Dumbfounded!

Up until last Thursday, I was quiet certain that my uni days would be over within the week….how wrong I was! I had my final assessment with my CCT on Thursday, it didn’t go as well as I planned, to be honest I wasn’t expecting high praises, but the words “I’ve failed you” were the last thing I was expecting. As my CCT went through my assessment, I found quiet a few discrepancies, and some comments were completely wrong, but at this stage I was way too upset to be able to discuss this with her.

It only got worse from there, I approached my FCE right away, and wanted an indication of whether she was going to pass me, I had explained to her that I had PCR coming up in the next week, and that I needed to get in touch with the coordinators at uni to organize things. The FCE of course didn’t want to discuss things with me, and she said she’ll go through the assessment the next day. The final ax was left till Friday afternoon, so I had pretty much been a wreck for almost 2 days, on top of having to see all my patients.
What frustrated me, is that I was given absolutely no indication I was failing at the mid placement. My FCE said she had no concerns, and that I was doing fine 2 weeks into the prac. My CCT made no comments either regarding failing, she just told me to work on improving what I had already learned. Even at the end of the 3rd week, both supervisers had told me “your passing”, but they wanted me to set the bar higher, and keeping improving in certain areas. Not once did they indicate they were overly concerned, my FCE on the 2nd last Friday even said, “you did really well today, just keep doing this, and you’ll be fine”. For the next week, I found I had very little supervision, and I was left to be more independent to ax & rx my patients. I took this as a good sign, as most students would, when they are given more independence, and less intrusion by their supervisers. Hence my frustration and confusion when my FCE decided to fail me as well. I pointed out to my superviser she had left me to be independent, to which my superviser replied, “I noticed you weren’t coping very well”, if she really felt I was incompetent and struggling how could she leave me alone to see patients??!! She had told me that the patients were her main priority, I was finding this a bit hard to believe, considering she had left someone who she believed to be incompetent responsible for these patients. If I was really struggling, why wasn’t additional supervision provided, as is stated in the unit outline. Almost feels like they wanted me to fail. My FCE also said the only reason she outright failed me is because it was my last placement, had I been in this situation earlier in the year (like many students), she would have passed me with a ADF. I certainly drew the short straw there.

So currently I don’t know whats happening in terms of PCR/ supp placement etc. The coordinators have indicated I wont be able to sit the PCR until the deferred timeslot. I haven’t had a chance to explain to them my side of the story, and I’m really getting worried, considering PCR is only a few days away, and I’ve been stressed out and haven’t been able to concentrate on anything since last Thursday.
I feel I haven’t been given a fair go, by the supervisers on clinic, and also the uni, as my situation has been left hanging, and no-one else seems to be in a hurry to sort it out. I feel like I’m being ignored, except for all the students out there who have been very supportive and understanding.
All I want is to be able to sit the PCR this week like the rest of you, go through the same experience/emotion of finishing together with the people I’ve been with for the last 4 yrs.

Good luck to you all!

Patient confidentiality- rural

This is going to be just a short and simple blog about patient confidentitality.
After my rural prac I found out you have to be especially careful about what you say to people in town. Its so different in the city where you can say "i saw a lady with a hip replacement today"... In a small country town there's only a hand full of patients who would have had a hip replacement. So if you tell someone that, rumours start flying about who is seeing the physio- and before you know it the whole town knows it!
Thats the only negative about living in a small town is everyone knows everyone's business. And most people are pretty wary about not letting anyone else find out stuff about them (though they're not so fussed about spreading gossip about other people!).
So for people going to start work in a rural area keep this in mind :)
Also keep in mind what you tell people about yourself, because sure enough if you tell one person you are pretty much telling the whole town! hehe.
Just something for you to be careful with. I'm sure most of you figured that out by now after your rural pracs if you were in a small town. Big towns aren't too bad :)
Good luck with the PCR
Caris

Wrap up

Final blog! Just thought I'd use it to reflect on my last four weeks on 3K. Gerontology was a good prac for a last one, as I had patients with neurological, cardio/respiratory and orthopedic conditions - a real mix. I also found the prac to be pretty rewarding from the perspective that most of the patients were really appreciative of the things I was trying to do for them. Getting pretty sizeable changes in function over a short time as their health improved was good too.

I had spent alot of my time being concerned about the outcomes for all of my patients post discharge, as you have seen from my previous posts in the last couple of weeks. I'm still not sure that the health of our aging population is being managed as well as is really needed, but I have seen a lot of people working hard to provide the best care that they can. What the prac gave me that others didn't was an opportunity to develop a bit more of a holistic perspective on my patients and to think about their cases beyond the point where they ceased to be my patients. It was an eye opener that I enjoyed. One day I might even look at employment in the area.
Congrats to one and all on completeing their pracs and best of luck for the PCR
M

Rural Experience

Last blog! On a cheerful note, I would like to blog about the really positive rural experience I have had. When coming to the town (a moderate-sized town of around 1800 ppl) I came with another physio student at the same facility, for which I was really grateful as I didnt picture that it would be easy to make friends in town. I had pictured that we would spend most nights quietly at the house together, as in most facilities I have been to although people are friendly enough at work there is never really an offer to extend that to after-hours. Not so here! As of the first day here we have been busy with barbecues, dinners, pub nights, playing netball/cricket/bowls and generally being very social most nights of the week. Everybody has made a huge effort to include us and make us feel welcome (whilst subtely suggesting that more physios are needed in the country!). My recommendation for other students would be to definately go rural for a different experience and also to say 'yes' to as many offers as possible, and not to be worried about not knowing people in town as friends are made really quickly and there is heaps of fun to be had.
Best of luck for the end of prac/PCR
Mel.

Manual Handling Talk

Hi guys
Myself and the other student have been asked to give a few talks on our country prac, which is great, and one if them which we're doing tomorrow is a manual handling presentation to nursing staff. At first I felt a bit intimidated when asked as some of the nurses at the hospital have been there for at least 30 years and I felt that they would know more than I would about the topic, and may resent being 'taught' how to do what they have been doing for years. This was made more apparent when I had to ask one of the ENs to assist me with a standing hoist as I wasnt completely confident with using it. However, since first being asked I have noticed some staff doing transfers that look unsafe to the backs of both the nusring staff and the patients, such as prapping a belt around their backs/chest and literally yanking them from chair to chair. Since then I have realised that even if I dont have the experience that the staff do, because I know the theory and/or can look it up easily, and also have a greatly deeper knowledge of injury mechanisms, I still have something to offer them in terms of helping to prevent injuries. I now feel more confident going in to do the talk. Hopefully it goes well!

Dry vs Moist cough

Hey All!

During the last 3 weeks, i've been seeing a patient mainly for chest and occassional SOOB, with 2 assist. During the first 2 weeks of this prac i saw the patient with my superviser, and we did the same thing each day - try to sit the pt out of bed, if unsuccessful then ROM for UL and suctioning.( at this stage i should mention, this is a 60 yr old gentleman, (R) hemi, drowsy, fully dependent with mobility, RIB majority of the time, weak cough, and bad chest).
At the beginning of last week, we had a new physio filling in temporarily for the next month. So now we see this patient together, and few times we've seen this patient in the last week, i've felt we havent done all that we can as physios. Treatment for this patient so far has consisted of SOOB for a few minutes, before we put him back down to rest. Everytime the patient cough, it sounded very moist and in definite need of suction. I've asked/mentioned whether she feels he needs a suction, and eachtime she's like no its sounds dry. Even though i completely disagree, i've just left it, and did as the physio wanted. I know this patient has a bad chest, given his history, ausc findings and cough, so i dont know if i'm jsut getting into a routine of suctioning him, because thats what my superviser did. But at the same time i'm left to wonder if the physio is right when she feels suctioning isnt indicated, because after all she has years of experience working as respiratory physio.

So i'm just a little confused about what i should do. Because when i'm in with the patient, i feel like were not doing enough for him, and beginning to doubt my own judgement, ie. is this cough moist or dry, and at the same time i dont want to create a fuss with the physio, where i feel she might think i'm undermining her experience.

Only 1 more week...

Rev

New Conditions

Hi all, hope you're enjoying your last week of prac! I'm currently on my rural prac, and spending most of my time in the outpatients department. I am seeing a massive variety of patients, most of which have conditions I have never seen/treated before. At first this made me really nervous, becasue I couldn't follow a direct recipe about what i need to Ax and what I need to treat. After the first week or so I realised that I shouldn't be nervous just becasue "I havent seen that before". If there was something I was unsure about I look it up before the patient comes, and use the basic skills we have to problem solve what's needed in terms of Ax and Rx. Now I am really enjoying the challenge of such a variety in the patient case load, and have learnt a great deal on thsi prac, now that I have got over the anxiety of seeing something new, in case I didnt know what to do. Like I suggested in my last blog, I think all we need (well what I needed anyway) is confidence in ourselves, and confidence in the skills we have learnt. We will graduate soon and surely enough come across many challenges, and uncertainties, and what i have learnt from this prac is that all we need is confidence in our abilities.

