rudeness and then carried on with my patients treatment. instead i chastised my paitent for his rudeness and ended up losing the rapport we had made during our earlier sessions and thus our following sessions were not as productive as i feel they could have been. after the talk with my supervisor, i ended up taking my patient to the other side of the gym to finish off the session but instead of being focused on the tasks as hand my patient remained uncooperative and defensive. in the following sessions, as soon as my patient arrived we immediatley went to the other side of the gym to the couple to work but we never managed to reach the same level of rapport and from this experience i learnt that its very important to show your patient 100% support and alliegance and a much better way to handle a difficult situation.

Depression

I'm currently on my neuro prac on an acute stroke ward. I recently treated a patient with (R) MCA. She was a (L) hemi with no movement in both (L) UL and LL. I've read her notes prior to seeing her. She is 73, lives alone and has minimal support with family. She has a PMH of HTN, OA, Depression, Renal Failure.

Upto seeing her, she was very quiet and shy at first. I proceeded to introduce myself and explaining the reason i was there. Still no reply. She actually turned away and realised she was clenching her fist. I continued with my session and asked her how she was feeling and that i was going to take her to the gym to do some physio. She mumbled out "good". I pushed her (in a W/C) to the gym where it was a quieter environment. It was just me and her. She slowly started to open up and spoke to me. However, her actions were still agitated and irritable. She had explained that she's had not much support from family and not have anyone visit her since her admission. She also shares that she has suffered from depression for a very long time and feels it's getting worse and worse. I further questioned her life prior to her stroke. It was a very monotonous and sedated lifestyle, she pretty much stayed home all day. It was very hard to treat her neurological symptoms, as she seemed very dis-interested in everything i was trying to do. I tried to explain everything i was doing to help her understand. But no matter what i was doing she really wasn't interested or trying to move her limbs.

I spoke to my supervisor afterwards and found out her depression is quite severe. She is on heavy medication and therapy with psychologist. My supervisor suggested trying to get her to open up, talking to her and understand her thoughts. She also said, sometimes they have good days and bad days, so it can be a luck of the draw thing.

I continued to treat the patient and slowly built up my rapport with her, i kept trying to ask her questions about her and really trying to understand her. And i think it helped. She now looks forward to our physio sessions and has shown good improvements on her stroke.

Initially reading her notes and her PMH, it had depression and i just skimmed over it. Because 5 out of 10 patients that you see have got depression in their PMH. And i've never realy had any problems (so far). However i have learnt you always have to keep it at the back at your mind and determine the severity of the depression. Because it could affect your physio Rx, like this one.

Unprofessional behaviour

Previously on prac I was informed by my supervisor that I had acted in an extremely unprofessional way. What she was referring to was I had taken one day off due to being unwell and I had got a family member to ring and inform the supervisor. Usually I would ring the supervisor myself and inform them but on this occassion I was extremely unwell and the supervisor was the most unapproachable person I have ever met and the last person I wanted to speak to when feeling that unwell was her.

I was actually amazed at how she acted towards me after this. She deemed me non competent on my mid placement for being unprofessional for not ringing her myself, she laughed and said she had told all her work collegues about it and said no one could believe I am graduating in a few months and still got a family member to ring up on my behalf. She them continued on (still laughing) that she hadnt done such an unbelievably unprofessional thing since uni!!!!!...........Unfortunately I had to remind her that I actually still was at uni. (probably not the best way to handle the situation)

I also was informed that I have no observational skills, poor assessment techniques and my treatments are not effective. I am still unsure what she based this on tho.I have never ever had such a horrible supervisor. Fortunately however out of the 4 weeks I saw her 4 half days (in total). Unfortunately tho I did not learn ANY physio.

It is wishfull thing to hope that after graduating I do not encounter such people although there is never harm in hoping.

Good Patients

As we are all discussing different scenarios about patients we have encountered, I thought it would be a good idea to talk about patients who do everything of which they are told to do.

On my recent rural prac, patient X presented to the outpatient department with a Hx of consistently rolling his (R) ankle - the latest of which was 3 weeks beforehand. He described that his (R) ankle was now causing him problems at work with activities such as walking, climbing ladders etc. He had tried various home Rx's at home without success. He wanted me to write down a Rx map for him for our upcoming sessions so he could see what was going on.

