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.

Patients that won't cooperate

On a medical ward, I had a patient who was admitted to hospital for an URTI, who also had relatively poor mobility. English was this patient’s second language, and at first I thought that he may not be understanding what I was saying to him as he was not reciprocal in communication and was not co-operating with treatment (which was essentially just to go for a walk), so I began to think of ways to overcome this language barrier, such as coinciding treatment with visits from his family. However he then, to my surprise, verbalized in fairly god English that he did not want to walk and would like to return to bed. This attitude persisted, and several days later while trying to reason with him as to why mobilizing as important he said to me “who says I want to go home? I like it in here.” The medical team were keen for the pt to go home as he was medically stable, but allied health still had concerns regarding his ability to cope at home. A nurse overheard me trying my best to reason with the patient why he needed to get up, and came over and literally forced the patient to get up. Whilst I was becoming very frustrated with this patient, I did not feel comfortable doing this. Instead, at the next treatment session I took a directive approach; whilst still asking the patient if he wanted to participate, gave him little room to object. As a result, I managed to get the patient mobilizing and a few days later he went home. Whilst the patient did not have complete contrl over the situation, I feel that this approach was needed to be able to get a patient home who had no good reason for occupying a hospital bed.

Reflecting on 4 years long years

Hey guys, I’d like to congratulate everyone on making it to this point, only a few days to go! I thought I’d take the opportunity in my final blog to reflect upon my final year of physiotherapy, and upon the last four years.

I have always wanted to be a physiotherapist, I just didn’t realise how much physiotherapy involved. I think we’ve all considered at one time or another; is all this work really worth it? While it’s too early to determine, at this point I feel like I am heading into an ever expanding profession that provides a huge amount of variety to work in many different areas. Furthermore, it can be extremely rewarding, provides opportunities to meet some great people, and provides opportunities to work all over the world.

It’s amazing how far we have come from first to final year; I never thought it was humanly possible to learn the amount that we have learnt. I have less than fond memories of anatomy lab exams, second year exams, and the multiple assignments we have done. It’s going to take several years to catch up on the sleep I have lost, and I am now a coffee addict. This final year has seemed to go by in a flash, but it has been a long hard year. Looking back to my first placement I can see how far I have come in terms of professionalism, communication, and clinical knowledge/reasoning. I spent my entire first placement with my supervisor, yet in the second half of this year I was left treat an entire ward by myself. While we have learnt a lot, and are well equipped to move into the workforce to be effective physiotherapists, there is still a lot more learning to do. From certain placements, particularly musculoskeletal and neurology, I have realised that we have really only been taught the foundations of physiotherapy and I have been exposed to a lot of treatment techniques that we were not exposed to at university. I’m looking forward to learning more.

I’d like to wish everyone good luck for PCR, and for their future careers!

Blogging

This is a blog about blogging (what?).

I must be honest, that at the start of this semester when I discovered that we had to do eight blogs, my initial thought was “what is the point of this?” The semester was already full of assignments; rural reports, self directed proposals/evaluations, students reflecting on teaching evaluations etc. All of this on top of actually going on placements, studying for placements, mid and end of semester placements, soapiers and placement presentations. So much to do, so little time! I’m pretty sure that I was not alone with this thought; many other students expressed similar sentiments to me.

While this was my initial thought, I can now see the value of blogging. While my blogs tended to occur in the last two months, I did regularly read the posts of others. The posts on this blog discussed points that I had not considered myself, described situations that I had not been exposed to, and provided great insight into how others have approached certain situations that I may also have experienced. Furthermore, it was interesting to reflect on my own experiences. Sometimes things may happen, but without reflecting on them at some stage, you may not learn from them. Through blogging, I have learnt valuable lessons from not only my own experiences, but the experiences of others.

I believe that blogging may be valuable to students in the coming years; however it may be better if the number of blogs required is decreased.

Gaining a patients' confidence

On my neurology outpatient practical, I had a patient who suffered a pontine stroke two years ago. She currently mobilises independently in an electric wheelchair, and requires x1 assist with chair to bed (to chair) transfer and bed mobility. She has been known to be abrasive with her therapists, and has a history of poor attendance. Prior to treating her for the first time, my supervisor warned me that she may be difficult, and that it was best not to joke around with her. Some may be grateful for such a warning, but for me I think I focused on this too much and as such I seemed to lack confidence to the patient.

The technique to transfer this patient from chair to bed is tricky, and was demonstrated by my supervisor on this first session. She has decreased voluntary control of the left lower limb, and a positive support reaction in standing causing her left ankle to plantarflex and invert. As such, the transfer is to the patients’ right, and she must weightbear only through her right lower limb. The therapist blocks the lateral border of the patients left foot and her lateral knee to prevent her ankle rolling over, while assisting her into standing by facilitating through the left upper limb. The patient then pivots on the right foot while the therapist looks after her other leg. During this first session she told me that she had been coming to outpatients for over a year, had seen many students, and did not rate most of them. She also rolled her eyes at me as I battled against her severe tone while trying to apply stretches. I am usually confident with most patients, but I must admit that I was rattled by her attitude toward me. The following session, on attempting to transfer, I appeared apprehensive prior to the transfer, and as such she would not let me transfer her, requesting that my supervisor do so. The following three sessions she did not attend.

At this point I felt like the patient had no confidence in me, and as a result I had lost confidence in myself. I decided that the next time I saw her, I would show no apprehension and appear confident to transfer her myself. I clarified the finer points of the transfer with my supervisor, as I knew that she was very particular, and if I did not get my foot placement right that she would not let me transfer her again. When she came in, I didn’t hesitate, immediately placing my feet in the correct position and as such I performed the transfer myself. The patient appeared impressed by this, and she turned up to the next three sessions (very unusual)!

From this situation I learnt that if we do not appear confident, the patient will have no confidence in us as therapists, and in the treatment we provide. A physio once said to me that it is amazing what a difference the transition from blue shirt to green shirt can make. This patient did not rate students in general; however once I gained her confidence she was much more compliant to physio. Hopefully I changed her mind about students too!

Treatment of students

Last blog ever!!

On my pracs this year I have had to work alongside numerous nurses, Drs, etc. as I'm sure everyone has. I have found that broadly (very broadly) nursing and medical staff tend to fit into 2 categories: they either treat you with respect as a fellow member of staff who can make a worthwhile contribution to the patient's care, or they treat you as a nuissance student. I guess it depends on the personality and mood of the staff member at the time.

I have found that in dealing with staff who fit into the "nuissance student" category, a confident approach tends to work best and achieve the most favourable results. If you shy away and apologise profusely, etc, etc as it is sometimes tempting to do- their attitude toward you will not change. However if you act like their manner hasn't phased you and you carry on as normal in a polite but confident way- then you are more likely to win their respect.

Being a student in large ward environments especially, it is easy to feel "in the way" and like you are an annoyance, and unhelpful attitudes of other staff members do not help. From my experiences this year I think I will have a great amount of empathy for upcoming students who I may encounter when I enter the workforce. I have found that it is easiest to learn when you are in a comfortable environment around staff members who are willing to share their knowledge as if you were a colleague. As such this is how I will approach students in the future.

Well done on finishing pracs everyone- we don't have to worry about being annoying students anymore!! :)

Womens Health 4 Patients who require psychiatric intervention

I brought this patient up already in my last blog, but as it was a different point, I felt it deserved its own blog/discussion. I found myself reflecting on what I could have done for my patient who refused a psychiatric review.

Just a bit of background: this patient was one of my 3 conversion disorder cases. She gave birth precipitately at home, retained her placenta, was brought to hospital and subsequently developed pelvic pain, lower limb weakness, what she describes as nerve pain down both legs, and lost her ability to balance in standing or walk. Oddly, she was happy as Larry about the situation. She had self-diagnosed herself as having a PMH of MS, ankylosing spondylosis, and vasculitis. She had been taking a corticosteroid without the medical’s team knowledge (don’t ask how she got them!) for the AS. She had a detailed FIVE PAGE birth plan, which obviously had not gone to plan at all.

