I can’t believe prac is completely over! The year has gone by too fast.
Mandurah was a fantastic note to end on, I feel that I really experienced true working life, and I loved it!
NATURE: I saw outpatient MSK referrals (as well as a few cardio and stroke patients!!). My supervisor was correct, I think I saw 90% back, neck and shoulder complaints, and about 95% of these were chronic complaints. (It showed me how well versed you need to be in chronic pain management in a community setting). I was involved in many classes, up to 3 a day. It was nice, almost a bit of down time before your next patient.
STRUCTURE: I was very independent!! I even had my own treatment room! My supervisor really left me to do my own thing, but I knew he was just in the next room. If I had a complex patient, needed advice or just wanted to talk through my reasoning he was very approachable.
ROLE: I did see a full caseload, and I feel I worked as if I was a new graduate. Sometimes we saw 9 patients/day including classes. If was great to know I could do it!! And it did involve good time management. The classes were very ‘client run’, we just supervised. The patients attend 8 weeks of class work and running it themselves gives them the confidence and skill to continue to do so independently.
CONCERNS: It was really hard to clinically reason in such a short time frame, but I’m glad I had to do it. It became easier and easier as the weeks went on, and now I have the confidence to do it in the workforce. Generally, as I was writing my patient notes, I had time to clinically reason and reflect on my chosen treatment. If I had missed something I would immediately put it in my plan for the patients next appointment.
All in all, I had a truly fantastic time. This last prac gave me the confidence to know that I can work independently and as part of an allied health team.
Friday, July 23, 2010
MSK week 5
S-I was referred a patient, Miss B, with an acute exacerbation of chronic low back pain. She was in a car crash in 1988 and from that time onwards she has been in constant pain, at the neck, shoulder and low back. She was initially involved in a compensation claim and has been off work since that time receiving a disability pension.
From the first moment I met her I knew she would be a tough patient. Miss B is only 44 years old, yet she walked into the treatment room with a WZF! I think now that this is in an attempt to display her sickness, especially seeing as she didn’t use it correctly. My first question to Miss B was ‘can you show me exactly where your pain is’…her response was ‘L4/L5.’ I couldn’t believe it! Throughout the assessment, many more yellow flags became apparent. She had underlined x-ray findings for me (degeneration at L4/L5, arthritic changes), she was on such a cocktail of pain meds she was unable to drive and had had numerous hospitalizations with CLBP.
In my first treatment session I tried a bit of everything. No movements of the back were relieving whatsoever, even gravity eliminated PT induced. I then tried IFT therapy with a heat pack but even this was aggravating. TENS also had the same effect. I then tried some grade II mobilizations to achieve a pain gate effect. Miss B had to sit in a special pregnancy chair as prone lying was out of the question. Doing these gentle mobilizations turned out to be disastrous. Miss B became so sweaty and was in so much pain she almost threw up. This shook me a fair bit, so I decided to leave her with just gentle pelvic floor contractions. (Even these tugged at her low back). It seemed hopeless.
T-my task was to provide appropriate treatment at her next session.
A-I realized that the above treatments I tried were not the right things for her. I had already recognized that Miss B’s pain was dominated/maintained by psychological factors and so my treatment really should have been directed at her thoughts/feelings and beliefs. So I decided to research pain in an effort to best describe it to her and decrease its threat value.
I re-read the book ‘explain pain’ and summarized what I thought was most important on 2 A4 pages. I booked an hour appointment for her next session and the first half of that we spent just talking about chronic pain and explaining her x-rays. The next half of the session we brainstormed a graduated exercise program. Miss B’s goal is to get back into pilates. Thus we made an 8 day program that encouraged gently re-entry into some basic moves…starting in sitting, moving to side-lie and then on day 7-8, into crook lying (to perform Miss B’s goal of leg slides). On day 8, she made another appointment to see me, and assuming everything goes to plan, we are aiming to start a graduated walking program.
R- Initially Miss B didn’t seem too won over by me. I think I was bit nervous because I didn’t want her to think I was suggesting she was making the pain. (Which she wasn’t…she was DEFINITELY in pain, it almost made her throw up! It’s just that the way she thinks and feels is sustaining this pain). After a while though I eased into it. Miss B seemed to be particularly open to the idea of increased sensitivity. (Having more ‘sensors’ in her low back and a lower threshold for them to fire). She understood the analogy of a car alarm that used to go off normally, and that now goes off when just a bird lands on it. This means that hurting doesn’t mean you are causing re-injury; rather it’s just a throwback to a state of heightened sensitivity.
Miss B left feeling quite excited and ready to take part in her graduated program.
E- I’m beginning to realize that with many patients, what you say can be SO MUCH more valuable to the person than what you do with your hands. It’s amazing, and probably the best tool we have.
STRENGTHS:
-Good preparation. The session would not have been successful otherwise!
-Incorporating Miss B’s goal into the graduated program. This enabled her to get on board with the idea…which I’m sure seemed very foreign to start with.
-Building a good rapport with Miss B, which was essential in order to get her to believe in what I was saying.
-Picking up on what Miss B responded to (pain hypersensitivity), I could then use this throughout the session to keep her on track.
WEAKNESSES:
-I was nervous to start with. I didn’t want Miss B to think I was saying she was making her pain up. My nervousness probably made it even worse to start with! I think next time I’ll practice my spiel on someone first so that I’m more comfortable with how to word things.
-Until I got into the flow of things, my talking may have seemed a bit rehearsed (I had written down all my important points on paper). Hopefully it becomes more natural with practice!
S- Good preparation
- Practice first on somebody I know
- Build a good rapport
- When describing complex concepts, create simple analogy’s to aid understanding
- Find out patient goals and use them to create a meaningful treatment
- Remember to treat what you identify as the cause of the problem
From the first moment I met her I knew she would be a tough patient. Miss B is only 44 years old, yet she walked into the treatment room with a WZF! I think now that this is in an attempt to display her sickness, especially seeing as she didn’t use it correctly. My first question to Miss B was ‘can you show me exactly where your pain is’…her response was ‘L4/L5.’ I couldn’t believe it! Throughout the assessment, many more yellow flags became apparent. She had underlined x-ray findings for me (degeneration at L4/L5, arthritic changes), she was on such a cocktail of pain meds she was unable to drive and had had numerous hospitalizations with CLBP.
In my first treatment session I tried a bit of everything. No movements of the back were relieving whatsoever, even gravity eliminated PT induced. I then tried IFT therapy with a heat pack but even this was aggravating. TENS also had the same effect. I then tried some grade II mobilizations to achieve a pain gate effect. Miss B had to sit in a special pregnancy chair as prone lying was out of the question. Doing these gentle mobilizations turned out to be disastrous. Miss B became so sweaty and was in so much pain she almost threw up. This shook me a fair bit, so I decided to leave her with just gentle pelvic floor contractions. (Even these tugged at her low back). It seemed hopeless.
T-my task was to provide appropriate treatment at her next session.
A-I realized that the above treatments I tried were not the right things for her. I had already recognized that Miss B’s pain was dominated/maintained by psychological factors and so my treatment really should have been directed at her thoughts/feelings and beliefs. So I decided to research pain in an effort to best describe it to her and decrease its threat value.
I re-read the book ‘explain pain’ and summarized what I thought was most important on 2 A4 pages. I booked an hour appointment for her next session and the first half of that we spent just talking about chronic pain and explaining her x-rays. The next half of the session we brainstormed a graduated exercise program. Miss B’s goal is to get back into pilates. Thus we made an 8 day program that encouraged gently re-entry into some basic moves…starting in sitting, moving to side-lie and then on day 7-8, into crook lying (to perform Miss B’s goal of leg slides). On day 8, she made another appointment to see me, and assuming everything goes to plan, we are aiming to start a graduated walking program.
R- Initially Miss B didn’t seem too won over by me. I think I was bit nervous because I didn’t want her to think I was suggesting she was making the pain. (Which she wasn’t…she was DEFINITELY in pain, it almost made her throw up! It’s just that the way she thinks and feels is sustaining this pain). After a while though I eased into it. Miss B seemed to be particularly open to the idea of increased sensitivity. (Having more ‘sensors’ in her low back and a lower threshold for them to fire). She understood the analogy of a car alarm that used to go off normally, and that now goes off when just a bird lands on it. This means that hurting doesn’t mean you are causing re-injury; rather it’s just a throwback to a state of heightened sensitivity.
Miss B left feeling quite excited and ready to take part in her graduated program.
E- I’m beginning to realize that with many patients, what you say can be SO MUCH more valuable to the person than what you do with your hands. It’s amazing, and probably the best tool we have.
STRENGTHS:
-Good preparation. The session would not have been successful otherwise!
-Incorporating Miss B’s goal into the graduated program. This enabled her to get on board with the idea…which I’m sure seemed very foreign to start with.
-Building a good rapport with Miss B, which was essential in order to get her to believe in what I was saying.
-Picking up on what Miss B responded to (pain hypersensitivity), I could then use this throughout the session to keep her on track.
WEAKNESSES:
-I was nervous to start with. I didn’t want Miss B to think I was saying she was making her pain up. My nervousness probably made it even worse to start with! I think next time I’ll practice my spiel on someone first so that I’m more comfortable with how to word things.
-Until I got into the flow of things, my talking may have seemed a bit rehearsed (I had written down all my important points on paper). Hopefully it becomes more natural with practice!
S- Good preparation
- Practice first on somebody I know
- Build a good rapport
- When describing complex concepts, create simple analogy’s to aid understanding
- Find out patient goals and use them to create a meaningful treatment
- Remember to treat what you identify as the cause of the problem
Saturday, July 10, 2010
MSK week 3
S- Mrs A was referred to me with R shoulder pain. After a thorough examination, I concluded she had a R shoulder impingement secondary to poor posture, namely a stiff and stuck thoracic spine (into flexion), protracted and ante-tilted scapulae, and an anteriorly sitting and internally rotated humeral head.
Taking her history, I began to realise she was also very dejected about her shoulder and the treatment she had received. The initial injury occurred 19 years ago (a SS tear). She was put on the waitlist for surgery. After being on the list for so long the surgeon told her it had gone beyond repair, and due to her age etc surgery was no longer an option. She was under the care of GP following this, and seemed to get lost in the system. She said she had been waiting two years to see a physio. She really felt like no one took her problem seriously. She knew it wasn’t going to miraculously recover, but she desperately wanted guidance in things she could do!!
T- Provide appropriate treatment and create a meaningful home exercise program.
A- I spent so long with the assessment I actually had to re-book Mrs A the following day for a treatment session. At this session I decided that my best tool was communication. I needed her to understand how posture causes shoulder pain to have any hope of her getting on board and performing her HEP. Most importantly though, I needed to reassure that her problem was important to me and that I was going to go out of my way to treat her as best I could. If I could get her feeling more positive about the care she received I felt we could make a real difference to her problem.
We spent 20 mins going over shoulder impingement and I made use of skeleton to demonstrate. I then performed a passive physiological in thoracic extension, provided an individualised HEP and referred Mrs A to the upper limb hydro classes.
R- Mrs A was extremely happy to have been listened to, taken seriously and be given the tools to start to take control of her life. At her follow-up appointment, 2 weeks later, she stated that her pain had reduced by up to 80%! And that she had regained function of the arm.
E- I was really amazed at the success Mrs A experienced! I’m not so sure she would experience benefits that rapidly from exercise, but I do think having an understanding of your problem and being given the ability to self-manage would make a huge difference….the power of the mind!! No one had explained any reason for her shoulder pain. Once she had an understanding she could start to control it. She no longer viewed her problem as completely unfixable and ruining her life. I’m sure that positivity changes your pain experience.
I was really proud that I could do that for her. I think it helped that I booked an hour appointment for her following our assessment. I feel that she benefited most from the time I put into education and demonstration and I feel that I communicated this really well.
