I am currently on my cardiopulmonary placement where I came across a young male patient who had pneumonia and required physiotherapy. This normally would have been straight forward by doing ACBT’s plus cough/huff, however this person did not speak very good English. Not speaking English is hard enough when you’re trying to ask the patient for information, but it is even more complicated when you want them to actually do a task.
My main problem for this patient was trying to explain the ACBT procedure with a breath hold at the end. It seemed every time I got them to take a deep breath in, they found it difficult so would just stop! I couldn’t seem to make them understand that they were required to take the ‘biggest’ breath in and hold. After about 5 minutes of demonstrating and trying to explain to the patient, I just tried my best to do the ACBT’s with what the patient had understood.
Questions raised from this treatment session, included; is it benefitting the patient to do a technique slightly incorrect? Or is it more beneficial to find an interpreter or changing your physiotherapy treatment session to something that the patient may understand.
Looking back on my treatment session, I think for this particular patient ambulation whilst deep breathing would of been more beneficial, as it is easier to demonstrate than ACBT’s and the patient is still getting some benefit from it.
IF IN THE SAME SITUATION AGAIN I WOULD STILL TRY TO EXAPLAIN/DEMONSTRATE THE MOST BENEFICIAL TECHNIQUE TO THE PATIENT. IF THAT FAILED I WOULD TRY THE SECOND MOST OPTIMAL TECHNIQUE. IF FAMILY MEMBERS ARE AROUND I WOULD CONSIDER GETTING THEM TO INTERPRET TO THE PATIENT, HOWEVER IN MY SITUATION THERE WAS NO FAMILY AVAILABLE.
Monday, June 30, 2008
Tuesday, June 24, 2008
When a patient is progressing well in terms of there rehab then they have a setback and you have to start again.
Whilst on my musculoskeletal placement, I had a patient who had an acute back strain, they came in to see me about 3-4 days after the initial incident caused by picking something up off the ground and they were still in quite a lot of pain and had symptoms into the anterior thigh as well. So the first thing was to do was to decrease the pain and this was going swimmingly with both the back and thigh pain decreasing, i was happy with this progress as it would mean i could progress to more manual techniques which would hopefully help the patient continue to recover.
I was seeing the patient twice a week and on about the 3rd week the patient arrived and when i went to get them from the waiting room i could see they were in quite a bit of discomfort. On questioning the patient they said that they had been doing quite a bit of squatting and bending at work and the pain was back up to the level of the original incident if not worse. I was quite upset about this and with the patient as they were progressing so well and for this to occur was quite a shock to me. We were back at square one and back to the main focus being to decrease the patients pain.
On looking back at the situation i think i could have been more understanding of the patients situation as it may have been necessary for them to work and it may have also been partly my doing as even though i did specifically tell the patient to avoid flexion type activities, through my response to the improvements I may have given the wrong idea about where the patients recovery actually was at.
I THINK IF I WAS IN THIS SITUATION AGAIN I WOULD TRY TO GIVE THE PATIENT MORE INFORMATION ABOUT WHERE THEY ARE IN TERMS OF THERE RECOVERY AND EVEN THOUGH THE PATIENT HADN'T DISCUSSED THERE RETURN TO FULL ACTIVITY AT WORK IN FUTURE I WILL TRY TO BE MORE CLEAR ABOUT WHAT EXACTLY IS APPROPRIATE IN TERMS OF THE PATIENTS RECOVERY AT WHATEVER STAGE THEY ARE AT.
I was seeing the patient twice a week and on about the 3rd week the patient arrived and when i went to get them from the waiting room i could see they were in quite a bit of discomfort. On questioning the patient they said that they had been doing quite a bit of squatting and bending at work and the pain was back up to the level of the original incident if not worse. I was quite upset about this and with the patient as they were progressing so well and for this to occur was quite a shock to me. We were back at square one and back to the main focus being to decrease the patients pain.
