On my womens health placement I initially had a bit of trouble getting my head around all the things we had to say and educate the patients on. Some of the things we had to teach were quite sensitive issues (e.g. perineal pain, bowel and bladders problems). I had sat in with the other physios when they were seeing patients and they seemed to go over these issues with no problems.
Eventually after I had done a few post natal educations of my own I realized that after birth patients are so used to people asking about their bowel and bladder habits and their perineum that it does not bother them anymore and they are more than happy to disclose the details to a physio student. Also as a result of all the antenatal edu pts get many of them know the technical terminology associated with womens health which makes it much easier. However some patients did not understand English very well and therefore did not understand what ‘Have you opened your bowels yet’ or ‘Did u have any constipation during your pregnancy’ meant. Initially this was difficult but I soon realized that if you didn’t get embarrassed or make a fuss about it the patients always thought it was funny if you re- phrased it and asked them ‘if they’d done a poo’.
This prac has show me that even if you are embarrassed about the things you are asking if you act confidently and are not immature then patients are less likely to be embarrassed and more likely to divulge important information to you.

Conversion Disorder

On my womens health placement I had a very interesting pt. This pt had had a home birth with a 5 page detailed birth plan, however everything did not go to plan when she retained her placenta and her and her newborn had to be rushed to hospital. When in hospital she lost sensation and power in her LL and pelvic pain. Within a few days of giving birth this pt was unable to walk without max assistance. She also AS and a number of other problems, all of which were self diagnosed. However with all these issues the pt was not phased at all and came across very cheerful, whereas the husband was very emotional and teary. The doctors had no idea what was wrong with this pt and blood tests and MRIs showed nothing.
Initially I found it difficult to see this pt as there was no apparent reason for her neuro symptoms and I cant help but think that maybe the patient is just being dramatic and making it up.

After talking to the other physios I learnt that this pt may have conversion disorder which is where the patients develops symptoms, such as this pt had, however there is no neuroligcal cause for these symptoms. It is thought to be brought on by psychological stress or trauma which would include childbirth, especially when the pt is rushed to hospital immediately after.
After learning this I found it easier to see this pt and it reinforced the (obvious) fact that diagnosis is not the be all and end all of physiotherapy and that we should not purely treat based on our Ax and not the diagnosis or lack there of.

Ortho pt on Cardio prac

When I was on my Cardio placement on a surgical ward all my Cardio patients were going well and then I was given an outlier pt who had had a TKR. The only orthopaedic placement id had were the 3 hours ones in second year when you were on placement with 5 other people and didn’t learn a lot because you spent the whole time doing subj and obj.
I knew basic things like ROM exercises and IRQ/SQ etc but other than that I didn’t have much idea what I was doing. To make it even more complicated the pt was so far behind on her pathway because she had had a PE post surgery. I had to see this pt twice a day for 3 days which took up a lot of my time when I should have been seeing cardio patients.
I did this until I my supervisor asked how I was going with everything and I told her that I felt like I had no idea what I was doing with this pt. Immediately after this she took the pt off me because it was my Cardio placement and I shouldn’t have had to see ortho patients.
This has shown me that if id just spoken up earlier then I could have saved myself 3 days of feeling useless and the pt would have prob got better treatment from a physio/ student who knew what they were doing

judging pts

Ive just had a womens health placement in a public hospital and in the last 4 weeks I saw a variety of patients from different socio- economic groups. A number of the patients I saw were also very young. After reading their notes I just assumed that because they were so young that they would not be interested in a physio student coming to give them 25 mins of post natal education. Many of them also had complex social histories so I thought physio would be the last thing on their minds.
I went into their rooms just expecting them to tell me that they couldn’t be bothered listening so to just leave the physio info sheets there. However almost all of my younger patients were the ones who were most keen to listen and asked the most questions. It didn’t occur to me beforehand that these are the patients that are probably keen to learn the most because they haven’t been taught anything like this before. It was nice to have patients that were actually interested in what you were saying and it showed me that you shouldn’t judge patients just on their notes because they can suprise you

Building Rapport

Whilst treating a patient this week I learnt the benefit of being polite but firm with patients. I was seeing a lady who was 3 days post C- section to give her some post natal education. She was complaining of mod pain however refused pain medication as she preferred more natural remedies. This pt also had a very interesting PMH and the nursing staff had warned me that she could be very difficult and wouldnt do anything she doesn’t want to.
So the first time I went to see her, I tried extra hard to be nice and build some rapport with her so that she would be compliant. Which meant that I let her brush her hair, put on some hand cream, helped her walk very slowly to the toilet etc. However this meant that I had already spent 15 minutes with her before id even started my education. She was extremely friendly with me and listened to my advice and asked questions. By the time Id finished, an education that should have taken a maximum of 25 minutes had taken just over 45 mins.
From this I learnt that whilst building rapport with the patient is essential, we still have to be in control of the treatment session because our time is very precious, especially next year when it would have been just me on the ward.

Pschology

On my paeds placement i became very interested in the psychological effect of parenting a child with a disability.
I came across a lot of parents on my placement and it was interesting to see how different people managed different scenarios. I researched a whole heap of journal articles regarding stress, depression and illness amongst parents of people with disabilities and gave a presentation to the staff.
We get given some advice to manage parents whilst we're treating their children, however I don't think it is highlighted enough. I've finished my placement and I'm still not sure how to manage a depressed parent, I don't think anyone is sure how to manage the situation. However I do know that we need the parents to continue with home exercise programs for their children and therefor we need them to trust us and be in the right frame of mind.
In my brief placement I learnt that active listening was effective especially for people who just need to vent and talk, However for people who are more at risk of depression its not the be all and end all. People manage stressors best when they have an internal locus of control and a sense of self mastery. Its not about always being "feel good" and "lovey dovey" you need to empower these people to take control of their life to break the depression cycle, be a motivator not just someone who tries to empathise with them.

Red Tape

On placement with a government department, not a hospital.
I have never seen so much red tape in an organisation before. These people will hold meetings and achieve nothing, they discuss their policies and procedures more than they practise and the whole environment is inefficient. It was hard to swallow how many resources this organisation squandered.
I finished my placement and I am glad i experienced it, I learnt the effects that red tape had through all levels of staff, It breeds inefficiency. I know better understand that a workplace needs to have the right balance between policy and procedures and freedom for individual thought and decision making.
Has anyone else found a placement to be a poorly run organisation?

Continuing Education

My self directed placement I took part in dissecting the brachial plexus on a wet specimen, it was a fantastic experiance. More to the blogg point of view, the biggest thing i learn't from dissection is how much anatomical knowledge we have. It doesn't take much to remember that Real Therapists Drink Cold Beers. (roots, turnks, divisions, cords, branches), and without blowing out own trumpet we have a very good level of knowledge when it comes to anatomy. However, with a little bit of revision you can realise that there is alot more detail available out there on anatomy and knowledge that is relevant to practising physiotherapists.
I know we all graduate soon, just wanted to make the point that there is heaps more for us to learn.

international health

Returning from China and reflecting upon my experience it made me realise that our health system is so advanced compared to a coutrny like China. We are in actual fact very lucky to be able to be part of a system that prioritises health over the economy andf everything else. You do not realise till you go overseas and work that Australia is such a lucky country to live in. We have access to the public health system which has mostly recent technology and knowledge. Quality of life is such a priority here compared to overseas where theressuch limited access to modern rehab techniques and actual therapists. It opened my eyes to the systems in place overseass as well as the status of physiotherapists overseas.

how do you tell someone they need to reduce weight?

I had a few patients that were fairly overweight presenting with low back pain. After multiple sessions of treatment their low back pain improved signficantly so the focus of the treatment was on self manaagement and their HEP. The other issue as mentioned before was the excess weight they were carrying. I knew from my initial treatment with my patient that I would have to address this issue. The only problem was that it is a very difficult topic to bring up, and most perople that are overweight are sensitive to the issue. Discussing with my supervisor there were many methods you could use to approach the issue. The very direct way or mor subtley or almost not at all. I approached the topic and fpund that it wasnt that hard to bring it up. The next session however my patient made excuses for this that and the other for not exercising and not eating right. This then continued in the next session and unfortunately there was not much i could do as my placement drew to an end. So how effective was my cozxing and education I wonder? At least I know now how to approach patients with this issue but in terms of how long the impression will last is another matter.

