Physio benefits vs therapeutic benefits

During my neuro placement i was assigned a pt who presented with Parkinsons but was diagnosed with a palsy that actually presented like PD. My pts PMH included lumbar spinal stenosis resulting in chronic LBP, a THR that had become fixated in external rotation and hip flexion, rheumatoid arthritis and heart issues. My treatment plan was developed in view of their PD, so treatment options to treat rigidity as well as assist with the bradykinesia and akinesia.
On applying this treatment plan i was met with a staunch refusal by my pt to participate in any activity that would aggravate their LBP. This contraindicated all my treatment options for their impairment of rigidity.
I attempted to retrain sit to stand, half way through encouraging leaning forward my pt stopped du eto the aggravation of pain in her LB.
In the end I decided to apply stretches for my pts LL joints in supine. Again this was short lived as it triggered their rheumatism.
My last resort was a gentle soft tissue mobilisation for my pts feet and calves to loosen it before mobilising. It was moderately successful with the only condition I do not touch the balls of their foot as that triggers their LBP.
My pt was very emotional about their limitations and became frustrated for not being able to be more mobile and 'treatable'.
What I learnt is that as much as we are in a position to help a pt to recovery from their illness sometimes even that is limited. Instead what we can offer is remedial support and ensure they are comfortable. I spent time to gently mobilise and massage my pts feet not just for a physio treatment but also as a therapeutic means to soothe my pt and make them more comfortable. I hope that others may see that when your physio treatment falls to bits we can still offer other options for the sake of pt comfort.

patients that you know

I was on an inpatient gerontology placement in a perth hospital. I was asked to go see a patient who had a chronic pain problem resulting in mobility issues. It is really weird how it came up…something about wine and Italian food…but this patient turned out to be a ‘distant relative’ of mine (by marriage not blood).

The supervisor asked me if I would be comfortable treating this patient. I decided that it would be ok because at the time I could see any reason not to treat her.

As I started treating this patient I realised that I felt a personal responsibility to get her better. Unfortunately, her problem was chronic, so my want to get this patient better was unreasonable but hard to get rid of. To make this situation worse, I wasn’t sure if she understood that I couldn’t get her better, but just get her home. This was a stressful situation for me.

From this experience I realised that treating family members is different because of the personal responsibility one feels to the patient. I felt this way even though this patient was a ‘distant relative’ not by blood. If faced with this situation again I would get someone else to treat this patient. In general I feel that the decision to treat people who are associated with family should be thought about very carefully. I feel that in some cases it would be ok to treat, but for me I don’t think I would feel comfortable treating another ‘distant relative’ with chronic pain.

TKR

I was lucky enough to watch a total knee replacement.
Very good opportunity and i would push for anybody that has the opportunity should go watch the surgery.
It gives you so much more understanding as why the patient will be sore post operatively and also what degenerate bone actually looks like.
I learn't so much and could offer my patients so much more infomation when they asked questions.

Hospital Vs Private.

On all placements I have been asked what field I would like to work in when I graduate and I answer honestly that i'm not 100% sure but more than likely sports private practise.
I find it hilarious how a number of hospital physios consider their work of more importance and more dignified than their private practice colleages.
I have found it very hard to deal with supervisers thinking that i'm some money hungry bloke who doesn't care for patients.
If I were to offer advise from my personal experiance it would be to remain vague when describing your future ambitions especially if its to work private practise.

Delirious pt

I was given a pt that was admitted with a query fractured femur post fall, after multiple tests it was cleared that they only had a fracture in their hip bone that was to be conservatively managed.

The pt required a companion all day as they were very confused, their past medical history being that of dementia, anxiety and depression. My pt required strapping to the bed during the 3 days tests were performed to determine the cause of the pain. This was the extent of their confusion, the pt could be heard screaming and yelling at nursing staff due to this delirium. On finally getting the go ahead by the orthos for conservative mx my supervisor and I went into try and start ambulating the pt.

