Group classes

While on my rural placement, I was involved in running Stay on Your Feet exercise classes numerous times a week. One of the classes was targeted at individuals with a lower functional level so the class was performed mostly in sitting. I was running these classes quite well, with good participation from all individuals. However on one session I decided to vary the routine somewhat as a bit of a change. The new components added more overhead upper limb movements, with all individuals completing these components. After the class some participants commented that they had shoulder problems and the added components were too strenuous.

The next session I reduced the time spent in these overhead upper limb activities and this was received well by the participants. From this experience I have realised that in the group setting it is imperative to always state at the beginning of the class that some activities may not be able to be completed by individuals who have particular injuries and that it is ok for them to sit out that activity or complete an alternative option. It also high lighted the importance of watching for signs that individuals are struggling with exercises and alter the exercise program accordingly. In the future I will always offer alternative exercises for activities that may be challenging and remind participants not to complete exercises that cause pain or discomfort.

Look at the bigger picture

In my rural placement, I had a 16 year old patient who had undergone an ACL repair about 8 weeks ago and is now attending outpatient rehab classes. He did his ACL while playing cricket for the school team. Each time he came to rehab, his only question is when can I start cricket again. He was someone who is not really vigilant with HEP and is really desperate to get back to his games. I explained to him that his knee needs time to heal and returning to cricket has to be a gradual process. Each time he came he complained of a knee pain but subjectively reported no change of his activities over the week. His progress was much slower than you would expect for someone at that age who had undergone an ACL repair. His muscle was still weak, he still had poor proprioception, some swelling around the knee and his range had plateud.

After the second session with him, I had a discussion with my supervisor as I suspected something just did not quite add up to the picture. I gave the mum a call and asked her some clarifying questions and all she said is that he still doesn’t do much. Just few days after that, I had another patient who goes to the same school as him asked how is his knee and I told him I can’t really discuss other patient with him. Then he responded jokingly, it must be doing well because he plays cricket now but he plays like a looser. Immediately the picture added up. So the next time he attended rehab, I asked him in an appropriate manner not to make him feel like I am accusing him. He eventually admitted that he started cricket about 3 weeks ago and since then he’s been having the knee pain. I then gave him an intensive education session and told him that if he does not back off from his sport he is going to damage the repairs and potentially not able to ever return to his sport again. He seemed like he had understood me as he said he is going to try and be a bit more active in his rehab. From then on, his swelling reduced and his knee range started improving.

This encounter had highlighted the importance of looking at things at the bigger picture and making sure that it all adds up. It is important to realize that when a patient is not progressing, we have to try and seek the barrier to this so that we are able to achieve better outcomes in the rehabilitation process and prevent any potential risk of further injury.

Treat them all the same.

During my neuro placement, I had a new patient and the handover notes was that the patient was a prisoner in shackles, he had two prison guards with him 24/7 and was a left hemiplegia with no sitting balance. The notes also did mention about him having a psych review and that he was diagnosed with bipolar disorder and mild psychosis.

This is my first time having to treat a prisoner in shackles and that really made me worried. We had to get permission from the prison authorities to unshackle the patient for rehabilitation and that made me worried as I had all the “what if’s” running through my head. Well, I tried to calm myself down and felt that if I treated him just like any other patient I will do fine and besides, if anything happens there is two guards to help restrain him. When I met him, I introduced myself and gave him a brief explanation of what the treatment is going to consist of. He did not respond much to what I had said and just looked away. Then I asked him, if he had anything bothering him and his reply was, “like you care”. That is the first time I had met a patient who spoke that way. I then just said politely to him, I’m only here to help and I need him to allow me to. So I asked him again, if he has any concerns? Then he said that his neck been hurting for a week now and it disturbs his sleep at night. I then decided to assess and treat his neck before looking at his sitting balance. He then became more interactive and looked pleased that I actually listened to his concerns and acted upon them. He then appeared more compliant to the treatment session which I thought was impossible at the beginning of the treatment just by the way he appeared to me. He then became a patient in my caseload for the next two weeks I was there. He became more and more compliant each session and this helped his rehabilitation progress smoothly. By the end of the two weeks we achieved sitting balance and I started working on standing balance.

This was an invaluable experience. It had thought me the importance of treating each patient with dignity and respect regardless of what their background is in order to have a positive contribution to the rehab process. Just by listening to him and making him feel that his concerns were important, he became a more compliant patient.

Do whatever it takes..

I was in paediatrics unit in my rural prac. One of the greatest challenges I faced was to create compliance of a paediatric client. It was my first time working in this area and I thought to myself, they’re only kids how hard can it get. Then I had my first patient and the notes read.. a bit of autism and a bit of developmental delay. Well, how different can they be to other kids? So I started doing assessment like I would normally do and 5 minutes into the session things started to fall apart. The little boy started to cry and just wanted to do his stuff, like pretend to fly. I was frustrated because I was thrown into the deep end left to figure things out for myself for the first time. So I kept myself together and thought to myself that I have to take control of the situation before it gets me. So i went with the flow and played with him. By playing with him I actually won him over for another 5 minutes. So I tried my best, modified every single assessment to make it “fun” and it was not easy.

Can you imagine, having to think of a way to modify assessment for muscle strength and endurance of the UL, LL and trunk turning it into something outstandingly “fun”? So I started using cartoon characters like superman and spiderman then doing some animal walks to test trunk strength and endurance. Just I was getting somewhere with the assessment, a sudden machinery noise started coming from the construction site nearby. The mother looked like she had given up not knowing what to do as well. I remembered reading somewhere that some autistic kids are affected terribly by unfamiliar noises. I quickly went and found some headphones to try and filter the noise out for him. It worked but only for a short time, enough for me to at least finish the last part of my assessment so that I could device a program to address the delay in his gross motor skills.

Form this experience I’ve learnt that things do not always go according to plan and that I have to be flexible with whatever challenges I face during a session with a client. I must be able to think and act promptly in difficult situations so that I am able to maximise the limited time I have with clients to gain sufficient information through an assessment. In this case, perserverance did pay off as I was able to gain enough information to provide a treatment strategy.

"I don't feel I am improving"

On my musculoskeletal outpatients placement, I had a patient who presented with lower back pain, with the main aggravating factor being prolonged sitting (approximately 30 minutes). My treatment and management with this patient involved mobilisations and postural retraining.


About 3 weeks from her initial visit, I began with my subjective assessment to see how she is progressing. She stated that she did not feel that she was improving, as the intensity of her pain was at a similar level as when she first started physiotherapy. I thought to myself that she must have had some improvement, as she has been having treatment for the past 3 weeks. I then decided to focus on the aggravating factors, and asked her how long can she stay in sitting until the pain increases. She then stated that she was able to sit comfortably for longer than that of the initial session (approximately 1 hr), making her realise that she has made some improvement.

I FEEL THAT MONITORING THE PATIENTS RESPONSE TO TREATMENT FROM THE PATIENT'S PERSPECTIVE AND GOAL SETTING WILL HELP GIVE THE PATIENT AN IDEA ON HOW MUCH THEY ARE IMPROVING, THEREFORE MAINTAINING THEIR FAITH IN PHYSIOTHERAPY TREATMENT. IN THE FUTURE, I WILL CONTINUE TO THINK ABOUT PATIENT'S GOALS AND THEIR FUNCTIONAL LIMITATIONS IN TERMS OF MONITORING RESPONSE TO TREATMENT, THUS, HOPEFULLY INCREASING PATIENT SATISFACTION.

Telling the patient the purpose of your treatment

On one of my placements, I encountered a patient with cerebellar atrophy who was quite anxious. Consequently, his major problem was impaired balance. Therefore my treatment was based around improving his balance. To progress the patient, I would challenge his balance by reducing the base of support, adding a soft surface, eyes closed etc.

As the tasks increased in difficulty, the patient would be less compliant, and say comments like "I can't do that, I'll be too wobbly", I woud then reassure him and tell him that I wasn't going to let him fall. As I would try new positions, he required more convincing to try and get him to comply. I then decided to explain to him that the purpose of these exercises were to use positions which will challenge his balance, and will make him feel somewhat unsteady, as there is no point in practicing balance in a position where he can maintain his balance quite easily. I felt that once he understood the purpose of my treatment, he became more compliant.

THIS SITUATION HIGHLIGHTED THE IMPORTANCE OF THE PATIENT KNOWING THE PURPOSE OF TREATMENTS. I FEEL THAT IF THE PATIENT KNOWS WHY A CERTAIN EXERCISE MAKES HIM/HER FEEL UNSTEADY, OR CERTAIN TREATMENT TECHNIQUES CAN BE SLIGHTLY PAINFULL, HE/SHE WILL BE MORE COMPLIANT WITH PHYSIOTHERAPY, THUS MAXIMISING THE TREATMENT OUTCOME.

Discharge planning

On my rural placement, I had an eldery patient who presented with an exacerbation of COPD. Considering discharge planning, I came to the conclusion that if she were to go home, she would have to be fully independent, as she does not always have someone with her at home. Throughout her stay in hospital, she was often non compliant with physiotherapy, and refused walks several times.

When she was for discharge from a medical point of view, I was unsure how well she was able to ambulate, thus, I was not sure if she was safe for discharge from a physiotherapy point of view. The patient refused a mobility assessment, and I was not surprised, as she had refused to ambulate prior to this. I decided to use her going home as motivation to ambulate, and explained to her that she can only go home once she is deemed safe from a physiotherapy point of view. In doing so, she agreed on a mobility assessment.