However, my assessment time management DEFINITELY needs some improvement. I spent so long with her assessment that I needed to re-book her for a treatment session. She did benefit from the extra time I was able to put into her treatment, but I can’t be doing that for every patient I see! What would make everything flow faster and smoother, would be not to perform every single test I know. I need to be more streamlined, right from my initial observations. For example, I only really need to test what I see. Looking at Mrs A’s posture (as described above) the key muscles to test the length of probably would be pecs, infraspinatus and lats. Whereas I tested every muscle around the shoulder/neck. In retrospect this definitely was a time waster, and had no impact on my treatment. I need to know what tests to omit rather than doing every single test I know! I’m hoping this improves with experience.
S- listening!
-education
-communication
These 3 things are, I think, what made my treatment successful, more so than any hands on treatment I could offer. I'm realising how important this is with every patient. You need them to be confident in you in order for them to do any home exercise/self management.
TIME MANAGEMENT! omit those things that are unnecessary to test in order to make my assessment smoother and faster!
Taking her history, I began to realise she was also very dejected about her shoulder and the treatment she had received. The initial injury occurred 19 years ago (a SS tear). She was put on the waitlist for surgery. After being on the list for so long the surgeon told her it had gone beyond repair, and due to her age etc surgery was no longer an option. She was under the care of GP following this, and seemed to get lost in the system. She said she had been waiting two years to see a physio. She really felt like no one took her problem seriously. She knew it wasn’t going to miraculously recover, but she desperately wanted guidance in things she could do!!
T- Provide appropriate treatment and create a meaningful home exercise program.
A- I spent so long with the assessment I actually had to re-book Mrs A the following day for a treatment session. At this session I decided that my best tool was communication. I needed her to understand how posture causes shoulder pain to have any hope of her getting on board and performing her HEP. Most importantly though, I needed to reassure that her problem was important to me and that I was going to go out of my way to treat her as best I could. If I could get her feeling more positive about the care she received I felt we could make a real difference to her problem.
We spent 20 mins going over shoulder impingement and I made use of skeleton to demonstrate. I then performed a passive physiological in thoracic extension, provided an individualised HEP and referred Mrs A to the upper limb hydro classes.
R- Mrs A was extremely happy to have been listened to, taken seriously and be given the tools to start to take control of her life. At her follow-up appointment, 2 weeks later, she stated that her pain had reduced by up to 80%! And that she had regained function of the arm.
E- I was really amazed at the success Mrs A experienced! I’m not so sure she would experience benefits that rapidly from exercise, but I do think having an understanding of your problem and being given the ability to self-manage would make a huge difference….the power of the mind!! No one had explained any reason for her shoulder pain. Once she had an understanding she could start to control it. She no longer viewed her problem as completely unfixable and ruining her life. I’m sure that positivity changes your pain experience.
I was really proud that I could do that for her. I think it helped that I booked an hour appointment for her following our assessment. I feel that she benefited most from the time I put into education and demonstration and I feel that I communicated this really well.
However, my assessment time management DEFINITELY needs some improvement. I spent so long with her assessment that I needed to re-book her for a treatment session. She did benefit from the extra time I was able to put into her treatment, but I can’t be doing that for every patient I see! What would make everything flow faster and smoother, would be not to perform every single test I know. I need to be more streamlined, right from my initial observations. For example, I only really need to test what I see. Looking at Mrs A’s posture (as described above) the key muscles to test the length of probably would be pecs, infraspinatus and lats. Whereas I tested every muscle around the shoulder/neck. In retrospect this definitely was a time waster, and had no impact on my treatment. I need to know what tests to omit rather than doing every single test I know! I’m hoping this improves with experience.
S- listening!
-education
-communication
These 3 things are, I think, what made my treatment successful, more so than any hands on treatment I could offer. I'm realising how important this is with every patient. You need them to be confident in you in order for them to do any home exercise/self management.
TIME MANAGEMENT! omit those things that are unnecessary to test in order to make my assessment smoother and faster!
Saturday, June 26, 2010
week 1 MSK- EBP
S- We are able to access our new patient referrals for the next working day. Checking through Tuesday’s referrals, I noticed I was referred a patient with Achilles Tendinopathy. Her doctor had recommended the ‘Alfredson Eccentric Protocol’ as a potential treatment strategy.
T- I like to prepare for the new patients I see, thus my task was to
a) find out what the Alfredson Eccentric Protocol involves, and;
b) find out if it is beneficial when compared with other treatments for Achilles Tendinopathy.
A- Searching Pedro, I found a systemic review of 8 articles, 4 RCTs and 4 cohort studies. 6/8 articles used the alfredson eccentric protocol, and 2/8 articles used a variation of the alfredson eccentric protocol. The various control groups used the following conventional treatment:
- Surgery
- Pain free concentric exercises
- Pain free stretching
- Night splint
- Night splint with eccentric exercises
R- Alfredson et al. (1998) developed the eccentric traning protocol as follows:
- 3 sets of 15 reps eccentric heel drops 2x/day, 7days/week for 12 weeks
- Work through non- disabling pain
- Progressively add weight
The benefits of the alfredson program above and beyond those of the control groups were as follows:
PAIN:
-In 5/8 studies improvements were seen in both the eccentric and control groups
-Results were on average 34% better the eccentric groups
FUNCTION:
-At 12 weeks function improved an average of 42% from baseline in the eccentric
groups
-The control groups also improved an average of 33% from baseline
As a result, I decided to use the Alfredson eccentric protocol with my patient the following day.
E- Some of the evidence I found was of questionable quality. There were varied ‘control’ groups, most of the studies were not randomized, various different outcome measures were used and various methods of diagnosis were employed.
However, the results were fairly persuasive suggesting that pain enduring eccentric exercise is superior to conventional therapy. From my own knowledge base, I would choose to use eccentric exercise anyway; regardless of what protocol I would be following. Thus, I decided to use the Alfredson protocol.
I feel that preparing for my patient and researching the protocol was a valuable task. It means I am continually learning, staying up to date with research, am able to write back to the doctor letting them know I was on top of what they asked of me and I was able to deliver better quality, evidence based care.
S- Electronic search of databases
-quality checking of articles
T- I like to prepare for the new patients I see, thus my task was to
a) find out what the Alfredson Eccentric Protocol involves, and;
b) find out if it is beneficial when compared with other treatments for Achilles Tendinopathy.
A- Searching Pedro, I found a systemic review of 8 articles, 4 RCTs and 4 cohort studies. 6/8 articles used the alfredson eccentric protocol, and 2/8 articles used a variation of the alfredson eccentric protocol. The various control groups used the following conventional treatment:
- Surgery
- Pain free concentric exercises
- Pain free stretching
- Night splint
- Night splint with eccentric exercises
R- Alfredson et al. (1998) developed the eccentric traning protocol as follows:
- 3 sets of 15 reps eccentric heel drops 2x/day, 7days/week for 12 weeks
- Work through non- disabling pain
- Progressively add weight
The benefits of the alfredson program above and beyond those of the control groups were as follows:
PAIN:
-In 5/8 studies improvements were seen in both the eccentric and control groups
-Results were on average 34% better the eccentric groups
FUNCTION:
-At 12 weeks function improved an average of 42% from baseline in the eccentric
groups
-The control groups also improved an average of 33% from baseline
As a result, I decided to use the Alfredson eccentric protocol with my patient the following day.
E- Some of the evidence I found was of questionable quality. There were varied ‘control’ groups, most of the studies were not randomized, various different outcome measures were used and various methods of diagnosis were employed.
However, the results were fairly persuasive suggesting that pain enduring eccentric exercise is superior to conventional therapy. From my own knowledge base, I would choose to use eccentric exercise anyway; regardless of what protocol I would be following. Thus, I decided to use the Alfredson protocol.
I feel that preparing for my patient and researching the protocol was a valuable task. It means I am continually learning, staying up to date with research, am able to write back to the doctor letting them know I was on top of what they asked of me and I was able to deliver better quality, evidence based care.
S- Electronic search of databases
-quality checking of articles
Friday, June 18, 2010
MSK initial entry
Tomorrow I start my MSK prac at the Community Health Centre in Mandurah.
NATURE: From what I understand I will be seeing MSK patients in an outpatient setting. I spoke with my supervisor yesterday who mentioned that the clientele are generally older and the most common complaints are back and neck pain and shoulder problems. I will also be involved in numerous exercise classes, including; hydro, pulmonary rehab, cardiac classes, tai chi, no falls and diabetes education. From speaking to other students, I may also be required to travel to Pinjarra hospital. I’m not too sure what I would be doing here. Perhaps seeing inpatients and utilizing my experience from previous placements?
STUCTURE: I gather that I will be fairly independent on this placement. I think my day will involve seeing patients who I have booked in, either new referrals or follow up treatments. I will also be involved in the classes and potentially travelling to Pinjarra Hospital.
ROLE: I believe that I will be expected to see a full patient caseload and work as if I am a new graduate given it is our final prac. I’m going to have to prioritize my time very effectively!! I will also be involved in a number of classes. My supervisor mentioned that I am not there to partake in the classes or run them as such; the emphasis is on patients running the class for themselves (so they have the power to continue independently). Thus I will be more of a supervisor during class time.
CONCERNS: I am really excited about this placement; so far MSK is something I’ve enjoyed from the outset. I have had 2 previous MSK based placements and I am looking forward to consolidating my knowledge from these experiences (mainly upper and lower limb type things). I am quite nervous about seeing back and neck pain patients, as it will be new to me. It’s obviously something you need to get right from the beginning, as there is a higher potential for these things to become chronic. Thus I’m going to need to clinically reason appropriately!
I’m also worried about clinically reasoning within a short time frame if I’m expected to see a full caseload. Often it is helpful for me to step outside the room and gather my thoughts in relation to the clinical reasoning outline, this way I can be much more confident of my treatments. If say, I only have half an hour to see a patient I’m going to have to do this as I go…which will be difficult, but also a good challenge!
NATURE: From what I understand I will be seeing MSK patients in an outpatient setting. I spoke with my supervisor yesterday who mentioned that the clientele are generally older and the most common complaints are back and neck pain and shoulder problems. I will also be involved in numerous exercise classes, including; hydro, pulmonary rehab, cardiac classes, tai chi, no falls and diabetes education. From speaking to other students, I may also be required to travel to Pinjarra hospital. I’m not too sure what I would be doing here. Perhaps seeing inpatients and utilizing my experience from previous placements?
STUCTURE: I gather that I will be fairly independent on this placement. I think my day will involve seeing patients who I have booked in, either new referrals or follow up treatments. I will also be involved in the classes and potentially travelling to Pinjarra Hospital.
ROLE: I believe that I will be expected to see a full patient caseload and work as if I am a new graduate given it is our final prac. I’m going to have to prioritize my time very effectively!! I will also be involved in a number of classes. My supervisor mentioned that I am not there to partake in the classes or run them as such; the emphasis is on patients running the class for themselves (so they have the power to continue independently). Thus I will be more of a supervisor during class time.
CONCERNS: I am really excited about this placement; so far MSK is something I’ve enjoyed from the outset. I have had 2 previous MSK based placements and I am looking forward to consolidating my knowledge from these experiences (mainly upper and lower limb type things). I am quite nervous about seeing back and neck pain patients, as it will be new to me. It’s obviously something you need to get right from the beginning, as there is a higher potential for these things to become chronic. Thus I’m going to need to clinically reason appropriately!
I’m also worried about clinically reasoning within a short time frame if I’m expected to see a full caseload. Often it is helpful for me to step outside the room and gather my thoughts in relation to the clinical reasoning outline, this way I can be much more confident of my treatments. If say, I only have half an hour to see a patient I’m going to have to do this as I go…which will be difficult, but also a good challenge!
Saturday, June 12, 2010
final entry cardio
NATURE: The nature of our placement ended up being a bit all over the place! We were actually situated on MANY wards as during our 5 weeks as so many of the staff were either sick or on holidays...so Chris and I had to fill the gaps. It meant that we saw patients from gen med wards, hematology and oncology, ICU, Cariothoracics and rehab wards!! Even though going up and down the stairs so often was frustrating (and hard work on the legs!!), it meant we got to experience such a wide variety of patients and situations. I would now feel confident in any situation on a ward!
