Too many cooks spoil the broth?

I have had a couple of placements now where I have had numerous supervisors. Whilst this annoyed me originally because i was never sure who i was supposed to be reporting to and i felt like i was sometimes getting conflicting opinions, I now think that it is not necessaily a bad thing. I now realise that having input from as many physios as you are learning can only be a positive thing. It is great to watch how each physio approaches a situation and what treatment techniques they use. It is learning from these physios, as well as PD after we graduate that is going to shape the physios that we are going to be in the future. In my last placement alone I had two supervisors who had very different treatment techniques, both of which are effective. They were both willing to help me and demonstrate to me any techniques that I was interested in and I feel that it will only stand me in better stead for when I graduate.

What its REALLY like in the country

On my rural prac i was working with a physio who covered an area the size of Victoria with one other physio. There were some parts of the region that would only get visited once every four months and even then patients would not necessarily get seen if the timing of the trip happened to fall on a funeral day, or if they had gone to visit relatives elsewhere. It is not hard to understand then how frustrated she got when she received referrals from major city hospitals asking for weekly physio for patients that they were sending back to some of these remote communities. Sometimes it is necessary to keep patients in Perth, even though they would prefer to be home with their families, because it is impossible for them to receive the kind/amount of treatment that they require back in their community.
Seeing first-hand just how remote some of these communities are, and how little clinic time they get has made me realise how important it is to make VERY careful decisions about discharge from the larger Perth hospitals. Discharge planning for patients who live in remote locations is of the utmost importance and I saw some very sad cases of patients who were lost to follow up due to the remoteness of where they live. I saw children with significant feet deformities who were pushed around in prams at the age of 6, and young men post-stroke who would have returned to normal function if they had had adequate rehab.... yet they have lost function of limbs.
I dont want to sound like I've jumped onto the "woe is us in rural" bandwagon, but it has really opened up my eyes to the reality of rural physiotherapy and the need for increased communication between the major perth hospitals and the rural hospitals to ensure that each patient is able to receive the treatment that they need and deserve.

RED FLAGS

We are always taught about red flags and told that we will probably not encounter too many in our time as physios, but on my musculoskeletal placement I was very thankful that we learnt about red flags.
I had a patient who was coming to me with severe hip pain that had been getting progressively worse for about 3 weeks. There did not seem to be any pattern to his pain provocation. He was what i would consider to be elderly and he had decreased ROM globally in his (R) hip, with Flex and Add being the most limited. He also had decreased glut strength on the (R) > (L) and had tight ITB and hip flexors bilaterally. He had no Hx of hip pain, no Hx of Lx pain and on examination of his lumbar spine he had good ROM and was not particularly stiff on PPIVMs and PAIVMs.
The thing that made me most concerned was that the pain was waking him at night, but he was able to decrease the pain with heat pack and painkillers.
I began treating his decreased ROM, gave him strengthening exercises for his glutes and stretches for his ITB and hip flexors, but after a week his pain had got a little worse.
As I was concerned that his obj findings did not correlate with his pain levels and was concerned that subj it was waking him at night i sent him back to the doctor. On the last week of my placement I received a letter back from the doctor saying that my patient had an osteo carcinoma. It was a very sad experience for me, but also very rewarding because it meant that my patient could now receive Rx for the cancer and would hopefully recover well. It made me realise how important it is to pick up on red flags and to seek further advice if our Rx is not progressing as we would expect.

Late patients

On my musculoskeletal placement i was constantly getting patients who would turn up late to their appointments. It happened so often that it became a bit of a running joke amongst the other students and myself. In all seriousness though, when do you say to a patient "sorry, but you are too late?".
Especially as students we want to do as good a job as possible with patients, so we want to do a thorough assessment and treatment with every patient. On a couple of occasions patients turned up to a 30minute appt with only 10 minutes remaining. Is it fair to ourselves or our patients to still treat them?
After a number of occassions running late for my following patients I decided that it was not fair on myself, or my other patients to continue treating patients when they arrive so late. It was a hard thing to do, because I felt terrible every time i had to turn a patient away (and it happened a number of times). However, I found that when I explained to patients that i would not have enough time to treat them properly due to their lateness they were usually very understanding. It is just another situation where as physios we need to learn to look after ourselves and do whats right by us... and our other patients!

"These People Wont Come To Your Funeral"

I have the habit of taking on board my patients' pain. I know that sounds silly, but because I am quite a sensitive person and i so desperately want to help a person when they are on pain, i can end up making THEIR pain MY problem.
One particular occasion this happened to me on my last placement is when I had a patient come to me with shoulder pain. I was seeing this pt in an outpatients setting and previously had been seeing her for her (R) shoulder post sh acromioplasty. When she came for her appointment I expected her to be travelling along nicely, but instead she came in hardly able to move her other shoulder due to pain which was radiating down her arm and into her wrist.
I was thrown by her presentation and could not understand why she was getting the pain she was getting. I had screened her Cx and that was ok, but was hardly able to get any sh ROM. After checking numerous things I FINALLY ended up checking her Tx. I now know that the Tx and the sh are closely related in terms of ROM and pain, but it took me so long to establish the source of her pain that she was getting visibly upset.
I ended up treating her for hypomobility in her upper Tx, but by the time the session had ended I was exhausted, upset because I didnt think i had done as well with the pt as I could have and upset because she had got so upset. My supervisor sat me down and told me something I will never forget. She told me that as physios we feel like we can fix everything that comes in our door, but really we can only do our best. She said that I needed to not take on the responsibility of people's pain, but rather make the pain THEIRS and try and help them to resolve THEIR pain. She said that if you take on too much of your patients' feelings and you run yourself down you are only hurting yourself, because those people dont really care about you and "those people wont go to your funeral". This statement really hit home. I learnt that although you need to care for your patients, you need to make sure that they always take responsibility for their pain and you do not take too much on personally.

Not one way to do everything

On my recent rural placement one of my projects was to organise and run a class on physical activity and exercise for aboriginal women for the local community centre. My supervisor gave me a lot of readings to do on understanding aboriginal culture to use for organising the class. Although I felt that I had gained some valuable information on aboriginal culture, I didn't think that it provided me with any information on how to run the class, i.e. what activities to do, how to make them relevant, how much exercise to do in the class compared to education etc...
As the class had not been run before my supervisor could not give me any information on who would be at the class or how many people we would be expecting. So I employed my usual tactic of being REALLY prepared. I organised a running sheet of what i would talk about and what activities i would do and prepared a handout to give to each of the ladies. I also prepared equipment, like a radio, balls and theraband.
Once we started the class, however, I realised that presenting the class as i had planned was not going to be well received by the small number of women who showed up. Their body language showed that they were not interested in what i had to say and they were less than enthusiastic in doing the exercises, which needed to be quite easy due to the large age range of the participants.
Although I struggled along for a while, I ended up discarding my lesson plan and starting a discussion with the women about what they thought about exercise, what exercise they did and what exercise they would like to be doing. This ended up being extremely valuable and we had a discussion for about 45 minutes. From this discussion we were able to get some solid ideas of what the women in the local community would like to be doing in terms of exercise and were even able to draft up an idea for a women's only exercise class to be run in the community.
From this experience I learnt that no matter how organised you are, you need to be flexible when dealing with people from other cultural backgrounds. The women were not interested in my talk (most of which they already knew) but instead wanted to organise some structured activities to maintain their fitness. I learnt that in a rural setting it is EXTREMELY important to be flexible and I definitely discovered the benifits of a good "yarn".

Effective learning

After the last clinic I have learned the importance of positively in learning. I was fortunate enough to have a supervisor with a very positive approach. She would emphasise what I was doing well and this gave me the confidence to build upon my strengths in order to improve my weaknesses. The placement before this I had not been as fortunate. My supervisor emphasised my weaknesses and although weaknesses need to be improved upon, I felt this was negative. I did not learn very much in that placement as I did not feel confident to be myself and demonstrate my strengths. From this personal experience I will keep in mind the importance of positively and incorporate it into treatments with my patients. For example, if a patient is doing something with a very abnormal movement pattern I will find something they are doing well and highlight this. I believe this will reduce fear and facilitate learning by encouraging them to build upon their strengths.

What physio responsibility is not

On my rural paediatric clinic there were many infants being treated for congenital talipies. Patients were being treated with the Ponsetti method which involves serial casting the foot first into supination, then abduction and finally dorsiflexion. If full dorsiflexion range can not be gained with serial casting alone, a single surgical procedure done with a local anaesthetic, which involves severing the achillies tendon is performed. There had been good outcomes for many children being treated with this method with full range of motion being gained with very minimal scarring. The senior physio staff were also pleased with the results. Before this method was implemented, the outcomes for children with talipes were not as successful. The surgical procedure was more complicated, required a general anaesthetic and usually multiple surgeries.

