Interstate Nerves

Hi All,
This week I started my elective clinic in a hospital in Melbourne. I have been to Melbourne many times before and know my way around the city, but did not know the area that the hospital is in at all, nor anyone at the hospital. I know all our placements in Perth are in new settings, but at least the areas and other students and some Curtin tutors are familiar and I usually find this comforting. The first day I felt really daunted by the prospect of having to go somewhere completely new, through suburbs that I don’t know, to a hospital where I really wasn’t too sure of what people would expect from me (the hospital didn’t send any placement expectations beforehand, so I didn’t even know if the patients would be more musculo, neuro or cardiopulmonary based). I was a little scared that some of the assessment procedures and documentation would be different and that there may be different expectations of students to those in Perth. I was also a bit nervous because I knew I was representing Curtin and wanted to do that well. All of these things were on top of the normal first day of clinic nerves.
So I just took one thing at a time. I used some of the weekend (after I had celebrated finishing my cardio clinic and the end of semester) to revise some general musculo and neuro concepts and conditions. I went to sleep early the night before, then I made sure that I knew the way and left half an hour earlier than I thought I would need to get there – and ended up being 45 minutes early (but better than being late). When I got to the hospital, I made a big effort to try to remember as many faces and names as possible and was orientated to the hospital straight away, so I knew my way around. The staff are very friendly and after 3 days, I recognise most of them and know those who I work directly with, so I don’t feel at all overwhelmed by not knowing anyone. I was given a timetable on the first day and told what was expected of me – which is exactly the same as my clinics in Perth. Documentation is slightly different because here only a SOAP format is used and the IER part is sort of fitted into the A and P parts, but I am encouraged to write in the way that I am familiar with, so there was nothing to worry about there. In terms of assessment all seems to be exactly the same as well. So now I feel a bit silly to have been worried about the start of the placement and am glad that I didn’t allow stress to get the better of me which probably would have made simple things seem more difficult.
I know this post isn’t really about physio skills per se, but from this physio related experience I have learned that when faced with something I think is likely to be stressful, I just need to be as prepared as possible and then deal with the situation as it presents rather than getting really overwhelmed. I think this experience will help when it comes to my rural placement, starting work at the end of the year or when changing rotations etc
Mel

First day-itis

Hi everyone, this blog is really late but some of you might read it sometime.
Today was my first day on a musculo-skeletal prac and it was one of the scariest days of my life. My second patient was a new patient and therefore required a full subjective & objective assessment and then a short treatment.
The patient was lovely but her condition was so complex that it ended up taking me 50 minutes to get a subjective out of her. I felt totally rude for interrupting her and trying to get her to answer direct questions the whole time, and I felt like she was getting really upset with me trying to hurry her along. Then the supervisor came in and encouraged me to hurry with the subjective and reminded me that I was taking WAY too long. Finally I squeezed the last information out but I was so exhausted by the end of the subjective that I had no energy for the objective and treatment!
I ended up being quite blunt with the lady and interrupted her during her stories fairly often. I was mixed between totally annoyed with her for going off track, but then totally annoyed with myself for not just sitting and LISTENING to her! After all, this ladies social history was so complex that she had no one she could talk to other than us... And what if her mental health was having a major influence on her physical well being!?! Then shouldn't I really be listening to what she had to say and not try and hurry her along to things that are relevant to me?
I understand why the supervisor was really trying to push me along and get on with it but as I walked out of the office for the day I wondered how much we should push our patients along to answer our questions or listen to them when they want to tell us every detail.
Just a thought. Any comments?
Caris

Employment Concerns!!

Hi guys,

I'm just writing for the final time this semester to voice my worries regarding employment opportunities on graduation. As our second and final semester approaches I am starting to feel a bit anxious about where and when we will find employment. After to speaking to my supervisor it occurred to me that action regarding finding a job will have to begin and I feel slightly unprepared. I am thinking that we have to initiate contact with certain people in high places but I was also wondering whether we should wait for the uni to assist us with sending out CV's etc. Is anyone else feeling the pinch just yet, or is my concerns coming along slightly too early??? Any advice would be much apprecitated!!

Thanks,
Kate.

Big mouth

Hi all. Final blog regarding my musculo OP placement which has been awesome. This week a lesson about shooting your mouth off. I'm a great believer in the saying "better to keep your mouth shut and be thought a fool than to open your mouth and remove all doubt". Unfortunately I don't always (rarely?) stick to my own rules...
Bentley out patients runs a back care ed. session for clients on the waiting list prior to seeing physio. I was with a couple of other students attending the class on friday morning. When any questions came up, the presenter was kind enough to direct the questions to he students. We managed fine until one of the patients said that she had been told that she had Scheurmanns disease and didn't know what that was. True to form, the presenter looked at us for an explanation. Lesson 1) if you don't know, say "I don't know". Anyway I thought i did know so off I went about the condition. The presenter seemed to be reacting positively so I figured my memory had served me well. My explanation seemed to satisfy the patient. After the session I thought I'd look it up to see if I had been correct about Schuermanns disease. I hadn't.

