Situation
A 26 year old female was referred to the Outpatient Department at Armadale hospital by her GP for ‘tennis elbow’. The injury resulted at a game of ten pin bowling 3 months earlier where the woman bowled on an unusual angle. She played ten pin bowling on a weekly basis and had never experienced an injury such as this before. The patient took two weeks off work initially as her work was manual in nature and the pain was limiting the tasks she was able to complete. She had also stopped ten pin bowling after the initial injury and had not yet returned.
Task
I was asked in the referral letter to assess and treat her accordingly.
Action
When the patient arrived I performed a full subjective and objective assessment, completely disregarding the diagnosis given in the referral, to ensure that I was unbiased in my own diagnosis. The patient did indeed have an extensor tendinopathy which was started to resolve on its own with the patient stopping the aggravating activities of ten pin bowling and work. However, there were still quite marked limitations in terms of elbow, forearm, wrist and grip strength and some pain especially with grip. I remembered from 2nd year the benefits of eccentric strength exercises in tendinopathy and prescribed the patient eccentric wrist flexion, extension, radial deviation and ulnar deviation with weights, education on continuing to avoid the aggravating activities where possible and wearing a tennis elbow brace when doing the tasks she cannot avoid. I also gave her general elbow and grip strengthening exercises and stretches for the wrist.
Before I next saw the patient I decided to look at the evidence on extensor tendinopathy treatment to ensure I was giving her the best treatment I could. I found an article called Lateral epicondylalgia: a musculoskeletal physiotherapy perspective by B.Vicenzino (Manual Therapy 2003, 8 (2), 66-79) which is a masterclass article on tennis elbow. It outlines appropriate treatments depending on the presentation of the patient. I found it especially interesting as my patient fit very nicely into one of the classifications given; pain-free grip strength deficit is much larger than pain elicited on direct palpation of the lateral epicondyle (i.e. the pressure pain threshold). It spoke about the Mulligan’s (1999) MWM and how it is extremely beneficial in the treatment of patients with this presentation, specifically the sustained lateral glide with pain-free grip. This technique can be done manually and then reinforced with taping of the lateral glide to continue improvements once the patient leaves the physiotherapist, as well as self mobilization techniques for home. Due to the strength of the evidence supporting these techniques I decided to try them on my patient when she returned if she still fit into the same clinical picture.
When the patient returned the techniques I had prepared were still relevant, so, I performed a sustained lateral glide while she performed pain-free gripping movements. She felt that the grip she could maintain with the glide was much stronger than without, and this was then confirmed with a handheld dynamometer. The treatment therefore seemed to be a successful one. I taped the patient before she left and she felt this helped the pain substantially. I decided not to teach her self-mobilizations as I was not confident she would be able to perform them correctly at home.
When the patient returned a week later she had significant improvements in pain and functional level and no longer had pain on grip. I was then able to focus more on improving her strength functionally to allow her to return to ten pin bowling.
Result
I believe that the patient recovered much faster with the evidence-based intervention that was chosen due to her specific clinical pattern rather than a recipe treatment for every tennis elbow available. Whilst I was treating her initially with eccentric exercises which are backed by strong exercises, I was able to incorporate even more specific treatments that really targeted her problems.
Evaluation
Whilst I believe that there was little that I could have done in this situation to have prepared or performed any better, it has definitely taught me the importance of evidence-based practice. We are taught over and over again at university the importance of knowing the evidence and using treatments that are backed by evidence, but until you experience it for yourself it is a hard concept to grasp. Just saying that you are doing a treatment because it was what you were taught to do just does not cut it in the real world with real patients, you must be able to back yourself up with hard evidence.
Strategies
I now know that when I graduate I am really only just beginning to learn. University has given me my base knowledge but I must continue the learning by keeping up to date with the literature in order to be the best physiotherapist I can be. I will definitely keep up to date once I graduate, as my supervisor is a great clinician and it is due to his very comprehensive knowledge of the evidence that is available.