Most parents whose infants required surgery were choosing to undergo the new procedure. However, there was one mother whose baby was soon to need surgery that indicated that she would prefer the older method. The physiotherapists at the facility were giving her information about the new surgery and hoped she would see the benefits of the new procedure. The mother had made her mind up and had it set on the old surgical procedure for her child. She could not be convinced otherwise. I found it disappointing to see the mother make, what I considered, the least optimal choice for her child. However the responsibility for making this decision was up to her. I learned that I have to accept where my responsibility is as a health professional and also where it ends. In this case it was the obligation of the health professionals to provide information and recommendations, but the final choice was the mothers.

Decision

While on my musculo placement, I had a patient who has moderate knee pain due to degenerative OA. Her initial complaint was primarily 3/10 knee pain and recently decreased functional activities such as walking and cooking due to the pain. I performed a relatively full assessment of the knee and the significant finding was that she has deformity of the (L) knee, Varus, and slightly swallowed (L) knee. I treated this with EPA and strengthening exercises for VMO and quadriceps, which made her feel better after the treatment.

I saw her few days later, the pain level was pretty much same as before treatment. However, I treated this patient with slightly increased intensity of EPA and I continued on with education of functional activity, which was not effective that much as I thought.

It was decision time whether I discharge this patient or not. It was hard because I spent a lot of time for treatment that was not working obviously even though I knew that I cannot cue OA. After this patient I realized that physiotherapy has limit line for some disease and we cannot change it. We have to admit it.

Different Approaches to Treatment

With a good few placements under the belt now and the days of placements coming to an end I find I am able to reflect back on the year as a whole. Although it will be great to get out there into the work force and start earning some $$, the experiences of this year really have been a privilege. It has been great to have been invited into different facilities and to have been shown the ropes. It amazes me how different the experience of each placement has been due to the differences between facilities and treatment approaches of each supervisor.

For example, on my first placement (musculo outpatients) one of my patients had knee pain due to significant degenerative changes. My thoughts for the first session were to treat her knee as guided by assessment, but to also brainstorm things the patient could do in her life to manage the condition (modifying aggravating activities and referral to community hydro classes). However, I was directed by my supervisor to focus very much on hands on techniques to treat the impairments (to get the length back in muscles, get the joints moving and to get the right muscles working and strengthened). In contrast to this on my current placement (geriatric outpatients) one of my patients has chronic lower back pain. My thoughts for the first session were to assess and treat impairments of movement, motor control etc. However, I was guided by my supervisor to focus on lifestyle changes and self management (refer to OT for correct seating, refer to hydrotherapy and modify aggravating activities).
Both approaches have value and as a result of these different experiences I feel I will be able to incorporate and apply a range of approaches in order to give the best, most comprehensive treatment to my patients when I am qualified

being a student who is Enlish, second language.

During my placement, I was daunted by the variety of client presentations at the hospital which is my weak part, as English is my second language. The tutors always said that I have to explain much more detail and have to catch the critical information from patient’s notes which I found really difficult. I never had bad comments for my professionalism and handling, but quite few times I had comments for my communication skills. In general I can take the criticism easily because I know that I have to improve and practice my communication skill for treatment. However, from my experience it is impossible I can speak English as my first language and read doctor’s notes, even hard for you sometimes, by tomorrow.

I chose going to oversea to study and I knew that it is going to be so hard. However, sometimes it is really uncomfortable to deal with somebody who is pushing me too hard.

As you guys as physiotherapist in Australia, you might have a chance to be a supervisor in near future. If you have a student from oversea, especially from non-English speaking country, please don’t push them too hard. They are normally studying so hard and push themselves a lot. Moreover, they don’t have family here.

Teaching somebody and pushing someone are not the same.

patient centred.

Hello guys, few steps more to get off Uni.

Currently I am on my cardio placement, surgical ward. The majority of my patients are post-op patients with reduced lung volume and impaired airway clearance. As you know, main treatments are deep breathing and ambulation.
In last week I had a patient who had upper abdominal surgery. Upon examination the patient was found to have decreased breath sounds. We went for a walk which the patient managed well without pain or other symptoms. Although the patient had few attachments, the patient had no difficulty to mobilize by himself (obs and Haemoglobin were stable), so as usual I encouraged him to mobilize regularly by himself to prevent complication after surgery I explained. Following day I would see the patient for treatment, each time he would report to me that he had not ambulated since the last time I saw him.

I found this quite difficult for me to understand why the patient was not exercise. So I discuss with other health professionals such as nurse and OT. They suggested that it could be due to his past medical history, depression and a lot of other surgical procedures.

In surgical ward the treatments are becoming programmed such as day 1, day 2 day 3….
And treating patients in the ward are same way like routine. However, after this patient I decide to pay attention more for their past medical history and psychosocial factors, not just only treating impairments.

Nearing the end

Nearing the end of my final prac it is great to finally be treated as a qualified physio. On my recent prac at PMH the supervisors, patients and parents all treat me like I am the physio, they are confident in my decision making and are happy to accept me as part of the team. My supervisor is able to have adult conversations with me about the real issues of a workplace so I am able to appreciate what it’s really like as a physio in the workforce.

This additional responsibility and accountability has given me the ability to reflect over the past year of the growth I have had since starting prac. I now am able to realise my strengths but more importantly my limitations. I feel my degree has equipped me with the tools of how to learn so I am able to independently maintain and update my own knowledge base. I am confident to enter the workplace and continue my learning.

my rural placement

When I was on my rural placement, I had really a great experience for me not just only as one of physiotherapy students but also as international student. It was like packed everything together of physiotherapy area.

First of all, there was a great opportunity that I can communicate with a variety of health professionals such as doctors, nurses, physiotherapists, pathologists, midwives, and occupational therapists. Liaising with doctors and nurses on general ward, midwives in maternity ward, occupational therapists in out-patient department was required to keep each other up to date with the status and progress of the patient present. It allows me to understand several different points of view in other areas and also to extend my clinical knowledge not only as a physiotherapist but also as a part of health professionals.

As an international student, it was a great opportunity to have clinical experience in an Australia rural health system. This practicum provided a good insight into the country health system and physiotherapy within that system. The Regional Hospital provided me with a mixture of inpatients, outpatients, community programs and interdisciplinary experiences. That each of ongoing outpatients’ timeslots was only twenty minutes challenged me the most, utilising knowledge and time management as a physiotherapist, not a student. Being as a part of physiotherapist in the hospital was very pleasant due to the friendliness of staff and community.

The ride to prac

Recently whilst travelling by train to one of my pracs on elderly lady was getting off the train and tripped on the platform causing lacerations to her legs, knees and hands bilaterally. The bleeding was significant so we asked anyone on the train if they had anything to stop the bleeding. We applied hankies to the areas and the lady was assisted back on the train to get off at Claremont where she could have an ambulance called by the train security.

This situation made me truly realise how importance walking aid prescription is for us in a hospital setting for elderly patients. I only get to see the end result of the person in a hospital bed having fallen and having their wound treated, requiring me to prescribe a walking aid. Having see the before and the incident I now realise how important advocating community balance and activity classes is. With our aging population we need to come up with more prophylactic methods of treating falls and utilise the programs already in place

Too Involved

Whilst on my paediatrics placement i had a three year old patient Jack whom i saw on a weekly basis. As with all paediatric patients the aim was to involve the parents as much as possible, however in this particular situation it was a case where the parent was too involved to the extent where it interfered with our treatment sessions.
The mother of this patient was extremely proactive when it came to management of her son’s disability. The mother had been to see just about every specialist available and had sought every form of alternative treatment available. She would also do quite a lot of research on her son’s condition and the available treatment. While this may sound like a good thing often the information she found on the internet and the principles of the alternative forms of treatment, contradicted the goals of our treatment and the information that we provided her. For example she had bought a full body jumpsuit for Jack that was designed to provide trunk support for her son (who had global hypotonia) and therefore allow him to have better peripheral control due to the proximal support. Although the jumpsuit appeared to be beneficial in some situations (Jack’s sitting posture improved slightly although he still had no independent sitting balance) both my supervisor and myself noticed that it greatly restricted Jack’s mobility and seemed to reduce the amount he interacted with his environment. In the few instances that i saw Jack without the suit he was able to roll in both directions on the floor, would actively reach with both arms for toys and was very verbal. While in the suit Jack would rarely roll, was unable to consistently reach for toys, was not verbal and generally appeared to fatigue very quickly due to the restriction provided by the suit. Both my supervisor and i agreed that the suit did provide some benefit and was a useful piece of equipment in certain situations, but we also thought that Jack would benefit from some treatment sessions without the suit on. When we suggested this to Jack’s mother she was very uncooperative and would insist that Jack needed the suit during the treatment sessions.
I often felt like telling this mother to let us do our job, but through speaking with my supervisor i realised that this would have been particularly unadvisable. My supervisor explained that although the mother may not completely understand what we were trying to achieve, if she didn’t agree with our management then it would never be effective because the most important aspect of paediatrics is getting parents to implement strategies at home.

