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.