I am currently on a prac where i was working solely with one patient for one full week. This patient is of aboriginal descent and the project i am working on in relation to this prac is specific to aboriginal people so it was in my best interest to get along with this person and get a lot of information out of him in a short amount of time as he was only in Perth for one week.
It was hard to balance both time management issues and achieving all of the things i wanted to get done in one week whilst trying to gain initial rapport with this person as this was the first time i had ever met him.
As the week progressed i thought i was achieving what i needed to in regards to the project and i also thought i was gaining rapport.
It became apparent towards the end of the week that i had achieved the rapport however i hadn't completed nearly enough of what i was supposed to get done on my project prior to the patient leaving. In fact it became apparent that i the patient, supervisor and myself had all had a different view point of the project i was to complete. Their opinion of what they wanted had changed since initially discussing the task a month prior and since we hadn't had another meeting to reiterate this point i was unaware. It meant that the final day spent with the patient was long and tiring.
In reflection i perhaps should have held a mini meeting mid week with my patient and my supervisor to simply ascertain if i was getting what they wanted done. If this had of been done earlier it would have provided some extra time for me to complete some of the extra tasks that i was initially not aware of.
It's a very typical example of different peoples expectations and how one should never assume anything. In hindsight another meeting would have been very beneficial. In the future clarification would have saved me a lot of time and stress.
Tuesday, September 30, 2008
Monday, September 29, 2008
Language barrier
I have just arrived home after completing my four week international placement in Kota Kinabulu, Borneo. I was allocated to NASAM (National Stroke Association of Malaysia), a non-profitable stroke rehabilitation centre in Sabah. The centre comprised of a small room with two plinths, a kitchen and a verandah with exercise equipment that had been donated by local hotels (treadmill, stepper, stationary bike etc).
Approximately 30 stroke patients attended the centre. Ages varied from 39-80+ with equal number of males and females. The amount of time post-stroke varied from 6months to eight years. The centre was run by volunteer qualified physiotherapists and other non-qualified volunteers. The patients received a two hour exercise class per day.
During the 4 weeks, both myself and another student ran the exercise classes as well as conducted one-one physio treatment sessions. The one-one sessions were most beneficial however they were quite a challenge! Some patients spoke Manderin, others Malay, some Haka, some Hokkein and very few spoke broke english. Trying to come up with ways to communicate to a patient with out using language is a very challenging experience and sometimes quite humerous.
I now know the facial expression for "I have no idea what you are saying" is and even when a patient smiles and nods, I learnt to understand that the patient really did not have a clue what I was trying to explain. I found visual demonstration, pictures, tactile cues and sing language where the best ways to convey my message. The patients where wonderful and so willing to learn that it was not stressfull at any time.
I now know how to count in Malay, Mandarin and Haka and have some idea of a few Malay words! It was a fantastic learning experience.
Approximately 30 stroke patients attended the centre. Ages varied from 39-80+ with equal number of males and females. The amount of time post-stroke varied from 6months to eight years. The centre was run by volunteer qualified physiotherapists and other non-qualified volunteers. The patients received a two hour exercise class per day.
During the 4 weeks, both myself and another student ran the exercise classes as well as conducted one-one physio treatment sessions. The one-one sessions were most beneficial however they were quite a challenge! Some patients spoke Manderin, others Malay, some Haka, some Hokkein and very few spoke broke english. Trying to come up with ways to communicate to a patient with out using language is a very challenging experience and sometimes quite humerous.
I now know the facial expression for "I have no idea what you are saying" is and even when a patient smiles and nods, I learnt to understand that the patient really did not have a clue what I was trying to explain. I found visual demonstration, pictures, tactile cues and sing language where the best ways to convey my message. The patients where wonderful and so willing to learn that it was not stressfull at any time.
I now know how to count in Malay, Mandarin and Haka and have some idea of a few Malay words! It was a fantastic learning experience.
Sunday, September 28, 2008
Is it your place to tell?
I recently completed my rural prac which I rather enjoyed as i had patient caseload with a lot of variety - including musculoskeletal oupatients, paediatrics, woman's health and inpatients.
A 7 wk old baby with a mild plagio was booked to see both my tutor and myself and after reading the operation notes, we realised that this wouldn't be a normal type patient. The mother had recently been off her medications for mental problems, there were family problems in the household and there was a very interesting birth history with the mother ending up in ICU bleeding out and the baby being born 4 weeks premature.
After the inital assessment of the baby, we realised that the child was lacking in certain motor milestones, altered tonal changes and had a hard time concentrating. The problem was that the baby hadn't been diagnosed with anything up until this point in time - ie undiagnosed CP. The mother was seeing a social worker, clinical nurse and GP to sought out all of her problems.