Enough is enough

I recently completed my paediatrics placement at the centre for cerebral palsy. Overall I found it to be a very good placement and thoroughly enjoyed my time there. However there was a period of time where I found myself overworked and stressing out.
On this placement my patient load was relatively low, as we were required to make home visits which often added half an hour of travel time each way. On an average day I would see about three patients, and usually never more than four patients a day. As a result of this low case load my supervisor deemed it necessary to give me additional work to keep me busy which was reasonable as initially there were often periods during the day where I had little work to do. However I think my supervisor misjudged the amount of spare time that I had, as she gave me so much additional work that each night I had to stay behind until the cleaners kicked me out at 730, to get the work finished. As a result my working days saw me leave home at 7 in the morning and returning after 8 o’clock at night. On top of this I also additional uni work to do and also worked part time on the weekend.
At the same time that I was at the centre there were several other OT ad physio students there from Curtin and Notre Dame, however none of them had the same supervisor as me and none of them seemed to have as much work to do as myself. When I talked to the other students about how much work I had they were shocked and told me I should just tell my supervisor that I was overloaded. This was something that I didn’t want to do as I wanted to maintain a good relationship with my supervisor, however it eventually reached a point where I had to speak to her as I was just too loaded down with work. To my surprise my supervisor was completely understanding of my situation. Apologising for overloading me, she said that she had only given me so much work because she thought that I might have been getting frustrated by the small patient load that I had.From this experience I have learnt the importance of communication with your seniors even when you feel that you might be saying something that they don’t want to hear. Although I still believe that it is a good idea to keep a good relationship with your seniors I think you have to be able to represent yourself to them without being too confrontational.

Parenting 101

Recently on paeds prac I found it extremely difficult when young children are hospitalised due to irresponsible parenting. A young girl sustained a C1/2 spinal cord injury due to a MVA as a result of the mother being high and crashing into a tree. Due to the mothers state she sustained no injuries however her perfectly normal daughter is now unable to spontaneously move any limbs and is only able to blink eyes and mime words through facial expression. The mother now racked with guilt very rarely visits her daughter who has been welcomed into the hospital family.

This situation for me was very confronting as I was to treat this girl and liaise with the family. I had to put all personal feelings aside and be professional in front of the family. No matter what I though about them for the events that occurred I had to treat them the same as any other parent and still provide all the advice and education that I would any one else. It was extremely difficult not to be judgemental but I had to maintain professionalism and constantly think of providing the same service I would normally provide.

This is one of the more upsetting aspects of our job but necessary none the less

Inspirational Children

Recently on a prac at PMH I came across a truly inspirational child who is able to maintain a positive outlook no matter what she is thrown. This girl is 10 years old and has recently acquired a spinal cord injury at T8. However this has not slowed her down in the slightest. Everyday she strives to challenge herself whether it’s being able to make it the full way up the ramp in her wheel chair or swimming unaided in the pool in her first attempt. She sees the positive in every situation and it is this incredible strength that has given the family joy in this terrible situation.

She has motivated me to see the positives in every situation her strength and motivation has inspired not only the ward but the whole hospital. She is always going up and down the lift visiting other kids bringing them joy. She has an amazing spirit and has motivated me to see life the way she does.

Multidiscplinary team

Recently on a prac at PMH the true importance of MDT became apparent. I was placed on the ward for children hospitalised due to obesity in endocrinology. For me I didn’t even realise kids were hospitalised for obesity… is this problem that bad. As the weeks progressed we run endo clinics comprised of education for parents while the kids do 1 hour exercise then an hour education for the kids. The topics each week vary from a physio, dietician and social worker all presenting the relevant info about obesity and how to combat it.

In these kids this education all though for some of us common sense is vital for changing habits and changing lives. It was great to be a part of this team setting as I can now fully understand how many aspects contribute to one problem. Now I realise how important all aspects of the puzzle are in combating obesity and will use the help of others when treating these patients in the future

Multidiscplinary team

Recently on a prac at PMH the true importance of MDT became apparent. I was placed on the ward for children hospitalised due to obesity in endocrinology. For me I didn’t even realise kids were hospitalised for obesity… is this problem that bad. As the weeks progressed we run endo clinics comprised of education for parents while the kids do 1 hour exercise then an hour education for the kids. The topics each week vary from a physio, dietician and social worker all presenting the relevant info about obesity and how to combat it.

In these kids this education all though for some of us common sense is vital for changing habits and changing lives. It was great to be a part of this team setting as I can now fully understand how many aspects contribute to one problem. Now I realise how important all aspects of the puzzle are in combating obesity and will use the help of others when treating these patients in the future

code blue madness...

Recently whilst on my neuro placement I experienced an interesting situation in an outpatient setting. A patient was preparing for a rehabilitation session by removing his shoes and sitting on the plinth. This patient is independent in doing these tasks and at this moment in time the closest staff member was eating lunch in an office along side the treatment room. A fellow patient was in the room and when seizure began, loud calling was responded to immediately by the physiotherapist. The senior physiotherapist and students attended to the fitting patient, who remained conscious throughout the seizure and was now convulsing uncontrollably on the ground, by applying pressure to the wound on his head. The patient was then positioned in a stable position on the ground in supine away from harm and comforted as the involuntary muscular activity subsided. From this position, I asked my supervisor who to call... it was then deemed that it was a medical emergency, 55 was dialed and a code blue declared. TEN MINUTES LATER... the medical emergency team arrived. Despite the late arrival, blamed on inability to find our location, the team entered some what disorganised. The crash trolley did not arrive until another 5minutes later... 15minutes after the medical emergency was called. The other issue I raise was bedside manner. As a physio student, we are analysed and critiqued all day long so it is only natural that we pick apart every situation we are faced with... especially when blogging is needed:) The bedside manner of the medical team was, shall i say, suboptimal. This was the patient's first ever seizure and anxiety levels were flying high! All it would have taken was a "Hello, I'm Dr Smith, You are going to be ok". Throughout the entire ordeal, the entire medical team remained on their feet looking over the patient on the floor. The patient was not aware of the medical professionals' role, let alone their names. As we all know, we don't know what a seizure can mean. This patient may have been having another stroke for all we knew and everyone should have assumed the worse and acted over cautiously. This however was not the case, a fantastic learning experience and valuable lessons to be learnt by all, experienced and inexperienced. I have taken a lot away from this situation and am thankful that this learning experience did not cost the patient their life.

Team meeting

Whilst on my neuro and cardio placement, I was required to attend multidisciplinary team meeting. Those present at these meetings included the consultants, the registrar, the resident, the speech pathologist, occupational therapists, physiotherapists and the liaison nurse. Each patient on the ward was discussed in detail and all staff members were asked for their discipline specific input. I was required to present the physiotherapist point of view on the patients I had been seeing. To a student with limited experience, especially in the field of neurology, this can be a daunting task when surrounded by very experienced professionals. I must admit that I was quite nervous sitting there waiting for the consultant in charge of your patient to say ‘Physiotherapy’ at which point your expected to provide valuable information to all those at the table about the patient’s condition.Despite the initial fear, these meetings were incredibly valuable. It helped me to see how each of the different health professions use their individual specialties to work together to ensure the best outcome for the patient. It also made me think about the real practical value of physiotherapy in these patients. Does physiotherapy have an impact on the other health professionals treating the patient? The answer is a resounding yes, sometimes the physiotherapist ensuring that the patient is safe to walk outside is all the consultant needs to be able to discharge them, other times the physio working hard to get the patient to be able to transfer with one person assist is invaluable to the nursing staff. The thing I also found enlightening from these meetings is how much our opinion as physiotherapists and as health professionals is important to the consultants and other medical staff treating the patient. The consultants really look to us and to the occupational therapists to understand what the patient’s functional status is, and as such make a decision about the discharge plan for the patient. These meetings are also important in the sense that the allied health professionals see the patients every day of the week, whereas a consultant can not, there are times when the physio may notice a slight decrease in strength of a patient or the OT may notice a slight change in their cognitive function. This type of information may not be picked up by the medical staff but may be an indicator of a serious change in condition that needs further investigating.These meetings helped me to understand that even though we may not have studied for as long or have the same rank as a consultant or those others around the table; our input is just as important to the patient outcome. If I was placed in the same situation again, I think I would approach it with more confidence and a personal sense of equality with those around me.

Open mindedness

On a geriatric placement at a day hospital a female patient presented after a fall. The assessment revealed high scores on the TUG, berg, clinical test of sensory integration and the dynamic gait index and her gait pattern was normal for a lady her age. Manual muscle testing revealed weakness and poor endurance of her pelvic and shoulder girdle muscles. When questioned, the patient reported a noticeable increase in general fatigue within the last 6 months, preceded by the onset and slow progression of fatigue over the past 2 years. My clinical observation and assessment of this patient led me to suspect an underlying neural pathology. An undiagnosed pathology was also suspected by her medical practitioner and she is currently undergoing investigative tests.

When treating this patient with physiotherapy I treat her impairments but am vigilant with continual assessment and modification of her treatment as necessary in accordance with her subjective and objective response. I take this extra care because I want to help her rather than exacerbate her symptoms such as fatigue. I pay extra attention to her clinical presentation because this is all there is to guide treatment as her pathology is unknown.

