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.
Monday, September 29, 2008
Cancellations
Hey Guys
i think i owe you a couple of posts...
When i was on my musculoskeletal clinic, one of the things that frustrated me the most was cancellations by patients, except most of the time they wouldnt even make the effort to cancel they would just not show up. This frustrated me quite a bit as i would always have prepared for my patients, and if it was a new patient this meant 1.5 hrs of my time wasted not being able to do anything, or see any other patients. Especially when they don't ring as you spend 20mins waitng for them and then cant go in and watch someone elses treatment which i also find you learn from. Also it does not allow you to fill the space with another client.
The thing i have learnt from this experience is that, if i were to work in private practice in the future where this would cost you money as apposed to the public system, i would put a reminder system in place where everyone gets a reminder the day before there appointment, wither by phone call, email or SMS. This way if something else had cropped up, they would be more likely to ring up, and give an opportunity for someone else to fill the space. On days when 3 or so patients would cancel i think you also have to consider using a cancellation fee, especially if people do not have a reasonible explanation, or ring so late. For clients that are frequent cancellers than i would also not consider booking them in ahead, and instead tell them to ring when they wanted another appointment. I know this may lose you an app. or two but i really hated when i spent an hour or so looking at different treatment optiona and planning my goals for them.
i think i owe you a couple of posts...
When i was on my musculoskeletal clinic, one of the things that frustrated me the most was cancellations by patients, except most of the time they wouldnt even make the effort to cancel they would just not show up. This frustrated me quite a bit as i would always have prepared for my patients, and if it was a new patient this meant 1.5 hrs of my time wasted not being able to do anything, or see any other patients. Especially when they don't ring as you spend 20mins waitng for them and then cant go in and watch someone elses treatment which i also find you learn from. Also it does not allow you to fill the space with another client.
The thing i have learnt from this experience is that, if i were to work in private practice in the future where this would cost you money as apposed to the public system, i would put a reminder system in place where everyone gets a reminder the day before there appointment, wither by phone call, email or SMS. This way if something else had cropped up, they would be more likely to ring up, and give an opportunity for someone else to fill the space. On days when 3 or so patients would cancel i think you also have to consider using a cancellation fee, especially if people do not have a reasonible explanation, or ring so late. For clients that are frequent cancellers than i would also not consider booking them in ahead, and instead tell them to ring when they wanted another appointment. I know this may lose you an app. or two but i really hated when i spent an hour or so looking at different treatment optiona and planning my goals for them.
Sunday, September 28, 2008
Communication
During my orthopaedic inpatient placement I was treating a patient named Tom* who had quite a complicated hospital stay after a fairly simple tibia fracture. His fracture was complicated by compartment syndrome resulting in a fairly lengthy hospital stay.
I saw Tom day 1 post LCL and biceps femoris repair. The post op orders were mobilise as able NWB, hinged knee brace locked at 10 degrees for 6 weeks. So I went and saw tom who was lying in bed, I started off with the usual questions and assessment. Tom seemed slightly anxious, as was understandable due to his long hospital stay and complications. I explained to Tom that the doctors had given us the okay to start mobilizing as able. Tom then told me that the consultant had just been around and told him that he was to stay in bed for the next 3 days. I told Tom that that wasn’t what i had been told and what was written in his notes but I would talk to the doctors and find out what they wanted.
I paged the registrar but received no response. I then chatted to my supervisor who said she would try and get in contact with them. The following day I met with the registrar who said it was okay to mobilize and to follow the post op orders. So I went and told Tom who was a little reluctant but was willing. I explained to tom our plan and how I wanted him to transfer and ambulate etc. and just as we were about to sit over the edge of the bed the registrar whom I had just talked to and had given the okay for mobilization came into Tom’s room. The doctor ignored me and starting talking to Tom, she then explained to Tom that he was not to listen to what the physio or nurses told him and was to stay in bed for the next two days. I was shocked, because about half an hour ago she had told me it was okay to mobilize and now she was making me look completely incompetent.
After the registrar had left I told Tom that we would do as the registrar and consultant says and wait as we didn’t want to cause any damage. The next day we walked with axillary crutches with no problems.
This situation made me think about communication and how important it is in effectively treating patients. There seemed to be not only miscommunication between me and the registrar but also between the registrar and her consultant. I talked to my supervisor about this situation and she told me that this was a fairly common occurrence. Upon reflection of this situation I should have tried to have a talk to the registrar about how she could have talked to me about the situation outside of Tom’s room to avoid undermining me and physio in front of Tom.
*Fictitious names used
I saw Tom day 1 post LCL and biceps femoris repair. The post op orders were mobilise as able NWB, hinged knee brace locked at 10 degrees for 6 weeks. So I went and saw tom who was lying in bed, I started off with the usual questions and assessment. Tom seemed slightly anxious, as was understandable due to his long hospital stay and complications. I explained to Tom that the doctors had given us the okay to start mobilizing as able. Tom then told me that the consultant had just been around and told him that he was to stay in bed for the next 3 days. I told Tom that that wasn’t what i had been told and what was written in his notes but I would talk to the doctors and find out what they wanted.