The pt was lying in bed on arrival, despite seeming asleep the pt was fully aware of our presence and replied to all our questions. The pt refused to get up at all. Calling us names and telling us to "get out and leave them alone" The nursing staff suggested that even if we arent able to get them up then we could at least assist by rolling her to insert a suppository. Despite a huge protest from the pt the roll ended up into a SOEOB. The pt continued to protest even in this position, repeatedly telling us to "get out" "leave them alone" passing ractist comments (as both my supervisor and I happened to be asian) such as "dont you understand english, read my lions- go outside" "mind your own business". As we were unable to leave them SOEOB without supervision we attempted to return them to bed but again met with protests such as the above. At this the pt raised the hand to strike us and raised their voice to match it. I couldn't get out of the way as I was supporting them in sitting. Even though the pt did not strike either of us it gave us both a fright to be met with such hostility. We tried negotiations asking if we leave would they lie back into bed. every thing was refused. The nurse then realised that the p.m. meds werent administered which may have caused the confusion. This did not help as the pt refused to take the meds. After a long time debating what to do we came to the decision to leave the pt SOEOB (as they had good sitting balance) and wait it out.

No more than 5 minutes had passed after we had walked out the door than the nurse came into assist her to walk the pt to the toilet.

So despite the good ending it was a difficult situation for myself as a student to decide what is the morally as well as safe thing to do. Despite our essentially good intentions pts with delirium are difficult to treat due to their confusion and swinging moods. It is equally dangerous as well as disheartening to be refused and attacked for trying to help. Its an experience that most of us will go through, strategies to cope are not based on theory but rather the pt type and experimentation. I find that the nursing staff are a huge help in this situation and that leaving textbook theory on the bookshelf helps as well.

Hope this helps others, you arent the only one!

Why cant we just get along?

I'm sure we've all had a variety of supervisors with a variety of teaching styles. Some are intense all the time and some are more laid back. Obviously, regardless of what the supervisor is like we've got to get along with them.

I dont think we should assume that a supervisor will adjust to our personal character. From wat i have seen from my pracs so far is how important it is for us to adjust to different supervisors.

Naturally some of us are more laid back. To certain supervisors this may come across as unprofessional or not interested, whereas it may suit another supervisor. On the other hand intense, highly motivated students may struggle to connect with laid back supervisors but may be admired by other supervisors for their initiative and dedication to learning.

In summary, i feel it is important for us to be aware of how we are percieved by our supervisors and that we have the ability to modulate our character to suit their supervision style. Personally i make sure that in the first week of prac i try to make a good impression and make a start on trying to understand their expectations of students.

Being tough

A pt I had had to wait for swelling to decrease before being operated on which was a number of days and during her wait she was ambulating independently with a WF NWB on the injured leg. After the surgery once she was allowed to start mobilizing we had to try get her onto using AC’s as she had a number of stairs to negotiate to get into her house. The first day I got her to use the AC’s she was a bit unsteady and so I told her to continue to use the WF within the room and around the ward unless she had someone to stand-by assist. The next day I had my CCT with me and I had read in the nursing notes that she had been amb to and from the toilet with the AC’s, so I explained to my CCT what I had told her the previous day and then what I had read in the notes that morning. My CCT asked me what I would say to the pt if it was true that she had been amb with the AC’s without any SB A. I knew I had to make a point to her that the reason I had told her to use the WF independently was for her own safety and what she had done was wrong, but I wasn’t quite sure how to make this point and I felt like it would seem a bit condescending being a student half the age of the pt reprimanding her for what she had done. When I went in to see the pt I made my point and she understood the reasoning and said the reason she had gone against my orders was because she wanted to improve her performance with the AC’s so she could go home sooner. During the Rx session she was still unsafe with her stand to sit transfer despite my constant reminders of the procedure needed to sit down safely. When giving me feedback after the Rx session my CCT told me I should have come down harder on the pt.

Although I feel uncomfortable being tough on pts when they don’t follow commands I know I’ve just got to learn to do it as its for the good of the pt. If I explain to the pt that it’s a safety concern and extremely important that they follow the instructions that I give them they should understand. I know its something that I really need to practice and work on but as I continue to gain experience through the year I’m sure my apprehension that I’ll offend the pt will lessen and hopefully eventually disappear.