Upon reflection I think it will improve my skills as a clinician to pay this extra clinical attention to all patients regardless of their diagnosis. No two people are the same even with the same diagnosis. Also, while much is known about the human body and pathology, much remains unexplained and I believe that keeping an open mind even when a diagnosis seems certain and being attentive to clinical signs and symptoms can only enhance practice.

post traumatic stress disorder

Hi Guys,
On my recent clinic I came across a fellow who was a former SAS member. I’m not sure if you guys are aware but these guys are the most highly trained soldiers in the world and take on the most isolated and dangerous work. This fellow was a Vietnam Vet and was now 65. Prior to meeting this fellow I had a discussion with some staff about him and they let me know of the situation. He had many psychological and emotional issues including the condition post traumatic stress disorder. He was on multiple meds and had a lot of surgery including lapband surgery and bilateral knee replacements. He had been attending the clinic for years for a variety of things. I was told he didn’t like strangers, didn’t like people getting too close to his personal space and didn’t like to be surrounded by lots of people. For these reasons it was sometimes hard to get him proper rehab because the gym and pool usually had a number of people using it at the same time. I began very cautiously with this patient and got advice of one of the more experienced physios, he thought it best that I stay clear of a lot of the hands on treatment as he thought much of the pain was of psychological origin. The poor fellows wife had just been diagnosed with breast cancer and after assessment it was a general consensus of the physios in the clinic that it was a cry for help as there wasn’t too many physical signs suggesting a mechanical origin of this pain and subjective nature of this pain was very random and a pattern could not be identified.
It was made clear to me by the owners that this fellow was a patient who should be given “special” treatment ie was a long term patient who was to be treated very gently. After a few private sessions which I viewed as more placebo/patient pleasing treatments than anything else involving some EPA, hot packs some gentle mobs and education, the patients condition improved. During these private sessions with the patient I worked hard on talking to this fellow, getting a feel for him character and really just trying to gain his trust and a mutually respectful relationship and slowly dropping subtle hints on were we needed to go with treatment. This was because after a few sessions it became clear to me that the this guy really needed to begin on a rehab program including gym and hydrotherapy asap, due to all these co-morbidities he had become very de-conditioned and was really in need of some general strengthening and endurance exercises. The reason I had to be so subtle and gentle with this idea of this sort of treatment was 1st the patient really wanted to be treated with EPA etc and secondly he was not very keen on been in the gym/pool with other patients around him or even a PT for that matter. Anyways after about a week and a half he actually said to me that he’s happy to go into the gym and pool and he also didn’t mind me been there. Getting him to do what I wanted is another story but I eventually succeeded with that via gentle education and compromise haha. He told me some amazing stories regarding SAS training and war, which I found very intriguing.
The main point I want to highlight with this blog is the importance of building a good patient/professional relationship even as in the case at the cost of “real” treatment. Because in the long run the gym and hydro sessions were going to help him far more than anything else and to get him in there I really needed to “trick” him into it. I have never really dealt with a patient of this sort previously and it made me very aware of the posttraumatic stress stuff. I feel much more prepared to treat this sort of patient in the future. I think the keys to this sort of patient is; patience, compromise and gentle confrontation of negative thought processes.
Yay last blog!
Thanks guys.

Scarey

Hi Guys,
On my recent clinic in a private practice I encountered an interesting fellow. Let me explain is case.
He was approximately 50 yrs of age, his appearance was that of a big burley labourer/rugby player with a big deep voice which he swore a lot with, the sort of tough stereotypical country aussie bloke you might imagine.
He came in to me with a referral from his GP. The referral was very brief, something along the lines of this pt has headaches possible a result of a stiff sore neck post a blow to the head your opinion would be appreciated. Then a list of PMH included throat cancer, septicaemia in both shoulders and a few other less serious things.
On Subjective examination, the case began to seem very complicated. It turns out whilst working in Kalgoorlie a 40kg fence feels on top of his head. He was taken to the hospital and treated for concussion and had a MRI which came back clear. He returned to work, but continued to have splitting constant headaches beginning in the bilateral temporal region and moving posteriorly. He had been unsuccessfully treated via meds for this. He also complained of memory loss. Eventually he was sent back to perth for Rx as his work MATES refused to work with him because they said he was a danger to them and a danger to them, as well as stating he “wasn’t the same”. He didn’t really think he had a sore neck at all, and just complained of these “F****ing headaches”. He suggested that he had numbness in his hands + tingling feelings. He also complained of dizziness, diplopia, dysphagia, nausea and photophobia. He had not had a CT scan or MRI or a review by a neurologist. I cant quite recall his meds. He really just wanted to stop the headaches and get back to “digging holes”.
On Physical exam he had markedly reduced neck movements limited by pain, a possible positive VBI sign, altered sensation but could determine sharp blunt and could localise LT and it felt the same throughout. Strength was ok, however had weak deltoids bilaterally, however it was believed this was due to the shoulder issues. Upper Cx ligament tests were negative.
PAIVMS of Cx region were very stiff and sore and muscles were very tight. Day one because I was very nervous to do much with him due to mechanism of injury, plus all the rest of it and the fact we couldn’t contact his GP for 2 days I just did some soft tissue work and Cx traction to be safe and sent him off for a through the mouth upper Cx Xray (this came back “normal”). 2nd time I got my supervisor in with me and we did some gentle unilateral mobs of the neck which increased his headache. The next day we saw him and he mentioned he was having more trouble swallowing his food than previously. At this stage he became my supervisors’ patient. As we got to know him he opened up a lot, told us about suicidal thoughts, depression, frustration, highly strung, impatience, problems at home, thoughts of hurting others etc. On discussion we began to suspect a large psychosocial component of the presenting complaints.
A few days later we were able to talk to his gp, he also seemed to think along similar lines to us. He had organized him an MRI which came back fine and a review with a neurologist. At this point our treatment became more aggressive as there definitely was issues with his neck and all the testing didn’t suggest any serious pathology. Also we began the hard task of dealing with the emotional aspects of his pain. Which really just composed of understanding, warmth, encouragement and advice on relaxation, gentle exercise, diet and tried to influence some of the negative thought processes. We also got him in for hydro in the heated pool.
This is were I left this patient as my clinic finished. I found this patient very challenging but also a great experience. It made me very aware of Cx instability, VBI stuff, the scans we can refer for and also docs have at the disposal to rule things out, also helped with my skills in talking to gps and other PTs. I got shown techniques to Ax alar ligaments integrity etc and also dealing with psychosocial influences . I think this help me to consider the balance between been overly cautious and negligent. Next time I will definitely feel more confident when I am confronted with similar patients.
Thanks Guys

my rural placement

I recently completed my rural placement. I had a very interesting experience on the prac. It was a great placement and I saw a variety of area in physio such as gerontology, musculo, neuro, antenatal and post-natal, etc, basically every area in Physiotherapy. I worked alone most of the time, which was good challenging for me. As you know, normally we work with at least one of supervisors and sometimes I feel like they are assessing me and I have to change my opinion to supervisor view. Even though supervisor view is correct I think we have to think about it, not like getting answer immediately. For me the time is a bit longer. But this placement was I have more freedom and I can treat my patient without anybody. It helped a lot for my clinical judgment, not supervisor view. I can think about my clinical judgment by myself. I have taken a lot of confidence away from this placement, especially in terms of my self-clinical judgment.

Bit of a shock

I recently had my cardio placement at SCGH in ICU. Having spoken to many students about this placements i heard that a lot of people had found it quite confronting as the patients are often quite close to death. On starting this placement I found that i had no problems dealing with this fact, as most of the patients are intubated and as such no real relationships were established between the patients and myself. However on one morning my supervisor told me to go and see a patient called Jason. Not expecting anything out of the ordinary I went to the patients bedside and discovered to my shock that it was someone that i knew. It took me a while to be sure because the sedatives totally relaxed the muscles in his face and none of his normal wrinkles were present, however his family had put photos up which confirmed that it was a guy who i knew as "Squiz". Squiz was a regular at a pub that I frequented and although i had never gotten to know his real name i knew him quite well. It was at this point that i bagan to find ICU a bit confronting as now it was someone I knew who was close to death. Fortunately Squiz was doing quite well and looked like recovering but i remember finding it very bizarre to be treating someone i knew. I found it very weird to think that i had done a full treatment but when Squiz woke up he would have no idea that i had been there.
Although quite confronting at the time I'm glad that I was treating Squiz because unlike his other friends who knew very little other than that he was sick, I was lucky enough to have the full picture and could see that he would probably recover. Having said that if the situation had been that he was unlikely to recover i think i would have preferred not to have been treating him.

opening new doors

I have been reflecting recently on how Musculoskeletal is taught at school and have concluded it is a difficult thing to teach. We as students have had to draw together a lot of different aspects and combine them when treating a musculoskeletal patient. A lot of this collaboration can only be done when actually treating patients, it is a learnt skill, not something that can ealisy be taught. The more experience I have with musculoskeletal physiotherapy the more doors that open. My current supervisor has broken down the formula that we were taught at school and opened up my creative side. She is New Zealand trained which involves a lot of Mulligan's techniques - mobilisation with movement. I have been treating along side two therapists who are trained in this area and have seen first hand how and when these techniques can be effective. The vitality of Ax, Rx, ReAx is highlighted when trying new techniques, if it doesn't work, try something different. The thing that interests me about Mulligan's techniques is the involvement of seat belts. When a constant force is needed throughout a mobilisation or movement a belt is used. It can often be a lot more comfortable for the patients and for the therapist! Just wanted to share a new discovery.