Return patients

Hi all
Another week on the gerontology ward and another lesson for me about just how difficult life can be for some of my patients. Last friday i discharged three patients. They had a number of different issues, some of them still with medical rather than mobility issues. I'm pretty conservative, so no patient gets my ok to discharge without me being well and truly satisfied that they are safe to go. Anyway, two of these patients were re-admitted (one through ED) the very next day. It was reported that one of them had suffered another fall. The other had another cardiac event. Obviously, to hear that one had fallen again so soon after DC left questions as to her safety for DC in the first place. Questions were asked. This patient was admitted to another ward, but my supervisor (who is very supportive) went and did some investigating. The truth of the matter was that the patient was re-admitted with a UTI, and in fact the hostel that she had returned to (she has been a resident there for 10 years) had decided that they were unable to provide the level of care she requires, so had her sent back to RPH. There had been no fall. This is not just a story about me being in the clear regarding discharging a patient. What was annoying was that we had done alot of rehab with this person, so much so that her mobility on DC was better than her pre-morbid status. Also, her mobility was much better than that required by the hostel as part of the criteria to return to their facility. But, somehow the facility must have changed their criteria overnight.
I think you can see a theme running through my last few posts. It has to do with the fact that gerontology is so much about finding somewhere to put someone. Sadly, it is not a very consultative process, and the wishes of the patients seem rarely to be taken into account. While this is in some ways unavoidable, the attitude of the hostel in question takes the cake. I hope bureaucracy has something sorted by the time I get old(er). Am I getting a warped view of the way our aging population is (mis?)managed? or have some of you felt the same way on your gero clinics
M
M

Go hard or go home...

Hey guys, I think this is my last blog (Peter??)
Ok I'm still on my rural prac... there are 2 physios working up here and both are taking 2 weeks leave while I am here so I have spent my first 2 weeks with one physio, and now the next two with another physio. Both have VERY different ways of treating patients in the acute stages. Lets take an acute ankle injury for example- the first likes to go in quite easy for the first one or two sessions ie. treat the swelling (ice, US, compression etc), and start gentle active movements etc, while the second likes to get straight in there and mobilise to get as much ROM as possible as early as possible. Considering I have just spent 2 weeks with the 'gentle' physio its a bit of a shock to the system to now be with the second physio!! I tend to agree more with the way the first physio deals with acute injuries, so I am quite reluctant to go against the grain with the second physio... this close to the end of uni and I am pretty content not to rock the boat so basically I'm just going along with how she does things (afterall she is marking my final assessment)... When I reflect on it later I think I should treat the patient as I see fit (ultimately making the patients progress more my responsibility), but at the same time I'm happy to take advice from either supervisor. Does anyone else out there modify what you would normally do to please a supervisor, or am I the only one who just wants to get through the year without rocking too many boats??
Cheers,
Ezza

Hi everyone
My post is about difficult musculoskeletal presentations. I had a patient present to me with a 14yr history of longstanding hip pain (since she was 11) that begun insidiously. Her presentation is that after playing sport (netball/hockey) she will feel her (R) knee turning in, and then for the next few days she will have intermittant stabbing sharp hip pain deep within her joint with certain mvmnts eg. crossing her legs. After a few days it will disappear again, and it is only in the few days post sport that this pain appears. Objectively she had decreased ER ROM actively and passively on the (R) side, and no other findings. The pain could not be reproduced as it is the 'off-season' and she only gets the pain after playing sport.

So I was pretty confused with this lady... the best diagnoses I could vaguely come up with was perhaps an old labral tear from whe she used to play gymnastics when she was young, which gets aggravated with sport (+/- synovitis?) and catches in the hip joint. Perhaps also related to poor glut med pelvic control making her knee turn in after sport? But I really wasnt too sure and neither was my supervisor. Treatment over 2 Rx sessions consisted of some ER mobs at 90 degrees flexion, ER self-stretches for home and a program to strengthen glut med (although (R)glut med was G4+ on testing, probably stronger than me).

The outcome was that we decided to wait until she was playing sport again and could monitor response to treatment more accurately and told her to come see us again then, bypassing the 5 month waiting list. We sent a letter to the doctor about our findings and suggesting that imaging could be the only was to conclusively diagnose her hip pain. We also suggested to her that if it was a problem within the hip joint capsule as it seemed, physio perhaps wouldnt really help too much.

What I learnt from this is that there are still so many musculoskeletal dysfunctions out there that I still have no idea about, and this will still probably happen for some time. Referring back to the doctor saying 'I dont really know whats going on' and requesting imaging is sometimes all that can be done.
Any ideas about what the pathologycould be would be greatly welcome!
Hope the tail end of everyone's last prac goes well.

Frozen Shoulder??

The other day a patient presented to the hospital outpatients with a referral from the Doctor for treatment of her frozen shoulder. Upon Ax the patient had full shoulder AROM - with a apinful arc, and full PROM of GHJ (90 degrees flexion, 90 degrees abduction, 70 degrees ER). At this stage I was confused.. The pt wasn't presenting like she had adhesive capsulitis. Upon completing my Subjective and Objective Ax, I presented my findings to my supervisor because I was confused how the Dr could think it was froen shoulder, but assuming that it must be, even though I thought it was biceps tendinopathy resulting in secondary subacromial impingement. My supervisor questioned me about what a frozen shoulder presented like? what this patient was presenting like? and did I think this was frozen shoulder? If not, what do I think it is? Feeling silly that I needed his confirmation I answered all these questions then he said GOOD, now go treat her. I shouldn't have needed my supervisor to confirm what I thought, I should have just trusted myself. Moral of the story... Don't always trust what the Doctor has written on the refferal and trust your instincts, we know more than we think we do :) This is not the only time on this prac where I have had a referral from a Doctor with a wrong diagnosis. Has anyone else been in a simialr situation?

Neuro

Hey all!

So only 2 more weeks to go, till we finish our very last pracs ever YAY!! Lucky for me I get to finish off with neuro. Compared to all my other pracs, neuros definitely the most challenging, I’m sure most of you agree. Towards the end of last week, I had to do an initial assessment on a patient. My superviser told me to do a quick mobility the check (for the nurses), and then do a more detailed assessment later. So that’s exactly what I did, a “quick” mobility check, ie. Rolling, supine à sit, sitting balance, sit to stand, standing balance and ambulation. I went back to the superviser who then asked me questions like, is the patient equal wt bearing, sitting posture, standing posture, what happening at the ankle, knee, hip, trunk during gait, what are voluntary movements at the arm like, any perceptual deficits – how did you test these, the list went on. Of course my answer to a majority of these questions was, “umm didn’t look that closely into it, was leaving it for later”. I was told that I’m 2 weeks away from being qualified, and that at this stage of the year, my skills were at a 1st/2nd year level. OUCH.

I’m not sure if that was a fair call, yes I’ve gone through 6 other pracs prior to this, but this is the first and only neuro prac I’ve done, and in an area as specialized as neuro, it shouldn’t matter if it was my very first prac for 4th yr or the very last one, because the level of competence would be the same.

But saying that, the fault on my behalf is that I wasn’t using my observation skills, it doesn’t matter what area of physio your working in, I should have been paying more attention to my patient, and picking up on things as I was doing the mobility assessment.
As a result of this, I feel that I’ll be better prepared for the next new patient I get, and will save a lot of time on assessment, rather than having to repeat things. Also I want to put forward the question, will students benefit more from having a neuro prac for 5 weeks, rather than 4?

Rev

Community Services

Hi all.
Regarding my patient from last week... Discharged with a functional ability better than her pre-morbid status so well pleased.
This has been an interesting week on 3K. Things are going pretty well. One of the most interesting parts of the week was a visit to Mercy Hospital Restorative Unit. I spent Wednesday morning doing home visits with the ACAT nurse and social worker. It was a bit of an eye opener to get into the homes of the sort of people I might otherwise be treating on the ward. The people we visited all had different issues ranging from dementia to repeated falls to parkinsons. I found it interesting the amount of assistance that can be made available to people in the community, and moreso the huge amount of assistance that so many people need. Alot of the people we visited were frustrated by having to seek assistance in the first place and then more frustrated by the "you can have this, but not that" sort of system that seems to be in place. I understand that there are limited resources in the community, and I think that the ACAT workers I was with do a great job. I just couldn't shake the impression that there were so many needs going un met. A tough one
M

Rural Prac- a mixed bag

Hey guys hope everyone is kicking goals on their last prac (ever!)
I'm up in Tom Price at the moment (thanks for all the dodgy handovers Marty just kidding)... Things are quite laid back up here, we have a primarilly musculo outpatients client load but also some womens health, hydro, cardio etc
Even though it's only the second week, I'm already feeling like I'm part of the team (physios, other allied health, nurses, doctors etc) and feel like I'm contributing (this feeling usually takes me until week 4 or 5 of other pracs)... anyway I was just reflecting and wondering if I'm feeling confident and part of the team up here because I'm in the country, things are more laid back and relaxed, I'm allowed to wear shorts and sneakers, the country air etc OR because this is my last prac and therefore my knowledge and skills have all finally kicked in??? Or maybe it's a combo of both, I don't know. So I was just wondering if you guys felt similar on your rural pracs/ last pracs??
Good luck
Ezza

No Faith In Physio Students

I’ve just recently come back from my rural prac, and absolutely loved it! I think a rural prac allows for a good transition between being a physio student to working out there in the real world. I found I was able to consolidate on the pracs have already had this year, and integrate everything I’ve learned. I also found that I was given a lot more freedom and independence, and actually felt like part of a team, rather than some tag a along student. Towards the end of the 3rd/ early 4th week my superviser went away, and left me in charge of the particular ward. She had already told the nurses and other persons concerned with that ward, that I’d be in charge (from physio aspect). By this stage I knew the ward quiet well, and knew what had to be done. On the first morning I was managing the ward alone, I went to have a chat to the nursing coordinator to find out if there are any new patients that required physio, or have physio referrals. On this particular ward we have blanket referrals to see patients of 3 of the Drs, the other Drs need to put a referral in if they need physio consult. Anyway the nursing coordinator said that there wasn’t anything I needed to worry about. Half way through the morning one of the physios came upto the wards to see if I was going ok, she then went to have a chat to the nursing coordinator and came back with a list of 6-7 new patients that needed to be seen. I was quiet annoyed that the coordinator had failed to mention this to me, because if the other physio had not come up to the ward, these patients would have not been seen. She probably assumed because I was a student it didn’t concern me, even though I made the effort to go ask her, and she knew I was running the ward for a few days.