I wrote down a Rx plan for him, making sure it was written down in terms he understood. I broke it down into 3 sections:

- Current symptoms (eg pain and swelling)
- Return to functional activites ( eg full ankle ROM, walking and squats)
- Preventitive management (ie no more further reoccurance)

The presentation of this simple plan to the patient got him very motivated to do his exercises and try and overcome this injury. After 3 treatment sessions, he was d/c from physio with nil pain or swelling swmptoms, had no problems with functional tasks ie walking and hadnt rolled his ankle in 6 weeks time.

It's an interesting case to bring up, I guess you learn throughout your pracs this year that every patient is different, therefore, will need a different approach to be taken with them in order to get positive results. It just so happens that the act of treatment planning for the patient made him very motivated to complete his physiotherapy. From this experience, I have learnt to take on board all of the different types of techniques other allied health professionals employ to get there patients motivated. I guess you never know when you will ever really need it but as the scouts say, always "Be Prepared". On this occasion it did for me.

Misunderstanding

I am currently on a prac where i was working solely with one patient for one full week. This patient is of aboriginal descent and the project i am working on in relation to this prac is specific to aboriginal people so it was in my best interest to get along with this person and get a lot of information out of him in a short amount of time as he was only in Perth for one week.

It was hard to balance both time management issues and achieving all of the things i wanted to get done in one week whilst trying to gain initial rapport with this person as this was the first time i had ever met him.

As the week progressed i thought i was achieving what i needed to in regards to the project and i also thought i was gaining rapport.

It became apparent towards the end of the week that i had achieved the rapport however i hadn't completed nearly enough of what i was supposed to get done on my project prior to the patient leaving. In fact it became apparent that i the patient, supervisor and myself had all had a different view point of the project i was to complete. Their opinion of what they wanted had changed since initially discussing the task a month prior and since we hadn't had another meeting to reiterate this point i was unaware. It meant that the final day spent with the patient was long and tiring.

In reflection i perhaps should have held a mini meeting mid week with my patient and my supervisor to simply ascertain if i was getting what they wanted done. If this had of been done earlier it would have provided some extra time for me to complete some of the extra tasks that i was initially not aware of.

It's a very typical example of different peoples expectations and how one should never assume anything. In hindsight another meeting would have been very beneficial. In the future clarification would have saved me a lot of time and stress.

Language barrier

I have just arrived home after completing my four week international placement in Kota Kinabulu, Borneo. I was allocated to NASAM (National Stroke Association of Malaysia), a non-profitable stroke rehabilitation centre in Sabah. The centre comprised of a small room with two plinths, a kitchen and a verandah with exercise equipment that had been donated by local hotels (treadmill, stepper, stationary bike etc).

Approximately 30 stroke patients attended the centre. Ages varied from 39-80+ with equal number of males and females. The amount of time post-stroke varied from 6months to eight years. The centre was run by volunteer qualified physiotherapists and other non-qualified volunteers. The patients received a two hour exercise class per day.

During the 4 weeks, both myself and another student ran the exercise classes as well as conducted one-one physio treatment sessions. The one-one sessions were most beneficial however they were quite a challenge! Some patients spoke Manderin, others Malay, some Haka, some Hokkein and very few spoke broke english. Trying to come up with ways to communicate to a patient with out using language is a very challenging experience and sometimes quite humerous.

I now know the facial expression for "I have no idea what you are saying" is and even when a patient smiles and nods, I learnt to understand that the patient really did not have a clue what I was trying to explain. I found visual demonstration, pictures, tactile cues and sing language where the best ways to convey my message. The patients where wonderful and so willing to learn that it was not stressfull at any time.

I now know how to count in Malay, Mandarin and Haka and have some idea of a few Malay words! It was a fantastic learning experience.

Is it your place to tell?

I recently completed my rural prac which I rather enjoyed as i had patient caseload with a lot of variety - including musculoskeletal oupatients, paediatrics, woman's health and inpatients.

A 7 wk old baby with a mild plagio was booked to see both my tutor and myself and after reading the operation notes, we realised that this wouldn't be a normal type patient. The mother had recently been off her medications for mental problems, there were family problems in the household and there was a very interesting birth history with the mother ending up in ICU bleeding out and the baby being born 4 weeks premature.