I paged the registrar but received no response. I then chatted to my supervisor who said she would try and get in contact with them. The following day I met with the registrar who said it was okay to mobilize and to follow the post op orders. So I went and told Tom who was a little reluctant but was willing. I explained to tom our plan and how I wanted him to transfer and ambulate etc. and just as we were about to sit over the edge of the bed the registrar whom I had just talked to and had given the okay for mobilization came into Tom’s room. The doctor ignored me and starting talking to Tom, she then explained to Tom that he was not to listen to what the physio or nurses told him and was to stay in bed for the next two days. I was shocked, because about half an hour ago she had told me it was okay to mobilize and now she was making me look completely incompetent.
After the registrar had left I told Tom that we would do as the registrar and consultant says and wait as we didn’t want to cause any damage. The next day we walked with axillary crutches with no problems.
This situation made me think about communication and how important it is in effectively treating patients. There seemed to be not only miscommunication between me and the registrar but also between the registrar and her consultant. I talked to my supervisor about this situation and she told me that this was a fairly common occurrence. Upon reflection of this situation I should have tried to have a talk to the registrar about how she could have talked to me about the situation outside of Tom’s room to avoid undermining me and physio in front of Tom.
*Fictitious names used
Saturday, September 20, 2008
Patients Refusing Treatment
During my placement in orthopaedic inpatients I experienced two patents who refused physio treatment. The first patient was an ex member of the bikie gang the coffin cheaters, who was admitted after an osteomyelitis infection and mal-union (which he blamed physio for). My supervisor and I tried to persuade this patient to do some form of exercise, but he was reluctant and told us that physio would only make things worse. We tried to explain to him that the doctors had told us to give him some exercises and that the aim of physio was to prevent further complications as well as enable him to return to function as quickly as possible. The patient still refused, commenting that he would perform his own exercises.
The second patient was an elderly Italian man who did not speak much English. He had been admitted after a fall which resulted in a hip fracture requiring a dynamic hip screw. My supervisor and I tried to persuade him to ambulate and perform some exercises. The patient refused, commenting that he would not get out of bed for 10 days. We then had a translator and the medical team come in to try and persuade him to ambulate with us, but he still refused and only agreed to perform some ankle pumps and deep breathing exercises while lying in bed.
Upon reflecting on these two incidents I was a little angry that both of these patients seemed to hold physio in such low regard, but further education on the benefits of physio with both of these patients proved unbeneficial. On further reflection I realised that we can only educate a patient to the best of our ability regarding the benefits of physio and mobilization but in the end it is up to the individual whether they decide to take the information on board. These situations have made me realise that we cannot change a patients mind but can only aim to guide them to the best treatment available and in the end the decision is theirs.
The second patient was an elderly Italian man who did not speak much English. He had been admitted after a fall which resulted in a hip fracture requiring a dynamic hip screw. My supervisor and I tried to persuade him to ambulate and perform some exercises. The patient refused, commenting that he would not get out of bed for 10 days. We then had a translator and the medical team come in to try and persuade him to ambulate with us, but he still refused and only agreed to perform some ankle pumps and deep breathing exercises while lying in bed.
Upon reflecting on these two incidents I was a little angry that both of these patients seemed to hold physio in such low regard, but further education on the benefits of physio with both of these patients proved unbeneficial. On further reflection I realised that we can only educate a patient to the best of our ability regarding the benefits of physio and mobilization but in the end it is up to the individual whether they decide to take the information on board. These situations have made me realise that we cannot change a patients mind but can only aim to guide them to the best treatment available and in the end the decision is theirs.
Tuesday, September 16, 2008
Flexibility
Oops it appears I am one blog short for P2 so here it is:
I was treating a very interesting Parksinson's patient on my neuro prac who elected to admit herself to hospital for a review of her Parksinson's medications. The patient was very much affected by the "on-off" phenomena associated with her medications, and was experiencing more frequent "offs" and unpredictable "offs". During her "off" times, before the medication kicked in she had marked bradykinesia, occasional freezing, slow shuffling gait and dystonia in her left foot. The patient told me that when she is at home (she lives alone), she tends to not be able to do very much during her "off" times- and mostly chooses to sit and do nothing and wait until she comes "on" again.
During her time in hospital, she was trialling a 2 hourly medication schedule- most of the time it took about 30 mins for her medication to really kick in, and started to fade just prior to her next dose- however this was not always the case. Being busy with other patients, I was not always able to see her during her "on" times and would often see her when she was quite "off". I think seeing a patient when they are at their best and at their worst is important- as it was during her "off" times when she had the most difficulty with her mobility. In the beginning I would plan out a treatment session and try and implement my plan regardless of how on/off she was. I soon realised this was not ideal- when "off" certain exercises exacerbated her dystonia and bradykinesia, whereas other more rhythmic exercises like simple walking would actually assist her to come "on".
So for the remainder of my time treating the patient, I was extremely flexible with my treatment sessions. I would hand a lot of the control and choices over to the patient, as ultimately, she was the one who knew what was most beneficial for her at any stage. Sometimes when she was very off, we would just walk laps around the ward until she started coming on, then I would throw in some simple exercises and variations along the way as we walked. When she was on, I could do quite a lot more with her, including trunk rotation exercises, fit ball exercises, etc.
I guess the point of this blog was just to highlight that with some patients, careful planning is very important but with other patients, all the planning in the world won't help! We need to be prepared to be very flexible and have a variety of options up our sleeve, depending on the state of the patient. I think handing many of the choices over to the patient also helped her gain a sense of control over her situation.