Another situation that same week was one of the nurses came to chat to me about a patient, because she was being discharged back into a high-care facility and needed a mobility review. The nurses went on the give me a detailed handover about the patient, then suddenly stopped half-way through, she had read my badge noticed the word “student” on there and went on to say “sorry I’m talking to the wrong person about this, it probably doesn’t concern you”. I told her that I can deal with these things, and said I’d go see the patient.

Its quiet frustrating that regardless of the fact that your in 4th year (about to finish), some people just assume you cant take on any responsibility and aren’t doing any proper work, but just following people around. Anyway only 3 more weeks of being a student…

Families of patients

Hi all
I've just had a week on my new placement on ward 3K at RPH WSC. It's a gerontology ward, but it has a focus on quickly returning patients to functional levels prior to discharge. So far it's going ok. My issue this week has to do with the family of one of my patients. This particular patient is always enthusiastic and keen to engage in the PT process. She still has a number of medical issues keeping her in hospital, but nevertheless she always tries hard with the rehab sessions we have with her. I was talking with one of her children the other day, who asked if physio was worth it, given that her mum is still ill (cardiac issues among others). This person actually became quite aggressive, accusing me of pushing her mum when she is sick, adding that her mother does nothing anyway. She seemed to feel that her mum was just waiting to die. I assured this person that the demands I place on her mother are minimal and quite safe. I also said that I had got quite the opposite impression from her mum, who is always keen to engage in PT. I was supported in my reply by the senior physio, who overheard the conversation. What made the biggest impression on me was the way this person spoke about her mother in such negative terms - she can't do this, won't do that. I listened to her for a while as she complained about the imposition her mothers health had made on her family and I realised that this person now thought of her mother only in terms of the burden that she had become over the last few years. What had started off as questioning the safety of what I was doing ended up in this person questioning why I bothered. Anyway, I felt that I had explained myself sufficiently so I moved on to my next patient. I guess it just shows the effect that chronic disease has on families.

Waiting Times

Hi everyone, I've just done the first week of my rural prac at Moora hospital. One issue that I have found difficult is the waiting list time for patient referrals from the doctors in town. There is just the one physio (my supervisor) who is publically funded. There was a vacancy in her position for some months before she got there and she has just recently taken some leave. The problem is that the waiting list for physio is around 80 patients long, and patients with non-urgent problems are waiting 5-6 months to see the physio. I saw a lady with hip pain today which she initially got a referrral for 5 months ago. This means that a lot of problems in town which were acute invariably turn to chronic by the time that the patient gets in to see the physio eg a few chronic ankles post-sprain, which if initially managed well may have recovered better. This also creates some resentment in town as to who gets in to see the physio when. The only other option is for the patients to travel to Jurien Bay to see the privat physio, which is a fair drive away. There isnt really any solution to this not involving extra funding for a second physio (there are two OTs!), or if someone began a private practice in the town.
Apart from this it is a great little town and prac is going well!
Mel.

Combined movements

Hi all
Thanks to Caris for her comments on my last post. That particular patient has since improved somewhat, and during my last session with her I concentated on reminding her how much she had improved in a week.

I know we are supposed to blog about clinical situations that we are having some trouble with, but my last week in Tom Price was really positive. With this in mind I wanted to tell you about a learning experience. Last Monday I had 6 new patients (all outpatient musculoskeletal). Two of them were acute back pain resulting from injuries sustained less than a week previous. One of these patients presented with alot of pain after spending the previous day rushing around the house doing the vacuuming. I did the subjective and objective and decided to talk to my supervisor about it before I started treatment. Although I had a reasonable idea of what was going on, I wanted to have a look at some treatment options that wouldn't aggravate or increase her pain. We discussed the patient and I noted that she had an opening/stretching (as opposed to closing) pattern of pain on movement. My supervisor decided that we should take a combined movements approach, which I didn't know much about. We looked at her two worst affected movements - flexion followed by right side flexion (both causing pain on the left side). From my understanding, combined movements approach involves picking the two worst restricted movements and working away from the pain. So, the ideal teatment plane was flexion and right side flexion. Because the patient was very sore, the first session used flexion with left side flexion (which was a movement that eased her pain). The treatment was done with the patient in right side lie and in as much flexion as possible. The I did some grade 3 side flexion mobs (same as used for side flexion PIVMS). The result was an increase in flexion and right side flexion with a reduction in pain. The most important part was that the treatment wasn't painful at all. Other treatment options (such as unilateral mobs ..) would have been too painful. I saw the patient again two days later and did the same treatment, but the side flexion was into right side flexion this time. The patient is still sore, but her pain has been reduced significantly and her AROM is almost back to normal. What I liked about this (apart from having some good treatment effect) is that I feel I am adding to the options I have to choose from when I decide on the treatment I am going to carry out.

Anyway that's all from Tom Price
M

Patient stats (AHS stuff)

Hi everyone.
My entry today is about patient data entry. In Perth the hospitals I have been to have all used AHS as the stats program. However in Morawa (rural prac) they have some wacky weird (and LONG WINDED) program for patient stats. It was so weird using the new program and you had to know all these special codes to put in information. I found it hard for the first week, and although I got the hang of it, I just felt like it was a total waste of time.. It took 5 minutes just to put one persons data in! And when you've got 10 to put in, thats almost an hour! Anyway, enough of my complaining. I just wanted to see what other people used on their rural placements? I told my physio about AHS and she sounded really interested about it. Can you believe I was actually promoting AHS? Thats when you know things are bad...Anyway I just think it would be great if rural areas could have an easy to use system like AHS.. Anyone else think so?
Caris

Difficult patient

My issue today concerns a patient that I have seen three times. She presented to my supervisor a number of weeks before I got to Tom Price with severe pain in her thoracic spine and shoulders, with pain radiating down into her arms. The first time I treated her, she spoke about how she was consulting reflexology books and how she was getting the oldest of her six children to do "pressure point" massages on her every day to relieve her pain. Additionally, she was constantly stretching her neck and shoulders in every direction in order to relieve her symptoms. Treatment involved some trigger point massage and education regarding posture, in addition to exercises to promote scapula stability. All of these were indicated by objective examination. Additionally I asked her to stop having her children trigger point her (even though it brought temporary relief) because aggressive soft tissue techniques such as that every day may actually be aggravating her condition. I also asked her to avoid the continuous stretching she was doing. My reasoning was the same. I wanted to see what the situation would be if her muscles were given a break for a week. This was always going to be difficult. The patient does have six young children and is always on the go so the concept of rest is understandably foreign to her at this point.

Nevertheless, and to her credit, the patient tried to stick to what we'd spoken about.
One week later, the patient appeared in similar condition, complaining that a host of pain medications had not made a difference either. On examination she had normal ROM, and the muscles around her upper back and shoulders were relaxed. Palpation was still very tender and she complained of pain no matter where I placed my hands. My issue is that despite the raft of tests I have done I have no idea what is going on. My supervisor is not sure either, and says that the patient is paying too much attention to her pain.

The lack of objective information is confusing, and I'm certainly convinced that there is a psychological and behavioural component to her pain. That said, I'm not about to label her an "attention seeker". Regardless, the next step is one that I'm not sure about. Ideas?
M

more rural

Hey guys, sorry for this late entry. I been having the same trouble as martin with not regular internet access on my rural placement!
My latest thoughts have been about the challenges of working in a rural setting.. I love it! Its so amazing being able to see people who have all different kinds of problems. Although you're totally exhausted at the end of the day, its so stimulating. The day goes so much quicker than it has been in the past working in a large hospital (eg orthopaedics placement where you do almost the exact same thing for each patient day after day).
During one day I had a seniors fitness class, saw a new patient wanting stroke rehab, provided asthmatic advice to nurses and organised a spirometry ed session on a patient, saw 2 patients with cervical and lumbar back pain, as well as provide ultrasound & e-stim. Its been crazy.
The hardest part is trying to switch between treatment modes, though I'm loving every bit of it and hope eveyone else is enjoying their rural placements this much. How have you guys been finding your rurals?
caris

Suctioning

Hi, sorry for the delay in writing my post from last week! I didnt have access to a computer.

I am getting frustrated with the inconsistencies between what we have learnt at uni and what we are being told by our supervisors and tutors. For example:
At uni we are told to suction in 15 seconds with an intermittant technique. My supervisor told em on day 1 that I should hold the suction on the whole time. My tutor tells me to use the intermittant technique and days we ahve alot longer to suction now that the patients are ventilated, becasue they wont be with out oxygen (where as in the old days the ventilation used to be disconnected to suction) - and said that my suction technique was too fast. After this my supervisor then told em that my suction technique was too slow!!

i am getting frustrated with trying to please the tutors and supervisors who all have their own way of doing things. i spoke to one of the physios on the ward and he was really helpful. he explained that I should simply do what i think is the best for the patient, and as long as I can justify my decision then it doesnt matter if its not the same as the supervisor and tutor.

