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.