The peer-coaching model worked really well. Working with Chris in the first week really put me at ease. It meant I wasn't as nervous as I could have been seeing our first ever ward patients. We broke it down well, with one of us doing the subjective assessment and the other doing the objective assessment. This way the patient only had to listen to one person, and the other student could watch and then give very valuable feedback. This is great, because your supervisor can't be with you all the time, and getting feedback from a third party is often what you need to improve. In the second week, Chris and I saw our own patients and I felt much more confident after a week of peer work. And, we DID run the ward in our last week. It was flat out, exciting and a great learning curve. Your time management has to be PERFECT!
STRUCTURE: The structure was as I initially thought. Seeing patients on the ward daily who are flagged as needing physio reviews/treatments. It was difficult to fit in around the other health professionals. Patients constantly have procedures to go to etc. But having so many patients meant there was always someone else you could see. As long as I prioritised my patient list and didn't miss any urgent priorities, my day ran fairly smoothly.
ROLE: My role really was as a colleague to my supervisor. With all the staffing issues Chris and I were running a ward by the end of our placement. Without us there I think many patients would have missed and I feel like our help was really appreciated!
CONCERNS: There were many sick people on prac, and it was overwhelming. But I think I managed it well. In the acute stages of illness/recovery you do see rapid improvements, so there was a lot of hope involved with many of the patients. Also, knowing I was on such a strict time schedule helped. At Shenton Park I sometimes had up to 3 hours with people, which was emotionally draining. I think that at Freo, I managed my patient list well and didn't let myself become too emotionally involved.
Oh my god. The attachments were so daunting! I was right to be concerned! I couldn't believe how many tubes and lines could be in one person! We were very lucky in seeing some surgery patients with our tutor. She talked us through all the attachments, and when you have done it once, it is much less scary the next time! Also, if I was ever unsure, I just asked the nursing staff. They mobilise people to the bathroom etc daily and probably have the BEST understanding of attachments and what can be moved/unplugged etc. I've decided no question is too silly!
My take home message: I thoroughly enjoyed working at Freo, but I don’t know if it’s something I would want to do forever. I found that in ICU my time was really warranted and people really needed chest physio. However, up on the general med wards, I constantly found myself taking people for walks and going through deep breathing cycles. For all that we need to learn at uni, I was a bit disappointed at our limited scope in practice.
BUT…for the people that did really need me, it was very rewarding. I think that as a student you should take every opportunity in the hospital. I always jumped at any chance to go down to ICU/cardiothoraics and try and experience every facet of hospital life. It meant that I was exposed to suction, MHI/VHI and other techniques that are used less frequently on the ward. It also meant that I could really fine-tune my cardio assessment skills to every type of patient. It really is so important to have your assessment skills down pat. You use the same assessment for every patient and having it together perfectly means you can best come up with a problem list and justify your reasons for specific treatments. (Also, the same recipe won’t work for every one. Assessing correctly allows you to cater to the individual.)
Lastly, from the moment a patient is admitted, hospital becomes all about when they can leave and how we can best prepare them for this. I realized that discharge planning is often the most important aspect of our treatments, and it should be on your mind from the first assessment with your patient. It is so important, and good discharge planning should keep patients from being re-admitted. Thus, we should all do our best to familiarize ourselves with the services out there so as to provide the optimal care for our patients.
The peer-coaching model worked really well. Working with Chris in the first week really put me at ease. It meant I wasn't as nervous as I could have been seeing our first ever ward patients. We broke it down well, with one of us doing the subjective assessment and the other doing the objective assessment. This way the patient only had to listen to one person, and the other student could watch and then give very valuable feedback. This is great, because your supervisor can't be with you all the time, and getting feedback from a third party is often what you need to improve. In the second week, Chris and I saw our own patients and I felt much more confident after a week of peer work. And, we DID run the ward in our last week. It was flat out, exciting and a great learning curve. Your time management has to be PERFECT!
STRUCTURE: The structure was as I initially thought. Seeing patients on the ward daily who are flagged as needing physio reviews/treatments. It was difficult to fit in around the other health professionals. Patients constantly have procedures to go to etc. But having so many patients meant there was always someone else you could see. As long as I prioritised my patient list and didn't miss any urgent priorities, my day ran fairly smoothly.
ROLE: My role really was as a colleague to my supervisor. With all the staffing issues Chris and I were running a ward by the end of our placement. Without us there I think many patients would have missed and I feel like our help was really appreciated!
CONCERNS: There were many sick people on prac, and it was overwhelming. But I think I managed it well. In the acute stages of illness/recovery you do see rapid improvements, so there was a lot of hope involved with many of the patients. Also, knowing I was on such a strict time schedule helped. At Shenton Park I sometimes had up to 3 hours with people, which was emotionally draining. I think that at Freo, I managed my patient list well and didn't let myself become too emotionally involved.
Oh my god. The attachments were so daunting! I was right to be concerned! I couldn't believe how many tubes and lines could be in one person! We were very lucky in seeing some surgery patients with our tutor. She talked us through all the attachments, and when you have done it once, it is much less scary the next time! Also, if I was ever unsure, I just asked the nursing staff. They mobilise people to the bathroom etc daily and probably have the BEST understanding of attachments and what can be moved/unplugged etc. I've decided no question is too silly!
My take home message: I thoroughly enjoyed working at Freo, but I don’t know if it’s something I would want to do forever. I found that in ICU my time was really warranted and people really needed chest physio. However, up on the general med wards, I constantly found myself taking people for walks and going through deep breathing cycles. For all that we need to learn at uni, I was a bit disappointed at our limited scope in practice.
BUT…for the people that did really need me, it was very rewarding. I think that as a student you should take every opportunity in the hospital. I always jumped at any chance to go down to ICU/cardiothoraics and try and experience every facet of hospital life. It meant that I was exposed to suction, MHI/VHI and other techniques that are used less frequently on the ward. It also meant that I could really fine-tune my cardio assessment skills to every type of patient. It really is so important to have your assessment skills down pat. You use the same assessment for every patient and having it together perfectly means you can best come up with a problem list and justify your reasons for specific treatments. (Also, the same recipe won’t work for every one. Assessing correctly allows you to cater to the individual.)
Lastly, from the moment a patient is admitted, hospital becomes all about when they can leave and how we can best prepare them for this. I realized that discharge planning is often the most important aspect of our treatments, and it should be on your mind from the first assessment with your patient. It is so important, and good discharge planning should keep patients from being re-admitted. Thus, we should all do our best to familiarize ourselves with the services out there so as to provide the optimal care for our patients.
Thursday, June 10, 2010
week 5 cardio-treatment
STARES
S- Mrs C is a 63 year old lady admitted to the ward with ?pneumonia. She also has a 30-year history of bronchiectasis, which she has managed well throughout her life. Her husband passed away 2 years ago and she admits he played a large role in her care. He built a makeshift tilt table and percussed her chest daily to help her secretion removal. Since being in hospital, Mrs C’s secretions have increased. She feels that being out of her daily rhythm fatigues her and decreases her ability to self manage.
My assessment found the following asterisk signs, moist cough++, widespread scattered wheeze (low pitched) throughout lung field R>L, coarse expiratory crackles R LL. So, I concluded impaired airway clearance to be her major problem.
T- I had to plan an appropriate treatment session to best cater to Mrs C.
A-Firstly, I decided to ask Mrs C how she would usually manage her secretions…with a 30-year history of bronchiectasis I assumed she was fairly well versed in self-management.
Mrs C informed me that her husband percussed her chest daily on a tilt table they had made together. She stated this was the best thing for her and related her husband’s death to her now more frequent hospital admissions. She said she was most productive in prone lying with two pillows under her chest.
With this information on board I developed the following treatment plan.
1. Ambulation to encourage deep breathing (via demand ventilation principal) to hopefully begin to mobilise secretions in the lower lobes.
2. Percussions in L side lying, 2 pillows under chest and 30 degrees of head down tilt.
3. Mrs C performed ACBT cycles throughout (I had taught her previous to ambulating)
4. Percussions in prone lying, 2 pillows under chest with 30 degrees of head down tilt and ACT cycles.
-Throughout the treatment I continually asked Mrs C how she was going, if I was doing it correctly/with enough pressure, and when she felt she had had enough.
R-I feel that our first treatment session went really well. Mrs C was productive of about 10x M2P2 sputum plugs and stated that, although tired, she felt much better afterwards.
E- STRENGTHS:
-By asking Mrs C what she usually did enabled us to build a strong rapport. She instantly knew that I wanted to listen to what she had to say in regards to what has been successful for her in the past.
-I incorporated what Mrs C suggested as well as some new ideas (walking first to mobilise secretions, L side-lying as position 1 ad utilising the ACBT throughout treatment). I feel that my choice of treatments were very effective because I had clinically reasoned to justify them.
-I was safe in all treatments, ensuring to ask all relevant C/I and precautions for percussion and GADP. Mrs C was clear of anything that may have contraindicated the treatments. She had had an abscess removed from her brain over a year ago, which I felt was not recent enough to exclude head down tilt as a treatment option.
WEAKNESS
-I used auscultation as my asterisk sign and re-measured this after treatment. However, I also think monitoring her sats throughout treatment would have been wise. I could have monitored for improvement as well as ensuring she could cope from a respiratory sense with the treatments.
-I think my hands-on treatment was appropriate as an inpatient, but I needed to think to d/c planning from the moment I met her. Obviously she can’t continue percussions at home (and her husband passed away 2 years ago meaning he can no longer help her out). My supervisor suggested calling silver chain. They can go to her home 3x/week for hands-on chest physio. All I had to do then was think of something she could do independently. (We decided upon walking first, then performing ACBTs, using bubble pep during the TEE’s.)
S- LISTENING! I think the biggest help in my treatment was asking my patient what worked for her. People have to manage their own chronic disease and so obviously know the best strategies.
-Think to discharge planning from the first meeting. This makes their whole hospital stay smooth and ensures they can cope when they return home.
-Create a good problem list! From this, it is very easy to clinically reason appropriate treatment.
-Check all C/I’s and precautions.
S- Mrs C is a 63 year old lady admitted to the ward with ?pneumonia. She also has a 30-year history of bronchiectasis, which she has managed well throughout her life. Her husband passed away 2 years ago and she admits he played a large role in her care. He built a makeshift tilt table and percussed her chest daily to help her secretion removal. Since being in hospital, Mrs C’s secretions have increased. She feels that being out of her daily rhythm fatigues her and decreases her ability to self manage.
My assessment found the following asterisk signs, moist cough++, widespread scattered wheeze (low pitched) throughout lung field R>L, coarse expiratory crackles R LL. So, I concluded impaired airway clearance to be her major problem.
T- I had to plan an appropriate treatment session to best cater to Mrs C.
A-Firstly, I decided to ask Mrs C how she would usually manage her secretions…with a 30-year history of bronchiectasis I assumed she was fairly well versed in self-management.
Mrs C informed me that her husband percussed her chest daily on a tilt table they had made together. She stated this was the best thing for her and related her husband’s death to her now more frequent hospital admissions. She said she was most productive in prone lying with two pillows under her chest.
With this information on board I developed the following treatment plan.
1. Ambulation to encourage deep breathing (via demand ventilation principal) to hopefully begin to mobilise secretions in the lower lobes.
2. Percussions in L side lying, 2 pillows under chest and 30 degrees of head down tilt.
3. Mrs C performed ACBT cycles throughout (I had taught her previous to ambulating)
4. Percussions in prone lying, 2 pillows under chest with 30 degrees of head down tilt and ACT cycles.
-Throughout the treatment I continually asked Mrs C how she was going, if I was doing it correctly/with enough pressure, and when she felt she had had enough.
R-I feel that our first treatment session went really well. Mrs C was productive of about 10x M2P2 sputum plugs and stated that, although tired, she felt much better afterwards.
