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.

emotional involvement

Being human is an often difficult thing to turn on and off when treating patients on the verge of life and death. Emotional attachment creeps up on you in the dark whilst working in Intensive Care. Without even knowing it you are starting to put emotional energy into a patient and becoming attached.
Recently while on a placement in Intensive care, I was involved in the twice daily treatment of a young girl with GB. I first saw her when she was admitted to intensive care following a five day history of neurological deterioration. She was ventilated and sedated and continuing to deteriorate when I began my acute respiratory care. Intensive care is a place that easily numbs you, you get excited when one of your patients can talk, so the argument can be fought either way - the lack of emotional interaction with the patient makes you less likely to become attached OR the critical situations the patients are in and the frequency of treatment makes you more susceptible.
I felt for this girl just after reading her file, meeting her and treating her twice daily faced me with a big challenge - to treat her as 'just another patient'. All patients are entitled to the same service. Finding the balance between being her friend and being her physiotherapists was the challenge.
So this patient began to improve, her sedation was reduced and her communication became frustrating. The muscular control of her jaw and lips made it difficult to lip read post trache insertion. She was becoming very frustrated, a deterioration over five days from a normal girl to not being able to move, breath for her self, communicate! I went out of my way to find some sort of communication tool we could point to and she could nod and spell out words etc.
I found myself going out of my way a few more times for various other things, and then realised my balance was out, I was becoming too emotionally involved.
So this lesson, amongst many, has taught me more about the balance involved in patient care. The balance between treating a patient and treating a person.

Elderly patient

In my rheumatology outpatients placement, an elderly lady was referred to me regarding core stability exercises and balance. This needed to be addressed because she had previous falls and because lived by herself and wanted her independence. Because she was a new patient, a full subjective and objective assessment was carried out but just the subjective alone took 45minutes!! Every question I asked was answered with a story and she tended to loose concentration and talk about another topic. I did interrupt her once or twice, but did not want to appear rude so just smiled and nodded. I understand that she was lonely because she did not get out of her house often but her objective and treatment time was shortened because of the lengthy subjective assessment.

When asking questions, I found it hard to ask specific questions that wouldn't confuse her but at the same time are not leading questions. It made me feel a bit helpless because I was not really in control of the assessment, instead was listening to a story about her pet cat! It probably occur ed because I need more practice in politely interrupting, or maybe asking more concise questions. This experience taught me that the questions that we ask our patients are important. We don't want to be rude but at the same time we do want to give the most optimal treatment to our patients. In the future I will try and guide the conversation and take control of the session by changing the questions I ask. If anyone has any ideas on how to steer the conversation onto the right track please let me know!!!

Doctor's can be Deceiving ... (not intentionally)

While on my musculoskeletal placement earlier in the year, I had a patient who was a young 12 year old girl who’s reason for coming to physio was knee pain. I had the doctor’s referral and had read through it, discovering that the doctor thought girl’s knee pain was indicative of patellofemoral dysfunction and I was asked to treat as appropriate. Simple! Or not…

When the patient presented to physio, she walked into treatment from the waiting room with a very peculiar gait pattern. I went through the subjective with the patient and although the patient was a bit vague with her answers, it was sounding like PFJ dysfunction. Then, when running through the general health questions towards the end of the subjective, I was ticking off my checklist and came to Arthritis. I was expecting this 12 yo to give a simple ‘No’ in response, but instead she said ‘Hmm yeh I think I do have arthritis”. I was puzzled and explained to her that it generally affects the older population when it suddenly hit me that she may have Juvenile Arthritis. I mentioned this term to her and she nodded and said that yes doctors had told her in the past that she had this condition. So after further investigation and discussion with the girl’s mum, I discovered that she had been diagnosed with JA a few years ago but after a few attempts at treatment, nothing had been successful and the family were experiencing difficulties with medical staff and decided to stop any ongoing treatment.