Walking Aids

Currently I am on my gerontology prac and treating a lady with parkinsons who was admitted to the ward from a nursing home due to reduced mobility and frequent falls. She came to the ward with a four wheeled walker (4WW) which she has been using at the nursing home. Her gait pattern is very shuffling steps, forward lean posture and pushes the 4WW a long way in front so it is easy to see when observing her ambulate why she has been having frequent falls. She responds very well to verbal cues while ambulating telling her to take long steps and counting 1,2 but she requires continuous verbal cues. Despite writing in her notes and on her mobility chart she needs verbal cuing when ever i saw her ambulating with another staff member she reverted to her poor gait pattern and they were not using these cues. I realised it was unrealistic to expect the other staff members to use the cuing when she was ambulating with them so i decided to give her a wheeled zimmer frame (WZF) instead of the 4WW. I thought this would prevent the frame from being so far in front of her and therefore hopefully help prevent falls. I gave her the WZF and had a practice with it and she seemed to be able to control the WZF much easier and prevent it from getting so far in front of her. After i saw how much safer she was ambulating with the WZF i wrote on her mobility chart and in her notes that she should ambulate with the WZF instead of the 4WW, told her this and put her 4WW in a corner in her room as i couldn’t remove it as it belonged to her. Despite this whenever i saw her ambulating around she was using the 4WW. I realised that it wasn’t enough to just write in the notes as the other staff members would see the 4WW in her room and get her to use that possibly because they do not have the knowledge that we do about different types of walking aids. I decided to fold the 4WW up and put it somewhere out of site so the only option of walking aid in her room was the WZF. In the future i will realise that just because i write something in someone’s notes does not mean it will be read or taken notice of so sometimes we need to take other steps to ensure something happens.

Time Management

The schedule of my current placement (Women’s health) is such that we go to the maternity ward in the mornings, and have outpatients in the afternoons. During busy days in the maternity ward, it is essential to prioritise patients to be seen based on the order of urgency.
On one particular morning, there were more than 4 patients that needed to be seen. After seeing my first patient, I realised there was limited time to see the other patients. As I had an outpatient appointment just after lunch, I ended up rushing through the next few patients. By the time I had finished writing all the patients’ notes, lunch time was over and I had to rush back for the next appointment.
From this experience, I realised that had I planned my time carefully such that each patient had an allocated period, there wouldn’t have been a need to rush. Things done in a rush meant that some important information or treatment component could have been missed.
With sufficient planning, I could ensure that the absolute essential component of treatment and education are covered within the amount of time given so that no time is wasted on unnecessary tasks. Next time, I will ensure to plan my time adequately for each patient prior to seeing them.

giving up

This blog reflects on my placement in a gen surg ward (cardio). I was given an 88 yr old female, post hemicolectomy patient to treat. She is independent with her ADLs and lives at home alone. On day 1 post op, she was alert and willing to participate with physio, treatment on that day was ambulation, SMI and education about the benefits of SOOB. She was very cooperative with us. On Ax, she has moist cough and some inspiratory crackles and wheeze. The next day, she refused and said to us, she knows the benefits of ambulation but unwilling to participate saying that she's unwell. We tried convincing her but in the end stopped trying. Over the next few days she continued to refuse ambulation but is willing to do breathing exercises, I tried getting another student to get involved but we all came to the same outcome. My supervisor then decided to approach the patient herself, and the patient ended up behaving rudely and not wanting to participate. We explained to her that she is at risk of getting lung infections and she said, ' I know, Let that take me'. I was shocked with that statement, and all I could say was, 'It's not good to think that way'. She continued saying that to me and also to her family. She was independent prior to surgery and has no other medical conditions and to see her giving up just like that it's just something really hard for me to digest. Her stay in the hospital was a long 3 weeks and my treatment with her in that duration was getting her to SOOB for most of the days, nebulise, deep breathing exercises and chest physio to clear secretions. Patiend ended up passing away after 3 weeks post op.
How do you deal with patients who are willingly giving up on life?. I couldn't reply to all of her 'giving up' statements as I don't know what to say to her, all I could say that 'I have to do my job'. The way she delivers all of her statement was in good spirit, she was a cheeky and lovely patient. We did joke a few times saying 'what if He doesn't want you?'. Reflecting on this experience, I don't think my approach will be any different in the future.
What will your approach be for these patients?