NOT ONLY DOES THIS HIGHLIGHT THE NEED FOR EXPLANATIONS ON CERTAIN INTERVENTIONS, BUT ALSO THE IMPACT MOTIVATION CAN HAVE ON A PATIENT. IN THE FUTURE, I WILL SET GOALS FOR THE PATIENT, AND USE MOTIVATIONAL TOOLS TO IMPROVE PATIENT COMPLIANCE AND SATISFACTION FROM TREATMENTS.

What is better for the patient?

On my neuro placement, I had a patient who was about 4-5 days post R MCA. At this stage, the patient was still occasionally quite drowsy. Nevertheless, I took her to the gym for some rehabilitation. As it is still her early stages of recovery, the patient was quite fatigued by the end of the session.

From a physiotherapy point of view, we like out patients sitting out of bed whenever possible, as it is a much better position for there chest, and alignment. On discussion with the nursing staff, they suggested to put her back in bed as the patient was feeling tired. After my supervisor and I gave the nurse our justification for sitting out of bed (better for her chest, better for her trunk alignment etc) we decided on keeping the patient in the wheelchair for a little while.

I LEARNT THAT LIAISING WITH OTHER HEALTH PROFESSIONALS AND GIVING OUR JUSTIFICATION IS AN IMPORTANT FACTOR IN THE TREATMENT AND MANAGEMENT OF A PATIENT. I WILL CONTINUE TO GIVE MY RATIONALE FOR DIFFERENT ASPECTS OF MY MANAGEMENT NOT ONLY TO THE PATIENT, BUT TO OTHER ALLIED HEALTH STAFF, TO ALLOW A BETTER RECOVERY FOR THE PATIENTS.

Using different instructions

In my neuro placement, I was working on sitting balance with 2 different patients, both left hemis. My treatment mainly focused on promoting anterior pelvic tilt with these patients.

For one of these patients, i was using cues such as "grow tall", and that worked quite well with her. I tried to use the same cue for the other patient, and that wasn't so successful, as it did not encourage him to anteriorly tilt his pelvis. I found that using the cue "chest out" worked much better in promoting anterior pelvic tilt with this patient.

AFTER THIS INCIDENT, I LEARNT THAT DIFFERENT PATIENTS CAN REACT DIFFERENTLY TO DIFFERENT VERBAL INSTRUCTIONS, ESPECIALLY NEUROLOGICAL PATIENTS. IN THE FUTURE, I WILL DETERMINE WHICH INSTRUCTIONS SUIT THE PATIENT BEST, AND USE IT WHEN TREATING THE PATIENT.

Pulse

On my rural placement I was treating orthopaedic inpatients. As most of you probably are aware by now, orthopaedic inpatients are very repetitive as it follows the post op routines as per each surgeon. Anyway, I was heading into a TKR patients room to walk him for the first time to the bathroom, and had seen him the day before in which he coped well at standing. The patient reported feeling well, nil complaints voiced. He was no longer on oxygen and all attachments removed. I checked his nursing charts which showed obs stable. I thought I should check them myself to get an immediate reading and for precaution. His oxygen and BP were normal, however his pulse rate was racing at 160 BPM!!! I was surprised, all other readings were fine, the patient was asymptomatic, and in fact the pt was quite cheerful. It was a little strange. I took his pulse manually, it was definitely high.

I decided not to walk him at this stage, and informed him why. I let his nurse know immediately. The patient was later taken to ED for a couple of hours, and his meds changed. He later returned to the ward, in which I was able to ambulate him to the bathroom when all his obs were stable.

This scenario highlighted to me the importance of checking stats prior to ambulating post op patients, even if the nursing obs are normal. Also, patients may be asymptomatic, therefore relying solely on pt responses is not adequate. I also feel that, with orthopaedic inpatients there is so much emphasis on checking Hb, Bp and oxygen that pulse rate gets a little ignored. In future I will take the extra 1 minute to take current obs of a patient that is post op as I have done in this scenario.

bad habbits

Whist on my rural placement I was treating a patient who had pneumonia. He had a 60 yr history of smoking and refused to quit while in hospital. Every day when I went to see him it would be a struggle to get him to complete any exercises and when he did he was quite negative towards the exercises and report that he just wanted to go home. I begun to develop an unenthusiastic mind set towards the patient and I found I would regularly tell him that he should consider quitting smoking and I was less motivational with my response towards treatment. I realised what was happening to y behaviour and decided to change my outlook towards the patient in a manner that I was required to educate him.

Everything I completed with him I educated him on the benefits of how he was going to return home sooner if he completed the exercises. In addition, I educated him on the negative effect s of smoking and the positive effects of quitting. We discussed options to help him quit and he begun to have a more positive approach towards quitting.
When the patient was D/C he still had not decided to quit smoking but was more aware of the options that are available to him.

I HAVE LEARNT THAT SOME HABITS ARE HARD TO BREAK AND EVEN IF THEY ARE HABITS THAT YOU CANNOT STAND, AS A PROFESSIONAL THE BEST YOU CAN DO IS EDUCATE THE PATIENT ON THE POSITIVES OF CEASING THAT HABBIT. IF I HAD ANOTHER PATIENT WHO WAS A LONG TERM SMOKER AND WAS NOT KEEN TO QUIT, I WILL ENSURE THAT I USE MY KNOWLEDGE TO GIVE THE CORRECT ADVICE, SUPPORT AND EDUCATION TO QUIT RATHER THAN DEVELOPING NEGATIVE BEHAVIOURS.

Team work

Whilst on my rural placement I was required to complete an initial assessment on a stroke patient. When I asked for a copy of particular stroke assessment the physiotherapist said that they did not have a copy of it. Being a regularly used stroke assessment I was surprised that they had not used it in the past and questioned their supply of resources to run a rehabilitation ward. I was able to access the university website and gain a copy of the assessment and complied a file of the assessment and other commonly used assessments.

At first I was taken aback by the lack of resources that the ward had and annoyed that I had to create a resource file. Although, I did not take into consideration that it was a rural hospital and it was a project to complete to benefit the other physiotherapists as well as the patients.

I BELIEVE THAT IT IS IMPORTANT TO BE ACTIVE IN CREATING AN EFFECTIVE AND WELL RESOURCED WORKING DEPARTMENT. IF WE ALL JUST SAID THAT WE COULD NOT BE ‘BOTHERED’ TO CREATE SUCH RESOURCES THEN THE DEVELOPMENT OF THE DEPARTMENT WOULD NOT EXIST. IF I HAD TO CREATE OR SERACH FOR ANOTHER RESOURCE AGAIN I WOULD HAPPILY DO SO KEEPING IN MIND THE ADVANTAGE OF TEAM COLABERTAION AND INPUT.

Full picture

Whilst on my paediatric placement I was treating a child with CF who was admitted quite frequently for tune ups, I had been told before I'd seen him that he was a bit of a difficult child and there were some social issues due to family problems.
On treating the patient I found that he had some behavioural problems but after developing a good rapport with him I found it quite easy to get the desired result from treatment.
This went on for several days and treatment session were going well, this was until an afternoon treatment session were I took the patient to the physio gym for some exercise. The exercise involved playing various games something which the patient usually enjoyed and was compliant with. On taking the patient to the gym I noticed that he wasn't his usual self he was a bit quitter than usual and just didn't seem as happy. Starting the gym session the patient was very difficult not wanting to play any of the games he had enjoyed previously. The session was completed and the desired outcome of the session had not been achieved, on reflecting about what had happened with my supervisor it had come to light that the patients mother hadn't visited or phoned the patient that morning, and that this may have been the cause for the misbehaviour during the treatment session.

FOLLOWING THIS INCIDENT IT MADE ME LEARN THAT I HAD TO LOOK AT THE PATIENTS MORE HOLISTICALLY PROBABLY MORE IMPORTANTLY IN A PAEDIATRIC SETTING AS THE ROLE AND INTERACTION OF FAMILIES WAS A LARGE PART IN HOW A CHILD WOULD BEHAVE.

Getting out of the comfort zone,Make the most of every opportunity

Whilst on my rural prac I had the opportunity to do some after hours work this included a taping session for a local junior soccer team. Given the choice of whether or not to be involved I was more than happy to be a part of it and being a part of it then became me organizing the material for the presentation and running the presentation session.
At first I was a bit apprehensive about running the whole session as I was in a a different place a bit out of the comfort zone, however I persevered. I devised a plan of what to include in the session and this was basic information on first aid and whether taping was appropriate, basic taping methods and also warnings about taping. After spending a few days preparing the material I felt I had a pretty decent presentation on my hands now all I had to do was run the session.
The night of the presentation came around and I must say there were a few butterflies flying around. Once i began though everything ran smoothly I had prepared adequately and I had about a group of 30 or so teens hanging of my every word and interested in learning what I had to pass on. The night went off with out problem and I am very happy I put myself a out of my comfort zone.

I FOUND BY DOING THE TAPING SESSION AND DOING SOMETHING THAT WAS OUT OF MY COMFORT ZONE I REALLY LEARNT A LOT AND I DEFINITELY THINK IT HELPED MY PLANNING AND PRESENTATION SKILLS, IT ALSO LEFT ME WITH A GOOD FEELING AS THE PARTICIPANTS WERE REALLY INTERESTED IN THE KNOWLEDGE I HAD TO PASS OVER. IF I EVER GET THE CHANCE TO DO SOMETHING SIMILAR I WILL JUMP AT IT.

