Intermittent Claudication causes Intermittent Doubt

Hi everyone!

Sorry for the delay in posting.

I am currently doing my cardio placement in RPH, but today my post is from a case on my last prac (Gerontology). The main aim of that particular ward is to allow patients additional time to gain confidence on their feet and extra rehab b4 going back home/hostel/NH.

I had an elderly lady diagnosed with unstable angina with a PMH of IHD, AMI, PVD and dementia. During her initial Ax, she was doing pretty well, and I got her to amb down the corridor of the ward. Since she was considered "medical" due to her angina, I kept asking SOB/chest pain/radiation symptoms. She was walking fine initially, then after 15m from being steady & safe, she suddenly wanted to sit, and FAST!!! She started to complain, on questioning of severe bilateral calf pain with a grimace on her face. This case is more complex than expected as her dementia made her lack insight, and was verbally non-spontaneous (would only tell you if asked).

Over the next few days, I got her on a walking program to increase her ex tol and walking endurance. Nearing the end of her stay, she was struggling ~35m with multiple rests. By then, the doctors were pushing for her to go back to her hostel. The requirement for her hostel was Indep amb ~40m, and she was almost barely reaching that mark. I expressed my concerns to the team and my supervisor, but they still wanted her back. I knew for certain that if "anything" happened, she will well be under that mark. I gave her a 4WW to go back with, and expressed all my concerns in her D/C summary.

It's not easy to decide who stays and who goes. Hopefully with more clinical experience, I'll be able to decipher that more easily.

Mark

Over qualified walker?

Hi all, I'm sorry for the delay in posting.

Im currently on my gerentology prac at RPH. Im on ward 5A/B which is aged care medical rehab. Basically its the relatively acute geriatric patients or those with many co-morbidities. I have only been there a week, but from my understanding, the role of the physiotherapist on the ward basically is to Ax how the pt can be transferred by the nursing staff, and to ambulate the pt if able. Full Ax is very rarely done ( I have not seen one yet) and the only physio intervention I have seen so far is deep breathing exercises, basic mobility assessments and ambulation. Considering the physio on the ward has to see around 20 patients a day I understand that there is not much time for treatment. But i find it really frustrating that there are stoke patients, patients with other co-morbidites such as broken bones, poor balance, weak muscles etc on the ward and the only treatment they are recieving whilst on the ward is basic chest care and mobilisation. These patients would benefit from rehab, and most of them will be discharged from the ward to a destination where they will recieve rehab, however; I feel frustrated that in the mean time, whilst the patients are on the ward they're not recieving significant treatment. I mean we go to uni for 4 years, and have the skills and knowledge to treat these patients, however, due to the limited time and resources (there is not even a gym on the level) we cannot use our knowledge and skills to help these patients to our full capacity. I also feel disheartened that we know all this theory but the application of it in this area is relatively limited. I also feel that due to the above circumstances Im not going ot learn a great deal on my prac so Im not enjoying it so much at the moment. I have expressed my concerns to my supervisor nad she agreed that we are basically over qualified walkers, and she said that this week I will be able to spend some more time with the patients on my own, so I will be able to do more with them. I know I just have to make the most of the placement and Im hoping Ill end up learning more about the things Im not expecting to. Has anyone else felt like this on any of their placements?

Code Blue

Hi guys,
On neuro prac this week we had a 57 year old guy (stroke patient with concurrent heart problems) start to deteriorate in the physio gym. We didn't have a supervisor with us so it was just 4 students and the guy. My advice for everyone out there is to revise the signs and symptoms of a patient deteriorating and find out how to call a code blue on each of your pracs. We ended up calling a code blue and the guy is ok, but it was really hard to know if we were doing the right thing at the time.
Ez

Stuck for creativity!