I was treating a very interesting Parksinson's patient on my neuro prac who elected to admit herself to hospital for a review of her Parksinson's medications. The patient was very much affected by the "on-off" phenomena associated with her medications, and was experiencing more frequent "offs" and unpredictable "offs". During her "off" times, before the medication kicked in she had marked bradykinesia, occasional freezing, slow shuffling gait and dystonia in her left foot. The patient told me that when she is at home (she lives alone), she tends to not be able to do very much during her "off" times- and mostly chooses to sit and do nothing and wait until she comes "on" again.
During her time in hospital, she was trialling a 2 hourly medication schedule- most of the time it took about 30 mins for her medication to really kick in, and started to fade just prior to her next dose- however this was not always the case. Being busy with other patients, I was not always able to see her during her "on" times and would often see her when she was quite "off". I think seeing a patient when they are at their best and at their worst is important- as it was during her "off" times when she had the most difficulty with her mobility. In the beginning I would plan out a treatment session and try and implement my plan regardless of how on/off she was. I soon realised this was not ideal- when "off" certain exercises exacerbated her dystonia and bradykinesia, whereas other more rhythmic exercises like simple walking would actually assist her to come "on".
So for the remainder of my time treating the patient, I was extremely flexible with my treatment sessions. I would hand a lot of the control and choices over to the patient, as ultimately, she was the one who knew what was most beneficial for her at any stage. Sometimes when she was very off, we would just walk laps around the ward until she started coming on, then I would throw in some simple exercises and variations along the way as we walked. When she was on, I could do quite a lot more with her, including trunk rotation exercises, fit ball exercises, etc.
I guess the point of this blog was just to highlight that with some patients, careful planning is very important but with other patients, all the planning in the world won't help! We need to be prepared to be very flexible and have a variety of options up our sleeve, depending on the state of the patient. I think handing many of the choices over to the patient also helped her gain a sense of control over her situation.
Monday, September 15, 2008
Rehab potential
I was treating a dense stroke patient on my neuro prac who has a long-standing large basilar artery aneurysm. Prior to this hospital admission, the patient had already had 2 strokes because of this aneurysm, as it kept expanding and compressing various structures eg brainstem. He had been in hospital approximately 3 weeks and rehab was going quite well (a referral to a rehab facility had just been made), when he had a 4th stroke- leaving him with almost no movement on his right side.
Rehab was coming along quite slowly, he was gradually getting some small amount of movement back in his right leg, and to a lesser degree, right arm. His sitting balance was definitely improving and we were eventually able to stand him with 2 MAX assist (the patient weighed 140kg!) and he could stand statically for about 3 mins max.
Anyway the discussion of discharge planning came up and the medical team was left with the following dilemma: due to the nature of this large aneurysm (which is inoperable) and his PMH, the sad reality is that this aneurysm will eventually be fatal, it could be days or it could be years- no one can ever know. The question posed to the medical team and the patient was- do we send him to a rehab facility for long-term rehab, knowing that he could have another massive and possibly fatal stroke at any minute?
Thankfully and rightfully, the decision was left entirely with the patient. He had to weigh up whether or not he wished to spend (potentially) several months in a rehab facility going through intensive rehab or whether he wished to spend his time closer to his family in a high care facility or with services at home. In the end he chose to go to a rehab facility.
The reason I brought up this particular scenario is that I'm sure it is not an entirely uncommon situation for terminal patient's to be in. The patient should be aware of all the facts and options, and then left to make their decision on their own. As health professionals we are used to giving patient's advice wherever possible, but in this particular situation I think it is actually better to keep our opinions to ourselves and let the patient make up their mind- then support the patient's decision, whatever it may be. Having come across this particular situation I think I will now have more empathy and understanding if faced with something similar in the future.
Rehab was coming along quite slowly, he was gradually getting some small amount of movement back in his right leg, and to a lesser degree, right arm. His sitting balance was definitely improving and we were eventually able to stand him with 2 MAX assist (the patient weighed 140kg!) and he could stand statically for about 3 mins max.
Anyway the discussion of discharge planning came up and the medical team was left with the following dilemma: due to the nature of this large aneurysm (which is inoperable) and his PMH, the sad reality is that this aneurysm will eventually be fatal, it could be days or it could be years- no one can ever know. The question posed to the medical team and the patient was- do we send him to a rehab facility for long-term rehab, knowing that he could have another massive and possibly fatal stroke at any minute?
Thankfully and rightfully, the decision was left entirely with the patient. He had to weigh up whether or not he wished to spend (potentially) several months in a rehab facility going through intensive rehab or whether he wished to spend his time closer to his family in a high care facility or with services at home. In the end he chose to go to a rehab facility.
The reason I brought up this particular scenario is that I'm sure it is not an entirely uncommon situation for terminal patient's to be in. The patient should be aware of all the facts and options, and then left to make their decision on their own. As health professionals we are used to giving patient's advice wherever possible, but in this particular situation I think it is actually better to keep our opinions to ourselves and let the patient make up their mind- then support the patient's decision, whatever it may be. Having come across this particular situation I think I will now have more empathy and understanding if faced with something similar in the future.
