In my first week of musculo out pts i had a pt referred from a regional hospital for chronic LBP. On subjective Ax, this was only a piece of the puzzle with pain down the (R) leg to her foot, severe cervical/thoracic pain and a recent shoulder reconstruction causing pain and AROM limitations. Most of the subjective questioning was open and the pt reported that most of the pain was from the cervical/throacic region. These were the most prominent symptoms so activities that brought these on were detailed, while she seemed to dismiss her LBP. On checking with my tutor, due to the LBP referral, this must be the focus of Ax and Rx, and if the other areas need Rx a further referral is needed.
When i returned to my pt and informed her that her LBP must be the focus of this Rx, she accepted this and gave me more details on her low back pain. During the objective Ax and Rx there was no further mention of any Cx or Tx pain, and her shoulder was holding up well. It seemed that as I put my focus on the LBP, so did she and any other pain seemed insignificant. As Rx was on the lumbar spine, post Rx she had greater range and less pain in this area.
This was interesting as the lumbar pain was insignificant at initial Ax, then was the main complaint when she was told it had to be. She also reported that her pain had been worse since she had time off work to recover. I believe as she was not at work she spent most of the day concerned with her pain, while at work she would be pre occupied. Prior to this encounter i didnt realise the effect of focussing on pain and the reinforcing effect it can have. I think for future encounters it will be worthwhile even encorporating some distracting activites in the home exercise programme.
Monday, June 30, 2008
Sunday, June 29, 2008
Appropriateness of expletives
Recently on muscuko outpatients prac I treated an elderly lady with low back pain which was moderately irritable. This was the first time I had seen this patient as she was a transfer from another physio. She's quite a lovely lady and I don't think she meant anything by what she said, it was just her way of dealing with the situation.
I began my objective assessment as usual; observing gait, AROM, palpation, trigger points, PPIVMS/PAIVMS and checked for pain and/or stiffness as I went through. Initially she was fine but when we got to palpation, PPIVMS and PAIVMs that's when the drama started. At first the swearing was just muttered quietly under her breath but then every time she felt a little bit of pain she'd scream out and then add in a few expletives for good measure. This was particularly the case with trigger point release, as you can imagine. It wasn't necessarily what she said either but it was the fact that it was quite loud. We aren't in treatment rooms either, the cubicles are only separated by curtins so all the other patients and treating physios were subject to her verbal display. It was when she got louder that I began to feel a bit awkward so I asked her if she wanted me to stop because I didn't want to make her pain worse but she told me to keep going and it didn't hurt that much.
I was actually a little confused as to what to do? Do I keep going with Rx and allow her to swear or do I change tact and try something different even after the patient asked me to keep going with my original Rx? I was concernend about what other patients would think after listening to this patient?
I decided to change Rx and go through her HEP which hopefully would be less provocative (thankfully it was!!). Then I went back to mob's and TP's and she had settled down little bit as well.
This experience was quite awkward to deal with and if she had started yelling when I returned to mob's and TP's the second time I would have had to tell her discreetly to keep her voice down. I probably would have said something implying that although I didn't mind we have to consider the fact that other patients may find it offensive.
I began my objective assessment as usual; observing gait, AROM, palpation, trigger points, PPIVMS/PAIVMS and checked for pain and/or stiffness as I went through. Initially she was fine but when we got to palpation, PPIVMS and PAIVMs that's when the drama started. At first the swearing was just muttered quietly under her breath but then every time she felt a little bit of pain she'd scream out and then add in a few expletives for good measure. This was particularly the case with trigger point release, as you can imagine. It wasn't necessarily what she said either but it was the fact that it was quite loud. We aren't in treatment rooms either, the cubicles are only separated by curtins so all the other patients and treating physios were subject to her verbal display. It was when she got louder that I began to feel a bit awkward so I asked her if she wanted me to stop because I didn't want to make her pain worse but she told me to keep going and it didn't hurt that much.
I was actually a little confused as to what to do? Do I keep going with Rx and allow her to swear or do I change tact and try something different even after the patient asked me to keep going with my original Rx? I was concernend about what other patients would think after listening to this patient?
I decided to change Rx and go through her HEP which hopefully would be less provocative (thankfully it was!!). Then I went back to mob's and TP's and she had settled down little bit as well.
This experience was quite awkward to deal with and if she had started yelling when I returned to mob's and TP's the second time I would have had to tell her discreetly to keep her voice down. I probably would have said something implying that although I didn't mind we have to consider the fact that other patients may find it offensive.
Tuesday, June 24, 2008
T8 neural tissue provocation
On a recent outpatient musculo clinic I encountered a 50 yo male who presented to with L shoulder pain, with concurrent elbow and axilla pain and pins and needles down his arm. 16 months before he was on a canoeing holiday where he travelled 90 km in three days. Since then he had developed a twinge in his shoulder which became progressively worse. In the last 3 months the pain in his elbow had developed. He has no previous history of L shoulder pain. Pain in the shoulder would occur first and if it was bad enough it would be followed by pain in the axilla which is a sharp pain occurring with elevation of the arm. Pain in the axilla is followed by pain in the elbow, this was a sharp pain that usually came on with lifting. The pins and needles were intermittent and came on 1% of the timelasting for a few seconds, there were located to follow the ulna distribution of the hand.
Main agg and easing factors in the subjective were elevating the left arm, particularly up and back, this brought an immediate onset of pain which would ease quickly when the arm was put down. Main easing factors were medication and keeping arm by side. There was no noticeable 24hr pattern other than it was slightly better in the morning.
Relevant findings of the physical examination were decreased AROM in shoulder flexion, abduction and external rotaton, limited by pain. Isometric mm tests were clear ( flexion, abduction, IR) except for ER which brought on 2/10 Pain in the shoulder and elbow. Empty can and full can were also mildly provocative bringing on shoulder pain. The Cx spine was also assessed which was clear for AROM. Flexion with L rotation brought on 3/10 L sided neck pain which did not travel down to the shoulder. Central PAIVMs were tender at C2, C7 and T1 again not referring to the shoulder. NTPT of the ulna nerve was positive for reproduction of shoulder pain symptoms were increased with CL cx lat flexion and decreased with neutral or wrist flexion.
The interpretation of these findings was that there was mechanical pain of the shoulder brought on with active movement of the shoulder joint. The pattern of pain presentation involving subsequent axilla then elbow pain pins and needles suggests some neural involvement. As the ulna nerve NTPT was positive and was more provocative than impingment test this indicates that C8 neural tissue sensitivity was the main cause of symptoms, due to the positive response of the impingement the initial diagnosis also included the possibility of a supraspinatus tendinopathy.
Initial intervention by the first therapist was lateral glides of C7 and T1 in an attempt to mobilise the nerve root of C8, which was moderately successful. Subsequent treatment focussed on neural mechanosensitivity including lateral glides and manual traction initially and the patient showed good increases in ROM and reduction in pain however progress appeared to slow a little over the next few sessions. As a result further techniques were attempted to treat the mechanosensitivity more specifically and correct any muscle inbalance that may be contributing to nerve sensitivity hence soft tissue release of rhomboids, pec major, levator scap, postural retraining, PAM of the GHJ and the first rib were used. The most effective treatments being Pec minor release, PA PAM of first rib, GIII with the patients symptoms now being mild pain and near full ROM, however there is still Neural symptoms in the provocating position so to further decrease neural sensitivity slide/glides of the ulna nerve were tried and given as a home exercise. The main difficulty in treating this patient was to think about finding ways to treat the problem specifically- such as mobilising the first rib in an attempt to affect C8 neural tissue, rather than just the Cx spine. I found this was an important lession in thinking of all areas that may be affecting the patient and not just sticking to the most obvious treatment
Main agg and easing factors in the subjective were elevating the left arm, particularly up and back, this brought an immediate onset of pain which would ease quickly when the arm was put down. Main easing factors were medication and keeping arm by side. There was no noticeable 24hr pattern other than it was slightly better in the morning.
Relevant findings of the physical examination were decreased AROM in shoulder flexion, abduction and external rotaton, limited by pain. Isometric mm tests were clear ( flexion, abduction, IR) except for ER which brought on 2/10 Pain in the shoulder and elbow. Empty can and full can were also mildly provocative bringing on shoulder pain. The Cx spine was also assessed which was clear for AROM. Flexion with L rotation brought on 3/10 L sided neck pain which did not travel down to the shoulder. Central PAIVMs were tender at C2, C7 and T1 again not referring to the shoulder. NTPT of the ulna nerve was positive for reproduction of shoulder pain symptoms were increased with CL cx lat flexion and decreased with neutral or wrist flexion.
The interpretation of these findings was that there was mechanical pain of the shoulder brought on with active movement of the shoulder joint. The pattern of pain presentation involving subsequent axilla then elbow pain pins and needles suggests some neural involvement. As the ulna nerve NTPT was positive and was more provocative than impingment test this indicates that C8 neural tissue sensitivity was the main cause of symptoms, due to the positive response of the impingement the initial diagnosis also included the possibility of a supraspinatus tendinopathy.