I was disappointed that this young girl was not receiving treatment for her condition. She had contractures in both legs which limited her dorsiflexion range so much that it affected her gait and was contributing to her knee pain – it wasn’t simply PFJ dysfunction. I was shocked that the diagnosis wasn’t mentioned in the doctor’s referral. So anyway, in the short time that I had to treat the patient before finishing my placement, I treated her to the best of my ability and worked hard to build a good rapport with her in hope of convincing her and her mother that we health professionals aren’t so bad and to seek further treatment, as it would benefit her greatly. There were other factors involved too, like diet issues and possible psychological effects which were understandable, so it was important to get the appropriate referrals for these issues as well.

This situation taught me a few things. One: Never assume the doctor’s referral is correct (I knew this already, but I didn’t expect a diagnosis of JA would be left out…). Two: Always include all of the general questions in the subjective, even if you assume the answers to be ‘No’. I hope the students after me were able to continue this patient’s treatment effectively and achieve some good results.

Partners who Interpret

In my elective placement, I am currently treating a Russian man who had a knee arthroscopy in February and still has moderate pain in his knee when walking and with straightening his leg. His wife come every session and interprets for him. After his operation in Feb, his wife reports that he was not given any exercises and instead just stayed in bed for a few days without moving his leg. Normally post knee arthroscopy patients are given knee flexion and extension exercises and given education on active rest and post op instructions.

After talking to my supervisor about this anomaly, he suggested that maybe after the operation, the education and and exercises might have been taught to the man without his wife present. This affected my treatment because I had to be sure to involve his wife and to make sure to explain the benefits of the exercises to her so they will perform the exercises at home and be more receptive to the treatment they receive from me.

From this situation, I learnt that even if a patient may be nodding and agreeing during a treatment, it does not mean they fully understand and making sure that you get the patient to demonstrate the exercise is important. In patients that need an interpreter, especially if it is their partner, making sure to involve them in the treatment is very important because they are the people that will make the patient perform the exercises and adhere to the program.

Anyone else running out of ideas for blogs??

While on a musculo placement recently, I was treating a 23 year old male who had undergone an ACL reconstruction. He developed subclinical septic arthritis 8 months post surgery and had to have his knee drained twice in a matter of days to reduce the swelling. He presented to physio with a hugely swollen knee and decreased range of motion with low pain levels. I started him on an ex program including cycling as a gentle ROM ex. The first time he did the bike with me in physio, he didn’t complain of any pain or altered sensation. However the next session when he rode the bike, he complained of some dull pain and numbness in his anterior tibials, calf and the sensation travelled further down into his foot. The patient was quite vague and disinterested in this pain and I wasn’t sure whether to take much notice of it, though I was querying circulation/nerve compression issues.

To be safe, I asked one of the physio’s to come in and have a look to give a second opinion. She was shocked at the size of the patient’s knee, she did a quick assessment and then got yet another physio in for a third opinion. The third physio also did some assessment and agreed that it was likely there were some claudication issues present and instructed me to write a letter to the patient’s orthopaedic specialist immediately suggesting an MRI be carried out for further investigation and to closely observe the patient’s claudication signs.

After all that, I was very glad that I had checked with the physio the extent of the issue, and in future will be more comfortable with asking for second and third opinions to ensure the safety of the patient.

Allied Health

I am currently on my elective placement and spend a lot of time on the ward treating patients that have been admitted for various rheumatology conditions. From my time on the ward, I have found out the importance of communication with other allied professionals.

For one particular patient, she had been admitted for a rheumatoid arthritis flare and needed physiotherapy and hydrotherapy for her stay in hospital. Due to her complex social history, regular meeting were held to work out a plan for discharge for this patient. Before this placement, I had never been to a ward meeting or had liaised with the doctor to this extent. When there was a problem with the patient and I was needing some input, I found it very helpful to talk to the doctor or occupational therapy and listen to their view of the situation. It was good because it made me see how important physiotherapy input is and to see how the doctors, nurses and occupational therapist's respect your opinion.

Becoming more involved in the ward and taking responsibility of my patient make me realise that talking and seeking opinions from other professionals is very helpful when dealing with patients because if helps you see the situations from different views and most of the time they are happy to help out. This placement has been very helpful in showing the value of communication with other members of allied health. They are can help us in difficult situations or when we are unsure of anything because they can give their opinion and might be able to give a variety of approaches. In the future I will make sure I liaise with other professionals and I am grateful for the benefits from talking with them.