I can certainly understand how confronting it is for someone to have very disturbing physical symptoms and to be told that a psychiatric review is indicated. And as it IS the patient’s choice, this was not pushed. But then what?? The person possibly best equipped to convince the patient that a psychiatric review may be beneficial is the psychiatrist or psychologist themselves… and the patient had just declined their services. I believe that when a situation like this presents, it may well fall on me to encourage the patient to consider the psychiatric services.

I didn’t do this for her. I believe I should have tried though. I could have explained to her what conversion disorder is. I believe the important take-home message in this situation is that just because the source of symptoms is in the head, it doesn’t mean that it is within the patient’s control or conscious processing. Feelings of shame or guilt may be responsible for a patient refusing psychological intervention. I think it is important for SOMEONE to point out to the patient that although conscious thoughts and cognitive processes are not necessarily responsible for this presentation, psychological intervention may in fact have very positive results. I realize that this is a bit of a fib, as I do believe that maladaptive thought processes were somehow involved in this patient’s situation. She had self-diagnosed herself a variety of disorders and was taking medication without the hospital’s knowledge. But she doesn’t need to realize that, whilst I’m encouraging her. I think that the next time I am presented with a similar scenario, I would give this approach a crack. I don’t know, does anyone disagree? Otherwise, who else will take on that role?

Womens Health 3 Conversion syndrome

On this placement on an obstetric ward, I’ve come across no less than 3 conversion disorder diagnoses! Well, even more confusing, POTENTIAL conversion disorder. For those of you who don’t know what that is, it’s basically a presentation of physical symptoms like intention tremor, visual deficits, loss of muscle strength or loss of balance thought to be mediated by psychological processes. So, nothing found on blood tests or MRI. It is generally diagnosed by psychiatric review. One of them very kindly declined a psychiatric review, without which you are a bit restricted in diagnosing conversion disorder.

It was very confronting for me at first. We have been trained to look for physical symptoms, and analyse the presenting information to form a problem list and a treatment plan. It’s confusing and frustrating to not be able to make sense of anything you see because it doesn’t necessarily add up.

However, upon assessment, it remains relatively easy to find impairments that you CAN have a positive effect on, and determine their functional mobility. You give them strengthening exercises, and lo and behold, they become stronger and it becomes easier to walk. As a result I’ve had 2 of my 3 conversion syndrome patients tell me or the doctor that the physios are the only ones who believed them. I reflected on this and realised that maybe it was more a case of “the physio was someone who was able to make a difference regardless of the diagnosis”.

As my supervisor said to me, at the end of the day, the diagnosis makes little difference to the physio. We effectively go in and look at the presenting symptoms and devise treatments and/or strategies for what we see. Regardless of the reason, if the patient is 2 assist, then she is 2 assist. Treatment and management are targeted accordingly. I felt this was an important point to remember. I don’t discount the fact that diagnosis is essential for correct treatment and management in a large proportion of cases, if nothing else for safety reasons. But I think it is valuable to remember that a physiotherapist still has a potential to make a difference without a clear physical or organic diagnosis. I really felt that this concept was empowering, because it made me realize that when I am a new grad, and I certainly won’t have all the answers, if I use my head and treat what I see, I still have potential to make a difference. The best part of this situation for me was how both patients felt we were their ally, simply because it didn’t appear to matter to us what their diagnosis was, in order for us to make a difference.

I know this seems painfully obvious to some of us, but it really brought home the message we are taught in musculo. We often refer to a diagnosis of non-specific LBP, and are yet able to treat this, as long as we 1) rule out red and yellow flags, and 2) treat what we see. This concept can be viewed more globally as well!

Modifying Your Treatment

Recently whilst on my cardio placement I was required to treat a patient who spoke almost no English and was acutely unwell. I saw this patient with my curtin clinical tutor. Throughout the treatment the patient appeared to be indicating that they had some form of chest pain or problem and head pain. In response to this we arranged for some pain medication and also decreased the amount that had been planned for the session.

In discussion with my supervisor after seeing this patient she said to me that with patients like this one it is really important to be extra cautious with your treatment, even if they are indicating that they feel ok because of the communication barrier. You can never be sure if they have actually understood what you’ve said or whether there response is just a generic response to all questions they don’t understand. You also need to increase your observations of physical signs and symptoms as this may be your first indication that something may not be right, whereas if a patient speaks fluent English they may be able to indicate to you before that point that something is not right and you can act a lot earlier. This situation just re-iterates the fact that every patient needs to be approached on an individual basis, there is no recipe and alterations need to be made as required, particularly in this case when the patients health and safety may be compromised if additional caution is not executed.

I think that the values from this situation can not only be applied to treating patients who speak little English in a cardio setting but to many different settings. It is very important for us to not forget to constantly be altering our treatments and closely monitoring the non-verbal signs and symptoms. For example on my paediatrics placement my supervisor taught me that when performing stretches on a child to always watch their face because that will tell you a lot more about how they’re coping than what they say verbally. Hopefully now and even as experienced clinicians we will always consider the extra factors that are ever present when treating patients.

Treating dead people

This is again, one of those strange situations that you pretty much would only see in ICU, but thought I would share it anyway.
A couple of days ago my supervisor allocated me a patient and told me to go and assess her and then report back to her with my problem list and treatment plan.
I began reading the patient's notes and quickly realised that the patient had been classified as "brain dead". The Dr had just completed the final set of tests which confirmed the diagnosis and they were about to inform the family.
I assessed the patient and determined that impaired airway clearance and reduced lung volumes were the patients 2 main problems. At first I wondered why my supervisor had asked me to assess and treat a patient whose ventilator was about to be switched off. After discussion with the nurse though, I quickly realised that the doctors were hopeful that the patients family would consent to organ donation.
So, when reporting back to my supervisor, she was happy when I outlined the patient's assessment findings and treatment plan as normal. I guess the point I am trying to make is that when confronted with a diagnosis like brain death where we know that the patient will not survive no matter what treatment we give- at first glance it may seem pointless to treat them. However, looking beyond the patient at the bigger picture- if those lungs are going to be donated to another patient, they need to be as healthy as possible. This is where physios actually have a very important role and the patient should be treated to the best of our ability, just like any other.

What happens when you hit the emergency button...

I was allocated a patient the other day, who was admitted to hospital following a fall which resulted in a R Colles fracture and a R fractured pubic ramus. This elderly lady is legally blind, and lives at home alone.

The handover from nursing staff was that the patient was to mobilize FWB as tolerated (also documented in notes) with no further information given. On reading the integrated notes, I noted that she had been given her anithypertensives earlier that that the prescribed time that morning as she was hypertensive overnight.

When I saw the patient, her BP was 135/70 (ish), and reported to be feeling OK. I stood her up and attempted to walk with a quad stick, but her pain was too severe so we sat down on the edge of the bed. Then she reported that she was starting to feel giddy, and became very pale and sweaty. As I then began to try to move her into supine, she became unresponsive (vasovagal episode). I lay her down across the bed sideways, but could not get her any further onto the bed. Still not getting a response, not 100% sure what was happening, and in my panic not being able to find a pulse I decided it was time to hit the emergency button.

The patient was in a 4-bed room, and as I looked around the room for someone to press “the button” that was located on the other side of the room, I realized that the youngest person in the room was about 80 and wasn’t going to get out of bed and across the room in a great hurry.

So, I left my patient half-on, half-off the bed as a ran across the room to hit the emergency button. 10 seconds later the room fills with half a dozen nurses and several doctors, by which time I have found a pulse and the patient has responded to pain and has begun mumbling. I felt very reassured when a nurse told me that I had done the right thing – as it was the patient was OK, but better that way than me waiting a little longer to work out was was happening to the patient and then potentially calling a code blue (is was difficult to tell what was happening as she was asymptomatic until right before it happened).

Her BP had dropped to 98/58, but with positioning in head-down tilt this slowly came up. An ECG was also done. I then found out that in addition to her usual dose of antihypertensives being given early, she was also given them at the usual time (effectively a double-dose) which was not handed over or documented anywhere else other than in the med chart.

So I wonder what peoples thoughts are? In reading the med chart, I always ensure that I know vaguely what each drug is for (if it is a HTN med, a cardiac drug, a steroid, an antistatin etc), and check the most recent dose of drugs such as pain killers, sedatives and anti-mimetics (metclopramide/maxalon).

