depressed pt

I am currently doing my cardiopulmonary placement on the general surgery ward, where most of my patients have undergone some type of upper or lower abdominal surgery
One patient that I was treating had been diagnosed with terminal cancer a few months ago and he was admitted for surgery to try and remove the cancer. Once he was transferred to my ward he was convinced that he was going to die during his stay in hospital. The first day that I saw him was day 1 post- op and he was very pessimistic. When I was checking his wound we found that it was weeping and needed to be redressed. His response to this was to swear at himself and the kept repeating ‘I’m going to die’. I tried to reassure him but he was so sure that he was going to die in the next week. When I took him for a work the insertion of his IV started bleeding. Although only one drop of blood came out from the bandaging the pt again began swearing and repeatedly saying that he was going to die. Again I tried to reassure him by telling him that he wasn’t dying and that it was only one drop of blood but then I remembered that he had terminal cancer and was likely to die in the next few months. After that I had no idea what to say to him because I didn’t want to keep telling him that he wasn’t going to die but what else could I have said in that situation? It was only one drop of blood so the pt was clearly upset about his diagnosis and because of that was making a big deal out of a small bleed that was not going to make him die. Does anyone have any suggestions about what to say/ do in this situation because it caught me by surprise and I had no idea what to say.

To tell or not to tell?

I am currently on the general surgery ward doing my cardiopulmonary placement. Most of the patients I treat have undergone abdominal surgery for resections of internal organs from cancer.

A patient under my care had undergone what was planned to be a liver resection due to metastases from their colonic cancer. Upon reading his notes it was found that the operation was abandoned due to multiple metastases which would have caused more damage on removal; the end result being an open- close surgery.

I found myself in a sticky situation on the initial assessment. The topic of his operation was brought up and he was asking me what had happened and why they didn’t take anything out. Being put on the spot I wasn’t quite sure what to say. So I explained to him that it was an open close surgery and to ask the medical team for further details. By this time I was sweating and panting, trying to avoid the topic and any further questions of prognosis and what they found during the surgery. The reason I was so uncomfortable broaching the subject was because I was on unfamiliar ground.

Having a patient rely on you for very important information concerning their health and future was something that I wasn’t very comfortable with. Even so, is it my place to even disclose this information?

So it brings me to question the limitations we have as a physiotherapist. As much we study three years on the conditions we treat the scope of our practice is limited. How much are we allowed to disclose to the patient their medical prognosis? How much are we allowed to tell our patients about their condition and its course? Or is this out of the question and it should be left in the hands of the medical team?

As physiotherapists develop a rapport with our patients that enables us to give them confidence to regain their mobility and to keep positive about their post operative condition. In doing so a trust relationship is developed, they trust that you know what you are doing and what you are talking about. Would be wrong then to deny them of information they seek on their long term prognosis when you know the answer? More so is it appropriate for us to tell them? Of course the right thing to do is leave it up to medical professionals. I would just like to share how difficult it is to face a situation where you are caught on the spot. Where a patient you get along with quite well asks you questions you know the answer to but they aren’t answers the patient would be happy with.

Falls risk

I’m on an ortho inpatient ward at the moment and we had a pt the other day who has had multiple falls in the past month and has fallen a number of times over the year. The pt does not think they are a falls risk because this is the only time they have actually had any injury from falling. The pt was angry with themselves for putting their arm out to try stop the fall and consequently fracturing their wrist (on their dominant UL) than actually seeing the problem in falling. The pt furniture surfs inside their house and only uses their w/s outdoors (which they hold in their dominant hand). The pt was told that they could go home in the afternoon by medical staff as their surgical procedure had gone well but this was before they had had any PT intervention. As you all know we have to say whether or not the pt is safe for discharge from our perspective, whether or not they can ambulate safely and will not be at risk of falling once they return home. From the S/E we established the frequency of the pts falls which were all happening while at home and from what the pt recalls were all falling backwards losing their balance (the pt has limited neck extension due to other PMHx). The pt was not keen to use their w/s in their non-dominant hand but as we wanted to see how they would cope outside of the hospital we needed to see that they could. Our plan was to walk down the corridor with the pt to see how they managed. After a few steps we noticed the pt was not using their w/s correctly and it was definitely too big for them but could not be adjusted, so our supervisor got another w/s for the pt, and one of us stood with the pt while the third person taught the pt the correct technique. With the new stick and technique the pt struggled walking 10m having 2x close SB A and stumbling at least 5times. As the pt’s expectations were that they would return home that afternoon the pt got really upset and was in tears when we told the pt that from our perspective they were not safe and we were going to let the medical team know they were unsafe for discharge and we wanted to refer the pt to a falls clinic and get geri-ortho to r/v the pt.
The pt was crying and trying to state their case that they manage fine at home and will not fall, despite us trying to rationalize the problem with them. Our supervisor was the one giving the bad news but it still made me feel a bit awkward having the pt so upset and I was not looking forward to going to see the pt the following day as we were the ones preventing the pt from going home. It was a situation that could have been avoided if the pt’s expectations where not that they would definitely be going home that day and if it had been explained to the pt by the medical team that she had to be deemed safe ambulating independently by the PT before being discharged.
This situation shows how pt expectations can be falsely raised if all health professionals dealing with the pt don’t take into account all areas that need to be considered before letting the pt know that they are safe to be discharged from hospital. It also shows how important it is to assess the pt’s ambulation before discharge, as the pt could have gone home and had a bad fall if not assessed by PT before discharged.
It was not a nice situation to be in (having the pt crying) but it was a good learning experience which I was happy to have seen dealt with by my supervisor so if I’m ever faced with the same situation again I’ll be prepared and know how to explain what our aims are and why we do not want the pt to return home, instead of just feeling awkward and not knowing how to respond. It was also a situation which reinforced the need to really monitor the pt well when assessing their ambulation and despite their great desire to return home you have to do what is safe and in their best interests even though they may not agree with you.