Initial intervention by the first therapist was lateral glides of C7 and T1 in an attempt to mobilise the nerve root of C8, which was moderately successful. Subsequent treatment focussed on neural mechanosensitivity including lateral glides and manual traction initially and the patient showed good increases in ROM and reduction in pain however progress appeared to slow a little over the next few sessions. As a result further techniques were attempted to treat the mechanosensitivity more specifically and correct any muscle inbalance that may be contributing to nerve sensitivity hence soft tissue release of rhomboids, pec major, levator scap, postural retraining, PAM of the GHJ and the first rib were used. The most effective treatments being Pec minor release, PA PAM of first rib, GIII with the patients symptoms now being mild pain and near full ROM, however there is still Neural symptoms in the provocating position so to further decrease neural sensitivity slide/glides of the ulna nerve were tried and given as a home exercise. The main difficulty in treating this patient was to think about finding ways to treat the problem specifically- such as mobilising the first rib in an attempt to affect C8 neural tissue, rather than just the Cx spine. I found this was an important lession in thinking of all areas that may be affecting the patient and not just sticking to the most obvious treatment
Thursday, June 19, 2008
Weight Limit
This happened sometime ago now.
Patient who had recently had a fall, as a result fractured his tibial shaft. He had an ORIF and the fracture was stabilised and was able to weightbear. He had been ambulating with a pulpit frame on a couple of occasion with 2xassist and managed about 5m with the ward physio. The patient normally uses a wheelchair and uses a zimmer frame for transfers. My supervisor had told me to go see this man and get him to ambulate about 5m. So i got everything ready; a pulpit frame and a nurse to help. We managed to get him into standing without any hassels and onto the pulpit frame. He walked a few steps and was doing really well. My supervisor walks past and stops and asks the patient to be seated. She then waved me over away from the patient and told me that the patient was 110kg and the weight limit on the pulpit frame is 100kg!! We eventually got a pulpit frame that had a higher limit and the patient managed fine.
Looking back at it, if something happened, it could of been really nasty. Pulpit frame breaking and as a result, patient falling and possibly other fractures. Then the patient would lose confidence in himself and in the physio. There are so many things that could happen. Luckily, it did, phew.
The thing is, weight limit on a pulpit frame didn't ever cross my mind and i wasn't aware there were other frames that took more weight than others. I did realise the patient was heavy.
There is only one solution to this. Next time check the weight limits of equipment (not just pulpit frames, but tilt tables, zimmer frames ...etc) and have a good idea of what your patient weighs, normally in the obs chart or notes. Now that this has happened, its a quick check i would with all my patients.
Patient who had recently had a fall, as a result fractured his tibial shaft. He had an ORIF and the fracture was stabilised and was able to weightbear. He had been ambulating with a pulpit frame on a couple of occasion with 2xassist and managed about 5m with the ward physio. The patient normally uses a wheelchair and uses a zimmer frame for transfers. My supervisor had told me to go see this man and get him to ambulate about 5m. So i got everything ready; a pulpit frame and a nurse to help. We managed to get him into standing without any hassels and onto the pulpit frame. He walked a few steps and was doing really well. My supervisor walks past and stops and asks the patient to be seated. She then waved me over away from the patient and told me that the patient was 110kg and the weight limit on the pulpit frame is 100kg!! We eventually got a pulpit frame that had a higher limit and the patient managed fine.
Looking back at it, if something happened, it could of been really nasty. Pulpit frame breaking and as a result, patient falling and possibly other fractures. Then the patient would lose confidence in himself and in the physio. There are so many things that could happen. Luckily, it did, phew.
The thing is, weight limit on a pulpit frame didn't ever cross my mind and i wasn't aware there were other frames that took more weight than others. I did realise the patient was heavy.
There is only one solution to this. Next time check the weight limits of equipment (not just pulpit frames, but tilt tables, zimmer frames ...etc) and have a good idea of what your patient weighs, normally in the obs chart or notes. Now that this has happened, its a quick check i would with all my patients.
met call
A few days ago on the geriatric ward one of the pt's i had been treating had a sudden episode of VF (ventricular fibrillation) and the met call button was pressed. The pt was eventually shocked back into regular rhythm and by the evening the pt was conscious and responsive. The pt had a Hx of SVT and AF and was awaiting the all clear before being transferred to a rehab hospital, which has now been posponed.
The interesting part of this story is that i saw this pt the afternoon before these events, and she was the best i had ever seen her. She was motivated, cheerful and went from 1x assist amb and t/f's to standby assist. She managed about double the length of mobilization and also tolerated a series of bed exercises. I thought she had really turned a corner.
When my supervisor and i were discussing this, my supervisor said that this is often the case and regretted not picking up on it earler. She reported that many pts are able to perform better, look better and are more up beat soon before they 'crash'. This came as an absolute shock to me as it really is the opposite to what you would expect. I would have thought that in a place like gero's unwell pt's would gradually decline, or in a step down process, until eventually 'crashing' or dying. I just found this fascinating and will definately be on the lookout for uncharacteristic cheerfulness and performance and hope that it is not a indicator that the pt is about to 'crash'.
The interesting part of this story is that i saw this pt the afternoon before these events, and she was the best i had ever seen her. She was motivated, cheerful and went from 1x assist amb and t/f's to standby assist. She managed about double the length of mobilization and also tolerated a series of bed exercises. I thought she had really turned a corner.
When my supervisor and i were discussing this, my supervisor said that this is often the case and regretted not picking up on it earler. She reported that many pts are able to perform better, look better and are more up beat soon before they 'crash'. This came as an absolute shock to me as it really is the opposite to what you would expect. I would have thought that in a place like gero's unwell pt's would gradually decline, or in a step down process, until eventually 'crashing' or dying. I just found this fascinating and will definately be on the lookout for uncharacteristic cheerfulness and performance and hope that it is not a indicator that the pt is about to 'crash'.
Tuesday, June 17, 2008
An unsuspecting patient
My two week placement in 2nd year was rather interesting as it was basicaly a gerontology clinic which was very similar to a rehabilitation unit. Many of the patients on the ward were fortunate enough to have many friends and family to come and visit.
On one particular visit, I was walking a patient who was 2 weeks post THR of her (L) hip and just before taking her for a walk on the wards, a close friend of patient, who she had known for over 30 years, had come and visited her. I explained to the visitor that we were going for a ten minute walk and that she could join us for a walk outside, of which she accepted.
A few minutes into the walk, the visitor had started to slow down a little bit and was falling behind us and really started to look unwell. I asked her about her condition and explained to her about having a sit down on a nearby chair, but she said she was ok. The condition had gotten worse and her face went bright red and looked very sick. Little did i know she was a diabetic and that she was low on sugar, she hadn't eaten for 5 hours since driving from the country to visit her friend.
The situation ended up ok with the help of some food and a nearby nurse. bu the thing that i couldn't believe was how quickly the situation got out of hand. If a similar situation was to happen again, as soon as the visitor started to show signs, you must immediately start to ask questions as it could be something very simple from her PMH that could causing the symptoms. Although this particular situation couldn't have been avoided, it could have been stopped in the early stages had the simple questions such as " Do you know whats going on?" or "Have you got a condition that provides these symptoms?" etc. These few simple questions could have saved me from being in a stressful situation
On one particular visit, I was walking a patient who was 2 weeks post THR of her (L) hip and just before taking her for a walk on the wards, a close friend of patient, who she had known for over 30 years, had come and visited her. I explained to the visitor that we were going for a ten minute walk and that she could join us for a walk outside, of which she accepted.
A few minutes into the walk, the visitor had started to slow down a little bit and was falling behind us and really started to look unwell. I asked her about her condition and explained to her about having a sit down on a nearby chair, but she said she was ok. The condition had gotten worse and her face went bright red and looked very sick. Little did i know she was a diabetic and that she was low on sugar, she hadn't eaten for 5 hours since driving from the country to visit her friend.
The situation ended up ok with the help of some food and a nearby nurse. bu the thing that i couldn't believe was how quickly the situation got out of hand. If a similar situation was to happen again, as soon as the visitor started to show signs, you must immediately start to ask questions as it could be something very simple from her PMH that could causing the symptoms. Although this particular situation couldn't have been avoided, it could have been stopped in the early stages had the simple questions such as " Do you know whats going on?" or "Have you got a condition that provides these symptoms?" etc. These few simple questions could have saved me from being in a stressful situation
Monday, June 16, 2008
Blue button/yellow button
Today at 4.30pm an orderly came up to myself and another Physio to let us know that a man in room ? needed to go to the toilet and can we walk him to the toilet. I had only seen this man once before and the Physio i was with was brand new on the ward that afternoon so didn't know how the ward operated let alone who this patient was and his mobility. We called the nurse but aparantly he had had his call bell on for about 30 mins and was now busting.