Hesitate to discharge patient

I am currently doing my musculo placement. It has been interesting so far, but sometimes I am unsure whether discharge a patient. Most of my patients are referred from public hospital and they don’t need to pay for treatment. Some are private patients who need to pay. Interestingly I found that private patients’ pain level is relatively lower than public patients’. Regardless of a public or private patient, patients report that pain is decreased and get better after treatment. When it comes close to discharge I asked to patients to discharge them who is from public hospital, public patients seems to be a bit more reluctant to be discharged due to high pain level. I provide same treatment to both groups of patients, private or public. Private patients stop making appointment once pain level is lower.
It may be not correct for all the patients from public hospital but sometimes I felt strongly from some patients.
Do you have any good idea to discharge that sort of patients?

for clinical decision

I am currently on my first placement for musculo-clinic. So far it has been quite interesting for me because I have patients with a lot of different conditions such as shoulder pain, knee pain, and LBP et. I found that manual therapy is so important in some cases to promote healing processing. One of my patients told me that she has been to other physio clinic, but what she had for treatment is only ultrasound and she didn’t feel better. I think main different treatment between previous clinic and this clinic is approaching method, U/S and mobilization with enough time to treat. After few sessions the patient’s symptom, pain, settles down and she is really happy with that.
That makes me feel happy as well.
However, on the other hand, as you guys know if you are paying for the treatment, $60 or more than that, you want to get better as quickly as possible and save the money. Because of that, sometimes physio has to decide the best way to decrease symptoms quickly but I think it is really hard. If the treatment is not effective, some patients won’t be coming back again to your clinic after first treatment session even though you have a lot of other treatment options and they are going to think you are a bad therapist.

I think there is no short-cut way to improve the clinical decision except experience.

I want to be a good therapist who don’t listen bad comment behind of back.

P.s And anyone know how often physio use U/S or H/P in private clinic in Australia?

Optimistic attitude

This week, I treated an amputee in the gym, 6 months post op. This young woman had been in a MVA and lost her leg. The accident was not her fault and instead of being bitter towards the other driver, she had a wonderful attitude and was very motivated for her rehab. Her recovery was going very well and she was progressing faster than expected. I know this might not solely be due to her attitude but I believe it played a very big part in her speedy recovery. From the other patients I had encountered in previous weeks, she was the most inspiring patient, always having a positive attitude even in bad circumstances.

I was very inspired by this patient and it made me feel encouraged in doing physiotherapy because she was so grateful for the input we were giving. I decided to share this encounter with everyone because it was so refreshing to see a patient that did not blame others (even though she of all people had the right to blame others) and was motivated and thankful for the rehab that she was given.

I think this experience was very beneficial to me because after treating her instead of feeling sorry for her, I felt like she had encouraged me and she had changed my perspective on life. The problems that I had were so insignificant compared to hers and yet she had a more optimistic attitude and managed to see the best in her situation. I hope to treat a lot more patient like her and to maybe make a change in my own attitude when encountering problems!!

Hitting that red button

Whilst on an orthopaedic inpatients prac having already experienced a patient having a TIA that morning i was trying to calm myself down from the dramas of the morning and focus back on treating my other patients. I went in to see my next patient who was only 56 and therefore considered a low risk of complications for surgery so i was told to see her alone. Day 1 post surgery following the pathway i checked she was medically stable then with the help of the patients nurse walked her to the shower and back.

On returning from the shower the patient as she sat back on the bed reported she was feeling dizzy. After trying to remain calm and remember this is normal post surgery and not to panic as this mornings event were a rarity, i encouraged the patient to take some deep breaths then lie back into bed. As the patient got back into bed she reported she was going to be sick so i reached for the sick bag and she started to vomit. She had just started to vomit and then she became unresponsive and fell back into the supine position. The nurse and i looked at each other an realised the seriousness of the situation. I directed the nurse to help me lay the patient on her side so she didnt choke on her vomit and i looked the that red button. The medical team were already frustrated that we has called an emergency this morning when they felt it was unnecessary so i was reluctant to call them again. i stared at the button for what felt like for ever and debated whether i should hit it. i reached out an hit the button and then the nurse and i stood back helplessly at the patient who was still unresponsive. The patient then opened her eyes and began the same conversation she was having prior to the vasovagal episode as if nothing had happened. the medical team came rushing in a little quicker than they had earlier that morning to see the same scene of the patient chatting away in bed and were again angry they had been called for nothing.