Very lucky

Hi guys,
Had an interesting experience on my rural prac this week. I am working in a private practise. REALLY great place, everyone is so helpful and teaching me a lot. I’m been helped with everything from taping to Cx mobs and manips. It really is a cool placement, feel very lucky to have got it. Anyways, one of the guys working there is a manips physio, and funnily enough he and a few other people actually started up the manips post grad course at Curtin. He has been working as a physio for over 40 yrs. When ever I have a spare slot I try and jump in with him and watch him work. He is really a good tutor, 15 minutes with him, I can feel my brain trying to tick over and have a big grin on my face. With PAIVMS and PPVIMS of the spine, according to this fellow the most important thing is the basics and not thinking too much and just feeling. When I say basics I mean, letting the patient get used to your hands, body position, hand position, technique (don’t be too firm, if your doing a PA make sure its PA/inline with the joint, physio biomechanics), and thinking about movement diagrams in comparison to what your feeling, R1, R2, P1, P2, always reassess after each particular intervention and having a rational to why you are doing something.
Another comforting thing I have noticed is that EVERY physio does things differently, especially when working on the spine. One of the guys said to me there is a wrong way to do something, but there are many right ways to do something. It’s quite amusing actually, I’ll be watching someone treat something one minute, and the next minute I will be watching another physio treat something similar in a completely different way and the patient in both cases will leave happy with what they have paid for.
I have taken a lot of confidence away from this clinic. One major thing I have been told to remember in this sort of setting is to never let on that you don’t know what’s going on. As soon as a patient sees your lack of confidence in your own ability to help with the problem they will switch off and not listen to a word your saying. Of course if you are really stuck then its better to be honest and ask them to see someone else. But in physio there is always going to be some trial an area, it is just the nature of human beings. We all respond differently. Also a patient hasn’t spent 4 yrs at uni learning what we have, so things which may seem basic and silly mistakes to us, a patient won’t realize it’s a mistake and will just think its part of our Ax, Rx.
Another great thing about this clinic is seeing how a private practise works, and learning how to work in such short periods of time. Ie prioritizing and cutting back Ax’. I feel I am much more prepare for private practise work if that is what I choose to go into in the future.

Indeginous care - a shift in mentality

Upon talking to various medical staff on my rural placement who have major roles in indeginous care I wanted to raise a point of discussion. Previous attitudes, in a nut shell, have been that we as trained individuals need to go out and care for people that cant care for them selves or do not have the medical knowledge to optimise their health them selves. Population health has different theories. There is a current shift with in the health system to withdraw from passive health care and place medical professionals in more health promotion roles as opposed to clinical care.
Although this shift in mentality is going to be a gradual process, for both parties, the carers/ health system and the indeginous communities. I was recently visiting a community with the community health nurse and we came across a little boy who had cut his foot badly on a rock. His carer yelled out from the verandah if we had some things in the care and if we could bandage the boy. The nurse replied, No, I do have a bandage in the care that I can give you and then you can bandage him up. You can see from this simple example that the attitude is going to take a while to change but with graudal persistance may shift.

Aboriginal care

Yet another rural and remote reflection... I have just spent the day with two community nurses travelling around in a 4wheel drive, packed full of what ever it is we may need, between aboringinal communities in the Pilbra. Tasks of the day,
- chase up birthdates of 10 children whose real names and birthdates are unknown to the elderly lady who is now caring for them in one community
- treat two teenage girls (aged 15) who have syphilis and also need cervical cancer immunisation
- follow up trasportation for an elderly man who will be transported 6hours away to the closest CAT scan facilities
- vacinate some children
What we encountered:
- an elderly lady distressed about one of the young boys in her care (one of the ten) who has scabies in his buttocks region and is tracking up his body
SO we went to the closest town where this boy was at school (40km away), collected him from school, inspected his skin, took him to the hospital, treated him with the local Dr and returned him home to the community with fingers crossed that his oral antibiotics would continue
- another elderly lady distressed about a young boy in her care (different community) that had cut his foot a week earlier under his little toe and could no longer walk due to pain
SO upon inspection this little boys foot was twice the size of his other foot and necrotic tissue had started to form around his little toe progressing into his forefoot. Our solution was to drive him back into town to the hospital for further medical care.
The young teenage girls were also tracked down in the community after visiting 5 houses and injected out of the back of our 'mobile 4wd clinic'. All in all a productive day.

Patients with other problems

During the last week of a cardio placement on a medical ward one of my new patients was a man admitted with a non-infective exacerbation of COPD. He had been admitted to hospital repeatedly for this in the past 6 months with 4 admissions within the past 2 months. Schizophrenia bipolar disorder and a tendency to be aggressive and argumentative were included in his past medical history. He lived in a hostel, smoked 50 cigarettes a day and was non-compliant with his medication. During the subjective examination, the patient told me to F*%! Off as soon as I introduced myself. I did manage to get him to explain the correct use of medications to check his understanding of this (but was not game to do anything else with him) before he told me to F#@* off again.

I found the situation with this patient is very difficult because he had health issues which were significant enough to have him admitted to hospital repeatedly. The experience confirmed for me how important it is for health professionals from all disciplines to work as a team to care for patients because although this patient had problems relevant to physiotherapy, psychiatric and social problems needed to be addressed before any other issues could be dealt with effectively.

Life in the outback

I am currently in Tom Price on prac, three weeks between this hospital and Paraburdoo, then a week out on the Mine Site. The point I wanted to raise is one of where as Physios do we fit into the community. My experience up here has highlighted the importance we have in the welbeing of the community. I find that sometimes we get lost in the crowd in the city, just another physio, that could easily be replaced! In rural and remote care, often the physio is the closest thing to medical staff and other allied health staff which can lead them often working outside their scope of practice. Also, the community is smaller and isolated making it easier to see how in your abscence what would happen. You can really see up here that we actually do make a difference to the quality of life of so many. Living in a small community makes it easier to recieve feedback and see patients out in the community participating in activities that in your absence they would have had trouble doing. It blows evidence based practice out of the water and is a very rewarding experience! Your place in the community as some one with medical knowledge is also highlighted by your participation in things like the SES - State emergency services... my supervisor yesterday was called out to a Gorge rescue to help an open tib fib # patient up out of a gorge. Work doesnt stop at the hospital door.

a recent reflection

I was recently pondering, as you do when thinking of something to blog about, and wanted to discuss my thoughts. I think if there was one piece of advice I would give to a new student starting out in there physio travels, it would be 'dont underestimate the importance of personal experience in influencing your professional life'. Being people people and being a part of the caring profession, our personal experiences enhance our relationships with patients and fellow staff. In particular I wanted to talk about travel. Over my student years I have tried to travel as much as I can, within the state, inter state and over seas. While we have had long holidays, I have prioritised travel. At times, I have been looked down upon by friends and fellow students as I have had to sacrifice possible professional development opportunities to travel. Over the last year, I have noticed the postive influence my travelling experiences have had on my treatment and understanding of other cultures. Even simple techniques such as communicating with a patient with limited english, I feel, are a lot better from my cross cultural experiences. Learning a second language is another technique that can often be underestimated. When it comes in handy is very surprising! I just wanted to raise these things as a point of discussion into how personal experience can enhance professional skills

communication

This has been discussed a few times, but not by me :P on a recent placement I had an issue with a supervisor or I should say they had an issue with me. I wasn’t sure why, because I was doing all the “right” things to get through clinics that all the students talk about, enthusiastic etc, my skills and knowledge weren’t bad. So yeh I couldn’t figure out what the problem was, the only thing I could think of was that he was under the impression that I didn’t want his help. I began noticing he was leaving me to my devises, whilst spending a lot of time with other students. This kind of annoyed me because I really wanted to learn as much as I could from him.
I decided to discuss this situation with him. He assured me he didn’t have any problems with me, but had no explanation as to why he was treating me in my eyes unfairly. However discussing this stuff with him, seemed to gain his respect and he finally started to give me nearly equal the assistance as other students.
By the end of the placement we were on reasonably good terms and developed a pretty efficient working relationship. Again this highlights the massive effect good communication can have on a work environment. In the future I will continue to approach people if I have an issue with them, or believe they have an issue with me. I guess the best way to approach someone is tactful and not aggressively.

Personal life affect professional life.