The co-ordinator should have included info re the double-dosing in the handover, but should I have checked the time of the last dose of every single medication?

Patient's families

In ICU, a lot of the patients are critically ill and there is a constant stream of emotional family members and friends visiting. Each visitor wants to know how the patient is going/what progress has been made. I personally have not been asked by any of my patient’s visitors about the patient, because there is always a nurse near the bed who is obviously more aware of the patient’s condition that I- having been with them all day.

Recently I overheard a brother of my patient asking the nurse for information about how the patient was going- and the nurse refused to disclose any more than basic information about the patient. She tactfully explained to the brother that the patient’s wife was the next of kin/primary contact person and they only tend to disclose information to that one person- as they have had many bad experiences before with family members getting different information at different times and people getting upset with them that they have not been told important information first. It wasn’t something I had really thought about but I completely understand why the nursing and medical staff would be reluctant to disclose information to all visitors- considering how quickly these patients’ status can change. I also understand how some family members would be very frustrated with this, however I think the way the nurse explained it was very clear and reasonable- and the brother was instructed that he wasn’t being denied information, but that he should get the information from the patient’s wife instead, as she was being constantly updated.

Just thought it was an interesting point that probably isn’t considered often enough. These patient’s families are obviously very emotional and it is important that consistent information is passed on at all times. The system that ICU has in place I believe to be a good idea.

Womens Health 2 A translator to discuss sensitive issues

I had a wonderful experience this week, which I thought I would share. Why is there always such angst and fear whenever some people read the words “Requires translator” or “minimal English” in a patient’s notes? Maybe on an obstetric ward, this is even more felt. I had such an experience on Friday.

I was to see an Iraqi woman, who had just undergone a vaginal delivery of a baby boy, for a PT check and post-natal education. When I read those words “requires translator” in the notes, I thought I would still try and see if she could understand a few words, or read some English so I could leave a pamphlet. Upon entering the room, I quickly realised that 1) The woman really understood NO English, 2) the husband who was present would DEFINITELY be required to translate. Now the angst and fear kinda went up. I guess I was a bit worried about how to discuss issues regarding perineal care, and bladder and bowel issues with an Iraqi male. About his wife. Sometimes the problem is that with language barriers (and also even Australians, to be honest), the patients don’t understand terms as “have you opened your bowels” or “close your front passage”. You find yourself having to use “have you done a poo” or “hold onto your wee”. And sometimes even then, they can’t understand. It can feel awkward using such unprofessional jargon and try and maintain your professionalism.

But to my surprise, he appeared to be pretty comfortable (of course, maybe he wasn’t), with trying to translate everything. He came forward with questions himself such as “could you help me get some cold packs for her perineum”. I felt reassured and encouraged by the husband’s manner, and continued with my session with the ease I’d felt with any other patient.

I felt after this, that the husband’s mature and professional demeanour was what put me at ease. I reflected on how the reverse is certainly possible. By this I mean, I have the potential, when walking into a possibly awkward situation, to act in a way to reassure others and ensure smoother and effective communication. As physios we will be asked to address touchy subjects +/- language barriers. Sometimes this will be with people of different cultural background who, we may be inclined to assume, may be uncomfortable discussing these. This attitude can be very generalistic and often we, as inexperienced students/new grads, are the ones who will be uncomfortable. A professional and mature approach helps to make everyone feel more comfortable.

Neuro 2 Team strengthening approaches

I thought I’d share my experiences on this neuro placement in dealing with patients with dysphasias and language dyspraxias. I hadn’t encountered patients with these impairments before so communicating with them was initially very challenging. I got a glimpse into how difficult it is to perform a neuro assessment when there are language difficulties. I would read the speech therapists’ notes but was a little stumped on some of the terminology, such as “semantic cueing” and “phonetic cueing”. As the prac developed, I found myself with 2 patients for whom the physiotherapy treatment per se was fairly straightforward, but communication was somewhat restricted due to the dysphasias.

One patient had expressive dysphasia. For those of you who haven’t encountered someone with this, they present with a reduced vocabulary, and just really searching for words. “Yes... ah... Monday... er... My kids… and Josh.... er... hospital... and ah... Wednesday... Wednesday, nine o'clock... and oh... Thursday... ten… ten… o'clock, ah doctors... two... an' doctors... and er... teeth... yah”. His PT impairments were a loss of proprioception and light touch sensation to the (R) forearm and hand.

The other presented with speech dyspraxia, and possibly some underlying expressive dysphasia. It’s hard to tell as it is so masked by the dyspraxia. It’s frustrating for her because her mouth just won’t do what she wants it to do. And so most times she attempts to speak, all that comes out is “Ooaaoo”. Her PT impairment was largely a decreased exercise tolerance.

As you can see, both those patients did not really tax the intellect in terms of physio treatment. But communication was restricted, which lead me to wonder if I could pick up a few speech therapy skills to make my treatment sessions a little more multidisciplinary and to improve communication all round. With no idea on how to do that, I decided to seek some extra help. I took the step of requesting to go to a couple of language/speech groups run by the speech therapist. This group was attended by both dysphasia and dyspraxia patients. I did pick up a few communication skills including cueing. In case you’re interested, semantic cueing means cueing with nonverbal signs like moving a steering wheel for car, while phonetic cueing is helping out with the sound of the start of the word, eg. Going c-c-c-ca-ca to try and get car. I’m definitely no expert, but my confidence has increased!

The greatest achievement from this move though, was that I got to know the other allied health staff. They started calling me by name, chatting, informally discussing patients… I learned from this experience that it is definitely worthwhile seeking help from all members of the multidisciplinary team. Not only does it contribute to better treatment, but it can help to strengthen team dynamics and make it easier for members to approach each other in the future.

Intubated patients

I am on an ICU cardio placement and the large number of intubated patients has raised some interesting points.
Most intubated patients have either a trache or an ETT- which means they cannot talk, even if they are not sedated. A lot of the patients are sedated, but to varying degrees.

Last week I was asked to see a patient who had just been extubated following cardiac surgery. The patient was awake and able to talk- so I did my assessment and treatment as necessary. For an intubated patient, there is always a nurse in the room or very close by, but not always for extubated patients. When the nurse left the room, the patient expressed to me how horrified he was the previous day when he was still intubated- and a team of about 5 or 6 doctors and nurses stood around his bed looking at the instruction manual for his ventilator. Of course he could not say anything to the doctors, and they probably didn't even realise he was awake.

Although the patient in this case was joking about it when he relayed the story to me, it does highlight an issue that is important in this setting- constantly communicating with the patient what is going on, even if they are sedated and may not hear what you are saying. You just never know how awake they may be! I'm sure if the doctors had explained what they were checking and why, the patient could have been put at ease.

gero placement

I am currently completing my gerontology placement at an outpatient day-hospital where most of the patients are at risk of falling or have balance problem. I have started to treat patients under supervision. I found some interesting information to share with you in terms of patients’ cultural background for balance issues.80 year old chinese lady was assessed in the falls clinic. She tells a fall-specialist she remains independent in her activities of daily living. She is living in a two storey home and is a non-drinker and non-smoker. The main problem is a two-year history of gradual decline in balance and gait. This is associated with her complaint of numbness in her bilateral fore foot. It is not associated with history of stroke, TIA or onset of arthritis, or leg weakness. Her performance deteriorates on uneven surface and there is a concern that she is thrown off balance by her small dog which she continues to walk with on a daily basis. Moreover, her gait seemed abnormal. She seemed off balance when initially standing and when turning. However, there was no evidence of tremor or cogwheel rigidity. She reports she does not understand why she needs to come to see physio and she does not feel she has any problem with her balance and gait.Overall, as far as I am concerned, her balance is not as sever as other patients in my placement.

Doctors!

In any hospital inpatient prac we may have had this year we have almost undoubtedly had some form of contact with Doctors whether it be in the team meetings on ward rounds or just in general. I'm pretty sure I'm not alone in saying this, but I have to admit that for most of this year I have found Doctors very intimidating, its like the Doctors are up here and down here's the little physio student. But it should not be that way and if we look at it in the right way it's not.