E- STRENGTHS:
-By asking Mrs C what she usually did enabled us to build a strong rapport. She instantly knew that I wanted to listen to what she had to say in regards to what has been successful for her in the past.
-I incorporated what Mrs C suggested as well as some new ideas (walking first to mobilise secretions, L side-lying as position 1 ad utilising the ACBT throughout treatment). I feel that my choice of treatments were very effective because I had clinically reasoned to justify them.
-I was safe in all treatments, ensuring to ask all relevant C/I and precautions for percussion and GADP. Mrs C was clear of anything that may have contraindicated the treatments. She had had an abscess removed from her brain over a year ago, which I felt was not recent enough to exclude head down tilt as a treatment option.
WEAKNESS
-I used auscultation as my asterisk sign and re-measured this after treatment. However, I also think monitoring her sats throughout treatment would have been wise. I could have monitored for improvement as well as ensuring she could cope from a respiratory sense with the treatments.
-I think my hands-on treatment was appropriate as an inpatient, but I needed to think to d/c planning from the moment I met her. Obviously she can’t continue percussions at home (and her husband passed away 2 years ago meaning he can no longer help her out). My supervisor suggested calling silver chain. They can go to her home 3x/week for hands-on chest physio. All I had to do then was think of something she could do independently. (We decided upon walking first, then performing ACBTs, using bubble pep during the TEE’s.)
S- LISTENING! I think the biggest help in my treatment was asking my patient what worked for her. People have to manage their own chronic disease and so obviously know the best strategies.
-Think to discharge planning from the first meeting. This makes their whole hospital stay smooth and ensures they can cope when they return home.
-Create a good problem list! From this, it is very easy to clinically reason appropriate treatment.
-Check all C/I’s and precautions.
Sunday, May 30, 2010
week 3 cardio. Communication.
S- Last week I was to do a quick screen of a patient, Ms B, admitted with hepatopulmonary syndrome to see whether she would benefit from PT. I looked up hepatopulmonary syndrome, and found it to be characterised by SOB and hpoxeamia secondary to vasodilation in the lungs of liver patients. Interestingly, this patient's liver cirrhosis was iatrogenic (caused from over-medication), she hadn't had a drink in her life! Reading through her EXTENSIVE medical file I also found out she has a fused R ankle and foot (caused by rotting bone that wasn't diagnosed for 12 years!), (R) TKR and (R) femoral pin and plate (secondary to this bone condition), chronic pain, severe depression (she had actually lost some of the function in her hands because she had previously slit her wrists very deeply) and a form of bipolar personality disorder. She had had a psych review that morning which concluded she had no current suicidal ideations. (This is just a snippet of her PMHx)
I then went to see the patient. In an hour, I only got through a subjective assessment because she spent the entire time crying. I began to realise it wasn't my PT skills that would benefit this lady, but my ability to advocate for her. I learnt that she didn't trust doctors (she felt her bone disorder and liver cirrhosis was directly the fault of her doctor), she had a very large financial debt, her children wanted nothing to do with her, and her carer was her alcoholic ex-husband. It was during this hour that the patient admitted to me she was suicidal but hadn't told the pysch. SHe said she wouldn't do anything about this in hospital but was considering suicide upon d/c.
T- My task was to communicate with the allied and medical team my fears for the patient and push for further psychological investigation.
A-I felt somewhat nervous about speaking to the Registrar because in their eyes they had already done enough and come up with a suitable answer. It was quite obvious they were writing the patient's concerns off. She had been admitted Freo 6 times in the past 2 months and so understandably seemed like quite a handful. She was medically stable (her SOB was due to anxiety) and so suitable for d/c in the medical teams eyes. I told them that I thought she wasn't ready for d/c. I felt she needed a social work r/v and another pysch consult. The registrar's first reaction was to roll her eyes. She told me the patient acted like this all the time and didn't need further consultation. Instead of agreeing I made note of all the relevant points in Ms B's history, including the fact she had attempted suicide before! I really tried to insist that more could be done for her as she really felt she was in a hopeless situation.
I then informed the social worker about Ms B, her home life and financial situation.
Lastly, I spoke with my supervisor. My supervisor really pushes for us to know when to d/c a patient from our care (even if they're not yet d/c from hospital). He feels it wastes your time and the time you could dedicate to other patients if you're still seeing people who have returned to their baseline function and are managing their problems independently. Thus I knew I would have to be very clear in my reasons for wanting to continue seeing Ms B. I felt she had some separation anxiety, with the loss of her kids from her life and being palmed off from health professional to health professional. Thus I felt it so important I keep seeing her, purely for some continuity of care. And with the stakes so high, it couldn't have been more important! I let him know I understood the reasons for d/c independent patients etc before leaping into my reasoning. He was very agreeable with my reasons.
R-The medical team agreed to keep her in hospital until she could see a social worker and begin to work through some of her difficulties. They also asked for another pysch consult as they agreed in the end she needed some strategies in place to manage her life and potentially some medications etc.
The SW was grateful for my referral as the patient was obviously in need of some extra services at home and help with welfare/financial issues.
Lastly, my supervisor thought that my reasons to continue seeing Ms B were valid and appropriate.
E-I was so proud of myself for viewing Ms B holistically and advocating for her. I felt that my communication was professional and mature, making my requests seem more urgent. When the Reg initially rolled her eyes I felt defeated, and was about to just agree...I feel I've been doing a LOT of agreeing on prac! I think people might view me as more polite if I agree but I'm starting to realise this isn't always the case. If something more needs to be done or said it is much better to say it (Still in as polite a way as possible). And I didn't need to be nervous, because when I clearly put forward my points she was very understanding. I think it helped that I had sat down before speaking to the doctor to gather my thoughts. I had made a concise list of reasons why Ms B needed to stay in hospital longer so my points had a lot more conviction.
S- STRATEGIES I USED:
-Make yourself known to the team from day one of prac. If people know who are they will be more willing to listen.
-Stand strong to your convictions, if you feel it's important don't let anyone brush you off.
-Make a list of points that are important and relevant to your case. That way you don't ramble about a whole lot of nothing! People are busy and need to know the most important facts first!
-Make note of the good things they have done for the patient before making any suggestions about further care, because ultimately you need people to be on board and in agreement with you to work most effectively as a team.
I then went to see the patient. In an hour, I only got through a subjective assessment because she spent the entire time crying. I began to realise it wasn't my PT skills that would benefit this lady, but my ability to advocate for her. I learnt that she didn't trust doctors (she felt her bone disorder and liver cirrhosis was directly the fault of her doctor), she had a very large financial debt, her children wanted nothing to do with her, and her carer was her alcoholic ex-husband. It was during this hour that the patient admitted to me she was suicidal but hadn't told the pysch. SHe said she wouldn't do anything about this in hospital but was considering suicide upon d/c.
T- My task was to communicate with the allied and medical team my fears for the patient and push for further psychological investigation.
A-I felt somewhat nervous about speaking to the Registrar because in their eyes they had already done enough and come up with a suitable answer. It was quite obvious they were writing the patient's concerns off. She had been admitted Freo 6 times in the past 2 months and so understandably seemed like quite a handful. She was medically stable (her SOB was due to anxiety) and so suitable for d/c in the medical teams eyes. I told them that I thought she wasn't ready for d/c. I felt she needed a social work r/v and another pysch consult. The registrar's first reaction was to roll her eyes. She told me the patient acted like this all the time and didn't need further consultation. Instead of agreeing I made note of all the relevant points in Ms B's history, including the fact she had attempted suicide before! I really tried to insist that more could be done for her as she really felt she was in a hopeless situation.
I then informed the social worker about Ms B, her home life and financial situation.
Lastly, I spoke with my supervisor. My supervisor really pushes for us to know when to d/c a patient from our care (even if they're not yet d/c from hospital). He feels it wastes your time and the time you could dedicate to other patients if you're still seeing people who have returned to their baseline function and are managing their problems independently. Thus I knew I would have to be very clear in my reasons for wanting to continue seeing Ms B. I felt she had some separation anxiety, with the loss of her kids from her life and being palmed off from health professional to health professional. Thus I felt it so important I keep seeing her, purely for some continuity of care. And with the stakes so high, it couldn't have been more important! I let him know I understood the reasons for d/c independent patients etc before leaping into my reasoning. He was very agreeable with my reasons.
R-The medical team agreed to keep her in hospital until she could see a social worker and begin to work through some of her difficulties. They also asked for another pysch consult as they agreed in the end she needed some strategies in place to manage her life and potentially some medications etc.
The SW was grateful for my referral as the patient was obviously in need of some extra services at home and help with welfare/financial issues.
Lastly, my supervisor thought that my reasons to continue seeing Ms B were valid and appropriate.
E-I was so proud of myself for viewing Ms B holistically and advocating for her. I felt that my communication was professional and mature, making my requests seem more urgent. When the Reg initially rolled her eyes I felt defeated, and was about to just agree...I feel I've been doing a LOT of agreeing on prac! I think people might view me as more polite if I agree but I'm starting to realise this isn't always the case. If something more needs to be done or said it is much better to say it (Still in as polite a way as possible). And I didn't need to be nervous, because when I clearly put forward my points she was very understanding. I think it helped that I had sat down before speaking to the doctor to gather my thoughts. I had made a concise list of reasons why Ms B needed to stay in hospital longer so my points had a lot more conviction.
S- STRATEGIES I USED:
-Make yourself known to the team from day one of prac. If people know who are they will be more willing to listen.
-Stand strong to your convictions, if you feel it's important don't let anyone brush you off.
-Make a list of points that are important and relevant to your case. That way you don't ramble about a whole lot of nothing! People are busy and need to know the most important facts first!
-Make note of the good things they have done for the patient before making any suggestions about further care, because ultimately you need people to be on board and in agreement with you to work most effectively as a team.
Saturday, May 15, 2010
end week 1 cardio
S-We work on the Gen Med ward in the mornings, seeing patients with a variety of conditions. On Thursday we were to see a lady, Mrs A, admitted for increased SOBOE. From reading her notes we were able to ascertain that she had a history of COPD (despite never smoking) and a severe thoracic scoliosis. The doctors impressions on admission were ? exacerbation of COPD, ? worsening thoracic scoliosis. We then had a look at her x-ray and saw that her scoliosis certainly was severe, and was causing a marked reduction in her lung volumes, and could well be the reason for her dyspnoea. Looking at her blood results, she had no signs of infection, making an exacerbation of COPD less likely in my mind.
On further reading, we discovered that english was her second language and communication was difficult. She also lives alone on home oxygen (plus she is a CO2 retainer, meaning we had to be careful with oxygen levels), is short of hearing (wears bilateral hearing aids) and has 2 very supportive children.
T- Mrs A was flagged for chest physio, and our task was to conduct an initial respiratory assessment and come up with an appropriate treatment plan.
A-We entered Mrs A's room not really knowing what to expect. It soon became clear she had much difficulty understanding more complex sentences and questions. Luckily her daughter was in the room and I looked to her to help answer my questions. We went through a very thorough subjective and objective assessment, utilising Mrs A's daughter to answer questions.
We gathered very good information, and on putting the 2 assessments together we soon realised that her chest was not the main issue at play. Mrs A's scoliosis was severely restricting her ability to take deep breaths and was almost completely closing down on the right lung. This is a structural problem and something that Chris and I realised we can have little effect on. Rather than leaving it there however, we decide to follow up on the other concerns voiced by Mrs A and her daughter.
1.Mrs A mentioned she has just started choking when she drinks water, thus we decided to refer her to the speech pathologist with the thought she may need to be on thickened fluids?
2.Secondly, Mrs A's daughter mentioned that she and her brother were taking it in turn to stay the night at Mrs A's house. They felt she couldn't be alone because she couldn't hear the alarm on her oxygen tank when it signalled it was empty. This had been going on for 5 months at the expense of their own families! They were also currently doing all house-work, cooking, gardening etc and were finding it too much to integrate with their own lives. Their mother did not want to go to a nursing home, and they loved and respected her wishes, but they also identified that they needed some form of help. Chris and I referred Mrs A and her family to the wards social worker, to have a family meeting and discuss the services and options available to them.