unrealistic pt expectations

I had a pt on my rural placement who was referred to me by the OT student who told me that he was a bit of an angry man. He had a thalamic stroke 2years ago and functionally he is independent with ADLs, he was referred to physio because he was getting pain in his buttock when cycling on his static bike. When I saw him he gave me a long story about when he had his stroke and the current symptoms he experienced. He told me at the time of the stroke he was out in his shed and when he started feeling the symptoms of the stroke, which he didn’t know was a stroke at the time, he went to his car and tried to get in and struggled due to the weakness but managed to get himself in. He felt that the pain in his buttock was from when he was trying to get in his car he thought he injured his leg, he thought ‘a sinew had been detached’ and he wanted an x-ray to show whether or not this was true. He was not too happy with the treatment he got when he was in hospital and said no one would do an x-ray for him. After doing the whole S/E I did the O/E and he had no musculoskeletal problems causing the pain, his pain was on his ischial tuberosity which was why he thought he had a sinew detached. I told him there was no treatment I could do for him to relieve his pain but I could give him a home exercise strengthening program as he had slight decrease in strength. His reply to this was that he didn’t want an exercise program as he was happy with his static bike cycling he was doing. His expectations in coming to physio were for a referral for an x-ray. I told him that I couldn’t refer him for an x-ray and if he wanted an x-ray he had to go to his doctor to get a referral.
This case showed me that pt expectations of what we can do for them are sometimes unrealistic and there are times that there is no treatment that we can offer the pt to help their condition. Sometimes all we can do is give them education and advice.
In the future I will take note of pt expectations and beliefs and treat the pt as I see appropriate trying to get to their expectations while still being aware that some expectations may be out of our scope as physiotherapists and possibly unrealistic and therefore pt education may be the only management I can offer the pt.

independence vs safety

I treated an 83 y.o. lady who was admitted for rehab after having a cerebellar stroke. She is mildly affected by the condition and is independent with her ambulation with no aid. Prior to admission, she lives alone in her own home and is independent with all ADLs. I decided to assess how well her balance is and so I did a Berg Balance Scale on her. Her score was 44/56 and therefore is a falls risk. Without me even suggesting to her any walking aids, she said to me that she doesn't want to be walking with any frame or stick and wants to be on her feet for as long as she can. I have no worries about her ambulation indoors (as she is walking around the ward by herself) but I am worried about her outdoors mobility (with the uneven surfaces and environmental factors). Prior to her discharge, i talked to her about her outdoor mobility and how it is very different to indoors. I also did the dynamic balance assessment (external displacement) on her to show her that she couldn't save herself appropriately if she is nudged by someone in the shopping mall or on the streets. I also told her that she will have a risk of being hospitalised if she does have a fall. I know that she doesn't like the idea of walking aids so I gave her a brochure which includes a range of 4WW which she could use as an outdoor walking aid to improve her safety. I am not sure if she went to get one in the end but I know that I have done all that I could in terms of educating her regarding her safety outdoors. I have also referred her to day therapy for more rehab.

Realising what my learning style is...

On the first day of one of my placements we did a learning style questionnaire. I was somehwere between a theorist and a reflector. One thing that the questionnaire mentioned was that theorists/reflectors require ++preparation prior to doing something. I really thought about this and agreed that this was soemthing that would benefit me. From writing notes to planning out a treatment session, when i have a plan i seem to perform alot better with greater confidence and efficiency.

I applied this to my practical sessions durin this placement by making sure i had thought about a plan before attempting notes or treatments sessions. It worked well and my supervisor noted that my confidence was improved.

Later in my prac (when motivation stated to reduce) i wasnt preparing for my treatment sessions. I was just doing things on the spot and funnily enough my supervisor picked up on this and told me that i was not as efficient or confident as i had been previously.

I have learnt fromthis situation that my learning style is most definitely theorist/reflector and that preparation is essential for me to perform well.

Comfort care

On my neuro placement, i treated a 92 y.o. male with parietal subdural hematoma as a result of a fall. Prior to the fall he is independent with all ADLs and ambulates with a walking stick. When i first see him, he appears confused and weak in his lower and upper extremities. He couldn't communicate well with everyone and has developed dysphagia. He also has anosognosia. I worked on his sitting balance all week and did not achieve much. It was also hard for nurses to transfer him with the pulpit frame due to his weak legs and trunk muscles. He is not taking in adequate food or fluid. The doctors and the family agreed to provide him with 'comfort care' instead of active treatment which will include tube feeding. I wasn't too sure what 'comfort care' means in terms of physiotherapy. My supervisor then asked the doctors if they are happy for physiotherapy to continue just to make transfers easier on the nurses. They were happy for that and so i continued treating that patient just to improve his sitting balance and ability to sit to stand to make transfers easier. However, one evening, when the patient was placed on a high back chair, the patient was seen kneeling on the floor trying to get back on to the bed. I felt responsible for the event as I was the one who encouraged the nurses to sit the patient out on the chair for as long as he could tolerate. It didn't occur to me that the patient also has lack of insight of what he is able to do and what he needs to do to get back into bed (i.e. call the nurses to assist). Since then I have decided that he could only sit on a recliner chair and that there is not much purpose in keep working on his sitting balance when sitting and transferring him via pulpit frame will be unsafe for him and the nurses. He is also seen on a few occassions trying to climb out of his bed trying to go to the toilet, and he has rails put up on the sides of his bed since. The nurses have been transferring him with the hoist after the incident and is now waiting for a HLC nursing home.
I realised that when treating a patient, we have to be realistic on what a patient is capable of and progressing a patient who is cognitively impaired is sometimes inappropriate.

Frustration

On a recent placement i was given a patient to treat who had a head injury. From the first session with him, he would thump his PCA, PT and me. It was frustrating because we couldnt punish him.

After talking to the clinical psych we implemented "gym rules" which said "keep hands and feet to ourselves, no hitting, punching etc...". This worked well. The patient did require constant reminders of the rules, but generally there was no thumping after it was implemented.

The treatment session i didnt start with a review of the gym rules, the patient started being physical. He continued to be this way even after being reminded of the rules. Then as i was sitting next to him, he scratched my eye with a bean bag. I reacted quicker than i could think and i took the bean bag from him and gave him an assertiveish/very annoyed/angry talking to. I mentioned that he was out of line, and that his actions were unacceptable. I was fuming!

For the rest of the session he did nothing...just sat there on the bed. We tried hard to get him to walk with our assistance but he declined. We ended up just t/fing him to his w/c and letting him go back to his room.

The following session i started off by mentioning to the patient that i didnt hate him and that i was looking forward to having a good session with him that day. We reviewed the gym rules together and actually had a good session with no thumping or innapropriate behaviour.

I learnt in this situation how difficult it can be to deal with children with head injuries. I learnt that there must be a consequence for their actions and being in a position to take something of value away from this child may have given me more leverage to control his behaviour. The problem was that there isnt much we can actually limit or stop him from doing.

patients with dementia

2nd week of my neuro placement. I had to treat a patient who came in with increasing confusion and slurred speech (with ? aphasia). There was nothing much written in his file regarding his social history and past medical history as the patient couldn't communicate well with the medical stuffs due to his confusion or aphasia. I went in to do a mobility review on the patient. The patient couldn't perform any movements on command but is able to do them voluntarily. He also had some difficulties understanding my instructions. i was thinking at that time that he has both apraxia and aphasia. My supervisor asked me if there is any other pre existing conditions that could contribute to his current confusion and i looked at his PMH and he has dementia. My supervisor told me to keep my instruction short and simple with this patient. I managed to get his cooperation and was able to assess his mobility. When we left the patient, i had a discussion with my supervisor regarding how much of the patients presentation is dementia and how much of it was due to aphasia and apraxia. I then called his current hostel and i found out that he is from a dementia specific ward and he is usually good with following commands. The other thing that could contribute to his current confusion too was the fact that he is in a different environment than what he is use to. Since then i decided to keep my instruction short with him and that i don't have to explain much about what i am doing.
This has taught me that when it comes to patient with dementia, they sometimes could also present with apraxia and the fact that he is confused doesn't mean that he has aphasia. I have also learn to keep my instructions very simple with patients with dementia.

wrong diagnosis

Third week of my neuro placement. A patient was admitted for a ? TIA due to increasing weakenss in the legs and 3 falls in a week due to her legs 'collapsing on her'. I did a full neuro assessment on the patient and she doesn't have any unilateral motor deficits or any neuro deficits. She has bilateral weakness in her LL (gr4). I assessed her functional tasks and she required maximal assistance to sit to stand (and could only stand for 5 secs before sitting down again). She gets very SOB on attempting to stand. She also desaturated to 82 just with attempts to stand. Her SpO2 in the morning was 88. I got the nurse and she put the patient on O2. I decided to stop my assessment there. I talked to the patients husband and according to him, the patient has been very inactive for weeks and she requires assistance going in and out of bed at night and could only manage walking short distances within home (i.e. bedroom to the lounge). I told my supervisor my findings and I told her that it couldn't be TIA because the patient has had the legs weakness for weeks and TIA usually resolves within 24 hours and the fact that she desaturates with attempts to stand, that suggests some other pathology that could be happening at the same time. Next day, I tried to see the patient again but the nurses told me that she had a MET call. She was transferred to another hospital that evening due to a large PR bleed. The patient also has a very long list of PMH which includes Cancer and therefore her current presentation might have been an exacerbation of her previous conditions. The fact that she is being diagnosed with a ?TIA doesn't really justify the signs and symptoms that she presents with. From this experience, I have learnt to just not to accept any uncomfirmed diagnosis and to go with the signs and symptoms that the patient presents with.