Reporting on parents
Hi Guys,
Hope everyone passed their clinic ok!
During my third week on my paeds prac I went on a home visit on my own, to the house of a client I had treated the week before on my own and the week before that with my supervisor. I got on quite well with the mother and the child, however before we had gone to see them the first week my supervisor had told me to be aware that the mother could be quite “stressy” and if she started asking me heaps of questions not to worry. The first time that I was there by myself was fine, she didn’t do anything inappropriate or ask many questions, she just seemed like she wanted to chat to me, but the second time (the next day) she seemed a bit stressed and made several strange comments about the availability of funding to parents and how it was allocated. She seemed to think that extra funding was being kept secret from parents so that it didn’t all get used up. I didn’t think that much of it at the time.
The next week I went there with my supervisor, who told me that she needed to speak to the mother about something and that I should treat the child whilst she was doing so. I did this and nothing seemed out of the ordinary and the mother seemed fine. However when I went back there on my own the next day she seemed very agitated and stressed, and was on the phone when I arrived, she seemed to be talking about the availability of funding for bathroom equipment. After this she chatted to me for about 10 mins before she received another phone call. After this she came back to talk to me, it was at the end of my session and I was just about to get the child out of her Trixie walker when she suddenly went into very strong massed extension (she has athetoid CP) and nearly tipped the walker backwards (on tiled floor). I grabbed the walker and stopped it from tipping, and the child was fine. As soon as this happened the mother started complaining that her child was “in between sizes” for the walker and was too big, and was supposed to be getting a new wheelchair but that my supervisor had told her yesterday that funding was not available and they would not be getting one. What she said next was very alarming, as she said that in that case she was just going to leave the child in the walker (she is unable to walk independently in it and really just stands in it) all day and if she fell over or tipped it that she would tell my supervisor that it was her fault! It did not seem to me like she was just making idle threats or bluffing, she was quite serious, and since the child has a lot of strong chorea movements that could very easily cause her to fall onto the tiled floor I was quite concerned.
When I got back to the centre I spoke to my supervisor about what had happened and what the mother had said as I thought that it was very important that she know exactly what the mother had said. She told me that I had done the right thing and that she would talk to the mother about it and sort the situation out, luckily I didn’t have to go and see them again.
When I looked back on the situation I know I did the right thing telling my supervisor about it, I felt really bad about “dobbing in” the mother and almost betraying her confidence, but in the end it was a matter of safety and even if the mother had just been bluffing it would have been wrong not to report it. If I was in the same situation again I would do the same thing, a child’s safety is more important than a mother getting mad at me!
Hope everyone passed their clinic ok!
During my third week on my paeds prac I went on a home visit on my own, to the house of a client I had treated the week before on my own and the week before that with my supervisor. I got on quite well with the mother and the child, however before we had gone to see them the first week my supervisor had told me to be aware that the mother could be quite “stressy” and if she started asking me heaps of questions not to worry. The first time that I was there by myself was fine, she didn’t do anything inappropriate or ask many questions, she just seemed like she wanted to chat to me, but the second time (the next day) she seemed a bit stressed and made several strange comments about the availability of funding to parents and how it was allocated. She seemed to think that extra funding was being kept secret from parents so that it didn’t all get used up. I didn’t think that much of it at the time.
The next week I went there with my supervisor, who told me that she needed to speak to the mother about something and that I should treat the child whilst she was doing so. I did this and nothing seemed out of the ordinary and the mother seemed fine. However when I went back there on my own the next day she seemed very agitated and stressed, and was on the phone when I arrived, she seemed to be talking about the availability of funding for bathroom equipment. After this she chatted to me for about 10 mins before she received another phone call. After this she came back to talk to me, it was at the end of my session and I was just about to get the child out of her Trixie walker when she suddenly went into very strong massed extension (she has athetoid CP) and nearly tipped the walker backwards (on tiled floor). I grabbed the walker and stopped it from tipping, and the child was fine. As soon as this happened the mother started complaining that her child was “in between sizes” for the walker and was too big, and was supposed to be getting a new wheelchair but that my supervisor had told her yesterday that funding was not available and they would not be getting one. What she said next was very alarming, as she said that in that case she was just going to leave the child in the walker (she is unable to walk independently in it and really just stands in it) all day and if she fell over or tipped it that she would tell my supervisor that it was her fault! It did not seem to me like she was just making idle threats or bluffing, she was quite serious, and since the child has a lot of strong chorea movements that could very easily cause her to fall onto the tiled floor I was quite concerned.
When I got back to the centre I spoke to my supervisor about what had happened and what the mother had said as I thought that it was very important that she know exactly what the mother had said. She told me that I had done the right thing and that she would talk to the mother about it and sort the situation out, luckily I didn’t have to go and see them again.
When I looked back on the situation I know I did the right thing telling my supervisor about it, I felt really bad about “dobbing in” the mother and almost betraying her confidence, but in the end it was a matter of safety and even if the mother had just been bluffing it would have been wrong not to report it. If I was in the same situation again I would do the same thing, a child’s safety is more important than a mother getting mad at me!
Sunday, September 14, 2008
things other than treatment
Hello everyone how are you guys going? That is good to have a week off that gives us a fine refreshment in between the placement. After 4 weeks of cardio placement, I just want to summarise what I have learnt from this placement.
