Potentially Violent Patient's

I’m currently on my musculo inpatients prac and have come across a potentially violent patient. Both myself and another physio student saw this patient together, the patient initially required some convincing to come to physio but did agree. She appeared to me to be a bit short and sharp in her communication but she was not unpleasant. We took her for a walk and whilst walking she began to be quite distressed about something which was unrelated and wanted to go home. The supervising physiotherapist tried to explain to the patient that she was not ready to go home just yet and that she needed to do more work in physio before she could go home. This was when the patient became threatening and the situation was quite tense, the physio stood back from the patient and it was decided that she could go back to her room which she was happy to do.

This was the first time I’ve been involved in a situation like this and it could have potentially been a lot worse. I didn’t feel unsafe however as the patients anger was not directed towards me or the other physiotherapy student, but it does make me think about how I would deal with a situation where a patient was potentially violent. I think that first and foremost we need to protect ourselves and make sure that we don’t place ourselves in a situation where we get backed into a corner or are left alone with the patient. Sometimes patients anger can be due to misunderstandings in which case it may be appropriate to try to reason with the patient and explain the situation, but in other cases the patient may be irrationally angry whether it be due to a mental illness or post-op confusion. Talking to the family can be quite helpful in finding out whether this is normal behaviour for the patient and what the best way to deal with it might be.

In this particular scenario, it was quite easy for the physiotherapist to back away slightly as both myself and the other student were still there to make sure that the patient did not fall and her anger was not directed towards us so I don’t feel that we were in danger, I would have acted in the same way. If the situation was different and you were treating the patient on your own, as I said above you need to consider your safety first and step back to a safe distance or place yourself in a position where you’re not in the patient’s firing line, chances are that if they’re going to lash out there’s not going to be much you can do to stop them from falling anyway. Ultimately, you have to deal with each situation as it comes to hand as every patient’s different and whether you choose to reason with the patient, call for help or step away from the situation, it’s a decision you have to make at the time.

Hidden Causes

Hey Guys

hope all is well.

Whilst on  prac earlier this year I was treating an 65yr old lady for a fractured neck of humerus, which was caused by a fall.  When performing my subjective assessment with this lady i asked her to recount her her fall.   She told me she had fallen whilst sorting the washing in her daughter's room. Having previously read the emergency and follow up reports written by doctor's of her story about how she had fallen, it remained vague and varied quite significantly with each account. 

Whilst I was primarily treating her fracture I noticed from her history that she had had another fall the previous year. I mentioned to her that given she had several falls it would be a good idea to work on her balance also during her hospital stay. With this comment she became very defensive and said she had not fallen and had not had several falls, however quickly retracted this comment and said that would be a good idea.  Given the closeness of this ward and the open rooms i would be walking to the gym and frequently see her in her room. She would be crying and looking quite depressed.  This all did not seem quite right to me especially how defensive she was in denying having a fall.

My supervisor later bumped into me and said her daughter to whom this lady was a full-time carer had dropped in when whilst I wasn't there. She appeared to bully her mother and would huddle over and whisper to her mother whilst looking agitatedly at the staff. I noticed my patient would also clam up and get upset at the mention of her daughter. My supervisor later asked if I thought it was possible that the daughter had pushed her over.  I thought this was quite possible as there were many things about the situation which didn't quite add up.  I have tried to include the main things in this blog but it was more a gut feeling something wasn't quite right.

This was quite a new situation for me and I hadn't dealt with this before.  In previous treatments due to her teary and depressed state, I had been more compassionate with treatment and tried not to push her to hard, whilst also making sure to veer the topic of conversation whilst treating her onto subjects which made her happy.  However due to my inexperience I discussed this situation with my supervisor, she told me that I should mention casually to my pt that if she wanted anyone to talk to there was the chaplain or a clinical psychologist who were able to help out and gave me some pamphlets to leave on her table.  I didn't think me delving into this situation would be any use given how defensive and withdrawn she would become at any mention of the fall.

If I was in this situation again I think I would still find it very difficult to deal with.  I think you have to read each patient in this situation as an individual as some people may be more willing to open up to you, however there are probably people better qualified to provide advice or counselling in this situation then us.  

Sorry for the long post and any comments would be much appreciated.

ICU treatment justification

Hi Everyone,
Hope everyone’s pracs have started well! I have just started in ICU, and in the weeks leading up to it I was really intimidated and not really looking forward to working with people who could quite easily die at any moment. Fortunately our supervisor, the other physios, the doctors and the nurses are all really nice, and really accommodating-they are always happy to explain anything I don’t quite understand or to help me with my problem solving. In fact we have all been getting mini tutorials from different staff members about various conditions, surgeries, CXR’s etc, and it has been a very interesting learning experience so far.
Despite this I was almost completely put off on my second day after treating a very young patient, with a multitude of problems (multi-organ failure), with one of the other students. We had just done MHI for the first time, with inspiratory pauses, and half way through our treatment the patient had some ECG changes and her heart rate and BP dropped significantly. Our supervisor told us not to do the inspiratory pauses anymore but to keep going with bagging. After we finished treatment the nurse said the patient had had an ischaemic episode whilst we were bagging-which in such a sick patient was a big deal! Three hours later the patient suffered complete heat block and there was nearly a code blue.
Even though this happened a number of hours after our treatment I couldn’t help but think that it was our treatment that caused it to happen, especially since it was the first time I had every bagged someone!
The next day I talked with the supervisor and the nurse, both of whom were very nice and explained that it was not out fault, since the patient was so sick and had such poor cardiac function that it didn’t matter who bagged her it would have had the same effect. There were indications that it needed to be done, and we couldn’t not treat her just because she was at risk of complications from the treatment, it was the same as with patients who have an elevated ICP-we have to decide whether the need for treatment is greater than the risk of causing adverse effects.
The ICU is a very high pressure environment, and the patients are all very unwell, however they also all need physio treatment, we just need to have justification for our chosen intervention, and be ready to deal with the consequences. We need to be confident in what we are doing and why we are doing it, and as long as we are careful to limit any possible negative effects then there is no reason to not treat someone. Just look carefully at the situation, and try to remember that what you are doing is most likely going to have a positive effect and going to aid their recovery.
Our patient is still in the ICU, and very, very unwell but at least they are still alive!