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.