Situation
An 84 year old woman was readmitted to Royal Perth Hospital on the 3/7/2010 after a failed discharge on the 1/7/2010. The patient had been admitted originally for pneumonia and after a week in a general medical ward she was transferred to the short-term rehabilitation ward. On discharge services were organised for the patient; RITH for physiotherapy and occupational therapy and Silver Chain for meals, shopping and showering services, as the patients mobility and ability to perform her activities of daily living had declined in the weeks prior to and during her admission.
When the RITH physiotherapist arrived at the patient’s home for the second treatment session, the patient had been sitting on her four-wheeled walker for four hours, too afraid to get up as she feared the brakes were not working and she may lose her balance. The therapist helped the patient to her feet, but she refused to walk any further than the dining room table 3 metres away. On discussion with the patient the therapist also found that the patient had not been eating regularly, had mobilized minimally and had not been taking care of her indwelling catheter. As there were no services organised for the weekend and the patient’s family were unavailable to assist, the therapist organised for the patient to be readmitted for more suitable discharge planning.
Task
My task was to assess the patient and treat accordingly, keeping in mind that her discharge planning was an important aspect of her readmission.
Action
On assessment of the patient she appeared to be slightly confused and frustrated with why I was there. I had explained to her that I was a physiotherapy student, there to have look at her chest and how she was moving and if necessary to treat her and give her some tools in order to help her get home as soon as possible. The patient kept asking questions such as “Why do you need to know if I have a cough? Of course I have a cough, I have a chest infection”. While I kept explaining that I needed to have an understanding of what she was experiencing in order to help her, she still seemed to lack understanding. She did however have an understanding of why she was there and have a good grasp of her situation. All in all it was a difficult subjective assessment and it felt as though I was continually justifying my presence.
The patient appeared much calmer on objective assessment and it went smoothly until I asked her to get up so that we could go for a walk. Initially the patient refused to stand at all, but with some encouragement and assistance she did. However, after about 20 seconds the patient insisted on sitting back down. I asked the patient why she needed to sit down and she refused to answer me or even look in my direction. I explained that in order for me to help her she needed to tell me what was wrong. Again, the patient ignored me. On my third attempt to mobilize the patient I explained that I understood that she might be nervous of standing but I would be there to assist her and that if she wanted to return home she would need to be able to walk. Finally the patient responded, stating that she just couldn’t walk, that she didn’t know why and that there was nothing I could do to help, as it was all her responsibility to start walking again. I asked a few more times what was stopping her from walking, suggesting things such as leg weakness, anxiety, fear, breathlessness or pain but she stated no to all options. I reasoned that it was most likely anxiety as she had stated that she was too nervous to stand from her four-wheeled walker at home due to fear of falling and she appeared to be a proud person, wanting to maintain that there was nothing wrong with her. I asked her if she would consider walking if I brought in a strong male to assist her to walk and she nodded, saying that she might consider it after lunch.
I found a time that suited my supervisor that afternoon and together we went back to see the patient. My supervisor just acted as a physiotherapy assistant and with his appearance as a strong male the patient ambulated approximately 12 metres without any complaints.
Results
As a result of my treatment the patient ambulated 12 metres with one person assisting the first day, 30 metres with stand-by assistance the second day and 50m with stand-by assistance the third day. The patient has also been accepted into transitional care for 8 weeks with permanent low-level care following that.
The patient also apologised for her reaction to me at our first meeting, stating that she had so many weeks of people asking her questions that she was unsure where they were all from and why they all couldn’t communicate the information between each other.
Evaluation
The importance of explaining who you are and what you are there for has really become clear to me. Patients in acute medical wards are constantly being bombarded with different staff wanting different pieces of information and explaining very little to them. I have witnessed countless medical teams and nursing staff just waltz into a patient’s room, ask them questions, test multiple things, discuss the patient without including them in the conversation and walk straight out. It leaves the patient anxious and confused about their medical treatment and the path that they will be taking. As physiotherapists we have the skills and the training to offer our patients superior communication skills and the time to give them explanations regarding their treatment and the direction that they will be taking.
We also have the skills and time to really evaluate our patients from an angle other than their blood test results and their ability to mobilize. It is our ability to really listen to what they are saying and look at their body language to assess what is really going on. If I had just listened to this patient without taking in all of the information available I never would have realized that she was just really anxious about mobilizing and I could have mistaken her anxiety and frustration for confusion.
Strategies
As a physiotherapist we should always take the time to really listen to our patients. Not just to what they are saying directly in answer to our questions but also to what they are saying outside of the context of the question. It is also important to read their non-verbal communication and gauge their reactions to certain situations. An entire picture of a patient is required to treat them effectively and that takes superior communication skills.
Sunday, July 11, 2010
Sunday, June 27, 2010
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.
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.
Saturday, June 12, 2010
Rotation 3 Fourth Year - Final Entry
I am very happy to say that my placement at Hollywood hospital in neurological rehabilitation was exactly as I had hoped it would be in my initial entry. I thoroughly enjoyed working in the area with the wide variety of presentations appearing right in front of me instead of just a description in a lecture or a book. It has definitely confirmed my passion in this area and I would be happy to work in an area like this when I graduate.
