Competitve Environments

I am on my final prac now and I am 1 week of being a curtin new grad... YAY. Working amongst new grads of Notre Dame I sometimes see a bit of competitiveness between those form the differing universities. I feel that competitiveness can often excell individual performance, however it definately hinders a team approach.
When confronted with a strong, stubbourn fellow student/ staff member who wants to do things their way I tend to always step down and let them lead an assessment or treatment. I think in fear of creating a competitive environment I wont continue to explain or clinically reason my ideas for treatment or assessment. This is something I would like to change once I am no longer a student. I have an open mind to the opinions and beliefs of others and enjoy discussing different ideas yet I know I must voice my own more.
Anyone have comments on this issue?

Live what we preach?

So days as a physio can often be spent motivating pt's to do exercises or live a more healthy lifestyle. I find that often I myself will not exercise the 30mins most days as recommended... I dont count walking to bus/ train stops or walking in hospitals at work :)
I have had one pt ask... "well what do you do?" and I had to be honest and say that I only exercise properly 2-3 times per week (walk/gym/run/swim). Then I begain thinking why that was the case and excuses to do with time and energy came to mind... I dont even have kids or have to do the house/ garden alone like many of my pt's!!! Eeek!
After this motivation I found myself easily fitting in time to exercise and exercised 4-6 times per week. It was not until I could tell my pt this that he began to listen to me. I disscussed with him the most suitable times of day for him to fit in ex in his schedule. Which we went about in a manner similar to what I had to do to get my ex regime into gear.
This proved to be much more successful that simply edu a pt what they need to do but properly setting goals and developing plans for a healthy lifestyle...
So how much ex do u all do?
How do u motivate pt's to change their lifestyles?

Creativity

It is great when you have a grasp of standard effective treatment options taught to us throughout uni. However, I still find it hard to vary these exercises when required to keep pts interested. I feel like that the creative area of my brain is a bit on the rusty side!! Doing multiple aqua classes and treatment in the form of games for children can get challenging to find new ideas over and over. Does anyone have some fabulous ideas for aqua aerobics or playing with children to add to my exercise brain bank? Thanks :)

Yellow flags

Hi all, on my last prac. Piecing all my knowledge together. Yet I have found there are just some patients where physio skills just cant beats lots, lots and lots of life coaching, listening, empathising and simply being a person who cares to a very distressed/ troubled/ depressed pt. I have found that providing this to a pt with yellow flags is very benefitial to them. However they then can get quite attached to you as their primary support network. Also as a student it feels quite silly spending so much time on subjective and speaking endlessly over massage and heat/ US when u are trying to demonstrate your skills to a supervisor.I have suggested councilling or joining social clubs to such pt's which I find hard to do at times. What approaches have you made in such a circumstance?

pt refusing assessment

Setting: RPH Oncology ward
Patient: 56 yo Indigenous female
Dx with cervical cancer and admitted for radiotherapy
Prev R CVA 10 ago; treated at shents but discont Rx as missed family
NIDM, smokes 15/day, asthmatic, obese
lives 5hr from Perth
prev non amb (owns W/C), use of quad stick and AFO for STS and T/F with one assist
lives with 2 sons who have helped her since CVA

pt would cont say things like "dont bother me, bother someone else". "No u cannot play with my leg or arm". "They dont work leave em alone, physio cant do nothing".

The concern was that the pts prev mobility would decline due to cancer related fatigue, weakness from RIB etc. The pt was content to just lay in bed all day and do nothing. It was easy to see the contractures already forming in the affected hand.

There was limited time for me to devote to developing rapour with the pt, she was not a priority on the ward. Her English was slightly limited, edu her was difficult, functional reasons required. What would u do to speed things up and Rx this pt effectively?

Intellectually impaired cardio pt

Setting: RPH Oncology ward
Patient: 38yo male with a congenital intellectual impairment (not classified)
admitted with pnemonia (3/52 Hx)
on a b/o progressive lung cancer with bony mets

The pt could not speak so the subjective was taken form his supervisor of the hostle he lives at. The pt was prev amb with a W/S and was independent will all ADL's.
The pt can understand language just not verbalise it.
Pt could maintain sats on RA, had widespread insp crackles LZ, R MZ
It was hard to gain the trust of the pt and he would not cough or breathe deeply on command. He would cont to take off a neb if applied (face mask).
Often he would hide under his covers and he would not cont to sit upright if put in sitting would slouch down in bed and tuck chin.
Much time was needed to gain trust before treating him. This was very detrimental to the length of treatment for other priority pt's.

The rationalised best treatment for his chest would be to amb. He had standby STS and good static standing balance, tests of dynamic where limited due to poor attention and compliance!
Upon amb with a WZF 1 standby assist the pt looked steady and had a good gait pattern.
Then due to his intellectual impairment? the pt took his toes off the floor, crouched and tired to sit on the floor.
I had to assist a decent to the floor so the pt did not fall...
I felt the only option for the pt to amb safely was with 2 mod assist. yet the effect of increasing tidal volume and mobilising secretions was minimal.
I reverted to simple STS and bed mobility ex to mobilise secretions which were effective (sm amounts of P3 sputum) but not enough to clear the majority of secretions. The pt also hated doing this.
I let the staff know about all this and enco the N/S to still try nebs and sit up.