This goes for all treatments not just suctioning. I thought it was really good advice!

To treat or not to treat

Hi all! Im currently on prac in the ICU, and came across a patient who was being treated for liver and kidney failure. She was sedated and ventilated so was recieving routine chest care and passive ranges by physio. On assessment the patient had added sounds on auscultation and changes on her CXR. On suction there was large amounts of M2P2 and a moderate cough, however she was not coughing spontaneously. Therefore chest physio was indicated.

The next morning I went to see the pt, and the NS reported that the patient developed cerebral oedema as a result of global ischemia overnight, that her pupils were now fixed and dilated and she had no cough on suction. The cerebral perfusion test had not been done yet, but objectively the patient appeared to be brain dead.

The dilemma I came across was whether or not to treat the patient. What was the point if she was brain dead? (Although not officially declared dead yet).

From speaking to my supervisor I found out that normally, even when a patient is declared brain dead, they recieve 4 hourly chest physio, in case the family decide to donate the pts organs. However in this case the pt was aborigional, donating organs is against their beliefs, and the ns seemed to think that the pt s family would decide not to donate them. As a result the pt did not recieve phsyio. Later that day the pt was declared brain dead and the family decided not to donate the pts organs.

This was just an interesting situation i came across and learnt from it, so thought I d share the experience. :)

Getting the all clear

Looks like I was the last person to post, so coming up with a comment for someone else isn't going to be to easy. Let me guess... you're all on your SDP right? Anyway, I have to post so here we go.
Things are going pretty well here in Tom Price. One of my patients is a boy who is 8 weeks post ORIF for a midshaft femoral #. I don't know what physio attention he was getting in the last 8 weeks, but the main issue with him now is that he only has 40 degrees knee flexion. Today's problem is not about that though. He presented with a note from the surgeon that roughly outlined the timeline for changes in his WB status. Reading the note, I ascertained that the patient was in the timeframe that the surgeon had outlined for him to begin T(touch)WB. Additionally, his Xray was looking good. So I prepared to commence gait re-education with TWB as part of my treatment. My supervisor wasn't keen for me to do this because we hadn't recieved any protocol from the surgeon, and the note that we had didn't explicitly give the all clear for TWB. My issue isn't with my supervisor, who is great. Nor is my issue that I spent alot of time on the phone with several doctors trying to get a verdict (although that was a pain in the rear end). My question is when is a referral a referral?

Waiting for the go ahead was pretty stressful for this patient's parents, who feel like they've been kept in the dark. Also, we had to wait nearly a week before any information was forthcoming, which is a long time to keep a major part of someones treatment on hold. Have any of you had the same experience? Do any of you know exactly what is required in terms of communication from Drs when changing WB status (in terms of communication). It's potentially a pitfall....

On the upside, the neural tension guy from last week is on the improve, and I've learnt a whole new bunch of freaky mulligans techniques too...
M

What the?

Hi all
Been ages since I blogged but i doubt any of you were that interested in "what I did today on my SDP", so I have had to wait to get my first clinical exposure in 9 weeks. Rusty is an understatement. So here I am in Tom Price. The weather's nice and warm so all is good. My issue is one that stems from the difficulties of being a primary care provider. Most of the stuff I'm doing is outpatients musculo, which is cool cos I'm interested in the area. My previous experience in this area was a positive (even successful) one, but I don't feel prepared for what I'm seeing now. Alot of acute backs (as in patients screaming in pain type acute backs) and other conditions that I'm finding difficult to work out. One particlular patient has pain radiating down the back of his leg and some lumbar flexion restriction, but otherwise his back was pretty clear to other examination. Huh? Going through all the pivms and paivms and all of that didn't produce anything. I had tried to be as thorough as I could but still no idea. My supervisor gave me a hand and it was decided that the problem was neural tension (the slump test I forgot to do...). Anyway the supervisor took over a bit which I'm ok with and went through a bunch of Mulligans neural mobilisation techniques that I've never seen before. They seemed to work ok and I'll be giving them a crack next time. Anyway, treatng people who have just walked off the street (without referral etc as with alot of the things I've seen) is proving a real challenge. Go Cats
M

Forgetting

Hi everyone.
I am on my rural placement at the moment & I have suddenly become aware of everything I have forgotten since my first prac already! My first prac was a stint in neuro out patients & I did a heap of gait retraining. Since I have been on my rural prac I have come across some people who need gait retraining & Ive forgotten heaps of techniques I was taught at royal perth!
It is so frustrating because I assumed I wouldnt forget them, seen as they were so indented in my mind at the time!
I realise now I should have written more of them down at the end of the day, because in a rural setting the physios often have forgotten stuff about that too! Especially where I am and there is only one physio who has worked by herself for the last 20 odd years...
So this is more of a reminder to everyone to write things down if you are as forgetful as me.. Has anyone else experienced this on their rural prac where you get all different types of patients coming in? I hope im not the only one forgetting!
Caris

It's nearing the end!!!!!

Hey guys,

I got so caught up with the holidays that I realised I forgot to post this final blog! Oops!

I've had so much fun in my last Musculoskeletal prac, that I've been having so many problems figuring out what to write in this blog!

I'd might as well write something about the course as a whole...Can you believe it guys? One more prac and that's going to be over! I've have to say that these past four years have been long and tedious, with bouts of stressful OSPEs and endless exams. But good things come to those who wait.

I wish everyone the best for their last prac and PCR! Enjoy your last few days as a student! :)

Mark

Running the ward

Hi everyone,
The last week of the Burns placement was very exciting. The ward was extremely busy and there were very few physios (as they were busy with conferences). I was being supervised by someone who never saw burns patients.

What made the last week exciting was that I was able to liase well with the nursing staff (mind you - they are our best friends on the ward when we choose to work in public hospitals), the physios (by dividing up the workload myself), asking the doctors about the patient's situation, giving the 3rd year patients to see (for the supervisor) and telling some cross patients how good exercise is (which most believed).

It was good practice and by the end of it all - i was able to give a verbal handover to the physios in charge and write the weekend list.

My supervisor gave the feedback that my communication had improved and it was a great opportunity to run the ward.

So my advise is this - take every opportunity to run the ward by the end of a placement. Not only do you gain confidence, but you are able to consolidate how everything works in the big picture.

Plateauing Patienits

On my recent musculoskeletel prac I have come across patients who take on a very passive role to treatment. I had a quite a few pts who i saw weekly over the couse of the 4 week prac who would come back every week with no progress made. They were still in pain and there was no change to their impairments such as mm length and strength , yet when you asked them how they went with their Home Exercise Program they report that they didn't have time to do it this week. (yet again).

Post treatment they make gains and subjectivelt report that they feel better, however when they come back the next week they report that post treatment they felt good then experienced a gradual decline throughout the week and were back to the same level.

This really frustrates me, and ethically I feel that it can t be right for us to continue treating these patients when they are not making any preogress. The patients are not taking any repsonsibility for their injuries at all.

I tried expalining to the patients that the reason they are plateauing is becaause there is only so much we can do as a physio in a 1 hr treatment session, once a week, and now the rest is up to them to work on their exercises and stretches to make improvement s and to maintain gains amde in the treatment session. I said this quite firmly and it worked quite well with a couple of them, But as this was in the 4 th week I wasnt able to stick aroudn to see if they made any gains by doing their home exercises.

Similarly, I had a pt who injured his disc doing "dead Lifts" at the gym, yet continued to go to the gym, lifting weights week after week, even though his back was not getting better, and some week s even worse. In thsi situation simple education didnt work.. quite firm encouragemtn not to go to the gym, and expalining to him that he needs to take more responsiblity for his injury had a better effect.

I guess as physios we will come across these patients wuite frequently. Teh question is if they are not taking responsibility for theri injures and taking on a very passive role in their recovery where do we draw the line and stop treating th epatinet, or do we continue treating the pt even though they are not making any progress weeek by week ( although they are making progress by the end of the treatemt session)

Aggressive patients

Hi guys,
Im at the Burns ward and I found that several patients were aggressive. One of the reasons is that several of them were smokers and/or used illicit drugs. My supervisor had warned me and went through a tutorial about dealing with difficult patients (which was really very helpful).

Knowing that I would be a having an unusually verbally aggressive patient, my supervisor took me through my first session with that man. Although the man seemed very keen in the beginning, he did seem to get agitated as the session went on. The man kept on asking repeatedly how the assessment would help him and how physiotherapy would help (even if we answered him with the necessary reasons).

What made it even more difficult was his lack of compliance with the medical treatment. He started to become aggressive (passively at first) and then yelled out that he was going to discharge himself against medical advise.

This is the point when my supervisor said no and we took him back to the room. She said that she felt very cornered in by the patient and had no room for her to run, had the patient lost control and physically become violent (could sense it with his agitation).

Hence, it's important to watch out for some warning signals before we keep trying to persuade a patient about how important physiotherapy is for them. We can only persuade them to a certain extent. At the end of the day, they will be making their own decisions.

I guess this has been an incident to realise the above.

