Final Entry

It is so overwhelming to actually be finished! I felt half way through that five weeks was definitely long enough but this last week has been so good I didn't really want to leave! I really enjoyed my placement, the people were so nice, my supervisor was really good and knowledgeable and the patients generally were great to work with. I feel like I have gained so much confidence from this placement, and everything I have learnt since first year came into play at least a little bit during the placement. I feel like instead of my knowledge being one big messy clump of not so useful information it is now all streamlined and consolidated and useful!!! I hope everyone else had a good placement too!

Week 5 Days 4-5

These last few days of prac have been crazy with 6 patients in one day (serves me right for being sick one day...) and sometimes only 40 minutes to see a patient, and now we have to go right through the assessment and treatment without getting any advice, unless we have a question or are unsure. Today I had 4 patients and I went through all of them without advice (almost...) and all of them within 30 minutes! I must admit I did sneak out in one patient because she had a sore back and we're not allowed to treat backs, and the patients were all follow-ups that I was very confident with and they just needed slight changes to there HEP or a few mobs. But it was a good confidence booster! I just hope I can carry some of this new confidence into the prac exams next week... Good luck everyone!!!!

Week 5 Day 3

Today I found out that my foot patient rang up and cancelled her appointment, and no longer wants any treatment!!! I was disappointed because I found her really challenging and wanted to see how much further I could progress her, but on the other hand she was very hard to deal with because of all the yellow flags. Everyone was really nice, especially my supervisor because I think they were worried I would take it personally and that I was thinking she was discharging herself because I wasn't doing a good job.

I had a really good discussion with my supervisor about yellow flags and how they can come in so many different forms and that if an improvement was being made, there is no way it could be me causing her to leave. We're not exactly sure why she discharged because she just left a message with the receptionist to say that she no longer wanted treatment. My supervisor and I think that she didn't want to get better, so as soon as I was improving her condition she ran in the opposite direction, we just couldn't work out what she was gaining from not getting better. Well I guess I'll never know why she left, but I wrote her discharge letter to her GP in a way that it was clear that she chose to leave and that if she had stayed she would have improved so that made me feel a lot better. You do have to wonder with a patient that has been to 2 podiatrists and 3 physios and 2 doctors and hasn't stayed with any longer than 6 months whether there is more going on than a sore foot...

Week 5 Days 1-2

Today we had a manual handling session run by the manual handling director at the hospital. It was really interesting to hear her perspective on the subject and the way she believes it works best in a hospital setting.

Whilst a lot of the tertiery hospitals use manutention, with Fremantle just bringing it in, Bentley has looked at the options and decided that manutention is not the best form of manual handling for them. They believe it costs a lot of money for the workshops or to buy the liscenses to teach it themselves, they believe that a lot of training is needed by everyone to really do it well and safely, and lastly they believe it is too complex for some people to really grasp well enough to perform it correctly and in varying situations. They are definitely not against manutention in anyway, the lady actually really likes it and told us how lucky we were to be trained in it, it just doesn't work well for them. Instead they choose to teach the basics of manual handling, with the things not to do and the best things to do and then allow people to apply that to different situations.

She gave us a few scenarios where you would use manutention and asked us to demonstrate how we would do it and pointed out any flaws. Overall I think we represented ND pretty well! It appears that manual handling within hospitals doesn't normally cause too many problems with physiotherapists because we have such great training in it. Looks like all those labs holding wieghtlifters position has really paid off!

Week 4 Day 4-5

Every Friday afternoon Monique and I get to to the hydro classes run by Bentley hospital. Because the hospital doesn't have its own pool, they hire out the multiple sclerosis society pool which is a bout a five minute drive from the hospital. Its the only service that patients have to pay for due to the hire of the pool, and it costs them $5 a session. Each patient is referred by their physio, and then they are given a program depending on their condition. There are about 10-15 different programs, ranging from shoulder programs to lumbar spine to total knee replacements. There are 3 40 minute sessions on Wednesdays and Fridays.