I felt very sad for the pt and his family and carers, also a little hopeless in this situation.
Could you suggest other Rx strategies?

Inappropriate behaviour

During my neuro placement on G66 I had a pt with a R CVA and presented with inappropriate social and sexual behaviour.
For example, after ending one session the pt said thanks gorgeous and smacked my behind in front of his wife.
His wife looked very shocked and upset and I did not know the best thing to say or do at that particular time . I simply said something similar to "careful, don't do that please" and left the room in a flash.
Obviously I needed to discuss with the wife later (alone), that behavioural changes occur in some pt's that have strokes.
However how do you think you would handle the immediate situation better?

Heart wrenching situation

My last placement was for cardio at the RPH Oncology ward. I experienced some difficulty with managing the psychological implications of one particular patient's family.
67 yo malay lady with progressive breast cancer
Her English was very limited, yet her son spoke and understood English well
The patient was previously completely independent prior to admission. During the chemotherapy and radiotherapy treatment she began requiring a WZF to amb and needed MUCH encouragement to amb, continue to perform all her transfers independently and SOOB.
To encourage this I educated her son to ensure the pt cont to be mobile.
However, the pt began to rapidly deteriorate. She soon did not want to amb to the toilet and SOOB or sitting upright was even too much for her.
The doctors informed me to no longer treat the pt as she did not have long to live.
It was very hard to discontinue treating this lady as her son was in denial. Due to the edu of the benefits of mobilising the pt etc. he was still asking that I see her and spend much time with her. I had other pt's that were my priority and knew that the pt would not tolerate bed ex's, sitting up etc.
How would you go about telling this womans son that you will no longer be seeing his mum/ treating her....

Adherence to exercise

HI there

This is just a query about patients and exercise in general.
As physios, it is our job that patienta are able to manage their problems on a long term basis ie placing a big emphasis on self management. Most of the time, patients are diligent with the home exercises we give them and are actually able to adhere to them for the duration of their treatment. There are some, though, who refuse to take an active management towards their rehab. Looking back , these were some of the reasons why patients did not want to do their exercises

too boring
no time
i just want a quick fix
As much as we try to vary the exercises make SMARTER goals and incorporate the exercises into their daily activities, these sometimes don't work.
At what point do we draw the line to say that patients are ultimately responsible for their recovery rate and if they do not adhere to their exercises and work with us towards their goal, then we should slow/stop treatment, even though it is our duty of care to ensure that patients get better under our care?

Impingement

HI Guys

Thought i would clarify something related to diagnosis of shoulder problems as i found that this was one of the difficult areas during prac.

Can anyone please correct my thoughts on this classification?

Primary impingement: structural abnormalities mainly acromial shapes that is the main cause of shoulder impingements. ( what i understand from this is that this can't really be fixed by the physio)

Secondary impingement: factors such as poor motor control of scapula stabilisers, hypo or hypermobility of the GHJ, traumatic contractile injuries. (ie something that physio can fix)

Your clarification is much appreciated and good luck with the PCR!

Cervicogenic headaches

During my muscolskeletal prac, a patient presented with what I had diagnosed as cervicogenic headache due to C1-3 hypomobility. When I reasessed her Cx AROM after G3 central PA on C2-3, she complained that her headache had worsened with movement. I then treated her with STM to the posterior neck and gave her some stretches for her levator scapula and upper traps. This lady never turned up for her next appointment.

I wonder if I should have been less aggressive during her treatment (used G2 mob for pain relief instead). I couldn't work on retraining her Cx posture as the underlying problem was the hypomobility. Looking back, maybe I should have strengthened her deep neck flexors first to provide more stability to the segments before I mobilised the joints. I guess I could also have focused entirely on pain-relief on the first session.

working hours

Hey guys,

On my rural prac my supervisor informed me at the start that if I did any overtime I was to write it down on a Time off in Lieu sheet (same as the staff) so if I wanted/needed to leave early/start late any days then I just do it. He was very trusting, just told me to keep a record, he didn’t need to see it or anything and worked out great when if I wanted to head back to Perth earlier on a Friday arvo or anything.

I’ve heard of other students on rural prac having to work really long hours with 10 mins lunch break so they end up working well over the 38 hours/week that we are supposed to. Have any of you had to work a lot of overtime with no offer of leaving early or compensation? I just wondered how I would go about asking for time off/to leave early and if this is even appropriate or are we just expected to do what we’re asked no matter what??

great prac!

Hey all!

SO excited I leave for China tonight!! So I'm going to post my last blog a little early....

I wanted to say how supportive and fantastic my final prac was in neuro at SPC. It makes such a difference when the staff enjoy what they are doing and actually care enough about the pt to teach us how to be better practitioners...Really this is what prac should be about - of course we need to know the basics, but uni can't teach us everything and I think one of the best ways to learn is by watching other, more experienced physios. Not only this but I found the learning environment to be really helpful to improve my learning. All the physios work in one large gym which has about nine beds and everyone just helps out everyone else - there are no politics about who does what and therefore as students we were often asked to help out with transfers, gait retraining, etc... which made me feel valued and confident and I think it really enabled me to continue to learn and really enjoy what I was doing!

