On my P1 prac this year I was placed at a neurology outpatient department and we had a variety of patients who came in twice a week. One particular patient was a 31 year old female who had suffered a pontine stroke 4 years previously, this left a perfectly normal young woman who was a naturapath with locked in syndrome. This means she had no gross motor funtion other than small, uncontrolled movements of her left hand, nodding/shaking her head, and the only sounds she could make were largely unrecognisable. Therefore her only means of communication were to let us guess what she was trying to say and nod or shake her head, which was slow and depended on how well the therapist knew here. She could also use a lightwriter, a small laptop like device that she could type words into, but this was also very slow. Despite this she had a great sense of humour and for the first couple of weeks she was a really great patient who was alway compliant and tried her best.
During one session around the third week I was trying to facilitate her sitting balance and i was asking her to lean back a little bit. She had very poor abdominal control and so tended to lean forward to get her balance but needed to sit back to get into a better posture. Halfway through this treatment my patient started crying. We were working an open treatment area so we didnt have any privacy and i was sitting behind her supporting her, which was made difficult as she was really upset and shaking. Initially I thought it might have been something to do with the treatment I had done, maybe making her feel unbalanced and not in control and we tried asking her if this was the problem. My supervisor, who knew her much better than me came and started asking what was wrong. It took nearly an hour to find out the problem because we had to guess what the problem was and she could only reply yes or no. Eventually she used her lightwriter to tell us that her ex boyfriend had just got married and this was what was upsetting her. I found this situation very difficult as initially i thought i had done something wrong and also didnt feel that i could say much once the supervisor arrived as i didnt want to upset her more. I also wasnt sure if she would really want me knowing the problem as it was very personal. I also wasnt prepared to face such personal issues from patients as its not often what you expect from physiotherapy. It was also really confronting to think that someone who is just like you and me could have their whole life infront of them and have it taken away in a day. I really had no idea what to say and thankfully my supervisor could say some really things to comfort her. The hard part about this situation is not taking it home but then also not feeling insensitive and as if you dont care. In the next session my patient was alot happier and was very grateful for our help but I still felt that without my supervisor I would have been lost dealing with the situation.
Thursday, May 29, 2008
Monday, May 26, 2008
Gero Prac
I am currently on my Gero Prac working on the general med ward. The patient I encountered last week was a cardio patient and I needed to do a cardio assessment on her. Upon entering her room she was surrounded by family members. I had introduced myself and briefed them on the purpose of which I was there for and what would be happening and the benefits of the treatments to the patient. The family did not respond well to me as I am a current student on prac. They told me to leave the patient alone and that they did not want any sort of intervention to be done on her. I then very calmly tried to re-establish my purpose for being there and the benefits that may be brought upon the patient. Again, the family very adamantly denied treatment and made me feel as if I were of no use. I was shocked and upset at their response.
I very politely left the room and went to look for my supervisor. I re-enacted the course of events to her and could not hold back my emotions. I felt like I had not performed up to standard in fulfilling my role as a physiotherapy student to this patient. I felt angry towards the family for not respecting me as an individual there to assist this patient. Upon analysing the situation, my supervisor was very understanding to the situation and told me not to worry and assured me that I had done the best I could. Although this had happened, my supervisor was very encouraging.
The next day, I went back to my prac only to hear the terrible news that this patient had passed on. All of a sudden, it made me realise that my reaction to the whole situation was foolish as I did not consider the family’s point of view. I had probably come at a time of grief for the family and the anger and frustration of the family was taken out on me. I am slowly starting to understand that there are some things that are beyond my control. When performing our occupations, there are limitations to what we can offer. I can only say what assessments and treatments I think should be done. However, the choice to accept these assessments and treatments lie solely upon the patient and their family.
It is from these experiences that I am able to fully understand the true meaning of being a physiotherapist and how I may offer my services to patients.