I've found that in the last placement I had within the hospital and my current one that Dr's are just people like us, it's obvious I know but it helps me to remember that. It's also really important that if, like me, you have a Dr phobia, that we overcome this because what we have to say is really important. I have found that on my current placement there's been many times when the Dr's have written in the notes, ?D/C this pm, and I've read that going, What?! No way! That's when we need to be confident that we know what we're talking about and either speak to the Dr directly or write in the notes that we don't exactly agree. I've also noticed on my last two hospital pracs how good a realtionship the senior physio on the ward has with the Dr's, including the consultants (If you're on first name basis with a consultant I would regard that as a good relationship) and the difference that makes. On many occasions the consultants will ask the physio what they think, and the better the relationship we can have with the medical staff the more beneficial it is for all involved.

So what I've learnt this year is that whilst there is a place for respect of Dr's and senior medical staff, we also need to be confident and sure of the importance of our role. There are so many different components of patient care and we are experts in certain areas of that care, intimidated or not we need to stand up as an advocate for the patient and say what we think when the need arises.

Keep working on your verbal communication

Hi guys, I would like to talk about my communication and its difficulities I encountered throughout these years.

As you realise, English is my second language but it is not something that is completely new to me. I have learnt English when I was in my home town but there was not many practical opportunities for me to use English except English exam, therefore my English is very much academic. When I first came to Aus, it took a long while for me to adjust or get used to the language ranging from the accent to the word usage. Throughout the years of studying Physio and living in Aus, I have encountered a countless experience of misunderstanding during the conversation. On my reflection, I believe it is due to my accent and pronounation. Sometimes it brings me into a frustration and lost of confidence because I cannot change it drastically and it will cause problem when I deal with patient.

The only way to cope with it is to say and pronoun it more slowly and clearly, with more up and down tone in between my speech. Initially, I find it very awkward but it profoundly improve my communication. And I realise that my mouth is as important as my hands to patients. By giving the good education to patients, it will provide them a thorough understanding and reduce any uncertainty or anxiety, which will improve the outcome of the condition.

Different views and approach

Hi all, I am currently at gerontology placement and I want to share some experiences with you about what I saw in this placement.
In the first 2 weeks of the placement, I was a bit shocked initally in regard to the workload and treatment approach. The philosophy of physio approach is entirely different from other placements I had before. Obivously, the patient population group is usually frail elderly who had previous history of fall and they comes here for treatment and consultation. I have a patient who had falls and history of OA knees, I was thinking of balance exercises to get him better and more stable on his feet. However, my supervisor adviced that the patient should get a 4WW for ambulation instead. I was confused initially because normally we as a physio want people to be independent as possible so that , I was not very convinced as the notion being delivered into my mind. Basically, the treatment approach is conservative and as I spend more time in this placement I realise that all we do for the patient not only does it prevent falling, it also prevent any aggravation of their concurrent conditions (e.g. pain, fatigue etc). Therefore from this placement, it is good to understand the patient in the other perspective.

Neuro 4 Self reflective practice

As I reach the end of my neuro placement, I wanted a summary of the biggest things I learned throughout these four weeks and highlight the feedback that came out of my final assessment. I’ve had a wonderful supervisor here, because she had this knack of getting you to reflect on your own performance. At our mid placement assessment, she got us to fill out our own blue form, and then she would go through it with us and discuss with us whether she agreed or not. Has anyone been asked to do this? I’d recommend you try it in your last placement, but unfortunately it’s a little too late now. I found it such a great exercise.

So she’d go through the form and discuss the points I made under each section, and made a plan with me for how I could improve them in the next 2 weeks. It’s a good indicator of whether you self-evaluate yourself accurately. Then at the final assessment, she brought out the mid-placement form and would see how we did on improving issues highlighted in week 2. She also asked me to think about how I felt I went, according to feedback I’d gotten on past pracs, and whether I had attempted to address issues highlighted then. I found this self-analysis so useful. In comparison, my current prac mid-placement evaluation involved my treating 1 patient, and my supervisor giving me feedback from that in quite a dictatorial list-type fashion.

My neuro supervisor taught me the importance of self reflective practice, as in a workplace, we are not going to be given a “blue form” every 2-3 weeks, but bosses will still expect to see improvements in our performance. Another positive aspect of this practice was that I found I didn’t kinda… “lump sum” my perceived disappointments as I would in the past. It helped give me structure to analyse those yucky experiences… somehow 

Best positive feedback of the year so far: that I seem to really love physio and am really enthusiastic! This supervisor left me with the most positive message of the year: self-reflective practice plus enthusiasm will make great clinicians. Isn’t it great when someone can do something cool for your confidence? *sigh* what a year…

Neuro 1 The education monkey is off my back!

Earlier in the year, one of the constant difficulties I experienced relayed to my explaining and educating a patient. By and large, I was concentrating so hard to learn Ax and Rx skills that I wasn’t developing my Education and Advice skills as I should have. I dutifully worked time out to include 5 minutes at the end, explaining, educating, prescribing exercises. Problem with that was that I was always rushed for time and I wouldn’t call the best quality 5 mins ever spent. Needless to say, compliance was an issue. It frustrated me that we didn’t reap the results I wanted. It was easy to see that my approach wasn’t working.

My musculo curtin supervisor highlighted some areas for improvement: she underlined the importance of spreading the education throughout the session to reinforce it, and being creative with different tools to help you out. For one particular patient, I thought back about how I could have done a better job of educating him. I came up with the idea of drawing a diagram of a shoulder joint from a superior view, pointing out how short mms vs long weak mms affect where the HoH sits on the glenoid and how that can cause irritation and pain in the anterior structures. I’d go on to explain that we need to work on strengthening one side of the joint, and releasing the other side with stretches etc. to maintain correct centering the HoH. Maybe this will then reinforce for him the importance of his exercises. I’m excited to try this next time when I see a similar patient.

Taking this reflection on board, I went onto my neuro placement ready to impart with the pearls of wisdom. Unfortunately, I again got caught up with learning for myself. The supervisor here emphasized the importance of always leaving ONE msg/task to take away from today’s session. I think of one patient with loss of sensation and fine proprioception of the (R) forearm and hand, and neglect of that hand… I really could have done a better job of explaining the pathology to him and the importance of using his (R) hand during ADLs. I got it towards the end though! I treated a man with moderate (L) sided neglect, (L) trunk and limb weakness. My “msg” for him was along the lines of: “Your brain is playing tricks on you and isn’t allowing you to pay much attention to things that are happening on your left. You need to take it upon yourself to take your attention to the left as much as possible...”

When I reflected over this, I thought how fruitful a little insight into the pathology can be for the pt. I have observed the improvements in rapport, patient satisfaction, patient’s confidence in myself as I worked to improve this aspect of my treatment. I feel that we weren’t given enough emphasis on this at uni. OSPEs for example, didn’t include a component about giving education to the patient. But on pracs this year, it was strongly emphasized… I feel it’s an important aspect of this profession to take on.

Cultural Time Differences

Recently, whilst on my rural prac in India I learnt how much the concept of time differs between cultures. The concept of time in India is completely different to ours in Australia. Here if we say 9:00 we mean 9:00, in India 9:00 could mean 9:30, 10:00, maybe tomorrow. There appears to be a very relaxed attitude towards time, things get done, but very slowly.

This was a very difficult concept for me to adjust to whilst I was there, and at times caused many frustrations. There were many plans that in the end could not be completed due to the difference in concept of time. It made me realise how busy our lifestyles in Australia really are, which is probably why so many of us can not live without a diary, everything is timed down to the last minute. Private practice is a prime example of this, if one or two patients are just a few minutes late, this can put out your entire day.

After I let go of my frustrations, the more relaxed view of time was actually really enjoyable, and it was refreshing to not be in a hurry all the time. There are many things that I will take from this experience. Firstly, I think my new awareness of this cultural difference will help me to be more understanding when treating not only those from the Indian culture, but also from other cultures. Before jumping to conclusions about why they’ve done this or that, I feel like I will now be more considerate that it may just be a difference in the way there culture and my culture view things. It may be that neither one or the other is right, but they’re just different, when treating patients in a society that is so multi-cultural as Australia’s we need to be aware and accommodating to these differences. It’s one of those extra techniques that they can’t really teach us at uni but will make us much more well equipped physiotherapists.

