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!
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