During a recent placement, I experienced a difficult time in my life. Someone very close to me was going through a really hard time and was really suffering a lot, more than I have ever seen someone suffer. This person’s behaviour really wasn’t appropriate and was really starting to affect my professional life indirectly and directly, but I understand why they were acting this way. Anyways, this had a huge effect on me and for the first time, I began taking home stuff to work with me. Normally when working with patients I forget everything else going on and just focus on my patient. However stuff going on was really stressing me and I was finding it hard to give my patients my full focus and I ended up getting sick due to it. I would even go as far as to say that this was the hardest time of my life. I was planning to pull out of my clinic to focus on the stuff going on in my personal life. I discussed the situation with my supervisor and explained it was beginning to affect my patient care and I felt guilty for not giving my patients my all , he encouraged me to do what I needed to do.
I decided to hang in there for a few more days and see if I could refocus. Surprising I did and completed the placement to a satisfactory standard.
The reason I decided to discuss this was to encourage people (not sure if anyone else is like me) to not make rash decisions on serious matters, and really take time to consider it and try work through it without running away from stressful situations. At the time I never thought I would be able to complete the placement, but I surprised myself and managed. so I reckon we are all capable of surprising ourselves with perseverance. Don’t give up, but dont try to be superman

treating patients you dont like

I want to begin by saying that I believe that a parent has and should take on more responsibility to their child than any other individual should to another. On one of my recent placements, I had an interesting experience.
On this placement I was reading patients notes who I was preparing to see for the first time, I noticed he was an intravenous drug user (ie a hard drug user), as well as having kids and a wife, his condition was also life ending and a result of drug use. So anyways, I am already quite frustrated with this person, because in ICU earlier I heard the patient complaining to friends that his “lifestyle” is going to change drastically. And this is a negative thing why? Shouldn’t his lifestyle have changed when he had a child? As I thought about this fella more and more I was really quite angry at him, and really wasn’t too keen to help him, rather I was thinking to myself, really terrible things like the docs shouldn’t have even bothered to waste their time and tax payers money on this guys life prolonging surgery. So in turn, I wasn’t really too keen on treating him, because I really thought he “sucked”.
After spending some time with this guy over the coming weeks, I stopped been so angry at him. I even spoke to him about his daughter. And he was so proud and delighted with her. But too this day I still can’t accept his decision to use drugs and ultimately kill himself with them, whilst his daughter is still a young child. I guess its impossible to understand why humans do many things. I eventually realized or at least am realizing that it’s not a physios role to judge people. It is purely our duty to do our job the best way we know how.
The main lesson I guess this situation taught me, was that even if I really feel strongly about something or someone, it is still my duty to treat every patient equally as well as the next and to the best of my abilities. And I know now that I am more than likely going to be able to treat those patients who I feel are bad people and really think the way they live their life is disgraceful. Finally I guess I’m realizing that we can never truly know anything when it comes to a person’s mind sets, and to believe our opinion is right, is being proud and self righteous.

removing a brain

I recently completed my SDP, my project was to dissect a particular part of the body. On one of the days, a couple of the lecturers decided they wanted to remove the brain from the cadaver I was working on to use in neuroanatomy labs. I remember back to the first day I ever met a cadaver about 6 yrs back now. I was so grossed out, scared to touch them, thought about it afterwards, didn’t like eating roast beef etc. Over the year I guess I became pretty desensitized to it all. Anyways I don’t know if anyone has ideas on how to remove a brain from a person, but basically you saw off the top of the skull and pull out the brain with your hand.
On this day there were 4 of us watching, plus one person doing the actual removal of the brain. It was a pretty gruesome thing to see. At the time I felt not too bad, I was actually quite excited, it isn’t something I get to see every day, and probably something I will never see again. I guess staying detached help me witness this without too many issues. If I let myself to think about the fact this was an actual person and all these sorts of thoughts, I may have felt quite sick or even scared :P.
I feel really honoured to have had this experience. In 1st yr they tell us about how these people donated their bodies, for us to learn etc, and for us to respect and appreciate them and all of these sorts of things. I can now honestly say something which I could not before, that I really appreciate what these people have done for us. They donated their body, so people like me can advance our knowledge in anatomy and thus improve as health professions. I really appreciate these people a lot.
Secondly I look at the human body in such a different light now. I guess I now just have what I consider a really great thought process about the human body, and how it all works. It’s really hard to put into words, until you experience it for yourself. I don’t know why but I really think this will help me to treat patients more effectively in the future. I feel I can see the “big picture” and that everything in the human body is related to everything else in the body. I’m really happy to think like this, and again I am very grateful for the experiences I have had in 4th yr, and they are making me grow as a physio and a person very rapidly and drastically.

Code Blue

Recently on my cardiopulmonary placement I encountered an experience which taught me a lot of varying lessons. This occurred on my last day which I think is quite amusing. Anyways, there was a patient who was a young man aged 15. He had been in hospital for approximately 8 months, he had been admitted for major transplant surgery, however had a multitude of different things going on pre and post op. This young fella was very popular throughout the hospital and my ward, as I guess most younger people are especially if their medical condition is serious, and long term. Everyone including myself had a soft spot for this patient and we all tried really hard to do our best for him.
Along with my supervising physio we had been progressing the intensity of activity this patients physio management, in the hope improve strength and exercise tolerance. On the day in question, I had come to the end of my placement and was working independently and just touching base with my supervisor if I had any queries. I decided to take the patient down to the physio gym, because I was aware he really enjoyed the gym, and therefore I thought he would benefit from the trip to the gym for physical and psychological reasons. My supervisor had done the same thing the previous day.
Anyways on this day I did all the stuff we should do before touching a patient, ie read notes, check obs, subjective and ongoing objective assessment. And there wasn’t anything suggesting to me or I think it’s safe to assume a qualified physio that the planned treatment would be contraindicated.
I took him to the gym and we did some fairly light work. The whole time the thoughts going through my mind was stuff like, “don’t forget this kid is sick. Don’t let him over do it”, I know from personal experience male teenagers have a tendency to do. So I was really trying to hold him back which I did quite successfully because he really was a great patient to work with. Coming towards the end of the session we were doing some light walking and all of a sudden with no prior warning he screamed out loudly “argh my chest”, grabbed his chest in agony and stumbled against the wall. Lucky there was a chair right next to us and I managed to slide it behind him so he could sit/fall into it. At this stage my brain started stressing very hard. Again luckily just as this was happening in a relatively quite part of the hospital another allied health profession student walked past. I asked her to call a cold blue, but she said she didn’t know what to do so I made the decision for her to stay with him for a moment whilst I ran and called a code blue.
Being near the physio gym, it wasn’t long before experienced physios caught wind of what was happening, and they were on the scene within seconds (I think :P). So I took a back seat and just tried to keep him comfortable whilst they checked his obs, and administered O2. After the emergency team came and took over my brain really started to race. Apart from the obvious worry for my patient, I was thinking about things like, what did I miss, what did I do wrong, what could have done to stop this from happening, am I going to fail on my last day after everything else had gone well thus far, is everyone going to hate me because I made this fella worse, plus many more negative thoughts. Basically I was blaming myself in my mind and stressing about the consequences for the patient and myself and what the rest of the staff would think of me.
Thankfully my supervisor was REALLY great, when he found out about the occurrence he came to find me ASAP. He really reassured me a lot, asked me what I did and promised me he would have done the same thing. He told me that these things happen and are normally out of our control. And b/c physio stress sick people’s bodies more than other professionals, it is more likely to happen with us. He reminded me that as long as we take the precautions we should, the benefits out weigh the risks for a carefully thought through treatment.
This helped me a lot and I appreciate it immensely, I held this person in high regard prior to this, and now I hold him in even higher regard and am very happy to have learnt from him.
What I learnt from this will help me a lot in the future. Firstly I saw how the experience physios dealt with the situation so calmly and surely and will definitely follow what they did in the future. Also all though it will never be easy to see a patient suffer whilst in your care, I know that sometimes these things happens and I won’t beat myself up as much. And probably most importantly I am and will continue to be even more alert and observant of my patients. I’m not saying I made mistakes however I am now VERY aware of what can happen and will do my absolute best to make sure I don’t make mistakes with patients especially of this nature.
I am actually very thankful that this happened to me, in the environment it did. I feel very lucky as I have throughout this year. For interests sake, when I left that day the docs still couldn’t figure out what happened, however they had pretty much ruled out heart issues.

CFS

I recently completed my paeds placement on an oncology ward at a children’s hospital. My patient for my final assessment ended up being a teenage girl with chronic fatigue syndrome – the fact that my assessment pt was not an oncology patient and she had a condition I’d never treated before is another issue that I won’t go into now… So, having never treated a pt with CFS before, I was pretty nervous before my assessment and I’ll admit I also had some preconceptions about this patient before I had even met her.

The concept of someone missing a month of school only to sit at home sleeping and watching tv all day was quite foreign to me. Admittedly, I’m not the most motivated person I know, but I just couldn’t grasp the notion of this syndrome. My initial thoughts were to get her into physio and work her hard in hope that she’d ‘snap out of it’ and realise that her behaviour was inappropriate. But as I read further into her notes and when I met her, I discovered that her father had CFS for 15 years (having a close relative with CFS is one of the classic clinical presentations of pt’s with CFS). I realised that it was only natural for her to behave in the same way she had seen her father behave her whole life. When we had our first session together, in the subjective the patient described all the activities she wants to get back into and gave me a perfect list of goals of rehab that were actually SMART (specific, measureable, etc, etc). So it seemed like this girl was aware of her condition and knew that things had to change, she just needed some extra help to get her there because she wasn’t able to get it at home.