On looking back at the situation i think i could have been more understanding of the patients situation as it may have been necessary for them to work and it may have also been partly my doing as even though i did specifically tell the patient to avoid flexion type activities, through my response to the improvements I may have given the wrong idea about where the patients recovery actually was at.
I THINK IF I WAS IN THIS SITUATION AGAIN I WOULD TRY TO GIVE THE PATIENT MORE INFORMATION ABOUT WHERE THEY ARE IN TERMS OF THERE RECOVERY AND EVEN THOUGH THE PATIENT HADN'T DISCUSSED THERE RETURN TO FULL ACTIVITY AT WORK IN FUTURE I WILL TRY TO BE MORE CLEAR ABOUT WHAT EXACTLY IS APPROPRIATE IN TERMS OF THE PATIENTS RECOVERY AT WHATEVER STAGE THEY ARE AT.
Monday, June 16, 2008
An over-enthusiastic patient
My first placement was in the musculoskeletal outpatient area. We had patients with a variety of musculoskeletal conditions and compliance towards PT treatment was variable across patients. We had patients attending clinic regularly but wouldn’t comply with their home exercise program and hence slowing down the recovery of their condition. Then we have patients at the other end of the spectrum that does too much in the hope of recovering in the shortest time span. I had one particular patient who initial diagnosis was rotator cuff tendinopathy secondary to a traumatic fall on the shoulder. He has been attending physiotherapy outpatient treatment for the past 6 months and is still attending treatment. Upon reading his notes, it appeared to me that his shoulder recovery has plateau about the 3rd month of PT with minimal improvement of ROM and pain symptoms. Upon subjective questioning, he did report that his shoulder is not much better from the start of his symptoms, in fact it sometimes feels like the pain has worsened. I started to wander if there were possibly any underlying issues apart from just a difficult shoulder.
The first step I thought was to go through his home exercise program and made sure that he was doing them right. Upon checking the exercises that he has been doing at home, he admitted that he was probably doing more than he should. Instead of the prescribed 3 sets of 8 reps, 3x/day, the patient decided to do 3 sets of 20 reps 6-8x/day. This is when I decided to give the patient some education on the possible negative effects of overdoing the prescribed exercises. I then checked to see if the patient was performing these exercises right. Upon doing that, I discovered that when performing the exercises, the quality and the mechanics of the movement was very poor. Part of his HEP also involved motor control retraining of LTrapz which was also performed in a wrong manner. Doing these exercises wrongly plus doing them in so many reps a day could only do more damage to an already compromised shoulder. I then reviewed his HEP, correction was done in stages and to help with proprioception and motor control of the shoulder, I attempted to tape the patient’s shoulder to facilitate LTrapz which had worked wonderfully for this patient. In the 5 weeks I was in this placement, I had seen this patient improved more than in the 6 months he was attending PT Rx. This was simply achieved by doing the right thing that best suited the patient together with some education for HEP.
My lesson in this scenario was that when confronted with a case that doesn’t quite add up when on clinics, it is important that we just do not passed it off as it’s a common thing but to look at things in all angles so that we do the right thing by the patient as well as our profession. Education played a vital role in this case where the patient was doing much more than is expected and doing the ex’s wrongly would have put him at risk of further damage to the shoulder. So a simple thing like reviewing his HEP brought a whole lot of improvement to his recovery.
The first step I thought was to go through his home exercise program and made sure that he was doing them right. Upon checking the exercises that he has been doing at home, he admitted that he was probably doing more than he should. Instead of the prescribed 3 sets of 8 reps, 3x/day, the patient decided to do 3 sets of 20 reps 6-8x/day. This is when I decided to give the patient some education on the possible negative effects of overdoing the prescribed exercises. I then checked to see if the patient was performing these exercises right. Upon doing that, I discovered that when performing the exercises, the quality and the mechanics of the movement was very poor. Part of his HEP also involved motor control retraining of LTrapz which was also performed in a wrong manner. Doing these exercises wrongly plus doing them in so many reps a day could only do more damage to an already compromised shoulder. I then reviewed his HEP, correction was done in stages and to help with proprioception and motor control of the shoulder, I attempted to tape the patient’s shoulder to facilitate LTrapz which had worked wonderfully for this patient. In the 5 weeks I was in this placement, I had seen this patient improved more than in the 6 months he was attending PT Rx. This was simply achieved by doing the right thing that best suited the patient together with some education for HEP.