Students who had previously been placed at Hollywood hospital told me that the staff were friendly, caring and very involved in the rehabilitation of their patients. This was also my experience. We were given a few days to follow our supervisor and other staff members around where we were able to jump in if we felt comfortable or just stand back and learn from their years of experience. After that the supervision was slowly taken away and we were left with a high level of autonomy. If however, we felt unsure or needed questions answered there was always someone willing to help us out.
Expectations throughout the placement slowly increased, but they were always clearly stated. Completing two SOAPIERS over the five week placement allowed our supervisor to assess our clinical reasoning skills and give us valuable feedback. Also, my first experience with a Notre Dame tutor allowed for greater feedback and more one-on-one teaching. It was a fantastic learning experience to assess and treat patients with someone with such a varied outlook on physiotherapy and a wealth of knowledge and experience. It is something I looked forward to every week.
I was very excited to experience new treatment techniques on this placement as our treatment toolbox from Notre Dame was limited in comparison to the treatment options available, and I was not disappointed. Between my supervisor and my clinical tutor I was taught a myriad of treatment techniques for such a large variety of patient presentations. I now feel that I can come up with some of my own treatments, but that I have a lot of learning to do once I graduate if I want to have the experience and knowledge required for a career ion neurological physiotherapy. The staff were so open to seeing the techniques that we knew, as well as open to teaching us the techniques they thought most suitable. I was very impressed with the fact that everyone here appears to be as eclectic as we are at Notre Dame, as I believe it results in the best treatment for patients.
The placement wasn’t structured exactly as I thought initially. We were given patients both in the acute neurological and neurological rehabilitation wards. Some of our patients were shared while others were given to us separately. Most of our patients had suffered from strokes, Parkinson’s disease or Guillain Barre and the different presentations of the patients allowed us to gain a good clinical picture of the possible stages, types and severity of each of the conditions. I feel that I have gained a lot of confidence in the area of neurological physiotherapy because of the mix of patients we were able to see which I believe is an invaluable tool for when I go out into the workplace.
I feel that my confidence in my observation, assessment, communication and clinical reasoning skills have grown hugely in this placement and I believe this will not just help me move forward in the area of neurological physiotherapy, but will carry over into other areas, other placement and hopefully into my career. I have learnt the importance of continual education, as without learning new skills and treatment tools I will not be able to work successfully as a neurological physiotherapist, or as any type of physiotherapist. I have also learnt the importance of good communication with patients coupled with n understanding of the patient as a person. Without knowing your patient holistically you cannot achieve those goals that they find most important and in neurological conditions these are generally very important skills such as bed mobility, ambulation or balance. Discharge planning is a huge part of neurological physiotherapy and of utmost importance. Sending a patient home without the proper services, skills or knowledge could quite easily see them back in hospital days, weeks or months after discharge in a much worse condition. However, the most important skill I have learnt is to be creative. If you are clear about what deficits a patient has and the goal they would like to reach you can think outside the box in order to reach that goal and it is generally in this way that patients reach their full potential.
Overall I have gained a lot from this rotation and am very glad to have been placed here. I feel that it has consolidated a lot of my skills and I hope that this caries through to my next rotation and into the future.
Students who had previously been placed at Hollywood hospital told me that the staff were friendly, caring and very involved in the rehabilitation of their patients. This was also my experience. We were given a few days to follow our supervisor and other staff members around where we were able to jump in if we felt comfortable or just stand back and learn from their years of experience. After that the supervision was slowly taken away and we were left with a high level of autonomy. If however, we felt unsure or needed questions answered there was always someone willing to help us out.
Expectations throughout the placement slowly increased, but they were always clearly stated. Completing two SOAPIERS over the five week placement allowed our supervisor to assess our clinical reasoning skills and give us valuable feedback. Also, my first experience with a Notre Dame tutor allowed for greater feedback and more one-on-one teaching. It was a fantastic learning experience to assess and treat patients with someone with such a varied outlook on physiotherapy and a wealth of knowledge and experience. It is something I looked forward to every week.
I was very excited to experience new treatment techniques on this placement as our treatment toolbox from Notre Dame was limited in comparison to the treatment options available, and I was not disappointed. Between my supervisor and my clinical tutor I was taught a myriad of treatment techniques for such a large variety of patient presentations. I now feel that I can come up with some of my own treatments, but that I have a lot of learning to do once I graduate if I want to have the experience and knowledge required for a career ion neurological physiotherapy. The staff were so open to seeing the techniques that we knew, as well as open to teaching us the techniques they thought most suitable. I was very impressed with the fact that everyone here appears to be as eclectic as we are at Notre Dame, as I believe it results in the best treatment for patients.
The placement wasn’t structured exactly as I thought initially. We were given patients both in the acute neurological and neurological rehabilitation wards. Some of our patients were shared while others were given to us separately. Most of our patients had suffered from strokes, Parkinson’s disease or Guillain Barre and the different presentations of the patients allowed us to gain a good clinical picture of the possible stages, types and severity of each of the conditions. I feel that I have gained a lot of confidence in the area of neurological physiotherapy because of the mix of patients we were able to see which I believe is an invaluable tool for when I go out into the workplace.