Facebook friends

This week I was put in an awkward situation with one of my patients. I have just started treating a 53 year old lady on my neurology outpatient placement. This particular lady has been a long term patient in outpatients due to several neurological events, and has been treated by a number of students. The same day as our initial session I came home and went on Facebook (as we all do!) to find that this patient had requested to add me as a friend. I also noticed that she was already friends with two other students who had treated her previous to me.

This put me in an awkward situation, I felt obliged to accept this patients request. I felt that if I didn’t she may become offended, especially as other students had accepted her as a friend, and this could affect future treatment. It wasn’t that I didn’t like the patient; in fact I think she is a remarkable lady who is extremely independent despite her deficits. I just felt uncomfortable, like I was doing something wrong or breaking a code of conduct.
After some thought, I came to the conclusion that I had done the right thing. In this particular situation there was nothing suspect, she was a 50-something old lady who wanted some friends (on looking at her Facebook page she only had 16 friends). Had I ignored the request it may have hurt her feelings, and with all the terrible things that had occurred in this ladies past that was the last thing I wanted to do. It did get me thinking though, had this been an 18 year old female, would this be acceptable? Probably not. When I was on practical at PMH, I was told that when treating an adolescent female that I should always have someone else present in the room. In the past female patients had been known to have “crushes” on their male therapists, and even made accusations against those therapists. Accepting them as a Facebook friend could easily be misconstrued by the patient, their parents, and even the physios’ employer. But then again, if it was an 18 year old male it would probably be ok…

I’m sure this situation has happened to many therapists. When I was on a previous prac, a young male patient had mentioned to me in conversation that he was Facebook friends with a female physio. At the time I remember thinking that this was inappropriate; in hindsight the female physio may have been put in same situation as me and did not want to offend. The only conclusion I can make on this is that there is no right or wrong, it depends on the circumstances, and it is up to the therapist to carefully consider these. It would be great to hear others thoughts on, or experiences with, this matter.

MET call

Today on my neurology outpatient placement I experienced my first MET (medical emergency team) call. We were just finishing lunch in the office, and a couple of patients had already arrived and were waiting in the outpatient gym. Our supervisor was describing to us a task he wanted us to perform before the end of the week when we heard someone scream, followed by large thud +++. We all ran out of the office and into the gym to find one of the patients lying on the floor having a seizure. There was also a small pool of blood developing on the floor, from the patient hitting his head. Our supervisor ran to the patient, supported his head and spoke comforting words while the patients’ seizure continued. In the meantime, the students ran around grabbing the first aid kit etc. to stem the bleeding, while another physio called the MET call.

The patients’ seizure lasted almost four minutes, during which he was conscious and talking. Once the seizure had subsided he continued to lie on the floor while we attended to the cut on his head, checked his pulse, and asked him what had happened The patient reported that his arm began “shaking” before he went into a full body fit causing him to fall off the plinth he was sitting on, onto the floor. He seemed quite calm and was making jokes and apologising for causing a scene. The patient was being treated in neurology outpatients for a stroke he had in January, from which he was making a good recovery. He had no past history of seizures or epilepsy. The MET took almost 10 minutes to arrive; they couldn’t find the location of neurology physio outpatients despite being given a clear description of the location. When they did arrive they turned up without the MET trolley, and no one seemed to be taking charge. Thankfully this event did not turn out to be serious enough to warrant a MET call; however I still found their response time, professionalism, and general organisation disgraceful.

This event was very confronting, particularly on initially finding the patient on the floor. The situation did not seem so serious upon seeing the patient conscious and talking during the seizure, but it was shocking nonetheless. After all the drama had finished and the patient had been taken away on a stretcher, our supervisor made the point that he was debating whether or not to call a MET call (the other option would have been to call the neuro ward and get a doctor to attend), but erred on the side of caution. I think if I was in the same situation again, and I was a senior physio taking charge, I would definitely make a MET call even if the situation did not seem serious enough to warrant one. We have a duty of care to our patients, and I would rather get in trouble for making a MET call when it was not indicated than for harm to be caused to a patient after neglecting to do so. I would hope that the response was more rapid and organised than the shambles I witnessed today though!

Anyone else had a MET call/code blue called on a patient??

Expanding Communication Skills

Hey guys

It is clear from reading these blogs that there have been many lessons learned by each of us this year. The biggest lesson I have learnt this year, by far, has been the importance of developing strong communication skills. In my opinion, you could be the smartest student in your year, but this will not necessarily translate to being a good physio without good communication skills.

Communicating with patients has always come very naturally to me, while the academic side probably hasn’t! In most of my placements my supervisors have noted that one of my greatest strengths is building rapport with patients. However there has been two placements in particular that I have found harder than the others, and these placements have highlighted to me that perhaps my communication skills aren’t as good as I thought they were. These two placements have been in paediatrics and neurology. These placements were more difficult to me because my greatest strength, rapport building, was taken away from me.

In paediatrics I felt just a little uncomfortable when it came to communicating with infants. I had no problem with handling these children, or knowing how I was going to treat them, but I felt extremely silly talking in a baby voice and singing! Building rapport with primary school aged children was fine because I could have a conversation with them and play games. As a result, my treatment of these infants was often ineffective because I did not engage them, and they were therefore less inclined to stay still for any length of time. In neurology, my current placement, I have also found that I need to expand upon the ways in which I communicate. Many of you will know how hard it can be to have a conversation with a dysphasic stroke patient, and not having any neuro exposure before has meant that I have found this quite difficult. This has sometimes been to the detriment of treatment effectiveness as I have been unable to describe to the patient exactly what it is I want them to do.

The point of this blog (or the take home message if I were Tom Briffa) is that you can’t use the exact same method of communication for every single patient you see. It is important to develop good communication skills (both verbal and non verbal) for different age groups, different racial backgrounds, for those who can’t speak English, and for those with dysphasia, to name a few. Like most things, this is developed with experience and exposure to these types of patients, and I have since learnt to use different strategies to communicate with these patients (including singing! Poor kids).

Understanding other disciplines

Hey guys, I got back from my rural prac about two weeks ago, which I was lucky enough to do in India through the OT school. There were 10 students that went, myself, four OT’s, 3 speechies and 2 pharmacy students. We worked for about 4 and half weeks at an orphanage/institute for children and adults who had some form of disability or mental illness or may be developmentally normal but orphaned. It was an incredible experience and one I’ll never forget.

One thing I noticed whilst I was over there was how little knowledge both myself and the others had on what each other’s professions actually do. We always talk about working within a team and how important the multi-disciplinary team is. We do learn and experience this to a certain extent this year on prac, but as we all know every prac is different and some may get this experience more than others. It shocked me when one of the speech therapy students, for whom India was her final placement, expressed that she didn’t really know what physiotherapists did. I also realised that I didn’t really understand exactly what speech pathologists did, or the exact role that pharmacists play in the hospital. I felt like I had a bit better an understanding of OT, but even then whilst over there I learnt more about other areas they work in, for example working with children with autism and social interaction and sensory integration. My only interaction with SP this year has been on my neuro prac, so I thought they were all about swallowing, but they also do a lot of work in other areas, like social interaction, encouraging turn-taking and communication.

I realise now how important it is to know the exact role of each person within the multi-disciplinary team and how this really values the patient. The students I went to India with, including the pharmacy students now have a better idea of when it might be important to refer to a physio. One of the pharmacy students even made a comment that if someone with a certain condition comes into their pharmacy now they know that they can refer them to a physiotherapist. I am also much more aware now of the role of the other health professionals and am much more confident that I can recognise when i might need to involve the SP or OT or even the pharmacist in the treatment of a patient, which I feel will enhance the care the patients receive.

Rural placement

Hi guys, sorry for the late entry because I have just came back from my rural placement, as if I have disappeared from the cyber network. Anyway, I would like to share my experiences I earned during my rural placement.