Rehab or not to rehab

Whilst on my neuro placement I was treating a patient who had been an inpatient for a long time they had multiple impairments, had a VP shunt inserted and they also had bilateral amputation one above knee the other below following an accident, concurrently they were experiencing vestibular disturbances.
Treatment consisted of vestibular habituation exercises, postural retraining and U/L strengthening exercises. As it was a neurosurgical ward the patient was only being seen once a day (twice if time permitted, which it rarely did) due to priority of more acute patients however the patient was stable and really needed intense rehab to improve their current function level as they were currently a hoist transfer. Not being a rehab facility and due to the ward we were just not capable of providing the rehab the patient required. Although the patient was wait listed for a rehabilitation facility he was continually being reviewed to determine his rehab potential and it didn't seem to be getting anywhere.
After speaking to my supervisor who was very aware of the situation we came to the decision that the patient would benefit most from treatment which was directed towards transfers the most appropriate being a slide board transfer. The patient had a great loss of strength in his upper limbs due to his immobility so it was devised that it would be of great importance to increase his U/L to strength help his rehabilitation.
The treatment continued and the patient progressed well throughout the sessions, it was also quite rewarding as on the last week of my placement there the patient was transferred to a rehab hospital, and due to the rehab we could provide he was getting closer to the prospect of self transfers

DEALING WITH THIS SITUATION I FELT I LEARNT A VALUABLE LESSON IN TERMS OF REHABILITATION AS EVEN THOUGH WE WERE NOT ABLE TO PROVIDE THE INTENSIVE REHAB, WE WERE ABLE TO WORK ON ONE OF THE PATIENTS MAIN ISSUES TO HELP THEM ON THERE WAY TO THE GOAL OF BEING ABLE TO TRANSFER INDEPENDENTLY. AS WELL IT HIGHLIGHTS THE LACK OF REHABILITATION FACILITIES OUT THERE, AS EVEN THOUGH THE PATIENT WAS REQUIRING INTENSIVE REHAB, IT JUST WASN'T POSSIBLE IN AN ACUTE SETTING.

death

Whilst on a placement I was treating a patient who had a chronic disease, the patient was a teenager and was in following an exacerbation. The patient was pleasant and completed physio well, and I had developed a good rapport with them after a few sessions.
After having a normal week of treament the weekend came and went and on returning on Monday and reading through the notes I noticed an incident had happend to the patients friend who also had the same chronic disease. The friend had been admitted to ICU with an exacerbation and on reading further I found they had passed away, the patient I was treating had also gone to visit them whilst they were in ICU. And had been informed and Psych involvment had already commenced.
On going to treat the patient I was unsure of wheter to mention what had a happend or not, as we got talking it came up that the patient hadn't had much sleep over the weekend and it was here that I mentioned as tactfully as I couldd that I had heard about what happened. I left it at that and continued to treat the patient. The patient was a little flat throughout the session which was in the gym, however I tried to not focus on what had happened and talk about anything else, and we did this without concern.

Just wondering if anyone can add their experiences to this. In my opinion it's not really our place to probe situations like this however I'm sure sometimes they are unavoidable and when this occurs the utmost compassion and consideration should go in to what is said

Waiting

Whilst on my rural I was asked to complete an assessment for a new pt as one of the PT’s was unwell. They did not want to cancel the appointment with the pt as she presented with an extensive referral from a major hospital highlighting many yellow flags.
The pt was booked to come in at 10.15am. At this time the waiting room is usually very busy as there is a balance class that takes place at 10.30am. 10.15am came and I had not been advised that my pt was here so I went to reception to check. The receptionist had gone to a meeting and the PTA was looking after the front desk. The pt’s name was not highlighted and when I asked the PTA if she had arrived she said no. It was 10.45am and I had been out 3 times to see if my pt had arrived, but she hadn’t. I assumed that she was not going to attend so I went up onto the ward and told the PTA to page me if she arrived. When leaving to the ward, the waiting room had settled down and there were only a few people left in the room. I asked the PTA if a lady sitting in the room could been my pt because I had seen her there now for a while, but the PTA told me it was another PT’s pt.
I had been 30 mins up on the ward when one of the PT told me that my pt in outpt’s had been waiting 1 ½ hour for me. I immediately felt embarrassed and very unprofessional on what just happened. I met the lady in the waiting room and it was the same one that I saw waiting there. I was very apologetic and told her there had been some miscommunication. I was anxious on how the pt was going to respond throughout the session. She surprisingly was understanding as her daughter is a nurse and understands that these things happened. I felt slightly relieved and more comfortable around the pt however, still very embarrassed. On leaving the session the receptionist was back and she as well as the PTA apologised for the situation that occurred.

IF I WAS FACED IN A SITUATION LIKE THIS AGAIN AND SUSPECTED A PT, I WOULD DIRECTLY ASK THE PT WHO THEY WERE BOOKED IN TO SEE. I NOW KNOW THAT COMMUNICATION BETWEEN NOT ONLY STAFF, BUT PT’S IS ESSENTIAL IN THE ORGANISATION AND SMOOTH RUNNING OF A CLINIC. IN ADDTION, YOU CANNOT ALWAYS ASSUME THAT EVERYONE KNOWS WHAT IS GOING ON.

Hygiene on wheelchairs

Whilst on a rural placement I was treating a stroke patient, who needed to go to the toilet mid way through a treatment session. I took the elderly lady to the toilet using a wheelchair and assisted her into the bathroom and transfer to the toilet seat. I helped her to pull her pants/nappy back up when she was finished and transferred her back into the wheelchair. We then wheeled a couple of metres to where the sinks were and I assisted her to wash her hands. Unfortunately her hands had been soiled but she hadn’t noticed.eeek! so a long hand wash was required.

After she had completed washing her hands with soap and warm water, I felt like she should scrub them again! But I couldn’t think of kind enough words or a good enough reason to tell her why to wash them once again. I wasn’t looking forward to having to touch her hands in the treatment. I got over it. However, I was thinking how unclean it could be sharing wheelchairs, the hand rests on the wheelchairs, the handrails in the toilet, the taps on the sink etc in hospitals and aged care facilities where patients may not be as ‘thorough’ with hygiene.

If a similar situation was to arise I would make sure the patients hands were thoroughly cleaned with hot water and soap. I would also wear gloves when assisting the patient in the toilet and wipe the wheelchair armrests with alcohol wipes if the wheelchair was to be used by other patients. This situation shows the need for continuing infection control and hygiene. It would be appropriate to kindly educate the patient on hand washing technique if you are with them whilst they are washing their hands, with emphasis on between fingers and nails that often get missed. In future I would also ensure alcohol wipes were readily available in my workplace.

Parent participation

At paeds prac at a community development centre, I ran 2 classes for children having difficulty with their gross motor skills like kicking, jumping and passing a ball. Like most things, gross motor skills require daily practice, and 2 sessions per week wouldn't be enough for a child to master a skill. One of the difficult parts about treating children in pre primary and year 1 is you can't just prescribe to the child a home exercise program and expect them to do it by themselves. Instead the responsibility is with the parents to cut out a small part of their day for play time with their child.

I would like to share some strategies which I used to good effect over my time doing paeds.
(1) Formal written program: For a few children who had complex family situations, such as their parents were no longer together, in foster care or being cared for by a faimly member it is not possible to liase directly with the parent of the child. I sent a formal written program home to these parents and carers outline what is being doing during the group and some tips for play at home. I requested that they fill in a grid at the back of the program outline what they were doing and if any difficulties or questions arose.

(2) Parent participation in the classes: During the class I directly called upon parents who had previously having difficulty playing with their children. This gave them the opposrtunity to supervise a balance beam activity or rocker board which allows them to get the feel and take a few ideas away from the class.

(3) Checking homework: Each week a good strategy I used was to check the child's "homework". This was in a grid similiar to the above which wasn't aimed at competition between the children but more so as a motivator during the week for both the parent and child.

The above 3 strategies worked really well for me during clinic. At the very beginning of prac I solely using repetition each week to the child and parent to practice the skills which wasn't really hitting home. So i put into practice some of these strategies based on the child's case and their worked really well. As most of you know already paeds can be a difficult area to work in, so hopefully if you are going to work in paeds or have an upcoming prac in paeds you can use some of these strategies to improve the outcome for the child, so they can all have fun participating well in sport at school and in the community.

Another cultural thing

On my rural prac, I worked in the paediatrics unit and the biggest group of patients we treat are of the indigenous community. It is an ongoing challenge to be treating this group of people as their beliefs, mentality and upbringing are so different from what I am use to. One of our clients was a 15y/o CP child and needed a physio review. I managed to get her mother on the phone after leaving about six messages. She then promised to come for several appointments but never did turn up and so I left it at there.

Last week the child was admitted to emergency for chest infection due to aspiration and had a seizure episode. Once the child was medically stable, I took the opportunity to assess the child and spoke to one of the speech therapist about the childs feeding issues. After assessment, the biggest problem identified was muscle contracture in her lower limb muscles. I was certain that this child is going to need some form of intervention that can range from serial casting, botox or even surgery for tendon release. Whatever the management ends up being, this child is going to need ongoing therapy which is not possible with non-compliant parents. Each time the mother saw me in the ward she would ask me when they can take her home. I was so frustrated that the mother appeared unconcern about the daughter being ill. I tried asking her how is she managing at home and she would just say “yeah, we’re managing awrite”. I asked my supervisor for guidance on how to convince this lady that her daughter is going to need ongoing therapy and that she must be able to attend the appointments. My supervisor just said to do my best but if I can’t just let it go because there is only so much we can do.

I then decided to have a chat with the aboriginal liaison officer and ask for some advice. He suggested contacting a family member that would be able to help out eg: aunty. The paediatrician had decided that the child is going to need a tendon release surgery. With the mother’s permission, I tried getting in touch with the aunty and explained the situation with the child. She agreed to bring the child for physio appointments and help with the rehab. She sounds genuinely convincing. Just to share something that I found interesting in their culture, the mother is just there to give love to the child but the aunty is also the mother of the child that is responsible for the upbringing and there to discipline the child. Therefore, by trying to get the aunty involved I hope to enhance the chances of this child receiving the rehab she is going to need post tendon release.