I feel that my confidence in my observation, assessment, communication and clinical reasoning skills have grown hugely in this placement and I believe this will not just help me move forward in the area of neurological physiotherapy, but will carry over into other areas, other placement and hopefully into my career. I have learnt the importance of continual education, as without learning new skills and treatment tools I will not be able to work successfully as a neurological physiotherapist, or as any type of physiotherapist. I have also learnt the importance of good communication with patients coupled with n understanding of the patient as a person. Without knowing your patient holistically you cannot achieve those goals that they find most important and in neurological conditions these are generally very important skills such as bed mobility, ambulation or balance. Discharge planning is a huge part of neurological physiotherapy and of utmost importance. Sending a patient home without the proper services, skills or knowledge could quite easily see them back in hospital days, weeks or months after discharge in a much worse condition. However, the most important skill I have learnt is to be creative. If you are clear about what deficits a patient has and the goal they would like to reach you can think outside the box in order to reach that goal and it is generally in this way that patients reach their full potential.
Overall I have gained a lot from this rotation and am very glad to have been placed here. I feel that it has consolidated a lot of my skills and I hope that this caries through to my next rotation and into the future.
Wednesday, June 2, 2010
Rotation 3 Fourth Year - Discharge Planning STARES
Situation
An 89 year old man was admitted to Hollywood Private Hospital on the 17/5/10 after a CVA – a left LACS. We were not introduced to the gentleman until the 20/5/10 where he had been to SCGH ED, and transferred to Hollywood Private Hospital. He already had a physiotherapist looking after him, so he was just an interesting case for us to look at until he was transferred down to the rehab ward. Due to other complications with his heart and multiple falls he was having he was a hard man to get in to see and his physiotherapy care could be described as intermittent at best. Once he was stabilised he was sent to rehab ward and was officially a patient of mine.
Task
My task was to assess and treat this patient accordingly.
Action
I decided to do a full initial assessment on the patient as my knowledge of his impairments and social situation was patchy at best. On initial assessment he appeared to have minor right-sided weakness of the UL and LL and some cognitive and perceptual deficits, namely agnosia and dyspraxia. His Berg Balance score was 49/56 with all of his scores being a 3 or a 4 except for single leg stance where he received a 1. He appeared to lose his balance with functional tasks such as dressing and leaned to the right with ambulation. He ambulated with no aids and only supervision for ~80m. I decided to focus his treatment on improving his balance and his awareness of his impairments, especially during functional tasks. He was progressing very well, with his Berg Balance score increasing to 53/56, he was able to keep his balance during functional tasks, he understood that his balance was not great and not admitted so and he had no more falls.
I had taken a social history initially, finding that the patient lived with his wife and they shared most of the tasks around the house. They lived in a retirement village with services and amenities at their doorstep and no stairs at all. He also has 3 very supportive children to help him out. I was very happy with him going home as long as he was supervised at all times and there were services put in place to assist him where needed. The discharge planning at Hollywood Hospital is a multidisciplinary process – generally. However, every now and again a doctor will decide to discharge a patient without input from the nursing or allied health teams. In this case I was convinced that the doctor and social worker were clear on his limitations however, the doctor decided that the patient would be discharged in two days, didn’t tell the patient or the family and had not organised the social worker to discuss the issues related to discharge planning.
When visiting the patient that day one of the nurses mentioned that he was going to be discharged in two days time thinking that the family was aware of the fact. The family were irate, and quite understandably. They demanded a family meeting to discuss the issues and I was able to put forth my opinion on his status and what he required.
Result
In the end it was decided that the patient would go back to his house with his wife and services for meals, cleaning and outpatient physiotherapy. The family was very happy with the outcome as were the medical and allied health teams.
Evaluation
This situation really highlighted the need for appropriate and timely discharge planning that includes every member of the team involved in the care of the patient. A family meeting should have been organised within 7 days of the stroke to discuss with the patient’s family what has happened, what his impairments are, the prognosis and what the plan is for moving forward. This would keep the family involved and informed and would help them in motivating the patient to reach their goals.
Another family meeting should also occur a week or so prior to discharge to discuss issues such as the patient’s discharge destination, the services they require, the skills they need to function once they have left and any ongoing issues either the family or the medical team have in regards to the patient.
This situation also made me realise the need to be on the ball with patient’s care. It is not good enough for me to assume that the doctor is listening to me in the meetings and leave it at that, but instead I need to be questioning them about their intentions for discharge and what they have in place for the patient. This is the second time that the allied health team has had to put their foot down and not allow a patient to be discharged and both times I believe the patient was much better off because of it.
Strategies
As I said above, I believe that it is important that communication between the patient, family, medical team and allied health team is open and regular and that each issue a party has to bring to the table is discussed fully and resolved appropriately. A formal discharge planning/family meeting timeline for stroke should be put in place as this would ensure that everyone is kept informed and all issues are resolved when they need to be.
An 89 year old man was admitted to Hollywood Private Hospital on the 17/5/10 after a CVA – a left LACS. We were not introduced to the gentleman until the 20/5/10 where he had been to SCGH ED, and transferred to Hollywood Private Hospital. He already had a physiotherapist looking after him, so he was just an interesting case for us to look at until he was transferred down to the rehab ward. Due to other complications with his heart and multiple falls he was having he was a hard man to get in to see and his physiotherapy care could be described as intermittent at best. Once he was stabilised he was sent to rehab ward and was officially a patient of mine.