Thankfully, the patient was mostly interested in finding out how she got it and I was correct in my explanation that you are born with the condition and there's not a great deal to be done to prevent it. Had I been correct though, I could have explained to her that it was not a condition that at her time of life (guessing 50?) would be progressing further. Ultimately not a great deal of harm done, but I felt pretty stupid.

Schuermanns disease, BTW, is a condition in which abnormalities or deficiencies occur in the growth plate of the vertebrae during childhood and adolescence. Typically this leads to wedging of the Tx vertebrae and exaggerated kyphosis. Disease process ends when growth does, but effects extend into adulthood. In keeping with my policy of ignoring my own advice, I have typed this simplified explanation from memory, rather than having a look at another book first. Be warned.
M

ASSESSMENT TIME

Hi guys,
Yay another placement is over! I hope you all went well in your assessments.
I am currently on a paeds placement and the patient they chose for my assessment was a 10 month old (The age bracket they knew I found the most challenging) and whose parents had limited english!
Talk about freaking out, I swear I spent the whole night having nightmares about how terrible I was going to go. But things ended up going pretty good in the end and the curtin clinical supervisor was awesome. She was a younger supervisor and instead of sitting there ticking off all the boxes in front of your face and making you feel like you were an ant under a magnifying lens about to be burned to smitherines she sat back from us and just watched. She also talked freely with the parents which made me more comfortable and able to perform to my ability.. In the end she gave me a report that didn't have negatives which I was sure would be on there. And when she said how confident I was I didn't dare say "actually I was freaking out the whole time and had no idea if what I was doing was right". So my question is when they ask us what areas we need to improve on should we (or I) be listing off all the things we (I) think I'm terrible at or should we (I) just keep it to myself. Just a thought.

Nursing staff AHHHHH!

Hi guys,
Ez here again. My current issue is Nursing Staff. I KNOW they are really really busy (I've worked in a Nursing home and hospital before so I have first hand knowledge) BUT it is so frustrating when patients aren't ready on time!! Here is my current issue-
On neuro prac, seeing a patient who is no longer on the neuro ward. The nursing staff on the actualy neuro ward are great, always have patients ready for physio... however on this new ward they are a nightmare! I write on the ward whiteboard the night before to please have him ready by 11.30am (not exactly the crack of dawn, and actually the last possible session before lunch) and please have him in pajamas (as we are taking him to the gym) and to please have him in his wheelchair (hoist transfer). I also write these requests (nicely) in the ward diary and in his notes the night before. THEN at 8.30am I go and find his nurse for the day and ask for him to please please please be ready and explain why... and he is NEVER ready! Today he did have pajamas on, but was still in bed!! Ahhhhh!!!
What more can I do?! It's doing my head in!!
Ez

Blogging

Hi guys,
I don't mind blogging... infact I actually quite like reading up on what else everyone is finding interesting or having difficulties with BUT does anyone else have issues with finding the time to Blog, let alone read all the entries??
Along with prac, I also work 4-5 night a week. I don't have the Internet at home, and have no access to it at prac or at work. When it comes to priotising things, I think it's a lot more beneficial for me personally to be reading up on neuro stuff and planning for patients (I'm on neuro prac) to ensure that I PASS my prac, rather than stressing about when and where I am going to Blog!!
Anyway I'll survive, anyone else have the same problem or am I just a whinger?!
Ez
PS I am posting 2 blogs this week as I didn't have time to post one last week SORRY!!

Rude and Intimidating Doctor

The other week whilst on prac I was in with a stroke patient doing an iniital assessment, when in barged the team of Doctors. They did not acknowledge that I was in the middle of doing something with the patient and rudely interrupted me. Not one word was said to me and they took over the assessment just leaving me standing there like an idiot. I felt partially embarrassed, becuase this showed a lack ofrespect for me, in front of the patient and his family, and quite mad. I couldn't help myself and I just looked at the Doctor in disgust. A few seconds later my facility supervsior walked in as she was coming to watch and assist me to Ax the pt. The Doctor must have noticed me looking at him and asked if I had Ax the pt, I explained that I was in the middle of it and had not completed the Ax. He asked me, with very initmidating body language, what I had found. I was nervous, because I was in front of my supervisor and a whole team of Doctors, but I began to speak, and told him that to start with he was showing signs of left neglect. The Doctor then interupted me mid sentence, and asked me in a rude and condescending voice if I had seen the scans. I hadnt. He then went on to say that I must be wrong because from where the lesion is you wouldnt expect the pt to have L neglect. I then explained why I beleived the pt had L neglect. The doctor disregarded what I was saying and then continued to Ax the pt. I began to doubt myself and thought I must be wrong. After a few minutes the Dr realised that I was right. He admitted so, and then as he went on was discussing his Ax findings with me by the end. I felt relieved that I hadnt made a fool of myself in front of all those people, happy that I was recieving more respect from the Doctor, and a little bit smug that I WAS right.
After the incident my supervisor expressed that I did when dealing with the Doctor, and from then on I've noticed that my supervisor trusts me more and has been giving me initial assessments to do with stroke pts on my own.
This blog was partly to vent a little frustration at the lack of respect for me that the Doctor initially showed and to encourage everyone to be confident with your findings, not to doubt yourselves. This also shows that it may not always be a good idea to look at the scans before you Ax the pt. First of all because the findings from the scans may bias your Ax findings, based on what you'd expect to see from the lesion location, and secondly because the findings on the scans do not always s accurately represent and correlate with the types of symptoms and severity.

