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.
Sunday, May 30, 2010
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.
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