Task
My task was to assess and treat this patient accordingly.
Action
I decided to do a full initial assessment on the patient as my knowledge of his impairments and social situation was patchy at best. On initial assessment he appeared to have minor right-sided weakness of the UL and LL and some cognitive and perceptual deficits, namely agnosia and dyspraxia. His Berg Balance score was 49/56 with all of his scores being a 3 or a 4 except for single leg stance where he received a 1. He appeared to lose his balance with functional tasks such as dressing and leaned to the right with ambulation. He ambulated with no aids and only supervision for ~80m. I decided to focus his treatment on improving his balance and his awareness of his impairments, especially during functional tasks. He was progressing very well, with his Berg Balance score increasing to 53/56, he was able to keep his balance during functional tasks, he understood that his balance was not great and not admitted so and he had no more falls.
I had taken a social history initially, finding that the patient lived with his wife and they shared most of the tasks around the house. They lived in a retirement village with services and amenities at their doorstep and no stairs at all. He also has 3 very supportive children to help him out. I was very happy with him going home as long as he was supervised at all times and there were services put in place to assist him where needed. The discharge planning at Hollywood Hospital is a multidisciplinary process – generally. However, every now and again a doctor will decide to discharge a patient without input from the nursing or allied health teams. In this case I was convinced that the doctor and social worker were clear on his limitations however, the doctor decided that the patient would be discharged in two days, didn’t tell the patient or the family and had not organised the social worker to discuss the issues related to discharge planning.
When visiting the patient that day one of the nurses mentioned that he was going to be discharged in two days time thinking that the family was aware of the fact. The family were irate, and quite understandably. They demanded a family meeting to discuss the issues and I was able to put forth my opinion on his status and what he required.
Result
In the end it was decided that the patient would go back to his house with his wife and services for meals, cleaning and outpatient physiotherapy. The family was very happy with the outcome as were the medical and allied health teams.
Evaluation
This situation really highlighted the need for appropriate and timely discharge planning that includes every member of the team involved in the care of the patient. A family meeting should have been organised within 7 days of the stroke to discuss with the patient’s family what has happened, what his impairments are, the prognosis and what the plan is for moving forward. This would keep the family involved and informed and would help them in motivating the patient to reach their goals.
Another family meeting should also occur a week or so prior to discharge to discuss issues such as the patient’s discharge destination, the services they require, the skills they need to function once they have left and any ongoing issues either the family or the medical team have in regards to the patient.
This situation also made me realise the need to be on the ball with patient’s care. It is not good enough for me to assume that the doctor is listening to me in the meetings and leave it at that, but instead I need to be questioning them about their intentions for discharge and what they have in place for the patient. This is the second time that the allied health team has had to put their foot down and not allow a patient to be discharged and both times I believe the patient was much better off because of it.
Strategies
As I said above, I believe that it is important that communication between the patient, family, medical team and allied health team is open and regular and that each issue a party has to bring to the table is discussed fully and resolved appropriately. A formal discharge planning/family meeting timeline for stroke should be put in place as this would ensure that everyone is kept informed and all issues are resolved when they need to be.
Monday, May 24, 2010
Rotation 3 Fourth Year - Evidence Based Practice STARES
Situation
A 61 year old man was admitted to Hollywood Private Hospital rehabilitation ward for two weeks elective respite and rehabilitation. He presented with a 21 month history of severe Guillain Barre Syndrome, post-infection in July 2008.
He had spent 7 months in Sir Charles Gardener Hospital initially where he was intubated 6 days post the onset of his symptoms and remained so until January of 2009. He had lost complete use of his upper and lower limbs until September 2008 when he regained a minimal amount of strength. He was completely dependent for all activities of daily living and experienced a number of pulmonary complications during this time including pneumonia and a pulmonary embolism.
In February 2009 he was transferred to Shenton Park where he underwent extensive rehabilitation. It was during this time that he regained a large amount of strength and functional ability. When he was discharged in September 2009 he had independent bed mobility, x2 assist sit-to-stand and step-stand transfer and could operate an electric wheelchair independently. He had very little use of his upper limbs due to decreased strength in his arms and minimal use of his hands due to contractures at the fingers and weakness. He was however able to eat independently and use a modified computer set-up independently.
Currently he is receiving private physiotherapy twice a week (neurological and musculoskeletal) and attending Shenton Park outpatient department physiotherapy twice a week. He also receives private OT and help with showering and toileting twice daily from an outside carer. All other care is provided by his wife.
To give his wife a break he elected to spend 2 weeks at Hollywood Private Hospital where he felt he could also have intensive physiotherapy rehabilitation as well.
Task
My task was to assess and treat this patient accordingly.
Action
This patient had two main goals; to walk independently with an aid ~15m in his home and to regain the use of his upper limb to decrease his dependence on people with his activities of daily living. I therefore focused my treatment towards these goals. Whilst I did do some treatment to assist with his upper limb function, I decided to focus on his goal of ambulation, as he had recently begun to ambulate x2 maximum assistance at Shenton Park outpatient department.
Whilst ambulating the patient with 2 therapists we noticed how cumbersome and dangerous the task was. The patient weighed over 100kg and was very unpredictable in the way in which he moved his weight around. This was due mainly to his lack of core and hip stability. It was therefore important to find a task-specific treatment method for this patient that maintained the safety of the therapists involved. It was important that whilst safety was a high priority, the treatment of the patient was as specific as possible.