3.Lastly, Mrs A previously walked with no aid, no more than 10 steps before she need to rest. Chris and I decided to test her out on a 4WW. This had so many benefits! She could fix her UL making her shoulder girdle available to be an accessory for breathing, she could sit on the walker if she needed to rest, and she could attach her O2 bottle to the frame for any outside trips! With the 4WW she was able to walk 3 times as far as her pre-morbid distance!
R-As a result of our extensive and thorough subjective questioning, Mrs A was referred to the correct departments and proper discharge planning could begin. I think we highlighted the crux of her problems and were able to get appropriately managed. I feel her diagnosis became more acopia, and we were the ones who were able to pick this up!
E-I was so happy with the result of our assessment. I think that as a first or second year student, I would have left the assessment thinking there was little I could do from a respiratory point of view-and felt that thus my job was done. Now, (as an almost graduate!!) I realise that there are so many aspects that go in to someone's discharge, not just physio. Our questioning flowed really well and as a result we could highlight the gaps in her care and refer her down the appropriate path. We were the first people to identify these gaps and I really feel it was because we built a rapport with her daughter and asked the right questions in the right order. For me, this case really highlighted the importance of the MDT and I feel that now it is something that will be in mind for every patient I see. Just because I can't do too many things to help there and then doesn't mean I don't know of people who can!
The weakness I identified, was that once I knew who she needed to see, I didn't really know how to go about it. I think that this is something that will come with experience and learning the certain procedures and protocol on my ward. I shouldn't be afraid to ask, because once we found out how to contact the speechy ad SW, they were more than happy to see Mrs A that day!
S-The strategies we used were
COMMUNICATION
-Involvement of Mrs A's daughter who could help translate
-Clear and slow voice when speaking to Mrs A, for ease of understanding and in recognition of her hearing loss
-If instruction were given to Mrs A, we asked for confirmation of understanding from her and her daughter
-Much use of body language and demonstration, particularly with using the 4WW (brakes, sitting to rest etc)
INVOLVEMENT OF THE MDT TEAM!!
-recognition of issues that can't be addressed by physio and appropriate referral to combat these.
On further reading, we discovered that english was her second language and communication was difficult. She also lives alone on home oxygen (plus she is a CO2 retainer, meaning we had to be careful with oxygen levels), is short of hearing (wears bilateral hearing aids) and has 2 very supportive children.
T- Mrs A was flagged for chest physio, and our task was to conduct an initial respiratory assessment and come up with an appropriate treatment plan.
A-We entered Mrs A's room not really knowing what to expect. It soon became clear she had much difficulty understanding more complex sentences and questions. Luckily her daughter was in the room and I looked to her to help answer my questions. We went through a very thorough subjective and objective assessment, utilising Mrs A's daughter to answer questions.
We gathered very good information, and on putting the 2 assessments together we soon realised that her chest was not the main issue at play. Mrs A's scoliosis was severely restricting her ability to take deep breaths and was almost completely closing down on the right lung. This is a structural problem and something that Chris and I realised we can have little effect on. Rather than leaving it there however, we decide to follow up on the other concerns voiced by Mrs A and her daughter.
1.Mrs A mentioned she has just started choking when she drinks water, thus we decided to refer her to the speech pathologist with the thought she may need to be on thickened fluids?
2.Secondly, Mrs A's daughter mentioned that she and her brother were taking it in turn to stay the night at Mrs A's house. They felt she couldn't be alone because she couldn't hear the alarm on her oxygen tank when it signalled it was empty. This had been going on for 5 months at the expense of their own families! They were also currently doing all house-work, cooking, gardening etc and were finding it too much to integrate with their own lives. Their mother did not want to go to a nursing home, and they loved and respected her wishes, but they also identified that they needed some form of help. Chris and I referred Mrs A and her family to the wards social worker, to have a family meeting and discuss the services and options available to them.
3.Lastly, Mrs A previously walked with no aid, no more than 10 steps before she need to rest. Chris and I decided to test her out on a 4WW. This had so many benefits! She could fix her UL making her shoulder girdle available to be an accessory for breathing, she could sit on the walker if she needed to rest, and she could attach her O2 bottle to the frame for any outside trips! With the 4WW she was able to walk 3 times as far as her pre-morbid distance!
R-As a result of our extensive and thorough subjective questioning, Mrs A was referred to the correct departments and proper discharge planning could begin. I think we highlighted the crux of her problems and were able to get appropriately managed. I feel her diagnosis became more acopia, and we were the ones who were able to pick this up!
E-I was so happy with the result of our assessment. I think that as a first or second year student, I would have left the assessment thinking there was little I could do from a respiratory point of view-and felt that thus my job was done. Now, (as an almost graduate!!) I realise that there are so many aspects that go in to someone's discharge, not just physio. Our questioning flowed really well and as a result we could highlight the gaps in her care and refer her down the appropriate path. We were the first people to identify these gaps and I really feel it was because we built a rapport with her daughter and asked the right questions in the right order. For me, this case really highlighted the importance of the MDT and I feel that now it is something that will be in mind for every patient I see. Just because I can't do too many things to help there and then doesn't mean I don't know of people who can!
The weakness I identified, was that once I knew who she needed to see, I didn't really know how to go about it. I think that this is something that will come with experience and learning the certain procedures and protocol on my ward. I shouldn't be afraid to ask, because once we found out how to contact the speechy ad SW, they were more than happy to see Mrs A that day!
S-The strategies we used were
COMMUNICATION
-Involvement of Mrs A's daughter who could help translate
-Clear and slow voice when speaking to Mrs A, for ease of understanding and in recognition of her hearing loss
-If instruction were given to Mrs A, we asked for confirmation of understanding from her and her daughter
-Much use of body language and demonstration, particularly with using the 4WW (brakes, sitting to rest etc)
INVOLVEMENT OF THE MDT TEAM!!
-recognition of issues that can't be addressed by physio and appropriate referral to combat these.
Sunday, May 9, 2010
week 1 cardio
Tomorrow I start my cardio prac at Fremantle hospital. Im really nervous as it will be my first experience in an inpatient setting in a large hospital! But I am also feeling excited as cardio is a subject I thoroughly enjoyed! I think it will be intense, challenging, and most of all, exciting!
NATURE: I'm not too sure about the nature of the setting. There wasn't much in depth information to go by under facility information so I spoke to some students who had been previously. From what I gathered, students are situated on particular wards, ranging from general medical, general surgical, cardiothoracics, ICU, ambulatory care and hematology and oncology. Either way, I'll be seeing very sick patients and must brush up on all attachments/ surgical approaches/ medications etc. Previous students also mentioned that Fremantle use a 'peer-coaching' model, where you work with another student initially and learn from one another. I think this is a great idea and I'm really looking forward to it. Having another opinion and point of view can only further my own knowledge! And I don't think my supervisor will be with me 100% of the time so it will be extra nice having someone else there! I think that as time passes and our skills improve, we will be seeing patients alone and almost running our own ward!!
STRUCTURE: From speaking to previous students I was able to gather a general idea of how my day will be structured. In the morning, you print off a patient list for that day, corresponding to your ward. From here, you can flag patients who you think will be appropriate, based on underlying chest conditions, pre-morbid status, long ICU stays/surgeries etc. Once you have a list, you must make time during the day to see them. I can imagine most of these wards will be bustling, with patients being constantly seen by members of the allied health and medical team, so fitting patients in and working around (and with) others may be tricky.
ROLE: I feel like my role will expand on this placement, and we may become more like colleagues rather than just students. Hospitals are very busy places and I can imagine supervisors enjoying an extra set of hands. Previous students mentioned almost staffing an entire ward by themselves! (Of course though, getting approval of the prioritised problem list before treating) I'm so looking forward to this responsibility! I think I will need to step-up and take this role head on. I imagine though that initially I will work closely with my partner and supervisor and that as time goes by I can up my patient load. All in all I am SO looking forward to the challenge! And lastly, as always, my role will be to learn as much as possible!
CONCERNS: I have quite a few concerns about this placement. Firstly, this is a brand new experience for me, working in a large hospital in an inpatient setting. I really hope that being surrounded by many sick and sad people will not be too overwhelming for me. I felt that during on prac at Shenton Park, I spent a lot of time being sad for patients. This doesn't really help anyone, and makes the day quite tough! Hopefully, I can distance myself (within reason) so that I can perform assessments and treatments to the best of my ability.
Secondly, I feel like I can understand cardio in theory, but until you've seen things in real life, you don't really have a handle on everything. For example, I understand attachments, their use and the fact that you need to move them while mobilising patients. But in real life, when I see someone with attachments galore I can imagine myself freezing and becoming flustered! I have to remember that people walk everyday and not to be put off by such a confronting sight!
Lastly, my 2 weeks off didn't feel like 2 weeks off! I think I was actually busier than when I was on prac! Consequently, I'm feeling quite under-prepared for tomorrow. I always feel like I don't know enough...but I do wish I put aside more time for study.
NATURE: I'm not too sure about the nature of the setting. There wasn't much in depth information to go by under facility information so I spoke to some students who had been previously. From what I gathered, students are situated on particular wards, ranging from general medical, general surgical, cardiothoracics, ICU, ambulatory care and hematology and oncology. Either way, I'll be seeing very sick patients and must brush up on all attachments/ surgical approaches/ medications etc. Previous students also mentioned that Fremantle use a 'peer-coaching' model, where you work with another student initially and learn from one another. I think this is a great idea and I'm really looking forward to it. Having another opinion and point of view can only further my own knowledge! And I don't think my supervisor will be with me 100% of the time so it will be extra nice having someone else there! I think that as time passes and our skills improve, we will be seeing patients alone and almost running our own ward!!
STRUCTURE: From speaking to previous students I was able to gather a general idea of how my day will be structured. In the morning, you print off a patient list for that day, corresponding to your ward. From here, you can flag patients who you think will be appropriate, based on underlying chest conditions, pre-morbid status, long ICU stays/surgeries etc. Once you have a list, you must make time during the day to see them. I can imagine most of these wards will be bustling, with patients being constantly seen by members of the allied health and medical team, so fitting patients in and working around (and with) others may be tricky.
ROLE: I feel like my role will expand on this placement, and we may become more like colleagues rather than just students. Hospitals are very busy places and I can imagine supervisors enjoying an extra set of hands. Previous students mentioned almost staffing an entire ward by themselves! (Of course though, getting approval of the prioritised problem list before treating) I'm so looking forward to this responsibility! I think I will need to step-up and take this role head on. I imagine though that initially I will work closely with my partner and supervisor and that as time goes by I can up my patient load. All in all I am SO looking forward to the challenge! And lastly, as always, my role will be to learn as much as possible!
CONCERNS: I have quite a few concerns about this placement. Firstly, this is a brand new experience for me, working in a large hospital in an inpatient setting. I really hope that being surrounded by many sick and sad people will not be too overwhelming for me. I felt that during on prac at Shenton Park, I spent a lot of time being sad for patients. This doesn't really help anyone, and makes the day quite tough! Hopefully, I can distance myself (within reason) so that I can perform assessments and treatments to the best of my ability.
Secondly, I feel like I can understand cardio in theory, but until you've seen things in real life, you don't really have a handle on everything. For example, I understand attachments, their use and the fact that you need to move them while mobilising patients. But in real life, when I see someone with attachments galore I can imagine myself freezing and becoming flustered! I have to remember that people walk everyday and not to be put off by such a confronting sight!
Lastly, my 2 weeks off didn't feel like 2 weeks off! I think I was actually busier than when I was on prac! Consequently, I'm feeling quite under-prepared for tomorrow. I always feel like I don't know enough...but I do wish I put aside more time for study.
Thursday, April 22, 2010
FINAL ENTRY NEURO
Most of my assumptions about the Wel-Tell centre were correct. Well-Tel is a play on ho-tel, ie: a hotel for well people! It is there for those people who need an intensive burst of physiotherapy but are independent enough that they don't need to stay on the ward. Not only is this better for the patients, but it saves a whole heap of tax payer money!