Terminally ill pt

One of the pts on my ward had recently been diagnosed with terminal cancer and the doctors had only given him a few weeks to live. He had just had palliative surgery and it was my job to get him up the day after his surgery. When i went in to see him and explain to him what we were going to do today the pt became quite aggitated and refused to get out of bed. When i went back the next day he refused again. As he was not refusing due to pain/ nausea/ dizziness etc my supervisor told me that he had to get out of bed today and that i should explain to him in some detail why it was important to get up after surgery. So i went back in and explained to him all the benfits of physio and ambulation post op. After i had explained this, the pt became even more aggitated and began swearing at me saying that i was pushing him too much and that i should leave him alone. On day 3 post op the pt finally agreed to come for a walk. He was able to ambulate independently and became aggitated when i initially tried to guard him. Whilst walking i questioned him on how he was feeling he again became quite aggressive and replied with 'why are you asking me that. Its a stupid question'
In this situation, where a pt has only been given a few weeks to live is there any point in pushing treatment on them like this? I was told by my supervisor to make sure that i treated him and i understand the benefits of post op physio but in hindsight i think it may be better to let the pt enjoy their life doing things that they want to do and not being pressured into things.

rambleramble

One of my first new patients on a musculoskeletal prac was a 60ish year old lady with OA. I asked the usual initial questions and gave her an opportunity to speak without interruption. She spoke for a good couple of minutes about her condition however she didn’t give me specifics that I required for the assessment form. I then asked her more specific questions about her the problems she was having. Even with closed questions I was finding it difficult to control how much the she was talking. This continued for the whole subjective exam and resulted in me having much less time for the objective exam and treatment.

I felt like I would come across as rude if I interrupted her and asked a different question. However, I think it comes down to how you interrupt the patient and redirect their thoughts. I would feel comfortable for a therapist to interrupt me if they showed me that they were listening and were interested in what I had to say. Maybe I didn’t interrupt her because I didn’t know what words to say to get this across?

Following this experience I did make an effort to try and interrupt patients if they were rambling. I’m still not very good at doing it, but I found that seeing patients was more rewarding when I was able to be more efficient with the subjective exam and give more time to treatment.

Does anyone have any techniques they like to use on patients that like to talk?

patients with Alzheimer's

I have had to treat a number of pts with Alzheimer’s which can be quite challenging at times, especially if you are trying to do a subjective examination with them. When I’ve asked some of them if they are in any pain they have told me about a chronic pain issue rather than what they are in hospital for and they aren’t actually aware that they have the injury that has bought them into hospital. When I went to see a pt last week, I had read her notes and noticed in the admission form that she was from a low care hostel. When I started asking about social history, she told me that she lived with her parents in a 3 storey house and had 6 children. I asked her a few other questions but knew I was going to have to call the hostel to get the relevant information I needed. When I was about to start my objective examination the patients daughter came in, so I took the opportunity to ask her the questions I needed answering, and I found out that the pt was actually a high care pt in a low care facility due to lack of places in high care facilities and the pts mobility had recently deteriorated as she had been hospitalized after a fall for 3 weeks a couple of weeks beforehand. The daughter gave me a very good social history about the pt as she was a nurse herself. I also phoned the hostel just to confirm what exactly the pt’s mobility was and the assistance level the pt needed as my supervisor said the daughter may have been a bit biased in her evaluation of the pts mobility and assistance needed.
So when going to see pts who have dementia I’ve tried to gather how orientated they are to time, person and place and then I’ve continued on with the S/E as with all other pts and if it is a first Rx session I’ve sought clarification from the facility at which the pt lives with regards to mobility, falls etc. When asking about things such as pain, cough, dizziness, nausea and other symptoms I’ve taken the pts word for what they say but known that it may not be entirely accurate and then relied more on watching for symptoms, reading body language and continually asking about symptoms throughout the treatment session. I had my gerontology placement at a low and a high care facility so I was lucky enough to get insight into how the facilities run and what sought of residents are at the different care levels. This has helped me in my understanding of what the pt’s I’m now seeing on my placement have to be able to do from day to day and the level of assistance they are usually given and I feel confident and comfortable treating pts with dementia.