Perceptual Dysfunction

I have been treating a patient who suffered from a (R) MCA with severe perceptual problems. He is very quiet, often looking glazed over with teary eyesm and is very very difficult to engage in a treatment session. I have to repeat instructions and explanations multiple times for each activity, and he is impulsive and usually ignores this information anyway! Does anyone have any suggestions for dealing with patients with such perceptual deficits?

thanks

dani

Sensory input to the hand

One thing I don't remember learning a lot about at uni was hand astereognosis. On my current prac we have been shown a number of techniques in which the palm of the hand and the fingers are bombarded with sensory information. Apparently the theory is to do with the sensory homunculus, as the representation for the hand/fingers is massive and consequently stimulation will help to improve function. We were shown techniques where the therapists scratches or rubs the pts hand with their own, as well as rolling an edged pencil down the hand proximal to distal (to encourage extension), and also 'colouring in' the pts hand. It worked quite a treat, and helped to reduce tone and allow other exercises such as reaching facilitation. Just a technique you might want to try!!

dani

Dysphasia

Now I know we always have learnt about dysphasia at uni, but until you come across it I don't think you fully understand the ramifications of the impairment. I came to realise this when I was told I had to do a full SOAPIER on a patient with SEVERE expressive and moderate receptive dysphasia. This particular patient had 2 phrases he could express - "OK" and "F***'N hell!". This may seem amusing, and he was incredibly good-humoured about the affliction, but it made some assessment impossible and very time consuming. Imagine my difficulty when attempting to assess hot/cold, sharp/blunt and proprioception? I tried assigning hand movements of his good hand to indicate which he felt, the direction the limb was moving etc. but due to receptive problems he got confused. It was a nightmare! I did my best, but in the end documented the communication difficulties, therefore questioning the reliability of information obtained. It was quite a learning experience in communication skills!!

dani

Conversion Syndrome

Hey guys,
Just a little something I found interesting...We had to give a presentation to ward 2 on a neurological area of interest. We chose 'conversion syndrome'. This is a psychological condition which manifests as neurolgical symptoms. Basically it's usually triggered by a traumatic event or stressful period, and the patient can present similar to a spinal injury or stroke. The weird thing is, the patient has 'real' symptoms. They are not putting it on nor imagining their deficit. There is no organic reason for the symptoms, but they do in fact lose innervation of ceratain muscles. The treatment involved is often a bit 'creative', in that the effects of physiotherapy and medical intervention are over-exaggerated - i.e "These foot mobs are really effective in your particular condition, most patients find they can begin to walk after about half an hour", or "We've found out what is wrong with you, it's a condition called X and rest assured, it usually resolves spontaneously within a couple of hours". These patients often end up in Ward 2 along with other strokes and get similar treatment, only psychological counselling is almost always needed as well.
Hope you enjoyed that!
dani

Slack staff

Hey guys,

On the rare occasion this year I have come across a situation that I didn’t really know how to handle so didn’t do anything about… Lazy/slack staff. You know the type, sometimes nurses, other physios, even doctors. They either do nothing while you feel like you do everything (I know that we are expected to be managing a full case load – just not while they listen to music or look up the internet!), or you have to ask 20 times the same request before something is done.

When I’ve encountered this during prac I haven’t really felt that its my place to speak up (being a student and everything), so I’ve tended to manage it by venting to other students!! I know this probably isn’t the best way to deal with it and once I’m qualified I’d like to think that I would speak up… but how do you approach it?? Do you speak to the colleague or senior first? And what do you say? Any ideas?

glut med tear??

Hey!

I wanted to write a little comment about Doctor's - now I know they have a lot of work to do and they are often stressed for time, but I think Physio's are just as squeezed for time.

I was working with a pt who has had a stroke who suddenly started complaining of acute back and lateral leg pain, of notable severity, which was limiting her ability to participate in physio. Obviously the pt had notified the nursing staff of her pain and so during the physio session the doctor came in to Ax her. I had already assessed her and been unable to reproduce her pain on palpation over the muscle belly, but had found her pain was easily reproduced on right side-flexion and extension and reduced with left-side flexion and flexion. Central and unilateral PPIVM's of her right facet joints revealed hypomobility and tenderness of L1-4 especially L2, which also increased her lateral leg pain. So from my Ax I thought it was due to a sprain of the right L2 facet joints and I had commenced gentle mobilisation.

The doctor then came in, assessed her strength, DTR's and tapped over her spine and came to the conclusion that she had torn her Glut Med muscle and advised her to take it easy in physio, despite me telling him what I had found - and he quickly bypassed my suggestion!

I was so annoyed because clearly, it would take severe force to tear a Glut Med muscle and my assessment findings made logical sense. Not only this, but this pt is difficult to motivate at the best of times, and thus the doctor's advice did not help!

quality vs quantity

hey all!