In my research I found the article:
Tuckey, J., Greenwood, R. (2004) ‘Rehabilitation after severe Guillain-Barré syndrome: the use of partial body weight support’. Physiotherapy Research International. 9 (2), 96-103.
It is a case report outlining the use of partial body weight support treadmill training in a man with severe chronic Guillain Barre Syndrome. It uses the evidence supporting partial body weight support (PBWS) treadmill training in other clinical populations such as stroke and spinal injury to justify its use in Guillain Barre and then follows the rehabilitation of this man to show its usefulness.
It outlines the fact that PBWS could allow task-specific gait training for patients in which purely therapist assisted ambulation is too cumbersome and poses a manual handling risk. This was especially poignant for our patient as he had decreased core stability which didn’t allow him to focus on the motor sequence of gait and the activation of his lower limb muscles. It also allowed the therapist to facilitate muscle activation instead of focusing on maintaining the patient upright and on balance.
It was then decided after a week of treatment focusing on his core and hip stability that the second week would include daily sessions on the PBWS treadmill system. It did take some trial and error, especially with the timing of the session as the patient was too fatigued for his treatment in the afternoon if he had been on the treadmill in the morning. Different facilitation methods were trialled but eventually it was found that one therapist was required at the trunk to facilitate trunk stability and weight transfer and one therapist was required at each leg to facilitate gluteal activation and knee extension.
Result
By the end of the two weeks, both on and off the treadmill, the patient was walking with improved core and hip stability, less trendelenburg signs in stance, less adduction of the leg in swing phase, larger stride length and a more rhythmical cadence. Whilst his dependence on the therapists during off-treadmill ambulation was still the same his gait pattern was greatly improved.
The patient also felt much more confident and a lot happier with his walking pattern and the psychological benefits of getting closer to his goal was definitely evident.
Evaluation
It is a hard balance to determine if low level evidence is reliable or not, especially in a clinical population as small as Guillain-Barre. However I think that it is important to extrapolate from evidence those benefits they may be useful for your patients and think outside the box. I believe that even if the case report did not exist I still would have chosen the PBWS treadmill training as a treatment due to strong evidence for task-specific training and the added benefits it gave in terms of safety of the patient and therapists and the ability to facilitate gait much more thoroughly than off the treadmill.
My one concern is that it was only one week of training and he may loose those benefits quite quickly. It has been shown that training such as this requires a program of at least six weeks for any long-term benefit, so the improvement may be short lived.
It may however open the door for Shenton Park or one of his private physiotherapists to offer the same treatment to him on a regular basis. I have sent a discharge letter to them to let them know what treatment the patient did receive here during his stay.
Strategies
I think the most important strategy here is to think outside the box and always remember that ‘a lack of evidence is not evidence of lack’ as people commonly say. If you can clinically reason a treatment choice that has been shown to help in another clinical population then there is no harm in trying as long as there is no risk to you or the patient. The evidence out there really did help to guide my treatment choice and made it an informed and reasoned one. It really does enforce the need to stay on top of the evidence once we have graduated and are out in the real world.
A 61 year old man was admitted to Hollywood Private Hospital rehabilitation ward for two weeks elective respite and rehabilitation. He presented with a 21 month history of severe Guillain Barre Syndrome, post-infection in July 2008.
He had spent 7 months in Sir Charles Gardener Hospital initially where he was intubated 6 days post the onset of his symptoms and remained so until January of 2009. He had lost complete use of his upper and lower limbs until September 2008 when he regained a minimal amount of strength. He was completely dependent for all activities of daily living and experienced a number of pulmonary complications during this time including pneumonia and a pulmonary embolism.
In February 2009 he was transferred to Shenton Park where he underwent extensive rehabilitation. It was during this time that he regained a large amount of strength and functional ability. When he was discharged in September 2009 he had independent bed mobility, x2 assist sit-to-stand and step-stand transfer and could operate an electric wheelchair independently. He had very little use of his upper limbs due to decreased strength in his arms and minimal use of his hands due to contractures at the fingers and weakness. He was however able to eat independently and use a modified computer set-up independently.
Currently he is receiving private physiotherapy twice a week (neurological and musculoskeletal) and attending Shenton Park outpatient department physiotherapy twice a week. He also receives private OT and help with showering and toileting twice daily from an outside carer. All other care is provided by his wife.
To give his wife a break he elected to spend 2 weeks at Hollywood Private Hospital where he felt he could also have intensive physiotherapy rehabilitation as well.
Task
My task was to assess and treat this patient accordingly.
Action
This patient had two main goals; to walk independently with an aid ~15m in his home and to regain the use of his upper limb to decrease his dependence on people with his activities of daily living. I therefore focused my treatment towards these goals. Whilst I did do some treatment to assist with his upper limb function, I decided to focus on his goal of ambulation, as he had recently begun to ambulate x2 maximum assistance at Shenton Park outpatient department.
Whilst ambulating the patient with 2 therapists we noticed how cumbersome and dangerous the task was. The patient weighed over 100kg and was very unpredictable in the way in which he moved his weight around. This was due mainly to his lack of core and hip stability. It was therefore important to find a task-specific treatment method for this patient that maintained the safety of the therapists involved. It was important that whilst safety was a high priority, the treatment of the patient was as specific as possible.