From my experience in this case, I have learnt that knowing and understanding one’s culture will definitely have an impact of how we are going to tailor our treatment to create better compliance. In the future I will endeavor to understand a culture that is different to mine with the hope of achieving a better treatment outcome.

Socket where the ball should be, ball where the socket should be

Whilst on my rural prac I was seeing a patient who had undergone a shoulder arthroplasty operation due to arthritic changes to the joint. This arthroplasty however failed and the surgeons performed a reversal so the ball and socket were reversed, this provided a problem from the outset in terms of rehabilitation potential.
Not only did techniques have to be altered for example a caudad glide was now performed over the clavicle but the issue of how much movement the patient was going to get back was also raised. The patient although 6-12 months post surgery had limited range, pain at end of available range was also a factor. The patient would continually ask how much range they would get back and whether the pain would go away. I found it quite difficult to answer these questions for the patient.
After each treatment there would be some improvements in range 10 degrees at most, however even though the patient was diligent with there exercises this would fluctuate, I tried to stay positive to encourage the patient but I could see the patient was starting to perhaps realise that there wasn't going to be much more improvement. It was at this stage that after discussing the situation with my supervisor that I talked to the patient and explained that this may be the case.
Following this in the next few session it was clear that this had helped the patient, they continued to work hard at maintaining the available range and strengthening in this available range in an effort to maximize function of the arm.

I think if i have to deal with a situation like this again I will try to be as honest as possible as although our aim of course is to get max range and minimal pain there may be cases due to unforeseen circumstances where this may not be the case, and for the patient to be aware of this I think a better outcome can be reached.

The addition of children

Whilst on rural placement I treated a patient who had an Achilles tendon repair. As I collected the patient from the waiting room she had two younger children with her who were both under the age of five. During the subjective ax, the children started to misbehave and the younger girl started to cry. I left the cubical and asked my supervisor if there we had toys which the children could play with and gave me playing cards and said he should have warned me about the children. The children continued to misbehave and I begun to feel frustrated that the mother was not disciplining her children. The older boy threw the cards playing cards over the floor and refused to pick them up. I was forced to pick them up as I needed the mother to complete a balance assessment. Both children then started running into the nearby cubicle through the curtain where there was another pt. The mother continued to stop her children apart from saying sorry to me. I was quite annoyed by this stage and told the children that they had to settle down a play quiet which I found hard to tell young children. The girl then started to cry again and went up to her mother on the plinth. She then found a box of gloves and started playing with them as did the boy and they both settled down.

NEXT TIME THIS PT COMES IN AND BRINGS HER CHILDREN, I WILL TAKE THE PATIENT AND THE CHILDREN INTO A PRIVATE TREATMENT ROOM TO AVOID THE DISTRUPTION OF OTHER PATIENTS. IN ADDITION, I BELIVE THAT SMALL ISSUES LIKE THIS SHOULD BE DOCUMENTED IN THE NOTES/TRANSFER SUMMARY IN A PROFESSIONAL MANNER. COMMUINCATION BETWEEN STAFF BE THAT WRITEN OR VERBAL IS IMPERATIVE TO THE SMOOTH FUNCTIONAING OF A WORKPLACE.

Establishing rapport in paediatrics

On paeds prac at a child development centre I see a wide variety of outpatients with tort/plag and gross motor skill delay. When referred for PT these children have already been screened by a by paediatrican for any neurological involvement. Children often attend their appointments with parents. When seeing these patients especially the infants and toddlers it is important to establish rapport with the parents but inparticular the child.

During my first few treatment sessions I found establishing rapport with parent's really easy as they were obviously adult. A challenge for me was to establish a relationship with the child. I found it especially difficult due to my limited exposure to infants and toddlers previously and did not know where to begin.

I have now seen children for the past fortnight and have developed a few strategies to establish rapport which i would like to share. In outpatient setting such as these often the child will be seen in a block of treatments. At inital treatment sessions I think its important just to let the child play in their new surroundings and just observe their play. This allows them to familiarise themselves with the environment and develop trust in you the therapist. There is no point trying to force the child to do a tone or other assessment at inital assessment as in some children they become very distressed and cling to their parent the whole session.

Another strategy that has worked well is positioning both of the therapist as well as the parents. Although the child may be playing with you, its important to position the parent in the child's view so that they always feel safe. This may mean positioning toys near the parent or encouraging crusing with a toy towards their parent. Often if a child is total un-cooperative with the therapist I encourage the parent to modify their play with the child so I can observe their behaviour.

Through this prac it has really developed my skills treating and communicating with younger patients. I now use these strategies when I encouter a difficult child who is un-cooperative or in distress at PT. This makes for a more trusting relationship between you and the child, making the physio session more productive and enjoyable for the child. Wasting an entire session forcing the child to do something they do not want to do will only decrease productivity of the session and make them less co-operative with future PT.

Sunshine

Whilst on my rural prac this year I had the task of running a exercise class for a group of over 60 year olds each Tuesday morning. The exercise class consisted of exercises including balance work, general stretching and flexibility and also some very lite cardio work (really walking and air punches was about the most we did), and due to the fact that it was a small town there were only about 8 or so participants. The class was run at a recreation centre in a freezing dark gymnasium and would generally go for 45 minutes to an hour.
Whilst on my prac it generally rained most days or was overcast, so the gym was the safest bet. On my last week however the Tuesday was sunny and quite warm, so whilst on the way to the recreation centre with my supervisor I suggested almost in jest, not expecting anything to come of it, that we hold the class outside today. My supervisor thought this was a great idea (I think he was kicking himself he hadn't thought of it) and proceeded to open a sliding door which led to a basketball court which had the full sun.
The usual activities were completed, but following the class you could see how much difference doing it in the sun had made, they all seemed a lot more chirpier and couldn't stop thanking us for having the class outside.

SO FROM THIS EXPERIENCE I LEARNT THAT ALTHOUGH SOMETHING AS TRIVIAL TO US AS YOUNG GO GETTER'S AS DOING SOMETHING OUTSIDE, FOR THE PEOPLE WHO PERHAPS AREN'T ALWAYS ABLE TO DO THINGS OUTSIDE IT MADE A HUGE DIFFERENCE AND IT WAS REWARDING FOR THEM AND FOR US AS YOU COULD SEE HOW MUCH ENJOYMENT THAT THEY GOT OUT OF IT.

Surgery

Whilst on a rural placement, I got to see a TKR surgery. Not only did I get to see the surgery, but I scrubbed in, wore one of those astronaut like head pieces and got to help out in the surgery by drilling, hammering, holding instruments and stapling. It was the highlight of my physio year! It was great to see the surgery, meet the surgeon and treat the patient post op. As fantastic as it was being able to be a part of the surgery, I wonder whether physio students or other allied health professionals are legally allowed to be so involved with such surgeries.

Whilst treating the patient post op, I never told her I had seen her surgery, let alone drill her new knee together. By being a part of the surgery I feel a little guilty as the patient would probably only expect a qualified surgeon to do their TKR. If I was the patient, I know I wouldn’t want an allied health student doing some of the surgery. Fair enough a medical student, but any other health professional seems a little dodgy.

From the surgery, I have learnt more about the process of a TKR and understand why orthopaedic patients are in so much pain post-op. I would be interested in finding out whether anyone else studying physio has been allowed to be hands on in an orthopaedic surgery. In future, I will continue to see different surgeries as it gives more of an understanding about the procedures, therefore will help when educating patients. If given the chance to be hands on again in a surgery I wouldn’t say no, unless of course this was breaking hospital rules/laws. Would really like to know your views on this issue.

Patient goals

While on my rural placement, there was a patient who had been transferred from a neighbouring town’s small hospital. His wife was also staying at the hospital. He had a discectomy at T11/12 and L4/5 with resulting weakness in the lower limbs. Whilst in hospital in Perth after the procedure the patient did not receive any physiotherapy and as a consequence was de-conditioned and unable to walk. The Physiotherapists organised for a transfer to our hospital for the sole purpose of physio rehab. I was seeing this patient twice a day and I had given him an exercise program to do independently. However, despite a strong desire to return home, this patient was not completing his exercises, therefore was not progressing as well as I had hoped.

Myself and my supervisor had decided that although the patient would have benefited from a longer stay in hospital, he wanted to be discharged and therefore we would use this goal to motivate him. Through using patient oriented goals we were able to motivate the patient. Together with the OTs we prepared him for returning home, but first he needed to stand independently. With a coordinated effort from the nursing staff and even the personal care assistants, the patient was reminded continually throughout the day to complete these exercises. This co-ordinated effort ensured the patient gained enough strength to stand independently to be able to be discharged.

This patient demonstrated the need to keep goals patient oriented, even if they don’t always match your own and that using these goals can be very motivating. This situation also demonstrated the benefit working as a multi disciplinary team to achieve patient outcomes.

Yet another difficult patient..

In one of my placements, I met a 53 year old lady, was admitted to the hospital 2/52 after a CVA. She is still employed as a CEO in a very reputable accounting firm. She sustained right (R) sided hemiplegia from the CVA . She has been attending inpatient physio rehab daily. Since then, she has shown some improvement in motor recovery. She was going to be discharged in a few weeks and will be attending outpatient rehab. She is very anxious about her recovery as she is adamant about returning to work as soon as she is able to. She has been one of my difficult, non-compliant patient as her frustration builds up quite easily during treatment sessions. One day however, she asked me about acupuncture and whether it is a good idea to pursue it once she gets out of the hospital. I had done a bit of research into it before so I gave her an answer. I told her that I can’t promise it will be helpful for her as research does show that acupuncture to some extend helps with recovery but not everyone really benefit from them. So my advice was to give it a try and see whether it works for her. Clearly she wasn’t happy with my answer and just looked away. Anyway I went on treating her that day and she appeared really apprehensive about me treating her. I wasn’t sure what was going on then I asked her politely, if everything is alright and then she became rude and used inappropriate words against me. I was so frustrated because I had worked so hard to get her on my side and then suddenly she reacted that way. I had to just leave her that moment. I spoke to my supervisor and she decided to take me off her case.