Patient's were generally well versed in self care, and I found that my role was supervisory, but not the extent I had guessed. I did have to ensure patients could perform their exercise programs well enough that they could do it at home. However, it was also a great time to utilise treatments techniques that could not be done at home, things like the tilt table, hydrotherapy, hands on mobilisations and stretches and normal movement facilitation etc. So not only did I supervise, I was a hands on therapist! I was correct in saying that patients were no longer in an acute phase of rehab, but this did not necessarily mean that that they needed higher level training. Some patients did require this type of therapy as they had been admitted straight after an inpatient stay on the ward, ie: were in the final stages of motor recovery post stroke or GBS. Most of the patients however had degenerative or genetic conditions like MS or HSP (hereditary spastic paraparesis.) They did not require high level training, rather treatment to maintain or improve their current functional status.
The structure of the of the program was that patients came to the gym for 2 and half hours in the morning. Here they had one on one time with a physio, doing all those things they miss out on at home, and also work independently on their tailored programs. The rest of the day is for themselve. They can book in with the OT, speech therapist, social worker, podiatrist, attend hydrotherapy or even come back to the gym in the afternoon. It is a really well-rounded program that includes every aspect of the multi-disciplinary team!! And as I had thought, patients did make some really good friends and it was definitely a motivation to work. We were all in the gym together and it made for such a nice and supportive environment!
Aside from Wel-Tell, I was also assigned to the ward 2 gym, which sees neurological inpatients. Here I dealt with stroke patients in their acute phases of recovery. This meant my role was very hands on. I felt that my afternoon patients were much more dependent and my role was to facilitate and re-educate normal movement patterns. I felt that this gave me a really huge opportunity to see such a range of conditions throughout all phases of recovery!!
Concerns:
I did feel that I was a bit behind in my neuro, but I learnt so much! I really realised that it is all related to normal movement, and as the weeks went on I was able to more effectively not the deviations from normal and why. I may have been less confident initially, but with time it became much easier. Once you develop a rapport with the patient confidence really just comes. My supervisor did expect a lot of me, but only what was within my knowledge base. She didn't expect me to have a million different treatment techniques up my sleeve. She was aware that you only learn a few at uni and the rest comes with experience. And I did learn HEAPS of different techniques, but I think I would be still learning 20 years into a neuro career...the scope of what you can do is enormous.
I did enjoy my placement, but I also found it very confronting and overwhelming. I think experience is also needed in how to detach yourself emotionally (although I also think emotion is what can make you a great physio!) It was really hard and challenged me in more ways than I imagined. I'm not sure that it's the career path I'm cut out for, but it's an experience I'll definitely remember! I think if you can master neuro you can probably master most things...having a normal movement base is what most physio is about!!
My take home message: To be really honest I felt that neuro physio was initially quite subjective, everyone seems to do everything differently and you have different feedback coming from every angle!! (I'm also aware that it is less evidence based because it's unethical to withhold treatments from these patient groups.) But I've come to realise that it doesn't overly matter if everyone does things a different way. Nothing is really 'wrong' as such...as long as you're achieving your aim of normal movement an exercise is appropriate! You need to experiment with techniques and constantly monitor and progress. This drives home the importance of assessment. If you get your neuro impairment list 100%, you can work a treatment to suit your aim! Lastly, I wasn't expected to know everything there is to know about neuro, so don't be afraid to ask! I became aware of my own limitations and as such I knew when to ask for help and advice.
Patient's were generally well versed in self care, and I found that my role was supervisory, but not the extent I had guessed. I did have to ensure patients could perform their exercise programs well enough that they could do it at home. However, it was also a great time to utilise treatments techniques that could not be done at home, things like the tilt table, hydrotherapy, hands on mobilisations and stretches and normal movement facilitation etc. So not only did I supervise, I was a hands on therapist! I was correct in saying that patients were no longer in an acute phase of rehab, but this did not necessarily mean that that they needed higher level training. Some patients did require this type of therapy as they had been admitted straight after an inpatient stay on the ward, ie: were in the final stages of motor recovery post stroke or GBS. Most of the patients however had degenerative or genetic conditions like MS or HSP (hereditary spastic paraparesis.) They did not require high level training, rather treatment to maintain or improve their current functional status.
The structure of the of the program was that patients came to the gym for 2 and half hours in the morning. Here they had one on one time with a physio, doing all those things they miss out on at home, and also work independently on their tailored programs. The rest of the day is for themselve. They can book in with the OT, speech therapist, social worker, podiatrist, attend hydrotherapy or even come back to the gym in the afternoon. It is a really well-rounded program that includes every aspect of the multi-disciplinary team!! And as I had thought, patients did make some really good friends and it was definitely a motivation to work. We were all in the gym together and it made for such a nice and supportive environment!
Aside from Wel-Tell, I was also assigned to the ward 2 gym, which sees neurological inpatients. Here I dealt with stroke patients in their acute phases of recovery. This meant my role was very hands on. I felt that my afternoon patients were much more dependent and my role was to facilitate and re-educate normal movement patterns. I felt that this gave me a really huge opportunity to see such a range of conditions throughout all phases of recovery!!
Concerns:
I did feel that I was a bit behind in my neuro, but I learnt so much! I really realised that it is all related to normal movement, and as the weeks went on I was able to more effectively not the deviations from normal and why. I may have been less confident initially, but with time it became much easier. Once you develop a rapport with the patient confidence really just comes. My supervisor did expect a lot of me, but only what was within my knowledge base. She didn't expect me to have a million different treatment techniques up my sleeve. She was aware that you only learn a few at uni and the rest comes with experience. And I did learn HEAPS of different techniques, but I think I would be still learning 20 years into a neuro career...the scope of what you can do is enormous.
I did enjoy my placement, but I also found it very confronting and overwhelming. I think experience is also needed in how to detach yourself emotionally (although I also think emotion is what can make you a great physio!) It was really hard and challenged me in more ways than I imagined. I'm not sure that it's the career path I'm cut out for, but it's an experience I'll definitely remember! I think if you can master neuro you can probably master most things...having a normal movement base is what most physio is about!!
My take home message: To be really honest I felt that neuro physio was initially quite subjective, everyone seems to do everything differently and you have different feedback coming from every angle!! (I'm also aware that it is less evidence based because it's unethical to withhold treatments from these patient groups.) But I've come to realise that it doesn't overly matter if everyone does things a different way. Nothing is really 'wrong' as such...as long as you're achieving your aim of normal movement an exercise is appropriate! You need to experiment with techniques and constantly monitor and progress. This drives home the importance of assessment. If you get your neuro impairment list 100%, you can work a treatment to suit your aim! Lastly, I wasn't expected to know everything there is to know about neuro, so don't be afraid to ask! I became aware of my own limitations and as such I knew when to ask for help and advice.
week 5 neuro
S- I have been continuing my treatment with Mr B in the neurological inpatient gym every afternoon. Mr B suffered a L pontine stroke on the 12/03/2010 and consequently is experiencing R hemiparesis and hemisensory loss, as well as decreased arousal, mild expressive dysphasia and moderate dysarthria. Mr B is displaying excellent movement return and we have minimised the amount of tone coming in. All in all he is displaying excellent potential for a good recovery!!
However, on Monday and Tuesday we experienced 2 set-backs in therapy. On Monday he had a fall in the PT gym. My supervisor and I were practicing 2 mod A STS with Mr B as this is major goal, he is VERY focussed on achieving this as he wants to be able to transfer without the hoist. Mr B is determined, but if something is too hard he will sit down without any warning to the PT, you just have to be ready. During STS from the W/C, Mr B made it about half way, then just could not straighten his legs any further. He slipped in front of the W/C, and as he weighs 97kg my supervisor and I just could not save him, so we began a controlled lowering to the floor. He then required a 3 max A to get back into the W/C. It turned out fine, but it shattered Mr B's confidence.
The next day, shortly after Mr B's arrival he needed to go to the bathroom. He has suffered some urge incontinence since his stroke so I quickly rushed him up to the ward. Once here, I offered my assistance but as he is a standing hoist t/f the nursing staff declined, they would just have to teach me to use the hoist and he was in a rush. I decided to wait for Mr B so I could take him back to the gym and save the PCA. I was waiting in the office and heard the nursing staff talking about me. It was very unprofessional. They suggested that PT never offer to help, they were run off their feet and I was just sitting down! (Meanwhile, they couldn't have been that busy if 6 people had the time to and around and talk about me.) It really upset me as I try my hardest to be polite and helpful, I would never intentionally not offer my assistance. So, I stood up and joined their conversation...with the end result being me bullied into getting Mr B off the toilet. This was really awkward for him. After the experience, he said he was too embarrassed to come back to phsyio and absolutely dreaded it!!
T-My task was to reinstate some of Mr B's confidence and reassure him about physio generally!
A-I wheeled Mr B back to his room for the day. Once here I shut the curtains to give us some privacy. I sincerely apologised for his experience in the bathroom. I let him know that I wasn't embarrassed and had taken many patients to the bathroom before. He explained that he felt physio's were for therapy only and he was mortified that I had to see him in another light. I empathised with this and understood exactly where he was coming from. We decided to put a few strategies in place to ensure that physio WAS only therapy time. They offer patients drinks while they're in the gym. Mr B felt his drink had upset his stomach, so we opted for water only while exercising. We also pushed back his start time till 2:30. This allowed his lunch to go down (he has just started to eat normal meals so he felt he needed some time getting used to it again.) This also worked well for me, as I had a higher level patient who could come and take Mr B's earlier time slot.
We then talked about his fall. Mr B was so nervous it would happen again, and it was such a struggle for him and us to get him off the floor. I let him know that he shouldn't view the fall as a set-back. If anything, it proves he can transfer from the floor without a hoist. I told him that falls were to be expected ( I had already seen 2 in that gym!) and now hopefully he's had his and that's it! I then really emphasised his great potential for recovery! I related hard-work to his goals and hopefully inspired him not to give up. Only with therapy time will he achieve a stand-step transfer and he has already come so far! I tried not to play into his nervousness and let him know that sometimes these things happen, it is not a reason to stop. I told him that he had to be in control of his rehab, and if he feels tired he has to let us know.
R-I feel that my talk with Mr B went really well. When I left, he was no longer embarrassed and was willing and excited to continue his therapy. He felt happy with the strategies we put in place and felt more in control of his own recovery. I feel that I built on our rapport and our professional relationship had grown. I was really excited to have him back on board, he has to want to be in the gym for us to make any type of improvements!
E-I really feel I handled the situation well. I was just as embarrassed as Mr B and I could have left without talking to him. I was really proud that I was professional enough to sit down with him and analyse the events. I really learnt the importance of listening. I felt Mr B's concerns were valid, and we worked through them appropriately and professionally. I left knowing that Mr B was reassured and had regained some confidence in his abilities (and some more confidence in me!!)
However, I did not handle the situation with the nurses very well!! I felt so worried and flustered when I heard them talking about me so I just stood up and did whatever they said. Looking back, it was definitely bullying, and it was not professional. I did not need to be rude, but I could have been more assertive. I should have reminded them that I did offer assistance and I am more than happy to help out whenever required, especially as I am a student and have more time on my hands, all they needed to do was ask. But I also should have reminded them to listen to the patients wishes, it was clear that he did not want me there and as such I shouldn't have been. In those situations I need to politely point out the facts and not fall into the trap of workplace bullying! I also need to find my voice sometimes and stand up for myself. I am not rude or lazy and shouldn't let people say that about me.
S-When Mr B next comes into the gym I am going to use the following strategies
1. Relate STS practice to his goals
2.Positive feedback to boost his confidence
3.Bolster him in so he feels really safe
4.Have confidence in myself, and let him see that! I can't let him know I'm nervous too because that won't help anyone.
In regards to the situation on the ward, I let my supervisor know what happened so she was informed. We then talked through strategies together on how to deal with anything like that in the future.
