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.
Thursday, November 6, 2008
Wednesday, November 5, 2008
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.
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.
Monday, November 3, 2008
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.
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.
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.
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.
Sunday, November 2, 2008
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.
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.
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.
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