What you know vs what you see

Hi guys,

I had a pt who recently was discharged back home. This 81 yo lady came into the ward for a gastric outlet obstruction, and I was treating her chest during her stay. I found out from her daughter that she had multiple falls at home in the past as she tends to clutter her house such as tripping on the carpet. She has poor standing balance, lives alone at home and is awaiting bilateral cataract removal. Her daughter expressed her concerns re. the pt's safety at home. As I ambulated this pt on the ward during her stay, she was intermittently unsteady at times especially on turns, and relies heavily on her hands.
Considering all these factors, I made it very clear in my notes that the pt was still not safe for discharge at that time as she was a falls risk. However, she made a remarkable improvement in her mobility over the weekend, and the team was pressing for her discharge home - she was ambulating around the ward independently. The problem was - I wasn't entirely sure whether she was really safe: her mobility was much improved from what the ward could see, but I kept going through all those risk factors in my head, it was just this "gut feeling" I had. In the end, she was discharged home with RITH, and I referred her for falls clinic - I've expressed all my concerns in her notes.
The problem I had was that her Hx implies a falls risk, whereas the patient was walking around the ward independently and safely. Which did I have to rely on to make the decision whether she was really safe - what you know vs what you see?
It's those pts who are borderline that I struggle with. I hope that with more exposure, I'd learn to be more certain with making such decisions. I've learnt to use different services to send pts home with that have helped to make decisions easier (RITH, falls clinic, community physio etc.) Falls are so multi-factorial and I don't want miss something important and end up with a pt coming back in for a NOF.
Do you guys face similar problems? Or maybe it's just me...haha.

Supervisors...yep got more to add!

This being the last blog for the semester, I thought I’d finish off by reflecting on the Curtin Clinical Tutors. I only have nice things to say about them! I’ve been very lucky this semester to have 3 very lovely and supportive tutors, who’ve made the clinical and learning experience an enjoyable one.

First of all, they have all presented themselves in a non-threatening way, which makes it so much easier to approach them, with problems, queries, and doubts, without the fear of them thinking your incompetent, and know nothing. Because of this non-threatening nature, I found it a lot easier to approach them, be more talkative, and provide more input, as I didn’t feel judged incase I said something wrong. They provide enough support and help you to think on your own, and make you realize that what you’ve learnt in the last 3 years, is still stored away somewhere, and you actually know more than you give yourself credit for. They have been very encouraging, and provided me with positive constructive feedback, and not just picking up on everything I do wrong and emphasize that, whilst ignoring other efforts I’ve been making.

The thing I’ve most appreciated about the tutors, is that from week one, they’ve been clear about their expectations, and as students what we need to know about for that particular prac, and where the resources are. During the first week they’ve thoroughly gone through assessment techniques, especially if its an area that we’ve hardly spent any time on during the first 3 years of the course. This was especially helpful on my rheumatology and paeds placement, where the tutor went through the assessment forms used, and guided me through them, for forms such as the rheumatology assessment form, the GMFM scale and ROM/Tone testing for CP.

Finally, the tutors I’ve had, do take into consideration that we’re still students, and that in the space of 5 weeks, were never going to be at the level of someone that’s been practicing for how ever many years. So there tutors are very patient and understanding, and of course they’ll push you to achieve your best.
So I hope everyone else has had a good semester, and have had really helpful and supportive tutors, making the placement a more enjoyable learning experience. :D

Family Members

Hi guys. I have found throughout my placements - which have all been in hospital wards so far - that having family members in a room can affect the treatment that the patient receives. The majority of time the family are really helpful. They can be motivating for the patient, persuading them to do the treatment in spite of delirium or pain the patient may be experiencing, especially in the gerontololy placement where I am on at the moment where the sons and daughters often encourage their parents to 'go and work with the physio'. The family can also be very questioning about the patient's condition and treatment being received, and it is great to be able to answer some of these questions as the family will most likely be the ones re-explaining to the family member once they are out of hospital and back to their usual selves at home. However, I have found that sometimes the family present can be intimidating to the therapist. During this placement one day I had overheard a conversation, and after asking my supervisor I had found that the son of an elderly patient I was treating had rung up and verbally abused the doctors in charge of this lady, to the point that the doctor on the phone was quite upset. The next day when I went in to treat the lady the son was in the room with her. I was reluctant to treat with him in the room because I was worried that he would verbally abuse me, so I decided ot leave treating the woman until the son had left. My supervisor agreed with this. Luckily the son left about an hour before I was meant to leave so I managed to treat the lady. However I worry that if the son stayed all afternoon I may have not treated her at all because I was too scared of the son. In hindsight I should have just bitten the bullet and gone in but at the time I was really worried. Hopefully next time I will just have to remember that that patients treatment should take priority over my fear of the son and have a bit more strength!

