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

Sometimes patients don't realise what they can do

On my rural placement, a patient was admitted after having a CVA. On first impression, this patient seemed very unmotivated, and convinced my supervisor and I that she "couldn't do anything". She would continuously compare how she is now with her premorbid status, and was very fixed on the fact that she had movement on her affected side.

For the first few sessions, everytime my supervisor and I would attempt to stand her up and walk her, she would state that she can't, and would just sit straight down. After setting the goal of walking to the toilet, we were able to stand her up and walk her with 2 assist, however, the more steps she took, the more she would actually contribute, needing less assistance.

The next session, she still refused saying that she was unable, until I reminded her of her performance the day before. This seemed to have improved her confidence, and she was able to walk a greater distance with less assistance.

I FEEL THAT SOMETIMES PATIENTS THAT HAVE DISABLING CONDITIONS SUCH AS STROKES, WILL TEND TO COMPARE THERE CURRENT STATE WITH THERE PREMORBID STATE, AND WILL ASSUME THEY ARE UNABLE TO DO CERTAIN TASKS. I THINK THAT A GOOD WAY TO TREAT THESE PATIENTS IS TO SET REALISTIC SHORT TERM GOALS, AND USE THAT GOAL AS MOTIVATION FOR THE NEXT SESSIONS.

I've broken my hip

I am currently on a musculoskeletal outpatient placement in which I am treating a lady diagnosed with traumatic trochanteric bursitis after a fall onto her side of her hip. During the initial session the patient explained that she felt she had pulled some ligaments or broken her hip. She has ideas regarding the basic anatomy of the hip in general saying she felt the “ball and socket isn’t rotating properly”. After doing the physical examination I was confident she hadn’t broken her hip nor pulled any ligaments.

I explained to the patient some of the reasons she was having the pain in the hip and thigh and our plan for treatment. I reassured her she hadn’t broken her hip and that I had tested for ligament problems and found them all good. On the second time seeing this patient she had noticeable improvement in pain, ROM and function. However she still felt she had a broken hip (even though she had nil pain, able to walk/run, all ADL’s). Once again I reassured her hip wasn’t broken and explained to her the healing that takes place and the muscles running over her G.T., bursa etc etc. She felt better and understood. At the very end of the session I showed and explained a picture of the hip, muscles and bones. She sighed of relief.

With this patient I focused a lot of the treatment session on education and getting the patient to understand the problem. But while understanding the problem the patient did not entirely exclude their own conception. This suggests the patient had not entirely understood what I had explained on the initial treatment. The patient finally understood when a picture was used that separated the area of interest (G.T) to the ball and socket joint (in which she thought she had broken/damaged ligaments).

From this patient I have acknowledged the importance of readdressing education regarding the cause of a problem. It also illustrated the benefit of using diagrams/visual aids to help in explaining mechanics and anatomy. In future I will try to use diagrams or visual aids in an initial treatment session. I have learnt the importance of ensuring patients understand the problem, but also reassuring and explaining any misconceptions.

Not enough info

While on placement in the community setting, my supervisor and I encountered a patient who had been referred to physiotherapy upon discharge from hospital. She had been admitted to hospital following a fall caused by her legs shaking and then giving way. No cause was discovered however her referral only stated the diagnosis as “leg weakness”. As her medical notes took a few days to come to our office we were not able to access the investigations carried out. On assessment the patient’s the patient had good muscle strength, however experienced fairly severe shaking when quads were activated against manual resistance or on sit to stand. This was relieved through activation of hamstrings or marching on the spot. Her muscle tone was normal. My supervisor and I queried anxiety or some underlying neurological problem as the cause, however the cause needed to be investigated. This patient was later readmitted to hospital for further investigations. I believe the cause of the shaking legs should have been investigated further in hospital, or information given in the referral as to the outcomes from investigations carried out.

This incident highlighted these issues
1) The need for a thorough assessment to be carried out prior to referral and adequate information should be included in referrals to other physiotherapists.
2) If inadequate information is contained in a referral I should always attempt to call the referring source for a verbal handover.
3) The need to fully investigate abnormal findings and refer onwards is vitally important in the community setting as you may be the only health professional that they speak to about a certain problem.


IN THE FUTURE, PRIOR TO REFERRAL TO ANOTHER PHYSIOTHERAPY SERVICE, I WILL ALWAYS ASSESS A PATIENT ADEQUATELY AND ENSURE MY HANDOVER INVLOVES SUFFICIENT INFORMATION FOR THE NEXT PHYSIO. I WILL ALSO MAKE SURE I CLARIFY ISSUES OR ABNORMAL FINDINGS AND DISCUSS THESE WITH A SENIOR OR REFER ONTO ANOTHER HEALTH PROFESSIONAL IF NECESSARY.