For the past 3 weeks I have been working with a lovely older Italian lady who is very fearful of water. Its so strange to me because swimming is such a part of our culture. When she first came into the pool she wouldn't let go of the railings unless I was holding on to both hands and she was still scared. Today I had here walking along the shallow end forwards, sideways and backwards without holding on. I have gradually worked out the safest way to have her in the pool as she gradually lets go but it has definitely been a learning curve. She is definitely one patient I will miss, as today was our last session. I'm really not looking forward to saying goodbye to a few of my patients next week!!!

Week 4 Days 2-3

So I had the foot lady back again and she seemed to be so much better! I think I find her one of my most rewarding patients because when I had her the first time I couldn't even work out what was really going on and put it all together clearly in my head, and she had yellow flags that I couldn't really work out either. So when she came in and said that she had 2 full mornings with no pain when she hadn't had a days rest from the pain for over 18 months I was so happy!

I decided that she was still not a great believer in physio (yet) so I would still keep her NWB and do the same treatment I had done the week before as it had obviosly done something. I also wrote a letter for her to take along to the podiatrist outlining what we had improved and what we were currently working towards with physio, so that we could work together to fix her foot. She seemed to be so much more willing and she even seemed excited that we were going to start working in WB the next week. It was a very different feeling to most treatments because most of my patients just accept what I choose without much explanation but with her it is more of a discussion of the options and what we each feel is best.

I hope my next treatment with her is just as good!

Week 4 Day 1

I had the strangest experience today...one of my patients came in that I had seen once before with a shoulder impingement. He said to me during the subjective assessment that he didn't feel like he had made any improvement during the week and that he didn't feel the HEP I had given him had helped at all. He also said he wasn't any worse luckily! I was a little worried that I had been completely off the mark with him and hadn't really found the root of his problem which seemed strange as he presented as a typical impingement with terrible scapula posture.

So I did the full objective assessment on him and straight away I could see a massive inprovement just in the muscle bulk of his rhomboids and that he was now activating lower traps. So I got him to do his active movements but didn't really take much notice and just wrote it down and moved on through the rest of the assessment. When I eventually looked back at the results he had from the week before he had moved from 90 degress of active flexion and abduction to 180 degrees. When I went back in and told him he was very casual about it and said that he hadn't really noticed. I felt like I was banging my head against a brick wall trying to explain to him that because he was so diligent with his HEP he had made a HUGE improvement that is so rare to see and that if he kept going like this he would be better in no time. But it didn't really sink in. Its amazing that you can give someone an extra 5 degrees of knee flexion and they rave about it because now they can go down stairs but something as big as a 90 degree gain of shoulder flexion and they barely notice, because its just not functional...

Week 3 Day 4-5

Thurday I had a patient that presented with a pretty typical condition, patellofemoral pain post knee surgery. However, he was really tricky to treat because he had just been diagnosed with depression, and treatment had barely begun.

Although I love the fact that physios get to be so friendly with their patients and thats what makes our job so rewarding and enjoyable and its why patients generally love to go to see their physio, it also poses a challenge. I found it very hard to stay focused with this patient, because he just talked so much about how hard everything was and how he just wanted to get back to being active and back to his job as a volunteer life saver. I felt so bad for him, because I think I would feel just like him if I had an injury stopping me from living an active lifestyle. However, the solution for him to get back to everything he wanted to was by listening to me and following my guidelines and he wouldn't do that! I felt like he had excuses for everything and I feel as though I underestimated the challenge of dealing with a patient with depression.

I tried to move him along and focus on what I needed him to focus on but it was really hard! Then when I came back into the room after speaking to my supervisor and I was all ready to go ahead with treatment he 'apparently' injured his knee. I feel horrible saying this but I'm really not sure if he did even hurt it. My supervisor and I didn't think the whole situation really added up and decided to go ahead with treatment and just stop if it all became too much for him. In the end I got through my entrire treatment and he had completely forgotten that he had even hurt it in the first place.