And why not...more about pain

Just in case any of you were feeling any doubts about what y0u are doing out there, a little story to remind you 1) How well we have been trained and 2) Just how important physiotherapy is

My newest patient is a middle aged lady who suffered a comminuted and displaced fracture of the proximal humerus after a fall. Surgical management, 12 days in hospital post op due to oozing wound. She presented (7 weeks post fall) the other day with severe pain in the anterior shoulder on movement and a 6/10 resting ache that worsened during the day. Additionally, she had alot of swelling in the entire arm (affected hand 2-3x the size of unaffected). Her referral from the surgeon read "decreased ROM in R arm. mobilise aggressively".

OK so firstly to the how well we are trained part. Here was model of the patient that the staff (particularly Evan) told us about in terms of antalgic positioning causing secondary complications. Due to immobilisation in a sling for a number of weeks, the patient had lost ROM in the shoulder, elbow, wrist and hand. Also, due to the collar and cuff sling she had prescribed herself, she was experiencing severe neck pain. Objectively PROM was severely pain limited in the shoulder and the elbow. However, when I was teaching her pendular exercises I noticed that she was able to gain significantly more shoulder and elbow ROM. Bending at the waist during pendular Ex's meant she could achieve 70 degrees shoulder flexion pain free. AND... when she stood back up she was able to actively lift her soulder and arm to hold in the sling position, without the sling. Hmmmmm... Now, me noticing this is not something to brag about. Anyone with our training would be able to match a number of her symptoms with her antalgic behaviours. Which brings me to my second point.
Why is physiotherapy so important in this case? Because in the nearly 2 months since her fall, I was the first physiotherapist she had seen. I don't really see how that could be possible, but that's not the point. If she had been seen by a physio, her problems might not be the same now.
Cheers
M

Pulmonary Rehab Classes

Hi Everyone,
I’ve been involved in lots of pulmonary rehabilitation classes on my current prac and have found that the patients in the classes vary greatly in the way they participate. Some classes have patients that come in and do all of their exercises then leave as soon as they are finished. For these patients I have felt limited in what I can teach them and a bit useless since they already know how to do their program. In these classes, I have ended up just standing around supervising. Yet in other classes, the patients are always chatting to me in between their exercises and asking me questions about the exercises or their health, or whether they can fly with their oxygen cylinders, or something related to their respiratory condition. For these patients I sometimes feel that they are not getting as much exercise out of the class as they could, but I feel like I am really helping the patients to improve their quality of life. This builds great rapport with the patients and these classes are always the ones with the highest attendance. Over the weeks, I’ve realized that the education component of pulmonary rehab classes is equally as important as the exercise component. In retrospect, I realize that the patients who have not been as chatty are those who are more breathless and would probably benefit more from the education component. In the future I plan to catch these patients individually in their breaks between exercises to ask them how they are managing and to try to identify any problems I may be able to assist them with.
Mel.

Demented Patients

In the gerentology area of practice quite frequently you come across pts with dementia. It is often quite difficult to get them to do what you want , whether it s to comply with your assessments or to encourage them to ambulate (as opposed to RIB).
On my placement at the moment I've often come across a patient who has dementia ( which could also be complicated by acute confusion) who simply refuse to get out of bed. One lady Im seeing at the moment has not been out of bed for 2 weeks. Every day she pleads with me "not to ask her to get out of bed" and she is very confused - not orientated to time or place. It did not take me long to realise that certain approaches do not work with her. Ive tried the nice apprach, explaining to her why she needs to get out of bed, so she can go home, Ive tried the stern approach which also didn't work. In the end I realised that because of her dementia and confusion the only way to convince her to get out of bed is to almost trick her with clever wording and reasoning to get her to ambulate. Ive also found with other demented patients that if an approach is not working, quite often, if you leave the room and come back in you get to start over again with a differnet approach because they cannot remember you from just 30 seconds ago.
I feel a bit guilty about taking advantage of the pt s disablilites; however Im acting in the pt s best interest. But how far is too far? Has any one found themselves in a simialr situation?

Liasing with doctors

In my last placement I found it extremely useful to build a relationship with the student doctors. They had so much useful information to tell me and not only that, but when I felt like I was asking the physio too many questions sometimes I could ask the student doctors for some help!
I have talked to a few of my friends and all of them have said that the student doctors they have worked with are either too scary and too busy to talk to, or that they feel the doctors think they are better than us.. So they avoid building a professional relationship with them.
If you come across this situation (even on your rural placement where you will be working with GPs) I put it to you to try as hard as you can to build a excellent repor with the doctors (and for that matter any other health professional that might be able to give you a few good pointers about how things work)... It opens up a lot of doors. I would be interested to know if anyone else has felt the same about working along side other health professionals, and whether you thought they were helpful or not.

Little things also make the difference!

Hi guys,

I had a 56 y.o patient on the ward who came in for surgery for his spleen, however in the process, he experienced a traumatic pneumothorax to the left side. This was treated medically with the pigtail ICC. The result was left sided basal atelectasis with pleural effusion. My supervisor saw him initially in the acute stage, and carried out the routine chest checks (SMIs and supp cough). Once the ICC was taken out, he began to use the 'bird' to help re-expand the collapsed lung. This helped to increase the airflow to the atelectatic areas and splint the airways open - however progress was slow. Ambulating him about the ward did help slightly, but as the patient recovery plateaued, I decided to push him a little harder (within his capability of course). We then walked a good 280 metres with ease, and walked 4 flights of stairs. After which, on reauscultation, the air entry into the problematic side was significantly improved!