My lesson in this scenario was that when confronted with a case that doesn’t quite add up when on clinics, it is important that we just do not passed it off as it’s a common thing but to look at things in all angles so that we do the right thing by the patient as well as our profession. Education played a vital role in this case where the patient was doing much more than is expected and doing the ex’s wrongly would have put him at risk of further damage to the shoulder. So a simple thing like reviewing his HEP brought a whole lot of improvement to his recovery.
IS PHYSIO INDICATED?
On neurology placement I treated an acute L. hemiplegic pt. On initial examination the pt was unable to maintain his airway and subsequently developed an aspiration pneumonia. The pt was completely flaccid on the L. side and had remained RIB since the stroke. I treated this pt for one whole week, seeing him twice daily as the pt was desaturating regularly.
A week passed and the pt’s condition had become stable, being fed with NGT and was able to cough up small amounts of secretions. It was at this time that the medical team requested that the pt not be seen for cardiorespiratory PT, a trial to see how the pt can mange his own chest. The plan for this pt was D/C to nursing home so the only thing holding him back was his respiratory problems.
At the time this confused and angered me as I felt the pt required PT input, as the pt had not progressed greatly since day 1 post stroke. I obliged and ceased treating this pt. The following week the pt to my surprise coped really well without PT managing his chest well, and subsequently discharged to a nursing home by the weeks end.
This above situation frustrated me at first but then I realised that this pt needed to be able to test themself without my input if he were able to be D/C and avoid long periods in hospital. This situation has resulted in me allowing pt to test things for themselves more often rather then giving them assistance. I have found that by allowing pt’s to attempt tasks such as getting out of bed for themselves they feel more independent and are able to make goals that impact on their lives. Also they find our help more valuable as we assist them through our treatment to achieve these goals, returning them to their previous level of function and leaving hospital.
A week passed and the pt’s condition had become stable, being fed with NGT and was able to cough up small amounts of secretions. It was at this time that the medical team requested that the pt not be seen for cardiorespiratory PT, a trial to see how the pt can mange his own chest. The plan for this pt was D/C to nursing home so the only thing holding him back was his respiratory problems.
At the time this confused and angered me as I felt the pt required PT input, as the pt had not progressed greatly since day 1 post stroke. I obliged and ceased treating this pt. The following week the pt to my surprise coped really well without PT managing his chest well, and subsequently discharged to a nursing home by the weeks end.
This above situation frustrated me at first but then I realised that this pt needed to be able to test themself without my input if he were able to be D/C and avoid long periods in hospital. This situation has resulted in me allowing pt to test things for themselves more often rather then giving them assistance. I have found that by allowing pt’s to attempt tasks such as getting out of bed for themselves they feel more independent and are able to make goals that impact on their lives. Also they find our help more valuable as we assist them through our treatment to achieve these goals, returning them to their previous level of function and leaving hospital.
Communication with medical staff
While on placement in a medical ward, my supervisor and I encountered a lady who was very deconditioed as she had been in hospital for a long period of time. My supervisor stated that the patient’s condition had grown worse in this period. The patient was no longer able to walk and needed maximal assistance with bed mobility. My supervisor had not witnessed any voluntary movement or contraction of the leg muscles and it appeared sensation was impaired. My supervisor came to the conclusion that the patient’s legs were not functioning possibly due to some kind of nerve block from the spinal cord. This was stated to the doctors and repeatedly written in the patient notes. However the medical team did not seem to pay much attention to this, until finally one day during ward rounds they asked the patient to stand up. Since the patient’s legs were not functioning the patient fell over. This then prompted the doctors to do a MRI and the results showed oedema which was compressing the spinal cord. The patient then received treatment for this.