In my research I found the article:
Tuckey, J., Greenwood, R. (2004) ‘Rehabilitation after severe Guillain-Barré syndrome: the use of partial body weight support’. Physiotherapy Research International. 9 (2), 96-103.
It is a case report outlining the use of partial body weight support treadmill training in a man with severe chronic Guillain Barre Syndrome. It uses the evidence supporting partial body weight support (PBWS) treadmill training in other clinical populations such as stroke and spinal injury to justify its use in Guillain Barre and then follows the rehabilitation of this man to show its usefulness.
It outlines the fact that PBWS could allow task-specific gait training for patients in which purely therapist assisted ambulation is too cumbersome and poses a manual handling risk. This was especially poignant for our patient as he had decreased core stability which didn’t allow him to focus on the motor sequence of gait and the activation of his lower limb muscles. It also allowed the therapist to facilitate muscle activation instead of focusing on maintaining the patient upright and on balance.
It was then decided after a week of treatment focusing on his core and hip stability that the second week would include daily sessions on the PBWS treadmill system. It did take some trial and error, especially with the timing of the session as the patient was too fatigued for his treatment in the afternoon if he had been on the treadmill in the morning. Different facilitation methods were trialled but eventually it was found that one therapist was required at the trunk to facilitate trunk stability and weight transfer and one therapist was required at each leg to facilitate gluteal activation and knee extension.
Result
By the end of the two weeks, both on and off the treadmill, the patient was walking with improved core and hip stability, less trendelenburg signs in stance, less adduction of the leg in swing phase, larger stride length and a more rhythmical cadence. Whilst his dependence on the therapists during off-treadmill ambulation was still the same his gait pattern was greatly improved.
The patient also felt much more confident and a lot happier with his walking pattern and the psychological benefits of getting closer to his goal was definitely evident.
Evaluation
It is a hard balance to determine if low level evidence is reliable or not, especially in a clinical population as small as Guillain-Barre. However I think that it is important to extrapolate from evidence those benefits they may be useful for your patients and think outside the box. I believe that even if the case report did not exist I still would have chosen the PBWS treadmill training as a treatment due to strong evidence for task-specific training and the added benefits it gave in terms of safety of the patient and therapists and the ability to facilitate gait much more thoroughly than off the treadmill.
My one concern is that it was only one week of training and he may loose those benefits quite quickly. It has been shown that training such as this requires a program of at least six weeks for any long-term benefit, so the improvement may be short lived.
It may however open the door for Shenton Park or one of his private physiotherapists to offer the same treatment to him on a regular basis. I have sent a discharge letter to them to let them know what treatment the patient did receive here during his stay.
Strategies
I think the most important strategy here is to think outside the box and always remember that ‘a lack of evidence is not evidence of lack’ as people commonly say. If you can clinically reason a treatment choice that has been shown to help in another clinical population then there is no harm in trying as long as there is no risk to you or the patient. The evidence out there really did help to guide my treatment choice and made it an informed and reasoned one. It really does enforce the need to stay on top of the evidence once we have graduated and are out in the real world.
Friday, May 14, 2010
Rotation 3 Fourth Year - Assessment STARES
Situation
A 72 year old man was admitted to the rehabilitation ward at Hollywood Hospital on the 25th of April 2010 with a decrease in mobility, an increasing number of falls and lethargy. According to his wife his memory was starting to fail and he was finding it harder and harder to cope at home. This in turn was putting an increasing amount of pressure on her and she could no longer manage on her own. His past medical history included a diagnosis of Parkinson’s disease in 2006 and ischaemic heart disease.
Task
I was set the task of performing a neurological assessment on this gentleman.
Action
In preparation for the assessment of the patient I read through his medical and bedside notes. There was very little mention of his Parkinson’s disease in the notes and, according to the drug chart, on the 27th of April he was taken off his Parkinson’s medication (Madopar). After this date the notes mentioned the diagnosis of progressive supranuclear palsy (PSP), however there was no clear time or indication that the diagnosis changed. I spoke to the registrar and the consultant but they too didn’t know where the diagnosis had come from, only that the medication was not effective so he was taken off it. I then decided that within the assessment I would include some tests that differentiated between PSP and Parkinson’s disease. These tests included observation of his posture in standing as in PSP the patient will lean backwards but in Parkinson’s disease the patient will have a flexed posture, testing of his eye movements, as vertical tracking and convergence decrease with PSP but remain normal in Parkinson’s disease, and lastly, observation for any resting tremor as this is present in Parkinson’s disease but absent in PSP.
On assessment the patient did show signs of bradykinesia, decreased cognition (MME 16), decreased balance (Berg 33) and a history of falls. These are all signs and symptoms of both Parkinson’s disease and PSP. There was no resting tremor, minor rigidity, no history of freezing or akinesia and he was not responsive to Levadopa, which are all signs of only Parkinson’s disease. Lastly, he had very minimal vertical tracking and convergence of his eyes and leant backwards in standing, all symptoms only present in PSP. Whist I couldn’t definitively say that the patient had PSP, clinically it appeared that it might be a possibility. I spoke to the registrar regarding my findings and she is now in the process of confirming a diagnosis.