I very politely left the room and went to look for my supervisor. I re-enacted the course of events to her and could not hold back my emotions. I felt like I had not performed up to standard in fulfilling my role as a physiotherapy student to this patient. I felt angry towards the family for not respecting me as an individual there to assist this patient. Upon analysing the situation, my supervisor was very understanding to the situation and told me not to worry and assured me that I had done the best I could. Although this had happened, my supervisor was very encouraging.
The next day, I went back to my prac only to hear the terrible news that this patient had passed on. All of a sudden, it made me realise that my reaction to the whole situation was foolish as I did not consider the family’s point of view. I had probably come at a time of grief for the family and the anger and frustration of the family was taken out on me. I am slowly starting to understand that there are some things that are beyond my control. When performing our occupations, there are limitations to what we can offer. I can only say what assessments and treatments I think should be done. However, the choice to accept these assessments and treatments lie solely upon the patient and their family.
It is from these experiences that I am able to fully understand the true meaning of being a physiotherapist and how I may offer my services to patients.
Confronting ICU
Hey Guys,
Whilst on my 3 week placement in the ICU at Fremantle Hospital, there were many uncomforatble scenarios that confronted me, especially concerning the many deaths of patients.
My first full day in the ICU was very confronting, despite being warned about what to expect, you never really think it will firstly happen, then secondly, ever effect you. This was high lighted when a patient was rolled out of ICU down towards the morgue in the first hour of the day. Although not directly effecting you, you know that these particular groups of patients, on occasions, have their life dangling by a thread sometimes.
After that particular incident, we didn't have any deaths in the ICU until the end of the 2nd week. This particular patient came via the Murdoch ICU and his very uncommon heart condition and lung infection had progressively been getting worse. The two days before the patient passed away were interesting, at one stage his condition had actually gotten better. On the Thursday afternoon before leaving to go home, the patient was considered to be in a serious but stable condition but this had dramatically changed over night.
Upon returning on the following morning, the patient had his wife, son and daughter at his bedside and you could obviously notice that they had been crying for some time, but it wasn't until the nearby nurse had said that he had just passed away about 5 mins before walking in this morning that you realise how upfront death is.
Although it didn't upset or anger me, you realise that in some clinical cases that we will (as physio students) come across these particular cases through our 4th year journey. Even despite your best efforts of administrating breathing exercises, getting a patient to cough and postioning patients in bed, patients will die and you'll have to accept this. I know it is a very mean thing to think anout it in this way but you have to remember that in certain situations, such as ICU, you are there to do your job as a physio and its best to not get yourself attached to your patients, eventhough its human nature to do so. I kind of applied this particular process to the patients who passed away in my last week of my clinic, with mixed results.
Has anyone had a patient, who they were treating on the wards or in a an outpatients setting, die on them? What were your immediate thoughts or feelings?
Whilst on my 3 week placement in the ICU at Fremantle Hospital, there were many uncomforatble scenarios that confronted me, especially concerning the many deaths of patients.
My first full day in the ICU was very confronting, despite being warned about what to expect, you never really think it will firstly happen, then secondly, ever effect you. This was high lighted when a patient was rolled out of ICU down towards the morgue in the first hour of the day. Although not directly effecting you, you know that these particular groups of patients, on occasions, have their life dangling by a thread sometimes.
After that particular incident, we didn't have any deaths in the ICU until the end of the 2nd week. This particular patient came via the Murdoch ICU and his very uncommon heart condition and lung infection had progressively been getting worse. The two days before the patient passed away were interesting, at one stage his condition had actually gotten better. On the Thursday afternoon before leaving to go home, the patient was considered to be in a serious but stable condition but this had dramatically changed over night.
Upon returning on the following morning, the patient had his wife, son and daughter at his bedside and you could obviously notice that they had been crying for some time, but it wasn't until the nearby nurse had said that he had just passed away about 5 mins before walking in this morning that you realise how upfront death is.