However, on Monday and Tuesday we experienced 2 set-backs in therapy. On Monday he had a fall in the PT gym. My supervisor and I were practicing 2 mod A STS with Mr B as this is major goal, he is VERY focussed on achieving this as he wants to be able to transfer without the hoist. Mr B is determined, but if something is too hard he will sit down without any warning to the PT, you just have to be ready. During STS from the W/C, Mr B made it about half way, then just could not straighten his legs any further. He slipped in front of the W/C, and as he weighs 97kg my supervisor and I just could not save him, so we began a controlled lowering to the floor. He then required a 3 max A to get back into the W/C. It turned out fine, but it shattered Mr B's confidence.
The next day, shortly after Mr B's arrival he needed to go to the bathroom. He has suffered some urge incontinence since his stroke so I quickly rushed him up to the ward. Once here, I offered my assistance but as he is a standing hoist t/f the nursing staff declined, they would just have to teach me to use the hoist and he was in a rush. I decided to wait for Mr B so I could take him back to the gym and save the PCA. I was waiting in the office and heard the nursing staff talking about me. It was very unprofessional. They suggested that PT never offer to help, they were run off their feet and I was just sitting down! (Meanwhile, they couldn't have been that busy if 6 people had the time to and around and talk about me.) It really upset me as I try my hardest to be polite and helpful, I would never intentionally not offer my assistance. So, I stood up and joined their conversation...with the end result being me bullied into getting Mr B off the toilet. This was really awkward for him. After the experience, he said he was too embarrassed to come back to phsyio and absolutely dreaded it!!
T-My task was to reinstate some of Mr B's confidence and reassure him about physio generally!
A-I wheeled Mr B back to his room for the day. Once here I shut the curtains to give us some privacy. I sincerely apologised for his experience in the bathroom. I let him know that I wasn't embarrassed and had taken many patients to the bathroom before. He explained that he felt physio's were for therapy only and he was mortified that I had to see him in another light. I empathised with this and understood exactly where he was coming from. We decided to put a few strategies in place to ensure that physio WAS only therapy time. They offer patients drinks while they're in the gym. Mr B felt his drink had upset his stomach, so we opted for water only while exercising. We also pushed back his start time till 2:30. This allowed his lunch to go down (he has just started to eat normal meals so he felt he needed some time getting used to it again.) This also worked well for me, as I had a higher level patient who could come and take Mr B's earlier time slot.
We then talked about his fall. Mr B was so nervous it would happen again, and it was such a struggle for him and us to get him off the floor. I let him know that he shouldn't view the fall as a set-back. If anything, it proves he can transfer from the floor without a hoist. I told him that falls were to be expected ( I had already seen 2 in that gym!) and now hopefully he's had his and that's it! I then really emphasised his great potential for recovery! I related hard-work to his goals and hopefully inspired him not to give up. Only with therapy time will he achieve a stand-step transfer and he has already come so far! I tried not to play into his nervousness and let him know that sometimes these things happen, it is not a reason to stop. I told him that he had to be in control of his rehab, and if he feels tired he has to let us know.
R-I feel that my talk with Mr B went really well. When I left, he was no longer embarrassed and was willing and excited to continue his therapy. He felt happy with the strategies we put in place and felt more in control of his own recovery. I feel that I built on our rapport and our professional relationship had grown. I was really excited to have him back on board, he has to want to be in the gym for us to make any type of improvements!
E-I really feel I handled the situation well. I was just as embarrassed as Mr B and I could have left without talking to him. I was really proud that I was professional enough to sit down with him and analyse the events. I really learnt the importance of listening. I felt Mr B's concerns were valid, and we worked through them appropriately and professionally. I left knowing that Mr B was reassured and had regained some confidence in his abilities (and some more confidence in me!!)
However, I did not handle the situation with the nurses very well!! I felt so worried and flustered when I heard them talking about me so I just stood up and did whatever they said. Looking back, it was definitely bullying, and it was not professional. I did not need to be rude, but I could have been more assertive. I should have reminded them that I did offer assistance and I am more than happy to help out whenever required, especially as I am a student and have more time on my hands, all they needed to do was ask. But I also should have reminded them to listen to the patients wishes, it was clear that he did not want me there and as such I shouldn't have been. In those situations I need to politely point out the facts and not fall into the trap of workplace bullying! I also need to find my voice sometimes and stand up for myself. I am not rude or lazy and shouldn't let people say that about me.
S-When Mr B next comes into the gym I am going to use the following strategies
1. Relate STS practice to his goals
2.Positive feedback to boost his confidence
3.Bolster him in so he feels really safe
4.Have confidence in myself, and let him see that! I can't let him know I'm nervous too because that won't help anyone.
In regards to the situation on the ward, I let my supervisor know what happened so she was informed. We then talked through strategies together on how to deal with anything like that in the future.
Saturday, April 10, 2010
week 3 neuro
S- Today I was to perform my first treatment of Mr B in the neurological inpatients gym after assessing him the day before. Mr B suffered a L pontine stroke on the 12/03/2010 and is now experiencing R sided hemiparesis and hemisensory loss. He also has moderate dysarthria and expressive dysphasia, and since the stroke he has noticed a decrease in motivation, increase tiredness and a general flat affect. Mr B is displaying great movement return, with his number one impairments being a decrease in postural tone and stability, decrease R sided voluntary control and decrease in static and dynamic sitting balance. He doesn't seem to have the abdominal strength to save himself once outside his base of support. Mr B's main goal for now is to be able to stand up and transfer without the use of a hoist.
T-My task was to perform an initial treatment of Mr B targeting his main impairments . As he is quite difficult to transfer (due not only to his lack of voluntary control but also the fact that he is over 6 foot tall and over 90kg) I had to structure the session so that it flowed well (none of my usual sit up, lie down sit up again). I also had to maintain Mr B's interest in order to keep him focussed and motivated.
A-I decided to treat Mr B in supine first and work on his abdominal strength. I thought it was important to get this firing before he was in sitting to prepare his abs for balance work. We worked on sit-ups with a wedge behind Mr B. This made the sit-up easier for him as he didn't need to start from a fully lengthened position. We also worked on posterior pelvic tilt in crook lying, progressing to a bridge. Once we completed these, we moved to sitting. Here we worked on reaching out of his base of support with the left and right hand. We emphasised lateral tilt of the pelvis and trunk righting. Rather than growing on the reaching side Mr B seems to slump or pull down. We practiced component work when reaching with the right working first at the shoulder and breaking the movement into parts. After this, we came into standing and practiced finding the centre (Mr B pushes to the R). To end the session, I gave Mr B a list of exercises for his hand that he can do on the ward. (Previously he was squeezing a stress ball which only works to reinforce the flexor pattern of the arm.)
R-Mr B was happy with the treatment session, particularly coming up to standing. This is his short-term goal and he was so proud to be making the first steps. I was happy that he could prove this to himself, as he was feeling like the situation was hopeless prior to treatment. I also felt that the exercises we did in sitting were very successful at firing up his trunkal tone, as I could see good extensor activity happening in his back after reaching.
E-All in all I think our first treatment session together worked well. I think that the flow of the exercises worked well from a transfer perspective as well as preparing him for each new and more challenging exercise. However, I feel the work we did in supine didn't achieve the desired effect. Mr B seems to take whatever support is given him, thus in supine, he completely switches off and does very little work, which isn't really achieving anything... aside from making me work more! I also found that Mr B led his sit-ups through global extension, particularly leading with his head, so I need to think of some strategies to improve this. In sitting, reaching was very effective at firing up postural tone and preparing him for standing. On the left I made this interesting by incorporating coits, but on the right, he cannot hold coits. As such, Mr B found this a bit boring and lost interest. He is quite hard to motivate, and I became slightly disheartened as he starting yawning a lot! I also felt that reaching to the R is particularly problematic because he hinges from his trunk rather than switching it on to provide a stable base for the scapula. I feel that it would thus be best to reach to the R in standing while his trunk has max input, but his being so tall may not make this possible with only 1 assist. I do however think that we made a great start and I developed a good rapport with Mr B. I really feel that the best thing to come out of the session was proving to Mr B that there is hope and a point in trying, and that with continued work he can only get better!
S-For our next session I have decided to eliminate supine all together. I think for now it is important for Mr B to be doing most of the work and reminding his brain that he can! I do think it is so important for him to work on his abdominal strength, but I will try this in reclined sitting. I will not let him fully rest or let go in the reclined position, forcing him to do the work for himself. I will also get him to do this ab work with his chin on chest, hopefully this prevents global extension and leading with the head. To make the reaching to the R more interesting and in order to involve Mr B more in his own treatment I'm going to try and relate it to something that interests him. He previously worked full time as a bus driver and loved this job, so maybe we can look at holding a steering wheel or flicking indicators. I can also use my voice here to fire him up. Lastly, I think I will give him generally less support. He is capable of working on his own, but takes whatever you give him. I need to make sure that I give him every opportunity to do this, within reason and staying safe. Plus, this will go towards helping him see that he is indeed capable and there is much hope of being functional again.
T-My task was to perform an initial treatment of Mr B targeting his main impairments . As he is quite difficult to transfer (due not only to his lack of voluntary control but also the fact that he is over 6 foot tall and over 90kg) I had to structure the session so that it flowed well (none of my usual sit up, lie down sit up again). I also had to maintain Mr B's interest in order to keep him focussed and motivated.
A-I decided to treat Mr B in supine first and work on his abdominal strength. I thought it was important to get this firing before he was in sitting to prepare his abs for balance work. We worked on sit-ups with a wedge behind Mr B. This made the sit-up easier for him as he didn't need to start from a fully lengthened position. We also worked on posterior pelvic tilt in crook lying, progressing to a bridge. Once we completed these, we moved to sitting. Here we worked on reaching out of his base of support with the left and right hand. We emphasised lateral tilt of the pelvis and trunk righting. Rather than growing on the reaching side Mr B seems to slump or pull down. We practiced component work when reaching with the right working first at the shoulder and breaking the movement into parts. After this, we came into standing and practiced finding the centre (Mr B pushes to the R). To end the session, I gave Mr B a list of exercises for his hand that he can do on the ward. (Previously he was squeezing a stress ball which only works to reinforce the flexor pattern of the arm.)
R-Mr B was happy with the treatment session, particularly coming up to standing. This is his short-term goal and he was so proud to be making the first steps. I was happy that he could prove this to himself, as he was feeling like the situation was hopeless prior to treatment. I also felt that the exercises we did in sitting were very successful at firing up his trunkal tone, as I could see good extensor activity happening in his back after reaching.
E-All in all I think our first treatment session together worked well. I think that the flow of the exercises worked well from a transfer perspective as well as preparing him for each new and more challenging exercise. However, I feel the work we did in supine didn't achieve the desired effect. Mr B seems to take whatever support is given him, thus in supine, he completely switches off and does very little work, which isn't really achieving anything... aside from making me work more! I also found that Mr B led his sit-ups through global extension, particularly leading with his head, so I need to think of some strategies to improve this. In sitting, reaching was very effective at firing up postural tone and preparing him for standing. On the left I made this interesting by incorporating coits, but on the right, he cannot hold coits. As such, Mr B found this a bit boring and lost interest. He is quite hard to motivate, and I became slightly disheartened as he starting yawning a lot! I also felt that reaching to the R is particularly problematic because he hinges from his trunk rather than switching it on to provide a stable base for the scapula. I feel that it would thus be best to reach to the R in standing while his trunk has max input, but his being so tall may not make this possible with only 1 assist. I do however think that we made a great start and I developed a good rapport with Mr B. I really feel that the best thing to come out of the session was proving to Mr B that there is hope and a point in trying, and that with continued work he can only get better!