As the assessment allowed me to construct a concise problem list, a definitive diagnosis did not affect my treatment of this patient. It does however guide the medical treatment, so it is an important finding from the registrar’s perspective. My problem list included decreased dynamic standing balance, decrease insight and attention and abnormal standing posture. I then treated the patient with exercises that focused on these problems, keeping in mind the patients discharge destination, low level care.
Result
My actions resulted in the patient having further investigations into their condition, therefore leading to a better diagnosis and hopefully better treatment. This however did not affect my treatment much except that with a clear diagnosis I have a better idea of how the disease is predicted to progress, the prognosis, the best treatments and what to look out for in the future.
Evaluation
Whilst I am happy with the outcome of the situation, I am quite aware that without the mention of PSP in the notes by another healthcare practitioner I would not have even considered it. It makes me realise the importance of knowing each condition in detail and the possible options for differential diagnosis. Even a basic knowledge of a condition and its differential diagnoses would allow the options to be known. I will definitely be revising my neurological conditions over this placement and ensuring that I know the other similar conditions out there. In this case it was not detrimental to the patient however in the future a lack of knowledge such as this with another condition could possibly result in a negative outcome.
Strategies
As stated above, knowledge of the various neurological conditions and their differential diagnoses would have ensured that this possible misdiagnosis was picked up. Also, thorough reading of the notes ensured that any miscommunication within the medical notes was picked up and that all health care practitioners are treating the same condition.
A 72 year old man was admitted to the rehabilitation ward at Hollywood Hospital on the 25th of April 2010 with a decrease in mobility, an increasing number of falls and lethargy. According to his wife his memory was starting to fail and he was finding it harder and harder to cope at home. This in turn was putting an increasing amount of pressure on her and she could no longer manage on her own. His past medical history included a diagnosis of Parkinson’s disease in 2006 and ischaemic heart disease.
Task
I was set the task of performing a neurological assessment on this gentleman.
Action
In preparation for the assessment of the patient I read through his medical and bedside notes. There was very little mention of his Parkinson’s disease in the notes and, according to the drug chart, on the 27th of April he was taken off his Parkinson’s medication (Madopar). After this date the notes mentioned the diagnosis of progressive supranuclear palsy (PSP), however there was no clear time or indication that the diagnosis changed. I spoke to the registrar and the consultant but they too didn’t know where the diagnosis had come from, only that the medication was not effective so he was taken off it. I then decided that within the assessment I would include some tests that differentiated between PSP and Parkinson’s disease. These tests included observation of his posture in standing as in PSP the patient will lean backwards but in Parkinson’s disease the patient will have a flexed posture, testing of his eye movements, as vertical tracking and convergence decrease with PSP but remain normal in Parkinson’s disease, and lastly, observation for any resting tremor as this is present in Parkinson’s disease but absent in PSP.
On assessment the patient did show signs of bradykinesia, decreased cognition (MME 16), decreased balance (Berg 33) and a history of falls. These are all signs and symptoms of both Parkinson’s disease and PSP. There was no resting tremor, minor rigidity, no history of freezing or akinesia and he was not responsive to Levadopa, which are all signs of only Parkinson’s disease. Lastly, he had very minimal vertical tracking and convergence of his eyes and leant backwards in standing, all symptoms only present in PSP. Whist I couldn’t definitively say that the patient had PSP, clinically it appeared that it might be a possibility. I spoke to the registrar regarding my findings and she is now in the process of confirming a diagnosis.
As the assessment allowed me to construct a concise problem list, a definitive diagnosis did not affect my treatment of this patient. It does however guide the medical treatment, so it is an important finding from the registrar’s perspective. My problem list included decreased dynamic standing balance, decrease insight and attention and abnormal standing posture. I then treated the patient with exercises that focused on these problems, keeping in mind the patients discharge destination, low level care.
Result
My actions resulted in the patient having further investigations into their condition, therefore leading to a better diagnosis and hopefully better treatment. This however did not affect my treatment much except that with a clear diagnosis I have a better idea of how the disease is predicted to progress, the prognosis, the best treatments and what to look out for in the future.
Evaluation
Whilst I am happy with the outcome of the situation, I am quite aware that without the mention of PSP in the notes by another healthcare practitioner I would not have even considered it. It makes me realise the importance of knowing each condition in detail and the possible options for differential diagnosis. Even a basic knowledge of a condition and its differential diagnoses would allow the options to be known. I will definitely be revising my neurological conditions over this placement and ensuring that I know the other similar conditions out there. In this case it was not detrimental to the patient however in the future a lack of knowledge such as this with another condition could possibly result in a negative outcome.
Strategies
As stated above, knowledge of the various neurological conditions and their differential diagnoses would have ensured that this possible misdiagnosis was picked up. Also, thorough reading of the notes ensured that any miscommunication within the medical notes was picked up and that all health care practitioners are treating the same condition.
Sunday, May 9, 2010
Rotation 3 Fourth Year - Initial Entry
I am really excited about this next placement at Hollywood Hospital in the area of neurological rehabilitation. Neurological physiotherapy has been one of my favourite areas during my studies and I have been looking forward to seeing the patients and their symptoms that that I have only read or heard about. As it is an area I am possibly looking to work in I think it will be good to see if I still feel that way after five weeks immersed in the area.