I only saw this patient once but even in that one session I gave her exercises to do on the ward outside of physio which she happily agreed to. It’s possible she was just doing an act on me by falsely leading me to believe that she would do them, but I really hope for her sake that she was compliant with the rest of her rehab and can get over her condition. I feel that I learnt a lot from this situation because I was a little judgement initially, but after this experience I’ve learnt not to have any preconceived opinions about patients and simply treat the patient that presents to me on the day.

I will just let the student do my job

i have just recently been on a cardio prac where i was placed at the same place as i had been in third year. As i had already been competent in this exact prac i asked if i could be placed on a surgical ward so i could experience a different area of cardio physio and challenge myself. I was then informed that this was not possible as i had already been allocated to the same medical ward as i was previously on and they wanted to me to be proficient at running the ward. This idea of runnning the ward was ok as it was a new challenge.

However i became increasing frustrated when i realised that i was to run the ward so my supervisor didnt have to do any work. While i would treat the ward patients she would have coffee with nursing staff or chat to other disciplines. My curtin supervisor also became frustrated as i was missing out on learning opportunities in a new field because the staff wanted to slack off. I was then told by my supervisor to request surgical patients when i was with her. They complied with my request but would not let me follow those patient through as i was to return to my ward duties.

This posed the question whose learning is prac benefitting. My understanding is that we were to go out on prac so we are able to sharpen our skills learnt at uni. This was not the views of this hospital and it frustrated me greatly that they take on students so their staff can have a holiday.
I then realised that if i wanted to further my learning i had to see to it myself by going to organised events like the lung lunch myself and asking other students to give me a tour of ICU

Team Work

I am currently in rural prac and i have found it extremely refreshing to arrrive at a prac and be immediatiely welcomed into the community as part of the team. Having only experienced city hospitals as the student i have become accustomed to being the wandering student looking for equipment, other staff members and wondering who else from the team i can get involved. So far on my my rural prac i was immediately part of the team and the multidisciplinary approach began from day one. All disciplines were keen to teach me the skills of their trade and provide me with as many learning experiences as possible.

It was so refreshing to have other staff take an interest in my learning and take the time out of their day to pass on the skills they have aquired over the years. This made we wonder why does this welcoming not happen in the city. The competitive nature of city life means that nobody has the time or patience to give students more learning opportunities. If you dont create opportunities for yourself in the city you dont get them.

This has been a great experince for me as i now have a greater understanding of the skills of other disciplines and are better able to utilise their services. I also feel that it has been a great personal experience as i can now see how i would like to conduct myself in the workforce.

Docs with Ego's

My entry this week refers to an issue in the interdisciplinary team who work together on inpatient hospital wards. In my limited experience on placements at hospitals, I’ve noticed a trend among most of the doctors – a large proportion of them are really arrogant. It just seems to be a common that most of the registrars and consultants on these wards are intimidating, rude and think very highly of themselves and don’t have much respect for the other members of the interdisciplinary team. They seem to display a belief that they are superior to their colleagues.

I’m aware that I am generalising and stereotyping the medical profession in saying this but it seems that my views are shared by many other students as well as qualified allied health professionals working with doctors. I mentioned my thoughts to my supervisor on my current prac and she replied ‘Welcome to the hospital setting’.

I think this snobby attitude employed by some (not all, but a lot) of these doctors can effect the harmony and effectiveness of the interdisciplinary team. It can result in a lack of communication and interaction between the doctors and nurses/physio’s/OT’s, etc which could be detrimental to the patient. It teaches me to be more aware and conscious of how I interact with the other health professionals because I don’t want to have the same effect on them. This will hopefully mean patients will receive optimal treatment from an interdisciplinary team that really do work as a team.

Does anyone else share my views on this topic? Or have suggestions on how to handle an egotistical doc or any other member of the medical team?

Cultural Differences

On my cardio placement on a medical ward, one of my patents is an Indigenous man. He lives in a remote area and identifies with traditional Aboriginal culture. I found the subjective examination extremely difficult. He is a cooperative patient, appears to understand the questions I ask and always answers me, however I have been unable to obtain a specific subjective history. His accent is different to what I am used to hearing and he speaks softly and quickly. He also avoids eye contact which makes it difficult to read facial expressions and comprehend fully what he is saying. His answers to my questions are indirect and I feel I am missing the point of his answer.

I am aware that I understand little about Aboriginal culture and that there are cultural differences between Australians from urban areas and Indigenous Australians who identify with traditional culture. The experience with this patient has given me some appreciation of how big those differences are. It amazes me that we can be citizens of the same country and not be able to verbally communicate when speaking the same language.

I spoke briefly with a friend who has lived and worked with Aboriginal people from communities in remote areas. She said that to offer information as the conversation progresses, rather than asking and answering questions may be the way things are usually done in this man’s culture. Next time I see the patient I will try explaining my reasons for wanting information and rephrase things so I am not asking direct questions. Hopefully this will lead to obtaining a better subjective history.

If anyone has any other ideas please let me know.

Family Centred Practice

Having had nothing to do with children before my paediatric placement it was a little strange at first getting my head around all these little people and seeing in the flesh how they move and communicate. It did not take long before I felt comfortable assessing and treating children. I actually found children to be uncomplicated. Even the children with severe disabilities were relatively uncomplicated compared to the real complexity - the family situation.

An example is of 2 children, both 16 months old who were referred to physio by the same child health nurse because they were not weight bearing through their legs. The assessment and treatment of these children were pretty much the same. The real issue became the assessment and treatment of the parents! One of the mothers felt so guilty for not bringing her child in earlier that she burst into tears at the end of the session and much gentle but firm counselling and education about her child’s developmental delay and what could be done to improve things was required in order to hopefully gain compliance with the home program.

The mother of the other child had a history of depression and had difficulty attending appointments. During physio she appeared distant and uninterested and did not voice any concerns even when asked. A home visit by an early intervention teacher was arranged for this patient in order to assist with implementation of the home program and monitor the child’s progress.

The experience made me appreciate the importance of “family centred practice”. After all, our hands on treatment with the child may only be half an hour a fortnight. This will only provide the tools for treatment. It is what goes on everyday at home that counts.

The chatty patient

I am currently on my musculoskeletal placement and have encountered the problem (on a number of occasions) of the patient who likes to talk... and talk... and talk... and talk!
We are taught at university the importance of taking a thorough subjective assessment and how important it is that you don't let the patient ramble, otherwise it can be a very time consuming procedure. Until this placement I did not realise just how important it is. When you have patients booked in back to back a subjective assessment that takes too long can really put you behind schedule.
I have found that with some patients trying to keep them on your current line of questioning, and trying to get them to answer your questions as briefly as possible is next to impossible! At first I felt rude interrupting a patient if they were telling a story (albeit irrelevant) or if they were not giving me the information that I had asked for. After a number of extremely long subjective assessments, however, I have realised that it is necessary.. no matter how rude you feel.
I now try to keep my questioning as direct as possible and try to redirect any stories a patient is telling back to their presenting problem.
Although I feel that I am getting better at shortening my subjective assessment, I think I have a long way to go. It is particularly important to fine tune this skill if I go into private practice after graduation as the time available with a patient is much more limited than what we are given on prac. It is one of my aims for this placement and I hope to be much better at dealing with the "chatty patient" by the time I have finished!

Hip Pain

I am currently on my neurology placement and am currently treating a man diagnosed with Fredrick's Ataxia 15 years ago and has been attending physiotherapy for 10 years. He is currently experiencing hip pain which has been narrowed down to his hip flexors. This pain is perpetuated by the fact that he has a flexor withdrawal reflex so when there is sensory input in the soles of his feet, he goes into hip and knee flexion involuntarily. Last treatment session, he was going to be admitted into hospital to help manage his pain but he refused admission because he did not want to be in a hospital. He lives independently and refuses help because he does not want strangers in his house and his family lives far away.

Intervention so far has consisted of stretches and trigger point release. Focus has been on reducing his hip pain so he is at risk of his progress going backwards or plateauing. Although I know that independence is very important for him, his hip pain is inhibiting him in all ADL's. I have considered doing US for him but because the flexion is involuntarily and occurs numerous times a day I do not know how effective it will be. I feel helpless in this situation because when I am treating him, I am causing him pain and not helping him at all. Our supervisor is running out of ideas to help him because he has refused hospital admission and most pain drugs cause him to be drowsy and he does not take them. If anyone has any different interventions or approaches to this situation let me know.

Enthusiatic Patients

I am currently on my neurology placement and am treating a gentleman who had a (R) MCA stroke 12 months ago. He is progressing very well and his treatment is mainly consisting of high level balance. This man is very motivated to do his exercises and during treatment he will try and push himself to get the very best from the session. The only problem is that he thinks that we are not giving him hard enough exercises and has been taking exercises off the Internet and performing them at home. We have explained that it is not safe for him to do all the exercises at home because he is at home by himself and his balance and diminished eye sight is a risk factor. Even though he said he understood this, he is still pushing himself, modifying his home exercises to make them 'harder'.