What I have learnt from this is that it may look so simple, but mobilising a patient and getting them to increase their respiratory demand can actually help them so significantly and quickly. If you can spare the extra few minutes, don't just walk your "respiratory" patients for the sake of it, make sure it's worth while, and you'd see the benefits right away.

Oh - and don't forget positioning as well! This patient's Sp02 was 93 semi-recumbent, and when sat out of bed it jumped to 98%.

Superviser Trouble

I’m going to use this weeks blog to vent some frustration towards my superviser on my current placement. Over the past week and a half there I have been in situations where I’ve come out feeling as if I’d done something wrong, and felt as if I’ve presented myself as being irresponsible and incompetent.

During the first 2 weeks of the placement, there was very little for me to do, I spent most the time just tagging along, and watching. So the senior physio organized for me to see an overseas client that would be coming in for the entire week, and wrote the times down in advance. So I let my supervisor know the arrangement that had been made, she then organized hydro sessions for me, however it coincided with when I’d be with the overseas client. When I pointed out this clash to her, she simply told me to go ask the senior physio to change the clients appointment. I felt really bad, having to go back and ask for the change, especially considering this was organized first. When I approached the other physio, he said he couldn’t change it, because this was the only time to suit the clients. I spend the rest of the day chasing up the physio who ran the hydro session, to ask if she required extra help. But after all that, I ended up being sick, and took the day off.

However this situation has come up again this week, and this time she was like, you need to prioritize, you’re the physio, you need to sort something out. Its just frustrating because I didn’t get myself into this situation. But I’ve decided that the client is my priority, because I was told about it first, also because the hydro session will run without me, and I feel I’d learn more assessing and treating the client, rather than assisting in a hydro class.

Another thing that’s really got to me this week, is the mid-placement assessment. The superviser made the comment that she didn’t believe I have a “positive attitude to learning, and I need to take more responsibility towards my learning”. I was quiet upset with this remark, because I know its not true. The superviser thought that I hadn’t been taking enough notes during tutorials, and during clients sessions. I told her that it was difficult writing down notes when your hands on with the clients, and that I usually wrote my notes afterwards. As for taking responsibility for my learning, for the tutes I’d missed, I got the notes off the other student, and because I’d been sick a couple of times last week, I’d offered to come to prac for the whole day Monday. Also I’d been faxing through my Soapiers, exercise programs for patient, whilst I was at home sick. But obviously all these efforts have been ignored. Again this is frustrating because we spent 15 minutes discussing this little point that appears in the assessment form, and also because she seems to ignore other efforts I have been making.

Sorry for this being so long & winded, but I just needed to vent. Please don’t get me wrong, aside from prac, my superviser seems like a really lovely & nice person, but just as a superviser, I feel is being very pedantic. If you guys see it from a different point of view, and think perhaps I’m over-reacting, please let me know.
Rev

Pain ++

Hello all
My blog this week is about how high levels of pain can greatly affect treatment, which I know has been brought up as an issue by other people. A lady that I am treating as an inpatient at of the major hospitals is suffering from severe back pain which she is rating at 9/10 at rest and 10/10 with any movement. She claims that the only thing to relieve this pain is supine lying and subsequently this is all that she does, and she did not get out of bed all one weekend. Now obviously we all know how bad this is for pretty much every system of the body, and to add to it she is elderly and so is at increased risk for developing complications as a result of bed rest.

However, when I have tried to get her out of bed on two occasions and try to make her walk she is in such high levels of pain to the point that she is screaming, crying, hyperventilates after a few metres of walking and once vomited as a result of her pain. She is already taking extremely high doses of pain medication, predominantly narcotics. I find it quite distressing to continue to try and make her get up out of bed as it is clearly so painful for her, and I feel as if the nursing staff see me as being cruel to her.

This is where having a really open, supportive supervisor is appreciated, as I brought it up with her and we then saw the patient together. The supervisor was able to make the judgement call that continued attempts to mobilise is important and I should keep up with it, however discussed with me that fact that issues needed to be brought up with the doctors as soon as possible as a patient experiencing this level of pain should not be happening, which she then fully backed me up on when I spoke to them.

I feel that sometimes it is hard to weigh up how far you can go with someone who is in extreme pain, as we know the consequences of prolonged bed rest, and at this point it is still really good to have an experienced supervisor to help me to make the judgement call and reassure me that what I was doing was correct.

Has anyone else had similar dilemmas when treating inpatients?

To D/C or not D/C

Hi all.
Still slugging away at musculo outpatients and really enjoying it. My issue at the moment is the fact that my patient list is growing exponentially. I know I posted a reply giving some advice about this a few weeks ago, but the issue I have is slightly different. It is worthwhile treating the patients that I have (have I just answered my question there?) but there has got to be a time when the line is drawn discharge wise. Example: an elderly gentlement post THR. Has made great gains, independently walking, ROM good, strength more than adequate. Seeing as I felt that he was close to discharge I even asked him to go from supine lying on the floor to standing to check his safety - no problem. However, he still has a residual limp. I have added to his specific gait HEP with the aim of eliminating the abnormal gait and taking advantage of the strength gains he has made. I'm seeing him again this week.