Sunday, February 28, 2010
Saturday, February 13, 2010
Rotation 1 Fourth Year - Assessment STARES
Situation
A 71 year old woman was referred to the Outpatient Department at Armadale Hospital by her GP with a diagnosis of tibialis posterior tendonitis and medial malleolar zone pain. This was after an accident at the supermarket where another woman ran into her ankle with a shopping trolley 4 months earlier. An x-ray had ruled out fractures as a possible cause of her pain, and an ultrasound had found some degeneration in both the medial and lateral malleolar zones as well as marked swelling.
Task
I was asked in the referral letter to assess and treat her accordingly.
Action
Wanting to be prepared for the patient and have all of the possible causes of her pain fresh in my mind, I read up on medial ankle pathologies and the possible differential diagnoses of these. I assumed that while the diagnosis may not be correct the GP would have at least correctly described the area of pain. However, when the patient arrived I quickly found that her pain was not in her medial ankle but instead in her lateral ankle. All of the pathologies and tests I had revised were no longer relevant to this patient. I quickly rethought my approach to my objective assessment to include structures in the lateral ankle such as the ATFL, deltoid ligament and CFL and did my best to bring on the patients symptoms. However, no matter what I tried, whether it be a functional test, muscle strength test, muscle length test or ligament integrity test I could not bring on her pain except in weight bearing activities. Even in the weight bearing activities she could not pin point the part of the activity that aggravated it except that it was when her weight went through her ankle. I was becoming thoroughly frustrated and nervous as my supervisor was present and offering no solutions to me. After taking too long to complete my objective assessment the patient announced that she had to return home straight away as she was a carer for her disabled husband. My supervisor spoke up and said that it was ok to rebook and continue the assessment later that week if the patient is happy with that. Luckily the patient was very understanding and was happy to come back a few days later.
Result
My actions eventuated in a patient leaving the department with no diagnosis or understanding of her problem and no treatment was given. If it were another patient they could have been very unsatisfied with the length of time I had spent with them without any resolution to their problem. However, I was lucky enough to have a very understanding patient who did return to the department to continue their treatment.
Evaluation
Of all of the bad experiences I have had on a placement this would have to be the one that I am most ashamed of. I feel I completely let down my patient, offering them no explanation or solution to their problem. I believe that I let myself assume what was wrong with the patient before they even arrived. Not by believing the referral as it was exactly, but by believing the referral at all! She is not the only patient who has arrived with completely different sore body parts than the ones spoken about in the referral. This is not only because of the GPs but also because of the length of waiting time that is unavoidable in the public system and some pain symptoms can change in a matter of months. I also believe that I didn’t take the patient’s chronicity and non irritability into account and was not aggressive enough to bring on the patients symptoms. Whilst part of me does wish that the supervisor had stepped in at the time, I feel that he didn’t want to embarrass or undermine me in front of the patient and we later had a lengthy discussion about the patient regarding what I could have done to avoid the situation and how to approach the patient the next time I saw her. Whilst I believe that the situation was terrible and one I never want to repeat I believe the discussion and therefore the things I have learnt from the situation would not have come about without making the mistakes that I did. I am also glad that I kept my cool in front of the patient and never let her know that I was concerned and frustrated. To her it just appeared I was doing my job and ran out of time.
Strategies
I believe that my objective assessment was not dynamic and flexible enough, as I had already made assumptions about what was wrong with the patient before I had seen them. All areas of assessment and treatment should be always changing depending on each new piece of information the patient presents to me. I should never stop at the end of the objective assessment and start thinking about what is wrong with the patient, I should be already forming ideas as I go so that I can change my assessment if need be. Also, my objective assessment was not aggressive enough for a patient that was non irritable and chronic. A patient like her requires an aggressive assessment to find the source of the symptoms. Through the week I practiced my objective assessment on the ankle and when the patient returned later that week I was a lot more aggressive, dynamic and flexible with my assessment. Unfortunately I still couldn’t find the source of symptoms but my supervisor and I discussed it and decided that there may no longer be an injury, hence no reproduction of symptoms, but that the pain is centrally mediated. Whilst it would have been nice to find a source of symptoms, I can safely say that I performed an effective objective assessment and that my findings were accurate the second time around.