I have heard only good things about this placement from at least three people, some who have just attended the rotation and some that have been there in other years. Not only have they expressed their enjoyment about the work that they did and the patients that they saw, but also that the staff were friendly, passionate and very helpful. This gives me a feeling of confidence that it I put the effort into this placement I will reap the rewards of a successful and enjoyable learning experience.
Of course I am also feeling the usual nerves of starting at a new rotation and the expectations that they may have of me. It is a constant worry throughout this year as to whether you are meeting the high expectations of clinicians in the workforce to a graduate level by the end of the placement. It usually takes me the first week to feel comfortable in the new surroundings and with the new supervisors, so I will have to be patient. This will also be the first time that I will have a tutor, so this will bring a new dimension to the placement that I have never experienced before. I really have no idea what to expect in terms of the tutor as I have heard that they, like the supervisors, are all very different in their approach. I think I will just have to wait and see!
There is one thing that I am really looking forward to in this placement and that is seeing the various treatment techniques used. We were taught only a small selection of treatments in our neurology unit due to the large amount of treatment options available. I am really hoping that we are taught and shown some new techniques to use and that they can be added to our already eclectic tool box of neurological treatment techniques.
I have heard from past students that I will be working in the rehabilitation area rather than the acute neurology area. Patients will have mainly suffered from strokes and Parkinson’s disease and some other conditions such as multiple sclerosis may also present. I believe that the last two students there worked predominantly together, however they may be splitting us up this time as they would like to see how we work independently. I think that this plan will depend on the staffing availability in terms of supervision so it will be interesting to see what happens. I’m not sure as to the level of supervision there and how much we will be allowed to do independently. I am hoping for a lot more independence in this placement as I was supervised quite heavily in the last placement and I feel I don’t work my best having someone looking over my shoulder at all times.
I believe my role at the hospital will begin as a student therapist, a combination of observation of the clinicians, some observation of my skills and a small amount of independent treatment. I then think that the supervisor will gradually take away supervision until I am working at the level of a new graduate by the end of the placement. I think it is important that I emulate a skilled, independent therapist, but at the same time have respect for those with greater skills than I and treat them accordingly. I also need to remember that I am a guest in their workplace and to respect this fact at all times. Most of all I think my role is to learn and gain experience from this fantastic resource that I am so lucky to be a part of.
Overall I don’t really have any concerns about this placement as I have complete confidence that if I work hard and use the tools I have been taught over the past three and a half years I will be fine. My concern is usually about the supervisor that I get but as I have been told that I will have a great supervisor I feel much better about the rotation. I really can’t wait to get in there and start!
I have heard only good things about this placement from at least three people, some who have just attended the rotation and some that have been there in other years. Not only have they expressed their enjoyment about the work that they did and the patients that they saw, but also that the staff were friendly, passionate and very helpful. This gives me a feeling of confidence that it I put the effort into this placement I will reap the rewards of a successful and enjoyable learning experience.
Of course I am also feeling the usual nerves of starting at a new rotation and the expectations that they may have of me. It is a constant worry throughout this year as to whether you are meeting the high expectations of clinicians in the workforce to a graduate level by the end of the placement. It usually takes me the first week to feel comfortable in the new surroundings and with the new supervisors, so I will have to be patient. This will also be the first time that I will have a tutor, so this will bring a new dimension to the placement that I have never experienced before. I really have no idea what to expect in terms of the tutor as I have heard that they, like the supervisors, are all very different in their approach. I think I will just have to wait and see!
There is one thing that I am really looking forward to in this placement and that is seeing the various treatment techniques used. We were taught only a small selection of treatments in our neurology unit due to the large amount of treatment options available. I am really hoping that we are taught and shown some new techniques to use and that they can be added to our already eclectic tool box of neurological treatment techniques.
I have heard from past students that I will be working in the rehabilitation area rather than the acute neurology area. Patients will have mainly suffered from strokes and Parkinson’s disease and some other conditions such as multiple sclerosis may also present. I believe that the last two students there worked predominantly together, however they may be splitting us up this time as they would like to see how we work independently. I think that this plan will depend on the staffing availability in terms of supervision so it will be interesting to see what happens. I’m not sure as to the level of supervision there and how much we will be allowed to do independently. I am hoping for a lot more independence in this placement as I was supervised quite heavily in the last placement and I feel I don’t work my best having someone looking over my shoulder at all times.
I believe my role at the hospital will begin as a student therapist, a combination of observation of the clinicians, some observation of my skills and a small amount of independent treatment. I then think that the supervisor will gradually take away supervision until I am working at the level of a new graduate by the end of the placement. I think it is important that I emulate a skilled, independent therapist, but at the same time have respect for those with greater skills than I and treat them accordingly. I also need to remember that I am a guest in their workplace and to respect this fact at all times. Most of all I think my role is to learn and gain experience from this fantastic resource that I am so lucky to be a part of.
Overall I don’t really have any concerns about this placement as I have complete confidence that if I work hard and use the tools I have been taught over the past three and a half years I will be fine. My concern is usually about the supervisor that I get but as I have been told that I will have a great supervisor I feel much better about the rotation. I really can’t wait to get in there and start!
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