First impressions

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

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

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

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

Depressed patient

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

Rude neuro patient

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

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

Depression

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

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

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

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

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

Unprofessional behaviour

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

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

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

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

Good Patients

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

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

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

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

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

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