After the inital assessment of the baby, we realised that the child was lacking in certain motor milestones, altered tonal changes and had a hard time concentrating. The problem was that the baby hadn't been diagnosed with anything up until this point in time - ie undiagnosed CP. The mother was seeing a social worker, clinical nurse and GP to sought out all of her problems.

After finishing of the session with HEP of stretches and exercises and simple education about placement of child vs environment, the mother went on her way with her baby.

The tutor explained to me that she didn't want to bring up all of her finidngs to the mother as she has a lot on her mind at the moment. We discussed this further with the mother's clinical nurse who had also noted the baby's changes. The nurse explained that she would explain the potential diagnosis of the baby to the mother on their next visit in 3 days time, as she had just been back on her meds and in a better frame of mind.

This was a very complex situation to be a part of but I think my tutor did the right thing in this situation. If this situation was to come up, especially once reading the complex Hx of both mother and child, I think I would have contacted the other allied health professionals involved with that specific patient and then see what they had observed and noted and what they had planned for them, or perhaps even work out if the baby's diagnosis had been discussed with the parents. I certainly learnt a lot from this experience.

Exercise Types

I've just recently finished my SDP with a private practice. My project invovled creating exercise sheets for this private practice. I had to come up with the most common conditions seen at the practice and create 4 exercise leaflets as patient education. In order for me to create this, i had to do a literature review to find out which was the most effective/evidence based exercises for lower back pain (as one of the condition).

I had read a good amount of journal articles and had come up with about 6 exercises for lower back pain. I discussed my findings with my supervisor. He agreed with some of the exercises and disagreed with some. He gave me some exercises that the practice uses most and would like them in the leaflet. Interesting enough, the aritcles that i read actually said that the exercises he had asked me to use were found to be less effective. After i noticed the exercises he wanted were found to be less effective, i brought it to his attention. He did acknowledge what i had pointed out but still preferred me to use the exercises he had suggested. He told me that even though the exercises maybe more effective than others, i had to also consider the therapist's experience and preference. Most of the physios that work at the practice had been in the profession for 10years+, so they would have a pretty good grasp of treating LBP and exercises for patients.

A couple of interesting points from this incident.
-Even though some techniques maybe more effective than others, you need to always consider the therapist's skills and experience. But also have a closer look at the journal article, as to the age, gender, race etc..... and the article was actually written in US, so maybe it wasn't as applicable in Australia? So there were lots of other factors to consider
-It also points out the importance of continual education for us as physios. I found out the practice actually doesn't have any type of professional development within the clinic. So unless the physio themselves keeps up-to-date with reading new journals, their treatment techniques maybe outdated or their might be more effective techniques out there that they have not been exposed to.

Next time if i was to do a similar project, i should discuss with all the physios at the clinic and ask what exercises they use and prefer. So know the therapist's preference and incorporate that with the project and my literature review. Find a balance between the two.

Asking for Help

I have just completed my rural placement where i saw many different conditions across musculoskeletal outpatinets, paediatrics and woman's health.

One particular patient I had in outpatients had a total shoulder replacement a year before after suffering major tauma to his shoulder. The operation notes were just incredible and the x rays, both pre and post operation, were the most interesting I have ever seen.

Mr X had been back working for the past few months but was still lacking ROM from his shoulder especially abduction and flexion. Closer inspection revealed that his scapulohumeral mechanics had been altered and this was impeding him getting past 60 degrees in both directions.

I thought my inital 2 treatments should be starting to address this problem but further reassessment 2 weeks later revealed that only minimal improvements had been achieved. It was at that stage when i decided to get the senior involved as I was starting to run out of options for treatment. The senior and I both worked together on Mr X's shoulder for the next 3 sessions with minimal changes. It was then decided between the both of us that we needed further help and started contacting physios in perth, who had experience working with shoulder replacements and altered shoulder biomechanics.

If a situation like this was to present itself again, then as soon as i realise that i'm out of my depth, in terms of knowledge and treatment options, I should ask for help or advice as soon as i can. It will always be in the patient's best interests if I do so and i'll will always then learn from the experience. Has anyone ever come across a very hard patient to treat in an outpatients setting and were way out of the depth?