Hey All,

I’m currently on my 3rd placement at CPA primarily working with school-aged children. In my first week the superviser went through CP, the assessments used, botox and its protocols. During the first 4 months post botox there is a rehab protocol that is used. First month – stretches, second month – agonist muscle strengthening, third month – antagonist muscle strengthening, and fourth month – combination. So the superviser told me to make a list of potential exercises for each month and report back to her, targeting the following muscles: hip flexors & extensors, abductors & adductors, quads & hamstrings, plantarflexors & dorsiflexors. Thinking the task was pretty straight forward, I managed to get down several stretches and strengthening exercises. But when I went through it with my superviser a lot of the strengthening exercises were inappropriate for school aged children who have physical and sometimes cognitive impairments. My ideas for strengthening exercises relied on the use of therabands, ankle weights and eccentric muscle strengthening, though appropriate, it didn’t suit the target age group. The supervisor emphasized the importance of combining exercises/treatment into games to increase childrens compliance. With a lot of prompting from the superviser I was able to come up some exercises incorporated into playground equipment/sandpit etc. But I was completely stuck on ideas, and considering I’m going to have to do this for another 4 weeks, I’m somewhat worried. Having focused too much on getting ideas from what we’ve learnt in musculo and neuro pracs, I’m having difficulty trying to think of exercises to accommodate for younger children.
So if anyone has any suggestions on activities/games that can be used during the treatment session, or know of any resources I can have a look at, help would be very appreciated!

Rev

To treat or not to treat????

Hi guys,

I have recently had my first 2 pracs on the spinal and medical wards at RPH where I have dealt with many serious acute medical conditions and with patients who are at a very large risk of mortality and serious illness. So you can forgive my surprise I'm sure that when I started this week at the Outpatients Curtin clinic at SCGH I felt unsure of how to respond to some of the patient reason's for attending physiotherapy.

One such example, is my patient of 60yrs who came into see me with a referral of lower back pain.Prior to the session, I studied up on all of the relevant subjective and objective assessments I needed to carry out and then brainstormed all of the possible intervenions I could use to help reduce her pain. However, when the the subjective examination began, I started to feel slighlty bewildered as to what her specific problems were. She reported 0/10 resting pain and at the worst 3/10 pain on movement. More interestingly, she reported only ever experiencing this pain when she slumpled momentarily awkardky on her chair and the pain instantly resolved when she sat in a better position. The only objective result that I could possibly find on assessment, was slight hypomobility on (L) L4/5 unitateral and L5 central PAIVMs and slight TOP over the (L) qudratus lumborum muscle. The only possible treatments that I could justify for that session was soft tissue massage over QL and PAIVM's over L4/5. I gave her simple HEP of ROM ex's in standing and gave some education on correct posture in sitting. The patient re-booked for another session next week, as she felt that the treatment had made her feel better.

I have several concerns about this situation. The first is that I feel lost in the treatment session as I am struggling to find significant asterick signs and therefore am not sure how to fill the session effectively. The second is that some of my other patients are not recieving regular enough appointments as all my times are booked up. The thrid is that as she is a private patient, she is paying for the treatment sessions and I am wondering wherether it is ethical to allow her to make another appointment?

My dilemma is that do I explain to the patient that I think that physiotherapy is not really required for her problem or do I continue treating based on her subjective reports of pain. If I continue treating, does anyone have any idea's what I can do to help this lady??

Look forwards to hearing some opinions,

Kate.

When to stop?

Hi Everyone,
I recently saw an elderly patient who has been suffering from an anxiety condition for many years. This condition has progressed to a point where he is afraid to leave his house. He lives with his wife who does his shopping for him but otherwise he is independent inside the house with a WZF. He has had numerous falls and lost confidence in his balance which makes him even more fearful of leaving the house. I was seeing him at the hospital to assess and treat his balance and muscle strength in order to reduce his risk of falling.
During his assessment, he told me that even if he was able to overcome his anxiety and leave the front door, he wouldn’t be able to manage since the WZF would bump on the concrete and he wouldn’t feel safe. So I thought it would be useful for him to trial a 4WW to use outside. His wife was very excited about this, as she finds it difficult that he won’t go outside with her and felt that having the 4WW would enable him to accompany her outside.
As soon as he took the first step with the 4WW he said he felt unstable and that he did not want to use it. His wife told him to give it more of a try, so he did, but he kept saying that he did not want to try it. I was a bit confused about what to do. He was saying he didn’t want to keep walking with it, but he was doing so and managing quite well and very safely with it. I thought that if he gave it more of a go he would get used to it; however his words were clearly stating that he did not want to keep going. I asked him to stop walking and if he would like to sit down or if he would like to try to walk to a nearby chair and then sit down. He agreed to go to the chair and then sat down. I asked him to think about whether he would like to give it another try at his next appointment and he said he would think about it. The following week, he wanted to give it another try and did quite well, saying that maybe he could get used to it which I thought was huge progress.
This situation made me think about how we draw the line on when to stop a treatment if the patient is saying they don’t want to do something but is still actively doing it. If the patient says they don’t want to do something and either stops doing it or won’t do it to begin with, it’s obvious you can’t make them. But it’s not so obvious what to do if they say they don’t want to keep doing something but continue with it even though they don’t have to. It’s even harder when family members are there encouraging them to keep going and it seems they don't want to.