I'm currently doing my neuro prac in neurosurgery, which I'm finding really interesting! My supervisors have been really helpful in exposing us to a variety of high level and lower level pt's, with a mix of inpt and outpt load. I get really excited about working with the pt's and seeing the progress that they make within a couple of days of physio input - it really puts into perspective what we're doing and gives me hope that we can actually make a difference!

I guess one of the difficulties with neuro is getting the balance between quality of movement, and just getting movement. Its really important to have good handling skills so that you are able to effectively facilitate the movement that you want, yet at the same time you have to be aware that sometimes pre-existing factors, or co-existing factors may prevent the pt from ever getting 'perfect' movement and you have to be able to progress the pt functionally too.

Sometimes I feel like we've been working on the same thing for three sessions and the pt really isn't improving (eg: pelvic tilt) and I feel like we need to move on, but then this movement is vital to being able to STS and walk normally - which leaves me questioning do we keep working on this until the pt has it, or do we just move on??

Has anyone else experienced the same thing and have any suggestions on what they would do in this situation?

Shaped by prac?

Hey guys,

I'm currently on my neuro prac and loving it! Was just thinking about my experiences on prac and the number of areas I've been exposed to. I guess it's relevant at the moment as we are now all looking into jobs for next year. One of the things I was pondering is how much we are shaped by our experiences on prac, and not only that but also how guided we are into choosing a selected field (Private practice vs hospital, neuro vs musculo, etc) based simply on our exposure to selected areas. Looking back I have now had three neuro pracs over the last three years, and now find myself interested in working in a hospital, with a bias towards neuro physiotherapy. In contrast I have only ever had one musculo prac, which I didn't particularly enjoy, and now feel slightly unqualified and unconfident in the area and hesitant to go straight into a private practice job. I'm guessing those people who have had more experience, and more positive reinforcement in this area may be more inclined to pursue this type of job as a new grad?!

I wonder if that's true for everyone? and if it is then does it come back to the responsibility of the university to attempt to give everyone a more equal exposure to the available areas of physio??

Just thinking out loud really, and I'd be interested in what others think!
Have a good week!

Treating chronic pain

Hey guys,

On my rural prac at a Community Health Centre (therefore treating a lower socio-economic population) I have come across a lot of chronic pain (predominantly LBP). I have tried to focus on ‘hands off’ Rx and one patient in particular I just worked on relaxation techniques and educating her movement isn’t bad for her pain, etc. Has anyone had any prac’s where they’ve dealt with a lot of chronic pain pts or been taught some really helpful techniques to use with chronic pain pts? Just after some tips on what I could try next time???

Being students...

On my rural prac (mainly musculo outpts) I was assessing and treating pts completely independently (if I needed help or anything I could go and ask) – I was in my own treatment room and would collect my pts from the waiting area and bring them in.

I was under the impression that when the pts book appts they would be told that they were seeing a student… Not the case. A number of times pts (or their wives) would ask, “so how long have u been fully qualified” or words to that effect and I would have to explain to them that I’m not actually fully qualified (but I was on my final prac). I always felt really nervous/awkward telling them that I’m not a ‘real physio’ yet and thought that they probably should have been told before they saw me. It was a government facility so at least they weren’t paying for it I guess…

One weekend is not enough...

As I'm sure you'll all agree, one weekend is not enough to switch from one mode of thinking to another completely different, as we often have had to do this year between pracs. While trying to tie up loose ends at one prac, giving student presentations, completing final assessments and updating stats, it proves almost impossible to find time to prepare for the prac starting the following Monday. Even being given a three day weekend and finishing the previous prac on a Thursday would help somewhat, do you guys think it's worth putting this to the school of Physio? I think it would greatly help with being prepared for the next practical...

Frustrations

I'd like to have a little vent about the general frustrations we as students encounter while on prac. In the last week I have been constantly reminded that we really are at the very BOTTOM of the pecking order on the ward. As our caseload has peaked in our final week, I have found it a constant challenge to get hold of patient notes to read the latest update, let alone to write in them once I've actually seen the patient! It seems such a waste of time wandering aimlessly trying to locate notes which don't seem to be anywhere, yet of course it is necessary to do this before seeing a patient to ensure there are no safety concerns etc which might impact what you do in your treatment session. When finally finding the precious papers, they are nearly always taken off you for one reason or another by any other health professional! I know we are students and they are paid employees but if we are the only physiotherapy intervention the patient is having then surely we have just as much right to the notes as a Speech or Occupational Therapist? This issue makes time management impossible!

oncology

Hello!
I had one of my pracs (elective)at the oncology ward in RPH. During my time there, i treated patients with various diagnoses of cancer, some terminal. I was amazed at how every single patient had the zest , optimism and strength to carry out their exercises and physio willingly, given that they were not limited with fatigue and nausea.

Before coming to this prac, i was expecting it to be a depressing and challenging one as i believed many of them would throw me the question of "what's the use of doing any exercise when i'm going to die anyway". INstead i was uplifted by their determination and strength to be as independent as possible. Most of them were motivated to do the exercises that were prescribed, making my job as their physio just that bit easier!