I knew he could shuffle with a wheeled zimmer frame with 2 x assist so the new physio tracked down the older physio (the normal one on the ward who is also my supercisor) and together, my supervisor and i walked with him a few metres to the toilet. We both noticed his profuse sweating on the way to the bathroom.
Once we got there he had difficulty turning around, eventually he was lined up okay and could take a seat on the commode. Both my supervisor and i noticed the man's colour and increased sweating and i ran to get a sats machine. I took all of 30 secs but by the time i returned my supervisor told me i should press the met button.
I couldn't see the met button so pressed the yellow one (the semi serious one but not the met one...) until i finally located the met button but he had reagined consciousness so it wasn't necessary bu this stage. I went and tracked down his nurse and the head nurse while my supervisor stayed with him in the bathroom.
I've never really had anything serious happen to me at a clinic so this would have to be the most serious thing i've come accross. I was a bit panicky when i couldn't locate the met button and also a little angry at myself cos i should know where it is (but it was located near the door entrance near the light switch which i found a bit odd instead of behind the bed-oh well).
It just makes me think that i should never take any situation too lightly and while this seemed like a bit of a hassle, almos,t to start with, just to walk him to the toilet it turned into a situation very quickly. Im glad i had someone else there at the time cos i don't think i could have handled the situation myself.
In the future i'm going to try and act faster on my observations (when i noticed him sweating a lot i probably should have sat him down straight away) and i will look at where that blue met button is in future!
I knew he could shuffle with a wheeled zimmer frame with 2 x assist so the new physio tracked down the older physio (the normal one on the ward who is also my supercisor) and together, my supervisor and i walked with him a few metres to the toilet. We both noticed his profuse sweating on the way to the bathroom.
Once we got there he had difficulty turning around, eventually he was lined up okay and could take a seat on the commode. Both my supervisor and i noticed the man's colour and increased sweating and i ran to get a sats machine. I took all of 30 secs but by the time i returned my supervisor told me i should press the met button.
I couldn't see the met button so pressed the yellow one (the semi serious one but not the met one...) until i finally located the met button but he had reagined consciousness so it wasn't necessary bu this stage. I went and tracked down his nurse and the head nurse while my supervisor stayed with him in the bathroom.
I've never really had anything serious happen to me at a clinic so this would have to be the most serious thing i've come accross. I was a bit panicky when i couldn't locate the met button and also a little angry at myself cos i should know where it is (but it was located near the door entrance near the light switch which i found a bit odd instead of behind the bed-oh well).
It just makes me think that i should never take any situation too lightly and while this seemed like a bit of a hassle, almos,t to start with, just to walk him to the toilet it turned into a situation very quickly. Im glad i had someone else there at the time cos i don't think i could have handled the situation myself.
In the future i'm going to try and act faster on my observations (when i noticed him sweating a lot i probably should have sat him down straight away) and i will look at where that blue met button is in future!
The Public System
I am on prac at a hospital that is divided into a public sector and a private sector. At first look there is really no difference with the facilities provided and when talking to the physios, there is no difference in the time spent with patients or the amount of care patient receives. This got me tinking about why then would people pay all this money to be in the private sector of the hospital when they could have the same treatment in the public for free!
For three weeks now I have been treating patient on the public ward, who is a very dense right hemiplegic and still remains non responsive to verbal commands. Treatment so far has included positioning, passive movements of UL and LL and mm stretches of tight muscles esp Pect mj, lat dorsi, wrist and long finger flexors, hip adductors and IR. With the assistance of another physio we hve been moving him from supine to SOEOB (max 2xA) and working on some sitting balance (and also beneficial for his lungs) and we have also slide sheeted him onto a tilt table which he tolerated well. For three weeks he has not made any progress. He still remains non responsive (GCS 9/15) and he is max assist of 2 people for bed mobility and supine to SOEOB, and requires a hoist transfer.
His prognosis is poor and is very much likely to be transfered to a nursing home instead of rehabilitation. I do understand that it is very hard to rehab someone who is non responsive but my impression from being on the ward is that this patient is too expensive to keep in hospital. I am having a lot of difficulty accepting that in the public sector it is mainly about how much the bed is costing the government each day then what is best for the patient. I have not a lot of experience and I dont know what will be best for this patient in the long term but should it really come down to money? Its a persons life we are dealing with here...not a bed number.
I have talked to the physio about this briefly and really thats the way it is...unfortunately. I know as I enter the work ofrce I will encounter many frustrating things and maybe with some I might beable to change somethings for the better of the patient. Right now tho as a student I do believe somethings are just out of our reach.
For three weeks now I have been treating patient on the public ward, who is a very dense right hemiplegic and still remains non responsive to verbal commands. Treatment so far has included positioning, passive movements of UL and LL and mm stretches of tight muscles esp Pect mj, lat dorsi, wrist and long finger flexors, hip adductors and IR. With the assistance of another physio we hve been moving him from supine to SOEOB (max 2xA) and working on some sitting balance (and also beneficial for his lungs) and we have also slide sheeted him onto a tilt table which he tolerated well. For three weeks he has not made any progress. He still remains non responsive (GCS 9/15) and he is max assist of 2 people for bed mobility and supine to SOEOB, and requires a hoist transfer.
His prognosis is poor and is very much likely to be transfered to a nursing home instead of rehabilitation. I do understand that it is very hard to rehab someone who is non responsive but my impression from being on the ward is that this patient is too expensive to keep in hospital. I am having a lot of difficulty accepting that in the public sector it is mainly about how much the bed is costing the government each day then what is best for the patient. I have not a lot of experience and I dont know what will be best for this patient in the long term but should it really come down to money? Its a persons life we are dealing with here...not a bed number.
I have talked to the physio about this briefly and really thats the way it is...unfortunately. I know as I enter the work ofrce I will encounter many frustrating things and maybe with some I might beable to change somethings for the better of the patient. Right now tho as a student I do believe somethings are just out of our reach.
Difficult patient
I am currently on my neuro prac and it has been such a great experience so far. I m treating one patient who has not been diagnosed with Parkinson's Disease but presents with all the common signs of Parkinson's incl bradykinesia, flexed posture etc. I see this patient every day, and every day all he says to me is that he is going home today regardless of what the doctors say. He is very reluctant to do any physio sessions as he claims why would he need physio if he is giong home today? Everyday I have managed to kindly encourage him to participate in physio but each day it is getting harder and harder and the sessions are tking longer to get through as half the time is spent trying to encourage him to participate.
Today I went to see him and I received the same responce "Im going home today so I dont need physio". So it took me about 20 min of explaining the importance of physio and how beneficial it is to stay mobile and active blah blah blah and eventually he concented to physio (I think he realised I wasnt going to leave until he did!). He stood and ambulated with a shuffling gait (even after lots of verbl cueing to take big steps) for about 5m then stopped said he had enough nd that his legs ached (which was a common occurance). After much encourging +++++++++ he managed to walk to the door of the physio gym which was 15m away (I was hoping to do some balance exercises with him in the PT gym) and that was the end on treatment. He decided tht he had had enough and was going bck to his room. So I walked with him back to his room nd left him SOOB in a high chair. All up the treatment session took 45min! I had prioritised him at the top of the PT list and 2 other patients who are so keen for PT and try their absolute hardest at every exercise missed out.
My friendly encouraging is not having much effect on this patient nd other patients are missing out on treatment because of time wasted "encouraging" this patient to get up! At this present moment I am unsure how I will approach this tomorrow. Hopefully with experience I will learn how to manage each difficult patient I come across.
Today I went to see him and I received the same responce "Im going home today so I dont need physio". So it took me about 20 min of explaining the importance of physio and how beneficial it is to stay mobile and active blah blah blah and eventually he concented to physio (I think he realised I wasnt going to leave until he did!). He stood and ambulated with a shuffling gait (even after lots of verbl cueing to take big steps) for about 5m then stopped said he had enough nd that his legs ached (which was a common occurance). After much encourging +++++++++ he managed to walk to the door of the physio gym which was 15m away (I was hoping to do some balance exercises with him in the PT gym) and that was the end on treatment. He decided tht he had had enough and was going bck to his room. So I walked with him back to his room nd left him SOOB in a high chair. All up the treatment session took 45min! I had prioritised him at the top of the PT list and 2 other patients who are so keen for PT and try their absolute hardest at every exercise missed out.
My friendly encouraging is not having much effect on this patient nd other patients are missing out on treatment because of time wasted "encouraging" this patient to get up! At this present moment I am unsure how I will approach this tomorrow. Hopefully with experience I will learn how to manage each difficult patient I come across.
I have never made this many people cry!
I have just finished my forth week in a peadiatric placement and I have never made so many people cry, by people I mean children. I really have a lot of respect for those physios who work with children as is is an extremely difficult job!