Ward Rounds

While on my gerontology placement in a rehab ward I am treating an 88 year old lady who lives alone and was admitted due to reduced mobility and increasing falls. She has been on the ward for several weeks and her mobility has improved and she has not had any falls. When I went to treat her one day she was very excited to tell me she was going home that day and she had packed all her things up. I was slightly surprised to hear this as I knew the plan was to discharge her but I thought it wasn’t until a week later as usually they do a home visit with the discharge nurse, OT and sometimes a physio before discharge when they are going home alone. When I asked her who had told her she was going home that day she stated that on the doctors ward round she heard someone say “I don’t see why she couldn’t go home today”. Once she told me this I realized she probably wouldn’t be going that day she had just taken the comment literally. I wasn’t sure what to say to her as she was so excited about going and I wasn’t completely sure what would be happening with her discharge. I told her that I hadn’t heard anything about her going home that day and I wasn’t too sure what would be happening with her discharge and that the discharge nurse would talk to her about what was going to happen. After treating her I asked someone when the plan was to discharge her and I discovered she was going to have a home visit the following week and then if everything went well she would be discharged a few days later. This situation made me realize it is important to be careful what you say in front of the patient when discussing them with other staff members as they may take it the wrong way. Although I cant control what the doctors say in front of patients on the ward rounds if I am on a ward round and am asked a question about a patient I will be very careful with the wording of my response when the patient is able to hear.

Disparaging

Recently had the pleasure of treating the most self involved patient alive.
Every session would go over time and be mainly due to her talking about herself.
I dreaded treating this patient everyday because it would be so frustrating that she could happily waste my time, repeating the same story about her life.
So, upon discharge I reflected on the way I managed the patient, thinking that I may have been less than effective in my session because of my personal feelings toward the patient.

Looking back at the notes, all the sessions were appropriate and effective, however when discussing the patient there was some unprofessional banter between nursing and medical staff too which I joined in. Hindsight is 20-20, but it is not acceptable practise of professionals and it serves no purpose in being derogatory about a patient.
The next time I'm involved with the treatment of a similar patient I know I will be professional and not disparaging about the patient.

to treat or not to treat

This blog reflects on my cardio placement in a gen surg ward. I received a referral from an intern requesting chest physio for a patient (78 y.o female) who has 'moist cough' and her sats dropped to 95%RA(non smoker) over the weekend. After going through patients notes, she is admitted for a bladder washout and possibly going for surgery in a couple of days. She has always had a moist cough although non productive and it is normal for her to be having these coughs. She is independently ambulating with her 4WW and has been out for walks with her daughter while admitted. On auscultation, she has good BS throughout nil added. There was pretty much no indication for Rx from Pt point of view as she is able to clear her own airways and mobilising. I documented that in the notes as per requested by my supervisor. The following day, i had the same request from the intern. I consulted my supervisor and she said just keep an eye on the patient and monitor her. So I did that and document every session (objective and subjective Ax) i had with the patient despite no intervention given and no further chest PT was requested. I guess what i could have done as well is to explain to the intern that Chest PT is not indicated in this non surgical (not yet) patient who is mobilising, clearing her own secretions and have obs thats WNL. I guess we can all learn from this experience that i had.

Rude patient

I am on my cardio prac on the general surgery ward, I was assigned a pt who was admitted for an emergency laparoscopy. A 49 year old, their past medical history revealed obesity and high cholesterol. Socially they were an excessive ETOH drinker 1-2L/day and smoker 1-2packs/ day.

On seeing them day 1 post op I walked in seeing my pt walking with a frame back from the shower. Objectively I observed their red eyes, flaky white skin and shaking tremor in their hand. As the pt was too tired from ambulating to the shower and back my treatment was education on deep breathing exercises and the importance and benefits of ambulating ASAP post op. On hearing this the pt was extremely verbal in explaining how they had worked in hospitals for so many years now. My pt was very uncouth and rude in telling me that “You bloody well don’t need to tell me what to do,” and comments along the lines of that. It wasn’t meant to sound angry or aggressive but the way my pt talked to me was plain rude. At one stage my pt raised their hand in a mock slap; reflexively I stepped back but I interpreted it as part of their character. Although compliant with requests to ambulate my pts personality was very off putting and they weren’t a pleasant pt to work with. Rude comments about doctors and complaints about everything when I was preparing the environment. A harmless pt overall, but they just had a mouth that wasn’t very nice.

My attitude to this was to take it in a laugh it all off, I kept a pleasant attitude towards them and kept my mind on the task at hand. Initially I was very weary about my pt and did not know how to respond to the rude comments that were made. So I just ignored them and did my job.

Has anyone encountered a pt like this? if so what did they do?