Hypoxic Drive to Breathe

Prior to seeing my patient who was admitted with Type 2 Respiratory Failure, I checked the medical chart for his cardiovascular status. I noticed that his SpO2 was at 97% with 2L entrained Oxygen via a BiPAP machine. This raised concern, as the patient would have relied on hypoxic drive to breathe considering his diagnosis. This meant that a small rise in his oxygen levels could have caused a huge reduction in his ventilatory drive, which could have resulted in further deterioration of his resp status. In addition, I recalled that the doctor had specifically noted that his SpO2 should be targeted at 88-92% on BiPAP.

The ward nurse didn’t seem to know anything about the situation, and I was not sure if I was allowed to adjust the setting on the BiPAP machine. So I approached the NIV physiotherapist, whom happened to be in the ward that morning, to seek guidance. Immediately, she notified the nurse and requested that the flow be adjusted to ensure his SpO2 was within the targeted level.

I was reminded that, as a clinician, it is essential that I am thorough with my examination of a patient and be analytical in every situation because this could ultimately prevent any unnecessary mishap. Also, it is important to approach the most suitable clinician in seeking the most appropriate step to take.

Total Knee Replacements

On my rural placement I saw two pts post TKR, the first was an elderly lady in her 70’s and I saw her for her r/v 2/52’s post-op, she was doing well with her rehab, getting over 90° active flexion and only had a few degrees of quads lag but this had improved greatly from her pre-op status. She was compliant with all her exercises and keen to do more. The second TKR was a man in his 50’s, he requested to be sent up to the hospital I was at, as it was closer to his home, after a week post-op in the hospital where he had his operation, in a nearby bigger country town. When we went to see him he only had 40° passive flexion and no activation of his quads, he was in a lot of pain when he tried to move his operated leg and he had quite a bit of swelling around the knee and his quadriceps was extremely tight. He told us the physio management and treatment he got in the hospital where he had his operation was not good at all, he said he hardly saw the physios and the CPM machine was left in his room for him to put on and use himself if he wanted. We couldn’t be sure that he was giving an entirely accurate description of his treatment but from the state of his leg it didn’t look as if he had had very much intervention. We had to do some intensive treatment on this man to try get some movement happening in the knee and get the quads muscle firing. We put him on the CPM machine for a few hours during the day and got him doing passive and active quads exercises. Before the quads exercises we tried to release some of the tension in the quads muscle but he could only handle gentle massage as anything deep caused him intense pain. After a bit of massage his quads started firing a bit. By the end of the week and my placement he was doing a lot better but still not good enough to go home.
From these two cases it really showed the importance of good management post-op. If you took a 70 year old woman and a 50 year old man you would expect the younger of the two to recover better, and even though the woman was a week further in her rehab when I saw her, the man was not even close to the same level after a few days of seeing him which would have been at his 2 weeks post-op mark. A number of factors go into the recovery of a pt post-op but in these cases I think one of the major reasons for the poor recovery of the second case was due to poor post-op management. It also shows that the first few days post-op are extremely important and good management and treatment from the start can cut down the number of days it takes to recover but conversely poor management and treatment from the start can extend the recovery period greatly.

Depends on the supervisor

I have had the unfortunate experience to have to repeat a prac due to being incompetent. I was absolutely devastated to have had to repeat 4 weeks which i could have had off. Having to repeat the placement has made me realise how much it depends on how well you get along with your supervisor. on my initial placement the supervisor was such an intelligent person that the expectation for us to be have that same amount of knowledge. The teaching style was very focused on independent learning and it was expected that your clinical reasoning skills were fine tuned. The on repeating the prac I have found it SO much easier. My supervisor is very open and friendly and completely down to earth. They give you positive feedback constantly rather than the constant negative comments that i was previously receiving. On my initial placement after not having a mid way placement i was told 2 days before finishing that i was to fail. Just the unfairness of it all really made me fume. To think that had i been on another hospital i would have passed instead of having to do back to back placements from Feb to now. Despite the setback I have learnt alot more from the current placement I am at. Its been really helpful learning environment even though my confidence completely dropped after the initial attempt.

6MWT

A patient with Idiopathic Pulmonary Hypertension was admitted to the hospital respiratory ward for further investigation due to ‘failure’ of achieving the targeted distance in her most recent 6MWT, as was told by the clinical physiotherapist. She expressed her disappointment during my subjective assessment, as it was explained to her that she has to ‘pass’ the 6MWT before she could be prescribed a specific medication that could prolong her lifespan. In other words, if she fails the 6MWT again she would not be given the medication. She had also stated that her right patella was removed and the knee joint was fused secondary to OA. This meant that she was not able to flex her knee during ambulation and would thus slow her walking speed. To complicate the matter, she had acquired LRTI in the hospital.

As she had not been out of bed on my initial session with her and her Obs and BP were stable, I decided that ambulation was the most appropriate intervention. I observed that she became quite SOB after about 10m of ambulation, so I asked if she wanted to sit down. (Her SpO2 was within normal limits) She declined and said “it’s alright, I can do this.” As we resumed, I realised that her SOB had increased progressively but the patient did not want to stop until she walked back to her bed (20m). Nonetheless, she recovered in about 2-3 minutes with relaxed breathing and other coping strategies to reduce her SOB.

On hindsight, I realised that the likely reason for the patient being so determined to keep walking despite mod-severe breathlessness was her perception that if she kept walking she would eventually be able to ‘pass’ her 6MWT (which was to be performed in a week). As a clinician, I should have insisted the patient to stop and rest to avoid any unforeseen circumstances. The following day, I ensured the patient understood that the 6MWT was not about passing or failing. It was to determine her functional and cardiopulmonary status and whether she was able to adequately manage her SOB. I also assured her that her speed limitation secondary to the fused knee would be taken into consideration.

Strange case

I had a pt who presented with swelling around her ankle, mainly around the lateral malleolus but also slight swelling across the anterior aspect of the ankle as well as the medial side. She had a constant 5/10 pain along the anterior aspect of her lower limb about ¾ of the way up (below the knee) and down to the ankle. Nothing she tried eased her pain but her pain increased over the course of the day especially with prolonged standing or walking. She had no history of injury, the pain just started one day and she noticed the swelling. She said she had been to the gym three days before it started but she just did her normal routine and didn’t roll her ankle or anything. She went to a doctor who thought she had just sprained her ankle so he gave her a cortisone injection (a bit weird I thought); this didn’t affect her pain or swelling at all. So she went to another doctor for a second opinion and they referred her to us. She had had an x-ray which showed nothing abnormal and the second doctor had also referred her for a bone scan (which was booked in to be done 5 days after I saw her). I assessed her and had no findings that I could make a diagnosis on. Her ankle stability tests did not show anything significant. She had pain with dorsiflexion and plantarflexion both active and passive and her inversion and eversion were pain free. She was TOP over the medial aspect of her tibial shaft but not TOP around her ankle joint. None of the subjective questions revealed red flags but because she had no findings that correlated well I decided not to try treat the swelling with ultrasound or any other modalities for fear of a more sinister pathology. All I could give her was some advice to try a compression bandage to reduce the swelling and I gave her some gentle AROM exercises. I advised her to contact us once she had got the results from the bone scan and then possibly with a diagnosis we may have been able to know how to treat her more effectively, if treatment was indicated. Unfortunately by the time I had finished my placement the pt had not got back to us which could have been because physio treatment was not indicated but unfortunately I’ll never know, it was a different presentation to what I’ve seen before so I was curious to know whether or not the scan showed anything and a diagnosis was made.
This presentation highlighted the importance to me to really be aware of red flags if the objective examination doesn’t seem to add up, even if no subjective red flags are highlighted. I don’t know if it was a red flag situation but I didn’t want to take my chances and when discussing it with my supervisor she agreed with what I had done and also found my findings didn’t point to a specific musculoskeletal diagnosis and it was a good idea to wait for further investigations. I can’t remember exactly but I think it may have been the fact that a bone scan was ordered that caused me to be a bit more aware of the possibility of a red flag situation. I would definitely take the same approach if similar situations occurred in the future and I hope I can stay alerted to the possibilities of red flags in my future practicing as a physiotherapist.

Learning and talking

On my paeds placement in China I was allocated to a room catering for a few conditions such as autism, Down Syndrome, ADHD and cleft palates. On entry I was greeted by blaring music, screaming kids and general mayhem. This was completely out of the ideal working conditions for a therapy room. In the general chaos of the room there was some sort of organised schedule and we managed to see the structure of the class.