Although it didn't upset or anger me, you realise that in some clinical cases that we will (as physio students) come across these particular cases through our 4th year journey. Even despite your best efforts of administrating breathing exercises, getting a patient to cough and postioning patients in bed, patients will die and you'll have to accept this. I know it is a very mean thing to think anout it in this way but you have to remember that in certain situations, such as ICU, you are there to do your job as a physio and its best to not get yourself attached to your patients, eventhough its human nature to do so. I kind of applied this particular process to the patients who passed away in my last week of my clinic, with mixed results.
Has anyone had a patient, who they were treating on the wards or in a an outpatients setting, die on them? What were your immediate thoughts or feelings?
greetings from the mentor
Hello to all you folks in TeAM AWEsoME. You guys are off to a great start as the scenarios posted so far are excellent examples of the challenges you will face in clinical practice. They also provide good opportunities for you to reflect. That, in fact, is the challenge, so understandably you will be a bit tentative on your first go. But do try to push a bit further each time.
For example the pt with 'elbow/neck' pain, it would be nice to know how the student physiotherapist felt about how they handled the situation, had they thought of strategies to manage each relationship (student-supervisor vs therapist-pt). Its OK to say, hey I feel like I'm caught in the middle and I don't quite know how to manage one or both of these relationships.
Remember that the reflection process is about working through the problem, it doesn't mean you always have to have a solution.
So, keep up the good work :-)
By the way, is there any background to the group name?
For example the pt with 'elbow/neck' pain, it would be nice to know how the student physiotherapist felt about how they handled the situation, had they thought of strategies to manage each relationship (student-supervisor vs therapist-pt). Its OK to say, hey I feel like I'm caught in the middle and I don't quite know how to manage one or both of these relationships.
Remember that the reflection process is about working through the problem, it doesn't mean you always have to have a solution.
So, keep up the good work :-)
By the way, is there any background to the group name?
How can we as physios help this 18mnth old walk?
I am on my paediatric placement at the moment. During my first week an 18 month old child presented to the clinic as his mother was concerned that the child did not tolerate walking and when the child was assisted to stand, he would weight bear on the medial aspects of both feet.
She also stated that she was trying to purchase some supportive shoes in hope this would help the child to stand.
On observation the child appeared alert and happy. He was interacting with the PT, the mother and myself well. He ws able to crawl to collect objects and toys effectively. When he was assisted to stand, he stood with both ankle extremely extremely everted and did not tolerate this position well. Ax found an increase in ROM in both ankle especially the talocrural joint and extreme ligament laxity.
The PT taped both ankles into a neutral position using fixamul and rigid tape and educated the mother on how to tape correctly. After the tape was applied the child was able to tolerate longer periods of standing and short burts of assisted walking. After the treaatment session the PT and I tried to brainstorm some ideas to help this child. The PT explained to me that even if the child is referred to podiatry, a splint or brace for both ankles will not be make until the child is WBing. Our issues is that the child wont WB without support, but they wont make the necessary support until the child WB.
Apart from taping to provide external stability we have yet to find a solution. Does any one have any ideas that both the PT and myself can try to help this young child to WB?
She also stated that she was trying to purchase some supportive shoes in hope this would help the child to stand.
On observation the child appeared alert and happy. He was interacting with the PT, the mother and myself well. He ws able to crawl to collect objects and toys effectively. When he was assisted to stand, he stood with both ankle extremely extremely everted and did not tolerate this position well. Ax found an increase in ROM in both ankle especially the talocrural joint and extreme ligament laxity.
The PT taped both ankles into a neutral position using fixamul and rigid tape and educated the mother on how to tape correctly. After the tape was applied the child was able to tolerate longer periods of standing and short burts of assisted walking. After the treaatment session the PT and I tried to brainstorm some ideas to help this child. The PT explained to me that even if the child is referred to podiatry, a splint or brace for both ankles will not be make until the child is WBing. Our issues is that the child wont WB without support, but they wont make the necessary support until the child WB.
Apart from taping to provide external stability we have yet to find a solution. Does any one have any ideas that both the PT and myself can try to help this young child to WB?