Supervisor vs Uni

I was visiting a day-2 post-natal woman in the inpatient maternity ward, together with my supervisor. As the patient had a prolonged 2nd stage during labour and a 1st degree tear of the perineum, it was essential that we taught her to exercise her pelvic floor muscles (PFM).
We were taught at uni (Task 4 Assessment content sheet in PT prac 352 Women’s health unit) to teach a patient to “close back passage, let go. Close front passage, let go. Close back & front passages, and feel them gently drawing up inside you, hold 2-3 sec, let go. Repeat another 4-6 times.” I taught the patient exactly as we were taught to do. The rationale was to facilitate muscle pump, decrease swelling and increase sensation of the PFM. The aim was to build up muscle endurance (submax hold to 10 sec) as the muscles recover and swelling decrease. However, my supervisor questioned the part where I taught the patient to hold the contraction, as it was not reasonable to hold a contraction at such an acute stage, and muscle pumping effect would be facilitated by just gentle contractions and letting go. She added that holding the contraction could have decreased blood flow to the area, as the blood vessels may be compressed.
Being a student, it has been a frequent battle to know which option to choose when there is a discrepancy between what is taught at uni, and what is being practised by the supervisor. In this instance, the rationale given by both uni and the supervisor are reasonable and trustworthy. Considering that my supervisor has been working in this area for so many years, her rationale would have come from much expertise. In other cases where the advices of the supervisors contradict what were taught at uni, to challenge them might not be the best option.
Being under their supervision, I would choose to follow the advice of my supervisor if such situation arises again. When I graduate and become a qualified practitioner, then will I have the liberty to do what I think may be the best option.

Anyone has other opinion in this?

Mobility Chart

Currently on my gerontology placement I am treating a 77 year old lady with parkinsons, she was admitted to the rehab ward I am working on from home as she lives with her husband and he was no longer able to cope with her reduced mobility. On her mobility chart above her bed it stated she was supervision for ambulation and 1x assist for bed mobility. While treating her she seemed to improve every day and I thought her ambulation and bed mobility were safe and independent. However I had also seen her walking around the ward by her self very confused with a festinating gate which did not appear safe. Initially after her improvements in the treatment sessions I was thinking about changing her mobility chart to independent for bed mobility and ambulation but I was slightly unsure if the improvements would carry over to when I was not there so I decided to wait a day or two before changing it. After I saw how confused and unsafe she was ambulating independently I realized that even though she was performing very well during treatment her mental state and possibly her medications were affecting her mobility and it would not be appropriate to change her mobility status. I now know that just because a patient is performing well during their treatment sessions it doesn’t mean it will carry over to when they are by themselves.

Slooooow Dooooown.

Currently on a ward that fluctuates from no patients to four patients to be seen and i am really struggling to maintain motivation on the ward. On my last two placements the wards were so full that they constantly had over census patients in the corridor and it was essential to priortise who recieved physiotherapy.
I have been told to slow down my treatment sessions and relax a little, but I feel I could end up relaxing too much and come across as slack.
At the moment I am using free time to review journal articles and really over treating my patients spending alot of time with them.
Any ideas on managing a slow ward ?

Confidence builder

I am currently on my cardiopulmonary placement on the general surgery ward. I was assigned a pt with my partner to mobilize and review deep breathing exercises.

Our pt was a 75 year old, two weeks down the track from an anterior resection of the bowel. On observation and questioning the pt felt fine and confident to go for a walk down the corridor and back. The obs were within normal limits and her attachments were an IDC and IV drip on a pole.

So we trundled down the corridor which is about 50m, on questioning she started feeling tired so we start them down in a chair. After a few deep breathing exercises and a rest we decided to head back. For no physical reason they were unable to stand and refused to get up and walk back. The pt kept on repeating “I can’t do it, I’m going to fall over” despite there being two of us students at hand. So in this dilemma we decided to grab a wheelchair to transfer them to. Attempt number one was unsuccessful as was attempt number two by my fellow student. We were doing everything correct in terms of manual handling skills but the pt just refused to use any of her strength. She still kept repeating “I can’t do it, I’m going to fall”. So my fellow student and I swapped places and I attempted the transfer. I MMT her knee extensors to boost her confidence. After that I looked her in the eye and told them that they CAN stand up and the DO have the strength, they just got to have confidence in themselves and trust in us. On the count of three I stood them up despite much hesitation and physical opposition. The pt felt like a dead weight as they weren’t helping much at all so I had to really facilitate the lean forward stage. Luckily they had a slight build. The third attempt was a success and they were wheeled back to their room.