It was really really exhausting trying to work with him but I feel like I made the right desicion in going ahead with treatment because if he did really hurt it I would have stopped straight away. I really think Ben Wand was right when he said not to stress about seeing yellow flags because they will be so obvious you can't miss them. They really were for this patient!

Week 3 Day 2-3

I'm kinda getting into the swing of things now, and it really feels like I'm working full time!!! We're treated so well here, not like silly young students that get in the way, which is kind of what I was expecting. It all seems to work really well though because we're given so much independence which then leads to more and more confidence with patients, which I needed for today, because I had the foot lady back again...the one from Week 1.

It was her 2nd appointment, and I'd already established from her first appointement that she didn't believe in physio and she just wanted the pain to go away. I thought that we had come to an understanding at the end of the last treatment that it would take time and that she was willing to give it all a go, but I was wrong!!! She came in and absolutely blasted me. Well not me specifically but just let rip about everything her foot was stopping her from doing and that she couldn't wear shoes and that she just wanted he foot to be chopped off because it was annoying that much! I decided that I should just let it go and let her have her vent with a few "i completely understand" 's chucked in there. Once she had run out of things to complain about I just went through and explained all over again that it was going to take time and that having foot surgery was going to permanently change her foot and it would never be normal again but I would try to relieve her pain. She calmed down and listened to me and turned from my meanest pateint into one of the nicest! I took her HEP off WB to stop it from flaring up as WB irritated it. I hoped that if she had less pain during the week I would get her on my side and she would then be more open to treatemnt when I got her back to WB again. I truly do believe that there are some BIG yellow flags going on with her but I just can't work out what they are because it's not something as obvious as a workers comp claim.

Shes coming in next week so I'll have to see if my way of dealing with it worked...

Week 3 Day 1

I had a really grouchy patient today... and I think I let it get to me a little bit and consequently maybe I didn't do the best job I could have.

Apparently the first appointment this patient was meant to have was all mixed up. He then had to reschedule and the only time we were both available was in 3 weeks time, so he went for 3 weeks without physio treatment only a few weeks post a rotator cuff repair.

The receptionist had told me he was grumpy when he was made to reschedule but I just didn't expect him to be THIS grumpy as he had 2 weeks to cool down. But he walked in with his sunglasses on (yes he sat in the waiting room for 20 minutes with sunglasses on) and I wasn't sure he was going to take them off, but he eventually did to my relief. I could tell that he wasn't in a good mood from the moment I called his name so I tried to be extra polite and friendly to get him on my side, but he still had a chip on his shoulder. After doing my subjective with no eye contact from him and one word answers I was starting to give up, and then when I got to do the objective and had to ask him to remove his shirt he didn't smell the best so it all added up to a not very nice situation! I tried to do a good job but it just got me down a bit. I think next time I'm just going to have to keep going with the friendly atmosphere even if I get nothing in return. He did mellow out a little bit by the end so hopefully he'll walk in a little happier next time and it will go a lot smoother!

Week 2 Day 4-5

On Friday I had a patient that made me really nervous just from reading his notes. He had fallen off a table at his own 50th birthday party after a few drinks and dislocated his elbow. From looking at his x-ray it was a huge displacement and amazing that he had so little soft tissue damage.

He was delayed in getting into the physiotherapist in the first place due to the long waiting lists, and apparently there is only a small window of opportunity for regaining ROM with dislocation, which he consequently missed. When he presented to the physio department he had 2 treatment sessions which regained some of his ROM but not much. After the 2 treatment sessions he returned to his specialist for his routine check-up, and the specialist was so worried that physio was stretching his ligaments too much that he stopped him from seeing a physio until the specialist decided it was ok to go back.

Luckily, when he went back to the specialist he had to see another doctor instead who promply put him back into physio and couldn't believe he had been taken out in the first place. Once he began treatment again he was 20 degrees off full elbow extension. He had 6 treatments; 3 with a curtin 4th year and 3 with a curtin 3rd year. When I was speaking to my supervisor about seeing this patient I expressed my concern about more experienced students not being successful with the patient and that they had exhausted all of the treatment options I had in mind. We decided that I would give it a go after having done my own assessment and if there was no improvement by the time my placement was up he would have to be discharged.