Drugs

On my most recent placement in ICU there was a great deal of information i had to absorb when assessing and treating a patient. Not only were there the usual stuff but also the ABG's, Blood count, ECG and central venous line measurements, patients fluid balance throughout the day and the effects of that, not to mention learning all the drugs they were on and the effects they might have on their system as well as all the usual objective measures and PMHx, HPC things to absorb. I was a little worried about remembering all the drugs at first because my memory isn't great at the best of times but it was kind of important to remember what drug a person was on because sometimes it would have an affect on the treatment planning.

One drug in particular, nitric oxide, works by breaking down a blood clot (i.e. when you have a pulmonary embolism). This drug however will break down a blood clot in the preferentially ventilated lung. So on ICU when people are ventilated the preferentially ventilated lung is the opposite of normal and is the more superior lung. This is important because if you want the nitric oxide to work at its best and the patient has a pulmonary embolism in their left lung you should place them in right side lying for the full effects of the drug. By placing them in right side lying it also means that majority of the perfusion will be going through the right lung, which is then diverting blood away from the blockage where the PE is.

I couldn't believe how smart this drug seemed to be! Amazing! I was even more amazed when another student i was on prac with commented that they overheard an intern asking a registrar about what nitric oxide did and the registrar commented "oh it's just a bronchdilator". Perhaps they meant a vasodilator but even that doesn't explain the intricacies of how this drug works.

It just embedded the fact that it is so important to have a further understanding of drugs. Not only did we not learn very many drugs in uni but it really does effect what we do as physio's. In the future, even though it may take me a little longer to look up the drugs, i will make sure i have a full understanding of the patient, including their medications prior to treating them. This experience has taught me how important a broad understanding of each patient is.

PE

Currently on my neuro prac, I have had a number of pt's that have come directly from ICU or become acutely unwell. Last week was no exception, with one pt i had been seeing bidaily, desaturated overnight and a code blue was called.

This pt has GB and Rx consists of chest management including ACBT's and suctioning via trache, with passive movements of UL's and Active assist of the LL. Early last week, the pt was tolerating Rx well and getting much better chest expansion and breath holds. This made me think that his intercostals or accessory muscles were again being activated after nerve conduction improving. I encouraged the pt to take deep breaths and the pt was satisfied with his new improvements.

The following day the pt was complaing of mild constant (L) chest pain, that was worse with deep breathing and passive movements of the (L) UL, particularly flexion of the shoulder. I thought the pain was possibly of a musculoskeletal origin, after the big session the previous day, maybe the pt had strained a number of intercostal muscles. The pain also could have been due to remylination of nerve fibres with muscle reinervation, which can cause pain. I checked with my supervisor and she shared my view. I limited DBing ex's and the pt had a gentle session.

The pt was diagnosed with a PE and spontaneous pneumo-thorax (L) the following day after crashing overnight, and was placed under more acute care. This was a surprise after our suspected diagnosis, and i thought if there was anything i had missed and could have alerted Dr's earlier. We checked the area and palpated, auscultated, subjective questioning and nothing indicated a sinister pathology. This situation just indicated even if you think you've covered all your basis this is not always the case. Even being cautious and getting an X-ray that day would have picked up the pneumo-thorax or other tests to indicate a PE. I felt like i should have known or done more, but i wasnt exactly sure. We tried to do DBing that day but cut it short, in hindsight avoiding this altogether would have been better. These situations probably happen alot in clinical practice, and hopefully if it can be prevented actions are taken for optimal pt outcomes.

Manual Hyperinflation

I am currently on cardio prac in intensive care. Most of the patients are intubated and generally treatment is suctions, manual hyperinflation and vibes, but not in that order, or a combination of all 3. So far in the prac we had very few patients in the first few days and more supervision and now the patient case load has increased and the supervision has decreased as it is the final week this week. Today i had a different supervisor due to my normal one being busy and this supervisor kept reiterating the need for manual hyperinflation with patients to mobilise their secretions.

I wasn't aware, prior to today, that you would manually hyperinflation most patients as a general rule to mobilise secretions prior to suctioning and only on the patients where it was contraindicated would you not perform this.

I realise the reason why one would manually hyperinflate prior to suctioning an intubated patient. This being recruiting alveoli, potentially reducing areas of atelectasis and getting some inspired air behind the secretions and moving them into the larger airways to then allow suctioning of them. The problem i had with accepting what my supervisor said was that i reasoned in my head that if you can improve a patients chest (objectively measured via sats, chest expansion, auscultation and possible respirator rate) by simply suctioning and positioning techniques then only use manual hyperinflation in the patient where this is not working or perhaps a patient who has had an extensive stay in ICU and may need another treatment modality to mobilise secretions perhaps.