Health Insurance
I am currently on a neuro prac placement at Joondalup Hospital. I have never been to joondalup hospital prior to this and it is all very new to me (unlike SCGH) where we have been a thousand times. Joondalup Hospital mainly runs east west and has west wings and east wings. In general they reserve the west wings for private health care patients and the east wings for public health care patients.
Due to the fact that there are different sections of the hospital there are different charges that apply if you're in the private as apposed to the public section. Mostly the public section runs the same as other hospitals and you see people needing physio as often as possible, and while gaining consent is a must, you are almost advised to bribe them into agreeing sometimes.
I am located on the private section and it's very different. People who have private health cover may not have physio coverage and in this sense you kind of need to respect their choice as to whether or not they get physio a little more because they will get a very large bill at the end of their stay if they have had services that aren't covered.
I had an elderly patient who presented with a facial droop and slurring of speech. She had two strokes 20 years earlier and consequently her level of function prior to her admission this time was wheel chair bound but independent with transferring by using her unaffected arm and leg. We wanted to assess if she had any motor deficits from the most recent stroke that would affect her performing her transfers but she flat out refused for a few days in a row and we couldn't ascertain whether she would be safe at home prior to her discharging herself.
There were also a couple of patients this week that were holidaying here, visiting their children and had strokes whilst in Australia. It means they have to hope their travel insurance will cover all the allied health services that the hospital provides.
It puts you in a bit of a tricky situation as i found myself hesitating before treating a man from overseas who had a very dense stroke as his son had not ascertained yet whether the travel insurance would cover any of the costs. It took me a while to explain to my curtin supervisor that it wasn't that i had written him off as having no hope for rehab but that i knew his son was waiting on his father to be stable before flying him home where they have staff employed in their homes to do all the cooking/cleaning/washing etc. and it was more that i didn't want to visit this man, only to find that he could barely sit again and then send his family a bill for that when he would be leaving in a day or two and has care already organised.
Due to the fact that there are different sections of the hospital there are different charges that apply if you're in the private as apposed to the public section. Mostly the public section runs the same as other hospitals and you see people needing physio as often as possible, and while gaining consent is a must, you are almost advised to bribe them into agreeing sometimes.
I am located on the private section and it's very different. People who have private health cover may not have physio coverage and in this sense you kind of need to respect their choice as to whether or not they get physio a little more because they will get a very large bill at the end of their stay if they have had services that aren't covered.
I had an elderly patient who presented with a facial droop and slurring of speech. She had two strokes 20 years earlier and consequently her level of function prior to her admission this time was wheel chair bound but independent with transferring by using her unaffected arm and leg. We wanted to assess if she had any motor deficits from the most recent stroke that would affect her performing her transfers but she flat out refused for a few days in a row and we couldn't ascertain whether she would be safe at home prior to her discharging herself.
There were also a couple of patients this week that were holidaying here, visiting their children and had strokes whilst in Australia. It means they have to hope their travel insurance will cover all the allied health services that the hospital provides.
It puts you in a bit of a tricky situation as i found myself hesitating before treating a man from overseas who had a very dense stroke as his son had not ascertained yet whether the travel insurance would cover any of the costs. It took me a while to explain to my curtin supervisor that it wasn't that i had written him off as having no hope for rehab but that i knew his son was waiting on his father to be stable before flying him home where they have staff employed in their homes to do all the cooking/cleaning/washing etc. and it was more that i didn't want to visit this man, only to find that he could barely sit again and then send his family a bill for that when he would be leaving in a day or two and has care already organised.
Pelvic fractures
A pt presented to the ED after a fall and subsequent DKA (diabetic ketone acidosis) from lying on the floor for several days, and unable to get to medication. X-rays were performed on the femurs and lumber spine and were cleared for fractures. The pt was medicated and there were no contraindications to physiotherapy, so exercises to improve strength, endurance and balance were commenced.