Earlier I had had another discussion with my supervisor about the use of accessory mobilisations and that he believed that if a joint was stiff it wasn't so important what direction it was moved in, but just that it was moved. So I decided that I would have a try at a different direction than the other students had attempted, even if it was against convention. It so happened that I got 4 degrees improvement. It was one of the best feelings!

Week 2 Day 2-3

On Tueaday and Wednesday all of my patients except one had fractures or knee conditions such as ACL reconstructions, menisectomy's or TKR's. The other patient I had presented with a typical shoulder impingement, however the reason he had it was so interesting.

He has a condition called Arnold-chiari malformation. It is a condition that causes the brainstem to be elongated and displaced into the opening of the base of the skull and the spinal canal. It occurs in most people with hydrocephaly and spina bifida. It affects not only the brainstem, but also the cranial nerves and the cerebellum. Consequently, anything controlled by the brainstem, cranial nerves or cerebellum can be affected.

Althought he had had surgery 3 years ago to decompress these structures, he still presented with posture control, upper limb weakness and unsteady gait. It was due to his weakness of scapula muscles that he had a secondary impingement.

When I was reading his notes his conditioned was only mentioned twice; in his subjective assessment in the 'past surgery' section, and in his transfer summary from his previous therapist. I therefore didn't consider it a major part of his condition. It wasn't until he walked in that it dawned on that a big part of his therapy would revolve around his condition. I really learnt that co-morbidities should never be ruled out and can always affect your treatment and assessment.

Week 2 Day 1

Today I had 3 very different patients, a stiff knee, a shoulder impingement and an elbow post joint wash out from a golden staff infection. They were all very interesting but the lady with the shoulder impingement was especially interesting as she really demonstrated to me the importance of posture.

She had a secondary impingement in her right shoulder that caused her RC to tear and therefore required rotator cuff repair sugery. However, due to her poor scapula posture which had caused the impingement in the first place, it failed. The specialist has decided that there is no way he can repair it again so she has a shoulder that remains in neutral. Now, her left shoulder is affected by her poor posture and is causing a secondary impingement. We are trying to correct this poor posture to save this shoulder from surgery and possibly becoming useless aswell! Its really shown me the importance of physios and surgeons working closely together, as good posture, one of the basics of physio could have saved her a lot of problems.

Whilst its generally easy to fix scapula posture, for this lady its another story. her major problem is her abduction and protraction as she is 15cm from her midline!!! She also has bilateral medial rotation, elevation and winging. She showed huge improvement today but she still has so far to go, problems with endurance and over 60 years of bad posture to contend with! I'll be very interested to see how she progresses over the next few weeks, and I'm aiming to have her with full ROM with correct scapula posture by the end of placement.

Week 1 Day 4-5

My most interesting patient over these two days was not interesting because of the condition but because of his age, and the changes I had to make to my assessment and treatment because of this. He was a 91 year old that was referred to the physio because of degenerative changes in his knee that were not suitable to be fixed surgically. We were asked to improve his musculature to assist in decreasing the symptoms associated with the degeneration.

I had to speak slowly and loudly as he was hard of hearing and his hearing aid had broken that morning. I also had to ensure that I was in his line of sight when I was speaking as he lip read a lot of the time. The entire assessment took a long time for these reasons and also because he moved very slowly to the positions I needed him and his skin was extremely frail from anticoagulants, so I had to be extra careful. It took a lot of planning to ensure that I didn't have to move him around a lot and completed all the tests in each position and then moved on rather than all of the tests for strength etc.

I found that his gait was very shuffly due to the pain, fear of falling and tight gastroc and hamstrings. He also had very decreased VMO activation. After some VMO strengthening exercises, some stretches and some gait reeducation he walked out of the clinic like a different man. He was also very happy to have been taught to walk properly as he felt ashamed to walk how he was in public, as he thought people would label him as old and senile.