First of all, my rural placement was really enjoyable and rewarding. I mainly did outpatient so that MS outpatient and class works were something that I need to handle in a regular basis. It was my second time to do MS outpatient apart from the actual MS outpatient placement. In comparison to the actual one, I found the true enjoyment of MS outpatient in my rural placement. I used to dislike outpatient because of my poor clinical reasoning and manual handling skills and lack of degree of freedom. During my rural, my feeling towards MS outpatient was vastly different from what I found previously. The facility allowed much more degree of freedom in treatment options that gave me a good training ground to practice and consolidate my knowledge and skills. In addition, there was a wide range of patients’ condition in the rural, and I have treated almost every major joint as compared to the knee joint I mostly treated in my actual MS placement.

In addition to the MS outpatient, I involved in different classes (plum, cardiac, hydro, chronic disease, community class rehab) as well. Those classes sharpened my communication and instruction as well as exercise ideas in different levels of clients.

Therefore, the rural placement was my favorite placement throughout this year as I can truly apply my knowledge into a real practice.

Womens Health 1 Cultural differences

I am currently completing my women’s health placement, focusing largely on inpatient obstetrics, so… post-natal, mostly. My newfound… “insight” this week pertains to the conversations that go on during the lunch breaks in the staff room. The sorts of informal conversations, as per usual, revolve around patients’ cases, situations, social circumstances, decisions etc. Some of the comments that had been flying around made me stop and think for a bit.

One physio was explaining the case: “She had a vaginal delivery, one Caesar, 3… 4… maybe 5 more vaginal deliveries, then this recent one was a Caesar”. In case you’re lost, that means she has 8 kids. At which point most people in the room gasped (which I’m sure you all are too, and which is not too surprising). But then the myriad of comments flying around were along the lines of “You’d think she’d learn after the first 2!” This reaction made me stop, because I found it a little… judgmental? I’m sure they were meant in light humour, and I personally wasn’t that offended but I realised that this reaction wouldn’t be a common one if the conversation was amongst my family, or in my country. I am the oldest of 5 girls, and we actually have one of the smallest families in my extended family. My mother is one of 9. I guess my point is we see nothing “wrong” with large families, and this is largely a culturally different attitude.

Another example from this week revolved around a young patient, a 17 yr old woman who had just given birth to a baby girl, and who she had decided to give up for adoption. The conversation between one staff member and I was regarding this choice. One comment was “Wouldn’t it be easier at that age to just end the pregnancy? Especially if she was going to give it away anyway. Surely that’s the easiest thing.” This one made me stop again… I replied “maybe she’s catholic”, and felt this was dismissed as a “silly” reason. Other than that, I think it pays to remember how hard this situation is for a 17 yr old, who not only has to face the social stigma of an unwanted pregnancy, who may find it hard to tell people, before having to make the decision of what to do with it…. I found that comment unnecessarily judgmental.

Those examples made me reflect on the differences in values present in such a place as a physiotherapy staff room. This is no doubt more likely to surface in a hospital caring for patients with a range of highly sensitive cultural and personal issues. But they made me ponder on the power of how comments we make, driven by our cultural and personal values, have the potential to offend people who hold different values to our own. They risk appearing judgemental, insensitive and… arrogantly western, quite frankly. Of course, this can happen anywhere but I guess I was surprised that I saw it happen so readily in a professional environment. These reflections made me more aware of the importance of my showing respect for others’ cultural differences in professional settings.

Rural 1 Friday afternoon panic

I thought I’d share with you a situation that occurred on a medical ward that, to me, really hit home the importance of interdisciplinary approach and good communication, as well as respect for others’ medical opinion. The patient was an elderly gentleman who was day 7 post a dynamic hip screw as he had sustained a NOF fracture due to a fall. He had also developed mild post-op complications which had resolved but left him weak.

He lived at home alone. He did not receive any home services but had 2 supportive grand-neices. They held strong values against the idea of nursing home or hostel care and they were to help with all ADLs. However, one of them had very recently undergone abdominal surgery. As it was, he was 2 mod assist for transfers and ADLs, and he suffered from dementia and was often very confused. However, his medical condition was stable, so the medical team was pushing for discharge.

Wednesday, the social worker had started an ACAT and had entered in the notes that there were a few home services she deemed appropriate that she couldn’t get organized before the following Wednesday. Thursday, the physio (my supervisor) had entered in the notes his mobility status and had written “not at pre-admission level”. Friday, this patient is on my list, and (very unfortunately for me) I get around to him at around 3.30pm. An entry for Friday from the medical team says amongst other things “For physio mobility r/v” and “planned for discharge Saturday”. I go to do this mobility r/v but the drowsy and confused patient refuses treatment. I turned to my supervisor for help. The medical team had somewhat put her in the awkward position of asking for her medical opinion of his mobility status, even though her entry of the previous day said “not at pre-admission level”, while at the same time pushing for discharge the following day. And the patient wasn’t cooperating. At 4.00pm on Friday. My supervisor and the social worker are a little concerned at this stage about discharging this patient, who was 2 mod assist, didn’t yet have home equipment, and had a carer who had just undergone abdominal surgery. Paging the medical team at what is now close to 5pm on Friday is fruitless. It turns out that the social worker knew of the medical team’s impending discharge as early as Wednesday and had tried to page them on Wednesday, again with no reply.

The eventual outcome was really… not much. Both the social worker and the physio documented that they had tried to page the medical team, but had received no response. The physio also documented that the patient was drowsy, confused, had refused physio and was not at pre-admission level. On Monday, we found that he was indeed discharged on Saturday, and I really have no idea whether this family coped or not.

I reflected on this situation searching for some ideas on what any of us could have done better. It was very unfortunate that I got around to this patient so late. If I had gotten to this patient sooner in the day, I’d like to think that the medical team may still have been contactable. I’ve since learned to try my best to read all the notes in the morning, talk to the nursing coordinator, and prioritise my day’s load. Since doing that, I’ve managed to avoid another sticky situation. I think sometimes it’s difficult as a student because your presence is not really noticed as much as the physio, and the nursing coordinator may not keep you in the loop as he/she may (or may not) have done with the physio. I’ve learned to talk more to nurses, doctors etc, and they’ve responded well, including me in latest developments by word of mouth, rather than my finding out through notes.

Musc 4 Harsh Criticism

First of all, I have to apologise to my fellow students and Peter G for the lack of blogs throughout both semesters. As my final blog for my musculo placement, I thought I’d try and reflect on my biggest learning experience so far this year. This has taken me most of the year to think back upon, digest and finally accept it in a way I can discuss it, hence why it is so late. I really underwent a hard time with my supervisor. I wouldn’t even call it a personality clash, simply a learning style clash. With a lot of other external factors in the mix, for sure. I’ve discussed some of the difficulties I’ve had on this placement in a previous blog.

Firstly, I think the first impression my fellow student and I made on him may have had something to do with it. Maybe he’s just not down with 2 outgoing, cheerful girls, and we may have seemed like airheads to him. The prac unfolded such that both the other student and I felt we were on the receiving end of some slightly hurtful remarks and eye-rolling to our apparent lack of knowledge.

My frustration developed further by other factors such as the very structure of the placement. Time, or lack thereof, was a MASSIVE issue. With so many patients being seen and very little time to reflect on anything learned, or NOT properly learned, blogging became a real nightmare. The 4 to 1 student:supervisor ratio felt very restrictive. I felt like I wasn’t given the support I required for my learning. I fully admit that I was confused a lot of the time (from a musculo knowledge point of view) and have discovered I’m actually not the strong musculo student I thought I was. I felt like reflection was impossible.

At my final Ax with him, I was told that my first week was disastrous and that I looked like I hadn’t studied at all for the prac. I was left feeling really angered at this. First of all, if anyone knows me: so not true. Admittedly, I may not be a strong student and I do think on reflection that I hadn’t prepared the RIGHT things. But I prepared as I thought was necessary and it wasn’t for lack of trying. But really the issue for me was: what does one gain from telling a student that?? I wasn’t left inspired to “redeem” myself and study my butt off. HE doesn’t even really win anything by telling me that.

What I learned from this? Unfortunately, not all the positive ending we all hope for. I walked away from my musculo placement with overwhelming relief that it was over, a massive sense of incompetence in musculoskeletal physiotherapy and a whopping blow to the self-esteem. I guess one positive thing I took away from the experience was my need to work on dealing with tough situations and not get put down by comments at times when I feel frustrated. I wholeheartedly wish I could undergo my musculo placement with this insight and be left with a more positive perspective of musculo. My reduced self-confidence in dealing with supervisors is apparent and has been remarked upon by my current supervisor. As she quite rightly brought up, people are going to be more than happy to criticize us along our career, and sometimes it will feel unfair or not very insightful. I’m glad I had this early exposure to it, and can learn to not let it affect me so much once I’m a graduate.