When I looked back at what had happened, I am still not sure how I would have handled it differently but I have a certain regret that I was taken off the case without a chance to learn a way of dealing with a situation like that so that when faced with a similar situation in the future I will be better at knowing how to handle it. However in the future, if I do come across a situation like that, I probably will give them the space they need for a bit and come back on a different time and attempt finding out what the issue really is. I guess in a lot of patient it important to make them realize that we are there to help them in their recovery and we can only achieve it if they allow us to. Whether this is the way to go, I am still not sure, anyone have any ideas?

maintaining control during a treatment session for the safety of the patient and physio

Whilst on my neurology placement I encountered a patient who presented with a cerebellar bleed, as well he was displaying frontal lobe behaviours, was highly impulsive and quite a tall man which complicated matters a bit. The patient had also had a trache and as he was improving his trache was removed so he began to be able to communicate a bit more.
The first few occasions of treatment were really based upon transfers and basic functional exercises, this was progressing well but as the patient improved in terms of there function they became more impulsive, and it became harder to complete a full worthwhile treatment session which would address the goals I would set out at the start of each session.

Following a discussion with my supervisor they provided some tips on how to achieve these goals. The first tip was to make sure each time the patient did something for example supine to SOEOB that they would perform it in the correct manner and pattern and if they didn't to make them perform it again. The second was to try and keep the sessions short as the patient would tend to lose interest so perhaps two shorter session in the day would be more effective. A final tip that I was given was to. The final tip was to take a more of a controlled role in the session using verbal and tactile measures to make sure the patient was paying adequate attention and performing the correct task, and even if the patient became impulsive it would be easier to get them back on task.

THROUGH IMPLEMENTING THE ABOVE TIPS ALTHOUGH THE PATIENT WAS STILL DIFFICULT AT TIMES IT ALLOWED FOR THE SESSIONS TO BECOME MORE EFFECTIVE IN ADDRESSING THE IMPAIRMENTS, WHERE AS BEFORE A LOT OF THE TIME WAS SPENT ON JUST TRYING TO GET THE PATIENT TO PERFORM THE CORRECT TASK, NOW THE TREATMENT WAS BECOMING EASIER FOR ME AND ALSO MORE BENEFICIAL FOR THE PATIENT, AND SAFER FOR BOTH OF US.

Autism

On paeds placement at a child development centre, my first patient at this setting was a 4yo child with autism who was generally small for his age and had developmental delay. I was to see this patient following initial assessment from another physiotherapist. When reading through his file it was evident that he had problems with jumping, kicking, hoping, climbing and stairs.

I subsequently set up the gym with equipment I thought could be useful having not seen the patient. Having created a curcuit I had to think of strategies for this child to engage him in play. What would I do?

I made a checklist for the child with all the activties drawn on the sheet, which included SLS, trampoline, jumping through series, hopping, strairs with and without railing, basketball and soccer. Next to each activity I put a square so I could either get the child to tick it once he had done it or put a stamp/sticker on completion.

This suprisingly worked well. I allowed the child to do what they would like first rather then trying to have some flow to my session. The child I felt they were more in control of the play session because they could choose what they were doing, but he also knew he had to complete all the tasks on the sheet. This was my first strategy I used to deal with a child with autism and by the end of the session I had achieved the goals I had set out to do.

From this session I learnt that treating children half the battle is motivation and attention. By creating an environment mimicing a fun play session I achieved what I had set out to assess and treat and the child was allowed to play, and I think will be more likely to attend physio again.

Next time I see this child or in fact any other children with motivation and attentional problems I could use this strategy. But also I think its important to have a couple of strategies that you can call upon. Some of these which I have used subsequently with this child are, playing whats the time Mr. wolf with heel-toe walking, and hide and seek at the end of the session.

Autism

Chronic Pain

While on placement in the country I received a referral for an elderly patient who had multiple problems associated with Polymyalgia rheumatica, which had been present for two years. This patient had multiple sites of pain- the shoulders, neck, temporal area (due to associated giant cell arteritis), low back pain radiating into the left leg and also bilateral hip pain. She mobilises with the aid of a four wheeled walker and was previously completing a home exercise program consisting of walking and LL strengthening exercises. However she ceased these following a fall five weeks previously.

Initially I was unsure of where to start with my assessment, however she stated the wish for her lumbar pain to be treated. I initially felt a bit overwhelmed with all her areas of pain, however as she wished I focused solely on her back during the sessions, with advice to recommence the walking program. After the initial session where I performed PPIVMs (rotations) and piriformis releases and soft tissue massage, she reported a reduction in her pain in the lumbar area. Over a series of treatment this continued.

From this patient I have realised that although a patient may have multiple problems and areas of pain, if you can start by easing just one area, this provides great relief to the patient. Also I have realised patients often don’t expect you to treat everything initially, but gradually work through the problems. In the future I won’t feel pressured to work on multiple areas of pain (unless they are related) and understand that to someone with chronic pain a small reduction in pain (or in one area) may greatly improve their quality of life.

Whiplash

While on my rural placement I encountered a patient who was admitted for pain management following a whiplash injury three months previously. A CT Scan eliminated a fracture. The patient complained of pain in the cervical spine radiating into the head causing headaches, and thoracic spine pain with generalised pain in the surrounding muscles and shoulders. The patient was on very high dosages of pain relieving medications, however still complained of pain ranging from 8-10/10. The patient was discharged with a physio outpatient appointment, however did not attend, then was soon re-admitted for pain relief. This patient had also been seen previously in the outpatient setting by the previous student when the individual was approximately two months post injury, where he received ultrasound, however did not attend follow up appointments. This patient had a few yellow flags such as chronic pain, fear avoidance behaviours and reporting high amounts of pain. He was also receiving input from the Psychologist.

Assessment showed loss of cervical lordosis, significant stiffness throughout the cervical and thoracic spine and “tightness” in rhomboids, upper traps and erector spinae. The patient would not tolerate mobilisations (passive physiological, accessory and distractions) and only allowed us to treat through gentle massage. This situation was particularly frustrating because although we explained the need for mobilisations to decrease the hypomobility, which was contributing to his pain, he refused this treatment each time we attempted it. Although he stated the massage eased the pain during the session, it soon increased the pain. I felt like I was not able to help this patient because he would not allow me to treat him with the optimal treatment strategies. We were also receiving criticism from a doctor who didn’t believe in the value of Physiotherapy.

From this experience I realise the need for early treatment for whiplash injuries to prevent further complications arising. The need for education is also vital to ensure the patient understands the need for treatment. For complicated patients such as this a multi-disciplinary approach is also required. Does anyone know what other techniques we could have used?

Education

While on placement at a rural hospital a patient came to see me in the outpatient department regarding pain involving the entire arm and shoulder. On examination the patient showed signs of ulnar nerve sensitization such as positive neural tissue provocation tests and pain in the distribution of the ulnar nerve. I performed lateral glides to the appropriate cervical spinal segments. I briefly explained the pathology behind the pain and explained it would take at least 6 weeks for any improvements.

This lady did not attend her next appointment, which I was disappointed about because my supervisor was going to demonstrate a taping technique that unloads the shoulder which significantly reduces pain.

I decided to ring the patient, she said she didn’t come back because she didn’t notice any improvement in her pain levels. I realized I may not have taken enough time to explain the pathology and give a realistic picture of recovery of function. I explained this over the phone and told her I would try a taping technique to relieve her symptoms.

From this experience I have realized that for complex problems that require an extended recovery period, thorough explanations are required, and you need to ensure the patient understands this. I also think I should have asked my supervisor to demonstrate the taping technique on the initial visit because this would have helped the patient trust that we can actually help relieve the pain.

Next time I have a patient who I think may require extended treatment to reduce pain I will ensure patient education plays more of a role in my session.

Severe Dementia

I was treating an elderly lady with a # hip who had severe dementia. I had never had a patient with severe dementia before. This patient was difficult to wake up, and communication was very limited. I was to assess the patient’s hip and mobility status. It was difficult to get a precise assessment of her hip in regards to strength and ROM.I tried different techniques, saying short words, repeating words and allowing plenty of time, to try get her to do the actions I required for assessment.

It was frustrating as it wasn’t going as easy as I thought. Assessing muscle strength seemed to be the most challenging. In the end I found a way that suited this lady. This involved doing repeated passive movements and gradually taking my assistance away with each repetition and saying a couple of prompts. In the end this patient showed general strength to be sufficient to stand and walk. Surprisingly, this lady was quite good at standing and walking and required very little prompting. She responded well to physical guidance rather than verbal.

From this situation I was introduced to some of the challenges faced when treating patients with severe dementia. Although challenging, once I had worked out the best strategy for this patient, it became easier in treating the patient at the end of the session and simple on subsequent sessions. Some of the strategies we learnt at university when dealing with dementia patients included breaking down tasks, gentle physical facilitation, clear slow voice, visual cues, eye contact/facial gestures and limit distractions. When seeing the patient, I also thought it was important to try having the same therapist treat the dementia patient as this would mean the patient and therapist would be familiar with each other.

