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.
Tuesday, June 3, 2008
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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