Musc 3 The importance of picking up at the right place

One of the initial difficulties I found on my musculo placement was picking up patients who were handed over to me. This related to my ability to read someone else’s notes and develop a good picture of where a patient is at. I found that quite difficult, and I would go in and assess quite a few things until I understood what was going on and where the patient was at. This would then leave me very little time to do any treatment, and invariably what suffered was my checking that they were doing their HEP correctly, and progressing it as necessary.

Looking back, I can think of one particular patient whose treatment suffered because of this. She is a 41 yr old woman who presented with knee pain. A thorough Ax revealed that she was very deconditioned in lower limb muscle groups, particularly gluts, had some mild joint hypermobility, and poor muscular control of loaded joints. I hypothesized that this contributed to poor lower limb biomechanics, and as such her treatment consisted of strengthening and gait retraining. This woman also had some cognitive difficulties, the nature of which I am not too sure. Basically, she presented with very poor body awareness, very poor memory and performance of her exercises, poor insight in how strengthening would help her, and poor motivation to do her HEP or apply ice as required. She displayed quite strong catastrophising behaviours, and would report 10/10 pain with everything.

Now, as obvious as it may seem now, I was so focused on working out for myself the cause of her knee pain, that I overlooked that this had really already been worked out by the previous student. Although it doesn’t quite state “patellofemoral syndrome” anywhere in the notes, my clinical reasoning skills should have been sufficient to put the clues together when reading through the notes.

On reflecting back, I saw how I essentially wasted my AND her time because I hadn’t spent enough time reading the notes. I learned through this experience to actively read the notes to really create an image in my head of the patient and the condition before even walking into the cubicle. I also focused on developing my assessment skills to target the specific things the notes suggested to be important, rather than assessing everything under the sun. Thankfully, when I saw a few patients the Ax becomes quicker and I developed more efficiency. But this taught me a lesson to trust the previous therapist’s thinking a bit more, and I applied this to the subsequent patients on my placement. This has also taught me to make sure I am clear in MY notes, to make the next person’s job of picking up after me easier. So a word of advice, please be kind to the people following your place!!

Differences of opinion

On my pediatrics placement I was supervised by three different physiotherapists, spending varying amounts of time with each depending on their schedules. I initially thought this would be a great learning opportunity, and while it was, it was also very difficult because each physiotherapist approached their job in a different manner.

At Curtin we are taught to assess, treat and document in a certain way in each clinical area. On the first day of this particular placement I assessed, treated and documented in the way that we were taught, and was criticised by my supervisor (physio 1) for certain aspects of what I had done. The fact that my supervisor had criticised me did not bother me at all, after all I was there to learn and gain more clinical experience. The next day I was with a different physio (physio 2), and seeing the same patient as the previous day, I took the advice of physio 1 and adjusted my treatment accordingly. Once again I was criticised for certain aspects of the session, however the points of criticism were different than before, and some conflicted with those of physio 1. A similar pattern continued over the next couple of days until I had a firm grasp of what each physio expected and preferred, and from that point I adjusted my approach to suit each supervisor. The differences between the approaches of each supervisor were minor, however they were all quite set in their ways and it was therefore in my best interest to conform to these rather than argue.

My placement did turn out to be a great learning experience, more so for the fact that I learnt how to approach the same thing in different ways. What I did in those treatment sessions was not necessarily wrong, however each of my supervisors had different opinions of what was right. I believe the difference in their opinions was based not only on the fact that they were of different ages and studied in different places, but also that they had found that certain things work for them from past experience. I now realise that what works for one person, may not work for another, and while we have been taught to do something a certain way, there is no reason why you can’t do it differently provided you follow the basic principles.

Learning Opportunities

Hey guys

Sorry i just wanted to finish my blogs off for the year so im posting this early. Through out the year, there have been pracs which i look back on now and just cant help but think that i didnt make the most of them when i was there. I think at different points in the year i lacked some motivation or was just feeling burnt out and didnt extend myself as much as i could have. Sometimes this was the case of not having the opportunities available and quite frankly not asking for them on my behalf either.

I am currently on my rural prac at the moment and i absolutley love it. Every day the effort is made to teach us something and anything i want to learn whilst i am there i can do i just have to ask. The orthopaedic senior will give us tutorials whenever we ask on any joint, has taught us heaps of mulligans and mckenzie techniques and stuff, plus im on inpatients but i prefer outpatients so ive been allowed to spend extra time in OP if i ask, if i want to do more community trips im allowed. Basically i just find it so much more relaxed, before i was worried i would look like a pain if i asked to try different things, now i realized instead of just waiting and hoping the learning opportunities will be presented to you, that sometimes you have to go out and seek them yourself. I have found that the pracs that i have made the effort to really extend myself, i have enjoyed much more as i have not been getting bored from just doing the same thing, or feeling im not learning that much. Which at times has left me quite frustrated.

I think this is the perfect time to try and learn other things were not taught at uni and expand our knowledge as much as we can. It is much easier to give new things a go when there are other people around to give you feedback and tell you how to improve what you are doing. So I guess if anyone has a proper prac left rather than SDP, try and make the most of it and see as many different things as you can and just take responsibility for your own learning, because i think you get a far better feeling of accomplishment for it.

Good luck with the rest of your placements

Documentation

During one of earlier my placements I came under scrutiny for my documentation in the integrated notes. I was a little confused as I was still using the SOAPIER format but I was just missing out the A and the P, as this tended to be just a rewritten list of the above assessment. The other physio’s had written even briefer entries tending to write only the most essential things and often taking up less than 4 lines ( I was taking up about ¾ of a page). I discussed this with the supervisors and agreed to write out full SOAPIERs for every patient to further my understanding of the patients problems, my entries were now well over a page.

During subsequent placements I managed to shorten the length to about ¾ for a new patient and about half a page for continual patients. I dropped the A and P and focussed on the other areas.

I was still writing more than most physios and it made me wonder if I was writing too much. I talked to a couple of physio’s about this and they had differing opinions. Some would say that it would always be better to write too much than not enough, while others would say that you should write the bare essentials as doctors, nurses etc often get annoyed at having such thick files for patients integrated notes.

This made me think and reflect on not only my own notes but what the purpose of writing integrated notes was. Surely we need to describe our assessment we have performed and the treatment we have carried out not only for legal reasons but to enable other health professionals to gain a greater understanding of just exactly what we are doing and have done with the patient. Giving a 4 line entry not only gives false impressions as to what we are doing with the patients but undermines our role as it portrays a simplistic and seemingly unnecessary treatment. This situation made me realise that we need to be thorough with our documentation to ensure our continued role in the health profession as well as to ensure the safety of the patient.

The anxious patient

Hey guys! My apologies, I owe you multiple blogs…

On my current rural practical, I spend half of every day in musculoskeletal outpatients. Last week I had a patient called Lucy* who had been referred for neck pain. Upon getting Lucy from the waiting room it was instantly clear to me that she was very anxious++.

On the short walk from the waiting room to the treatment cubicle Lucy made several comments, including “it’s like going to the dentist”, and she appeared overwhelmed by the size of the physiotherapy department. During subjective questioning it became clear that she had some psychosocial issues (she was being treated for depression), and she became very apologetic if she could not recall the answer to certain questions. When it came to assessing PAIVM’s during the objective assessment, Lucy became claustrophobic from lying in prone with her face in the hole. As a result she had increased tension throughout her cervical and shoulder girdle musculature and this made it very difficult to gain any information from PAIVM’s.