For the physio treatment techniques, it is not that many options compared with neuro or musculo. Treatment techniques that I always use are ACBT, positioning, SMI, percussion or vibration and ambulation. In addition, the selection of the treatment technique is based on the 10 cardio problems that give us a nice and clear guideline to follow. Therefore, in the purely treatment point of view, there should not be any extreme difficulties that we might encounter.
However, what challenging for me in this placement were treatment progression and discharge planning. I found it struggling to decide the discharge plan for some of the patients and it was just too many things to consider. For instance, we need to consider their home situation, whether or not patients’ physical condition will be able to cope at home. If we decide they will not be able to cope as where they were, then there are certain of pathways that patients may go like high or low care nursing home, retirement village, or just rehab in the home. In the decision process, it requires the whole allied health team involvement in order to best suit patients’ discharge planning so that our clinical judgement and experience is essentially important. Thus cardio placement is a good place to learn and understand the decision process of the discharge planning.
In addition, patient prioritisation and time management is also something worth mentioning in the cardio placement. Perhaps there is only one or two physio at the cardio ward so that it is a good practice to organise which patient you see the first and which you see the last, which depends on the patient condition. It really challenge my time allocation on each patient and meanwhile providing the effective physio treatment.
Last but not least, cardio is not just about cardio, it is more than I think it was. In particular effective communication, patient prioritisation and teamwork are needed in the placement.
For the physio treatment techniques, it is not that many options compared with neuro or musculo. Treatment techniques that I always use are ACBT, positioning, SMI, percussion or vibration and ambulation. In addition, the selection of the treatment technique is based on the 10 cardio problems that give us a nice and clear guideline to follow. Therefore, in the purely treatment point of view, there should not be any extreme difficulties that we might encounter.
However, what challenging for me in this placement were treatment progression and discharge planning. I found it struggling to decide the discharge plan for some of the patients and it was just too many things to consider. For instance, we need to consider their home situation, whether or not patients’ physical condition will be able to cope at home. If we decide they will not be able to cope as where they were, then there are certain of pathways that patients may go like high or low care nursing home, retirement village, or just rehab in the home. In the decision process, it requires the whole allied health team involvement in order to best suit patients’ discharge planning so that our clinical judgement and experience is essentially important. Thus cardio placement is a good place to learn and understand the decision process of the discharge planning.
In addition, patient prioritisation and time management is also something worth mentioning in the cardio placement. Perhaps there is only one or two physio at the cardio ward so that it is a good practice to organise which patient you see the first and which you see the last, which depends on the patient condition. It really challenge my time allocation on each patient and meanwhile providing the effective physio treatment.
Last but not least, cardio is not just about cardio, it is more than I think it was. In particular effective communication, patient prioritisation and teamwork are needed in the placement.
things other than treatment
Hello everyone how are you guys going? That is good to have a week off that gives us a fine refreshment in between the placement. After 4 weeks of cardio placement, I just want to summarise what I have learnt from this placement.
For the physio treatment techniques, it is not that many options compared with neuro or musculo. Treatment techniques that I always use are ACBT, positioning, SMI, percussion or vibration and ambulation. In addition, the selection of the treatment technique is based on the 10 cardio problems that give us a nice and clear guideline to follow. Therefore, in the purely treatment point of view, there should not be any extreme difficulties that we might encounter.
However, what challenging for me in this placement were treatment progression and discharge planning. I found it struggling to decide the discharge plan for some of the patients and it was just too many things to consider. For instance, we need to consider their home situation, whether or not patients’ physical condition will be able to cope at home. If we decide they will not be able to cope as where they were, then there are certain of pathways that patients may go like high or low care nursing home, retirement village, or just rehab in the home. In the decision process, it requires the whole allied health team involvement in order to best suit patients’ discharge planning so that our clinical judgement and experience is essentially important. Thus cardio placement is a good place to learn and understand the decision process of the discharge planning.
In addition, patient prioritisation and time management is also something worth mentioning in the cardio placement. Perhaps there is only one or two physio at the cardio ward so that it is a good practice to organise which patient you see the first and which you see the last, which depends on the patient condition. It really challenge my time allocation on each patient and meanwhile providing the effective physio treatment.
Last but not least, cardio is not just about cardio, it is more than I think it was. In particular effective communication, patient prioritisation and teamwork are needed in the placement.
For the physio treatment techniques, it is not that many options compared with neuro or musculo. Treatment techniques that I always use are ACBT, positioning, SMI, percussion or vibration and ambulation. In addition, the selection of the treatment technique is based on the 10 cardio problems that give us a nice and clear guideline to follow. Therefore, in the purely treatment point of view, there should not be any extreme difficulties that we might encounter.
However, what challenging for me in this placement were treatment progression and discharge planning. I found it struggling to decide the discharge plan for some of the patients and it was just too many things to consider. For instance, we need to consider their home situation, whether or not patients’ physical condition will be able to cope at home. If we decide they will not be able to cope as where they were, then there are certain of pathways that patients may go like high or low care nursing home, retirement village, or just rehab in the home. In the decision process, it requires the whole allied health team involvement in order to best suit patients’ discharge planning so that our clinical judgement and experience is essentially important. Thus cardio placement is a good place to learn and understand the decision process of the discharge planning.