I can totally justify the reasoning I have applied to this gentleman. I'm not unhappy that he is coming back. My issue is that by not discharging him sooner (when his main problems are well in hand) I am adding to the significant waiting list at the clinic. As a student I think I have the luxury of being this thorough with a patient and it's an excellent learning experience. Problem is, I struggle with this luxury affecting patients who are in greater need of treatment but who are still waiting.
Martin

The power of trust and its effect on our treatment sessions

Hi Everyone,

I am exriencing a difficult patient at the present who I feel slightly fustrated with. 2 weeks ago, an 80yo lady presented to me at the outpatient musculoskeletal department 9 weeks post greater tuberosity fracture and associated dislocation post-fall. The lady came in wearing a colar and cuff sling and bagan to tell me how much difficulty she has been having with her broken arm. She stated that she was told to do NOTHING with her arm until such time that she could begin attending physiotherapy sessions.

Once the physical assessment was under way it became very clear that this elderly lady had been very protective of her arm as extensive muscle guarding was present and extensive bruising still remained. The PROM measures I was taking were extremely limited and the lady began to get very irritated with me for moving her arm. After speaking to my supervisor who expressed her concern that PROM exercise had not even begun yet, I gave the lady some very light passive flexion and abduction exercise to complete for the following week. However, the following day, I recieved a phone call from the lady, telling me that I don't actually understand what has happened to her arm and that the exercises given were too difficult and not appropriate. She went furthur to say that she would no longer come to physiotherapy and would just wait until her arm healed by itself. I was very worried about her doing this, because as we all know, her arm will never get better by not using it, so I strongly suggested to the lady to return for another seesion and told her to cut her repititions in half until she saw me next. At the next appointment, I used heat to calm her down, gave her extensive education about the need to do exercises with her arm and used a slings to assist with increasing her PROM. As she is still very far off being introduced to active assisted exercises, I told her to continue with her PROM exercises at home.

My problem with this entire situation is that the lady is far behind in her rehab timeframe and I see no fast acceleration in the near future. Yes, she is quite elderly, she seems to have a low pain tolerance and she was given poor advice initially however now it is my responsibility to get her arm moving again. I feel that her trust in me is very important that perhaps she is not doing her exercise as she feels uncertain about whether I am doing the right thing for her. I also would like to give her some exercises that will encourage her to move her arm more (rather than the simple PROM exercise with the stick that I have already given her). If anyone has any good suggestions related to gaining trust and improving ROM post humeral fracture, please shed the light???!!!

Look forward to heariung back from someone,
Kate.

Initial Difficulty Encountered

Hi all,

I am currently on my cardio prac in RPH, and am now enjoying the practical. Initially, I faced lots of difficulty on this prac, and I know I shouldn't be saying this...but I felt very unsupervised from the start. This prac is a new one which is currently on trial, and the ward has never had a physio student on board. The facility supervisor is a new grad, and has never taken on a student before. During the first week, I followed the supervisor around the ward. The supervisor performed his/her subjective & objective assessments really quickly, for example, he/she only auscultated the lobes known to be "problematic", did not assess CE, etc. At the end, the supervisor said that he/she had to be quick on the assessments due to the huge workload on the ward, and told me not to pick up his/her bad habits. The supervisor also said that with experience, I'd be able to be clinically efficient and learn to do the most clinically appropriate thing needed. But without practicing the correct sequential list of things to be performed, how would I get efficient without missing important bits?

I sincerely am not flaming my supervisor, I bet that there will be others like me who have supervisors who aren't trained to teach or are new to the field themselves. I understand that the supervisor is new to the field and is trying to help me through this prac.

Thank goodness the Curtin tutor has been really hard on me, and this has helped me. Hopefully I pass this prac! *fingers crossed*

Mark

When patients can't follow instructions

Hi Everyone,
I saw an elderly patient one day post AAA repair in the ICU last week. His main physiotherapy problems were reduced lung volume and impaired airway clearance. My treatment plan was to increase his lung volumes by asking him to take deep breaths and to facilitate airway clearance by asking him to cough. However, when I went to treat him, he was confused +++ and not following many instructions, so this plan was clearly not going to work and I needed to find other ways to achieve these goals. Having come from only outpatient pracs where all my patients have been able to follow instructions and have been very compliant with treatments, this made me feel quite nervous and a bit panicked about what I was actually going to do for this man. I really wasn’t sure that I would be able to give him any effective treatment. To increase lung volume, I tried getting the patient to lift his arms with the thought that this would increase his tidal volumes. Since he wasn’t following instructions, I gave him a target to reach for and lifted his arms showing him the movement that I wanted him to do. At first this didn’t work either, but I continued with helping him move his arms and after about the third go, he got the hang of it and moved on his own. When I asked him to cough, he made an attempt, but it was not at all effective. So I demonstrated a big cough and asked him to copy which again was very ineffective. I tried to stimulate a cough using the tracheal rub technique, but got nothing, so resorted to a catheter tickle at the back of his throat which stimulated a good effective cough and let me suction the secretions straight after. After finishing the treatment I realized that I had in fact made a difference in treating this patient and that while it called for a bit of creativity it is still possible to achieve physio goals in patients who are not able to follow verbal instructions.
Has anyone had a similar experience and do you have any creative ways of achieving treatment aims.
Mel.