Last week I was given a referral from a paediatrician that said "child not rolling by 7 months (just starting to) now at 10.5 moths not WBing. Sitting, reaching, casting OK.". This was all the information I was given prior to the session. I prepared and thought through what i was going to assess and had some idea what interventions I could do if i found certain impairments. When the child arrived with his mother he walked into the room! At that point all my preparation and planning went out the window. I got through the subjective assessment ok with the mother and found out her main concern was that her points at objects with his middle finger and uses that finger to grasp objects. She also stated that the child is terrified of strangers and will scream and cry with any one except her and her husband. I decided to perform the objective assessment by telling the mother what to do and observing. As I had not prepared for him to be walking I was relly stuck on what to test! The child became more aggitated and I became more stressed and my clinical supervisor kept telling my to keep the session going and the child began to scream and cry and I kid you not the child screamed and cried for half an hour. The clinical supervisor took over and tested ROM and mm tone etc with this child who was hysterical. I hve never felt so terrible in all my prac career. At tht point in time I thought if this is what physio is all about then I am not fit for the job. The clinical supervisor came to the conclusion that the child may have sensory defensivness and he used his middle finger as this is less sensative to the index finger.
I was really stirred up about the whole experience, it was awful. Next time I will be more prepared to face any situation...I guess it will take time and experience. Peadiatrics is very hard as you cannot explain to young children why we have to do what we have to do. I have come to realise that with children it is very hard to prepare for a session as it could go anywhere.
Last week I was given a referral from a paediatrician that said "child not rolling by 7 months (just starting to) now at 10.5 moths not WBing. Sitting, reaching, casting OK.". This was all the information I was given prior to the session. I prepared and thought through what i was going to assess and had some idea what interventions I could do if i found certain impairments. When the child arrived with his mother he walked into the room! At that point all my preparation and planning went out the window. I got through the subjective assessment ok with the mother and found out her main concern was that her points at objects with his middle finger and uses that finger to grasp objects. She also stated that the child is terrified of strangers and will scream and cry with any one except her and her husband. I decided to perform the objective assessment by telling the mother what to do and observing. As I had not prepared for him to be walking I was relly stuck on what to test! The child became more aggitated and I became more stressed and my clinical supervisor kept telling my to keep the session going and the child began to scream and cry and I kid you not the child screamed and cried for half an hour. The clinical supervisor took over and tested ROM and mm tone etc with this child who was hysterical. I hve never felt so terrible in all my prac career. At tht point in time I thought if this is what physio is all about then I am not fit for the job. The clinical supervisor came to the conclusion that the child may have sensory defensivness and he used his middle finger as this is less sensative to the index finger.
I was really stirred up about the whole experience, it was awful. Next time I will be more prepared to face any situation...I guess it will take time and experience. Peadiatrics is very hard as you cannot explain to young children why we have to do what we have to do. I have come to realise that with children it is very hard to prepare for a session as it could go anywhere.
Emotions
I was asked to see a patient with some gastro problems, just to do some basic maintainence exercise and keeping the patient mobile. Prior to seeing this patient i had read up on all the notes and medical tests and realised the patient has liver problems. Now, it was only a few days ago that my mum told me that my auntie in Hong Kong has recently been diagnosed with liver cancer. I did feel a little uncomfortable seeing this patient. Upon entering this 'white carded' room, i saw this patient lying in bed asleep, jaudice (+++) and abdominal distention (+++). The patient slowly woke up and patient's eyes were bright yellow. The patient's appearance was quite confronting. Here in the back of my mind i kept thinking, "is that what my aunty looks like?" I've checked all the obs and done a quick assessment and asked the patient to SOEB. The movement was slow and the patient was already fatigued. The patient was very sick. I managed to get the patient in standing and a couple of steps with a WZF and some basic exercises. But the patient fatigued very quickly and needed frequent rests. I felt emotional in treating the patient, trying to envisage what my aunty looks like (with her condition) at the same time. (Is she jaundice, abdo distended?...the list goes on). I continued to treat the patient for the next 3 weeks. I guess my question is, how can you detach personal emotions away from your treatment? It does effect your treatment. I think in the future i just need to remind myself of the reasons why i am seeing the patient (to maintain their mobility) and not to let personal matters affect you (easier said than done i think). If anything, i think even talk to someone about it. I wasn't comfortable in discussing the matter with my supervisor at the time.
Has anyone come across such issue? A patient having a similar condition to a family member of yours or maybe even yourself? How did you deal with it?
Has anyone come across such issue? A patient having a similar condition to a family member of yours or maybe even yourself? How did you deal with it?
Sunday, June 15, 2008
Failed treatments
During my musculo placement, i treated a 25yo male who had a hx of anterior shoulder dislocations. He was part of the 10% bracket who'd had surgery to repair a bankart lesion and it failed resulting in contined dislocations. He was an ongoing patient at the clinic and on reading his notes i saw that he was progressing quite well and the last student who'd treated him recommended him for d/c as his ROM was WNL and his strength was up. He cancelled his first appointment with me and rescheduled for the following week. when i did my initial sx ax with him he told me that the reason why he's cancelled his appt was that when he woke up that morning he'd stretched as he got out of bed and re-dislocated it. so from being ready to d/c my patient was now back to limited ROM in F, Abd and ER and weak rotator cuff. He was now back to basic ROM exercises and strengthening and this is the continous cycle he goes through and has repeated many times over the past few years. as far as he is concerned another operation is not an option as his wife is not working as they have a 3 month old and a 2 year old, they've just bought a house and he's just started his own business. it was so frustrating not being able to "fix" his problem because both the patient and i knew that he's been through the exact rehab i was doing with him many times before and it had no effect. over the few weeks i treated him he progressed really with full ROM and increasing strength in rotator cuffs. on speaking to another student who took over this patient when he left, i found out that the patient had recently re-dislocated and was back to basics. i was so disappointed on hearing that the outcome of all our hard work over the weeks had not changed anything even though everyone involved in the rehab program were realistic about the outcome. it made me feel like my whole treatment program had been for nothing. looking back on my treatment i know there's nothing i could have done differently but i cant help feeling that i've let the patient down, does anyone else take failures personally?
Saturday, June 14, 2008
The Demented Patient
I have been treating this patient every day since the beginning of P3. She was living by herself independently before she fell and fractured the mid-shaft of her femur. She is now incontinent, confused and displays many of the signs of a person with dementia. Currently she will need high level care. It's like treating 2 different people depending on the time of day. If I manage to treat her in the mornings she is much better but if I don't get to the ward until the afternoon she will blatantly refuse to do anything (more oftent then not). There is no reasoning with her...she will cry and scream and yell and kick till eventually you have to leave her alone. This was quite confronting the first week I saw her because I didn't really know how to handle it. She is rude and crude and will not let you touch her.
The solution to this was quite simple. Treat her in the morning. Sometimes I have to come back several times in the one morning because I can now tell as soon as I walk in the room whether the session will be productive or not. The best part about treating this patient is sharing with her the times where she actually remembers. You can actually see the change in the person and you know she's not in some fantasy land. Prior to this I didn't realise how difficult it is (emotionally) to treat a patient like this. It's hard to sit and watch them, knowing that at some point long ago they were living their life as we are now. And I think what's harder to deal with is that we could be just like that in the future.
The solution to this was quite simple. Treat her in the morning. Sometimes I have to come back several times in the one morning because I can now tell as soon as I walk in the room whether the session will be productive or not. The best part about treating this patient is sharing with her the times where she actually remembers. You can actually see the change in the person and you know she's not in some fantasy land. Prior to this I didn't realise how difficult it is (emotionally) to treat a patient like this. It's hard to sit and watch them, knowing that at some point long ago they were living their life as we are now. And I think what's harder to deal with is that we could be just like that in the future.
Thursday, June 12, 2008
Ortho placement
I was at an orthopedic outpatient placement when I was asked to conduct a treatment session on a patient who was day one post TKR. This patient was approx 50 years old and i spent a fair amount of time reading her notes, establishing her pre-op status, which was independant, living at home. She had no major relevant PMHx and she had a general anaesthetic during her op and had no risk of motor block and there were no unusual post op precautions, she was FWB. Her Hb was 90, the limit to standing a patient at this facility was 80. So fully prepared I went into to stand the patient. After assessing both legs strength, which was surprisingly good and Knee ROM which was almost 50 degrees, with no quads lag we decided to stand the patient. The patient was almost able to reach a sitting position by herself and standing was no trouble at all.
Once the patient got to standing with a pulpit frame she was feeling really good so we tried marching on the spot. I had my knee blocking her knee through the frame and she managed three steps before the operated leg suddenly gave way. I managed to block the knee to stop it from collapsing completely and we put her back on the bed. As we went back to the bed her leg appeared to be fully externally rotated and she was in severe amounts of pain. It appeared that her prosthesis had been compromised. As any student would probably react, I was certain that she had done something terrible and it was because of something that I had missed!!! My supervisor immediately contacted the intern who ordered an xray to check the condition of the prothesis. Throughout the process the supervisor and intern were extremely reassuring to the patient but i couldnt think of anything to say, I was just so worried for the patient. After we left the room my supervisor took me aside to debrief, she said first of all that I had checked everthing I could have and if the TKR had indeed failed that there was nothing we could have done differently. She also reinforced that all of the permanent staff were so prepared to react to the situation that it has happened before and will happen again and not to let it upset me.