After finishing of the session with HEP of stretches and exercises and simple education about placement of child vs environment, the mother went on her way with her baby.
The tutor explained to me that she didn't want to bring up all of her finidngs to the mother as she has a lot on her mind at the moment. We discussed this further with the mother's clinical nurse who had also noted the baby's changes. The nurse explained that she would explain the potential diagnosis of the baby to the mother on their next visit in 3 days time, as she had just been back on her meds and in a better frame of mind.
This was a very complex situation to be a part of but I think my tutor did the right thing in this situation. If this situation was to come up, especially once reading the complex Hx of both mother and child, I think I would have contacted the other allied health professionals involved with that specific patient and then see what they had observed and noted and what they had planned for them, or perhaps even work out if the baby's diagnosis had been discussed with the parents. I certainly learnt a lot from this experience.
A 7 wk old baby with a mild plagio was booked to see both my tutor and myself and after reading the operation notes, we realised that this wouldn't be a normal type patient. The mother had recently been off her medications for mental problems, there were family problems in the household and there was a very interesting birth history with the mother ending up in ICU bleeding out and the baby being born 4 weeks premature.
After the inital assessment of the baby, we realised that the child was lacking in certain motor milestones, altered tonal changes and had a hard time concentrating. The problem was that the baby hadn't been diagnosed with anything up until this point in time - ie undiagnosed CP. The mother was seeing a social worker, clinical nurse and GP to sought out all of her problems.
After finishing of the session with HEP of stretches and exercises and simple education about placement of child vs environment, the mother went on her way with her baby.
The tutor explained to me that she didn't want to bring up all of her finidngs to the mother as she has a lot on her mind at the moment. We discussed this further with the mother's clinical nurse who had also noted the baby's changes. The nurse explained that she would explain the potential diagnosis of the baby to the mother on their next visit in 3 days time, as she had just been back on her meds and in a better frame of mind.
This was a very complex situation to be a part of but I think my tutor did the right thing in this situation. If this situation was to come up, especially once reading the complex Hx of both mother and child, I think I would have contacted the other allied health professionals involved with that specific patient and then see what they had observed and noted and what they had planned for them, or perhaps even work out if the baby's diagnosis had been discussed with the parents. I certainly learnt a lot from this experience.
Tuesday, September 23, 2008
Exercise Types
I've just recently finished my SDP with a private practice. My project invovled creating exercise sheets for this private practice. I had to come up with the most common conditions seen at the practice and create 4 exercise leaflets as patient education. In order for me to create this, i had to do a literature review to find out which was the most effective/evidence based exercises for lower back pain (as one of the condition).
I had read a good amount of journal articles and had come up with about 6 exercises for lower back pain. I discussed my findings with my supervisor. He agreed with some of the exercises and disagreed with some. He gave me some exercises that the practice uses most and would like them in the leaflet. Interesting enough, the aritcles that i read actually said that the exercises he had asked me to use were found to be less effective. After i noticed the exercises he wanted were found to be less effective, i brought it to his attention. He did acknowledge what i had pointed out but still preferred me to use the exercises he had suggested. He told me that even though the exercises maybe more effective than others, i had to also consider the therapist's experience and preference. Most of the physios that work at the practice had been in the profession for 10years+, so they would have a pretty good grasp of treating LBP and exercises for patients.
A couple of interesting points from this incident.
-Even though some techniques maybe more effective than others, you need to always consider the therapist's skills and experience. But also have a closer look at the journal article, as to the age, gender, race etc..... and the article was actually written in US, so maybe it wasn't as applicable in Australia? So there were lots of other factors to consider
-It also points out the importance of continual education for us as physios. I found out the practice actually doesn't have any type of professional development within the clinic. So unless the physio themselves keeps up-to-date with reading new journals, their treatment techniques maybe outdated or their might be more effective techniques out there that they have not been exposed to.
Next time if i was to do a similar project, i should discuss with all the physios at the clinic and ask what exercises they use and prefer. So know the therapist's preference and incorporate that with the project and my literature review. Find a balance between the two.
I had read a good amount of journal articles and had come up with about 6 exercises for lower back pain. I discussed my findings with my supervisor. He agreed with some of the exercises and disagreed with some. He gave me some exercises that the practice uses most and would like them in the leaflet. Interesting enough, the aritcles that i read actually said that the exercises he had asked me to use were found to be less effective. After i noticed the exercises he wanted were found to be less effective, i brought it to his attention. He did acknowledge what i had pointed out but still preferred me to use the exercises he had suggested. He told me that even though the exercises maybe more effective than others, i had to also consider the therapist's experience and preference. Most of the physios that work at the practice had been in the profession for 10years+, so they would have a pretty good grasp of treating LBP and exercises for patients.
A couple of interesting points from this incident.