Hi everyone! I hope you are all enjoying your placements,

I am blogging this week about being sick whilst on prac (but this could also be generalised to when we start working for real :) )

On my last placement I began to feel sick. I didnt want to miss any days of prac because I felt as though I was going to miss out on something, so I continued to force myself to go. Despite feeling absolutley terrible one day and going home sick I went on with this for about 2 weeks. At this time I was working almost every week night and on weekends at my casual jobs. Eventually I came to the point where i was almost in tears in the morning on my way to prac because I felt so terrible (tired and sick) and i knew I still had the whole day ahead of me. In the 3 rd week of prac I got sent home sick and i went straight to the doctor. It turned out that i had a virus. The Dr advised me to take the rest of the week off prac and work. At first I was worried about missing too many days off prac in fear of failing it and missing out on money at work. But I worked out a compromise with my tutor and supervisor to make up the extra time in the following weeks and knew my health was more important than money After having the week and weekend of sleeping and resting all day, i felt 100% better the week after. I suddenly felt like I was learing so much more and I was enjoying myself whilst on prac because I didnt feel so run down and i was generally alot happier.
From this experience I learnt that Im not actually a machine and I cant keep pushing myself to my limit. I need to cut down on work and extra curricular activities where possible.

Had i taken a day off when i first started feeling ill and not pushed myself too hard with other work i prob wouldnt have had to take so much time off prac later. So i guess what I have learnt from this experience and I hope you all can take away with you from reading about my experience is that despite having alot of pressure to go to prac and perform well, plus the added pressures of working (so we can actaully live!!) and extra curricular activities, we need to listen to our bodies, and have time for ourselves to relax, do nothing and recouperate, especially if you are feeling run down and sick. Where as, before i used to just push myself like I am sure alot of you do too! Slowing down a little but now will save you time in the long run!

Until next time!
Kel

Dangerous Opinions!!!!!!

Hi Guys,

My apologies for the late entry - the public holiday kind of threw me!!! As we approach the mid-way mark of our third and final placement of the semester, an interesting issue has been playing on my mind. This thought is based on my amusement that us as stressing physio students, often let the talk of other students influence how we interepret different academic situations. More specifically, I refer to how prior to me attending my musculoskeletal outpatients clinic and for the good part of the initial two weeks of the prac, I was completely terrified about how I was going to cope with the demands of the placement. Other students had told me the case-loads are massive, the notes take forever and the overtime hours sepnt organising my day would be unbearable. My fear based on these assumptions however was uncalled for.

After getting used the placement, I have found that I rarely spend additional hours at the hospital, my case-load is comfortable and I have learnt the best ways to efficiently organise my days. The supervisor is very supportive and I rarely feel out of my depth with the vast erray of patients that I see.

The thing I find quite annoying about this issue is that I managed to allow myself to get upset about an experience without actually experiencing it. I'm not sure what the rest of you guys think, but I often feel that the undue hysteria within our little physio community can sometimes cause those stressors among us, to become extremely overwhelmed. For the rest of my up-coming placments, I'm going to try desperately hard to block out these dangerous opinions and focus on my own preparation and abilities independently. If anyone else has some strategies to deal with this kind of issues, please share!!!

Thanks guys,
Kate.

Reflect on your

Dear Bloggers

I am really enjoying reading your experiences in clinical practice but am going to ask that you provide MUCH more reflection on your posts. You have been very good at explaining the experience but need to:

1. Tell us how you felt as a consequence of the experience, tell us about what you have learnt (some of you are touching on this), tell us what you didn’t know or understand (be honest – you are not judged on your feelings).
2. Make some conclusions about the experience – what did you decide, what were the outcomes
3. How would you change your practice if you were in the same situation again?

Being a reflective practitioner is critical to your ability to learn. You need to think deeply about the experiences so that you can understand what happened, why this happened and how things might have been better.

Kind regards

Bea

Communication Break-Down

Hey All,

I’m sure some of you at one stage or another have come across patients who didn’t speak much English, and had a lot of difficulty communicating with eachother. I’ve had a few of these in the past clinics, and I really felt I wasn’t able to relay all the information across to patients and vice-versa, potentially making the session quiet unproductive.
If I was seeing the patient for the first time, there would always been a family member there to translate, however its all the follow up appointments where I struggled. One such incident was on my cardio placement.

I was able to do an intial assessment and treatment with the patient whilst his daughter translated almost all of it. However when I went back the next day, there was no family member, so having to ask things like pain level, dizziness, nausea, cough, sputum production was a real challenge. When I found that using hand gestures or mimicking actions werent helping get the message through, I’d just ignore the question, and move on. I really don’t know how much the patient was able to understand me, and whether I got reliable answers for my questions. At times I was unable to tell how the patient was feeling, if he was in any pain to get up and move around. I found I had to rely a lot on the nursing obs to get a better a picture. Whilst I would be walking the patient, it was really difficult trying to find out whether he wanted a rest, or if he was in pain, feeling unwell etc.

