When the end is nigh

On my cardiopulmonary placement on a ward, I had several opportunities to go down to ICU to treat patients (organised by our supervisor to give us an exposure to a wide range of cardio patitients). On our first encounter in ICU, the other student and I, with our Curtin tutor, treated a patient who had been in ICU for many weeks with renal, liver (etc) trouble, and had been intubated several times. The previous day, the patient was able to sit over the edge of the bed and cooperated with treatment, however his nurse reported to us that he was not as well today but to go ahead with physio treatment. As we bagan to speak to the patient it became aparrent that treatment would be limited to "chest physio" in modifications of supine.
During our treatment the patient desaturated on rolling onto his left, but recovered quickly on repositioning. At the end of our treatment the medical team was using the patient's notes so we said that we would come back after lunch to write in them. We came back after lunch to be informed by one of the physios that the patient had passed away, as the patient and their family decided against re-intubation. Our initial response was 'oh gosh wht did we do?' We were reassured by the physio that our treatment was fine, but in hindsight if they knew that he that close to slipping away physio treatment would have been witheld.
I do not think we were to know how close the end was for this patient, and although we felt terrible, we did not do anything wrong. If I ecountered this situation again, I feel I have a better understanding of how quickly patients can change, and would ask the medical team directly what they feel the best course of action to be.

If something smells fishy...

Whilst on a clinical placement in an inpatient setting, I, together with my supervisor, assessed and treated a patient who had vestibular symptoms. Symptoms reported included dizziness, spontaneous nystagmus (usually in the middle of the night) and nausea. Assessments and investigations done by the neuro (medical) team could not ascertain a diagnosis or cause of the symptoms, and the patient’s mother was becoming somewhat frustrated and worried, almost catastrophising, making it increasingly difficult to reassure her.
In out physio assessment and treatment, we noticed that the patient’s symptoms did not always correlate with findings of our examination. Yes, the patient showed vestibular dysfunction, but some tests that should (according to reports of what brings about his symptoms) have elicited some of his symptoms. I also noticed that the patient’s account of their symptoms also depended on whether their mother was in the room with us or not.
We established that there was some vestibular involvement, so proceeded to treat with desensitizing exercises. We also discussed our concerns with the medical team, who revealed that they had similar concerns and referred the patient for a psych consult.
From this I learnt that if you feel something is not quite right, it is best to consult with other members of the team, as they may have noticed similar things, or they may be able to explain to you why something was noticeable. I took this experience and applied it to a couple of other situations where I felt that I person’s social situation may be influencing their medical presentation.

Effective Coomunication

Hi Guys

Whilst on my ortho inpatients clinic one of my patients had had a bilateral TKR, he had had a troponin rise and therefore instructions from the medical team were not to get him out of bed. Unfortunatley the patient had not been informed of this troponin rise or its implications by the doctors. When i went to go and treat him he beccame quite upset at me and was asking why he hadnt been up out of bed and if i knew what i was doing. I almost opened my mouth and told him he hadnt gotten out of bed due to his troponin rise however luckily i didnt as my supervisor arrived, and explained to me that i am not in a position to tell the patient that, and it has to come from the RMO. However this patients blood pressure was going through the roof as he had worked himself into such a state as to why he wasnt getting out of bed.

This situation was resolved by paging the RMO and getting him to come down and explain the situation to the patient. However i hope the RMO realised that by not informing the patient of his change in condition, that the patient became highly stressed and anxious which probably put even more strain in his heart. If i was in this situation again, i would follow the same actions. I never knew before this situation that we werent allowed to disclose certain things to the patient unless the doctors had told them first and this is what i learnt from this situation