Suctioning in ICU

In ICU, suctioning and manual hyperinflation is used alot by nursing staff and physiotherapists. On the second day of prac I was one of four PT students being shown the procedure for suctioning and MHI. The patient was intubated and fairly agitated and the smell bedside was putrid. The supervisor proceeded to suction the patient. The patient violently coughed and made a sickening noise.

I felt nauseous and light headed. I just stood there telling myself that I would be ok because I had never felt sick before on prac.

Following this we had the opportunity to try suctioning with the supervisors support. I didn’t put my hand up because I didn’t feel confident in my ability to suction without fainting or vomiting. Because I didn’t put my hand up I didn’t have to suction that patient. After this I spoke to the other PT students about what had happened. It was comforting to know that their experiences were similar. The reassurance gave me confidence in my own ability to suction.

This was a fairly confronting situation for a PT student new to the area. It showed me that I shouldn’t have expectations on myself that are unreasonable for a new situation. It also demonstrated the value of discussing personal experiences with fellow PT students.

The following day the supervisor asked me to suction a patient. At first I was a bit anxious, but as soon as I started to follow her instructions I was fine (there are so many things to monitor, I soon forgot about how I was feeling). From that point forward I wasn’t nauseous suctioning a patient.

I hope this reassures anyone who has been in a similar situation.



I have completed 3 pracs for Sem 1. So all my posts will be about situations from earlier this year : )

Objective Ax on a Highly Irritable Patient

It was my first outpatient women’s physio session with a lady in the third-trimester of her pregnancy. She presented with acute, sudden onset unilateral low back pain. With detailed subjective and objective assessments, I concluded (with the guidance of my supervising physio) that the pain was due to an acute muscle spasm of the Quadratus Lumborum and Piriformis, with an underlying (R) lateral shift of L3/4. Due to the problem being highly irritable and the muscle spasm being 7/10 pain and tender on palpation (TOP), I decided to give soft tissue massage (STM) on these muscles (5 mins each) in sidelying, hoping that treatment could be more effective as the muscles settle.

During the treatment, frequent questioning of symptom response was performed. The patient felt the muscles have eased slightly as I was giving STM. After the massage, I requested for the patient to stand up for reassessment. To the surprise of both my supervisor and me, the pain levels have increased to the point where she was limping.

As the pain was so severe, I was hesitant to provide any further treatment for fear that it could get worse. However, it was also not appropriate to send her home while she was limping. As I recalled in my subjective assessment, the patient said that heat (hot shower/ hot pack) eases the pain. Immediately, I told her to lie back down and placed a hot pack over the muscle belly. Again, symptom response and erythema was checked every 5 minutes. After 20 minutes, the patient got up and the pain did not subside. She was still limping. I did not know what else to do.

After consulting the supervisor, we decided to rent out a walking frame for support in ambulation until the muscle spasm settles. In addition, I gave her advice to avoid ambulating and to rest until pain subsides.