From a physiotherapist point of view there was not much to apply in terms of therapy, despite this I actively questioned my fellow OT partner on methods of calming sensory seeking behaviours and encouraging play with autistic kids. I realised that how I was learning which was learning the theory and practical at the same time was so effective. I was able to think of strategies on the spot and apply the theory immediately. I then started to combine PT techniques that worked on balance and gross motor coordination which made more sense as you kill two birds with one stone. In this room the language barrier is most evident, joint with attention deficits made it extremely hard for the child to follow instructions. Being a room full of other kids and blaring music it will naturally be hard for any child to follow instructions. Observing the set up of this room reflects the infancy of the centres practice. What they have already is amazing but again there is much to work on. The staff aren’t even qualified in therapy yet are dedicated to their job. If only I had the language to explain to them techniques to assist the children I would feel more useful. I cant ask them if they know the rationale for the task the children do or if they know of any other techniques or even if they know the condition of the children they’re working with. It shows to me that language is such a powerful tool that can’t be taken out of the equation of communication.

:(

On a paediatrics placement, i went with my supervisor to see a 2mth old girl who had been in hospital from birth due tummy problems. The infants social situation was horrilble to say the least. For various reasons the mother and family were rarely present which meant that this infant would spend a huge amount of the day on her back in the cot only being held when she needed changing or medical attention (try and picture this...its not nice!)

The plan was to see this infant regularly for developmental play. When I was playing with this baby i was fine, i really enjoyed it. It was only once i got home that i realised how much this infants situation had affected me. I was overwhelmingly sad that night and i decided to talk to my supervisor the next day.

I expressed the reasons for my sadness to my supervisor. My supervisor encouraged me and gave me some simple advice. Suprisingly i felt a lot better following our chat. I was able to treat/play with this baby without my sadness getting in the way.

I have definitely learnt the value of debriefing with colleagues when something challenging happens at work.

Palliative Lung Cancer

I was to see a patient who was diagnosed with a 4th stage lung cancer (under palliative care) for chest physio review. Just to outline a little bit of the patient’s background: he was notified by his radiologist a few years back that he was suspected of having bronchogenic carcinoma. He was told that he would be referred to a hospital for further investigation. However, he waited for an appointment with the hospital that never came. He was recently admitted to the hospital by a ?neighbour when they saw his current condition.

The patient was on oxygen therapy via Venturi mask, and looked frail and exhausted. He was initially compliant with my subjective questioning, but became slightly agitated when I asked for permission to perform auscultation. He refused any form of physiotherapy intervention, and blamed the hospital system for not following up with him during his initial stage. I attempted twice to persuade him for physio, but was unsuccessful.

In such situations, I felt that any form of persuasion or intervention rationale became inappropriate as the patient had already decided that he would benefit from nothing at his current state. After consulting other physiotherapists in the hospital, I learned that although PT Rx could aid in the management of his respiratory condition, it was best not to push the patient since he refused even after several attempts. After all, PT intervention cannot be indicated without the patient’s consent. However, the approach should differ if the patient's recovery was more promising. In this instance, I could perhaps consider consulting the doctor or referring him to a clinical psychologist?

Patient compliance with home programs

I had a number of pts on my rural placement with chronic conditions where I had to write up care plans for them and give them home programs to try to improve their condition. I gave them the exercises and then reviewed in 2/52’s to see how they were going and if the program needed modifications, progressions etc. With these types of programs it always seems questionable whether or not the pt will be compliant with their program but self management is the only way to try to improve their condition. One of my pts had had a number of TIA’s and as a consequence had decreased mobility, was walking with a 4WW and had a few balance issues. During the initial treatment session after writing up the careplan, I went through some balance exercises and some strengthening exercises with him and wrote them out as a home program. His wife was present during the session and she was very encouraging and happy with the program. On review his wife told me that over the past 2 weeks the pt had hardly ever done his exercises and said she had tried to get him to do them but he wouldn’t. I ask him why he wasn’t doing them, if they were too hard or if it was more just him not being bothered to do them. He said it was just him being lazy, so I emphasised along with his wife the need and benefits of him doing his home program and told him it was up to him to do something about his decreased mobility and balance problems because at the end of the day he is only disadvantaging himself. I went through his exercises with him again to make sure he at least did his exercises with me and to make sure again that he would manage fine at home with them. While we were doing the exercises (I did them with him as encouragement) his wife said maybe she should do the exercises with him as well at home and that may increase compliance, I told her that was a great idea. I also referred him to the mobility group exercise class that we ran twice a week for him to also get some added exercise and which could possible add to the motivation of exercising. Two days later the pt came to our mobility class and his wife said she had done his exercises with him that morning. From these experiences I have found that most pts are noncompliant most of the time with their home programs but its still best to give them the exercises and hope they will at least do something. It has also shown me that we have to try many different things to motivate the pt to do their exercises and having family involvement is one of the best ways to do this especially in the older population. Also if there is some community based exercise program that is also a good thing to get the pts to attend because at least you know if they attend that twice a week they are getting some exercise. At the end of the day the pt has to take some ownership of their management and it is important to emphasise this to them that if they want to improve they have got to do their exercises.

baby talk

On a previous prac i observed several therapists treating a 10yo boy who had a variety of neurological problems. The child was often non-compliant in treatment sessions and regularly punched the therapists in frustration and anger. I felt the reason for this is that the therapists' rewards, instructions, intonation and consequences were innapropriate for this child. I believe they treated this boy like he was much younger than he was.

I decided to talk to the child's clinical psychologist about her opinion on the therapists management of this child. I was glad to hear that the clinical psychologist felt the same way about this matter. In a series of discussions about this i told the clinical psychologist that i did not feel comfortable talking to my supervisor about the appropriateness of the treatment sesssions. Together we compiled a list of recommendations that could would be more appropriate for the child in the treatment session. Following this the Clinical Psychologist presented these recommendations to the therapists'. Several of the recommendations were implented and resulted in greater patient compliance, no more hitting in treatment sessions and improved patient-therapist rapport.

I decided to not discuss this issue directly wiht my supervisor as i didnt feel comfortable at the time. This may have been different if i had known my supervisor for longer than a week and if i was a qualified physiotherapist.

I feel that i acted appropriately by discussing this issue with a health professional that is well educated in this area of health care. If i encountered this situation again i would act in the same manner (providing i was still a student...).

LISTEN

After performing the usual subjective and objective assessments on a patient with pleural effusion complicated with pneumothorax, I was in preparation to ambulate the patient when she blurted out, “What is a shadow (on CXR)?” So I explained the possible interpretation of a shadow, which could have either been a tumour, fluid or foreign particles in the lung where x-rays were unable to penetrate.

Shortly after, she began to cry as she expressed her concern for her recent CXR result (which at that moment hadn’t yet confirmed her diagnosis). She further stated that she recently lost a good friend who died of a lung cancer, and was afraid she was to follow. I was speechless. Although I sympathised with her, I wasn’t able to empathise her feelings as I hadn’t experienced such an encounter.

However, I decided to take a moment of my schedule for the day to listen and allow her to express her emotions, as well as to provide some reassurance. I realised it was crucial that someone paid a listening ear so that she wouldn’t end up bottling up her feelings, which could pose detrimental effects on her health.

After that incident, the patient became more compliant with ambulation and other interventions. I learned that rapport with patient can be built with a step as simple as taking the time to listen.

Aboriginal Patients

I am currently on a general surgery ward and treating a 45 year old aboriginal lady from a remote aboriginal community who underwent a right hemicolectomy about 2 weeks ago, she developed several complications and is having a fairly slow recovery therefore she is still on the ward. As she is from an aboriginal community she is not used to being in the city and doesn’t have any family in Perth communicating with her is quite difficult. It is very difficult performing the subjective assessment on this patient as she will rarely speak. To overcome this I have found the best way get information from her is asking very specific questions and generally she will answer them, also I can read her body language to determine some things such as if she is in pain. The more I have treated this patient I have also found that she has become more responsive to me as she is familiar with me. In the future when treating aboriginal patients who are not comfortable in the city I will remember my experiences with this patient and use similar strategies.

Conflict between staff

Currently, the hospital I am on prac at is undergoing refurbishment and expansion. The wards had to shift down to new wards the other day, which meant that the staff were very busy trying to shift everything down on time and order things. The physio department has a drawer of information usually kept in the nurses office which was moved earlier and placed in an empty space in the new ward before everything else was moved. One staff member decided that was "innappropriate" and the physios were taking up the nurse's space. She also disliked how the allied health staff (physios, OTs and social work) sat in the old nurses office and wrote notes, even though I have never heard the nurses complain about this.

When the ward was moved to the new facilities, she still had a problem with this even though she is not a member of the nursing or medical staff. Fortunately, there was more space in which we could sit and write notes. However, the staff member continued to cause conflict with the allied health staff, saying that it was the nurses handover room and no-one else should be using it. We all thought this was ridiculous, as there is extra rooms to do notes. The issue was resolved during a meeting between staff later that day. This demonstrates that some people still don't understand that allied health staff and nursing staff play equally important roles and all staff need to collaborate to create a pleasant and efficient work environment.