It just shows that as therapists we face many pts that will lack confidence in their ability to mobilize and be independent. This is especially evident in surgical wards as well as relevant to the increasing number of gerontology patients. It also shows that despite our course giving us a sound background to the theory of manual handling, there is still a huge gap between applying it and learning it in different situation. I put my back at risk during the transfer since the pt refused to help. It also emphasizes the importance of giving the pt confidence and feeding them A LOT of encourage and positive reinforcement. I don’t think our course really prepared us for the psychological side of our job. Do you think this is true?

Draping

At a musculoskeletal outpatient clinic, I had a patient who was a mum in her mid 20’s with back pain. After we had covered the subjective exam I asked her to take off her top. Before I finished my sentence she was saying ‘yeah that’s ok’ and proceeded to remove her top. She seemed very comfortable.

As I started to assess her lumbar spine movement with PPAIVMS in side lying my supervisor entered the room. I was having trouble with feeling the movement so my supervisor demonstrated on the patient. Before my supervisor started assessing the patient she folded a towel and placed it over the patient’s upper chest. The patient seemed to really appreciate just that little bit extra privacy and care.

I didn’t think to drape the patient. I think it was a combination of the patient initially appearing very comfortable and me forgetting what its like to disrobe in front of someone else. After this experience I know that I will be more vigilant with my draping and more considerate of how my patients feel even if they come across as being comfortable.

day 1 post op pts

After a pt has had surgery it is very important that we get them up and mobilize them as fast as possible. However after surgery some pts are given an epidural to relieve pain. This presents a problem for physios because it often causes low BP in theses pts.
In my first week on the general surgery ward I was helping my supervisor mobilise a Day 1 post-op pt who had an epidural. After speaking with the nurse we decided that we would attempt to get the pt out of bed and walk them a few metres to the shower. Before we started the nurse took the pts obs and everything was WNL except their BP was only 106/70. After discussing it with my supervisor we decided that we would still get the pt up and that we would just take it slowly and monitor for any signs of dizziness or light headedness. I assisted the pt to move from supine lying to SOEB and once there asked about dizziness. The pt replied that her pain levels had increased but that they felt no dizziness. After sitting and dangling their legs for a few minutes we decided to attempt to stand up. We managed to stand the pt up and the pt still reported that they did not feel light headed or dizzy. The pt then marched on the spot a few times and then with my supervisor guarding the patient and me standing nearby pulling the oxygen bottle we started to take a few steps towards the bathroom. At this point the pt started complaining of feeling very nauseous and faint. As I was walking in front of the pt I had to climb over all the pts attachments to get to the chair which was a few metres behind the pt. The pt didn’t pass out however they came very close but once they sat back down they felt fine.
This situation highlights the importance of setting up your treatment area because it would have been much easier if we had a chair closer or if I had been following behind with the oxygen bottle so I wouldn’t have had to climb over the attachments and risk pulling them out, to get to the chair. It also enforces how important it is to have 2 therapists with a day 1 pt because they can go from feeling good to feeling sick in a few seconds.

In this case where the pts BP is borderline it is a tough decision as to whether or not the advantages of early mobilization outweigh the risks. In this situation we decided to proceed with the treatment and although we constantly questioned the pt regarding symptoms of dizziness, it was nausea that made the pt feel faint in the end. This also shows how important it is to question the patient about all different symptoms.
When pts BP is that low what have other people been told to do; bed exercises or get the pt up?

Counselling?