After implementing bed exercises on day 1, amb began day 2 with other strength and balance exercises. The pt was complaining of inguinal pain on the (L) that came on intermittantly with WBing. Pain radiating down the thigh was also reported with knee pain. The pt was very weak in th LL's with a glut med gait on the (L) from a gradual decrease in exercise and the recent episode of fall and DKA. The pain was thought to be related to this weakness and deconditioning, so the exercises were continued to be progressed. The pt was tolerating exercise well and their spirits were up, so a fracture in the hip seemed unlikely.
Mid-week, the consultant suspected a fracture as knee pain is often associated with a hip/acetabular fracture, and on bone scan and follow up X-ray of the pelvis a acetabular, sacrum and sup/inf pubic rami fractures were found. The pt was given RIB orders, with non-Wbing (L) LL for transfer to commode. Otherwise the exercises he had been performing and progressing with were contraindicated.
From this experience having a greater knowledge of the signs and symptoms of an acetabular fracture, it may have been spotted earlier and a potentailly harmful programme would not have been implemented. Also, so muscular pain can be excluded, more investigation should have been undertaken to realise the pt's atrophy was not the cause of the pain and the cause of the decrease WBing on the (L) LL.
After implementing bed exercises on day 1, amb began day 2 with other strength and balance exercises. The pt was complaining of inguinal pain on the (L) that came on intermittantly with WBing. Pain radiating down the thigh was also reported with knee pain. The pt was very weak in th LL's with a glut med gait on the (L) from a gradual decrease in exercise and the recent episode of fall and DKA. The pain was thought to be related to this weakness and deconditioning, so the exercises were continued to be progressed. The pt was tolerating exercise well and their spirits were up, so a fracture in the hip seemed unlikely.
Mid-week, the consultant suspected a fracture as knee pain is often associated with a hip/acetabular fracture, and on bone scan and follow up X-ray of the pelvis a acetabular, sacrum and sup/inf pubic rami fractures were found. The pt was given RIB orders, with non-Wbing (L) LL for transfer to commode. Otherwise the exercises he had been performing and progressing with were contraindicated.
From this experience having a greater knowledge of the signs and symptoms of an acetabular fracture, it may have been spotted earlier and a potentailly harmful programme would not have been implemented. Also, so muscular pain can be excluded, more investigation should have been undertaken to realise the pt's atrophy was not the cause of the pain and the cause of the decrease WBing on the (L) LL.
Upset patient
Im on musculo placement at Curtin Clinic. I was treating a patient with LE on a patient who had severe constant elbow pain. i performed the 3 specific LE tests and they all came up negative as they did not reproduce the pain. My supervisor came in to see how everything was going and she started to palpate the patient's neck to see if that could be the source of the problems and referring pain to the elbow. the patient became upset as she said she came in with elbow pain and now she had a very sore neck. the supervisor explained how her neck could be the problem and told me to do an ax on the neck to see. She left the room and the patient strated to cry saying that she was now in even more pain and she didnt like my supervisor. the patient wanted to leave and not continue the rx session, i suggested that i do a STM on her elbow as that had previously been effective in decreasing her pain - she agreed and i started to massage her elbow. When i was finishing up the massage my supervisor came into the room and asked the results of the cervical ax, i explained that the patient was in a lot of pain and would prefer to come in next week for a more thorough ax. the patient then asked my supervisor what day she was working so she could come in on that day. My supervisor said that as she was there most days she would probably be there. Once again she tried to explain that the neck could be the source of her problems especially as it was so tender. the patient made another appt and left saying that if she now had neck problems then my supervisor would be hearing from her.
All in all it was a very frustrating rx session as the patient left in more pain and had decreased confidence in our ability to help her. It is going to be an extremely challenging next rx session as she does not want my supervisor involved and i have no previous experience in treating LE.
All in all it was a very frustrating rx session as the patient left in more pain and had decreased confidence in our ability to help her. It is going to be an extremely challenging next rx session as she does not want my supervisor involved and i have no previous experience in treating LE.
Sunday, May 25, 2008
A Very Confused Patient
Hi Guys,
I am on my ortho placement. This particular patient was from the #NOF ward and as you can imagine these patients tend to be quite elderly.