I think these patients really deserve a pat on the back!

Rural prac

HI everyone

I'm guessing most of us have done our rural prac. I did mine in Geraldton as an inpatient physio.
That time was an invaluable experience as by the end of the placement, we eventually got to run the ward. I managed to see a bit of every area including neuro, musculo inpatients, gerontology, womens health, cardio.

This experience provided me with greater confidence to continue with the rest of my pracs and most recently with my cardio prac as i had to learn to manage the ward on my own. My previous experience just made the task of managing the ward even better than the last time.

Just a not to all those who are on rural prac, make sure u have loads of fun and learn as much as you can. treasure the experience its not that bad being in the country ;>

Supervisors

On a prac in a major teaching hospital you often share the gym as a meeting place with physios and students from numerous wards. One day as I walked into the gym to collect my bag (it was late so most people had gone already) I overheard a supervisor and a CCT discussing a student from another ward. As much as I tried not to listen and grabbed my bag as quick as I could I probably heard some things I shouldn’t have.

I don’t think it was my fault, I was clearly a student and once they saw me walk in ( I couldn’t avoid it, they weren’t in a private area) I think they should have stopped and waited for me to leave. I never said anything to the student or my supervisor (regardless of whether it was positive or negative comments) but I don’t think what they did was very respectful for to the student and I wouldn’t be very impressed if I knew a supervisor was discussing my ability/skills in front of anyone, let alone my peers! What do u guys think?

Parents

Hey guys,

I didn’t get a paeds prac this year but I did encounter some ‘pushy parents’ on my ortho ward. Occasionally on the ward >14 year olds are admitted if the fracture is complicated and needs to be ORIF’d . I had seen a few young guys that had their parents present during Rx and am not bothered by them watching or asking questions etc. This one boy (14yrs from a tiny country town) had both his parents present for both Rx sessions (am and pm) every day he was on the ward. The difficulty arose when it came time to attempt crutches for the first time. The parents really wanted him to use elbow crutches and the kid was terrified (he was WBAT), their biggest argument was that they were easier to get in/out of the car!! I agreed with the parents in that EC’s were the best option but for his first attempt I was happy to allow AC’s. He had only ever mucked around on crutches and they were AC’s and he didn’t think he’d be able to use EC’s. I felt like the parents were bullying him into what was best for them. T o keep everyone happy I let him use AC’s first then later that day after he was confident he progressed to EC’c then D/C the following morning…everyone was happy. Has anyone else had to deal with ‘pushy/ parents’ and how did you handle it? I know my case was pretty minor but got me thinking there must be more exteme cases…

When to draw the line?

Recently I was treating a man on prac who was quite medically unwell. He had responded badly to pain killers / general anaesthesia and was narcotised, disoriented and somewhat delirious. The doctors and surgeons kept stressing to anyone who would listen that the only people who could help him at the moment were the physios - no pressure! My problem was, while attempting to treat this man he was so out of it that he would repeatedly fall asleep midway during an SMI and be difficult to rouse again for several minutes. He remained like this for a couple of days, yet the medical team kept insisting that we see him many times a day for chest clearance. He was in no state to even respond to questioning let alone follow commands and clear his airways. My question is, when is a patient too unwell (or almost unconscious!) to receive beneficial help? Surely they need to be able to actively participate for it to be in their best interest?

Dani

Woopsies

I had a "learning experience" at prac last week (which I forgot to blog, woops!). Steve and I were doing a joint treatment of a guy who needed 'birding'. We took the machine in and began to set it up with the portable oxygen cylinder. We detached the oxygen flow meter from the bottle, with the intention of attaching the bird machine, but before we got that far there was a hurrendously loud squealing/rushing of air as oxygen began to pour from the cylinder. As you can imagine, this was fairly comical in hindsight, but at the time we both packed ourselves! Clearly we had overlooked the small matter of turning off the cylinder valve before taking off the flow meter - OOPS! This was an error that I'm sure only students could make, and I'm sure it is one we will never make again! What I learnt from this scenario? MAKE SURE YOU KNOW HOW TO USE THE EQUIPMENT BEFORE YOU ENTER THE TREATMENT SESSION! This will save a lot of embarrassment and looking stupid in front of nursing staff...! Please take this on board :)

hydro

hi again,
this would be my final post and i thougth i would post it earlier since rural prac has provided me with alot of brand new experience to share. I have never run a hydro class before until this prac (despite requesting over and over again in the city) but never had the opportunity to do so. I believe many of you would have tonnes of experience at it and can definitely provide me with strategies to handle hydro classes as well as any land based exercises. My main problem with running these classes is that I tend to get stuck with ideas during these classes and unsure what other exercise to do next even though I did plan earlier and had it all set up in my mind but all these ideas tend to disappear then. I ran my first land based exercise with notes written in a small piece of paper and that got me through alright however I thought this would be inpractical when you are in the water. Just wondering how does everyone do it and I will really appreciate it if any advice/ideas I can have.
Thankyou so much for reading all my posts and all the comments you have given and good luck with PCR

