Angry patient

On a recent neuro placement I was 7min late for my appointment with a patient. He was very angry and difficult to understand. To make things worse I had never seen this patient before. I was caught by surprise, thinking that it’s not that big a deal, and wondering why he was so angry?

I feel I handled the situation well. I told this gentleman calmly and gently that I was sincerely sorry and that I will not let it happen again. I said this without making excuses for my absence. I think this was a good response and he seemed to appreciate the apology. His anger resolved shortly after once we had started treatment.

I suppose the biggest thing I realised out of this situation is how much patients value their time in physiotherapy and how much they must look forward to their treatment sessions. This experience has improved my understanding of the patients view of physiotherapy.

Luca

Child with Cerebral Palsy

On my paeds placement, one of my clients was a teenager with a diagnosis of Cerebral Palsy (CP). It was my first session with her, so I did a full subjective and objective assessment under the supervision of the FCE. From her notes, I gathered that she had moderate intellectual disability, and required assistance with speech and comprehension.

Initially the Assessment went smoothly, and she could understand the instructions I gave and performed them correctly. She was also able to hold a decent conversation and laughed at jokes. However, when I was doing Manual Muscle Testing (MMT), my client seemed to become increasingly confused. She paused for a long time after each instruction before doing them, yet performed incorrectly most of the time. She found it most difficult to understand ‘hold it there; don’t let me move you’ (isometric resistance). I then modified my instructions, and tried a variety of ways (eg demonstration, visual, tactile, and verbal prompts, and used other illustrations) to explain my instructions to her. Only after many trials did she manage to perform them correctly.

I was baffled as to which part of the messages/instructions broke down. From her initial performance I thought it would have been easy for her to understand my instructions and do them without difficulty. After discussing this with my supervisor, I learned that these situations are common when treating children with disabilities. Despite the many factors that could have potentially obstructed her comprehension or execution of the tasks, my instructions (in the future) must be slow, clear and succinct at all times. It is also important that I be creative in the way I deliver the instructions. More common than not, it is about getting to know the client over time and modify my language to suit each individual.

Getting thrown into the deep end

On the very first day of my musculoskeletal outpatients placement I was thrown into the deep end with 4 follow up patients to treat. I was to collaborate with my facility supervisor after the subjective and objective to discuss the issues and problems of the pt. My supervisor was not present to view my rx or discuss a better technique. I find this difficult as I was not sure of my technique & whether I am treating the pt appropriately or not. Being only a student and having the expectation to know every technique we have learnt in the last 3 years is a fairly hefty load. How am i to know the best and most efficient technique to apply to each of my pts? On the other hand my supervisor articulates the situation to challeng my judgement and really determine the cause of the presenting problem. There is on offer very good advice and information but the rx is still up to our own decision as students.

As a student I have very little clinical experience and my aim in this placement is to develop my clinical reasoning as well as treatment skills. I do not feel that this is possible if I am to little supervision whilst treating my pts. As this facility supervisor has supervised for years I do not feel fit to challenge this method of teaching. I guess as a student there is a benefit in motivating one to really nut out the problem independantly but there is also the downfall of exacerbating a pts problems that could have been prevented.