This situation evoked strong frustration in my supervisor and I as it appeared the medical team did not respect our opinion and consequently placed the patient in danger and delivered compromised patient care. This situation occurred due to a suboptimal working relationship with the medical staff.
This situation shows the need for an open relationship between health professionals to exist to allow optimal patient care. This situation highlights the need for improvement in communication within this ward.
IF I WAS TO EXPERIENCE A SIMILAR SITUATION, I WOULD PURSUE THE ISSUE MORE STRONGLY AND VISIT THE PATIENT WITH THE TEAM AND SHOW THEM MY FINDINGS. I WOULD ALSO WORK HARD TO ESTABLISH A RELATIONSHIP WITH THE DOCTORS, WHICH ALLOWS CONCERNS FOR PATIENTS TO BE AIRED OPENLY.
This situation evoked strong frustration in my supervisor and I as it appeared the medical team did not respect our opinion and consequently placed the patient in danger and delivered compromised patient care. This situation occurred due to a suboptimal working relationship with the medical staff.
This situation shows the need for an open relationship between health professionals to exist to allow optimal patient care. This situation highlights the need for improvement in communication within this ward.
IF I WAS TO EXPERIENCE A SIMILAR SITUATION, I WOULD PURSUE THE ISSUE MORE STRONGLY AND VISIT THE PATIENT WITH THE TEAM AND SHOW THEM MY FINDINGS. I WOULD ALSO WORK HARD TO ESTABLISH A RELATIONSHIP WITH THE DOCTORS, WHICH ALLOWS CONCERNS FOR PATIENTS TO BE AIRED OPENLY.
compromise
On my surgical placement, i had to see a patient who was day 1 post op. He had an epidural insitu. My initial goal was to ambulate him when I saw him. Since he was attached to an epidural, it was necessary to check blood pressure in supine and standing, muscle strength and sensation in the LL's prior to walking the patient as a safety precaution.
In doing so, I found that he had slightly reduced sensation in his R LL and was unable to SLR with his R leg. Therefore, ambulating him would not have been a good idea, as he would have been at risk of a fall. I did not want to leave this patient without any physiotherapy input, so i decided to transfer the patient to a chair using a front on transfer, and did some deep br ex's, as sitting out of bed is a much better position for this patient than lying in bed.
THIS SCENARIO REAFFIRMS THE IMPORTANCE OF CHECKING THE SAFETY ASPECTS PRIOR TO STANDING A PATIENT UP. ALTHOUGH MOST OF THE TIME, IT WILL BE OK, SOME INCIDENTS HOWEVER, IF IT WERE NOT CHECKED THEN IT MAY BE UNSAFE FOR THE PATIENT. ALTHOUGH MY PLAN DID NOT GO AS I WANTED IT TO, I FEEL HE STILL HAD SOME BENEFIT FROM PHYSIO BY SITTING OUT OF BED. IN THE FUTURE, IF I AM UNABLE TO DO WHAT I INITIALLY PLANNED FOR THE PATIENT, I WILL COMPROMISE AND DO AS MUCH AS POSSIBLE WITH THE PATIENT, AS THIS WILL BE BETTER THAN NO PHYSIO TREATMENT.
In doing so, I found that he had slightly reduced sensation in his R LL and was unable to SLR with his R leg. Therefore, ambulating him would not have been a good idea, as he would have been at risk of a fall. I did not want to leave this patient without any physiotherapy input, so i decided to transfer the patient to a chair using a front on transfer, and did some deep br ex's, as sitting out of bed is a much better position for this patient than lying in bed.