New Grad Supervisors

I am currently on my cardio placement and my supervisor only graduated last year and has been rotating wards. This means he doesn’t have as much knowledge in the area as a supervisor who is a senior in that area. This made me a little bit concerned that I wouldn’t get as much out of the placement and therefore not be as prepared for my PCR as if I had a more experienced supervisor. To overcome this problem I decided I needed to make the most of my curtin supervisor visits and use him to answer any questions that my facility supervisor wasn’t sure about. This worked well as my curtin supervisor was happy to help as he understood my facility supervisor was a new grad.

Dealing with difficult patients

I have recently had a chronic LBP patient (mentioned in my previous blog entry) who had a lot of psychological yellow flags. Firstly, he was ignoring my advice to decrease his activity levels and continuing to garden for 6+ hours nonstop lifting heavy loads because he was "competing" with his neighbour to have the best garden. Thus every time he came in, his pain levels hadn't improved and the treatment that I had done previously had been undone. 

His expectations of physiotherapy were also quite unrealistic. The hospital only offers a maximum of 8 outpatient treatment sessions and he wanted a lot more. He also expected that I would give him an in depth maintenance program incorporating hydro and a gym program. I explained to him that his Dr referred him to outpatients as a trial to see if it would help his pain because his other option was to have spinal surgery. I also explained that outpatients didn't really have the resources to give him an in depth program and that we should sort out his problem of immediate pain first before thinking of anything further. 

My patient was also unavailable for afternoon appointments, as he had to work as a crossing guard in the afternoon for an hour. I asked him if he could schedule an afternoon off to get physio but he said he had to work (which is understandable). Due to this factor and his uncompliance, physio wasn't going to be very successful in addressing his problem. After I explained this to him (not using those exact words), he self discharged (fortunately) and from this experience I have learnt how to tactfully deal with difficult uncompliant patients.

unsafe vs non compliant

Week 4 of my ortho ip placement (Final Ax). I treated a 48 y.o male who has a # L tibfib as a result of a fall. He has to remain NWB for 6/52. He is a construction worker. When his PCA was removed, I took him to the gym to try him out on crutches. He said he doesn't need to be taught how to use the crutches as he has used them before, I insisted and said that I need to review his mobility before the doctors decide to discharge him. I gave him brief instructions on using the crutches. When he stood up he didn't wait for my command and began ambulating. He got the sequence of movement right, but it seems to me that he was rushing through movement and is potentially unsafe, I had to keep telling him to slow down. I taught him how to get up and down stairs the same day. He didn't have trouble with that either but he was rushing through the movement as well. He managed the stairs safely but its a falls risk if he rushes through the movement and i explained that to him. My supervisor was there with me and she told him that 'if you fall here, you will have to stay longer in the hospital' and he slowed down. I took him back to his room and wrote in his progress notes that he is currently ambulating independently and is safe to go home. Despite him being potentially unsafe, I thought that given he is a 48 y.o. construction worker who is physically fit and able, and it is in his nature to tend to rush things and just want to get things done quickly. My supervisor told me that it was good that i managed to keep calm and be appropriately assertive with the patient but to actually get this patient to be compliant I will have to tell him the consequence of his action and be more than 'appropriately assertive'.
From this experience I have learn that sometimes we just have to adjust to our patients behavior and alter our sessions and judgments regarding their safety accordingly.

PMH

On the 3rd week of my ortho ip placement, I treated a 65 y.o lady from Sydney with # R tib fib as a result of a fall , she is currently on holidays in Perth. She has to remain NWB for 6 weeks. It is now day 3 and to date she only manages transfers. I took her to the rehab gym to do a mobility review and to practice ambulation in the parallel bars. Prior to her fall, she is independent with her ADLS but she has poor exercise tolerance. When ambulating within the parallel bars, she was struggling to weight bear through her upper limbs as she hop forwards, she has really poor upper limb strength. She managed one lap on the parallel bars doing mini-hops and shuffling her left foot instead of stepping through. She looked really exhausted and her RR has clearly increased. I didn't really take notice of this and i just assumed that it was because it was her first time ambulating after her operation. I took her to the gym again the next day for ambulation in the parallel bars, her quality of movement doesn't seem to have improved and she is as exhausted as she was yesterday. There was nothing listed in her PMH. I then decided to ask her if she is normally this puffy and exhausted with walking, and she said yes, and it was since her MVR that she has limited exercise tolerance. I then decided that i should go easy on her and keep monitoring her PR. I told my supervisor about it and she said that the doctor may have missed it as she is from Sydney and her PMH may have been purely subjective. I was glad that I was able to pick up the signs and manage to alter my treatment to suit the patient. When the patient was discharged, she was given a zimmer frame instead of e/c as she has weak UL strength and her husband was taught how to assist her when going up and down step.

pt's comment vs PT's observation

Week 2 of my orth ip placement. A 58 y.0 lady was going to be discharged from the hospital after the revision of her THR (post-op order PWB). I was going to teaching her how to use her e/c when going up and down the stairs. On s/e she reported that she only has one step going into the house and going to the shower but i decided to do the stairs (~4steps) that they have in the gym as she is a 58y.o previously independent lady. Prior to practicing the stairs, I told her to walk ~5 m within the gym with her crutches just to double check that she is really safe with it. We were going up the steps and she looked as though she was struggling (breathless) but still manage to keep up with conversation, she was rushing through her movements too. She told me that she is fine and wants to keep going, I was going to allow that but my supervisor stopped me and told the patient to take a breather. After ~ 2 minutes we went down the stairs. She rested in her wheelchair and had a glass of water, still look breathless but very involved in conversations. I told her that we are going to practice the stairs one more time and if that is okay with her and if she's feeling dizzy or fainty or pain, she said she'd be happy to do it again (my supervisor asked my why i chose to do it again as the patient looked as shes struggling, I told her that i wanted the patient to be really familiar with the e/c when going up and down stairs). We practiced the stairs again after ~10 minutes of rest, and this time the patient manage the stairs well and with less difficulties. After the treatment session, my supervisor told me that it was a good idea to re-check her stairs mobility. My supervisor was worried that the patient was not coping well during the treatments session. I then told my supervisor that I have seen this patient for a few days now and she always look breathless but she still manage well (i.e. obs stable and able to keep up with conversations, nothing significant in her PMH) and the patient reported that she is feeling okay. I trusted that the patient is telling the truth and i trusted my gut feelings, but I am still not quite sure if it is the right thing to do. Anyone has any comments feel free to post them up.

Micro alerts

Week 1 of my orthopaedic in pt placement, I was asked to bring a patient to the rehab gym for some exercises in the parallel bars. The patient was micro-C alert and I consulted my supervisor about that. She told me to bring the patient down to the gym only when there is no other patient using the gym (which is hardly the case as there is only one in pt gym), I consulted the nurse looking after the patient and she said it was totally fine taking her out of her into the gym and micro-C is only a hospital precaution and there are many micro-C carriers out in the community. I told my supervisor about what the nurse said and she decided it was okay to take her to the gym at anytime as long as her wound is dry and covered. When i took the patient to the gym with gown and gloves on the other physios were wondering why i took the patient in when she has some infection precaution going on, they too had to double check with other physios and nursing staff to make sure it was really okay to have the patient there amongst others. From this experience, i have decided to then read up on the micro alerts and the specific precautions for each of them (although, in general they all requires gown and gloves, equipment rub down, handwash).

Covering your back

A patient was recently referred to me for treatment of chronic LBP which he sustained after an accident 10 years ago. Since his accident was workplace related, he got workers comp and lots of intensive physio and hydro after his operations. However his worker's comp ran out a long time ago and he found he was able to manage his pain by going to the gym and doing hydro. In spite of his pain, he works a job which involves periods of standing and enjoys gardening.

This patient reported much higher levels of pain and neuro symptoms which had been increasing over the past 18 months. His neurosurgeon suggested he have a spinal fusion +/- laminectomy of his Lx spine due to central canal narrowing and disc degeneration, and my pt has to make a decision by November. My patient asked me if physio or surgery would be the better option and he would rather not have surgery because the surgeon gave him a 50% chance of improving. 

He also told me he didn't want to be a burden on the health system and having lots of physio would mean that he didn't need to take up a bed in a hospital. He said that he knew that it would take more than 8 sessions (the maximum the outpatient dept offers) to get better. I wasn't comfortable in telling him what to decide but advised him that his CT's showed degeneration which wasn't going to get better over time and if he continued to do heavy gardening and not rest while he was standing up to work he probably wouldn't see a decrease in symptoms. I also told him that outpatients couldn't see him for anymore than 8 sessions and he would get physio after an operation if he decided to have one. I advised him to go and seek the opinion of his neurosurgeon and ask specific questions about why it was in his best interests to have the operation and then he could make an informed decision rather than asking someone (me) who doesn't have the knowledge to give him accurate advice. 

From this experience, I have realised the  important for pts to be informed and educated about their condition by the right people so they can make decisions themselves and we can decrease the chance of legal repercussions back on us. 