In future, I would approach a dementia patient using less verbal communication and more physical facilitation, keeping in mind dementia patients may respond differently. It is important to allocate time for these patients especially in the initial session so the therapist can work out the best means of assessing and managing the patient. I also learnt that a patient with dementia can fluctuate throughout a day, so a therapist needs to be able to be relatively flexible in when they can see them. I hope to continue developing the skills to treating patients with dementia, best done by further exposure to such patients.

Potential (for) Pool Problems

Whilst on my paediatric placement during the first week of the prac I was thrown into the deep end during a hydro session, not literally the deep end but figuratively. The class for which I was involved on this occasion only consisted of 5 participants with varying conditions including forms of muscular dystrophy, juvenile arthritis and hypotonia and developmental delay, so really each child presented differently so each child warranted a different approach to the session.
Even before the session had a begun I noticed there was a child who seemed a bit older that the others and he was also quite excitable. On entering the pool it was also clear that he was more independent in the pool with regards to keeping afloat and performing the activities, however it became apparent very quickly that it would be necessary someone remain with him due to his excitable nature. As the student i was assigned this task, and I must admit at first i found it quite daunting having a over excited child in the pool who didn't seem to be following instructions too well either.
This presented me with a few issues, firstly the safety of the particular child then also the safety and well being of the other children participating in the class who had more of an issue keeping their head above water, as well as this I had to devise some way that would ensure the child was still getting benefit out of the session.
So the first thing I tried to do was try and develop somewhat of a report with the child and work out a way of communicating with them, bribery goes a long way and i made sure i always made direct eye contact with them as this seemed to make the child listen. Also the child was able to complete the tasks with the other children however a harder aspect was added to challenge this child more. To address the increase in energy I tried to use basic things in between each task like jumping on the spot and swimming out to a point then back to the wall however i had to be careful using these things as every so often it tended to excite the child even more.

All up the strategies worked quite well and as i went to more sessions it became easier to interact with this child. As I became more confident in the situation and also more proficient with communicating at the child's levels I feel my initial concerns were dispelled.

cultural? language barrier?

On a recent prac I had to give a new mother post-natal information as per protocol. Unfortunately, my Vietnamese isn't quite up to scratch and I was told by the nurses she doesn't speak a word of English. I asked the nurses if she has any regular visitors who might be able to translate and it turned out she did. I came back the next day when they were visiting and found out their English wasn't that great either, but it still helped a lot. I tried my best to used gestures and work with the relatives translating. They were all friendly, however, there was either an awkward atmosphere or they knew less English than I thought. At times it was like one of those movie moments where the subtitles show how ridiculously wrong the translations are. 

Upon reflection, I realized that it may have been culturally inappropriate for them to translate the questions about topics like bladder and bowel problems in front of the husband. If anyone happens to know about Vietnamese culture a comment on this would be much appreciated.

I also realized that organizing to see the patient with visitor/translators was not something I would have known to do a year ago... we are learning a lot after all!

Next time in this situation I would ask the translating relative if it is appropriate to ask the wife personal questions in the presence of a male.

You please everyone

Whist on an outpatient’s placement I treated a lady who had neck pain for 14 years and had been coming to Physio for 2 months. The previous treating students ceased trigger point release as that is all the patient said improved her pain and had nil compliance towards HEP. When I Ax her she said there had be no improvement. I decided to do trigger point releases as they were indicated as well as postural re-education and other exercises. Over the course of the 4 weeks her pain improved to nil neck pain. When I told her that I was going to D/C her, the lady got quite defensive and said that her pain was back and she made a mistake. I was taken back by this and spoke to my supervisor. We decided to discharge the lady due to her improvement- Subjectively and objectively.

Initially I felt like I was did the wrong thing by using trigger point release and then felt bad for D/Cing the lady but now I am aware that sometimes some people can lie about their symptoms to either gain their desired treatment ‘massage’ or for social interaction. If faced again with a situation like this I will ensure that I am clear with my objective examination findings so I will have more confidence when deciding that PT Rx is no longer indicated. Further I will investigate her social hx and suggest social groups they could go to. You cannot please everyone.

On a recent neurology prac I was working with a lovely patient who had a L MCA stroke rendering him expressively aphasic among other things. At first there was some receptive aphasia too, but that quickly resolved so he could understand perfectly well but speech was minimal. Initially he was unable to verbalize at all, but could phonate to command (ie repeat kaka, gaga...) After 2 weeks he was still unable to form sentences but could respond to questions where options were given, and occasionally when they weren't. Having to spend 2hrs a day for 3 weeks with someone who can't speak, I had to employ some strategies to enhance assessment and communication. I thought these might come in handy for anyone who encounters a similar patient.

• Patience, patience, patience. If you get frustrated (or can't hide frustration) the patient would become more frustrated or self conscious. These emotions detract from the task making speech harder... similar to us in an OSPE if an examiner fired questions at you faster than you can respond.
• Open questions are a waste of time. If someone can't form a sentence, closed questions are the only option when an answer is required eg during Ax (as opposed to speech exercises)
• No stroke patient would like being talked to as though they're stupid. It is possible to simplify language &/or talk slower without sounding condescending if you consciously try. In this example, 'dumbed down' speech would have been totally inappropriate and annoying for the patient (once the receptive aphasia disappeared).
• Extra checks can help you determine whether aphasia is influencing the Ax results eg for light touch localisation, practise with eyes open first.
• Non-verbal response options to Ax questions include: thumbs up/down (good for joint position sense); smile/frown (good for sharp blunt or shoulder pain screening)
• Try not to feel awkward with silence. Occasional silent times give the patient a chance to relax and is probably as important for cognitive rest as sitting down after gait retraining.
• Think about what you say before it comes out to ensure that there's an easy way for the patient to answer it
• Ask one question at a time
• Everything requires more concentration post-stroke so don't attempt multi-tasking when both tasks are hard eg UL facilitation + conversation
• Minimize background noise and distraction
• Put in as much effort to develop rapport as you would with any other patient. After 3 weeks I actually felt like I knew this guy quite well. I was surprised at how few words are needed for quality conversation.
• Liaison with the speech therapist equipped me with lots more tactics that I wasn't aware of before, eg
• Practising automatic language like the alphabet, counting, days of the week...
  
• Finishing doubles eg hot and... (cold), light and... (dark)
  
• Naming objects nearby
  
• Giving options in closed questions eg are you from Australia or overseas? rather than 'what country are you from?'
• These were useful to practice during breaks from physical tasks. As the speech therapist was unable to see the patient everyday, our input in this area could be invaluable.

I'm sure lots of these ideas were already common sense to everyone, but hopefully there are some new ones too.

Refer on

In my first week in an out pt setting I received a pt that had been coming to physio for 4 months and had been seen by other physio students. She presented with a neck strain after turning too quickly while driving. Former students had also begun a walking program with her as she had a BMI of 37. When I asked her how her neck was progressing all she could talk about was her sick father who was in a nursing home. She told me some disturbing issues and the conversation was getting very personal. Whenever I asked her a question she always responded about her father and she argued that she was unable to complete any exercise or the walking program as her father would not cope without her there. I responded by discussing with her that her health was very important and that she needed to commence her walking program. I was unsure what I could achieve with this pt and felt like that she needed to discuss her personal issues with someone who was more qualified in that area. After talking to my supervisor, I decided to refer the pt on to the clinical psychologist. I was hesitant on how I was going to tell the pt by being professional as well as not being harsh. I told her that I believed that she could improve her level of physical activity and her neck pain if she tried to off load her personal issues and speak to someone with more experience than myself. The pt begun to cry but took it well and agreed to the referral.

This was an interesting yet new situation for me. Afterwards I started to feel guilty for referring her on simply because the stigma that is related to a psychologist. However I then realized that I was just more overwhelmed by my role and responsibility as PT student. I now understand how someone’s physical ability can be so affected by personal issues. I wouldn’t change how I treated the situation, next time I will have more confidence in myself as a professional. Do not be afraid to refer on!

Never make assumptions

On my prac in the geriatric area, I had a patient a 78 y/o lady who attended outpatient due to her chronic lower back pain. She is physically independent and mentally alert. She walks with a 4WW due to her LBP and bilateral knee pain. As part of her physiotherapy treatment, I felt that she would benefit from hydrotherapy exercises. I discussed with her about the class and how it will help ease her pains. She seemed happy to participate and so I assumed that she had agreed to attend. I then went on to fill out the papers required for the hydrotherapy classes. The following week she had failed to attend the class and so I rang to find out why. She just said that it wasn’t a good day for her that day so she did not attend. Then the 2nd week came and again, she was absent from the class. I then suspected something is not adding up to her reasons. Initially, I was not sure how to pursue the matter without making her feel like I don’t trust her words. I just felt terrible at the fact that this lady has an ongoing problem with pain and has not received any treatment for the past 2 weeks and the thought of it turning into a vicious cycle and all that really bugged me.

I then organised for her to come for treatment with me, I thought it’ll be better dealing with the issue face to face rather than over the phone. So I rang her and asked f she could come in within the next few days for physio and she agreed. So I saw her two days after that and gave her some education on how a chronic pain can become a huge problem and impact her functional levels. At this stage it is really important that we do whatever it takes to try and preserve whatever function she has in her daily life. And some of the things that can help was hydro, I subtly brought the topic up again and she begin to tell me how she is afraid of the water as she doesn’t like the cold and also she does not own a swim wear. I assured her that the pool is heated and we will be able to loan out a swim wear. She seemed more convinced this time around and I was sure in a way that she will be attending the next hydro session. When the day came, she turned up. I was glad to see her and she seemed to have enjoyed her first hydro session. She then made it again the following week and reported having had a bit of relieve from her pains after the first session.