Robin

supervisors

hi all,
hope clinics are going well for everyone. Just wondering if any of you had the same experience during rural placement. I am currently looking after outpatient physio. as well as other inpatient and community physio. My spervisor has his own ways at doing things which sometimes very different to what we have learnt in uni. as well as other pracs. An example which is that he does not agree with the idea of loading disorder and more of an mckenzie and mulligen orientated physio. It is good that I get to learn more techniques from him but in a way it really confuses me and hence completely changing all my approach to treat patients. Apart from this, the different ways of performing tests as well as issues with use of ultrasound. It's quite frustrating when you have performed well in recent musculo. prac and now having to strt all over again in a 'new musculo' prac. I understand it will be perfect to integrate all these knowledge but I think 4 weeks of part time musculo is not enough to do that. So my question is if you are in my position, would you carry on using what you have already learnt from last prac and uni or would you 180 degrees convert yourself to suit the supervisor?

Robin

yellow flag

hi everyone,
just thought I would share this little experience with all of you as I think many of you might have or will definitely come across similar situation like this.
I had a patient who came in with LBP and through subjective and objective examinations, he presented to have L4/5 disc pathology. I began treating him with lots of education, postural correction and local mm fascilitation. In the beginning, having come across similar patients before and I thought this would be pretty straight forward and easy however the patient suddenly became frustrated during the treatment and apparent he has been to physios prior to this episode and has been receiving similar treatments but has not been compliant with HEP prescribed nor advice given. His reason of not being compliant was because of the pain in the muscle spasm of the lower back so I told him to use a heat pack to reduce that spasm and he said he knows the fact that heat pack helps with muscle spasm but has not been using it.
I asked him why and he wasn't sure. The patient apparently is unemployed and is relatively young in his early 30's. I carried on with the treatment giving all the information he would require anyway and gave him new HEP which I doubt that he will be compliant with. new appointment was made and my question is, the only reason he is coming to physio was for the DTM to the mm spasm and obviously will not benefit from physio in the long term. Would any of you discharge him anyway if he continues to be incompliant?
Good luck with mid placement if you haven't had one already!

Malingering versus chronic pain

Hello!

Just thought i would begin the post by defining the terms malingering and chronic pain.

Malingering is a defined as a medical and psychological term that refers to an individual fabricating or exaggerating the symptoms of mental or physical disorders for a variety of motives, including getting financial compensation (often tied to fraud) avoiding work, obtaining drugs, getting lighter criminal sentences, or simply to attract attention or sympathy.

Chronic pain: pain that persists longer than the temporal course of natural healing, associated with a particular type of injury or disease process.

On a recent musculo prac, I encountered a patient, who according to my supervisor had been a patient at the clinic since it started operation several years ago. When i was treating her, she presented with pain in her Cx, Tx and Lx regions, which varied from a week to week basis. I thought back to uni, when we were first introduced to the concept of chronic pain and how real it it is and often how practioners brush it off as malingering.

This particular patient had a long history of treatments from student physios ever since the clinic started. I was not sure what to make of the pain and stiffness she presented with as it seemed to vary from a week to week basis. While testing her AROM, she would often ask what the normal range of motion for that particular movement was. I found this an odd question to ask as i felt she was pretending to get a value that was under the "normal" so that there would be something for us to treat. On a few occassions, i also found that this patient did not have consistent objective findings in that same session for the same AROM.

My question is, has anyone experienced a patient similar to this and how do you tell the difference between malingering and chronic pain? How would you handle a patient like this?

Yes I'm a physio student, No i won't give you free treatment

Hi there

recently on my cardio prac, i was approached by the ward's social worker asking my advice on her c/o knee pain and kindly asking if i could take a look and perhaps suggest some treatment options or provide some treatment. Since i was available during the patient rest time, i obliged and managed to give her some treatment and also some management tips for long term.

The next day, i was approached again for the same treatment as she was so happy that the treatment i gave her worked. This went on for another day or 2 and i had the feeling i was taken for granted as she got to the point where she was "expecting" treatment progressions!

I eventually told my supervisor and he advised me to politely decline as he had a similar experience before and we simply just do not have the time to treat all staff members who ask for a favour. Has anyone been in a similar situation with other staff members or even friends who expect you to give them "free" treatment just because you have the qualifications?? How would you handle a situation like that??

Ward Members

At my recent cardio prac, I had a post op patient with multiple complications resulting in him requiring multiple drips and drains. and i mean multiple! Some of his drains included 2 nephrostomy tubes, an IDC, a colostomy bag, IVC, PICC line, 2 drainage bottles.

When it came time to ambulate the patient, the nursing staff on duty at the time was kind enough to offer her assistance. Because this patient had not gotten out of bed for at least 7 days (plus the fact that he was in loads of pain) , he was quite deconditioned. It took about half an hour to ambulate the patient a mere 5m, and throughout, the nursing staff was kind enough to sacrifice her tea break to help me with the patients drains.