A 71 year old woman was referred to the Outpatient Department at Armadale Hospital by her GP with a diagnosis of tibialis posterior tendonitis and medial malleolar zone pain. This was after an accident at the supermarket where another woman ran into her ankle with a shopping trolley 4 months earlier. An x-ray had ruled out fractures as a possible cause of her pain, and an ultrasound had found some degeneration in both the medial and lateral malleolar zones as well as marked swelling.
Task
I was asked in the referral letter to assess and treat her accordingly.
Action
Wanting to be prepared for the patient and have all of the possible causes of her pain fresh in my mind, I read up on medial ankle pathologies and the possible differential diagnoses of these. I assumed that while the diagnosis may not be correct the GP would have at least correctly described the area of pain. However, when the patient arrived I quickly found that her pain was not in her medial ankle but instead in her lateral ankle. All of the pathologies and tests I had revised were no longer relevant to this patient. I quickly rethought my approach to my objective assessment to include structures in the lateral ankle such as the ATFL, deltoid ligament and CFL and did my best to bring on the patients symptoms. However, no matter what I tried, whether it be a functional test, muscle strength test, muscle length test or ligament integrity test I could not bring on her pain except in weight bearing activities. Even in the weight bearing activities she could not pin point the part of the activity that aggravated it except that it was when her weight went through her ankle. I was becoming thoroughly frustrated and nervous as my supervisor was present and offering no solutions to me. After taking too long to complete my objective assessment the patient announced that she had to return home straight away as she was a carer for her disabled husband. My supervisor spoke up and said that it was ok to rebook and continue the assessment later that week if the patient is happy with that. Luckily the patient was very understanding and was happy to come back a few days later.
Result
My actions eventuated in a patient leaving the department with no diagnosis or understanding of her problem and no treatment was given. If it were another patient they could have been very unsatisfied with the length of time I had spent with them without any resolution to their problem. However, I was lucky enough to have a very understanding patient who did return to the department to continue their treatment.
Evaluation
Of all of the bad experiences I have had on a placement this would have to be the one that I am most ashamed of. I feel I completely let down my patient, offering them no explanation or solution to their problem. I believe that I let myself assume what was wrong with the patient before they even arrived. Not by believing the referral as it was exactly, but by believing the referral at all! She is not the only patient who has arrived with completely different sore body parts than the ones spoken about in the referral. This is not only because of the GPs but also because of the length of waiting time that is unavoidable in the public system and some pain symptoms can change in a matter of months. I also believe that I didn’t take the patient’s chronicity and non irritability into account and was not aggressive enough to bring on the patients symptoms. Whilst part of me does wish that the supervisor had stepped in at the time, I feel that he didn’t want to embarrass or undermine me in front of the patient and we later had a lengthy discussion about the patient regarding what I could have done to avoid the situation and how to approach the patient the next time I saw her. Whilst I believe that the situation was terrible and one I never want to repeat I believe the discussion and therefore the things I have learnt from the situation would not have come about without making the mistakes that I did. I am also glad that I kept my cool in front of the patient and never let her know that I was concerned and frustrated. To her it just appeared I was doing my job and ran out of time.
Strategies
I believe that my objective assessment was not dynamic and flexible enough, as I had already made assumptions about what was wrong with the patient before I had seen them. All areas of assessment and treatment should be always changing depending on each new piece of information the patient presents to me. I should never stop at the end of the objective assessment and start thinking about what is wrong with the patient, I should be already forming ideas as I go so that I can change my assessment if need be. Also, my objective assessment was not aggressive enough for a patient that was non irritable and chronic. A patient like her requires an aggressive assessment to find the source of the symptoms. Through the week I practiced my objective assessment on the ankle and when the patient returned later that week I was a lot more aggressive, dynamic and flexible with my assessment. Unfortunately I still couldn’t find the source of symptoms but my supervisor and I discussed it and decided that there may no longer be an injury, hence no reproduction of symptoms, but that the pain is centrally mediated. Whilst it would have been nice to find a source of symptoms, I can safely say that I performed an effective objective assessment and that my findings were accurate the second time around.