S-For our next session I have decided to eliminate supine all together. I think for now it is important for Mr B to be doing most of the work and reminding his brain that he can! I do think it is so important for him to work on his abdominal strength, but I will try this in reclined sitting. I will not let him fully rest or let go in the reclined position, forcing him to do the work for himself. I will also get him to do this ab work with his chin on chest, hopefully this prevents global extension and leading with the head. To make the reaching to the R more interesting and in order to involve Mr B more in his own treatment I'm going to try and relate it to something that interests him. He previously worked full time as a bus driver and loved this job, so maybe we can look at holding a steering wheel or flicking indicators. I can also use my voice here to fire him up. Lastly, I think I will give him generally less support. He is capable of working on his own, but takes whatever you give him. I need to make sure that I give him every opportunity to do this, within reason and staying safe. Plus, this will go towards helping him see that he is indeed capable and there is much hope of being functional again.
Saturday, March 27, 2010
week 1 neuro
WEEK 1
S-In the afternoons we work in the neurological inpatients gym. Here we mainly see stroke and brain injury patients in their last month or so of rehab before discharge. Patients on the ward make appointments with the physios here and can spend up to three hours in the gym! It is a real team orientated environment. All the physios work in one large room asking each other for help when required. (i.e.: if they’re having difficultly pinpointing the patient’s impairments or need extra assistance walking a patient.)
I was to see a new patient on my very first day. Ms A has multiple sclerosis and was admitted to Shenton Park that morning experiencing her 2nd relapse since her diagnosis (2003). She became aware of her condition deteriorating as she could no longer transfer with a slide board independently; she felt her balance was too poor. Ms A is fiercely independent and her ability to transfer is thus very important.
T-My task was to make the initial assessment of Ms A. Seeing as Ms A experiences most of her fatigue in the afternoon, we decided to just complete an assessment that day. We felt it may be too exhausting to include treatment in the one session as well.
A-I completed a thorough subjective examination whilst Ms A was in her chair. I tried to elicit as much information as possible about her condition, so that our objective examination could be specific from the outset to minimise her fatigue levels. While she was still in her chair we quickly ran thorough cranial nerves and sensation. We then transferred her onto the plinth to assess her motor status and tone. I quickly realised that muscle testing muscle testing was not clear-cut with Ms A. She had almost no movement in her lower limbs and I didn’t want to overly fatigue her by getting her in and out of numerous ‘gravity eliminated’ positions. I found the best way to elicit movement was to perform active assisted LL movements and document as such. It showed me the importance of palpating the muscle whilst moving it so I could feel for any muscle flickers. After these assessments Ms A came into sitting for a postural and balance assessment. She was not safe to be sitting unassisted and I noticed that her trunk was very ataxic. Because of this I decided to test her coordination looking for signs of potential new cerebellar involvement.
R- From this assessment I produced a concise impairment list, and thankfully I didn’t tire my patient out too much. She did in fact have positive results on cerebellar testing, including a new (3 week old) intention tremor. These findings will cause us to go down a different treatment path, focussing more on core stability and target type training.
E- I felt that my assessment went well. It was very important to be well organised as Ms A said asthenia really hinders her ability to participate in any kind of therapy. I thought that my subjective examination really helped to direct me to what was important, namely her new found LL worsening weakness and balance issues. I didn’t spend too much time on other aspects, such as cranial nerves as I had already asked about visual and swallowing difficulties etc. I also thought I did well in not making her moving around too much, as that is something I am usually terrible at! I’m always asking patients to sit down, stand up and sit down again!
The problem list that I came up with was reflective of her impairments but probably not prioritised well enough. I needed to remember that Ms A came in wanting to fix a specific problem, her transfers. So number one on our list should be to work on her core stability and practice transfers, and things like spasticity and LL weakness should be lower priorities. This is something I think I should do more every time I see a patient. I need to remember why they are here, what they want to achieve, and look more globally at the person.
S- The main strategy I used was preparation! Knowing that she fatigues easily meant I needed to be really well organised, focussed and specific. Before I saw the patient I wrote down what was essential to find out in my subjective examination. From here I worked out was most important to assess and tried to put that at the start of our objective examination. I also thought hard about testing positions and what would flow best. I think being well prepared was really the most important thing in making this a successful assessment.
S-In the afternoons we work in the neurological inpatients gym. Here we mainly see stroke and brain injury patients in their last month or so of rehab before discharge. Patients on the ward make appointments with the physios here and can spend up to three hours in the gym! It is a real team orientated environment. All the physios work in one large room asking each other for help when required. (i.e.: if they’re having difficultly pinpointing the patient’s impairments or need extra assistance walking a patient.)
I was to see a new patient on my very first day. Ms A has multiple sclerosis and was admitted to Shenton Park that morning experiencing her 2nd relapse since her diagnosis (2003). She became aware of her condition deteriorating as she could no longer transfer with a slide board independently; she felt her balance was too poor. Ms A is fiercely independent and her ability to transfer is thus very important.
T-My task was to make the initial assessment of Ms A. Seeing as Ms A experiences most of her fatigue in the afternoon, we decided to just complete an assessment that day. We felt it may be too exhausting to include treatment in the one session as well.
A-I completed a thorough subjective examination whilst Ms A was in her chair. I tried to elicit as much information as possible about her condition, so that our objective examination could be specific from the outset to minimise her fatigue levels. While she was still in her chair we quickly ran thorough cranial nerves and sensation. We then transferred her onto the plinth to assess her motor status and tone. I quickly realised that muscle testing muscle testing was not clear-cut with Ms A. She had almost no movement in her lower limbs and I didn’t want to overly fatigue her by getting her in and out of numerous ‘gravity eliminated’ positions. I found the best way to elicit movement was to perform active assisted LL movements and document as such. It showed me the importance of palpating the muscle whilst moving it so I could feel for any muscle flickers. After these assessments Ms A came into sitting for a postural and balance assessment. She was not safe to be sitting unassisted and I noticed that her trunk was very ataxic. Because of this I decided to test her coordination looking for signs of potential new cerebellar involvement.
R- From this assessment I produced a concise impairment list, and thankfully I didn’t tire my patient out too much. She did in fact have positive results on cerebellar testing, including a new (3 week old) intention tremor. These findings will cause us to go down a different treatment path, focussing more on core stability and target type training.
E- I felt that my assessment went well. It was very important to be well organised as Ms A said asthenia really hinders her ability to participate in any kind of therapy. I thought that my subjective examination really helped to direct me to what was important, namely her new found LL worsening weakness and balance issues. I didn’t spend too much time on other aspects, such as cranial nerves as I had already asked about visual and swallowing difficulties etc. I also thought I did well in not making her moving around too much, as that is something I am usually terrible at! I’m always asking patients to sit down, stand up and sit down again!
The problem list that I came up with was reflective of her impairments but probably not prioritised well enough. I needed to remember that Ms A came in wanting to fix a specific problem, her transfers. So number one on our list should be to work on her core stability and practice transfers, and things like spasticity and LL weakness should be lower priorities. This is something I think I should do more every time I see a patient. I need to remember why they are here, what they want to achieve, and look more globally at the person.
S- The main strategy I used was preparation! Knowing that she fatigues easily meant I needed to be really well organised, focussed and specific. Before I saw the patient I wrote down what was essential to find out in my subjective examination. From here I worked out was most important to assess and tried to put that at the start of our objective examination. I also thought hard about testing positions and what would flow best. I think being well prepared was really the most important thing in making this a successful assessment.
Sunday, March 21, 2010
INITIAL ENTRY (NEURO)
Tomorrow I start my Neuro placement at the Well-Tel Centre (part of Shenton Park Hospital). From what I can gather, it is a place that provides accommodation for people undergoing rehab or other services, but do not necessarily need to be admitted as an inpatient, in a ward environment. This will mean that the patients have much more independence and are in a less acute phase of their illness/recovery. For me, I think this means that the patients will be well versed in self care and will require more high level rehabilitation.
NATURE
I found it quite difficult to find much information on the Centre, but speaking to students who went previously confirmed my above ideas. The Centre is almost like a 'halfway house' for those who don't really need to be in hospital. Thus, PT sessions can be much more intensive, up to an hour of one on one work. As the patients are no longer acute, I think I will need to be prepared for 'later stage' training, ie: the final stages of motor recovery/high level balance work/coordination and power etc, all those things that make up a more 'normal' movement (as opposed to initial periods of flaccidity immediately following stroke for example.)
STRUCTURE
I have only been in outpatient and hospital settings, so as far as the structure of the Well-tel centre is concerned, I think I may be in for a whole new experience!! I imagine it will be similar to an outpatient setting, with patients seeing you at previously booked times, but then they can go back to their rooms! Similar to a hotel or boarding house! I am also curious to see if they run any group sessions. I think it would be a great way to exercise as patients there for a week or more would most likely make friends (if it's similar to a hotel environment?) -this could be a great motivation!!
ROLE
I also found out I will be dealing mostly with disorders like multiple sclerosis, acquired brain injuries, spinal cord injuries and potentially some amputees. I think my role as a student will be to perform one on one rehab sessions with these patients, involving more high level and independent activities. I think I will become more of a 'supervisor' and less of an 'assistant' as patients at this Centre are independent, and will need more supervision of programs to ensure they're doing it correctly at home. I think I will also become an educator. I can only imagine how difficult it would be to live with MS, and I think I will need to be on the ball with advice, encouragement and support. I think my role is also going to be to learn as much as I can. As I understand from Ali, there are many different ways to approach neuro rehab, and I am hoping to learn many new skills, as well as consolidate those I already have.
CONCERNS
I have SO many concerns about this placement! I feel like my past 2 placements were very MSK based, and thus I have a much better idea about the MSK subjective and objective assessments and treatment techniques. (Not to mention more confidence!) I also missed the first placement as I was doing my project. We were told that now supervisors are less lenient and expect more because it is placement number two...but I am behind. I literally haven't seen any patients since Collie last year! I don't know if I trust myself. Plus, I have my usual worry about not living up to my own expectations or those of my supervisors...but that is nothing new:)
But, if it's anything like my previous 2 placements, I will love every second of it!!
NATURE
I found it quite difficult to find much information on the Centre, but speaking to students who went previously confirmed my above ideas. The Centre is almost like a 'halfway house' for those who don't really need to be in hospital. Thus, PT sessions can be much more intensive, up to an hour of one on one work. As the patients are no longer acute, I think I will need to be prepared for 'later stage' training, ie: the final stages of motor recovery/high level balance work/coordination and power etc, all those things that make up a more 'normal' movement (as opposed to initial periods of flaccidity immediately following stroke for example.)
STRUCTURE
I have only been in outpatient and hospital settings, so as far as the structure of the Well-tel centre is concerned, I think I may be in for a whole new experience!! I imagine it will be similar to an outpatient setting, with patients seeing you at previously booked times, but then they can go back to their rooms! Similar to a hotel or boarding house! I am also curious to see if they run any group sessions. I think it would be a great way to exercise as patients there for a week or more would most likely make friends (if it's similar to a hotel environment?) -this could be a great motivation!!
ROLE
I also found out I will be dealing mostly with disorders like multiple sclerosis, acquired brain injuries, spinal cord injuries and potentially some amputees. I think my role as a student will be to perform one on one rehab sessions with these patients, involving more high level and independent activities. I think I will become more of a 'supervisor' and less of an 'assistant' as patients at this Centre are independent, and will need more supervision of programs to ensure they're doing it correctly at home. I think I will also become an educator. I can only imagine how difficult it would be to live with MS, and I think I will need to be on the ball with advice, encouragement and support. I think my role is also going to be to learn as much as I can. As I understand from Ali, there are many different ways to approach neuro rehab, and I am hoping to learn many new skills, as well as consolidate those I already have.
CONCERNS
I have SO many concerns about this placement! I feel like my past 2 placements were very MSK based, and thus I have a much better idea about the MSK subjective and objective assessments and treatment techniques. (Not to mention more confidence!) I also missed the first placement as I was doing my project. We were told that now supervisors are less lenient and expect more because it is placement number two...but I am behind. I literally haven't seen any patients since Collie last year! I don't know if I trust myself. Plus, I have my usual worry about not living up to my own expectations or those of my supervisors...but that is nothing new:)
But, if it's anything like my previous 2 placements, I will love every second of it!!
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