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