From this encounter, I have learnt never to assume that we have patient’s compliance just because we have given them a good run down on all the benefits of doing the things we ask them to (just like how I’ve assumed here) .To a certain extend I think we are in an industry that we have to be able to sell and it can be very challenging especially when we do not understand our buyers needs. If I just took a step back and asked a few more questions I would have been more successful the first time around and that would have meant that the patient started hydro 2 weeks earlier rather than later. This was yet another experience for me to take on board and help me be a better advocate of exercise and treatment as a qualified physio one day.

Motivation?

On cardio clinic at a large hospital I treated a young lady in her early 20s following drug overdose and subsequent 2 week coma. Following he stay in ICU the patient was discharge to the ward where I began to see her. The lady was quite obviously markedly obese and had developed bilateral foot drop as a result of prolonged positioning in ICU.

The main aim for this patient was to mobilise her, beginning right back with basic bed mobility. This patient was to be seen 3 times per day for physiotherapy. I subsequently devised her a general exercise program which she could perform 3 times per day and on weekends, and would check on her daily. Through the week the patient was obviously very unmotivated to do anything, constantly becoming emotional around medical staff, however I noticed she was totally the opposite when conversing with friends who came to visit or on the phone.

For this patient to get better and leave hospital I thought this lady needs motivation. I proceed to ask her what she wanted to get out of physiotherapy in hospital. She said she would like to get back to ballet. I subsequently used this as a source of motivation throughout her exercise sessions to good effect. I also suggested to the medical team the patient's problem with her weight and the doctor said the patient would have to loose 40-50kg to be considered for gastric banding surgery. So together with the patient wanting to return to ballet and the need for her to loose 40-50kg this made her more motivated to do physiotherapy. I found that I would just need to pop my head in to progress her exercises rather then having to actually go through 3 sets of exercises per day.

THIS SITUATION IDENTIFIED TO ME THE NEED TO SET GOALS FOR PATIENTS. THE GOALS IN THIS CASE SERVED TO MOTIVATE MY PATIENT AND KEEP HER COMPLIANT WITH THE PROGRAM.

IN THE FUTURE I THINK ITS IMPORTANT TO SET GOALS FOR PATIENTS DURING INTIAL TREATMENTS SO THAT THEY FEEL THEY ARE WORKING TOWARDS SOME BIGGER THEN JUST GETTING OUT OF BED OR AMBULATING WHICH IS MORE IMPORTANT TO PHYSIOTHERAPIST IN A WARD BASED SETTING.

Sharing ideas

On this particular morning my scheduled pt’s on the acute ward all became either unavailable or physiotherapy Rx was not indicated at that particular time. My supervisor suggested that I assist another student. The other student was mid way through looking through the notes when I told them the plan. I said that I would check the chest X-ray whilst they finished reading the notes and then we can come together and briefly talk about the pt. The student told me that this was one of their favourite pt’s and preferred if I did not look at their X-rays until they did first. I was taken back by that comment and felt like I was not apart of the team treating this pt. We looked at the X-ray together and then went to treat the pt. The student said to me that they know exactly how this pt likes to be treated and they will ask for help if needed. I ended up assisting with transferring the pt and Rx.

THIS SCENARIO HAS TAUGHT ME THAT NOT ONLY DO WE HAVE TO LEARN TO WORK WITH DIFFERENT PERSONALITIES AND WORKING STYLES BUT SOMETIMES IT IS TOO EASY JUST TO AGREE AND ACEPT WHAT THE OTHER PERSON IS SAYING WITHOUT VOICING YOUR POV IF YOU DISAGREE. THIS IS ONE TRAIT THAT I NOW KNOW I NEED TO FURTHER DEVELOP.

IF I WAS IN A SITUTAITON LIKE THIS AGAIN I WOULD BE LESS PASSIVE AND ACTIVELY ASK MORE QUESTIONS UNTIL I TOO AM HAPPY WITH THE PROFILE OF THE PT. I FURTHER WOULD CONSTRUCTIVELY AND PROFESSIONALLY DISCUSS WITH THE PERSON IDEAS ON HOW I BELIEVE THE RX SESSION CAN BE PLANNED.

Messy

During a placement there was one student who constantly had a messy plinth area during and between patients, and did minimal to help in ‘house keeping’. This made the rest of us students look bad even though the rest of the plinths were tidy. A physio in the department had a word with us, but the messy student wasn’t even there. As ridiculous as this sounds, the mess irritated me.

I think I have become one of those pedantic neat physios. I found myself tidying their plinth because it was irritating. I just thought there was no reason to have a messy area (sheets half on the plinth, pillows randomly placed, towel messed up, US machine in cubicle) since the rest of us are able to keep a tidy area. On a couple of occasions, after waiting 15 minutes or longer to see if the student would tidy their area, I reminded the student that their area needed tidying ( very very very very nicely/subtly of course!). By the end of the placement the student was somewhat neater.

From the situation I have learnt that people do notice messiness/tidiness and that it is important to keep an area tidy. It also highlighted to me memories of 1st 2nd and 3rd year pracs thinking some physios were pedantic about specific ways of having things organized and set out, but now I understand where they were coming from.

I have learnt that people might not realize that their habits/ways of doing things can irritate others, no matter how small the issue. Physios should have their individual style to how they carry out and organize things; however I believe keeping a plinth area tidy should be simple enough no matter what organizational style they have. If in future a similar scenario was raised, it would be worth nicely addressing the issue with the person which could result in a better working environment. Little irritations in the workplace could lead to greater arguments, which is why it would be important to address the issue sooner rather than later.

Constantly Becoming Stronger

On an acute ward there is a 24yo girl who presented with Gillian Barre Disease 9/7 ago. I had seen her in the past but today she was taken of sedation and awake and responding to commands. She is currently on a ventilator via an ETT and therefore cannot talk. After I treated her chest she started to make rapid head gestures and I asked her if there was something she wanted. She tried to talk but was unable and just had the movement of her mouth. I went through a few issues that she was trying to talk about until it was concluded that she was uncomfortable and wanted to move onto her back as she was positioned in side-lying. I informed her that the turning team was coming but she started to cry and kept attempting to talk which lead to her BP and RR increasing dramatically. I attempted to calm her down by stroking her hands.

I felt panicky and really sad as this girl was around age and so vulnerable. The nurses assisted my supervisor and myself to calm her down and we advised the turning team to turn her next. She calmed down once turned and went to sleep. This situation touched me as I kept thinking this could be one of my friends or even myself.

THIS SCENARIO HAS REINFORCED THAT THE LACK OF ABILITY TO COMMUNICATE, ESPECIALLY IN AN AREA WHERE THERE ARE CONSTANTLY NEW PEOPLE COMING AND GOING IS A SCARY THING. IT FURTHER TEACHES US TO DEAL WITH A VARIETY OF PATIENTS AND EMOTIONS THAT WE WILL FACE IN OUR PROFESSION.

I BELIEVE THAT AS YOUNG PROFESSIONALS, SOMETIMES WE CAN OFFER MORE TO YOUNG PT’S BY RELATING TO HOW THEY MAY BE FELLING AND BEING ABLE TO PROVIDE THE ADEQUATE LEVEL OF SENSITIVITY AND SUPPORT THAT IS REQUIRED. I DON’T THINK I WOULD HANDLE A SITUATION LIKE THIS DIFFERENTLY IN THE FUTURE, JUST HOPEFULLY BE MORE PREPARED.

Surgery

On rural prac I was lucky enough to be exposed to various aspects of physiotherapy that I wouldnt normally in a perth based hospital. On final week of prac, with all going well my superivisor suggested I go in to see a TKR.

I didn't think seeing a TKR would be the best idea. I dont normally like blood and felt I wouldnt be able to survive seeing surgery. With much convincing I attended the surgery first think in the morning. I subsquently survived the experience and actually really enjoyed my experience.

This situation helped me push myself outside my comfort zone. See surgery made me more aware of what a patient goes through during a TKR and therefore allowed me to better manage my patients.

By pushing my limits I feel more comfortable around blood. I think in the future its important to continually expose yourself to situations outside your comfort zone as their are various benefits from experiences we sometimes fear. In the future, after seeing surgery I would feel more comfortable seeing a surgical patient day 1, trauma patients in ED and acutely sick patients in ICU. With this fear out of my system this better equips me to use my skills as a physiotherapist to help a patient in need.

I would suggest to all my peers to take up opportunities as a student in seeing things such as surgery, as I believe the experience was invaluable.

Changing your tone

On cardio placement at a large WA hospital I was referred a patient with dyscopia. During my interaction with this patient I learnt how I have to tailor my communication for each patient.

When doing my general check up prior to commencing treatment of the patient I only had access to an XL BP cuff. Not considering how my communication may affect the patient, as the cuff kept malfunctioning because the patients arm was too small for the cuff I told the patient "your arms a bit skinny for the cuff". This is resulted in the patient becoming extremely emotional. She explained to me how she wasnt coping at home and how once she was alot more fitter then her currently.

This interaction with this patient demonstrated how sometimes patients are emotional and distressed coming into hospital from home. The conversation I had with this patient obviously was found as rude and deeply upset the patient. In the future I think during initial assessment it is best to be cautious with your communication, as getting the patient off side on day 1 wouldn't be good for future physiotherapy. Once you better get to know a patient I think then your better equipped to get a feel what the patient is like, e.g. in distress with being hospitalised and dependent on nurses/doctors compared to a patient who is quite outgoing and comfortable with thier current situtation.