It was nice to have had a postive experience with an older gentleman, as to be honest I wasn't looking forward to working with older people, as I thought it wasn't a strength of mine. After that experience though, I feel a lot more confident. I would have liked to have been a little more consistent with the words I used to cue actions though, as he seemed to get confused with some aspects of the assessment, especially strength testing.

Week 1 Day 2-3

I had some pretty standard patients on day 2; an 18 year old girl 3 weeks post ACL reconstruction, a 15 year old girl 8 weeks post partial meniscal tear and possible ACL tear seeking conservative treatment and a 43 year old man post meniscal tear repair who was experiencing bilateral patellofemoral pain. While they each presented some small challenges, they were almost as if they came from one of our case studies.

On day 3 however, I had a very interesting patient. She presented with pain on the head of her 5th metatarsal during weight bearing, and had been passed from doctor to podiatrist and back again, each palming her off to the next health professional but never actually diagnosing or helping her. It took me some time to get a really good picture of what was going on and I still wonder whether I really understand the extent of her problem.

She presented very differently, with cortisone and ultrasound both aggrevating her more. My supervisor advised me that if her condition didn't make sense medically, I was better off being honest with her and coming straight out and telling her. It turned out that I not only understood her problem, but she didn't even want to be there, and she didn't believe that physio would help at all. It was amazing the different turn the treatment took at that point, because she then for once felt like there was someone being honest with her. I proposed that we attempt my treatment for a few weeks and at the end if it hasn't been successful we will reassess and take a completely different route.

Although treatment wise I felt like I achieved the least of all of the patients I have had, I believe it was one of my most sucessful patients as she now wants to go ahead with treatment and doesn't feel like she has been palmed off again onto someone that doesn't care. When I see her again next week I plan to really get to the cause of her problem now that she is open to treatment.

Week 1 Day 1

The first day we arrived at placement I wasn't exactly sure what to expect. All we were told was that for the first hour of the day we would be having a general orientation of the hospital and then after that we would go to our respective areas. It just so happened that one of the first places we were taken in the orientation was the reception, and we were shown the patient appointment book. I casually glanced at the book and saw a column with my name on it, and a patients name for 10.30am! I spent the rest of the orientation stressing about having a patient in about an hours time and having absolutely no idea what I was about to be thrown in to.

It ended up being one of the best things I've ever done and an experience I will never forget. Monique and I were each given a patient, mine was in the morning and hers in the afternoon. We were given time to research our patients and plan our treatment and the other person was allowed to come in with us for support, but not to be too involved in the assessment and treatment. I did a full subjective as it was a new patient and then went to find the supervisor where we discussed the findings and decided on an objective assesment that wold be appropriate. After the objective testing I was allowed to speak to my supervisor and discuss an appropriate treatment, and then go through with it.

I really suprised myself. Although my supervisor really cleared up why I was to do what I needed to do, I came up with the skeleton of the assessment and treatment myself. It was amazing to know that I could calmly deal with the situation. I would have liked to have improved the flow of my objective assessment but I feel that the case studies we did in the lectures and the practice clinical reasoning panels from 221 really helped with my subjective assessment.

Initial Entry

Thoughts and feeling about going on clinical placement:
I'm nervous to go on placement, mainly because I have no idea of the expectations the placement has for me. I'm also nervous about my surperviser and just hope that I get along well with them and that I can make a very good first impression. I'm looking forward to actually getting out there and having a go and seeing what my strengths and weaknesses really are, as in the uni environment its really hard to get a realistic look at your progress. I really just can't wait and start so that I can get into it and stop being so nervous.

How I see the physiotherapist working with other physiotherapists and health care porfessionals in the clinical setting:
I think that the within the environment I am going to be working in (outpatient department) there will be a lot of work between physiotherapists and other health care professionals. I think that it will involve a lot of communication and gathering of information between professionals and working very solosely together to provide the best care possible.