This patient was an elderly Aboriginal male from the Gascoyne region with a # NOF (L). We were asked to teach this man how to climb stairs so he could get up into the plane in a few days time. In comparison to many patients on the #NOF ward this man, at first appearance, seemed quite good. So we wheeled him to the therapy area to get him started on the stairs.
We first demonstrated the process and then assisted him to the steps. Ascending the stairs he required much prompting but completed them successfully. However, when we reached the top he seemed to get stuck. We asked him to turn around but it was like he was frozen. We tried explaining that once he got down he could sit and have a rest...no response. And then (i'm assuming he was quite tired at this stage) he began to sit down. Both of us screamed to get him to stop and i jammed my leg behind him to stop him from sitting. We eventually got him back down.
It's horrible watching your patient slowly descend to the floor because you know once they're on the floor they won't have enough muscle strength to get up. The only option would be to get a hoist because the set of stairs are quite narrow and it would be near impossible to get a person either side of the patient to help get him up. I think the reason it happened was because we talk to much. I thought we actually simplified many of our instructions but on further consideration i think we continue to talk to fill the empty silence. It takes a long time for patient's to do simple things like take a step and so we fill the silence by explaining why we're doing it, what we're going to do after this task etc. But they can't focus on more than one thing at once and are easily distracted. So, unconsciously, we might have said the word 'sit' in the preceding sentence and before you know it that's what he was doing =p
Next time the instructions have to be less wordy and very simple. I think even a sentence might be too much. And commands will have to be one or 2 words. I would stop talking in between and just allow him to take his time and complete the task. I would consciously try to avoid using the word sit (especially when the patient is at the top of the stairs). Using hands to guide the movement more than we actually did may have been useful for this patient as words seemed to confuse him.
After the initial scare on the stairs this patient progressed quite well and is noew able to manage stairs with much less prompting and assistance. He should be getting on the plane some time this week.
I am on my ortho placement. This particular patient was from the #NOF ward and as you can imagine these patients tend to be quite elderly.
This patient was an elderly Aboriginal male from the Gascoyne region with a # NOF (L). We were asked to teach this man how to climb stairs so he could get up into the plane in a few days time. In comparison to many patients on the #NOF ward this man, at first appearance, seemed quite good. So we wheeled him to the therapy area to get him started on the stairs.
We first demonstrated the process and then assisted him to the steps. Ascending the stairs he required much prompting but completed them successfully. However, when we reached the top he seemed to get stuck. We asked him to turn around but it was like he was frozen. We tried explaining that once he got down he could sit and have a rest...no response. And then (i'm assuming he was quite tired at this stage) he began to sit down. Both of us screamed to get him to stop and i jammed my leg behind him to stop him from sitting. We eventually got him back down.
It's horrible watching your patient slowly descend to the floor because you know once they're on the floor they won't have enough muscle strength to get up. The only option would be to get a hoist because the set of stairs are quite narrow and it would be near impossible to get a person either side of the patient to help get him up. I think the reason it happened was because we talk to much. I thought we actually simplified many of our instructions but on further consideration i think we continue to talk to fill the empty silence. It takes a long time for patient's to do simple things like take a step and so we fill the silence by explaining why we're doing it, what we're going to do after this task etc. But they can't focus on more than one thing at once and are easily distracted. So, unconsciously, we might have said the word 'sit' in the preceding sentence and before you know it that's what he was doing =p
Next time the instructions have to be less wordy and very simple. I think even a sentence might be too much. And commands will have to be one or 2 words. I would stop talking in between and just allow him to take his time and complete the task. I would consciously try to avoid using the word sit (especially when the patient is at the top of the stairs). Using hands to guide the movement more than we actually did may have been useful for this patient as words seemed to confuse him.
After the initial scare on the stairs this patient progressed quite well and is noew able to manage stairs with much less prompting and assistance. He should be getting on the plane some time this week.
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