-Even though some techniques maybe more effective than others, you need to always consider the therapist's skills and experience. But also have a closer look at the journal article, as to the age, gender, race etc..... and the article was actually written in US, so maybe it wasn't as applicable in Australia? So there were lots of other factors to consider
-It also points out the importance of continual education for us as physios. I found out the practice actually doesn't have any type of professional development within the clinic. So unless the physio themselves keeps up-to-date with reading new journals, their treatment techniques maybe outdated or their might be more effective techniques out there that they have not been exposed to.
Next time if i was to do a similar project, i should discuss with all the physios at the clinic and ask what exercises they use and prefer. So know the therapist's preference and incorporate that with the project and my literature review. Find a balance between the two.
Thursday, September 18, 2008
Asking for Help
I have just completed my rural placement where i saw many different conditions across musculoskeletal outpatinets, paediatrics and woman's health.
One particular patient I had in outpatients had a total shoulder replacement a year before after suffering major tauma to his shoulder. The operation notes were just incredible and the x rays, both pre and post operation, were the most interesting I have ever seen.
Mr X had been back working for the past few months but was still lacking ROM from his shoulder especially abduction and flexion. Closer inspection revealed that his scapulohumeral mechanics had been altered and this was impeding him getting past 60 degrees in both directions.
I thought my inital 2 treatments should be starting to address this problem but further reassessment 2 weeks later revealed that only minimal improvements had been achieved. It was at that stage when i decided to get the senior involved as I was starting to run out of options for treatment. The senior and I both worked together on Mr X's shoulder for the next 3 sessions with minimal changes. It was then decided between the both of us that we needed further help and started contacting physios in perth, who had experience working with shoulder replacements and altered shoulder biomechanics.
If a situation like this was to present itself again, then as soon as i realise that i'm out of my depth, in terms of knowledge and treatment options, I should ask for help or advice as soon as i can. It will always be in the patient's best interests if I do so and i'll will always then learn from the experience. Has anyone ever come across a very hard patient to treat in an outpatients setting and were way out of the depth?
One particular patient I had in outpatients had a total shoulder replacement a year before after suffering major tauma to his shoulder. The operation notes were just incredible and the x rays, both pre and post operation, were the most interesting I have ever seen.
Mr X had been back working for the past few months but was still lacking ROM from his shoulder especially abduction and flexion. Closer inspection revealed that his scapulohumeral mechanics had been altered and this was impeding him getting past 60 degrees in both directions.
I thought my inital 2 treatments should be starting to address this problem but further reassessment 2 weeks later revealed that only minimal improvements had been achieved. It was at that stage when i decided to get the senior involved as I was starting to run out of options for treatment. The senior and I both worked together on Mr X's shoulder for the next 3 sessions with minimal changes. It was then decided between the both of us that we needed further help and started contacting physios in perth, who had experience working with shoulder replacements and altered shoulder biomechanics.
If a situation like this was to present itself again, then as soon as i realise that i'm out of my depth, in terms of knowledge and treatment options, I should ask for help or advice as soon as i can. It will always be in the patient's best interests if I do so and i'll will always then learn from the experience. Has anyone ever come across a very hard patient to treat in an outpatients setting and were way out of the depth?
Wednesday, September 17, 2008
Drugs
On my most recent placement in ICU there was a great deal of information i had to absorb when assessing and treating a patient. Not only were there the usual stuff but also the ABG's, Blood count, ECG and central venous line measurements, patients fluid balance throughout the day and the effects of that, not to mention learning all the drugs they were on and the effects they might have on their system as well as all the usual objective measures and PMHx, HPC things to absorb. I was a little worried about remembering all the drugs at first because my memory isn't great at the best of times but it was kind of important to remember what drug a person was on because sometimes it would have an affect on the treatment planning.
One drug in particular, nitric oxide, works by breaking down a blood clot (i.e. when you have a pulmonary embolism). This drug however will break down a blood clot in the preferentially ventilated lung. So on ICU when people are ventilated the preferentially ventilated lung is the opposite of normal and is the more superior lung. This is important because if you want the nitric oxide to work at its best and the patient has a pulmonary embolism in their left lung you should place them in right side lying for the full effects of the drug. By placing them in right side lying it also means that majority of the perfusion will be going through the right lung, which is then diverting blood away from the blockage where the PE is.
I couldn't believe how smart this drug seemed to be! Amazing! I was even more amazed when another student i was on prac with commented that they overheard an intern asking a registrar about what nitric oxide did and the registrar commented "oh it's just a bronchdilator". Perhaps they meant a vasodilator but even that doesn't explain the intricacies of how this drug works.
