Tuesday, September 30, 2008
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.
Monday, September 29, 2008
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.
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.
Friday, September 26, 2008
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.
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.
- 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.
Thursday, September 18, 2008
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.
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.
Wednesday, September 17, 2008
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
Tuesday, September 16, 2008
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.
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
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.
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.
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.
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.
Monday, September 15, 2008
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.
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.
Tuesday, September 9, 2008
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
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.
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.
Sunday, September 7, 2008
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?
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.
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.
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.
Tuesday, September 2, 2008
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!
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!
Monday, September 1, 2008
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.
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!
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!
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