As it turns out the patients TKR was fine and it was probably just pain inhibition which caused her to collapse. The experience was actually helpful as it helped me to realise that we cant be perfect and control stiuations, these things will happen even if we have done all possible preparation and taken all precautions.
Once the patient got to standing with a pulpit frame she was feeling really good so we tried marching on the spot. I had my knee blocking her knee through the frame and she managed three steps before the operated leg suddenly gave way. I managed to block the knee to stop it from collapsing completely and we put her back on the bed. As we went back to the bed her leg appeared to be fully externally rotated and she was in severe amounts of pain. It appeared that her prosthesis had been compromised. As any student would probably react, I was certain that she had done something terrible and it was because of something that I had missed!!! My supervisor immediately contacted the intern who ordered an xray to check the condition of the prothesis. Throughout the process the supervisor and intern were extremely reassuring to the patient but i couldnt think of anything to say, I was just so worried for the patient. After we left the room my supervisor took me aside to debrief, she said first of all that I had checked everthing I could have and if the TKR had indeed failed that there was nothing we could have done differently. She also reinforced that all of the permanent staff were so prepared to react to the situation that it has happened before and will happen again and not to let it upset me.
As it turns out the patients TKR was fine and it was probably just pain inhibition which caused her to collapse. The experience was actually helpful as it helped me to realise that we cant be perfect and control stiuations, these things will happen even if we have done all possible preparation and taken all precautions.
Tuesday, June 10, 2008
Frustrating patints
My very first patient i saw with my curtin supervisor on my outpatients clinic was very frustrating over the course of his treatment sessions. He had been referred to outpatients after undergoing a THR and was 6 weeks post op. The two things that you notice about him initially is that he had a pathological gait (looked like one leg was longer than the other) and that he had some underlying mental problems.
The patient explained to me that he had been in a car crash more than 30 years ago and since ten had ben walking funny and it was because of his long leg which did this. After measuring ASIS to medial maleolous - both legs were exactly the same length but you could notice a Lx spine scoliosis which was probably the main problem in regards to the patients walking and posture. After showing him the measurements, the patient sad this was not true and said there was 5cm difference between them. This discussion took up half the treatment session and became frustrating as i could only half do the S: and O: and only game him one home exercise.
The following session, the patient said that one of his legs was longer than the other - which we had already discussed beforehand. After showing him the measuring tape and assessing the length properly with the supervisor - it was again the same length. This discussion again took up most of the session.
This patient became very frustrating as he kept thinking he had one leg longer than the other, but kept forgetting about this on a weekly basis, but more importantly, it was impeding on his Rx session.
After a discussion wih the supervisor, we decided that we should reinforce this every session to him - but only for 5 mins - so a full and proper treatment session could be had. I felt rude initially about donig this but the patient needed to know and he slowly started to understand after using the mirror. The remaining two sessions with him were a lot easier, the issue was discussed at the start of each session for 5 mins then we went on with the session, so I could get the most out of the session with him.
Its hard working with patients who have a mental disability as you don't know to except their thoughts on what us happening to their body, or do you step in and be rude by telling them what is actually going on. This issue was impeding on treatment time so had to be dealt with.
Next time, if a simialr patient was to present to me in an oupatient setting, i would have to way up whether or not to let the patient except their wn self diagnosis or actually tell them what is going on. This should be done in a strong but empathetic manner and should not take uup valuable treatment time.
The patient explained to me that he had been in a car crash more than 30 years ago and since ten had ben walking funny and it was because of his long leg which did this. After measuring ASIS to medial maleolous - both legs were exactly the same length but you could notice a Lx spine scoliosis which was probably the main problem in regards to the patients walking and posture. After showing him the measurements, the patient sad this was not true and said there was 5cm difference between them. This discussion took up half the treatment session and became frustrating as i could only half do the S: and O: and only game him one home exercise.
The following session, the patient said that one of his legs was longer than the other - which we had already discussed beforehand. After showing him the measuring tape and assessing the length properly with the supervisor - it was again the same length. This discussion again took up most of the session.
This patient became very frustrating as he kept thinking he had one leg longer than the other, but kept forgetting about this on a weekly basis, but more importantly, it was impeding on his Rx session.
After a discussion wih the supervisor, we decided that we should reinforce this every session to him - but only for 5 mins - so a full and proper treatment session could be had. I felt rude initially about donig this but the patient needed to know and he slowly started to understand after using the mirror. The remaining two sessions with him were a lot easier, the issue was discussed at the start of each session for 5 mins then we went on with the session, so I could get the most out of the session with him.
Its hard working with patients who have a mental disability as you don't know to except their thoughts on what us happening to their body, or do you step in and be rude by telling them what is actually going on. This issue was impeding on treatment time so had to be dealt with.
Next time, if a simialr patient was to present to me in an oupatient setting, i would have to way up whether or not to let the patient except their wn self diagnosis or actually tell them what is going on. This should be done in a strong but empathetic manner and should not take uup valuable treatment time.
A Fresher Look
With such an AWEsoME same I thought the blue was a bit boring and 'common' so I've taken advantage of my admin rights and changed the blog template. You guys are becoming AWEsoME reflective learners, keep up the good work!
Monday, June 9, 2008
Awkward Situation
I went to treat a patient in her hospital room last week with the aim of taking her for a walk to the hysio gym on the ward, performing some balance assessment exercises and treatments and then walking back to her room.
On arrival at her room she appeared not to recognise me, from the previous day, at first, but then when i reminded her she said she remembered me fine.
So off we started on a walk and halfway out the door a nurse passed us and my patient said "wow she's huge! I can't believe how fat some of these nurses are here..." etc. But the nurse wasn't close enough to hear so i kind of just ignored it and we kept walking. We completed what we needed to do in the Physio gym and were returning to her room. We entered her doorway and the OT was treating the patient who shares the room with her. As we walked in she said "see like that one, look at her (word for backside), she'd be a good 15 stone...etc." However the OT was well within hearing distance this time. I almost instinctively shot her a look to display the message of "shhhhh" but i don't think she understood/picked up that anything was wrong and just continued on.
This whole situation made me feel awful. I felt terrible that she was saying these things about the OT, who i spend a lot of time with but not enough for her to laugh about it with me afterwards.
It made me think afterwards that perhaps i should have picked up on it earlier because of what she said on the way out to the physio room and perhaps i should have had some diversion conversation ideas up my sleeve to dtsract the patient.
I haven't had much experience with dementia patient's previously but once i documented her inappropriate comments in the notes it arose that the patient is actually displaying these behaviours regularly.
If the same or similar situation occurs again i will make sure i have something interesting to say to draw her away from focussing on one particular (sometimes touchy) subject.
On arrival at her room she appeared not to recognise me, from the previous day, at first, but then when i reminded her she said she remembered me fine.
So off we started on a walk and halfway out the door a nurse passed us and my patient said "wow she's huge! I can't believe how fat some of these nurses are here..." etc. But the nurse wasn't close enough to hear so i kind of just ignored it and we kept walking. We completed what we needed to do in the Physio gym and were returning to her room. We entered her doorway and the OT was treating the patient who shares the room with her. As we walked in she said "see like that one, look at her (word for backside), she'd be a good 15 stone...etc." However the OT was well within hearing distance this time. I almost instinctively shot her a look to display the message of "shhhhh" but i don't think she understood/picked up that anything was wrong and just continued on.
This whole situation made me feel awful. I felt terrible that she was saying these things about the OT, who i spend a lot of time with but not enough for her to laugh about it with me afterwards.
It made me think afterwards that perhaps i should have picked up on it earlier because of what she said on the way out to the physio room and perhaps i should have had some diversion conversation ideas up my sleeve to dtsract the patient.
I haven't had much experience with dementia patient's previously but once i documented her inappropriate comments in the notes it arose that the patient is actually displaying these behaviours regularly.
If the same or similar situation occurs again i will make sure i have something interesting to say to draw her away from focussing on one particular (sometimes touchy) subject.
Dealing with information
For my orthopaedic inpt prac i covered a number of wards, one of which was trauma. One pt i began seeing with my supervisor the very first day, was handed over to me completely by the end of the 1st week. This pt had a complicated Hx the result of which were #'s of the sup and inf rami unilaterally, coccyx, L5 and multiple sacral #'s (amongst other UL and rib #'s). The sacral and L5 #'s were managed with internal fixation and fusion, the rami #'s managed with a pelvic ex fix. The post op orders were strictly RIB with no WBing through LL's.