During 1 of these sessions, as soon as the patient finished walking and sat down, he vomited. What concerns me is that the whole time, I had no indication of how he was feeling, all he had told me everytime I asked something was “fine fine”. However the whole communication situation was made a lot easier when I discovered his daughter had written down all the English words (pain, nausea etc) and translated them as well, so everytime I needed to ask him something, I’d just have to point to the word.

So what I learnt from this prac was that something as simple had writing down common words used, and having them translated makes somewhat of a difference.

Has anyone else had similar communication problems, and if so, how did they manage to deal with it?

Till next week

Rev

COVS

Hello all

I have a short post about the COVS scale ('Clinical Outcome Variables Scale', used to assess mobility). This is the predominant scale used at the prac which I am on - gerontology - to assess and quantify the mobility of the patients. However, I find that when I am using it I don't fully agree with all of the measures and am finding it difficult to use. For example, one of the areas to rate out of 7 is about wheelchair mobility and if the patient does not use a wheelchair I am under the imoression that you are just meant to score the highest, but this does not seem very representative if the patient does not use a wheelchair? Other inconsistencies seem to be in it. My supervisor says that she initially disliked the scale but has grown to like it more as she practices in gerontology more. Obviously it is meant to be reliable and valid etc etc... I was wondering if anyone else has had experience with using COVS and what they thinkof it?

Thanks,
Mel.

DVT

Hey guys,
I'm on neuro at the moment. We had a lady 2 wks post stroke who was c/o calf pain. She'd rolled her ankle a few months pre stroke so was also c/o ankle pain. There was a palpable 'knot' mid calf so we raised the issue of DVT with our supervisor. Doctors didn't really think much of it, basically told us we were wasting everyones time by requesting U/S. Anyway, the short story is that it WAS a DVT... so basically what I am trying to say is that as PT students we've been taught all the signs and symptoms of DVT so are in the best position to identify possible cases.
Cheers
EZ

Knee assessment

Hi everyone. Doing the blog thing while I have some spare time. Just in case you were interested, a quick update on my patient from last week. Was able to complete the objective Ax and did a gentle GII transverse mob at the relevant level. No immediate change, but the gentlemen left an item at the clinic and returned the next day to get it. He reported that his back was still sore but "...the pain in my leg is gone. Strange. I wonder how that happened?". So it feels good that I had some effect on the referred pain that was one of his main complaints. Now I just have to talk him into the fact that it was the treatment that is responsible for the change.

Anyway, I'm posting about a patient to whom I might not be able to make any change. A young man has presented post patella subluxation x3 over the last 6 months. All incidents were in a sporting context, where (via sharp direction change or external force) the knee has given way in a valgus direction. No current pain on any activity. Is still playing some sport but is scared of recurrence. Given the mechanism of injury I expected to find laxity in at least one direction and started a thorough knee assessment, going through all the orthopedic tests. No pain, no laxity, no clicking. I wasn't gentle. The only finding I have is from observation. He has a patella that sits high and laterally.

So what can I do? Well firstly I can see him again to re-check a number of things that I wanted to be more sure of: Foot position, tibial rotation, VMO activation/sequence, ITB tightness... Thing is, there's nothing wrong with his VMO activation. His stability around the hip and lower trunk is excellent (used some PNF techniques to assess: static and dynamic stability...). There is no way that I could claim that my initial objective assessment was good enough to exclude every problem, which is why I'm seeing the patient again. It will be interesting to see if I find anything more, given that now my focus is on trying to find a reason his patella sits high. So we'll see what happens. Patella alta can be surgically corrected, but I want to be sure before I suggest surgery as an option.

I'm writing about this patient because so far it has been a really good learning experience. Not only did I get to do the full bunch of orthopedic tests (among other things) but having to reason my way through a number of different ideas has really prepared me for my next knee patient.

Auscultation and asking questions

Hi Everyone,
I’m on a cardiopulmonary placement at the moment and this reflection is based on something I learnt about auscultation and communication over the last week or so. I have been working on a ward and many of the patients I have seen have had quite severe dyspnoea. When I first started the clinic, I would auscultate posteriorly but whenever I went to listen anteriorly my supervisor said not to worry about it. Rather than asking why, I figured it was because the patients were too short of breath and so began fairly routinely just listening posteriorly. Then I had another supervisor for the day and they wanted to know why I was only auscultating posteriorly and therefore missing the whole of the middle lobe and lingula. I explained that based on my experiences with the other patients that I had thought that it was OK to only listen posteriorly if the patient was very dysponeic; however I now realized that it really wasn’t, because it meant that I had been missing a significant portion of the lungs. From then onwards I have been listening both posteriorly and anteriorly and the very next patient I saw actually had very significant wheeze in the middle lobe and lingula that could not be heard posteriorly. So, I have learnt how important it is to auscultate in a routine fashion both posteriorly and anteriorly. After this experience, I asked my initial supervisor why she hadn’t wanted me to listen to those initial patients anteriorly as well. She said it was because she already knew that their pathology was in the lower lobe and not the middle lobe and so she had thought it unnecessary to make the patient go through all of the auscultation when we wouldn’t learn that much from it.
So while this experience has taught me a bit more about auscultation, I have also learnt how important it is to ask questions about why someone is asking you to deviate from what you have learnt. They probably have a good reason and it lets you learn from their experiences.
Mel.