Fourth Year Rotation 4 - Treatment STARES

Situation
A 39 year old man with cerebral palsy was admitted to the general medical ward at Royal Perth Hospital with a suspected chest infection due to an increase in his respiratory rate and audible wheezing and secretions. Due to his inability to communicate with the medical team and the fact that the medical team could not be sure how much he could understand, he was monitored very carefully and observations were taken more regularly. The patient’s oxygen saturations were stable at around 97% and his clinical symptoms appeared to be remaining the same.

Task
As the patient was neither improving nor declining in condition the medical team asked that we obtain a sputum sample from the patient and continue with chest therapy as appropriate.

Action
As the patient wasn’t coughing voluntarily and we were unable to induce a cough, it was decided that suction was our only option for obtaining a sputum sample. It took one physiotherapist and myself to restrain the patient while another physiotherapist inserted the nasopharyngeal airway and suctioned the patient. It was a tough task as with any physical contact with the patient his tone would increase and he would writhe around trying to remove the oxygen saturation monitor and the airway. We did complete the task successfully, however, the patient was in obvious distress by the time we had finished. His mother returned to the room and told us that he was just angry and that it would pass. Observations were taken every 20 minutes over the next 2 hours and the physiotherapist in charge of his care checked on him over the afternoon to make sure he was stable.

When we returned the next day, his physiotherapist reported that he calmed down quite quickly and that he remained stable through the rest of the day and overnight. However, his most recent portable chest x-ray was available and it did not look promising. Originally his chest x-ray showed collapse of the right lower lobe but his most recent x-ray showed that the entire left lung had collapsed. According to the radiologist this was due to mucous plugging causing widespread atelectasis. His oxygen saturation was still stable at 97%, which amazed us all considering the state of his lungs.

Along with the medical team it was decided that regular suctioning, gravity assisted drainage positioning and percussions would be appropriate to dislodge the mucous blocking the patients airways. That morning, I was given the task of inserting the airway and suctioning the patient. As I had never inserted a nasopharyngeal airway into a real person, let alone one that was writhing around trying to stop me from inserting it, I found the task very difficult. With some guidance and help from my supervisor I was able to insert it, although not as confidently as I would have liked. I found the suction just as we had practiced it, just a little easier as you could hear the patient coughing and feel the secretions at the end of the suction catheter. It wasn’t all that successful as only a small amount of secretions were brought up and due to the patient writhing around he obtained some small abrasions to his nasal passages. Despite how ineffective it appeared to be throughout the treatment session, according to the patient’s mother he was only angry for a short amount of time and appeared to be a lot calmer and to find breathing much easier after the treatment session.

Result
As a result of my actions suctioning the patient he appeared to be in a much better condition than prior to the treatment. However, his oxygen saturation remained at the same level, as did his respiratory rate. The results of the patient’s x-rays and arterial blood gases will not be seen until next week, so a concrete conclusion about the effectiveness of the treatment cannot be drawn until the full clinical picture is available. It does seem that there may be a chance the patient is in a better position because of the treatment given.

Evaluation
Whilst the decision to suction the patient was not mine to be made, I am glad that it is the treatment I was thinking of doing throughout the assessment of the patient. This shows that my clinical reasoning skills are at least on the right track, even though I am not sure how much of my thought process was mine and how much was influenced by other people.

I feel so lucky that I was given the opportunity to insert a nasopharyngeal airway and suction a patient while I am still a student as it is completely different to doing it during labs on people who know that it is going to happen or on dummies. Another physiotherapist present throughout the treatment of the patient was very unsure of performing the treatment herself as she was never given the opportunity as a student and therefore wasn’t able to build her confidence. Whilst I know that my insertion of the nasopharyngeal airway was far from perfect and required some assistance from my supervisor I feel that it is something that must happen as a student and it is much better that it happens know than when we are fully fledged practicing physiotherapists.

Strategies
From this experience I feel I have learnt to never turn down an opportunity presented to you as a student or even as a qualified physiotherapist. Everything is a learning experience no matter how minor it may appear at the time, because you never know when it may be a skill required to be performed in an emergency situation or when you are the only person available to perform it.