On one occasion on treating the pt, when i was performing a quick subjective Ax, the pt reported that during the night they were feeling restless and decided to stand. She reported that her muscles were not taking the weight well and she was unable to stand for long. I immediately reminded her of the post op orders and the importance of how not following them may result in another 6 weeks of bed rest or possibly permanent damage. Following this the pt became defensive emphasising she had not been standing for long, and there was no ill effects. She also repeatedly told me not to tell anyone.
Following this encounter, i remember thinking 'i wish she hadn't of told me that', though knowing is obviously better as measures can be put in place to reduce risk to the pt. Not knowing exactly how to handle the situation, i told my supervisor and was instructed to put an entry in the integrated notes descibing what had happened, and pass on to the physio of the ward to let the consultant know. When i next saw the pt, she quickly defended her actions and said i had gotten the wrong impression.
I think the real issue in this case was as the pt was about my age and we got along well, she may have seen me more as a friend than a physio. This could have lead to her being more comfortable to tell me things that she may not have told others, but also thought that i would not pass this on. So in this case it has good and bad points; both that i got the information, but also that i had to pass it on, and betray the 'friendship' we had made.
Beginning with this pt, i have been more professional, and although being friendly, giving the impression of physio first. Prior to this encounter giving a friendly approach i thought was equally as important, but i think pt's must know that your Rx is for their benefit even if that means possible comprimising your 'friend' relationship. I would love comments on this situation.
On one occasion on treating the pt, when i was performing a quick subjective Ax, the pt reported that during the night they were feeling restless and decided to stand. She reported that her muscles were not taking the weight well and she was unable to stand for long. I immediately reminded her of the post op orders and the importance of how not following them may result in another 6 weeks of bed rest or possibly permanent damage. Following this the pt became defensive emphasising she had not been standing for long, and there was no ill effects. She also repeatedly told me not to tell anyone.
Following this encounter, i remember thinking 'i wish she hadn't of told me that', though knowing is obviously better as measures can be put in place to reduce risk to the pt. Not knowing exactly how to handle the situation, i told my supervisor and was instructed to put an entry in the integrated notes descibing what had happened, and pass on to the physio of the ward to let the consultant know. When i next saw the pt, she quickly defended her actions and said i had gotten the wrong impression.
I think the real issue in this case was as the pt was about my age and we got along well, she may have seen me more as a friend than a physio. This could have lead to her being more comfortable to tell me things that she may not have told others, but also thought that i would not pass this on. So in this case it has good and bad points; both that i got the information, but also that i had to pass it on, and betray the 'friendship' we had made.
Beginning with this pt, i have been more professional, and although being friendly, giving the impression of physio first. Prior to this encounter giving a friendly approach i thought was equally as important, but i think pt's must know that your Rx is for their benefit even if that means possible comprimising your 'friend' relationship. I would love comments on this situation.
Many Supervisors...
At the beginning of the placement myself and another student were introduced to about 8 different physios. We didn't realise that we were going to have to report to 8 different physios. In the past my experience has been that even if you work with different physios you usually report to one mainly and maybe a second depending upon the area in which you're working.
In the beginning stages of the placement, not only were we grappling with the placement itself we were also reporting and trying to link in with all the different physios. This proved to be a challenge. Each physio had a different idea of what they wanted from your treatment and the time that they wanted it done. This meant we spent more time running around trying to let everyone know where we were at then actually treating. We deliberated for a while trying to decide whether to let someone know or not. Finally we mentioned it to the acting senior and she responded really well. She wrote up a list and made a plan each day of what we should do and basically said that we let her know when we’re done and she’ll organize it from there.
The outcome worked well for everyone because they knew where we were and we knew where we stood. We weren’t wasting time hanging around and wondering what we should be doing because we had a plan. Sometimes it’s hard to know whether to speak up or not but in our case it ended working in our favour. In the future, I think you have to be careful how you bring the topic up and be tactful in the way in which you say it. But I think it's important to let supervisors know how you're feeling.
In the beginning stages of the placement, not only were we grappling with the placement itself we were also reporting and trying to link in with all the different physios. This proved to be a challenge. Each physio had a different idea of what they wanted from your treatment and the time that they wanted it done. This meant we spent more time running around trying to let everyone know where we were at then actually treating. We deliberated for a while trying to decide whether to let someone know or not. Finally we mentioned it to the acting senior and she responded really well. She wrote up a list and made a plan each day of what we should do and basically said that we let her know when we’re done and she’ll organize it from there.
The outcome worked well for everyone because they knew where we were and we knew where we stood. We weren’t wasting time hanging around and wondering what we should be doing because we had a plan. Sometimes it’s hard to know whether to speak up or not but in our case it ended working in our favour. In the future, I think you have to be careful how you bring the topic up and be tactful in the way in which you say it. But I think it's important to let supervisors know how you're feeling.
Sunday, June 8, 2008
Unclear diagnosis
A 25yo presented at the musculo outpatients clinic with intermittent knee pain. He is the ruckman in his footy team and jumps off on his left knee and has had to stop playing due to the pain. He only gets pain with SLSquats and very mild pain when coming up from a full squat. McConnel's fx test was positive which hinted at PFJ problems which we ruled out by further ax. when we tried McConnel taping the pain also became much worse. Apart from tight ITB and hip flexors, all other knee ax came up normal. the only pain he has is on the tibial tuberosity, no pain in the tendon, patellar or reffering pain. The pt says there was no traumatic event where he could have landed on his knee and bruised the tibial tuberosity and the pain started a few weeks ago and is gradually getting worse. By process of elimination, my supervisor and i came up with the diagnosis of Osgood schlatter's disease as his symptoms mirror that condition and the pain was relieved by infrapatellar taping to unload the tibial tuberosity which is commonly used to rx OSD. So we are treating him by taping, regular icing over the tibial tuberosity and stretches. However, im still sceptical as to how a 25 yo with no PMH of OSD could get this condition as he is definitly out of the age bracket! does anyone else have any ideas on what could be the problem?
Wednesday, June 4, 2008
Cultural issues
For my ICU placement I spent a week in the high dependancy unit. One pt i was asked to see was a foreign woman day 1 post mastectomy and was in need of a cardio Ax, and likely some deep breathing exercises and potentially a sit out of bed. I approached the pt as per normal, introduced myself, my role and how the Ax was going to take place. The patient looked wide eyed and slightly uncomfortable, but i reassured the pt and began a subjective Ax. I asked the pt a number of questions regarding cardio status both pre op and comparisons to present. The pt also reported feeling quite well.
Following this i began to give instructions on auscultation (open mouth, deep breaths etc) when the pt looked very anxious. It was at this pt that my supervisor stepped in and said would the pt prefer a female physio for Rx. At this pt the pt looked very relieved and nodded her head. She then apologised to me multiple times, thinking that she had offended me. I assured her that she had not, and i apologised for making her feel uncomfortable.
After this encounter i was thinking of ways in which i could have avoided this awkward situation for both the pt and myself. I had obviously missed the cues that my supervisor picked up, that the patient was not comfortable with a male treating her. I think being more aware of cultural and personal issues would have been benefitial in my approach to this lady. This could have even involved me simply asking "Are you ok if I do your Ax". A chest Ax post mastectomy in itself would likely create anxiety.
Prior to this incident i approached pts in a similar manner and the thought had not occured to me that being a male physio student i was not always welcome to treat female pts. From this point I have tried to pick up more on cues that may lead me to question the best approach for Rx and get help if needed. I think a lot of this comes from experience but would love comments on this situation.
Following this i began to give instructions on auscultation (open mouth, deep breaths etc) when the pt looked very anxious. It was at this pt that my supervisor stepped in and said would the pt prefer a female physio for Rx. At this pt the pt looked very relieved and nodded her head. She then apologised to me multiple times, thinking that she had offended me. I assured her that she had not, and i apologised for making her feel uncomfortable.
After this encounter i was thinking of ways in which i could have avoided this awkward situation for both the pt and myself. I had obviously missed the cues that my supervisor picked up, that the patient was not comfortable with a male treating her. I think being more aware of cultural and personal issues would have been benefitial in my approach to this lady. This could have even involved me simply asking "Are you ok if I do your Ax". A chest Ax post mastectomy in itself would likely create anxiety.
Prior to this incident i approached pts in a similar manner and the thought had not occured to me that being a male physio student i was not always welcome to treat female pts. From this point I have tried to pick up more on cues that may lead me to question the best approach for Rx and get help if needed. I think a lot of this comes from experience but would love comments on this situation.
Tuesday, June 3, 2008
The dreaded questions!
I was on my geriatric placement at the Moss st centre, which is apart of Fremantle Hospital. The Moss st centre provides patients with an allied health team (consisting of physio, OT, clinical nurse, GP and on occasions - a speech pathologist) and is considered to be the Parkinsons centre south of the river, therefore, approximately every 2nd patient that you see as a physio student is a Parkinsons patient.
Many of these parkinson patients usually come back for their annual check - up as we apply objective tests, such as TUG, 6 min walk test and berg balance, and compare them to how they have gone compared to their results from the previous session, approx 12 months before.