So often, we underestimate the importance of good teamwork and the impact it has on our job. Be it a receptionist, the ward cleaner, or even the PCA's, i feel that it is our duty to acknowledge them as they make going to work every morning, just that bit more pleasant.

stroke

hey guys,
Hope everyone is enjoying their new pracs. I had a stroke patient and he was being absolutely incompliant where me and my supervisor were constantly being pushed away and being aphasic, he was making hand signals telling us to bugger off the whole time. I ignored his behaviour and went on being quite firm forcing the session in the end and being aphasic and weak, the patient had no choice but to follow my commands and did what was told and finished the session successfully (although more effort required). In the end we did find out the reason behind his repulsiveness from his sister where we were told that he dislikes being close to Asians. In my case, it didn't really bother me as I still managed to get his initial sessions done and did not have to see him again as I embark on my new country prac. However, would anyone have done any differently to what I did or would you have handballed it to someone else?

Robin in Geraldton

priorities...

Hey guys,

Had my final Ax at PMH with a little ex-prem baby on O2. He is now nine months corrected age and has barely left hospital since November last year, hence he has three huge volumes of notes! I had a really busy morning on my final day as I had to see three pt's as well as finish two HEPs for two other pt's whom I obviously wasn't going to see again. Knowing I had my final Ax that afternoon, but also assuming I would be given time to look over the notes (as I had not seen him before) I prioritised my other duties over preparing for my Ax. In the twenty minutes or so I had to prepare for the pt I did my best to familiarise myself but ended up having only a sketchy idea of this baby's medical history (due to the massive past medical history). In my handover I gave all the relevent info but got drilled on not having a good understanding of the pt's history and medical plan. I was also told that I should have prioritised preparing for my Ax over my other work and should have asked my facility supervisor for more time...or shortened my lunch break in order to allow myself time to prepare thoroughly.

I guess had I known the history of this bub was so extensive I would have allowed myself more time, but in the same way I felt like the other work was just as important and I felt like I was organising my time effectively. I also find it difficult to tell one supervisor I can't finish my work so that I can prepare for my other supervisor, as I am obviously being assessed by them both.

I know it is improtant to prepare adequately before seeing a pt, but at the same time in reality time limits everything and usually having a quick look at the notes is all you can fit in. Sometimes it just feels like prac is a constant contradiction!!

Honours and staying focussed!

After almost 2 years of working on my honours project (The impact of generation y in the physiotherapy workforce) i am beginning to find it difficult to keep drafting my article. I think this is because now I have been dealing with the topic for so long that it's almost too close to me now and it's hard to step back and see if what I'm writing makes sense anymore. To me, it all makes sense of course! I have sent a draft to a couple of friends to give it a fresh pair of eyes, however I was wondering if anyone had any hints to keep me fresh for just one more month whilst I finish it off! (and yes I have been taking lots of breaks... to master my winter surfing skills hehe)
Cheers! Amanda

Depressed Patients

Hi Everyone!

Working on a stroke ward it is inevitable that you will come across a depressed patient. I have had patients who start crying and can not stop or are so depressed that they say very nasty things about themselves or their situation. I am aware that it is often more complicated with a stroke or peripheral disorder patient than simply being bubbly and positive to ease a negative/ sad attitude. However, in such situations does anyone have an uplifting quote or good phase to use to get the patient motivated/ happier? Looking for any ideas really, thanks

Communication

Hi all!!!
I was previously on my neuro prac at SCGH in G66. For my final Ax I had a R hemi pt who was aphasic and a pusher. These two qualities combined made it quite difficult to be in control of the session. I tend to have a "teaching approach" to many patients. An aim to educate the patient (purpose of a given exercise/benefits of correcting posture etc) to encourage ownership of their treatment and if possible work towards treating themselves independently. So the difficulty in this senario was in correcting the paitents movement; gait, STS when she had no idea what I was trying to help her achieve and why. She was pushing a lot and refusing my manual guidance.
Has anyone got some tricks up their sleeve for such a situation? I know reaching or dual tasking with the pushing arm or fixing the pushing leg in a good position is very important, but anything else?
Ta

China prep

hey guys, how exciting another prac is over! For my rural prac I am going to china to work with kids with cerebral palsy which I am really looking forward too! We have a lot of preparation to do before we go so will be spending the next few weeks trying to learn some mandarin and refresh my knowledge of cerebral palsy. Just wondering if anyone could suggest some good books or resources about assessment and treatment techniques to help me with my study. Ive had a look through my old neuro notes but dont have a lot of info! Thanks guys, enjoy the week off!

Bakers Cyst?

Hi all, eeek last week of prac again! Hope it's been a good one. I was just wondering if anyone had come across a patient with a Bakers' Cyst before. i have a lady with arthirits in a hydro class tomorrow who arrived on crutches 2weeks ago as she ruptured a bakers cyst. She states she is unable to bend her knee even in the pool. I am supposed to give her a home exercise program this week and am struggling.... I guess common sense would be some RICE (although subacute now?), strength for around the knee (quads and hammys?) and some lower limb stretches. Tried to have a look in some journals but there seems to be no evidence regarding the indications for physio in patients with this problem. Just would hate to flare her up more, given she is polyarthritic already. Cheers!

Thinking outside the box

Hey everyone,

I can't believe there's only one week left of this prac!

