Rural Prac '09 Topic One - Communication

Situation
On Wednesday, I had an 82yo male patient on 'Ferns Ward', which is the orthopaedic ward, at SJOG Bunbury. He was 6 day post-op for a R TKR. Everyday, the new patients are seen in the morning once the bloods have come in and then the other patients who are day 2 onwards are seen in order of priority. Wednesday was a particularly busy day, and we hadn't yet been able to see this patient who was pretty standard except for not doing his exercises. On our way rushing down the corridor to see other patients with more pressing matters we overheard a nurse saying that this patient had decided to go home that afternoon. On hearing that, he very quickly found his way to the top of our priority list! Apparently the doctors tell the patients that from their point of view the patient is ready to go home, but they don't mention that the nurses, social workers, dieticians, physios, OT's etc. also have to clear them for discharge as well. As you can imagine, all that this patient heard was that he was going home. Unfortunately, his family didn't think it was a good idea because his day before had been rough in terms of obs and he was going home to a farm that they felt he wasn't ready to cope with. The nurses were also concerned about his obs. The OT and social worker we concerned about him returning to his remote farm where it was just him and his wife and there were no services available to them. As physios, we were mainly concerned with his lack of compliance with his exercises which had resulted in his inability to SLR which means no chance of going home and ambulating.

Task
Our task was to communicate to the patient that staying in the hospital for at least one night was going to benefit him in the long run even though he was very determined to go home and seemed very distressed at the prospect of staying another night.

Action
My supervisor and I attempted to discuss the matter with the patient and his family, but his family were afraid to verbalise how they really felt in case it upset him. We decided that the best course of action was to speak to the nurse who would have heard from the doctor. She told us that the doctor was only happy for the patient to be discharged when the entire team was happy. She also said that the nursing team was concerned with his obs and also his ability to cope on his own. After hearing this we took his family outside to hear how they really felt. It turned out that they felt very strongly about keeping him in the hospital for at least another night, and they were very distressed at the idea of him coming home. My supervisor decided that the best course of action was to tell the patient that when he could SLR he could go home.

Result
In the end, although the patient was unhappy with the prospect of staying another night I think it made him understand the importance of doing his excersices as well as having a clear goal to achieve in order to go home. The family and nursing staff were very happy with the outcome.

Evaluation
I believe that we dealh with the situation very well and did the right thing. I however don't like the fact that one member of the team can tell a patient they can be discharged without ensuring that the rest of the team is ok with it aswell. I am very happy to know that physios don't do this at all! I think the other staff and family were worrying too much about stepping on his toes and upsetting him instead of seeing the bigger picture and doing what was best for the patient. At no time were we cruel to him and he fully understood the logic, and we fully understood that hospitals are not the nicest places to stay.

Strategies
Without communication, this patient would have been sent home prematurely and probably would have ended up back in the hospital for even longer in a few weeks/months time. Team work was very important as well, to make sure that every aspect of the patients care was of the highest level . I only wish that I could have had the chance to go in and speak with him again today to really discuss and explain the situation again when he was no longer upset about the situation, and get him really appreciating and liking physios!

Rural Prac '09 Initial Entry

I'm pretty nervous about this prac, but no where near as nervous as I was for out 2nd year one. I think the first prac gave me the confidence to know that the supervisers are there to teach you not to fail you! I'm really happy with the placement I have, SJOG is meant to be really good and the prac is split into inpatients and outpatients so I should see a bit of everything. I'm not worried about the outpatient side because my last prac was all outpatient, but I'm worried about the inpatient side. I feel like I've forgotten about everything cardio and orthopaedic from 2nd year and that's mainly what inpatients will consist of. I'm hoping that the days will be split in half between inpatient and outpatient, or at least the days will be split equally so I can experience them both thoroughly. I'm expecting that the supervisors will have much higher expectations of us compared to our second year prac as we've down an extra semester, but I also know that they will be realistic about the level of knowledge we have. I hope I gain as much if not more from this prac as I did from the last one, fingers crossed!!!

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!!!