One of my first patients that I treated on my clinic was a very active 67 year old male who only had just been recently diagnosed with parkinson's approximately 4 weeks beforehand. I was halfway through completing the berg balance tests with the patient when he looked across the room and started to watch another parkinsons patient go through the same testing process. This parkinsons patient had been diagnosed for about 6 years and was really starting to struggle with the harder aspects of the berg balance tests such as single leg stance. It was then my patient turned around asked those two dreaded questions, "how long do I have until i start becoming like thaat guy? and how long do I have left to live?" - the awkward questions that you hoped no patient of yours would ever ask.
My facility supervisor was watching the treatment session up until this point and came and sat on a chair next door to me as i began to explain. After explaining to the patient about the usual things such as everyone is different, there are always other factors, course of the disease is unknown - you could tell that the patient was getting frustrated as his two qestions were not getting directly answered.
My facility supervisor helped out with a similar explaination - but it didn't seem to help. After the end of the session, the patient walked out of the centre and you could tell that he was frustrated, not knowing what the disease will do to him, both physically and mentally.
It's one of those hard situations, the only thing you can do is explain the pathology and how it progresses as there isn't a one word answer to the question of how long do i have to live? You can't just say - ok approx 6 years - as there is far too many factors that need to considered and it goes onto the old cliché that "everybody is different".
My supervisor explained to me that I did quite well despite the situation but you start to wonder what else you could have done and how else to explain it. She went on explaining to me that she says those particular questions are the hardest questions to answer as there usually is no answer to patient that will make them feel happy. Have any of you guys ever come across any of these "dreaded" questions? Would be interesting to see how you go about it.
Many of these parkinson patients usually come back for their annual check - up as we apply objective tests, such as TUG, 6 min walk test and berg balance, and compare them to how they have gone compared to their results from the previous session, approx 12 months before.
One of my first patients that I treated on my clinic was a very active 67 year old male who only had just been recently diagnosed with parkinson's approximately 4 weeks beforehand. I was halfway through completing the berg balance tests with the patient when he looked across the room and started to watch another parkinsons patient go through the same testing process. This parkinsons patient had been diagnosed for about 6 years and was really starting to struggle with the harder aspects of the berg balance tests such as single leg stance. It was then my patient turned around asked those two dreaded questions, "how long do I have until i start becoming like thaat guy? and how long do I have left to live?" - the awkward questions that you hoped no patient of yours would ever ask.
My facility supervisor was watching the treatment session up until this point and came and sat on a chair next door to me as i began to explain. After explaining to the patient about the usual things such as everyone is different, there are always other factors, course of the disease is unknown - you could tell that the patient was getting frustrated as his two qestions were not getting directly answered.
My facility supervisor helped out with a similar explaination - but it didn't seem to help. After the end of the session, the patient walked out of the centre and you could tell that he was frustrated, not knowing what the disease will do to him, both physically and mentally.
It's one of those hard situations, the only thing you can do is explain the pathology and how it progresses as there isn't a one word answer to the question of how long do i have to live? You can't just say - ok approx 6 years - as there is far too many factors that need to considered and it goes onto the old cliché that "everybody is different".
My supervisor explained to me that I did quite well despite the situation but you start to wonder what else you could have done and how else to explain it. She went on explaining to me that she says those particular questions are the hardest questions to answer as there usually is no answer to patient that will make them feel happy. Have any of you guys ever come across any of these "dreaded" questions? Would be interesting to see how you go about it.
Monday, June 2, 2008
How to deal with depression
My previous placement was musculoskeletal outpatients. I prepared by going through pst lecture notes and refreshing my mind on how to do subjective and objective assessment etc. What I was not prepared for was an encounter I had with a patient who had come to the clinic due to chronic LBP. This patient was a 65 yo male, who had a history of chronic LBP for 10 years. As I observed this man I noticed tha he sat with very poor posture and he was quite over weight. But my main concern was not what I saw...it was what I found out subjectively.
Initially the patient was reluctant to "chat" with me and only gave me short, quite abrupt answers to my questions. My initial reaction was to be abrupt back and I began to think why am I even bothering with this man! (It is a reaction that thankfully I am beginning to change) As this reaction got me no where, I changed my attitude and opted for the really nice and caring approach. The patient finally opened up and began to tell me about his life. He used to be a doctor, never married, no kids. He sleeps 15 hours a night with a 5 hour nap during the day (that right he was awake for 4 hours a day) however he then said to me he suffers from insomnia??. He stated that he becomes extremely depressed if a letter (from anybody) arrived in the mail and he hs 2 dogs which never get walked.
I have never ever come across someone so depressed, I cannot explain by writting words how sad this man was. Prior to this encounter I honestly thought depression was something every second middle aged office worker had. This man made me realise how depression is such a serious illness.
I saw this man 3 times on my placement. Initially I focused on his LBP through massage, PAIVMS and PPIVMS and propriceptive taping. I soon realised this was not enough to help this man. So I drew up a day to day life plan for this man. I told him he ws allowed to sleep for 10 hours only, he then had to get out of bed and take the dogs for a 30 min walk and I provided him with very basic exercises to do after his walk eg 1/4 squats, marching etc. I told him he was allowed to have a 2 hour nap in the arvo but no more and then he had to get up and go for a walk or take the dogs to the beach again. This may sound strange that I told this man how to life his life but I honestly did not know another way to break this depression cycle.
This patient had huge effect on me. I can not imagine living a life like he was, but he has made me understand how serious depression can be. Unfortunately my 5 week prac finished and Im not sure how he is doing or if any of my ideas to help him had any impact. Id like to hope that I made some difference to this mans life but realistically I really doubt that my small attempt to change this viscious depression cycle would have worked.
I am still unsure what I will do if a similar event like this occurs (I am sure it will!). I will have to read more psychology texts I think. It is a really sad sad issue and I will need a lot more experience and knowledge to deal with situation again.
Initially the patient was reluctant to "chat" with me and only gave me short, quite abrupt answers to my questions. My initial reaction was to be abrupt back and I began to think why am I even bothering with this man! (It is a reaction that thankfully I am beginning to change) As this reaction got me no where, I changed my attitude and opted for the really nice and caring approach. The patient finally opened up and began to tell me about his life. He used to be a doctor, never married, no kids. He sleeps 15 hours a night with a 5 hour nap during the day (that right he was awake for 4 hours a day) however he then said to me he suffers from insomnia??. He stated that he becomes extremely depressed if a letter (from anybody) arrived in the mail and he hs 2 dogs which never get walked.
I have never ever come across someone so depressed, I cannot explain by writting words how sad this man was. Prior to this encounter I honestly thought depression was something every second middle aged office worker had. This man made me realise how depression is such a serious illness.
I saw this man 3 times on my placement. Initially I focused on his LBP through massage, PAIVMS and PPIVMS and propriceptive taping. I soon realised this was not enough to help this man. So I drew up a day to day life plan for this man. I told him he ws allowed to sleep for 10 hours only, he then had to get out of bed and take the dogs for a 30 min walk and I provided him with very basic exercises to do after his walk eg 1/4 squats, marching etc. I told him he was allowed to have a 2 hour nap in the arvo but no more and then he had to get up and go for a walk or take the dogs to the beach again. This may sound strange that I told this man how to life his life but I honestly did not know another way to break this depression cycle.
This patient had huge effect on me. I can not imagine living a life like he was, but he has made me understand how serious depression can be. Unfortunately my 5 week prac finished and Im not sure how he is doing or if any of my ideas to help him had any impact. Id like to hope that I made some difference to this mans life but realistically I really doubt that my small attempt to change this viscious depression cycle would have worked.
I am still unsure what I will do if a similar event like this occurs (I am sure it will!). I will have to read more psychology texts I think. It is a really sad sad issue and I will need a lot more experience and knowledge to deal with situation again.
Trying to treat a two year old
I have just completed my second week in my paeds placement. It is a very different learning experience as the "patients" are between 4 weeks to 7 years old. I have been finding it really difficult to find different ways to treat these children as they do not understand why they have to do these exercises or why they have to do these tests etc.
I have been asked to design an exercise program for this 2 year old child who is delayed in his gross motor skills eg climbing stairs, jumping, climbing over obstacles etc. The first week I designed an obstacle course for him that involved lots of climbing activities and what I thought would be fun games for a 2 year old. What I learnt from the first week is that it does not matter how prepared you are or how good your plan is it all goes out the window when trying to treat a 2 year old whos attention span lasts approx 2 seconds.
I have had one session with him and I hve three more to go. From observation I hve noticed he favours his right side and really has difficulty climbing down the stairs and climbing down the climbing frame which I believe is due to poor proprioception and balance. Does any one have any suggestions of ways to treat this 2 yo with games and activities?