Walking Aids in Neuro

Hi All,
I learnt something this week that seems really obvious now but wasn’t at the time. One of my patients had a right MCA stroke about two months ago and for a variety of reasons, my supervisor and I thought that it was best for her to use a stick in her right hand during ambulation and transfers. Over the first three weeks of my placement, the patient had marked tone in her left UL, especially in the wrist and finger flexors, but also in the biceps, pecs and lats. I had been doing a lot of work trying to reduce this tone, but did not feel like I was making a lot of difference. Then my patient was offered a place on a Bobath course being run at the hospital. At this course she was treated by an extremely skilled Neuro Physio from the UK as well as other Physio’s who have spent years specialising in Neuro PT. When I saw her after the week long course, the tone in her arm was significantly reduced and they had told her to stop using the stick for walking and transfers. What I hadn’t realised but makes sense now, is that when using the stick in her R UL, she was getting carryover into the left UL and the tone in that arm was being encouraged. Now she is managing transfers without the stick, although I haven’t had the opportunity to see her gait yet, and the tone in the UL is much better. While we still may have to get her using the stick so that she can be discharged safely within a given timeframe, I found this a really interesting learning experience. When I first heard that she was managing without the stick and that the people on the course had managed in five days to achieve what I hadn’t been able to in three weeks, I lost a bit of confidence in my Physio skills. But then I realised that these people were specialists who have been working in Neuro for years and that I have only had four weeks of clinical Neuro experience, so I shouldn’t be so hard on myself. I have realised though that when providing aids to Neuro patients you really need to consider what compensations or other problems they might cause.
Mel

The STRESS at the end of a prac...

Hey guys,
Well here is my last whinge, oops I mean Blogg, for a few weeks (I’ve got 5 weeks off before rural prac, yeah!) Has anyone else had this experience this year… getting into the last week of prac, feeling pretty good about how you’ve done on the prac etc… then getting a few comments from a supervisor (curtin or facility) that make you start thinking “Holy c**p, they’re going to fail me! AHHH!). I don’t know if it’s just me, but towards the end of every prac I start to get the impression that I’m about to be blindsided and fail the prac… causing a massive amount of STRESS!!! I’m not sure if this is a personality trait of mine, or if it is something that other students also experience?? I’ve had a few pracs where I have been pretty confident I’m going to pass, but a couple that I’m been chewing my fingernails with nerves up until the last day… which makes the last few days of prac HELL and not very enjoyable at all. I can see why a supervisor doesn’t want to tell you you’ve passed until the last day or so (because I assume that if you knew you were going to pass you MIGHT slack off a bit) BUT sometimes I think it would make the last week so much more relaxed and enjoyable if we were told early in the week that we were going to pass. Anyway that’s my whinge/blogg for today. Hope prac has been good to everyone!
Ezza

Discharging DNA patients

Hi Everyone,

I hope you are all enjoying your final week of this placament. I am writing this week about a new patient given to me in my first week here in the outpatient department and of which I have still not managed to actaully assess. This particular patient was referred to me by an surgeon for rehabilitation after he performed a laminectomy on her 2 months previously. The patient did not attend three times in a row, each time stating that she got her appointment times confused. On speaking with her after the initial DNA, I was fustrated bacuase she was not very apologetic and lacked concern about the hassle it had caused but yet still wanted to make anoother time to see me. On the third DNA I rang the patient to find out what had happened and to discuss the problems associated with continually DNA'ing (i.e. three DNA's and your out policy) and came across a difficult situation. (NOTE: I had discussed the events with my supervisor and he said if, after speaking with her, she agreed to show up for another final appointment genuingly, it was my call whether or not I agreed to try and see her again). The woman sounded very upset about her lack of organisation and when I asked her about her motivation for physio, she was very keen to make another appointment.

Weak as it might have been, I told the patient that yes, I would make another appointment with her and she was very grateful. I discussed with her that this was her final opportunity for physio and she agreed to my terms. I feel that in this situation I appeared weak and that through my actions, I was disadvantaging other patients who are on our waitlist and are not being seen due to lack of availability of physio's. My problem was that I felt that this patient would benefit from physio and I don't feel comfortable turning people in need away from our profession. Perhaps if she doesn't show up for the final appointment, I will know that I made the wrong decision. Would any of you guys have handled this situation differently? Do you think that in order to get respect from patients we have to portray a tougher policy approach in regard to the consequences of DNA'ing?

Thanks for your input,
Kate.

Conflicting treatments

Hi Everyone,
I have found on numerous occasions when discussing treatment options with my supervisor on prac that she well disagree with treatments we have learnt at uni. My supervsior will then go on to say suggest "the best treatment option" for me to do. I repsect that my supervisor has studied alot more than me and had alot more experience so I learn alot from her and trust alot of the things she tells me; howver I thought our lecturers have too. So when I suggest a treatment that we have learnt at uni and she tells me that "she wouldn't do that", this frustrates me because it conflicts with what we have previously studied.

When I try to explain to her why I'd prefer a treatment or why I thought a certain treatment is more indicated, she dismisses it with out a good reason. My supervisor believes her way is the best way, and thats that. I dont want to appear defensive so my solution to the problem is just to agree with her and go with her ideas, when I find myself in this situation. When I finish I can take away what I have learnt from her, what I have learnt at uni and combine it with my personal experince to decide what I beleive will be the best for my patients. (Not forgetting evidence based practice :) )

Having to say it's finished

Hey guys,

I am currently on my Musculo prac, and due to administrative changes that are to be made (no students in between rotations, physiotherapist there having to work alone), we are having to discharge as many patients as we can. A lot of these patients we are discharging are able to self-manage and are ready for the discharge (they have been told that being back at 100% is a low possibility).

However, I've come to realise that most of these patients have been clients to the department for probably 3-5 months (having been passed on from one student to the next). I found it quite hard especially in this past week to begin the discharging process. Some of the patients actually looked sad, probably with uncertainty how they would be able to handle it themselves. Educating about empowerment and self-management is key, but still...

I found it quite helpful to develop a program for them, and told them that I'd put them on hold. They will have to call up in a month's time to inform the clinic of their ability to self-manage, and probably arrange for a last check-up for the older patients.

Am I wiping my hands too cleanly? What else can I do to better manage the situation?

Mark

Selecting a walking aid (yes, just like 1st year OSPE!)

Hi all,
I’m currently finishing up my gerontology prac and have come across a few differing opinions in regards to walking aids. A lot of the gerontologic population coming into the outpatients department have recently had a fall or been ill in hospital, and have been issued a walking aid by the hospital. Some clients have even just been given a walking aid by a family member or friend. When discussing the benefits of certain WA’s for certain clients with my supervisor, I expressed my belief that what the client wants is very important, and so it is extremely important to ask them what walking aid they prefer and what their goal is. For example, are they happy using a WZF or do they want to get back to using no aid or a walking stick? My supervisor disagreed with me, saying that our job is to get the client back to the most functionally independent they can be, so if they are capable of walking independently or with a stick, we should be actively pushing for that. Reflecting back, I do agree with her, BUT I also think that if someone is happy using a frame, then we could better spend our time (and theirs) helping them be functionally independent WITH that frame, rather than spending our time (and theirs) retraining them to use a stick or nothing at all… especially if that is not one of their goals. I can definitely see my supervisors point of view, but was just wondering if anyone else had faced similar situations, and what other peoples opinions on this are. Cheers, Ezza

Treating Aboriginal patients

Hi Guys,
Im at Burns ward and treating quite a few aboriginal patients.

In the country, people tend to light bonfires in winters and end up getting burns, especially if they are intoxicated.

I treated 2 aboriginal men. This was the first time I was treating aboriginal men and found great differences in the way they behaved around young females (my supervisor and me).The first one was young in his early twenties and the second one was in his late fifties.

The older man tended to avoid eye contact and to look away whenever I tried to politely ask him questions or explain the exercises that I wanted him to do. The strategies that I had to use was to stand at some distance, looking away from him and talk so I don't have eye contact with him. I even talked at his back in one session. This made him more comfortable. I also had to limit my explanations to very simple words and also just using diagrams for the patient to understand (as the patient's reading and writing in English was understandably not great). The patient spoke an Aboriginal dialect which was very different to the other Aboriginal patient that I had to treat.

Rapport with the younger aboriginal male patient was easier as he played football and went for Eagles (even if I go for dockers). But his writing and reading in English were understandably not great either because he belonged to a community where they spoke only an Aboriginal dialect. So I had to use very similar strategies as I had to for the older male. I had to be simple in explanations (using gestures) and write diagrams while explaining. He also felt more comfortable as I maintained distance, as I had to for the older man.

I also learnt the various ways of referring a patient to a nearby hospital when they are discharged. The patients live in communities close to the towns. Usually they are a few hundred kilometers away. So the physiotherapist at the town needed to be informed about the exact location regarding this. So direct communication by phone calls was essential with the physiotherapist who would need to travel a few hundred kilometers to reach the community.

Rapport with these patients was also easy when I talked about camping, fishing and dancing - as these are the regular activities that they enjoy.

Building rapport is essential while treating the Aboriginal patients. They also feel very isolated coming to Perth - which is a huge place to them. Approaching them as a friend can help them very comfortable and show them that the therapist cares.

On the whole, this was a great learning experience.