Looking back i am glad i reacted the way i did, you always wonder how you will react in a crisis and i is good to know that i did react, i acted. Although the medical team were not required i feel it was better to be safe than to not have acted and something serious have happened. Although at the time terrifying i am glad i experienced this situation so i have seen an emergency and dealt with it.

Autopilot- a Medical emergency

Whilst recently on an orthopaedic outpatients prac  in a secondary hospital i had settled into the sleepy ward where patients were put on pathways and each day the plan was already dictated for you. Each day was much like the one before it and i had flipped over to auto pilot. A normal day on the ward saw me having 4 TKR patients to see for the day. The first we were conducting a routine day 1 where we were walking the patient to the shower. Prior to treatment the patients obs had been checked and medically the patient was stable. On entering the bathroom the patient reported he felt slightly dizzy. This being a completely normal response when a patient gets out of bed day one we calmly told the patient to make his way to the shower where he could sit. After his next step the patient began having a TIA where his left hand was gripping the crutch and his right arm had gone into a flexor synergy and right side of his face drooping. My supervisor who had seen this before grabbed the comode chair and we guided the patient onto it the nursing staff hit the emergency button but no one came so we rushed the patient back into his room and four of us lifted him into bed. The instant that the patient was supine the patient returned to normal and sat up in bed asking how he got back from the shower and why there were so many people in his room.

A few minutes later the medical team strolled in to see the patient chatting to us in bed and asked why the emergency button had been pressed. We explained the situation but they were unable to comprehend the seriousness due to the patients normal appearance. For all of us that had experienced the situation we were extremely angry that the medical team were not able to see the seriousness of the incident that had just happened. For me as a student i was amazed at how something that is so routine can change so quickly, dizziness and nausea post surgery is very common and it is impossible to have picked the situation unfolding this way.  My supervisor assured me i had done nothing wrong the patient was stable prior to the intervention, dizziness is normal could have done nothing to prevent the situation from occuring.

This was a huge situation to show how routine this environment can become for everyone, the medical team strolling in demonstrated their casual response to a medical emergency. As the ward is in a secondary hospital where there are very rarely complications, people are slow to react in an emergency. There was no crash cart, people finished what they were doing and then slowly made their way to the room where the alarm had sounded, everyone was on autopilot.

This situation has made me realise that no matter how comfortable you are with what you are doing and how routine it becomes, each situation needs to be treated as a separate experience. It has show me the dangers of autopilot. 

Soldier with some issues

I recently completed my rural placement at an army barracks physiotherapy department. One of my patients was an army mechanic who presented with knee pain and a history of ITB friction/impingement syndrome. On clinical assessment, it turned out his main problem was now meniscal damage. The patient was quiet and vague during subjective assessment, and anxious and highly irritable during objective assessment. His nervousness and anxiety continued as myself and a senior physio explained that it was likely he would need surgery. The patient was opposed to this idea and wanted to learn more about other options. I prescribed gentle ROM exercises and booked an appointment with him for the next day.

I spoke with the senior physio afterwards and he explained to me the importance of developing a good rapport with patients like this because there were obviously other factors contributing to this patient’s anxiety that we were yet to find out.

So the next day I was with the patient by myself and had a treatment plan prepared to work through with the patient. But when I sat down with him in the treatment room, the patient appeared much more relaxed than the day before and more prepared to chat. So I dug a little deeper, and found out that the patient’s partner was pregnant and due and any moment, and that his mother had a history of multiple surgeries which had resulted in many complications… This explained a lot about why he was so apprehensive about having surgery and had wanted to know specific timeframes for recovery because he was worried about how he would look after his family. My treatment plan went out the window and I just spent the whole session just chatting with him and explaining the simplicity of the surgery and although he was still hesitant, he seemed to relax a lot and appeared a lot more comfortable about the situation.

I thought this was a good example of the importance of developing a good rapport with your patient and getting their complete social history!