Group work

Although was only able to go to half of them (because I was not in Perth for most of this semester) I found the seminars to be, for the most part, very interesting and useful. Whilst I may not have retained a great deal of information from them, they at least gave an introduction to each area, and the resource list will be invaluable should we end up working in, or coming across one of the areas or topics covered.
Because we are on prac nearly full-time on top of all other commitments such as work, sport, family etc, I believe it was very difficult for many groups to find a time to meet up to organize their presentation, so most communication and organization was done via email. This works well, however it means that the content of each members ‘part’ is not able to be thoroughly checked by other group members, which may result in a less-than-professional presentation.
One way of overcoming this problem is to allow students to decide their own groups, so that students can choose to be part of a group that will work well together to produce a quality presentation. I made this suggestion, however it was explained to me that this would result in all the ‘left over’ people being grouped together. There is a reason why these people get left out of groups – people have had bad experiences with them in the past not ‘pulling their weight’ or producing sub-standard material.
I am now meant to come up with a solution, but think that this is just one of those things that we have to put down to ‘the experienced gained’.
(PS Bronwyn you did a fantastic job, I am sure you know what I am talking about)

When the doctors are still arguing...

On a medical ward, I was allocated to assess a patient for a mobility review, following his admission for fatigue and lethargy, and shoulder pain with UL weakness. The mobility assessment was quite simple – I provided the pt with a WZF whilst his balance an confidence improved. The medical team entertained the possibility that the pt had had a CVA, and this appeared to be the case from a physio assessment of his motor function (affecting his UL only), and hence physio treatment commenced based on this assessment. However, following some imaging, the consultant decided that it was not a CVA, but rather a rotator cuff tear. As this did not fit the clinical picture of distal had weakness and altered sensation, we approached the registrar on the team to ask how they had come to this conclusion. She informed us that she agreed with us, believing that it was a CVA. So, we continued to treat this patient with UL retraining exercises – it did not really matter what his diagnosis was, as we were treating impairments as they were assessed, however it would have been more comforting, especially for the patient, to have a diagnosis. Unfortunately my placement finished before a diagnosis was established, as it would have been interesting to find out. The lesson I learnt from this is to treat the patients impairments that you identify in your assessment (provided this will not have an adverse effect on the patient), rather that waiting for a team of doctors to decide exactly what is wrong with a patient, as it is best to start treatment as early as possible, so that they can return home as quickly as possible.

Patients who 'battle the bulge'

Many postural loading disorders, especially of the lumbar spine, can be attributed to a patient’s excessive weight. To treat their condition in a holistic manner to ensure the condition does not become chronic, the weight loss issue must be addressed. I often do not feel comfortable talking with patients about this, and often tip-toe around the topic, just hoping for the patient to realise what I am getting at, and identify the issue themselves. I have incorporated it into my explanation of why they have back pain, and usually make a comment in the third person, such as “if you’re carrying extra weight around the abdominal area…” as a feel that this is least confronting, and I feel more comfortable saying it. Of course the rapport you have built with you patient is very important, and this may allow you to discuss more complex or sensitive issues with your patient in a better way, especially for those patient who require a bit more of a ‘push’ in the right direction. In the future (especially when I have my own patients that aren’t passed between students and physios) I will take time to build a good rapport with the patient in the first few sessions, and then approach the topic in a way that is appropriate for that patient, as I will have gauged what type of person they are during those sessions

The importance of handovers

Recently I was reminded of the fact how important patient handovers are. In collaboration with another student, the two of us were responsible for looking after a ward, which involved obtaining a handover from the nursing coordinator, and dividing the workload between us, with some patients also allocated to our supervisor. Some of the more complex patients would be given to other staff members, and we did not need to treat them. However, it came to my attention that these patients would be seen for a couple of days by the other physio, and then they would stop seeing that patient and treatment would stop.
I was quite frustrating when we were not given a handover as to whether they were going to continue treating the patient or not, and if we were to see the patient, how were they going. Next time I would feel more confident in actively seeking a handover from the physio, especially as this ack of communication meant that patients sometimes missed out on treatment, and ‘physio’ appeared very disorganized to the rest of the team.