Confidence

Hi All,
This week I had to review a patient’s short and medium term goals for a team meeting. I have been working with this lady, who is 2 months post right MCA stroke for 3 weeks now and have seen good gains in the muscle activation of her upper limb. So, one of my goals was to improve the fractionated movement of her upper limb to enable some use in ADLs over the next 4-6/52. Before the meeting, I had to discuss the goals with my supervisor. She told me that this goal was unrealistic and it was unlikely that the patient would ever have very good function of the limb. I was quite surprised and confused because the patient is already able to use the arm with minimal-moderate facilitation and has been improving. But with such little experience, I wasn’t confident enough to say this to the supervisor because I thought that maybe I was just being too optimistic. Later in the week, after I had the afternoon off and my supervisor had to treat this patient, she told me that she thought that the goal was realistic and that she hadn’t realised the current status of the upper limb because she hadn’t seen the patient since I had started treating her. From this experience, I have realised that I need to improve my confidence in explaining my assessments and thought processes. I may still be wrong, but at least I’ll know why I am wrong and be able to learn from the process, rather than just being confused.
Mel

Allied Health Support

Hi guys,

My post this week refers to my astonishment at the poor relationship between the OT and PT department. This week I had a patient who is 91yrs old and living at home with his wife. He came into see me in a wheelchair post-fall (only soft-tissue injuries) with reduced mobiulity. Prior to the fall the man was ambulting with a WZF and transferring independently. Now however, he can only be transfered from wheelchair to recliner chair and back (unable to get into bed). On arriral to the session I noticed the terrible condition of his wheelchair (uneven foot plates, broken back rest, very poor brakes and lots of rust). The wife stated that they have no rails in their house and no aids to assist with washing/ADLs. When I asked about seeking assistance from an OT, the wife stated that she had alreadly been referred to the OTs and when they refused to provide her with a better wheelchair, she declined their services all together. After treating the patient personally, I discovered that the need for OT intervention was paramount, so I referred the patient back to the OTs.

The relationship between OT and PT is not very healthy in my particular facility: the OTs do not like to associate with the PTs and they have a particular dislike of students all toghether. Thus after I referred the patient back to the OTs they were less than impressed. The OT involved told me that the patient would go straight to the bottom of the wait-list and that she would get to it in a month or perhaps later. I felt particularly hopeless in this situation as I know my patient is in desperate need of help but a) they already declined the service and b) I feel that the OT does not trust in my clinical judgement. I went about organsising silverchain as an interim to the problem and have had to accept the wait-list for OT.

In this situation I feel that students are not taken seriously enough. Given that we are given patients to manage independently I feel that the system ends up affecting the patient the most. Have any of you guys out there experienced similar problems and do you think there would be a better way to deal with more experienced health professionals more equally.

Kate.

PPIVMS AND PAIVMS

Hi All!

I'm currently on my msc sk prac and am having to do alot of Ax of PPIVMS and PAIVMS in the Lx, Thx and Cx region. I am getting really frustrated that I cannot pick out the segment/s that are most restricted. No matter how hard I try, or how much I think "maybe I can feel this segment is stiffer" I am never sure. My supervisor then comes in and picks out all these levels that are 'more resticted' and they are most often not the ones that I have nominated. It really disheatens me becasue if I can't do it by the end of the prac what am I supposed to do once we start full time work if I am working in the msc sk area!?

I have been told that research now days shows that you should treat multi levels as oppossed to one anyway, but it still disheartens me that I cannot "feel it". Is any one in the same boat? Or was any one the same as me but have found something to asssit them in being able to feel the most resricted segments?

Thanks

What patients say about other physios, they'd probably say the same thing about you.

Hi guys,

I am currently on my musculo outpatients at Charlies, and I'm just enjoying it! I had a patient last week who came in for mechanical neck pain, and it was her 2nd visit when she came to me. She presented rather guarded and quite wary, so I guessed she probably was still in a lot of pain/fear.

During my assessment, I explained what I was doing as I went through, especially when it came to PPIVMs. Halfway through, she started to compare my manual skills with others, and said that the student before was pushing her neck through range, and that our supervisor had really good guiding hands. So she mentioned that I was roughly in the middle. I was in a dilemma, cause I couldn't agree that the student before was not as skillful, so I tried explaining relativity in light that she was probably very acute and was in a lot of pain during her initial assessment. I knew that if I agreed that it was probably due to a lack of skill of my previous colleague, it will somehow come back and bite me one day. What patients say about other physios, they'd probably say the same about you.

I mediated the situation by explaining how difficult this technique is, and how is takes roughly 20 years to get good at it. So she decided it was all due to practice, and that it all takes a matter of time. She responded really well to the treatment thankfully! She also mentioned that she was wary of turning up that day, fearful of being handled inappropriately (manual).

This was not the 1st incident when patients asked me whether what their physio did previously was correct. Just remember, unless it's unsafe or unethical, I feel it's not in our best interest to undermine the reputation of our profession, and it's really important to defend one another. Even though you do not totally agree with what other physio may have done, never appear like they have done the wrong thing - tell them instead how good the physio was before, and how you can see the direction they have taken.

That's my two cents worth. :) What do you guys feel? Have you been in a similar situation?

Mark

Expectations

One thing that has become very apparent to me this year is the importance of establishing with your supervisor early in the clinical placement what their expectations are of you. I am currently 2 weeks into my gerontology prac. For the first week I wasn’t given a very big workload and was left to do my own thing quite a lot, but I put it down to my supervisor sussing me out to decide if I could handle a bigger workload and that I would be safe with patients. I was quite unsure of what expectations she had of me for this first week, so I bought this up with my curtin clinical tutor on the Friday thinking the 2nd week would be better. After watching one assessment early in the first week, I was left to do my own thing all week (ie assess and treat some patients). At the end of the week my supervisor sat my down and basically ripped me apart with regards to what I had been doing… however I’d had NO feedback throughout the week and had no idea what was expected of me, so it all seemed to come out of the blue. Anyway, being the professional that I am I took everything that she said on board and went into the second week thinking all would be rosy. However, last week was almost exactly the same as the first! I still have absolutely no idea what my supervisor expects or wants from me… and everytime I ask a questions she looks at me like I am the biggest idiot to ever walk through the door. Its driving me bonkers!! Anyway I think I have the place and my supervisor sussed out now (ie how they like things done) so I’m sure things will pick up this week and next week… but I can’t help feeling that if my supervisor had sat me down at the beginning of the prac and gone through everything she expected me to be able to do ie. By the end of the first week, second week, end of prac… at least I would have known the standard I’d need to be at, and wouldn’t have had to feel my way through things for the first 2 weeks!! Has anyone else had a similar situation? Do you think I would be better off at the start of a prac asking the supervisor directly what her/his expectations are of me? All of my other supervisors have been very very clear on this from the get go, so it if frustrating to be somewhere that doesn’t seem to have any guidelines or expectations.

Chronic Pain

I’m sure it’s a situation we are all familiar with… a patient with chronic pain. Current patient- elderly lady, chronic back pain, in rehab hospital due to decreasing mobility and falls, focuses on pain, catastrophizes etc My job is to increase her bed mobility so that she can return home rather than off to a hostel or NH. Her pain is increased +++ with any bed mobility tasks. The first time I saw her and got her to show me how she gets in and out of bed, she cried due to pain, and could not get in or out of bed or roll without x2mod/max assistance, refusing to initiate any rolling herself. Obviously a rapport was not developed between us (as she then associated me with making her to do things that cause her pain). Over the next few days I gradually developed a rapport with her and starting building up to getting her to get in and out of bed independently ie. Activities on the plinth, weight shifting, going down onto her elbow, lifting legs a little bit independently etc. I thought I was doing quite well with her, and we were making progress… however, when my curtin tutor came in on Thursday she told me I wasn’t pushing the patient enough! This was really frustrating because I feel as though I have developed a rapport with the patient and know her quite well and feel that if I pushed her to get in and out of bed she would flatly refuse, cry, catastrophise and refuse any further physio. It seems like such a fine line with these patients… when do we push and when do we take it slowly? I thought I made good clinical judgement with regards to this patient, only to have my judgement questioned by my tutor. Now do I start pushing this patient like my tutor has suggested, or stick to my guns and my own clinical reasoning and do things the way I have been as it does seem to be working (but maybe not working fast enough??). Obviously I want to pass my prac so I will probably do whatever my tutor asks of me, but we are final year students now, almost at the end of the road, so when does our clinical judgement become regarded as highly as an actual physios?? There are 2 students at the hospital who were in the GEM program alongside us (ie graduated a few months ago so don’t really have all that much more experience than us) and I have noticed that their clinical judgements are never questioned!! Geez it’s going to be nice to not be a student…

Stimulating environments

Hi All,
This week I have been working with a patient who is very motivated in physiotherapy and works really hard for the whole 3 hour session. As a result, he is making noticeable gains in his balance leading to improvements in gait - which is his major goal. On Thursday, he came to Physio really agitated after a disagreement with the nursing staff and left after about 10 minutes because he was still really angry. We left him for 20 minutes and then my supervisor went and convinced him to return to Physio. I expected the session was going to be really ineffective due to his mood. But I was really surprised that he was able to do most of his exercises with a lot more control than usual. In reflection, I wonder whether perhaps this was because he had been stimulated by the disagreement which made his muscular activity more accessible. If so, I wonder if by making the patient’s environment in the hospital more stimulating we could get better treatment results. Has anyone had a similar experience with their patient’s?
Mel

Balancing pain and movement

Hi everyone,
I've been treating a patient who was stabbed in the hand. When I first saw him, he was in a lot of pain and my tutor just showed me how to move his hand and educated about his functional return. I was asked to see him again in the arvo.My tutor asked me to really push this man to do his exercises even with a lot of pain - as he lectured about neuroplasticity.

When I went to see him and asked to move his fingers, he was in little pain. I looked at the med chart and noticed that he had pain killers only 1/2 hour ago. As he tried to move more, his pain increased. I gave him regular breaks so that the pain subsided and i could begin the exercises again.

At some point, the patient was starting to become agitated and distracted (especially because there were 3 other visitors in the room staring at me). So I said I will come back. I went back quite discouraged about how I didn't achieve much on the first day.