Uncooperative Patients

I am currently on a general surgery ward and treating a patient who is very non compliant with physiotherapy. He was previously living with his wife and independent with all ADL’s but since his operation has been refusing to ambulate and has the idea in his head that when he gets home every thing will be back to normal and he will be able to do everything he used to do. When treating this patient he will usually consent to chest physio but will refuse to ambulate or even sit out of bed at times. This makes progressing him and preparing for discharge very difficult as he has been in hospital for about 3 weeks and is therefore very deconditioned. On a couple of occasions I have been able to convince him to ambulate but usually he will just become very agitated with me and refuse. When my supervisor has attempted to treat this patient he has received the same reaction. This has really frustrated me as no matter what strategy I use with this patient to convince him to ambulate he refuses as he is under the impression that everything will just fall into place when he gets home. I have now realised there is nothing I can do if the patient refuses to ambulate and all I can do is keep trying. I have also found this patient is more likely to be compliant if I see him when he is sitting out of bed rather than lying down and also if I plan with the nurses to attempt to ambulate him when he is about to have a shower. In the future I will attempt to treat this patient when he is out of bed but if he still refuses to ambulate there is nothing I can do except come back later and try again.

Infection Control

Whilst on my international placement in Borneo I had to get used to a very different hygiene and infection control standards in the hospital.
As I was working in a private hospital we had to charge the patients for every single thing that we used during their treatment session, including gloves or gauze. This often resulted in things being reused which really shouldn’t be reused, such as suction catheters. On more than one occasion I saw a member of the nursing staff suction a patient, rest the catheter on the bed, resuction and then put the catheter back into its wrapper so they don’t have to charge a patient next time they suction then.
This goes against absolutely everything we have been taught in uni and on prac. After speaking to the physios there, in particular the physios that were trained in Australia, I realized that they were all aware this happened but when medical care is so expensive and most of the patients struggle to pay for the basic treatment there is not much else they can do. It took a while to get used to but it is understandable why it does happen.

Non compliant patients

A patient of mine has recently been admitted to hospital for some investigations and a possible surgery pending the outcome of the investigations. She is quite elderly but was previously independently mobile and living in her own at home, with family members coming in 2x a day to help with cooking and some ADLs.

A few days ago I was aiming to do a mobility assessment on her because she was new to the ward and I needed to document her current mobility status. I checked her obs, bloods and medication before going in to see her and these indicated that everything was stable. So I went in and introduced myself to the patient, only to have her tell me that she felt sick and didn't want to move.

I explained that my job was to see how she was getting around and compromised with her that we didn't have to walk if she felt ill and we could just transfer to a chair. She adamantly refused but with some assistance from my supervisor we managed to coax her to sit over the edge of the bed. It took 2x max assist to get this patient to SOOB even though her status prior to admission was independent. I asked her to sit and hold herself up without me supporting her and she started to fall backwards even though she was clearly capable of sitting independently.

Everyday since then, I have had this patient verbally abusing me and refusing any form of simple ambulation or any transfers. However I found that if I liased with nurses and planned my treatment around showering and toileting times, I can "trick" the patient into transferring and mobilising a little because it is something she needs. It is not optimal but its the most I can get from her at the time being. From this I have learnt that trying to coax non-compliant patients into treatment can sometimes require less effort than I previously thought.

Supervisors

I am currently on my cardio placement and my Curtin supervisor was meant to come on Fridays, in the first week he couldn’t come on Friday so it was rescheduled and he was going to come Tuesday and Friday of the second week. Because of work commitments my Curtin supervisor wasn’t able to come twice in the second week so he is now only coming on Friday of the second week. I think this is a bit unfair since my mid placement assessment will be the first time my supervisor has seen me so it doesn’t give me a chance to work on any problems I may have. I decided to discuss my concerns with my facility supervisor and asked if he could go through a patient with me like a Curtin supervisor would so I would be more prepared when the Curtin supervisor comes. He agreed to do this with me and also suggested I speak to my Curtin supervisor when he comes about making up the time I missed in the third week.

fine nursing line

A while ago now I was on an orthopaedic placement managing mainly total knee/hip replacements. I was asked by a patient(TKR) wether they could rest a pillow under their knee whilst lying supine, I replied to the patient that in the interest of regaining a straight leg, no you can't, I apologised for the tough love and suggested they could actively flex to relieve pressure on posterior structures. Moments later I was in earshot of this patients room and heard a nurse tell the patient that I didn't know what I talking about and she lets all her patients do it and know one has had a problem.
I returned to the patients room, sat down and explained in greater depth the rehab progress and desired outcomes. Tried desperately to regain some rapport and explain that I knew something about TKR's. I tried to do this all without disrespecting the nurse. In the end I put the responsibility on the patient to get the best for themselves, with correct advice put the onus of rehab back on them. I found that this worked really well and was a pretty good motivator for the patients/

Large Patients

While on my musculoskeletal placement I was recently treating a very lage patient with lower back pain. As I am quite small I found some components of the objective assessment quite difficult particularly flexion and extension PPIVM’s. This made me think about what the appropriate thing to do was, should I still attempt to assess these PPIVM’s and risk injuring myself or was it appropriate to skip this part of the assessment to save my back. I thought I would rather not risk injuring my back to perform a full objective assessment on this patient and it would be better to simply modify my assessment. When I did this I was still able to find objective asterix signs and come up with a diagnosis and treatment plan. Later I spoke to my supervisor about it and she said it was appropriate to not perform some parts of the assessment if it was likely to risk my back and usually in these situations it is possible to modify the treatment and still receive the same results. In the future if I have a very large patient I will modify my treatment to protect my back rather than trying to perform all parts of the assessment and risk injuring myself.

dealing with anxious family members

I was treating a pt with GB, and we were doing passive movements for all joints as he could only pump his ankles and we were also there with the speech therapist during the decuffing of the trache for any chest treatment that needed to be done. This pts wife was around for most of the day and was very anxious for a lot of the time. This pt had a few complications and didn’t tolerate the decuffing process very well. When his wife was around during decuffing times and physio treatment times she would constantly try to get us to stop what we were doing as she felt her husband couldn’t handle it and that we were hurting him. We explained to her our reasons for doing what we were doing and the importance of it but she still kept on with the comments and it wasn’t only to us students it was also to the speech therapist and one of the ward physios. The pt knew that what we were doing was only to benefit him in the long run so although our passive movements may have been uncomfortable at times he wanted us to continue even when his wife was trying to get us to stop. The wife was hard to handle and only had bad things to say about the staff. On my second last day of the placement this pt developed a PE in his (R) lung and pneumothorax with possibly pneumonia in the (L) lung so he wasn’t doing too well. I was asked to go in to treat him to do some chest treatment and possibly some passive movements. I walked into the room and before I could even speak to the pt his wife told me to leave him today that he couldn’t handle physio today. I went to the pt and asked him what he’d like me to do, if he just wanted me to do passive movements for his legs or arms or just a chest treatment. He asked me to just do some passive movements for his hands and wrists and leave the rest as he was exhausted. So that’s what I did as well as some suctioning as required and some DBE’s.
From dealing with this pts wife I learnt to just sort of ignore her comments and just go with what the pt wanted and needed. We also tried to educate her as to why we were doing what we were doing but this didn’t seem to change her behaviour so we just had to get on with what we were doing while monitoring the pts symptoms and responses. As this pt was on a trache the whole time we were on our placement and therefore non-verbal it also really tuned me into watching for facial expressions to monitor how he was going and tolerating the movements.

Unmotivated patients

Each afternoon at my neuro prac, we take a small group of patients to the gym for a high level balance class. This involves a gym circuit with light weights, cardio and balance exercises. One of the patients attending suffered an anoxic brain injury but doesn't have any major deficits apart from some very mild (L) sided weakness and decreased high level balance. He doesn't attend regular physio apart from the high level balance class. I always have difficulty trying to encourage this patient to participate in classes as his motivation levels are very low, and when I ask him if he's had a busy day with appointments and is tired, his reply is always "I haven't done anything, I've been so slack". 

This makes treatment hard because he does have the right to refuse it, but when this occurs everyday it is frustrating because it looks like I'm letting him get out of exercise. Most of the time we eventually come to some sort of compromise like going for a walk just so we can get him out of bed but when we are trying to give patients optimal treatment to allow them to go home and function closer to their previous level, simply walking is not really doing our job properly. Does anyone have any suggestions for motivating these type of patients?