less fortunate

On my last day of rural prac (abroad), i had the opportunity to visit a Community rehab centre for children with special needs. I went for home visits which is normally done once a week. As i was chatting to the staff members, i gathered that they visit each patients once a year (mainly CP kids). I had the opportunity to see one of the most severe CP patients. Pt is 8 y.o female. When i arrived, her carer was carrying her in her arms like a little infant. The rehab centres' staffs were talking to her carer and did a rather informal subjective examination (which only includes, have you been doing the exercises with the pt, and anything significant happened in the past yr). One thing that struck my patient immediately was that the exercises that were given last yr might not be appropriate this year and needs some progression or alterations. I asked the carer if the patient has been sitting much. Her carer said that, she will be carrying the pt most of the time and letting her sit on her lap, and if that is not the case, she will be lying down on the bed. When i had a look at the pts back, she had obvious spine deformity due to positioning. Quickly I suggested that she has to be sitting +++ with support (custom made seats specially for CP kids) to at least prevent the worsening of the deformity. I talked to the rehab centres' staff and her carer and they said that it is difficult to get these type of chairs in this town and it's hard to convince the patients parents to invest their money on these equipments. I was quite frustrated with that and i insisted on proper positioning for this patient. I was thinking on the spot on how to improvise. The patient has a younger brother who is approximately 5, I asked the carer if the brother has a little feeding baby chair or play chair. Her carer took it out from the storage room and we fit the patient on it. Because she is so kyphotic and scoliotic, we took a towel and tied it around the patient to provide her with some trunk support. The chair comes with a tray in which the patient can rest her hand and play with some toys while sitting. I don't know how well the 'special chair' will work in improving or maintaining her condition but it is always better than just lying down or being carried by her carer. It is really interesting to see how healthcare systems work differently in areas out of Australia, kids with special needs in this area is less fortunate and it is really sad to see.

paediatrics vs adult

This entry reflects on my previous placement in a paediatrics setting. When I first started this prac, i found it hard to communicate with little kids, especially when at uni, we learn how to communicate professionally with patients. My supervisor told me that in order to get the kids to cooperate we have to get over ourselves and act silly. It took me awhile to get used and i had to brush up on my nursery rhymes. I had to learn new terms for the different types of exercise (i.e. sea saw for active hip flexion, flamingo stand for single limb stance). I tried using normal terms with them (i.e. lift ur bottom up for bridging) but they find it so boring and hardly willing to cooperate. My supervisor then told me to say 'make a bridge for teddy to go under' and it worked. My supervisor keep telling me not to be afraid of using my voice and cheer them up. I do admit that towards the end of my practicals i still haven't mastered the ability to communicate with young children, i guessed it comes with experience and i have learn to let myself all out when working with young children as they will be no one there judging how silly you look.

limitations: pathology?

I'm in my 3rd week of rural prac in a stroke centre and i have been treating this patient with cerebellar stroke for the past 3 weeks. He told me that he has had his stroke for 3 yrs and have always wanted to walk again. He has been going to therapy on an on and off basis. My supervisor told me that they have worked hard to treat this patient but thinks that he has plateaued in his recovery. He is still wheelchair bound. I assessed on his sitting balance and found that he doesn't have appropriate saving and equilibrium response and have difficulties coordinating his movements. He is able to sit to stand independently but needs close standby as he tend to overshoots his movements. I tried letting him walk along parallel bars and found that he needs +++ support and cues to slow down and control his movements. Further assessments revealed that he has poor trunk muscle strength and control and tend to slump all the time. From my limited knowledge on cerebellar stroke, i think that if this patient is going to walk again, he needs to be working really hard in therapy and if he is walking further down the track, he will still need atleast 1x min assist (at least, if not more). I don't really want to demotivate him from coming to therapy but at the same time, will he ever be able to walk again?.

being unsafe??

In my second week at a stroke centre in a rural setting, i had to transfer patient from lying on the floor (on a mat) onto a chair after a mat exercise class. I was teaching the patients the sequence that we have learnt at uni. It didn't work and my supervisor just jumped in and provided full assist and just lift the patient up into standing. I was then told by the supervisor that patients here go down onto the mat with their unaffected leg down onto the mat in half point and to stand on their unaffected side to support them. All I could think of at that time was, 'as long as it works for them'. I guess these patients are futher down the track that they have learnt to compromise for their affected limb and learnt compensated movements. This prac has taught me alot about being more flexible and using what works for the patients instead of thinking what is wrong or right.

first week in stroke association (abroad, rural)