Saturday, February 6, 2010
Rotation 1 Fourth Year - Initial Entry
I am really looking forward to this placement, for a number of reasons, but along with the feelings of excitement come feelings of trepidation and mild anxiety. The excitement is due to the fact that my 2nd year placement at Bentley Hospital Outpatient Department was such a success and really set up my clinical placements for the future to be viewed in a positive light. My placement at Armadale Hospital also taking place in the Outpatient Department fills me with good memories of successful patients, many learning opportunities and 5 weeks of my confidence in myself and love of physiotherapy growing gradually. I hope that my experience at Armadale is a similar one.
My feelings of trepidation are due to the expectations of me growing now that I am a fourth year student. I have heard from past students that expectations of us are high – new graduate level by the 5th week on the placement – and that most people’s marks on placement drop compared to the marks they received in their 2nd and 3rd year placements. It is not the drop in marks that concerns me but that the lack of flexibility with the knowledge we are expected to have will decrease the learning opportunities presented to us. If I leave Armadale Hospital feeling confident to treat patients on my own in the musculoskeletal field, I will consider the placement a success.
I have read from the fourth year presentations given on placements last year that I will start my placement with a considerable amount of supervision, and that this will gradually decrease as the placement continues. I expect that my patients will represent a variety of musculoskeletal disorders/problems, ranging from the usual such as ankle sprains and TKR to the not so usual. I expect to get a considerable amount of patients with back pain as this is a common condition, and one that I am looking forward to treating as I am not overly confident with the condition and have never seen or treated anyone with back pain before. I will be expected to be a professional member of the physiotherapy team, proficient in both subjective and objective assessment and attempt to the best of my ability, experience and knowledge to clinically reason and then perform an effective treatment of the patient. I will be expected to improve significantly from day 1 of placement to my final day, especially in the area of clinical reasoning.
I think that the placement will be structured in one of 2 ways: supervised with supervision gradually decreasing, or leaving the patient to discuss their assessment and treatment with the supervisor. This is based on my past experience at Bentley and from what I’ve heard from other students. I think that both ways are beneficial, however I hope that I will experience the latter at Armadale as I believe my clinical reasoning and patient communication are far better when I am left on my own as I don’t feel as nervous.
I believe my role at the hospital will begin as a combination of an observer and a student therapist, and as the placement goes on will eventually be purely as a therapist. Whilst I believe I will be expected to conduct myself as a confident and proficient therapist I also believe it is important I remember my role as a guest in the hospital and my role as a student, continually learning and observing those with a much greater pool of knowledge and experience than I have.
Overall I am very excited at the prospect of starting my first fourth year placement, and looking forward to the skills and experience I will gain.
My feelings of trepidation are due to the expectations of me growing now that I am a fourth year student. I have heard from past students that expectations of us are high – new graduate level by the 5th week on the placement – and that most people’s marks on placement drop compared to the marks they received in their 2nd and 3rd year placements. It is not the drop in marks that concerns me but that the lack of flexibility with the knowledge we are expected to have will decrease the learning opportunities presented to us. If I leave Armadale Hospital feeling confident to treat patients on my own in the musculoskeletal field, I will consider the placement a success.