In addition, patient prioritisation and time management is also something worth mentioning in the cardio placement. Perhaps there is only one or two physio at the cardio ward so that it is a good practice to organise which patient you see the first and which you see the last, which depends on the patient condition. It really challenge my time allocation on each patient and meanwhile providing the effective physio treatment.
Last but not least, cardio is not just about cardio, it is more than I think it was. In particular effective communication, patient prioritisation and teamwork are needed in the placement.
Monday, September 8, 2008
Relationships with Supervisors
My first experience with my Curtin clinical tutor was a good one. She started our session by asking me what I wanted to get out of this prac, what I thought I needed to work on, what my learning style was and how I wanted our sessions to run e.g. with her standing back and just observing or playing a more integral role in the session. I commented that I would like her to interrupt only if I felt that I was doing something drastically wrong but still be available for support if I felt that something could be performed in a better way. She said that was fine and would only interrupt if something was unsafe or unless I asked her a question.
I was very appreciative that this supervisor was willing to adapt her teaching methods to suit my learning style and seemed to take everything I wanted to learn on board. As often supervisors can get carried away with the assessment part of prac, instead of the facilitated learning that we as students pay for.
So quite contented that my supervisor had listened to everything I had said we went off to see the patient we had organised to see. I started my subjective and was interrupted every couple of questions by my supervisor whereby she would ask me to ask a specific question with which I was just about to ask. Initially I let it slide and asked the question then as it continued to happen I started to get more frustrated and said still in a polite manner that “I was just about to ask that”. Then with my subjective over I started my objective assessment, this continued along the same manner with my supervisor interrupting me asking me about different things I should assess (some of which I had already performed). My supervisor’s interruptions continued throughout the whole treatment session and by the end I was starting to get quite frustrated.
Upon completion of the session with the patient my supervisor asked to talk to her about how I thought it went. I was unsure of whether or not to tell her how frustrated I was at her interruptions, especially because she had asked me previously how I had wanted the sessions to run. I decided to tell her as I felt that if I didn’t future sessions would continue along the same way and could eventually lead to some big problems. I told her that I felt her frequent interruptions interrupted my flow of the session and I felt very frustrated because often the things she would suggest was the things I was just about to ask or do and it made it seem as if I wasn’t going to do them. She was very open and admitted her mistake and agreed to do as initially mentioned and only interrupt if safety was compromised or I seeked guidance.
Future sessions ran very smoothly and our relationship had drastically improved and I feel much more comfortable seeking her guidance. Reflecting back on the situation I wonder if I should have tried to communicate my frustration to my tutor during the session with the patient, and I think I made the right choice by waiting till after the treatment session because although it may have saved me a lot of frustration I think it would have possibly compromised professionalism with the patient.
I was very appreciative that this supervisor was willing to adapt her teaching methods to suit my learning style and seemed to take everything I wanted to learn on board. As often supervisors can get carried away with the assessment part of prac, instead of the facilitated learning that we as students pay for.
So quite contented that my supervisor had listened to everything I had said we went off to see the patient we had organised to see. I started my subjective and was interrupted every couple of questions by my supervisor whereby she would ask me to ask a specific question with which I was just about to ask. Initially I let it slide and asked the question then as it continued to happen I started to get more frustrated and said still in a polite manner that “I was just about to ask that”. Then with my subjective over I started my objective assessment, this continued along the same manner with my supervisor interrupting me asking me about different things I should assess (some of which I had already performed). My supervisor’s interruptions continued throughout the whole treatment session and by the end I was starting to get quite frustrated.
Upon completion of the session with the patient my supervisor asked to talk to her about how I thought it went. I was unsure of whether or not to tell her how frustrated I was at her interruptions, especially because she had asked me previously how I had wanted the sessions to run. I decided to tell her as I felt that if I didn’t future sessions would continue along the same way and could eventually lead to some big problems. I told her that I felt her frequent interruptions interrupted my flow of the session and I felt very frustrated because often the things she would suggest was the things I was just about to ask or do and it made it seem as if I wasn’t going to do them. She was very open and admitted her mistake and agreed to do as initially mentioned and only interrupt if safety was compromised or I seeked guidance.
Future sessions ran very smoothly and our relationship had drastically improved and I feel much more comfortable seeking her guidance. Reflecting back on the situation I wonder if I should have tried to communicate my frustration to my tutor during the session with the patient, and I think I made the right choice by waiting till after the treatment session because although it may have saved me a lot of frustration I think it would have possibly compromised professionalism with the patient.
Psych aspects
Hello all,
I have come across an interesting patient on my neuro placement that I thought I would share with you. The patient is a lady in her 60s who has had a right cerebellar stroke.
She presented quite stangely for a cerebellar stroke patient- on testing there was no dysmetria or dysdiadochokinesia, but an obvious slowing of all movement (eg with finger-nose). She had a slight right sided tremor but only very occasionally. There appeared to be right sided weakness especially during gait- reduced foot clearance and step length, however on my initial assessment the difference between sides was only very slight.