Patients not attending appointments

I am currently on my musculoskeletal placement and have been getting frustrated by the number of patients that don’t show up to their appointments without cancelling. It has been happening to everyone on this placement, every day there at least one student (usually several) have patients that don’t show up. I am finding it frustrating as it is a waste of our time waiting for a patient that doesn’t show up. Also because we only have a limited amount of time in each area it is best for us to see as many patients as possible. If these patients called and cancelled it would give us the opportunity to book someone else in that place. I have found the best way to reduce this frustration is to use the time when I would have been treating that patient to catch up on notes and doctors letters/ handover summaries. I also think that if I was working in a private practice it would be a good idea to send out reminder emails or calls to patients before their appointments, particularly if they have not been for a while.

tone trouble

I’ve had trouble progressing a pt I’ve been treating over the past 3/52’s on my neuro placement because due to other complications this pt had a number of days that he could not stand up and weight bear. His tone in his (L) leg has increased and his ankle joint has also stiffened up as his foot has been in a bad position for the majority of the day. Therefore despite our best efforts doing foot mobilisations pre-treatment we cannot get this pt to weight bear through a flat foot on the (L). He also has parkinsons disease and therefore also has trouble straightening up to get his COM over his BOS. As we were struggling to get weightbearing through the (L) foot when doing STS and struggling to get his weight forward we couldn’t progress to ambulation. We decided at the beginning of last week to try the standing frame as this would help him get his weight forward and hopefully the weight through the foot would break the tone and the heel would drop to the floor for even weightbearing (L) and (R). We tried this the first two days but as soon as he tried to weight bear the tone kicked in even more and his foot inverted and plantar flexed and there was clonus through his whole (L) leg and he cannot get his heel to the ground and as a result his weight was over to the (R). We then decided to take it back a step further and try the tilt table with the thinking that as its more passive the leg can relax easier and the foot would remain in a better position and get some weight through it to once again try break the tone. With doing two treatment sessions per day it has got easier and the foot is getting into a better position each time and the foot is feeling better during the mobilisations but soon after moving up into a weightbearing position the tone starts kicking in and the foot slowly starts moving into the inverted and plantarflexed position and we have yet to get his heel to touch the floor fully even though in sitting and supine when doing the mobilisations we can get the foot into a neutral position. It is a very frustrating thing to deal with both for us as physios as we aren’t able to progress the pt, as well as for the pt as he is trying so hard and doesn’t seem to be improving much. This situation has taught me that sometimes as other complications interfere with treatment and pts decline in functional ability as a result that we may have to go back to treatment techniques that the pt should have past a long time ago and start close to the beginning before moving forward and once again progressing towards pre-admission status. It’s also shown that many factors can result in the pts inability to STS effectively and these all have to be worked on individually at times before the pt is able to put it altogether and complete the functional task. It has also highlighted the importance that daily treatment has in the acute setting and how easily tone can increase if the pt is unable to get out of bed or his chair and weight bear for a few days.

Treatment effectiveness

A patient of mine (B.H.) was involved in a serious MVA and as a result suffered many orthopaedic fractures and a head injury, rending him unable to walk. As a result of his car accident and head injury, he has heterotrophic ossification (growth of bone in muscles and tendons) of his (R) hip and his (L) knee. This makes flexing his hip and knee very painful and difficult even after analgesia. 

Currently we are working on ROM of his LL's and strengthening of his UL's, LL's and trunk. Progress is very slow because of his H.O. and varying pain levels. Other joints such as his (L) hip are also affected and not getting to their full ROM because of the painful (L) knee being unable to flex. We do the same basic slideboard exercises for ROM of his LL's everyday due to B.H.'s high pain levels. I feel that he is not really benefitting from doing slideboard exercises because of the restriction in his joints that we can't treat with physio. 

I still encourage the slideboard exercises to be part of our treatment program to maintain the remaining ROM left even though it isn't improving it. This has taught me the importance of still taking into consideration problems that can't be treated via physio but instead looking from the point of view of preventing further complications which ultimately could make a difference in a patient's quality of life.

organisational skills

I’m with 3 other students at the moment on my placement and we all have 3-4 very dependent pt’s who are 2x assist. We have different pairs for different pts so during the day we either work with 2 or all 3 other students and we have to all see our pts twice a day. The pts are also busy going off for investigations or on nasogastric feeds or being seen by other allied staff. So organizing the day becomes a very hard task.
I’ve had days where its been hard to organize firstly what times the pairs are both able to treat the pts and then after we pre-organized a time for the pts to be ready in their w/c with the nursing staff, we got to the pt who has either gone off for another investigation or is still in bed or has other issues which effect our treatment. This has caused times where we’ve been stuck unable to see any of the pts for a period of time and its been hard to then try get something constructive done in that waiting time and also means the treatment time with the pts decreases. To counteract this I’ve had to do treatments with the pt in bed or if waiting for another student who is busy with someone else I’ve taken the pt to the gym and started on preparatory treatments such as foot mobilizations or other treatments which don’t require 2x assist. Sometimes these types of things can’t even be done so I’ve found myself at times with spare time trying to think of something productive to do. I’ve generally then gone to look up different things like CT’s or read up a bit more on the pts notes or looked at assessment procedures in more depth. Any other ideas to fill free time?

Chatty Patients

While on my musculoskeletal prac I am treating an 80 year old man with subacromial impingment. He is extremely chatty and it is difficult to perform the subjective and objective examination as he tends to start talking about irrelevant things and it is hard to get a word in. This frustrated me as I only had a limited time for the assessment and wanted to keep him on topic. I wasn’t sure how to interrupt him once he started telling a story and get him back on track without seeming really rude. In the end I realised the only way to keep the examination and treatment running in a time efficient manner was to interrupt him from what he was saying with a question about his condition or telling him to do what I wanted from him. As the session went on it became clear that he didn’t seem to be offended by me interrupting him and then while I was performing hands on treatment he had an opportunity to talk about other things. I realised it is important to not let patients change the topic and talk about irrelevant things when I am trying to perform an assessment as we only have a limited amount of time with them and in the end they are there to get physio treatment. It is quite a common problem that patients will just want to have a chat, particularly with older patients as they may not have much other contact with people but we have to remember that they are there to be treated and we need to keep them on track to allow the assessment and treatment to be completed efficiently.

Communication and head injuries

A patient of mine suffered a head injury recently. As a result, he has developed severe dyspraxia, and only as the ability to understand one stage commands. During treatment, it makes it hard to get him to understand concepts such as pelvic tilt and lateral tilt, correction of which involves commands which even a person of normal cognition can find difficult.  After many attempts at trying to simplify my instructions with not much success, I decided do a more hands-on and less talk approach, with telling the pt to "move with me" and not say much more than that other than giving cues such as "straighten up" and "grow long". I found that this approach worked a lot better than giving mainly verbal cues (even though I was trying to make my initial instructions a lot more concise). Therefore I found my treatment a lot more effective, and saved me the effort from talking more than I needed. 

Friends vs Patients

A long time friend whom i play football with came to see me at the beginning of the season complaining of shin pain (shin splints). Without hesitation I agreed to treat him.
Breifly, on assessment his left leg was worse than right, we had both significantly increased our training workload, most of which was running. He also over pronated on both feet.
I explained that i thought it was only shin splints at this stage and that if we address his compounding factors we could manage the issue. I also explained some red flags that he needs to be aware of and what could happen should he fail to manage the simple shin splints.
So i advised him to start wearing his orthotics again and strapped his feet for training and games also asked him to reduce his workload or switch to swimming to avoid running. His left leg responded well whilst his right actually deteriorated, I continually asked him how he was doing and he always responded i'm doing alright.
It wasn't till he had to come off half way through a game that he revealed he had been having significant pain with ambulation, hadn't reduced his training load and had pain at night. I immediatley sent him to our team physio who sent him straight to a sports doctor who had him scanned and diagnosed him with a stess fracture in his right tibia.
Well, I felt like an idiot because I was looking after him and his condition deteriorated. It sidelined him for 6 weeks and I felt really guilty. It was when he decided to play against doctors recommendations that i realised it wasn't my management it was just the way my freind was.
I have realised that dealing with freinds just isn't appropriate, they can't dissociate between freindship and professional relationship. Now i'll give advise but ultimately freinds should see an impartial professional for treatment and on going management.
anyone else expeiranced this with friends and family?

BP issues

I’m on my neuro placement at the moment and treating a pt that had a stroke about 5 weeks ago, his PMHx also includes parkinsons disease. This pt was doing really well for the first few weeks post stroke and managing to walk back to his room after the physio session with the assistance of the PT students there at that time. Over the past 2-3 weeks this pt’s BP has been up and down. At 8.30 in the morning it can be up to 190/100 and then an hour later 80/40 just when we want to start our PT session with him. On this placement we are expected to try see our pts twice a day, but more often than not recently this pt who is normally hypertensive has a BP around 80/40. I’m working with another PT student with this pt and a few times now we have taken this pt to the gym when his BP has looked good, done some foot mobilizations, checked his BP again just before standing or transferring to the plinth and it’s plummeted again and we have to get him straight to bed again. It’s quite a frustrating thing for the pt, his family and us pt students because he has now gone backwards with his rehab because he is not getting the gym sessions he needs.
Unfortunately there is nothing we can do about his BP, the Dr’s are trying to work it out. To deal with this issue we have had to do a lot more sessions in his room when his BP is not great but this often only includes some UL and LL exercises to maintain ROM and strength and foot mobilizations as his feet have a lot of tone and this is not an ideal situation. We have managed to get him to the gym almost once a day in the past 1.5 weeks but as it is not as frequent as we would like, he is not making the same gains as he was when first admitted. We do all we can for the pt and have to modify our treatments to suit their situation. When his BP is stable we do as much as we can in the gym to prepare him to try get him up into standing and with his added PMHx of parkinsons it adds more challenges, so as yet we have struggled to get him to stand with his COG over his BOS but we are hoping to have some good BP days so the gym sessions can start to progress from one to another

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How are you expected to treat patients in a country where the local language has no translation for the word "Physiotherapist" Their title literally means "Person who treats with movement".
Working in Phnom Penh, no body in the general population understood what a physiotherapist actually does. The only way people would attend our rehabilitation centre is if they were referred from a neighbouring hospital or if they heard via word of mouth from a patient of the centre. Subsequently the centre we worked at was under patronised, they provided FREE physiotherapy and there were not fully booked. At first it was hard to believe but the more i thought about it, the more it made perfect sense. It might sound far fetched but I believe that it correlates back to Australia.
I realised that as physiotherapists we have a responsibility to each other, to ensure people envisage physiotherapists as important and valuable members of the allied health team. APA and as individuals we will advertise the profession. However we must work hard not just to better ourselves but ensure we leave a positive impression on our patients so that they will talk about physiotherapist favourably in general discussion.