I tried again the second day - boy - was the movement better. He started to make a full-fist. He was in less agony and this prolonged the treatment session so I could do more work with him.

Third day was even better. Second day - he hated the sight of me - The physiotherapy department person. But third day - he was actually happy to see me and was showing me how much movement he has.

Boy - has this been an experience! It took three days for this individual to realise that I was there to help him and not break his hand. And it also took me 3 days to realise that there is light at the end of the tunnel!!!!

So be encouraged my fellow peers/colleagues.

Sashi.

Mid-Placement Assessment

Hi guys,

On my prac, I have just been told that I am responsible for completing my mid-placement assessment and then my supervisor will add to it if he feels that there are discrepancies in my personal feedback. Originally, I was quite surpirsed at this and was not quite sure whether I liked the idea of not getting direct feedback from my supervisor. Even so, I agreed to his plan and will set about completing it in my free time.

I have several concerns about this and was wondering whether you guys agreed with me or not. My supervisor tells me that his other students have had to do there own feedback in previous pracs, but I have never heard of this occuring. I generally look forward to my mid-placement assessments as it is a chance for my supervisor to be honest and give me some very specific hints on ways to improve my performance over the next half of the placement. I am worried about providing postive comments about my performance in case my supervisor doesn't agree and then I am concerned about pointing out my poor performance aspects in case this highlights new weaknesess that he may not have noticed!!! See my dilemma!!!!! I do not want to tell him that I'd prefer not to do it alone and I do not think he'd be receptive to this. Do you guys think this is a reasonable request and do you think it is more beneficial for us to self-evaluate rather than just being told our strengths and weaknesses by our supervisor?

Thanks for your input!!
Kate.

Burns patient

Hi everyone,

I had a patient today that i saw with my supervisor. He is an adolescent with four kids. At the end of the assessment and treatment, my supervisor said that he may need to be seen again in the arvo. I said - okay and offered to give the pt a handout for his exercises that I said I will prepare.

But the supervisor also told me to re-inforce and push him a bit harder because he had complained of a lot of pain and the 'adolescent' does not know what pain is and is likely to keep complaining and prolong his hospital stay. I understood what my supervisor was saying to me regarding this man.

So I went in the afternoon and explained what I was going to do. There were 3 ladies in the room (family members). The patient said he was in some pain and that he has been moving and can move it a little bit. So I got everything ready and got the dressings down to help with the exercises. The patient was compliant with the first 1-2 hand exercises after which he complained of increase in the pain. I said it's okay to feel the pain because he's just had his debridement and that the movement will lower it down. Otherwise there is a risk of having it get stiff (since hand is notorious for that). I knew that the patient had his panadol 30 mins ago.

But the patient seemed to be getting extremely agitated. What made it worse was the comments such as "You are making it worse" by the patient's family -even after I explained what I was going to do.

This created a very awkward situation for me. So I said to the patient - I will see what I could do. So I went to see the nurse and said if there could be a pain killer that could be arranged. The nurse said that she had already given the patient the pain killer. I said to her that the patient complained of pain that was 8/10.

Being crowned "the longest initial assessment"

Hey guys,

I am currently on my musculoskeletal prac, and I am still trying to get a handle the overwhelming workload/theory involved. I am still struggling to ensure that I get most important things checked (good observation, palpation, arom, prom, ppivms, paivms, etc etc etc....). I had a new patient last week, and he was sort of a workers' comp with yellow flags...he had Cx, shoulder and LBP at the same time...so it was really hard to get a good idea..esp when there's so much pain.

Because he was referred for the Cx pain...i spent more of my time assessing his neck. However, on top of the spinal assessment, his pain was directly associated with his shoulder...and so I had to complete a "quick" shoulder assessment as well - he was limited in range in his shoulder too...

Getting my head around to the neck assessment techniques was hard enough...I managed to only complete a thorough Ax with Rx in 2 hours 10 min...LOL!

Hope someone can beat this record! I'd better buck up and be more efficient in my Ax!

Mark

heavy workload on prac

The prac that I am on at the moment is interesting and I am learning alot; however I am getting frustrated that I am struggling to keep up with the patient notes. In order to keep up with patient notes (because we are not given ANY time to do them during the day as we are booked out with patients) I have had to come in half an hour early and stay back an hour every day this week. On top of that we are only given a half hour lunch break everyday. Patients are often running late etc so we are lucky if we do get the full half hour, and not just 15 mins, which is bearly enough time to scoff down our lunch.
This leaves me quite exhausted by the end of the 9 1/2 hour s that we spend there each day. It wasn't such a problem this week but I will be starting back at my other job this week coming and I m worrried it will just be too much.

One of my fellow student collegues mentioned this to our supervisor (who is also our clinical tutor - which makes it impossible for us to discuss this with an outside party) and she advised the student that this is just how it has to be and there is nothing she can do about it. She knows and understands that it is a heavy workload but thats how it is in real life and you have to get it done. Fair enough, but we are not in the "real work force" yet, we are students who are meant to be doing 32 hours of prac a week with an hour lunch break every day. When we are actually working we wont have week night and week end jobs so it wont be such a problem to stay back an hour. We have also got a heavier patient load then the previous student s becasue they've had to squueze patients from 5 students into 4 students time slots.

So discussing this with the tutor/supervisor came to no reasonable conclusion, so I decieded to try something else. I decided to try writing the patient notes whilst I am in with the pt. This works ok sometimes, but other times it has been too messy and my tutor has asked me to re-write it, and if it is a new patinet we have to write up a full SOAPIER which is impossible to do whilst you are in with the pt. Doing this also means that the Ax and Rx dont flow smoothly because I am continually stopping to write things down.

Has anyone else been in a similar situation? How did you handle it? Has anyone got any other ideas of how I can manage this situation and my time more efficiently?
Thanks

Neuro

Hi Everyone,
I started my neuro clinic this week and have found myself on a very steep learning experience. The facility that I am at uses a predominantly Bobath approach and while we are encouraged to use any of the techniques we learnt at uni, we also have the opportunity to learn a wide variety of new techniques from the staff. I have been very focused on trying to learn these techniques and consolidate the ones from uni and because of this, I feel that I have not been able to give as much attention as I need to in observing the patients posture and position during treatments, even though I know it is vital that the techniques are performed in good positions. It has felt as though there are just too many things to think of because I have to consider my body position, the patients body position, the movements that I want them to do, the movements that I don’t want them to do and then what to do with my hands and actually coordinating that. I feel that I have already improved in being able to put everything together since I started on Monday, but am still finding it difficult. In order to improve my ability to put together all of these skills, I plan to take every possible opportunity to practice hands on skills so that they become more automatic and I can focus on other important aspects of the treatment. I will also consider using a mirror in front of the patient so that I can see their position when I need to be behind or at the side of them. Any other ideas??
Mel

Choosing what to treat?!

Hi all,

My post this week relates to my musculoskeletal outpatient prac. I had a very elderly patient come to me yesterday with hip pain following a total knee replacement three months earlier. On the subjective examination however, she came armed with a list of her medical conditions and another with all of her current pains and problems that she is experiencing currently. By the end of the assessment, she told me she had ongoing post-op-related knee pain and weakness in her left knee, pain in her right knee (which is awaiting to be replaced), new hip pain, long-stnding lower back pain, aching/painful feet and neck and shoulder pain. (It must be noted, this lady did not present as a psychological chronic pain patient, I do believe that the pathologies would be very easily indictaed on any exam - she is just very very old and over worked!!)

In order for me to actually get the assessment completed and some direction in my treatment for today, I simply asked the patient to pick the most severe pain that is causing her the greatest problemstoday. Luckily she was able to pin point her hip pain and I thus went about managing this problem. All of my objective measures were limited by her multiple array of 'pains' and it bacmae very clear to me that a very general rehab program would be the most effective way of managing her problems.

Therfore, even though I treated her hip pain on the first treatment, I now intend on giving her a general strengthing and stretching exercise program which I hope will assist to reduce many of her aches and pains. It just concerns me slightly that I am not focussing on her individual problmes and that perhaps these problems could be better improved by using more specific techniques. My question to anyone out there, is do you think that treating this patients problems individually at separate times would be more effective than the path I have actually chosen?

Thanks,
Kate.

The Importance of Good Manual Muscle Tests

Hey guys,

This post is going to be a short one. In my last prac, my tutor noticed that my MMT was not spot on - I was testing hip abductors of an elderly patient, with a little compensated hip flexion. My tutor said that MMT being taught so early in the course, most students struggle to be able to do them correctly by fourth year. It is vital that we are able to do these tests well as strength in these muscles are vital especially for function in these sort of patients.

I've come to realise that I have to spend some time reviewing these techniques so that myself or the next physio would be able to monitor any strength gains over time.

Hope the next prac goes well for all!

Mark

Treating patient needs.