As I reflect on the situation, I realized that my detailed objective assessment could have aggravated her symptom and the massage could have further worsened the situation. Being a novice practitioner/ an inexperienced student, it was difficult to know how far to go in the objective assessment in a highly irritable patient, as it has to be sufficient to determine the problem, yet be specific enough so that only the essential components are assessed. In the future, I would ensure to identify and discuss with my supervisor the most essential components prior to performing the objective assessment. This is so that the main problem could be identified with the unnecessary components avoided.

Discharge Plan

While on my gerentology placement I am treating an 80 year old man who underwent an AAA repair 8 weeks ago, he has an extensive PMH including COPD. At the moment his main problems are he becomes very SOB on exertion and has a decreased exercise tolerance and deconditioning due to his extended stay in hospital. He lives alone in a one storey house and has a very supportive daughter who helps with his shopping and anything else he needs. During one of my treatment sessions with him he became very upset and teary when talking about being stuck in hospital as he just wanted to go home and thought he would have to stay in hospital forever. When I saw how upset he was getting I realised he must not have been made aware of what the plan for him was as I knew the goal was to discharge him home. Before he could go home however he needed to be weaned off oxygen and improve his exercise tolerance.
I realised it was important for me to be very clear with my patients about what the expected outcome for them was. After he became upset I explained clearly to the patient that the reason he was still in hospital was because of his deconditioning and SOB and that’s why it was important for him to comply with physiotherapy to allow him to return home as soon as possible. Once he understood that he would not have to remain in hospital forever and the goal was to get him back to his home he was much happier. I now know how important it is that the patients understand fully what the plan is for their treatment and expected outcome is to give them hope and also improve compliance with their therapy. Also this situation has taught me not to assume the medial team will explain the expected outcome to the patient or they may misunderstand what they have been told so it is important for physios to clarify with the patient their expected outcome and plans for treatment.

AKA

I was doing my paediatrics placement and I had a patient with tumour in the proximal tibia. She is unable to weight bear of on the affected leg. The medical plan with her is to trial chemotherapy for 6 weeks and then if there is no success, an AKA. Things I have been doing with her is maintanence exercises and also encourage ambulation with her elbow crutches while she is undergoing chemotherapy. I have developed a very good rapport with her and her family during her stay in the hospital. Towards the end of my placement (4th week), she had done 2 rounds of chemo (in 2 weeks) and there was no improvement shown in the MRI scan, so the medical team decided to go bring forward the amputation scheduled to be at my final week of placement. The patient and the family too had agreed with it saying that she will be more functional without her current leg. Patient was allowed to go home for the week and is to be admitted the day prior to the surgery. However, when she attended outpatient clinic for review two days before her surgery, her parents approached me and said, they are planning to not go ahead with the surgery and asked me what do i think? Her family believed that the next round of chemo will be a miracle and her limb will be saved. However from my point of view, the tumour is malignant and its huge (visibly and radiographically) and it is better of to be amputated as she will be able to function better with a prosthetic. Patient and her family had disagreements with medical team and asked me what do I think. I was put in a situation in which I don't really know what to say. And all I said was "it is the medical teams decision'. I didn't tell them what i really think (which is to amputate), maybe i should have? I approached my supervisor later and she said, saying that its the medical teams decision was the right thing to do. What do you all think about this? Should i have just said, go ahead with the amputation as what is planned by the medical team? or should i not say what i think and be neutral?

My PTB

Low activity day at my last placement on a general surgery ward.
An intern calls for support with a patient, myself and ward physio enter the room to find the patients brother(ptb) had fallen in the patients(pt) toilet.
(For ease of description patient = pt /// patients brother = ptb).

Arrived to find ptb 4pt kneel in bathroom and can't independently t/f to standing.
pt was RIB, pt daughter and ptb wife present.
Myself and the ward physio assisted ptb from 4pt to stand. (2x assist)
o/e (ptb):
Cognitively Intact
Nil Pain
Independent with all ADLS lives with wife.
Hx of frequent falls - Tries to pick things up from the floor and can't stand back up.
Ptb was not confident to walk to his car.

PROBLEM: I wasn't not happy for ptb to drive home.

d/w intern about the ptb driving home, The intern was not happy to remove ptb's licence, I agreed with him, but perhaps we could persuade them to find an alternative way home.
I was offered no support from intern, ptb's wife, pt or pt daughter on the matter.
Instead I was asked to push ptb in a wheel chair to his car and 1x assist transfer from w/c to drivers seat.

I felt really powerless in this situation but worse than that I went against my own judgement, ptb could have killed someone when he drove home that afternoon and I would have just been a spineless physio student who didn't put his foot down. (luckily he didn't kill anyone)

One positive is that you guys can learn from my mistake and stand up for yourselves.