I have been asked to design an exercise program for this 2 year old child who is delayed in his gross motor skills eg climbing stairs, jumping, climbing over obstacles etc. The first week I designed an obstacle course for him that involved lots of climbing activities and what I thought would be fun games for a 2 year old. What I learnt from the first week is that it does not matter how prepared you are or how good your plan is it all goes out the window when trying to treat a 2 year old whos attention span lasts approx 2 seconds.
I have had one session with him and I hve three more to go. From observation I hve noticed he favours his right side and really has difficulty climbing down the stairs and climbing down the climbing frame which I believe is due to poor proprioception and balance. Does any one have any suggestions of ways to treat this 2 yo with games and activities?
Importance of a Medical Hx
I'm currently on my Ortho Inpatients prac, mainly TKR and THR. I work mainly in the therapy area and haven't really been on the ward much. So the patients get wheeled down to the therapy area and we go through a standard set of exercises for the hips and the knees.
I had one lady who had a (R) THR and she was excessively anxious ++++ all the time. She was quite emotional on more than one occasion and needed constant reassurance and encouragement. I thought it was simply due to her personality and didn't pay too much attention when she was stressing. I tried to be sympathetic and show her that she really was making progress but none of it seemed to do any good. This went on for a few days until something caught my eye when I was writing in the integrated notes....she had cancer which had metastasised . Her worry and anxiety suddenly made sense. Needless to say, I now try and read all my patients notes.
I felt horrible after finding that bit of information out. This patient had been struggling to come to terms with that diagnosis and if I had been aware I wouldn't have been so quick to judge. Luckily, in this case it didn't have an impact on the Rx i was providing.
From this experience I have learnt the importance of knowing a full history of the patient and have seen first hand how information can change your interaction with the patient and has the potential to alter your Rx of the patient.
I had one lady who had a (R) THR and she was excessively anxious ++++ all the time. She was quite emotional on more than one occasion and needed constant reassurance and encouragement. I thought it was simply due to her personality and didn't pay too much attention when she was stressing. I tried to be sympathetic and show her that she really was making progress but none of it seemed to do any good. This went on for a few days until something caught my eye when I was writing in the integrated notes....she had cancer which had metastasised . Her worry and anxiety suddenly made sense. Needless to say, I now try and read all my patients notes.
I felt horrible after finding that bit of information out. This patient had been struggling to come to terms with that diagnosis and if I had been aware I wouldn't have been so quick to judge. Luckily, in this case it didn't have an impact on the Rx i was providing.
From this experience I have learnt the importance of knowing a full history of the patient and have seen first hand how information can change your interaction with the patient and has the potential to alter your Rx of the patient.
More neuro happenings....
I was placed at a neuro outpatients prac at the start of this year. I must say it was a really good prac as I did learn lots about neuro rehab and was able to see the big picture of how this type of rehab was carried out. This was all so different to what we were thought at uni.
I guess the most challenging aspect of this prac was communicating with the patients and dealing with their emotions and frustrations of getting by their ADLs.
On the last week of my five week prac I was given a new patient. She was only 28years and had a pontine stroke. She has been thru a long rehab process and was now due to attend neuro rehab as an outpatient for the next couple of months.
I was given a brief handover about her from my supervisors. They told me that she was a difficult patient to work with. She was pretty demanding and would not do anything unless she wanted to. If she was in pain she would end up refusing in the engagement of any sort of activity. They said she was pretty crude and I had to be strong and stand my ground when dealing with her. They also told me that she was into an alternative lifestyle before her stroke. It was diagnosed that her condition was a result of overuse of ecstasy. Upon hearing all this information about the patient I was consumed by fear in the notion that I may not succeeded in treating this patient. I also began to doubt myself simple because handling this patient type was new to me. But yet I was looking forward to this challenge.
Upon meeting this patient my prior expectation of her was completely disregarded. She was completely charming to work with. I was firm with her and was able to get her to do the things I had planned for the treatment session. Even my supervisors were surprised with the outcome of my session with her.
From this experience I believe more in the saying “don’t judge a book by its cover”. We should take into consideration the handovers given to us by others and decide for ourselves the appropriate way to handle our patients.
I guess the most challenging aspect of this prac was communicating with the patients and dealing with their emotions and frustrations of getting by their ADLs.
On the last week of my five week prac I was given a new patient. She was only 28years and had a pontine stroke. She has been thru a long rehab process and was now due to attend neuro rehab as an outpatient for the next couple of months.
I was given a brief handover about her from my supervisors. They told me that she was a difficult patient to work with. She was pretty demanding and would not do anything unless she wanted to. If she was in pain she would end up refusing in the engagement of any sort of activity. They said she was pretty crude and I had to be strong and stand my ground when dealing with her. They also told me that she was into an alternative lifestyle before her stroke. It was diagnosed that her condition was a result of overuse of ecstasy. Upon hearing all this information about the patient I was consumed by fear in the notion that I may not succeeded in treating this patient. I also began to doubt myself simple because handling this patient type was new to me. But yet I was looking forward to this challenge.
Upon meeting this patient my prior expectation of her was completely disregarded. She was completely charming to work with. I was firm with her and was able to get her to do the things I had planned for the treatment session. Even my supervisors were surprised with the outcome of my session with her.
From this experience I believe more in the saying “don’t judge a book by its cover”. We should take into consideration the handovers given to us by others and decide for ourselves the appropriate way to handle our patients.
Neuro methods
This is just short one.
During my curtin supervisor's visit on last friday she asked if i had any issues before she left. I said not with the prac i'm on as such but we got on to an in depth conversation about how it was hard for us to come into a work place where people have trained at all different uni's accross australia and have a diverse experience.
In summary i pretty much explained how many Neuro Physio's have their own ways of doing things (treatments/transfers etc) and while we have practiced for many hours the way we have learnt; you feel when you are at a neuro placement that you should suddenly adopt their methodology of treating. However it means we have no practice in the new types of transfers and handling etc.
We came to the conclusion that whilst we are best at using the handling skills and treatments that we have practiced lots at uni it is good to try someone else's way and all the other available possibilities of treating and see what works best for what patient. But perhaps explaining to your placement supervisor that if their way isn't quite achieving the result you want (i.e. you want the patient to adopt a neutral standing posture and they continue to have flexed hips) then don't be afraid to try the way we know best even if they don't use it.
During my curtin supervisor's visit on last friday she asked if i had any issues before she left. I said not with the prac i'm on as such but we got on to an in depth conversation about how it was hard for us to come into a work place where people have trained at all different uni's accross australia and have a diverse experience.
In summary i pretty much explained how many Neuro Physio's have their own ways of doing things (treatments/transfers etc) and while we have practiced for many hours the way we have learnt; you feel when you are at a neuro placement that you should suddenly adopt their methodology of treating. However it means we have no practice in the new types of transfers and handling etc.
We came to the conclusion that whilst we are best at using the handling skills and treatments that we have practiced lots at uni it is good to try someone else's way and all the other available possibilities of treating and see what works best for what patient. But perhaps explaining to your placement supervisor that if their way isn't quite achieving the result you want (i.e. you want the patient to adopt a neutral standing posture and they continue to have flexed hips) then don't be afraid to try the way we know best even if they don't use it.
the importance of a diagnosis to a patient
During my gerontology placement i had a patient who came to see us in the outpatient department through the falls clinic. However, this patient had never actually fallen, she'd just become so scared of falling over the last few months that she went from no walking aid, to 4 wheeled walker to being house bound and dependent on friends and family for most of her ADLs. When she presented to the clinic she had no muscle weakness or balance problems but was extremely anxious when asked to carry out any task. However the patient reported feeling very dizzy and unbalanced when walking around. her family had previously sent her to numerous doctors for many tests, all which came back negative including vestibular. Her family came to us in the outpatient clinic hoping that we'd be able to give her some confidence and maybe be able to refer her on for a psych evaluation as they now all thought it was a mental problem not a physical one. After the initial ax and first few treatments for general strengthening and balance exercises with lots of encouragement and education on the importance of being active were having no effect on the patient, we started looking at possible causes for this patient's decline in activity. the patient reported being very anxious most of the day, and "flapped" her hands around when she got nervous, feeling dizzy, nauseas, breathless, sleep disturbances, numbness and excessive sighing. it was this excessive sighing that drew my supervisor to take more notice about the patient's mode of breathing. the patient would be talking and suddenly sigh out and take a deep breath in. on looking at her breathing pattern, her respiratory rate was found to be averaging about 22 per minute. my supervisor diagnosed the patient with chronic hyperventilation which explained all her symptoms. I started incorporating specific exercise for chronic hyperventilation along with her general exercise such as calming strategies when she got anxious, reading out aloud as books have structured grammar on when to take a breath and pause in a sentence and also other breathing strategies. The patient's lifestyle immediately began to change, she had more confidence, started venturing out of the house on her own and not having so many anxiety attacks. It took her a few weeks to master the strategies we taught her but by the end of my placement she was back to being independent and more active. the patient said that hearing that there was an actual physical problem with her and not a mental one as her family had thought gave her so much relief. it helped her understand the condition and work with us to help control this problem.
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