Education

Recently I completed a placement in Phnom Penh, Cambodia, my first contact with a completely different country and culture. I thought I had prepared myself for the placement, Three and a half years of studying and i thought i was more than qualified to treat and teach. I couldn't have been more wrong. to give some context Cambodia has been at war since the thirteen hundreds and the latest travesty was dealt by the hand of fellow Khmer, A political regime named the Khmer rouge murdered greater than a million people of the educated and intellectual Khmer population, essentially devastating their intellectual infrastructure across the board.

We started at our rehabilitation centre and I had trouble treating patients, the language barrier compounded by my ignorance served to hamstring my treatment sessions. I spoke to patients and facility staff assuming they had some level of knowledge of health. I mean we get taught basic health and anatomy at primary school, every Australian has a basic level of understanding about their body. It wasn't till i grasped the extent of devastation caused by the rouge that i could fully comprehend how illiterate the Khmer people are.
I quickly changed my approach and made my whole education a lot simpler. Sacrificing specific details and options to ensure that the essential information was delivered and understood. After this i found my rapport with patients improved and the staff we were working with understood what we were doing.
It guess my take home message is don't assume that every patient you treat will understand even the very basics and its important to identify this in order to be effective.

Retrospect

Sorry fellow bloggers but I will have to write my reports in retrospect because I have deferred my current placement. Also please excuse any small mistakes in spelling and gramma, I am typing one handed.
Thanks for the understanding.
Dave Kelly

Communication skills

I have been on my international prac for 1 week now and I have already learnt so much when it comes to communicating with people who speak very little, if any English. It is a private hospital and therefore only the wealthier people can afford to receive treatment there which means that most people speak some English however it is still so different. When I would normally babble on and give a patient a few instructions at once intermixed with a bit of conversation, ive now learnt that I just cant do this with some of these patients. Instructions and questioning often needs to be kept to the bare minimum and hand gestures have never been more helpful. It’s also forcing my facilitation to improve as this is often the easiest way to get a patient into a position without confusing them with too much English. This means that conversation to fill the silences can sometimes be difficult which is something I suppose I will just have to get use to with some people as all you can really do is smile or facial expressions to convey meaning or just rely on the tone of your voice to let them know if theyre doing it right or not. Its been really helpful in developing my non verbal communication skills and has also showed me that I often rely on talking too much to explains things and need to improve my neuro facilitation.

Language Barriers

I am currently on my musculoskeletal placement and was treating a patient who only spoke and understood limited English. He was an outpatient being treated for subacromial impingement. When he came to his appointments his wife was always with him to help with translating. At first I wasn’t sure if I should speak directly to him or if I should be speaking to his wife as she was the one that was translating to him and telling me his answers. However I also thought he could be offended if I was speaking more to his wife then him as he was my patient and therefore I was assessing and treating him. I decided it would be best to speak directly to him as he did understand and speak some English and if I needed anything his wife said to me clarified then I would speak more directly to her. When I used this strategy in my assessment and treatment of this patient he seemed to appreciate that I was talking to him rather then just about him to his wife. In the future with other patients with language barriers I will try to speak directly to them rather then talking about them through the translator as it is important that even though they may not be able to understand me fully they are still the patient and therefore should be spoken to directly.

Behavioural issues

I am currently treating a teenage patient who suffered a traumatic brain injury about 5 months ago. She was diagnosed with ADHD pre-morbidly and had a poor track record at school, with 25 suspensions in the 2 or so years she has been at high school. Many of these related to assault of other students in which the police have been involved.

Not surprisingly, if you add a brain injury on top of a history of ADHD, it makes patient compliance and successful treatment outcomes a challenge! She has regained normal 3 joint movement in all limbs, ambulates without any aids, and can run. Her high level balance and trunk stability remain a problem. I try to make our treatment sessions as functional and fun as I can, involving kicking and catching balls as well as using a variety of tasks, although I find it hard to stay enthusiastic about treating this patient as she can be verbally abusive and very difficult to manage. Has anyone else experienced a patient like this?

Family physio

I am currently on my international placement in the neuro ward of a private hospital in Malaysia. Treatment here is very different to in Australia because it is expected that the family take care of the patient as soon as they are medically stable. This means that pts are discharged from hospital straight away even though they have not had any physio and are still acute. After they are discharged the family will look after them and hopefully bring them back for outpt raheb. If the family decides not to come back for physio then the pt receives no treatment. Before discharge the physios are expected to teach the family the best way to transfer the pt and do as much physio as they can fit in, in the few wks the pts are in hospital. However teaching family that have no idea about correct manual handling or any physio techniques often takes up a lot of time and results in the patient having less actual treatment time. Having the pts at home also means that often the physios spend most of the treatment time undoing all the bad habits the pt has developed whilst at home. This normally includes poor posture and inparticular a very poor gait pattern and compensatory techniques, as family members often try to walk the pt before the are even close to being ready.
This has shown me how different the culture is here and how lucky we are that in Australia it is expected that we stay in hospital until we are able to be discharged from the multi- disciplinary team.

Child vs Family

My supervisor and I were discussing about one of our paediatric clients who was bed-ridden, severely contracted and cachexic due to her congenital degenerative condition. As a PT, we do our best to provide the best services for our clients. We act prophylactically to prevent deterioration of the musculoskeletal system eg contractures, scoliosis, deformities etc. We provide advice to the parents and explain the best options for their child. We provide referral to orthotics, orthopaedics, OT etc to ensure their best comfort.

During the discussion, my supervisor said she’d given all the options, and had done all she could within the limits of her profession and duty of care for the best of the client. Nonetheless, the parents chose not to have any wheelchair adjustments, not to take the child to school, and not to have any surgery done on their child. Their rationale was that their child is not going to live very long, so there was no reason for her to go through the ordeal of having a surgery or getting expensive equipment. Despite that, they would do stretches and passive movements regularly, and ensure their child receive love and care from them.

That made me realise that what I (from a physiotherapist point of view) think is best for the child, may not necessarily be so. It is about what the family desires, and what the family thinks is best since they are the child’s primary care-givers. It is vital that I take into consideration the family’s needs and concerns, and be able to adjust my intervention and goals accordingly in order to obtain their trust and co-operation. After all, it is a family-centred practice.

KISS

keep it simple stupid.
i found myself trying to address too many impairments in one session with my patients at a neuro outpatient clinic. Trunk work, reaching, muscle length, gait, balance, HEP...that was a common treatment plan for one of my sessions. To me, it sounds great if i could help the patient with all of those things, but the fact is i cant. the choice is, do 10things poorly or 1-2 things really well. My supervisor mentioned to me that one of the really experienced PT's will work on a shoulder for a whole session. THis got me thinking and i decided i would do the same thing. just work on the one area and give it a full sessions worth of attention. It worked really well, i was able to see things i couldnt see before in my observations and i had more ideas about treatment. I cant speak for other areas, however I think in the outpatient setting and with the appropriate patients it is important to reduce the complexity of ones treatment and treat a few things really well.

learning more stuff...

At an outpatient clinic i saw an older gentleman who had suffered a stroke. He had recovered really well, his major impairment was reduced with fine motor control in his right hand. I had big plans for his rehab, high level balance exercises, improving the fine control of his hand and UL etc. but he discharged himself from physiotherapy before he had started the exercises. I had to realise that the functional level that he leaves the clinic with will always be what he thinks he needs and not what i think he needs. I was thinking i could get him walking regularly and getting out of the house to play golf etc. but this was not realistic as he was content with where he was at functionally.

This was a good lesson for me to learn. I need to remember in the future that its not ok to impose your own expectations on a patients rehab, always focus on what the patient wants. However i still believe it is important for PT's to suggest lifestyle modifications where necessary, just not make them strive for something they feel they dont need.