I have read from the fourth year presentations given on placements last year that I will start my placement with a considerable amount of supervision, and that this will gradually decrease as the placement continues. I expect that my patients will represent a variety of musculoskeletal disorders/problems, ranging from the usual such as ankle sprains and TKR to the not so usual. I expect to get a considerable amount of patients with back pain as this is a common condition, and one that I am looking forward to treating as I am not overly confident with the condition and have never seen or treated anyone with back pain before. I will be expected to be a professional member of the physiotherapy team, proficient in both subjective and objective assessment and attempt to the best of my ability, experience and knowledge to clinically reason and then perform an effective treatment of the patient. I will be expected to improve significantly from day 1 of placement to my final day, especially in the area of clinical reasoning.
I think that the placement will be structured in one of 2 ways: supervised with supervision gradually decreasing, or leaving the patient to discuss their assessment and treatment with the supervisor. This is based on my past experience at Bentley and from what I’ve heard from other students. I think that both ways are beneficial, however I hope that I will experience the latter at Armadale as I believe my clinical reasoning and patient communication are far better when I am left on my own as I don’t feel as nervous.
I believe my role at the hospital will begin as a combination of an observer and a student therapist, and as the placement goes on will eventually be purely as a therapist. Whilst I believe I will be expected to conduct myself as a confident and proficient therapist I also believe it is important I remember my role as a guest in the hospital and my role as a student, continually learning and observing those with a much greater pool of knowledge and experience than I have.
Overall I am very excited at the prospect of starting my first fourth year placement, and looking forward to the skills and experience I will gain.
Thursday, August 27, 2009
Rural Prac '09 Final Entry
This prac has been better than I expected. I was a lot more confident on my way to the prac than I first thought I would be and actually didn't have any nerves at all. I was still a little shy when first introducing myself to patients in situations like the hydro pool where I was supposed to just chat but I gained more and more confidence as I went along.
The staff we absolutely fantastic and included two Notre Dame new grads, so they understood exactly what it was like to be a student from ND. They were constantly trying to teach us new skills and were always happy to give feedback. We were just tested on the knowledge that we should have but more so on how we took feedback and whether we improved the next time we tried. It was a great learning environment where I was comfortable to ask questions.
The variety of areas kept me always interested as I was able to see inpatients, outpatients, community classes, transitional care services and hydro classes. We were even able to spend a day at a residential care facility teaching staff manual handling. The days seemed to go so quickly.
My confidence has especially grown in the inpatients side of things which will be great for my fourth year cardio prac, and also for the cardio unit we're about to start.
Overall a great prac where I've learnt a lot and gained a lot of confidence.
The staff we absolutely fantastic and included two Notre Dame new grads, so they understood exactly what it was like to be a student from ND. They were constantly trying to teach us new skills and were always happy to give feedback. We were just tested on the knowledge that we should have but more so on how we took feedback and whether we improved the next time we tried. It was a great learning environment where I was comfortable to ask questions.
The variety of areas kept me always interested as I was able to see inpatients, outpatients, community classes, transitional care services and hydro classes. We were even able to spend a day at a residential care facility teaching staff manual handling. The days seemed to go so quickly.
My confidence has especially grown in the inpatients side of things which will be great for my fourth year cardio prac, and also for the cardio unit we're about to start.
Overall a great prac where I've learnt a lot and gained a lot of confidence.
Monday, August 24, 2009
Rural Prac '09 Topic Three - Conversion Disorder
Situation
In the medical ward there was a patient admitted for suspected myelitis. She presented with pins and needles, weakness and numbness on the left side of her body. Full neuro examinations were done by the neurologist in Bunbury and smaller neuro exams by the physios, but the results were variable and it was concluded that the problem was not neurological. Other medical tests were also done to rule out other possible causes. After 2-3 weeks with no answers the patient was becoming frustrated and asked for a second opinion up in Perth. She was transferred to Sir Charlse Gardiner Hospital where she was seen by 2 neurologists, an OT and a physio who all agreed that there was no known cause for the symptoms. It was fianlly diagnosed as conversion disorder which was further confirmed by a very full psychiatric history of the patient. After the diagnosis the patient was transferred back to Bunbury SJOG to be treated by her doctor here and monitored for a few days before discharge.