Pain!!!!

Guddday all. Currently at Bentley out patients musculo and enjoying it so far. My last placement was at RPH WSC ortho inpatients. Lots of people with lots of very broken bones. Some really interesting cases clinically and also some interesting cases for other reasons. One of the things that got my attention was the way that different people handled their pain. One patient, when given the option of pain cover before ambulation, explained that it was not his "policy" to take pain killers. Three metres later he was revising his policy. On one hand a tough tattooed young bloke had still not mobilised five days post femur ORIF, and in the next room a 14 year old girl with a T2 to L4 scoliosis revision had sat over the edge of the bed without complaint 2 days post op. Whichever patient, they required treatment and in this setting it was made easier by the fact that, generally speaking, help was only a Tramadol away. Moving on to the outpatient setting as I have, I'm still treating patients who vary widely in the way they respond to their pain.

I had a new patient yesterday (an older man with an extensive history of lower back pain) who was referred by the SCGH pain management team for treatment of lower back pain and radicular symptoms in the R leg. In their referral letter they indicated the medications they planned to provide him with, including buprenorphine patches and a number of other high level pain killers. Additionally, he had been prescribed anti-depressents due to a session with the psychologist, during which he expressed ideations of suicide. Three previous rhizotomies had been performed with fleeting success. No previous PT. During subjective examination he said that he had not actually been provided with any medication, and was frustrated by this.

Subjectively it was difficult to pin down aggravating factors at first. "Movement" seemed to be the main aggravating factor, but continued movement was also the main easing factor. Further questioning identified movement or loading in flexion (sit -stand, doing the dishes) produced most of his symptoms - stabbing 8/10 pain. Despite this, he presented as someone who was trying not to be limited by his pain. He still walks around the park, just has to sit down for 10 minutes half way round. Very interested in mechanics and is always tinkering with cars. Does all the house work at home. During the examination, his resting pain was 0. He consented to objective examination.

The objective was shortlived. Looking at his referral, I expected that would be the case, but his subjective and the manner in which he spoke suggested we might be able to do more than I had first intended. During active movements his demeanour changed significantly. He did not want to move because he knew he would experience that pain. He turned from a confident patient to someone who was afraid to move. I did a brief neuro examination before we terminated the session. He has agreed to return to continue objective examination. I know I have to further modify my examintion and I'm reasonably happy with how to do that (although suggestions always welcome). My issue is the fact that during my subjective examination I didn't identify that fear. The referral letter was a warning, but the presentation of the patient gave no indication before objective. The change was almost immediate.

I'm just wondering if anyone else has had a similar experience. I guess we'll see how he goes next time, but if anyone has some word of wisdom I'm all ears.