Group classes

Whilst on a community physiotherapy placement, I was taking a class of 9 patients for multiple conditions such as general deconditioning, post CVA, post TKR/THR, and one lady with Parkinson’s. The class consisted of a warm up, strength exercises carried out in a circuit format, then a cool down and balance exercises. The class was going very nicely and I was up to taking the balance exercise component. I got all the patients to stand behind/beside a chair in a circle. After beginning moderate level balance exercises the Parkinson’s client lost her balance and toppled over! I got the class to stop the exercises, and my supervisor and I went over to help the lady up. Thankfully she hadn’t hurt herself! She was more embarrassed and did not want us to make a fuss over her. I felt terrible!

My supervisor sat with the client for a while, asked her questions, and told her she’ll ring her to check she is still ok tomorrow. The patient reports that she had had a busy morning and was more tired than usual. My supervisor and I had a talk about the situation, her first question was “do you think you did all you could to make the exercises safe for this class?” I told her I did and why. The supervisor totally agreed, and that on previous classes this client had never shown any signs of being at risk of a fall. The client was also the most active and independent client of the class.

From this situation it reinforced the importance of positioning yourself in a class amongst clients that are of a higher need of assistance. It also showed that in class situations even with all the setting up of the environment for a safe exercise, positioning yourself appropriately between clients, choosing appropriate exercises and being cautious, accidents can still happen. In future I would inform clients not to undertake any strenuous activity prior to the class. (The situation also showed me the large amounts of paper work that must be completed after a client falls!)

Preparation

On my musculoskeletal placement, I had a new patient who made an appointment for back pain. When preparing for this patient, I noticed that her name sounded Arabic/Middle Eastern, and she was in her early teens. I was worried that this would be a problem, being a male therapist treating this young lady, especially for a condition like back pain, in order to gain an optimal assessment and treatment, a lot of physical contact is required and the area should be exposed.

I then made my supervisor aware of my concerns and asked my supervisor if I was able to trade patients with another student who was female, and my supervisor was more than happy to make the swap. Later that day, the student who treated this patient had told me that the patient's mother said that she was relieved to have a female therapist.

This experience confirmed the importance of preparing adequately for the patient, not just for the condition, but also other aspects such as age, gender and culture. I believe that this will help make the patient more comfortable, therefore make the treatment more effective. I feel that if I had not traded patients with a female student, or if i had treated this patient without being aware of the age, gender and cultural differences, the patient as well as her mother would have felt uncomfortable, and the treatment given would not have been very effective.

Cancer

While on placement in a general medical ward I encountered a patient who had been admitted following a fall. This patient was later diagnosed with cancer with brain metastases. The medical team estimated only a short time before this patient would pass away. On the first day I saw this lady for a mobility assessment I was a bit apprehensive as I had never encountered a patient with terminal cancer before. On initial assessment the patient was cooperative but very withdrawn as the news of her prognosis was still fairly recent. However on subsequent visits through an exercise program, her mobility improved to the stage that she was able to walk a few metres independently. She began to enjoy our sessions and look forward to them.

I know the literature has proven that exercise is beneficial to patients with cancer, but this patient just highlighted the fact to me. Cancer patient should still be seen by physiotherapists on the ward as exercises can improve their mobility or prevent decline and benefit their mental well being. In future I will ensure I take time to explain the benefits of exercise to these patients and give them the option of physiotherapy treatment.

Stage of Healing

On rural prac doing musculoskeletal outpatients I was referred a patient for management of his broken ribs. As a result of the patient having a fracture it was important as I know now what the contraindications/precautions would be for someone following fracture.

The standard assessment form was used for all new patients. In the OE for spinal assessment the headings were - AROM, PAIVMS, PPIVMS etc etc. Without taking the underlying pahology into consideration I started doing AROM of the Thx spine. Following end range pain I decided I would do PAIVMS. Luckly I stopped and thought, if i PAIVM his thoracic spine will that to produce motion at his rib fracture.

I thought to myself, if the patient had a broke ankle would i mobilise it a week after fracture? Similarly I tailored my management of this patient taking a more prophylatic approach to his fracture, performing a cardio assessment and giving him DB exercises.

Through encoutering this patient it highlight to me how important was to keep clinically reasoning while your performing assessment and treatments. If I had mobilised his thoracic spine maybe it might have caused a puncture lung or something more serious. In future treatments it is important for me to take things slower, stop and think what is going here? what is the stage of healing? Is my treatment indicated for this patient?

Prioritisation

On cardio placement on a medical ward there are numourous very sick patients. Often patients who are at end stage of disease end up here as admitting these patients into high dependency or intensive care units is seen by the medical team as futile given the patients stage of disease. At first was very difficult for me to digest, a patient was not receiving optimal management for their disease. All patients had consent to this type of management, which puzzled me as to think why a patient would basically 'give up'. This demonstrated to me how patients are often prioritised depending on their presentation.

As this was a very large ward comprisied of over 60 beds I too had to prioritise who were high priority and who didnt need to be seen. Prior to prioritising who I would see I thought to check the status of the patient in terms of management. As a result I was able to identify patients who were seen as had rehabilitation potential and prioritise them to be seen first. As a result I felt that my physio management was too prioritised so I could provide more time for patients who had rehabilitation potential and still see other terminal patients if time permitted.

By encountering this situation, I learnt how it is important to gather a full picture of a patient - interms of what the docs see is there rehab potential and then prioristise to see patients who are seen as having potential, however still providing terminal patients with physio if time permitted and only a couple of times per week instead of everyday. This made the ward more manageable however at first was difficult for me to make such a decision.

It is not always about physio.

On my prac in the geriatric area, one of my patients was a 86 y/o man who had led a very active lifestyle all his life. He lives with his wife who is in her 70’s and is still physically active and independent. He came to see us because he felt that of late, his balance is deteriorating and that he sometimes feels unsteady during ambulation. As a result, he had a couple of falls in the past year. I then commenced assessment to identify his key problems and the reasons he’s been falling. During the subjective assessment, I found out that he had a fall 2 weeks ago which he blamed his wife for. He and his wife were rushing to catch a tram because she didn’t want to miss it. He then tripped over a high kerb and fell landing on his forehead. The patient then started expressing some issues he had been facing with his wife ever since this had happened. He feels as though she doesn’t understand that he is not able to do certain things that he used to be able to do. She thinks that his problems are not real and that he is just trying to avoid having to drive her down to the shopping mall when she wanted to go to the shops. All of these had made him so frustrated and depressed.

Listening to this, I had to take a moment to try and see how I can help with the situation as it was really obvious it is affecting him terribly. They needed to get help before the situation gets too complicated. I then offered to refer him and his wife to a counsellor but he refused. At the same time I felt that if we did not find a way to deal with the issue, it is not going to help his rehabilitation process. I then decided to continue with objectively assessing his condition so that I was able to tailor and exercise program to help facilitate his rehabilitation. At the end I discovered that he had genuine balance issues as well as some weakness in his lower limbs which needed to be addressed promptly. I prescribed a home exercise program to help with his balance and improve his strength after the first session. Then, I realised that I have only addressed half his problems and I disregarded the problems he had with his wife as soon as he refused counselling. I was sceptical of his compliance to the home exercise program because to him, having a wife that does not understand his condition is a “bigger” problem. So I really thought that in order to achieve anything with him I must address his “bigger” problem.

So for the next session, I asked him if he was happy for me to talk to his wife about my assessment findings. He said I could try but he wasn’t sure if that was going to make things any different. I decided anyway to try and explain some of what I found with his balance. She was surprised at what I had commented about her husband’s condition but looked accepting. I also explained that he may improve if he kept to his home exercises and that she should play an active role in reminding him if he forgets. She seemed eager to be a part of his rehab. And after that session, I realised how much difference that had made to his motivation. He seemed a lot more compliant to physiotherapy which resulted in a difference to his balance score.

From this encounter, I’ve learnt the importance of dealing first with the patients primary problems regardless of whether it is physiotherapy related or not as this is one step closer towards achieving patients’ goals. Besides that, addressing patients’ specific concerns will help enhance motivation and compliance towards rehabilitation.

Making mistakes

While on cardiopulmonary placement I encountered a patient who was identified as a intravenous drug user. The patient had experienced a perforated bowel, which was subsequently repaired, however subsequent complications required an ICU admission. During the patient’s stay on the ward it drugs had been discovered in her room and she had crushed painkillers which she tried to insert into her IV. The patient was keen to return home to care for her children.

As the patient had been desaturating on oxygen, this needed to be tested to ensure her oxygen did not drop too low when ambulating. Initially the patient’s oxygen was 94%, but she refused oxygen as she was intent on going home, during ambulation her oxygen dropped to 88% at this stage I tried to apply oxygen to the patient, she refused, so I asked her to stop and take deep breaths prior to recommencing oxygen. However the patient did not listen to me as we were close to her room. During the last few metres to her bed, her oxygen sats dropped to 71%. Once again the patient refused oxygen despite warnings and education. With deep breaths her oxygen recovered to pre ambulation levels within 2-3 minutes. I promptly informed the my supervisor, the nursing coordinator and the medical team. A chest X Ray was performed and she was found to have significant bilateral atelectasis.

I felt I had lost control of the situation with this patient and I should have been more firm. Patient education is even more important with difficult patients to ensure they are aware of your reasoning behind your assessment and treatment to improve compliance.

I have learnt a few things from this experience
· ENSURE I AM IN CONTROL OF ALL TREATMENT SESSIONS
· BE FIRM WITH PATIENTS IF THE SITUATION BECOMES DANGEROUS
· EVEN IF I MAKE A MISTAKE, ENSURE I INFORM THE APPROPRIATE STAFF AS IT MAY INDICATE A SERIOUS PROBLEM THAT REQUIRES FURTHER INVESTIGATION