Task
My task was to give the patient a home rehab program before discharge. This was challenging because I had very little knowledge of conversion disorder or why she needed a home program, and I had also never met the patient before.
Action
After discussing it with my supervisor I decided to give her a generalised exercise program so that it appeared to her that the strength she has 'lost' was being regained, and also because she was so deconditioned from spending weeks in bed when she was normally very active, cardiorespiratory fitness and functional activities would be the focus of the treatment. She was given squats, heel raises and single leg standing to do at least three times a week. The focus was to be a walking program that increased on a weekly basis in conjunction with a diary so that she could monitor her progress. ADL's were to be undertaken as possible, adding 1 task or increasing the length of the task on a weekly basis. For instance, week 1 putting on one load of washing and hanging it out independently and week 2 doing two loads etc.
Result
The patient seemed very happy with the program as she appeared keen to get back to being active. This was a change from what I had read in the notes as from others accounts she had a severe external locus of control and appeared to feign symptoms if she wasn't getting enough attention.
Evaluation
Instead of pushing her outrightly, I decided to push her in a way she wouldn't realise. I told her that she could rest as much as she wanted during her exercises, but under no circumstance was she to not finish the exercises. I also told her to walk without a rest for a set amount of time for her walking program and then turn back, but she could take as long as she wanted and as many rests as she wanted on the way back. This seemed to appeal to her.
Strategies
I think incorporating her exercise program into her functional tasks was a good strategy, as well as given her some room to move in her program whilst still getting her through it all. I did involve her husband in the discussion, but I think some more family involvement and more time to spend with her to get a detailed social history would have really helped the patient.
In the medical ward there was a patient admitted for suspected myelitis. She presented with pins and needles, weakness and numbness on the left side of her body. Full neuro examinations were done by the neurologist in Bunbury and smaller neuro exams by the physios, but the results were variable and it was concluded that the problem was not neurological. Other medical tests were also done to rule out other possible causes. After 2-3 weeks with no answers the patient was becoming frustrated and asked for a second opinion up in Perth. She was transferred to Sir Charlse Gardiner Hospital where she was seen by 2 neurologists, an OT and a physio who all agreed that there was no known cause for the symptoms. It was fianlly diagnosed as conversion disorder which was further confirmed by a very full psychiatric history of the patient. After the diagnosis the patient was transferred back to Bunbury SJOG to be treated by her doctor here and monitored for a few days before discharge.
Task
My task was to give the patient a home rehab program before discharge. This was challenging because I had very little knowledge of conversion disorder or why she needed a home program, and I had also never met the patient before.
Action
After discussing it with my supervisor I decided to give her a generalised exercise program so that it appeared to her that the strength she has 'lost' was being regained, and also because she was so deconditioned from spending weeks in bed when she was normally very active, cardiorespiratory fitness and functional activities would be the focus of the treatment. She was given squats, heel raises and single leg standing to do at least three times a week. The focus was to be a walking program that increased on a weekly basis in conjunction with a diary so that she could monitor her progress. ADL's were to be undertaken as possible, adding 1 task or increasing the length of the task on a weekly basis. For instance, week 1 putting on one load of washing and hanging it out independently and week 2 doing two loads etc.
Result
The patient seemed very happy with the program as she appeared keen to get back to being active. This was a change from what I had read in the notes as from others accounts she had a severe external locus of control and appeared to feign symptoms if she wasn't getting enough attention.
Evaluation
Instead of pushing her outrightly, I decided to push her in a way she wouldn't realise. I told her that she could rest as much as she wanted during her exercises, but under no circumstance was she to not finish the exercises. I also told her to walk without a rest for a set amount of time for her walking program and then turn back, but she could take as long as she wanted and as many rests as she wanted on the way back. This seemed to appeal to her.
Strategies
I think incorporating her exercise program into her functional tasks was a good strategy, as well as given her some room to move in her program whilst still getting her through it all. I did involve her husband in the discussion, but I think some more family involvement and more time to spend with her to get a detailed social history would have really helped the patient.