Although it is very good that he is so motivated, this would have contributed to his progress, it makes me quite nervous to give him any exercises to do at home. He tends to do at home what was done with him at physiotherapy, so I have to make sure to reiterate that it is not safe to perform independently. It probably happened because he had seen such an improvement since his stroke and contributed it to the physiotherapy intervention, so he has assumed by doing more exercises it will make him better quicker.

I know I have done all I can but I still feel like there should be something I can do to prevent him from falling or hurting himself at home. Next time I will see him, I will try and review his exercises and try see if I can modify them so both him and me are satisfied! If anyone has any approaches to this situation please let me know!

Inspirational!

While on my paeds placement, I’ve come across a highly effective and motivational method of inspiring paediatric cancer survivors. A patient I’ve been seeing (mostly with my supervisor) was day 10 post complete hip disarticulation amputation that had to be done as a result of osteosarcoma in the patient’s proximal femur. The patient was a nine year old girl who had been discharged from the ward about 4 days earlier and had come back in to outpatient physio to get a HEP to work on. The physio (my supervisor) had found out a few days earlier that a well known paralympian was currently in Perth for a training camp prior to heading to Beijing to compete in cycling at the Paralympic Games. So she arranged for the athlete to come in and visit our patient.

It turned out that this athlete had had the same cancer in the same leg as our patient and had become an amputee at the same age. I was stunned at the effect the athlete had on our patient. She had been progressing fairly well since the op but she was so motivated and inspired after chatting to the athlete, who was able to show our patient that even though she had a disability, it didn’t have to be a life-long burden and she was still able to do pretty much anything she dreamed of. She has a passion for basketball and is now keen to get into wheelchair basketball, among other sports as she is able. The excitement and hope that was instilled in our patient by this athlete was wonderful to see and I’m sure it has changed her views on her (dis)ability.

I know it’s not likely that we as physio’s can get athletes of this status to visit our patients regularly, but it was so brilliant to see the influence they can have on these kids to pursue their dreams, even if they might not be the same dreams as they once had. My supervisor was lucky to get this special visitor for our patient and it took some effort for her to organise it. This has taught me the importance of doing everything in our power to find ways to inspire our patients who, especially on the oncology ward, might not have a lot left to be motivated by.

Undaunted by aphasia

On my recent neurology placement I had a number of patients that had expressive aphasia. At first it was very difficult to communicate with these patients and both the patients and I felt frustrated at times. It was difficult to remember to ask simple yes or no questions, let alone have the patient express what they were feeling to me.
It hit home to me how frustrating it must be for a person to be aware of what they want to tell you, but not have the capacity to do so. It made me very appreciated about the simple blessing of language!
I found that the patients with aphasia responded well when I chatted to them like any other patient. As long as I remembered to ask them yes or no questions we were able to communicate in at least a satisfactory way.
By the end of my placement I felt closest to some of my patients with expressive aphasia and felt that I was much more in tune with how they were feeling, without relying on words. Once I had discovered an appropriate way to communicate with them I felt that they really enjoyed our sessions together and I got a lot out of them too!

Supervisors

On my last placement, when treating musculoskeletal patients, I had to report back to the supervising physiotherapists after the subjective and objective. There was 4 different physiotherapists that I talked to and they all had very different approaches to treating injuries in the acute stage. One of the physiotherapists would like to be more cautious, using ultrasound and gentle ROM. The other physiotherapist advises to work through the pain, to just mobilise the patient and gain full ROM within the first few sessions. I found this confusing because they were 2 different aproaches but both physiotherapists were quite adamant that their intervention was most effective and the other one was wrong. I did not want to argue because being a student I did not want to cause a fuss but it did frustrate me. Maybe if I had more confidence to give my opinion this would not have happened, but on prac, I tend to just agree with what the supervising physiotherapist advises because most of the time they know best!

The dilemma in this experience is to know where your boundaries as a student is. Physiotherapists have different approaches to situations and they all work well but as a student, how do we know which approach to take? When I did present my subjective and objective to the physiotherapist, they would ask me my thoughts for intervention and I had to change my answer depending on what I knew they wanted to hear. I am not sure if this is the best way to handle this but I try stay away from confrontation especially with the supervisors who decide whether I pass or fail!! Next time, I will try and be more assertive, giving my rationale for my intervention and be more confidant.

If anyone has any advice on how to handle this situation please let me know.

Paeds placement

So here we are again, beginning another new placement at a new facility. I’m currently on my paeds placement on an oncology ward. On previous placements, I’ve learnt to come to terms with the likelihood of death among some of the patients we’re treating, but this placement is different. Now it’s literally helpless, innocent children facing a high risk of the worst prognosis.

In the first week of being on this ward, there have been two deaths of children under the age of five who lost their battles with cancer. I hadn’t met either of these patients, but I saw the impact it had on the rest of the staff on the interdisciplinary team who had been treating these kids and it was pretty harsh. I felt such sorrow for the families and was quite affected by the news and I hadn’t even met the children – How will I react if one of my patients passes away? All my patient’s on this prac so far seem like remarkably courageous kids and I’m amazed at how the patients and their families cope with everything from accepting the diagnosis, to getting through all the radiation therapy and chemo, and then all the rehab that follows.

Death is an issue in a lot of areas of inpatient physiotherapy, but I say it’s more prominent in this area. I hope that I have the strength and professionalism to deal with all the issues appropriately and I think I should be able to manage this by focusing on tasks as they come up and approaching my supervisors for assistance as necessary. Any other tips on this sort of stuff are appreciated!

tough physio

While on a paediatric placement I made some observations that brought me to the conclusion that it is often best to be tough on a child with a disability. Initailly I found the misfortune of young chilren with severe disabilities sad, however, children with disabilities have to try even harder than other children in order to achieve goals and create indepencence. I believe it does the children no favours if anyone (including their physiotherapist) is too soft on them. During placement I saw many children from different types of families with different dynamics, but two contrasting situations spring to mind.

Both children concerned were 4 year olds with quadriplegic cerebral palsy. The mother of one child appeared to do everything for the child and treat her like a baby. The mother would pick the child up and carry her in from the car (breaking her back) rather than using the stroller. This child was generally constantly fussed over. The child, as disabled as she was, had some significant behavioural issues which included intentionally eliciting a strong atonic neck reflex which she used to pull her hair out in order to gain attention.

The other child came from a family with 7 brothers and sisters. His mother did the opposite of fuss over any of her children. Some staff at the therapy centre would roll their eyes at how laid back a mother she was, saying that "the children just get left to themselves." This did not seem to be to the child's detriment as he was always willing to try a task. He did not engage in inappropriate attention seeking behaviour and attempted to help himself out of tricky situations. He was a surprisingly funcitonal boy in spit of his disability and had increadibly good motor planning skills.

the frontier of medicine - antibiotics

Recently whilst on a placement in ICU, I was faced with the overwhelming sight of the frontier of medicine, where medical knowledge ends and the unknown begins! It is a scary feeling sitting in a meeting watching doctors put their hands in the air as to the decision for a patients diagnosis and therefore treatment plan. Asking questions yourself that no one can answer. It leads you to reflect on the evolution of medicine, seeing patients transferred to the ward, conscious and breathing that if they had presented to hospital a year earlier than they did, may not have lived. Another scare I got whilst on this placement, is the theory and practice behind antibiotics. So many people I know take antibiotics at the drop of a hat, without thinking about what they are actually doing. Antibiotics provide the body with the tools to fight bacteria. If the bacteria is known the antibiotic can be specific. If not a broad spectrum antibiotic is used. I recently attended an information session about antibiotics and their use. They are very relevant to the acute respiratory treatment of patients. You don't find the right antibiotic then the chest can deteriorate and our work becomes harder. The greater the use of antibiotics, the more exposure the bugs have to our fighting weapons, the more chance they have at developing resistance. We only have one more known type of antibiotics left, this is all we have up our sleeve at the moment should bacteria develop, as they have begun to, resistance to all other types. Bacteria are mutating, resisting and killing people in ICU everyday, and all we have left is one type. A back plan of one type. Whoever is given the job to decide when it is appropriate to crack open the last vile of this antibiotic has a challenge at hand. The world of tiny bacteria is huge and scary. I believe antibiotic therapy in the community should be more conservative. We are showing off our weapons too readily to the bugs and may eventually loose the war!

Dinka child birth

I am currently on a women's health prac. I recently treated a woman one day after the birth of her second child. She was African, had very little English and required an interpreter for treatment. This interpreter however, was her husband. This proved difficult in the context of her culture as questions involved in postnatal assessment make reference to bladder and bowel habits and vaginal sensations. Topics as such are not often discussed between husband and wife in the Dinka culture. Assessment proved difficult, the patients was not willing to disclose any information to her husband and in turn us about continence issues or pain. Everything was fine, as in their culture women are made to have babies so they must grin and bear any complications. The most difficult thing when treating this patient was digesting the frustration involved in knowing that we could have treated her and given her a lot of relief. We are helpful and caring people but we also need to realise that we cant make everyone better and sometimes just need to walk away and respect that not all cultures accept modern medicine with open arms like ours does.