Anyway- the patient was about 4 weeks post stroke and really hadn't been showing any improvements, in fact she seemed to be deteriorating (when the physio did an initial assessment on her straight after her stroke, 2 wks prior to me commencing this placement, there was no tremor and her finger-nose was a lot quicker). There also appeared to be anxiety issues, she was becoming increasingly teary and seemed very frightened about going home. When I got the patient into supine to re-test her right lower limb strength she could not even lift her leg off the plinth and would actively resist us if we tried to passively move the limb. The patient appeared to be in pain also- so we begun questioning whether perhaps there was some lumbar spine pathology. A CT scan was performed and showed nothing significant- so we were back to square-one. One day the patient would be lifting her right foot 15cm up onto a step, and the next day she could only lift it 2cm when asked, and would drag it during gait- there was just no consistency!
Anyway it was discussed at the team-meeting and the general consensus was that perhaps this patient's issues were more about psychology as opposed to physical. Her anxiety, day to day variation and apparent depression is now the team's primary focus.
Just goes to show that when things aren't adding up- we need to be prepared to take a step back and view the patient as a whole and collaborate with the other members of the medical team to determine what is really going on. We should never under-estimate the influence of a patient's psychological well-being as a barrier to rehab.
I have come across an interesting patient on my neuro placement that I thought I would share with you. The patient is a lady in her 60s who has had a right cerebellar stroke.
She presented quite stangely for a cerebellar stroke patient- on testing there was no dysmetria or dysdiadochokinesia, but an obvious slowing of all movement (eg with finger-nose). She had a slight right sided tremor but only very occasionally. There appeared to be right sided weakness especially during gait- reduced foot clearance and step length, however on my initial assessment the difference between sides was only very slight.
Anyway- the patient was about 4 weeks post stroke and really hadn't been showing any improvements, in fact she seemed to be deteriorating (when the physio did an initial assessment on her straight after her stroke, 2 wks prior to me commencing this placement, there was no tremor and her finger-nose was a lot quicker). There also appeared to be anxiety issues, she was becoming increasingly teary and seemed very frightened about going home. When I got the patient into supine to re-test her right lower limb strength she could not even lift her leg off the plinth and would actively resist us if we tried to passively move the limb. The patient appeared to be in pain also- so we begun questioning whether perhaps there was some lumbar spine pathology. A CT scan was performed and showed nothing significant- so we were back to square-one. One day the patient would be lifting her right foot 15cm up onto a step, and the next day she could only lift it 2cm when asked, and would drag it during gait- there was just no consistency!
Anyway it was discussed at the team-meeting and the general consensus was that perhaps this patient's issues were more about psychology as opposed to physical. Her anxiety, day to day variation and apparent depression is now the team's primary focus.
Just goes to show that when things aren't adding up- we need to be prepared to take a step back and view the patient as a whole and collaborate with the other members of the medical team to determine what is really going on. We should never under-estimate the influence of a patient's psychological well-being as a barrier to rehab.
Sunday, September 7, 2008
Hurry up mate!
Hello everyone, this week I would like to share my experience with you for one of my patients in gen surg. He was the patient who has undergone Ivor Lewis, a complex surgical procedure of partial oesophagus removal. He was a day 5 post op patient that was just transferred up to gen surg ward from ICU. Since the complexity of the operation, my supervisor requested me, another student and my supervisor herself to see him together.
Before we saw this patient, we have planned what we will be doing on him and that included SMI, supported cough and ambulation. When we walked into his room, we went through normal assessment with him. Despite he was on moderate pain on his incision site, the pain was well managed by PCA and he was keen to stand up since the operation. During the whole session, I and my partner explained the information in regard to post-op care to the patient comprehensively, so that it slightly ran overtime. Therefore, my supervisor jumped in and told us that we got to be hurried. Then, when we stood the patient up, he started desaturating from 96% 8L HFNP to 90%, during that time we were not very nervous but we did not know what to do so that my supervisor was not so happy about our clinical decision making and she jumped in again and lead the treatment. Eventually, we finished the whole session in a hour time.
After the session, my supervisor criticized our time management and organization. Also she told us we have informed the patient in too much detail that was not necessary to do. On my reflection, I admitted that it was not the good session in terms of the overall flow and time management. However as a student I think that we need to inform the patient in fair amount of detail rather than just ‘do’. In addition, I felt so much pressure when my supervisor watched your performance and asked me question at the same time, it is just very distracting for me and I cannot concentrated in my performance.
Before we saw this patient, we have planned what we will be doing on him and that included SMI, supported cough and ambulation. When we walked into his room, we went through normal assessment with him. Despite he was on moderate pain on his incision site, the pain was well managed by PCA and he was keen to stand up since the operation. During the whole session, I and my partner explained the information in regard to post-op care to the patient comprehensively, so that it slightly ran overtime. Therefore, my supervisor jumped in and told us that we got to be hurried. Then, when we stood the patient up, he started desaturating from 96% 8L HFNP to 90%, during that time we were not very nervous but we did not know what to do so that my supervisor was not so happy about our clinical decision making and she jumped in again and lead the treatment. Eventually, we finished the whole session in a hour time.
After the session, my supervisor criticized our time management and organization. Also she told us we have informed the patient in too much detail that was not necessary to do. On my reflection, I admitted that it was not the good session in terms of the overall flow and time management. However as a student I think that we need to inform the patient in fair amount of detail rather than just ‘do’. In addition, I felt so much pressure when my supervisor watched your performance and asked me question at the same time, it is just very distracting for me and I cannot concentrated in my performance.