THIS SCENARIO REAFFIRMS THE IMPORTANCE OF CHECKING THE SAFETY ASPECTS PRIOR TO STANDING A PATIENT UP. ALTHOUGH MOST OF THE TIME, IT WILL BE OK, SOME INCIDENTS HOWEVER, IF IT WERE NOT CHECKED THEN IT MAY BE UNSAFE FOR THE PATIENT. ALTHOUGH MY PLAN DID NOT GO AS I WANTED IT TO, I FEEL HE STILL HAD SOME BENEFIT FROM PHYSIO BY SITTING OUT OF BED. IN THE FUTURE, IF I AM UNABLE TO DO WHAT I INITIALLY PLANNED FOR THE PATIENT, I WILL COMPROMISE AND DO AS MUCH AS POSSIBLE WITH THE PATIENT, AS THIS WILL BE BETTER THAN NO PHYSIO TREATMENT.
Ask for assistance if you feel uncomfortable.
This week I went onto a different ward and met a burns pt in his early 20’s. The pt had approx 9% of his body unaffected from the incident. Talking to the other student and PT who usually attend to this pt, it was revealed that he had a very extensive PMHx with behavioural issues. The other PT student and myself begun performing hand stretches when he shouted ‘stop touching my hands, F**k off’. The other student who knew him better explained how important the stretches were but he kept on shouting. He then just stopped and calmed down, and then the PT walked into the room. The pt then looked at me and said “are you stoned, because you look really stoned’. From the initial swearing and then being asked this question I felt very uncomfortable and taken back by the behaviour of this pt. I responded ‘no, i’ve recently been sick’. The PT spoke to him about his professionalism towards us and he responded with an inappropriate answer. The pt then went on to ask me to just leave my number on the table before I left. I was so embarrassed by this comment. The PT again spoke to the pt about his behaviour.
I have worked with non compliant pts before but working with this one was different. I felt really uncomfortable being in that room with him. We all left the room and the PT explained that I handled that situation well and that I did not have to see that pt again. I believe that if you don’t feel comfortable working with a particular pt then you don’t have too. If I was to see that pt again I would ensure that there was another person in the room with me.
KEEPING A PROFESSIONAL RELATIONSHIP BETWEEN YOU AND YOUR PT'S CAN HAVE GREY AREAS. IF HOWEVER YOU FEEL LIKE THAT BARRIER IS BEING CROSSED IN A WAY THAT COMPROMISES YOUR WORKING ABILITY THEN ACTION NEEDS TO BE TAKEN. WE WILL ALL WORK WITH NON COMPLIANT PT'S BUT I HAVE LEARNT THAT THERE IS NO HARM IN ASKING FOR ASSISTANCE FROM ANOTHER PERSON TO AID IN TREATING THESE PTS. PT'S HAVE NO RIGHT TO DISCRIMINATE AGAINST US.
I have worked with non compliant pts before but working with this one was different. I felt really uncomfortable being in that room with him. We all left the room and the PT explained that I handled that situation well and that I did not have to see that pt again. I believe that if you don’t feel comfortable working with a particular pt then you don’t have too. If I was to see that pt again I would ensure that there was another person in the room with me.
KEEPING A PROFESSIONAL RELATIONSHIP BETWEEN YOU AND YOUR PT'S CAN HAVE GREY AREAS. IF HOWEVER YOU FEEL LIKE THAT BARRIER IS BEING CROSSED IN A WAY THAT COMPROMISES YOUR WORKING ABILITY THEN ACTION NEEDS TO BE TAKEN. WE WILL ALL WORK WITH NON COMPLIANT PT'S BUT I HAVE LEARNT THAT THERE IS NO HARM IN ASKING FOR ASSISTANCE FROM ANOTHER PERSON TO AID IN TREATING THESE PTS. PT'S HAVE NO RIGHT TO DISCRIMINATE AGAINST US.
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