Wednesday, August 12, 2009
Rural Prac '09 Topic Two - Intervention
Situation
In my first week on the orthopaedic ward I was suprised at how similar each patient's acute rehab was for total hip and total knee replacements. Each patient was given the same program with the same timelines and exercises to do, and they all appeared to leave the hospital at about the same stage. But by week 2 my thinking started to change.
Task
I realised that the reason I was thinking that every patient was the same was because I was observing their interventions and learning the ropes, but not really having any input at that stage. By week 2 my supervisors were starting to ask me what stage I thought the patients were at in terms of their rehab, and the terms 'Day one, day two etc' started to take on new meanings. I was having to seriously analyse each patient and decide what stage they were at in their rehab despite what the timeline was stating or what was 'normal'.
Action
This really hit home with two patients that had their surgery at around the same time. One was a total hip and the other a total knee, and in terms of protocols they are almost identical. However, despite the total knee patient having their operation before the total hip, the total hip was much better off. I had to really look at the patients goals, past medical history, current medical complications and management and age to determine what stage of rehab they were at and then organise their post discharge services (along with other health care professionals).
Result
The total hip patient ended up walking over 100m day one, only staying in for 7 days (the hospitals minimum), walking out with only one crutch and being able to walk over a km before he left. He was very healthy before he came in, listened to every piece of advice he was given from every health care professional, took complete control of his own rehab and had very clear goals. The total knee on the other hand had COPD, severe asthma, was bariatric, didn't walk until day 3, came in using a walking frame and left only being able to ambulate about 10m.
Evaluation
I have learnt that no matter what the medical notes, charts and nurses tell you, you cannot predict the outcome for any patient until you walk in there and assess them yourself. Every patient is different and a different approach must therefore be taken every time you walk in to see them.
Strategies
I think being flexible is very important and not having expectations before you walk in to see the patient. I also think very thorough assessment is necessary to ensure that it isn't something you've missed that is holding up the rehab process.
In my first week on the orthopaedic ward I was suprised at how similar each patient's acute rehab was for total hip and total knee replacements. Each patient was given the same program with the same timelines and exercises to do, and they all appeared to leave the hospital at about the same stage. But by week 2 my thinking started to change.
Task
I realised that the reason I was thinking that every patient was the same was because I was observing their interventions and learning the ropes, but not really having any input at that stage. By week 2 my supervisors were starting to ask me what stage I thought the patients were at in terms of their rehab, and the terms 'Day one, day two etc' started to take on new meanings. I was having to seriously analyse each patient and decide what stage they were at in their rehab despite what the timeline was stating or what was 'normal'.
Action
This really hit home with two patients that had their surgery at around the same time. One was a total hip and the other a total knee, and in terms of protocols they are almost identical. However, despite the total knee patient having their operation before the total hip, the total hip was much better off. I had to really look at the patients goals, past medical history, current medical complications and management and age to determine what stage of rehab they were at and then organise their post discharge services (along with other health care professionals).
Result
The total hip patient ended up walking over 100m day one, only staying in for 7 days (the hospitals minimum), walking out with only one crutch and being able to walk over a km before he left. He was very healthy before he came in, listened to every piece of advice he was given from every health care professional, took complete control of his own rehab and had very clear goals. The total knee on the other hand had COPD, severe asthma, was bariatric, didn't walk until day 3, came in using a walking frame and left only being able to ambulate about 10m.
Evaluation
I have learnt that no matter what the medical notes, charts and nurses tell you, you cannot predict the outcome for any patient until you walk in there and assess them yourself. Every patient is different and a different approach must therefore be taken every time you walk in to see them.
Strategies
I think being flexible is very important and not having expectations before you walk in to see the patient. I also think very thorough assessment is necessary to ensure that it isn't something you've missed that is holding up the rehab process.
Thursday, July 30, 2009
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!
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!
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