Because i was thinking a lot about this i decided to do a little research. I found that a lot of the time manual hyperinflation isn't done correctly. The patient it also at risk of barotrauma to the lungs and breath stacking when MHI'd. When it is done correctly it can recruit alveoli and help with movement of secretions however no evidence is substantial enough to always adopt this as a treatment modality.

So i understand the reasoning why you would and could MHI but at this stage in my career i would rather only resort the manual hyperinflation when the other modalities are not achieving desired expectoration of sputum. It just shows me that just because you can do something doesn't necessarily mean you should. If anyone has any thoughts on this one or any other information to back up routine MHI i would love it if you shared. Thanks!

Brain injury

Last week on my neuro prac a very interesting incident occured with a pt on the ward. She was not my pt, but i had helped on several occasions as she was 2x max assist for transfers and i was called in as a 3rd helper for head control during transfers or additional support. Her HPC was a severe (R) sided haemorrhage that had caused a significant midline shift. She had a trache and was requiring regular suctioning due to having copious amounts of secretions. She was unable to communicate or respond to commands, and blinking for yes/no Q's was being trialled.

On one occasion last week, I entered the room expecting to see another physio student to liase with about plans for the afternoon. When i entered, the pt immediately turned her head and fixed her gaze on me. This was surprising in itself as the pt normally had no fixed gaze, if her eyes would open at all. I then asked how she was feeling, and she replied with not bad by mouthing the words and moving her (R) hand in a so/so motion. She also gave me a smile when i said she was looking much better.

We saw the pt again a few days ago and she was very talkative and moving her (R) side well, with some activation of her (L) UL and LL. We asked her if she remembered much and if she knew how far she had come. She replied saying she could not remember much of the early days, but from the week before she heard and understood everything, but was unable to respond in any way, and was getting very frustrated. She had made such and amazing and spontaneous recovery, in addition to the communication, requiring 1x min A for sitting compared with 2xmax.

This made me think of a few things. I didnt realise the turn around someone can have following an insult to the brain, where i was under the impression it would be a much more gradual process, especially after the acute stage (She had been in hospital for over 3 weeks). It also demonstrates the importance of physio and other therapy in these early days, even if a pt is very dependent and their outlook is not good, you just never know. Also, even though the pt is unable to communicate or respond in any way, they may still understand and this must be respected by always letting the pt know wat is going on and encouragement ++. I think this is really critical, even at the time if you think you mite be talking to yourself. This was a real eye opening experience and really illustrates the importance of all the care she received to aid her recovery.

Intubated pt's

I am currently on a placement where a lot of patients have ETT's and are very sedated or they have tachy's. One particular patient i have been treating quite regularly has a trachy. I had never come across intubated patients in any other prac before this one and so this was a very new experience to me. My patient with a trachy was becoming better every day and his sedation levels were being weaned so we could hopefully begin to increase his mobility. I hadn't thought about it too much before, simply i suppose because i haven't come across it, but once he was alert he had a great deal of difficulty communicating with me (as well as other staff) because he couldn't express himself in words.

It was a new situation i came across. I have experienced patients who speak very little English, as English is their second language however i seemed to always manage treatment sessions alright as these people were all fairly independent compared to my patient with the trachy.

I assumed that gestures etc. would always be suffice with patients that have a reduced ability to express themselves and if they were still struggling perhaps an interpreter would be a good idea. But with this patient there's nothing altered about his language. He speaks English normally and can communicate fine but due to the trachy it has affected his ability to tell staff if he's in pain or if he is short of breath etc.

Over time i have limited my talking with this patient to simple questions which he can either nod or shake his head to. This works well most of this time and some things that he commonly wants i can now interpret as i am starting to get to know the patient better.

In future i will endeavour to be more succinct with my questioning of patients as not only is it important for patients who have a compromised ability to express themselves via language but it also makes more sense when dealing with aged people, younger kids and pretty much everyone. Sometimes it's easy to fall into the trap that everyone is understanding what you are saying and are able to express themselves back in the same manner. It's good to experience this situation to realise not all people have the ability to say what they want when they want.