A lady in her 26 weeks pregnancy presented at the women’s outpatient with a low back pain 2 weeks ago. The last two treatment sessions demonstrated significant objective improvement and decrease in pain, with treatment effect lasting incrementally up to 2 days.
As this was her 3rd session, I expected the symptom to have reduced significantly. However, the patient walked in reporting that the pain had again returned over the course of the week. I further questioned to find out if the patient had done anything that could have aggravated the symptom. Initially, she said she had followed my advice and did the prescribed exercises daily. With probing, she revealed that she was doing all the house-chores and shopping (which aggravated the pain/strain due to instability around the pelvis and spine from hormonal effects), as well as sitting for long hours at work (which placed prolonged strain on posterior structures of the spine).
She looked at me with a guilty look, as she knew these were the aggravating factors and had been advised in the first session to avoid these activities. As she explained, I realised that the problem was more than just her back pain. She was facing financial pressures and the condition at home was not helping. As I listened, my supervisor (being a mother and a wife) started relating to the patient’s situation and gave her sound advice. The patient started tearing, expressing her frustration. After 5-10 minutes of counselling with the patient, her face lit up as she gave consent to commence treatment. The difference: she was then ready to take initiative to find help with her home situation.
At first I wasn’t sure what to do besides listening. Although I sympathised with her, I could not fully relate to her situation as I’m neither a mother nor a wife. Then I realised that the first 5-10 minutes of listening and counselling (from supervisor) was highly necessary. If I were to jump straight into treatment, the problem could have persisted and her pain could have repeatedly returned. Being a physiotherapist (student), my role is not just to treat the physical problem. My supervisor had confirmed with me that we also have an important role in counselling.
If similar events recur, I will ensure to take into consideration both external and internal factors that could affect the patient as a whole, as well as to give time listening and appropriately addressing the factors. If my supervisor is not there, and I have little experience and knowledge about counselling, I will seek opinion from my colleagues. The next approach will be to refer the patient to a counsellor.

Does anyone have any other approach in such situations?

pt refusal of Rx

How far can you or should you try push a pt into complying with your Rx when it’s the last thing they want to do. This is one of the hardest things I find doing, when going to see a pt to do their daily Rx and they say no I’m not doing it today; I don’t want to get up and go for a walk. On two of my placements so far the pts have been post-op and therefore need to get out of bed if medically stable and try go for a short walk. A pt I went to see the other day was going to be moved from my ward to the rehab hospital just after lunch and my supervisor asked me to go see the pt to go through the exercises the pt had been given and to go for a short walk with the pt as they had lost confidence in their walking since their accident. When I went in to see the pt I told the pt the plan of Rx and said I needed to go for a short walk with them. The pt was very frustrated at everything going on around them and having to have to go to the rehab hospital and was just in a really bad mood and said to me ‘I just don’t see why I have to do this right at this moment’. I tried a bit more convincing and encouragement and got the pt's stick for them and they were just about to get up and walk with me when they decided against it again and refused to comply with the Rx. I couldn’t think of anything else to do to convince the pt and the pt’s lungs were clear so I thought there was no use in going further with this pt who had made her refusal very clear. I left the room and went to speak to my supervisor who asked why the pt had refused, my supervisor said her reasons were not good enough and that the pt really needed to go for a walk with us before being transferred. So my supervisor who had seen the pt the previous day came in with me to see if she could get the pt to do what we wanted The pt was still refusing and the pt’s daughter came in and also tried to get the pt to comply with us and this wasn’t working either, and the daughter told us to ‘just leave the pt for today and the pt will continue with the rehab tomorrow’. My supervisors told the pt if the pt did her walking now then the pt wouldn’t have to worry about doing the exercises and walking later when the pt was transferred and could spend the rest of the day relaxing and settling in. The pt eventually gave in and got up but was not happy, when I was asking about symptoms while walking and how the pt was feeling the pt just snapped back at me saying ‘I will tell you if I don’t feel right’

Most of the pts I’ve come across have been very friendly and comply well with their treatment. When a pt is in a bad mood and very negative about everything and not wanting to do anything I find it very hard to convince them to do what I want them to do. Then if they do get up and go for a walk but are in a very bad mood I feel a bit uncomfortable and don’t really know what to talk to them about and then if they have to do other exercises on top of the walking I feel very awkward asking them to do those as well. What I’ve learnt so far is that you have to give the pt a very good explanation about why it is important for them to do what you want them to do. You have to give them the possible consequences if they don’t comply as well as the benefits if they do (e.g. decreased LOS). When a pt refuses you have to think why they are refusing, whether or not their reason is acceptable to you and look at the circumstances of how important is it that this pt gets treated today. If it is crucial that they do what you want them to do then and there you have got to use as much persuasive power as possible and this is something I really need to work on a lot.

Does anyone have any other suggestions or techniques with getting pt compliance after initial refusal?