Finding the Truth

Hi all
My post is to do with communication. I am currently on a gerontology placement and it is required that a comprehensive geriatric assessment be performed on every patient on admission to the ward, with emphasis on what is functionally required to enable the patient to return home. I was assessing a lady who was very resentful at being placed into a geriatric ward as she was only quite young at 69 years of age - although the admission critieria require the patient to be <65 years old the majority of patients are over about 85 years old. She was very anxious to return home quickly and during the assessment was giving the impression that she was coping at home just fine without any assistance, that her son was doing everything for her and this was all going fine. She insisted that she was fine to go straight home from the ward as I believed that she felt that saying this this would get her home quickly. However, the next day when I was speaking to her I had some extra time so I was allowing her a lot of time to talk through her worries and concerns. During this she confided that she actually was having increasing difficulty coping at home, especially with personal care such as showering even with the help of a shower chair, however she was afraid that it would slow her discharge if she revealed this to anyone. I reassured her that it was more important that she be able to cope at home and that there were many services available. I then spoke to the OT who has since spoken to her about alternative equipment, and the social worker who is arranging for services to visit the lady at home when she returns to help her with self-care. From this I learnt that during a quick assessment you may only get so much from a patient, it is only when you can spend some time with them and really listen that you can find out the true story. Unfortunately due to time constraints this rarely gets to happen as there is usually so many patients to be seen, but in an ideal world it would be good to have the time to really listen to what the patient is feeling, and that I guess that the answers from the assessment need to be taken with a pinch of salt in case the patient is saying different things just so that they get the outcome that they want.

Working with babies

Hi guys, as I don't have email access at home & im not too sure on the blogging process I though I would take this oppertunity while im at uni to post this blog & get things started:

Being the youngest on both sides of my family I have never had the oppertunity to handle children between the age of 0-1 yrs old. On my 2nd day at prac I was given a 6 month old who would not stop crying! I had one hour to assess (Ax) and treat (Rx) this baby re: gross motor development problems & plagiocephaly (secondary to muscular torticollis), but I could not do anything as he was screaming & crying uncontrollably (which was distressing the mother who was already EXTREMELY ANXIOUS about their child)...
During the session I ended up doing blocks of roughly 5 minutes Ax or Rx (with the baby crying) & then giving him back to his mother to hold for 5 minutes (when he would immediately stop crying). I continued repeating this. In the end, a lot of the session was wasted & the mother had become more anxious. I tried guiding the mother to do the Ax and Rx instead, but any time he wasn't hugging his mother he was distressed (especially trying to stretch his SCM). I tried using singing, toys and music as distraction but nothing would stop this baby crying.
Some insight into techniques used to calm baby's would be greatly appreciated...
Also ideas on how to avoid situations such as these...

Thanks, caris madden

Something to Comment On

If you are reading this well done. It means that you have managed to log onto your blogsite and can start the process of reflecting on clinical placements. To start the ball rolling and give you something to think about and comment on I have a reflection below that was posted by a student in the past.

Happy Blogging
Peter

Too Sick To Stay?

The past few days I've been feeling a bit crook. So I took Tuesday off as I was throwing up Monday night. I went in today, which was Wednesday as I had my final assessment and a presentation to do. I still felt sick, and I wasn't all there, but I really thought I was well enough to not miss clinic. Well anyway in my less than normal state I missed some stuff in the notes that I shouldn't have. So my question is, as a student how do we tell when to draw the line on feeling well enough to go in to clinics, without giving the physios you work with (who you are trying to impress) the impression that you are just not toughing it out?

Comment 1:
I’m sorry to hear you’re not feeling so well. Although, it’s completely understandable as it is easy to get run down doing this course.
I think you’ve raised a very good issue. I think what you have to ask yourself is, are you putting the patient’s treatment at risk? Do you think that in the state you are in you are able to clinically reason appropriately and provide your patient the best level of care you can provide as a student? Also, are your patients who may have decreased levels of immunity while in hospital at risk for developing the “bug” you’re currently carrying? All important questions when trying to determine if you are “too sick to stay”.

Comment 2
I am so sorry to hear that you are/were sick! And I can defintely relate to what you are feeling as I too got very sick on my cardio placement. I was bed riden for a day and a half but was told by my supervisor that if I missed another day that I would have to redo the whole prac. Now, I know that there if a reason for that rule (of only missing a certain number of days) but I agree with you that's there is a thin line between needing to go into prac and knowing that you shouldn't. I was quite surprised when my supervisor said that, as she clearly new that I was sick and that if I came in I would be working closely with these immune depressed patients. So, I braved it out, because who in there right mind, or "sick mind" for that matter, would choose to stay in bed if they new they had to repeat a whole prac? I just tried really hard not to breath on the patients and washed my hands lots...hey is there any research on that?.....