It was at this point I began to recall the communications units we did with Penny, waaayyyy back in second year. We discussed a similar scenario in which a patient presented to physiotherapy extremely anxious, either due to a preconceived notion of what physiotherapy was about, or because of a bad experience with physiotherapy previously. Penny made several points when discussing this scenario 1) that we should spend more time building rapport with such patients, 2) that we should go out of our way to make sure the patient is comfortable, and 3) that we should be more gentle in our assessment and treatment than we might otherwise be to ensure the patients return. Unfortunately I hadn’t really followed any of these principles! However after the flashback I changed my approach. I positioned the patient sitting in a chair, leaning forward and resting her head and arms on pillows placed on top of the plinth. This ensured that she was more comfortable. As treatment, I simply went for a hot pack for 10 minutes over the neck followed by a gentle massage of tight structures. The patient found this quite pleasant and her anxiousness decreased as a result.

In the future if I come across a patient that is particularly anxious I will follow the principles that were discussed in our communications units. This will help to ensure that I gain the patients trust and leave them with a better impression of physiotherapy than they may have had previously. Also, it is important to note that it is never too late to change things if we find that they are not working mid-assessment/treatment.

Supervision & Independence

My neuro placement was quite an interesting one. The hospital I attended did not have a specific neuro ward and instead was to be move and see neuro patients all around hospital. In addition to this I didn’t have a set supervisor, instead I was to report to the physio on the ward I was currently treating a patient on.

Initially it was quite disorientating, as I was constantly changing wards and supervisors. But eventually as with most placements you become accustomed to the routine and the structure. Due to the fact that I was on many wards and had many different supervisors it was often unfeasible to have a supervisor present with every patient. Although it was made clear that if I needed help or was unsure of something with a patient I was to come and get the supervisor on that ward, it was often hard to gain feedback on how I progressing on my handle skills and alternate treatment methods that I could employ with different patients.

Although this situation gave me independence and lead me to develop my organisational skills it left me a little unfulfilled as I felt I was learning as much as I could. I spoke to my curtin tutor about this and she suggested that I try and get at least one supervisor to see me with a patient at least once a day. I tried this but realised that it was unrealistic to get seen everyday, so I managed to get seen a couple of times a week by a supervisor. This initially worked well as I picked up a few incidental things that helped me to deliver a better treatment and assessment, but I still felt that it wasn’t enough. So I asked specific supervisors if I could observe them with some of their patients, and arranged times that I could have a chat to supervisors about patients regarding possible alternative treatment methods. This turned out quite well, enabling me to get a few different perspectives on treating similar patients.

Reflecting back on this placement I think I got the best of both worlds, by developing my independence (and finally feeling like a real physio) as well as still having that support there to be accessed (with some organisation on my part-which was also a learning experience) if needed. I think often we are “spoon fed” a little bit as a physio students by being told how to do everything with step by step instructions that often leave little room for creativity which can stifle us in the long run. With that in mind I think it is important to develop a little bit of independence while still keeping the training wheels on.

Rest Time

Hi guys

Where i am currently on prac, there is a 3 hour rest period for patients, which runs between 12&3. We get lunch during 12-1, however when we come back from lunch all the lights are still switched off on the wards. It is impossible however to get through a very full caseload if we abide this time and therefore the rest time is only intended as no visitors are allowed. The other day i went to go and treat a patient, and a nurse was quite aggressive with me she told me i couldnt see any patients till 3 oclock and that it was rest time.

I tried explaining to her that to get through a full caseload we cannot just not see people for 2 hrs, however she kept being stern with me and so i went and sat down for about an hour and a half and tried to use my time effectively doing paper work etc.

I ended up finishing half an hour late that day as i didnt see any one during that 2 hours. The next day i told my supervisor about the situation as i was quite angry i finished late, and i was quite sure we were allowed to see patients during rest time. She had been told the same thing by a fellow nurse a week earlier.

The physiotherapy department was very upset with this and sent one of the seniors up, to speak with the nursing coordinator, who was very angry at the staff that had told us this, another message was sent out to all nursing staff that we were allowed to see people in rest time, and i was told if anyone else tried to tell me that whilst i was there to come and tell them immediatley.

This situation again has just shown to seek out help if there is a situation you cant deal with. I didnt want to start an argument with the nurse and being a student didnt feel like i had much authority and didnt want to get offside with the nurse.

Mental Health

Hey guys

hope all is well. This part week i have been treating an elderly gentleman, who was in hospital for an amputated toe, he was originally discharged, however readmitted himself to hospital one day later. Over this time he has deteriorated significantly, mainly due to depression and severe lack of motivation, he is not eating and refusing to move out of the bed, previously i could get him to perform bed exercises and at least stand. Due to this increasing uncompliance with all staff members he has developed pressure sores on his heel etc. The other day i went to see him and he would not even perform bed exercises.

I had spoken to my supervisor and expressed my concern that if he didnt get up soon he wouldnt be bale to walk in the next few days. Due to his increasing non compliance she suggested i ask him if he wanted to end up in a nursing home, cause that was were he was headed as a last resort to try and get him up.

So I said this to him, even though i never felt particularly comfortable using this as a threat, this also had no effect on the situation. I know how important it was for me to try anything i could to get him up for his own welfare, however i dont think i will be using a technique like that again i felt absolutley horrible saying it, and i dont think it helped the patients current mental state either. I gave up for this treatment session and instead asked for mental health to review him. I will wait until this has been done as in the meantime my input is useless, i dont feel that anymore pushing will do anygood.

Displaying Presence

My next session with Tom* on my orthopaedic inpatient placement I was able to start mobilizing Tom. I saw Tom with my Curtin supervisor for this session. Because of Tom’s complicated and prolonged hospital stay I decided to take quite a cautious approach by explaining to Tom that if at any time he felt dizziness, nauseous or anything else abnormal to let me know immediately. I also explained to Tom that we would take it slow and we go to sitting over the edge of bed, stay there for a little while and then if things were okay there than we would try a stand with the pulpit frame. Tom agreed to all this. We moved to sitting over the edge of the bed and I continued to question Tom regarding dizziness etc and he said he was fine. I decided to try a stand with the pulpit frame, Tom was quite keen and seemed to be a little frustrated at how slow and cautious I was taking things. I explained to Tom how I wanted him to stand up using the pulpit frame by first pushing on the bed with both hands and then once half way up to bring his hands to the pulpit frame and take the weight through his elbows on the pulpit frame.

Tom then stood up but put his hands on pulpit frame too early, he still managed to stand but was not as safely as I had liked so I told him that I wanted him to sit down and try again. Tom was visibly frustrated but my supervisor and I tried to explain to him that it was important that he learn to transfer safely. I then re-explained to Tom how I wanted him to stand safely, and on the second attempt Tom stood safely.

When receiving feedback from my Curtin supervisor she commented that if this session was my final assessment she may be inclined to fail me on a safety issue. This obviously caused me to reflect on what I could have done to prevent this potential safety issue. I first thought about if I had explained how I wanted Tom to stand...yes I explained but I may have not enforced my presence and ‘authority’ enough. Then I reflected on why I didn’t do that and with some discussion from my clinical supervisor I came to the conclusion that it was the fact that I felt inadequate being so forceful when I was still a student. Reflecting on this made me realise that it is of the utmost importance to display confidence in what we are doing and display a sound presence to patients not only to ‘sell’ physio to our patients but to ensure safety at all times. During my next sessions with Tom and other patients I made sure that I displayed a greater presence and confidence in what I was doing.
*Fictitious names used

Pain Perception

Hi Guys

One of the things, i found on my musculoskeletal clinic, especially in patients whose english was their second language, or they were from a different country, was how much perceptions of pain can differ. I can not be sure whether, it is their perception of pain, or just greater difficulty expressing what exactly they are feeling, as they are not so familiar with the language.

But with quite a few of my patients when i was performing my objective assessment, some of my patients would say pain to just about every direction, or every test. Sometimes it was really hard to get a good idea of patterns or pain behaviour, or just some of the things they would say just didnt add up. (This is really hard to explain to you sorry.)

For example one of my patients would say there was "pain", but it was more just a muscle stretching feeling with AROM of the Cx spine when she had reached end range and not the pain she was complaining off.

What i have learned from this, is how important specific questioning is when performing objective assesments. As things such as combined movements often cause a bit of discomfort in everyone but this is not the same as pain. I think you have to be careful to only ask one question at a time, and find different ways of asking the same thing. Try and limit your words, and ask them to describe the pain, when they are saying everything is painful and it is not an acute problem i will also try to narrow it down by asking which is the worst test.