Friday, September 5, 2008
Issues with a supervisor
On this placement, first the first time this year, I have had a few issues with my supervisor (i.e. facility not tutor). I feel like my job there is to pick up their extra clients and to make their schedule easier rather than to learn, whilst I want to get extra experience and find out about all the different aspects of working at the centre I don’t want to miss out on other opportunities (and my lunch break) in order to help them out. I simply don’t have time to do all of the things I am being asked to do.
I have been doing playgroup, hydro, home visits (both with my supervisor and sometimes on my own), getting quotes for equipment, ringing parents to organize appointments and sometimes schools (once because a school wouldn’t respond to my supervisor so she got me to try instead), writing up and updating detailed ICF’s (impairment-activity limitation-participation restriction tables) for every client and writing progress notes for each client I saw on my own, going to different clinics, writing treatment plans and liasing with other staff, and (excepting playgroup and hydro) most of that was today!
They also don’t act very professionally in front of me sometimes and they don’t always seem to have the right attitude to working with families, such as this week when they called the mother of one of our clients some very rude words whilst discussing their case with another staff member, and acted like the person was going out of their way just to annoy them. I was treating that client (on my own) and knew exactly who they were speaking about, and whilst I can understand why they said it, I absolutely don’t think it was appropriate to say it in front of me.
Also, a few weeks ago, I had my phone with me in my bag (not on silent-because I needed to leave it on in case my supervisor had to call me whilst I was out and about on home visits), and I was talking with my supervisor in their office (early in the morning before my official start time) and my phone rang, I answered it because it was home calling and I thought it might be important. I apologized profusely (as it would normally never happen as a) I would usually have it on silence and not have it with me on prac and b) I wouldn’t normally answer it). They didn’t say anything at the time. The next day they told me it was really unprofessional to have it not on silent, especially when on home visits (when it is ALWAYS on silent) and that they really didn’t want to have to fail me because of it so make sure it never happens again. I immediately put my phone on silent and later that afternoon I drove all the way out to Armadale (in one of the centre’s cars-50km out of my way) because I missed my supervisors call to tell me that that client had cancelled, because my phone was on silent.
I have spoken to them about some of this and sorted it out, and in future I will always talk to my supervisor straight away to clarify any issues, because I waited a while to sort it out on this prac and I was getting really stressed. I will also speak up about the limits of my time and my need to have some free time, and time to learn (i.e. experience different aspects of the services available and how they work). Generally they reacted quite positively and explained why they were asking me to do those things and changed my schedule where needed to allow me to participate in the AFO clinic and do some appointments at PMH. I haven’t spoken to them about the issue of talking about clients in a derogatory manner because I am not sure how to broach the subject or how to deal with it, I am going to speak to my tutor about it but am not sure what else to do, any ideas anyone? Cos I feel like I'm whingeing and whining about this stuff (sorry for the long post) but I think it's an important issue.
I have been doing playgroup, hydro, home visits (both with my supervisor and sometimes on my own), getting quotes for equipment, ringing parents to organize appointments and sometimes schools (once because a school wouldn’t respond to my supervisor so she got me to try instead), writing up and updating detailed ICF’s (impairment-activity limitation-participation restriction tables) for every client and writing progress notes for each client I saw on my own, going to different clinics, writing treatment plans and liasing with other staff, and (excepting playgroup and hydro) most of that was today!
They also don’t act very professionally in front of me sometimes and they don’t always seem to have the right attitude to working with families, such as this week when they called the mother of one of our clients some very rude words whilst discussing their case with another staff member, and acted like the person was going out of their way just to annoy them. I was treating that client (on my own) and knew exactly who they were speaking about, and whilst I can understand why they said it, I absolutely don’t think it was appropriate to say it in front of me.
Also, a few weeks ago, I had my phone with me in my bag (not on silent-because I needed to leave it on in case my supervisor had to call me whilst I was out and about on home visits), and I was talking with my supervisor in their office (early in the morning before my official start time) and my phone rang, I answered it because it was home calling and I thought it might be important. I apologized profusely (as it would normally never happen as a) I would usually have it on silence and not have it with me on prac and b) I wouldn’t normally answer it). They didn’t say anything at the time. The next day they told me it was really unprofessional to have it not on silent, especially when on home visits (when it is ALWAYS on silent) and that they really didn’t want to have to fail me because of it so make sure it never happens again. I immediately put my phone on silent and later that afternoon I drove all the way out to Armadale (in one of the centre’s cars-50km out of my way) because I missed my supervisors call to tell me that that client had cancelled, because my phone was on silent.
I have spoken to them about some of this and sorted it out, and in future I will always talk to my supervisor straight away to clarify any issues, because I waited a while to sort it out on this prac and I was getting really stressed. I will also speak up about the limits of my time and my need to have some free time, and time to learn (i.e. experience different aspects of the services available and how they work). Generally they reacted quite positively and explained why they were asking me to do those things and changed my schedule where needed to allow me to participate in the AFO clinic and do some appointments at PMH. I haven’t spoken to them about the issue of talking about clients in a derogatory manner because I am not sure how to broach the subject or how to deal with it, I am going to speak to my tutor about it but am not sure what else to do, any ideas anyone? Cos I feel like I'm whingeing and whining about this stuff (sorry for the long post) but I think it's an important issue.
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