It just embedded the fact that it is so important to have a further understanding of drugs. Not only did we not learn very many drugs in uni but it really does effect what we do as physio's. In the future, even though it may take me a little longer to look up the drugs, i will make sure i have a full understanding of the patient, including their medications prior to treating them. This experience has taught me how important a broad understanding of each patient is.
One drug in particular, nitric oxide, works by breaking down a blood clot (i.e. when you have a pulmonary embolism). This drug however will break down a blood clot in the preferentially ventilated lung. So on ICU when people are ventilated the preferentially ventilated lung is the opposite of normal and is the more superior lung. This is important because if you want the nitric oxide to work at its best and the patient has a pulmonary embolism in their left lung you should place them in right side lying for the full effects of the drug. By placing them in right side lying it also means that majority of the perfusion will be going through the right lung, which is then diverting blood away from the blockage where the PE is.
I couldn't believe how smart this drug seemed to be! Amazing! I was even more amazed when another student i was on prac with commented that they overheard an intern asking a registrar about what nitric oxide did and the registrar commented "oh it's just a bronchdilator". Perhaps they meant a vasodilator but even that doesn't explain the intricacies of how this drug works.
It just embedded the fact that it is so important to have a further understanding of drugs. Not only did we not learn very many drugs in uni but it really does effect what we do as physio's. In the future, even though it may take me a little longer to look up the drugs, i will make sure i have a full understanding of the patient, including their medications prior to treating them. This experience has taught me how important a broad understanding of each patient is.
Sunday, September 14, 2008
PE
Currently on my neuro prac, I have had a number of pt's that have come directly from ICU or become acutely unwell. Last week was no exception, with one pt i had been seeing bidaily, desaturated overnight and a code blue was called.
This pt has GB and Rx consists of chest management including ACBT's and suctioning via trache, with passive movements of UL's and Active assist of the LL. Early last week, the pt was tolerating Rx well and getting much better chest expansion and breath holds. This made me think that his intercostals or accessory muscles were again being activated after nerve conduction improving. I encouraged the pt to take deep breaths and the pt was satisfied with his new improvements.
The following day the pt was complaing of mild constant (L) chest pain, that was worse with deep breathing and passive movements of the (L) UL, particularly flexion of the shoulder. I thought the pain was possibly of a musculoskeletal origin, after the big session the previous day, maybe the pt had strained a number of intercostal muscles. The pain also could have been due to remylination of nerve fibres with muscle reinervation, which can cause pain. I checked with my supervisor and she shared my view. I limited DBing ex's and the pt had a gentle session.
The pt was diagnosed with a PE and spontaneous pneumo-thorax (L) the following day after crashing overnight, and was placed under more acute care. This was a surprise after our suspected diagnosis, and i thought if there was anything i had missed and could have alerted Dr's earlier. We checked the area and palpated, auscultated, subjective questioning and nothing indicated a sinister pathology. This situation just indicated even if you think you've covered all your basis this is not always the case. Even being cautious and getting an X-ray that day would have picked up the pneumo-thorax or other tests to indicate a PE. I felt like i should have known or done more, but i wasnt exactly sure. We tried to do DBing that day but cut it short, in hindsight avoiding this altogether would have been better. These situations probably happen alot in clinical practice, and hopefully if it can be prevented actions are taken for optimal pt outcomes.
This pt has GB and Rx consists of chest management including ACBT's and suctioning via trache, with passive movements of UL's and Active assist of the LL. Early last week, the pt was tolerating Rx well and getting much better chest expansion and breath holds. This made me think that his intercostals or accessory muscles were again being activated after nerve conduction improving. I encouraged the pt to take deep breaths and the pt was satisfied with his new improvements.
The following day the pt was complaing of mild constant (L) chest pain, that was worse with deep breathing and passive movements of the (L) UL, particularly flexion of the shoulder. I thought the pain was possibly of a musculoskeletal origin, after the big session the previous day, maybe the pt had strained a number of intercostal muscles. The pain also could have been due to remylination of nerve fibres with muscle reinervation, which can cause pain. I checked with my supervisor and she shared my view. I limited DBing ex's and the pt had a gentle session.
The pt was diagnosed with a PE and spontaneous pneumo-thorax (L) the following day after crashing overnight, and was placed under more acute care. This was a surprise after our suspected diagnosis, and i thought if there was anything i had missed and could have alerted Dr's earlier. We checked the area and palpated, auscultated, subjective questioning and nothing indicated a sinister pathology. This situation just indicated even if you think you've covered all your basis this is not always the case. Even being cautious and getting an X-ray that day would have picked up the pneumo-thorax or other tests to indicate a PE. I felt like i should have known or done more, but i wasnt exactly sure. We tried to do DBing that day but cut it short, in hindsight avoiding this altogether would have been better. These situations probably happen alot in clinical practice, and hopefully if it can be prevented actions are taken for optimal pt outcomes.
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