Whilst being on the musculo-outpatients prac, I recently had an on-going patient return after a few months of not attending physio. Whilst looking through his previous notes, I found he had attended physio for all different problems, the last visit was regarding his low back pain.
On subjective, I found out the only reason he returned was because he wanted to have his exercises reviewed and progressed. This was an 84 year old man, who liked too keep very fit and active. He reported no pain, or any other concerns affecting his everyday activities. So I though that this was a pretty straight fwd and easy case, I just had to go through his exercises, make sure he was doing it correctly and modify it.
So I did a brief objective, quickly screening all the joints/ rom etc. Some of the main findings were he had about 5-10degrees reduced PFlxn and Inversion on his (L) ankle, excess pronation L>R, and a length length discrepancy with the (R) being 2 cm longer. However none of this were his problems, so I didn’t take that into consideration, in my mind I was there to sort out his exercise program. Of course all this had to be reported to the superviser, she then came into the room to further assess his ankle. So ½ hr later there I was treating his ankle, trying to improve 5-10 degrees of Pflxn and Inversion. So at the end of the session I achieved full and equal range at both ankles, provided him with ankle ROM ex, taping, and advised him on the need for orthotics.
Normally I’d think that was a successful treatment session, however in this case, I felt the needs of the patient weren’t being addressed. The patient came in just wanting his exercises reviewed, instead he’s got his ankles treated, which weren’t causing him any pain or referred problems. I just felt the superviser overtook the session, and directed it away from the needs of the patient.
My concern is that at the end of the day, the patient didn’t get what he wanted, he was due for a review session for the following week, where is modified exercise program would have been prepared and ready to go, unfortunately he didn’t attend the following week.
So my question is, should I have just been concerned about what the patient wanted, or should I have let assessment guide treatment..

Demotivated patient

Hi everyone,
I was in a neurosurge ward and had to treat a patient who was very demotivated about her recovery. At first when i met her, she seemed to be a very enthusiastic and motivated patient. I found that she was very compliant.

At closer look, she seemed to get quite distracted easily. She would start commenting on what the patient is doing next to her bed that she was in, etc.

Treatment also became quite difficult when I found that she seemed to get slightly agitated when i tried to bring her attention back to what I wanted her to do. My supervisor warned me that she does get very distracted and sometimes even agitated. Walking became even more difficult with her. The patient seemed to just want to stay in the bed and listen to others' conversations.

But one day I found out what was really happening in her house that she goes to during weekends. Her daughter is the carer for her mother. And currently - she can transfer with s/b * 1. But the daughter reported that she was needing two people to transfer her to the wheelchair. The daughter became frustrated and said that the mother may need to be put in a hostel.

This time, my supervisor advised me to be a little "hard" on the patient. Being a "softy" i found this actually quite difficult at first. But i learnt to tell the patient of the consequences of what happens if she regresses back to becoming dependent.

I realised that one of the biggest roles of the physiotherapists is to use their voices to motivate the patient to get out of their established comfort zones. I started to tell her how well she was doing and what will happen if she doesn't do well. Everyday - she was in tears because of this. But as my supervisor told me - i found it rewarding in the end - when i said to my patient that her STS took 1:35s - compared to 10:45 s one week before.

My patient felt happy and i found that being a great way of motivating her. In this way - the moral of my story is this - u may think u are being mean to a patient when u are hard - but one will do more favour if they help the patient get out of their comfort zones and help them achieve a goal.

sashi.

OT/PT Overlap

Hi guys, hope your pracs finished off well!
I have found on this ward (neurology) particularly that there is a huge overlap between what the OTs/OT students do with the patients and what we do. In other wards I have been on we seem to target different things and it works quite well, for example they would be assessing and working on showering, toileting, giving the equipment, fixing the home and looking at services once they leave hospital. However, in the ward I am currently on the OTs also target sitting balance, standing balance, UL function, motor recovery and bed mobility. This presents a problem in that the patients get very frustrated that, for example, the OT might see them in the morning and then I see them in the afternoon and I might assess muscle power, cerebellar signs & symptoms, sitting balance and standing balance and then perhaps work on rolling, facilitation of a recovering upper limb and standing balance, and patients get grumpy having to do the same things all again . Not to generalise too much but there are also mistakes made, perhaps from a poorer knowledge of anatomy - one OT student excitedly told a patient that he had return of his finger flexors when it was simply tenodesis occurring with wrist extension. I had to adjust for this on the ward by finding out what they were doing in their sessions and try to avoid doing those things to prevent overlap but it was disappointing as sometimes I felt that I could do a better job than what they were doing with particular things. I feel that there needs to be more of a line drawn as to who works on what to avoid patient frustration.

referrees

Hello bloggers,
I am currently applying for a few jobs (scary I know) and although I have provided a list of referrees, the company I am applying for has requested to speak to my most recent facility supervisor. I got along quite well with my supervisor and got a good report from her, but it just seems really weird and more than a bit awkward to ask someone who I have known for 4 weeks to act as a referree. Has anyone else had a similar situation? I really want the job, so will jump through hoops to get it, but all the same I don't want to put my supervisor out in any way as she is really busy, and I'm no longer on that placement so she has new students to deal with. Are we supposed to be looking at all our supervisors as future referrees? They have so many students come through that I'm sure they don't want to have to remember all of us and be called up out of the blue. So what do you guys think? Will be interested in any advice!
Cheers
Ez

Family member's disrupting treatment sessions

Hi everyone,

This is my final post for this placement, hope you are all satisfied with your performance in this prac and are looking forward to our third last one ever!!

This blog relates to a situation I had during my final assessment for my respiratory placement. After reading the notes of my selected patient, it became aware to me that this patient may be very complicated given that she is under 50yrs and dying of COPD due to her extensive smoking history, has suffered ETOH abuse in the past, has anxiety issues (related to her poor relationships with her children) and is living in a shared hostel with minial support. On entry to the room my initial concerns were hightened when the patient began complaining about being kicked out of other hospitals, "just because they don't like her because she's a smoker". Half-way through my exercise program that I was prescibing (mobilisation was not indictaed due to a massive migraine and intense shortness of breath), her only 'supportive' son entered the room he: a) began ranting about his run in with the police due to a brawl he'd had earlier, b) about how he shouldn't have gotten 'high' on drugs that morning, c) about his issues with his girlfriend, d) began rolling cigarettes (NOTE: in a respiratory ward whereby most of the patients are admitted due to smoking-related causes!!!). As expected, my patient lost all interest in the exercises, her breathing began to get worse and her headache progresses so much so that she no longer wished to continue treatment.

I felt very confronted in this situation. My supervisor and I had already established that in order for this patient to comply with our treatment now and in the future (she is to attend COPD linkage services on discharge) a good relationship needed to be formed and therefor, by sending her son out of the room would have caused resentment towards instead. I was very upset that while I am educating the patient in regards to the benefits of quitting smoking, her son averts attention towards his habit which I'm sure has an influence on her ability to quit herself. My relaxtion techniques went out the door when her anxiety levels increased due to her sons ranting and I felt that my treatment session was not as effective as it could have been without the presense of her son. In future with this patient, I will time my session for times when the son is not present ans provide some education regarding the importance of reducing stress levels to assist with relaxed breathing.

Do you guys think it is the patient's due right to have any person they want in the room with them during our treatment sessions and how do you think I should broach the topic with the patient about how passive smoking and temptation to smoke are only making her condition worse?

Kate.

'Freezing' patient

Hi guys
Today I was treating an elderly patient on the neurology ward that I had seen all last week, where she had been fairly mobile and I had walked 80m with her at the max. I knew that she had had a bad wkend with neurological episodes of unresponsiveness and so I was prepared for a decline. However, when I saw her today she was a changed woman, she moved with such a slowness of movement with really slow initiation and could not follow commands properly. I kept downgrading my planned treatment session in my head until I would have been happy if we just did a lap of the bed with her WZF then let her lay back down again. However, just past the foot of the bed as we were walking to the other side she froze and could not take the next step with her right foot that she needed. It looked really similar to when I have seen Parkinsons patients freeze in doorways, although she does not suffer from Parkinsons (her condition is rarer and more complex than this). I spent 5 min with her in the one spot, trying counting, prompts and tactile facilitation, with her getting more fatigued from the prolonged standing. A chair was only1.5m away but I had justified that it had taken her so much effort to stand from SOEB that if I moved the chair to behind her and let her sit I might not get her up again easily! Plus I didnt want to move from a guarding position to grab it. Luckily another physio walked past at that point, so I asked her to help and we tried one person weight shifting with another person trying to move the right leg to help her take the step to get her going again. However, the patient felt unsteady and began to cry, saying that she thought she was going to fall. The other physio decided that she would guard the patient whilst I grabbed the chair, we put it behind her and let her sit down, then we (big no-no I know!) dragged/lifted the chair with the lady in it to the side of the bed where she could sit in it and relax.

The things I learnt were that it can really be great to ask for help, especially from a more experienced physio, and also that it is often a better idea to let the patient rest instead of continuuing to try to push and push the same thing and distress the patient.

However I also wondered, does anyone else have any clever tricks for a neurological patient who has just seemed to 'freeze' to help get them moving again (taking into consideration frail elderly w a WZF)?

Thanks

Bed sheets

Hi everyone!
This is a post for those of you who have been in a hospital and have come across the people who use that extra 'fluffy' sheet that is on top of the bed sheet, to SLIDE their patients up the bed.
All the physio's that I've seen do this have whispered to me "Don't do it while any of the nurses are looking or in front of your examiners"... They always say it is best practice to use a slide sheet, because it is easier on your back (provided you use the correct lunge technique and not a lift).
And this is totally understandable because thats what slide sheets are designed for. But when you think about it, it is almost harder on your back to use the slide sheet because you have to put it in first. You have to roll the patient from side to side just to put the slide sheet in, and in most of my experiences just that is the most demanding on your back!
I think if a patient is already lying on the extra sheet, and you use a technique that is used for a slide sheet (ie not a lift) it is occasionally the best way to go. Especially with those heavy patients.
I know with most patients its best to use the slide sheet because of the ease of sliding around, but my point is that using the second bed sheet occasionally shouldn't be frowned upon! Any comments anyone? Would love to hear what you think.