It was my first week in a rural (abroad) stroke association. I was surprised with the way stroke patients being treated here. The way the association works is, 2x exercise classes in the morning for the stroke patients (duration:2 hrs per class) and individual sessions in the afternoon (45 minutes each). For the exercise classes, its divided to intermediate group (patients who are able to walk and are further down the track) and early group (patients who are still in early stage and wheelchair bound). For the intermediate group, exercises include weight training with theraband, and mat exercises (yoga, pilates) and for the early group exercises include active assisted ROM exercises, functional training (STS) and weight transfers. I was really shocked with the way they work here, first of all, patients who are in the intermediate group are walking with poor gait pattern and most of them are unable to WB on their affected UL. Also, their affected side are mainly grade 2. To even think of giving them resistance work to be done on the affected side is already not right. I was thinking in my head that there are alot of things that can be done with this group of patients like gait retraining and retraining of UL function but it is impossible to get it done as it is a group exercise class and there are ~12 people in the class. I questioned the facility supervisor and she said this is how they have been running the centre. In the end, i had to carry on what they have always done and just think of it as running a normal exercise class. I have also learnt to think of it as an association (where patients come to socialise) and not an outpatient clinic.

gut feelings..

Placement: Cardio (gen surg)
I was given a patient to see with a supervisor in a HDU ward. Patient is a 90 y.o male who has undergone a cholesystomy. He has COPD which reduces his tolerance for ambulation, he then developed pneumonia and has to be admited to HDU. His obs are really unstable (low BP and sats) and has increased secretion which can be heard with his breathing. He was given a BiPAP. I was asked to decide how to treat this patient. I decided to sit him up over the edge of the bed and if he copes well, get him to stand up and sits him on a high back chair. I talked it through my supervisor and we decided to go ahead with it. Transferring the patient was challenging enough as he has many attachment and that took awhile. When patient was sitting over the edge of the bed, his sats was coping well but because of his upright positioning, we had to detach him from the BP monitor. We managed to get him to stand up and transfered him to a high back chair. He sat there while i do my ACBT cycle. He looked really unwell (but then again, he's always dyspneic), my gut feelings told me to check his BP and my supervisor told the nurse to assist with that, his BP at that point was ~80/50 (can't remember exactly but low enough for a code blue). We decided to quickly put him back onto the bed with the leg rest tilted up. His BP quickly stabilised. From this experience, I have learn that we have to constantly monitor unstable patients from all aspects (and cannot be dependent on O2 sats only). When monitoring is not available, always opt on the save side and follow our gut feelings.

pt honesty

One of my post op cardio pts was being quite difficult and refused to get out of bed and walking. On day one and two post op, after much encourgaement the pt agreed to come for a walk with me. The next few days the pt refused treatment because she was tired or in pain. As the pt was clearing her own secretions by coughing up moderate amounts of sputum without any PT intervention i didnt push the issue. According to the nursing notes the pt had managed to get themselves downstairs and outside to have a smoke. When I asked about this the pt assured me that they had walked themselves down there and because the pt was walking independently and the cough they had was normal for them I planned to D/C them from PT. However when I was walking home one day I saw the pt sitting out the front of the hospital in a W/C. I had just assumed from what id read in the nursing notes and from what the pt had told me that she had been walking downstairs. This shows that you can not always believe what a pt tells you and that you should always double check with the nursing staff

Understanding neuro...implications for a student physio

Since day 1 of my neuro placement I have felt overwhelmed with the idea of getting stuck into treatment the very next day. The expectation to be responsible for the pt's recovery and treatment was overwhelming. We learn the basics to treating neuro pts but to apply our knowledge without supervision on real pts made me very self doubtful. These are pts that are relying on our treatments to boost their confidence & get them back on their feet. Our technique as students are far from perfect and at times i really am in doubt about their effectiveness.

Can i be confident that I am giving my pts the best possible chance of recovery? I have stressed and worried myself into a ball of self doubt & criticism. On the other hand everything is a learning experience and these placements are tastes of what its going to be like in the working world. So I really have no need to stress myself over this issue, but from a moral point of view I feel that they derserve.. better I guess?