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!)
Thursday, September 18, 2008
Tuesday, September 9, 2008
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.
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.
Monday, September 8, 2008
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.
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.
Sunday, September 7, 2008
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?
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.
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.
Thursday, September 4, 2008
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.
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.
Wednesday, September 3, 2008
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
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
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