I'm on paeds prac and I'm treating a little 2 year old boy with a mild (R) side hemiplegia. His dad said that before the stroke he did not communicate vebally, but now he is more delayed due to the damage to his language centre. Currently he is making only a few sounds but nothing coherent, and he is being seen by the speech therapist. The difficulty I'm finding is trying to engage him in therapy when he doesn't speak. I mean it's hard enough to get a 2yo to participate in any activity for longer than 10seconds, but it's even harder when he doesn't seem to understand what I'm asking and doesn't respond to me. I try to plan the session beforehand, and then it feels like he ends up controlling it as he does whatever he pleases. One of the strategies I have been using, is getting dad to come to the sessions and join in on the games. I have also been demonstrating what I would like him to do and that has been a fairly effective method of improving participation. I guess sometimes I just feel like I'm observing what he can and can't do and not really treating, although I know that playing is a form of therapy.

Has anyone else been in a similar situation, and have any ideas on how I could be more effective in my treatment session? Cheers!

paper work!

Hey guys, still on my musculo outpts placement which I am suprisingly really enjoying! except for the fact that there is sooo much paperwork to be done. In the last week or so my pt load has increased dramatically partly because I am seeing pts in less time but also because the notre dame student who was here on prac aswell has just finished and therefore has transferred all of his pts to us! This means that aswell as trying to reschedule all my usual pts and new pts I also have to try to see most of his pts and there simply isnt enough time in the day! Next week I have pts booked back to back which is going to make it very difficult to complete any paperwork. We have been given friday afternoon off to wright out all of our transfer summarys and discharge letters etc, however my supervisor decided to book me in a pt after lunch without my knowing and as a result I am only going to have like an hour and a half to do all my paperwork :( Unfortunatley I think I am going to have to stay back on my afternoon off and try to get the majority of it done as I wont have much time on friday. I know this isnt the end of the world but I would really prefer to spend my thursday afternoon off doing something a bit more exciting than paperwork!

Spinal Pts

I’m currently on my ortho inpts prac and all the acute spinal injuries come to my ward (once they’re stable – not in ICU) before they go to the spinal unit at shents. Tomorrow I will be treating my first paraplegic (T12) whose spinal cord was completely severed in a work incident a few days ago.

He does not speak English and I will be doing a full neuro Ax on him every day for the next week (to monitor swelling around the cord, etc). It is standard protocol that the pts are not informed about their future function until 6 weeks post-injury to allow for any sensory/motor recovery so my pt will be unaware that he wont walk again.

I haven’t been in this situation before and am worried about what to say if he asks me or gets really upset when I ask him to move/feel something and he can’t…

Has anyone had a similar experience and would like to share some tips with me about how to handle this?

Nasty patients!!

Hey guys,
Sorry i'm so late with this post!!! I'm putting 2 up today coz i forgot last week!!

I’m on an ortho inpt prac at the moment and last week had to deal with an extremely difficult pt…
He was admitted with a tibial plateau fracture that had been immobilised with a Richard’s splint. His surgery was being delayed until some of his swelling had settled so the doctors asked for him to be RIB. While talking to the pt I found out he had been an inpt for multiple other lower limb fractures, was a heavy smoker and had been treated with antibiotics for the 3 weeks prior to his admission for a chest infection (? Pneumonia).

While an inpt he had been transferring himself to a wheelchair so he could go outside and smoke (at least 8 times a day)…

I explained my role to him, showed his some bed ex’s, attempted some deep breathing ex’s and cough/huff and explained that moving around/transferring would increase his swelling and that was the only thing delaying his surgery and that the doctors would like him to RIB. He was quite angry with me… “You’re the first person that has told me that, no one else said anything and your just the stupid physio so what would you know!!”

He nastily told me he knew all the bed ex’s and not to waste his time. He refused to cough or huff due to pain in his knee and I thought his pain may be the reason for his aggression.

I went and asked the RMO to come and chat to my pt, and suggested he may need some more pain relief as he appeared to be in quite severe pain (probably exacerbated by his excessive mvt!!) – I went with the RMO to chat to our pt and I was not the only person the pt was angry with… The doctor explained to him that they would like him to RIB to decrease the swelling and he offered him some immediate release pain relief (the pain team were coming to R/V him later that day and we’d explained that to him)… The pt refused pain meds and asked to be left alone (not in those words, a lot more expletives were used)!!!

I feel as though I did the right thing by getting the RMO to come and talk to the pt and offer him pain relief but he was a very angry man!!

What would u guys have done in this situation or do you have any suggestions of how I could have handled it better…
Thanks
xox

Working with the health care team as a student

Hi All,
I am on a neuro inpatients placement. What I have sometimes struggled with during this prac is working with a senior OT.
After speaking to the senior PT I discovered that I was right in feeling the vibe that the head OT sometimes does not approve of the way in which PT progresses patients. This OT is lovely and great at her job, very committed to the patients. However, sometimes it is hard to rationalise certain decisions that are made by the PT team.
For example, taking away a lateral support she had fitted and replacing it with a lumbar role and a towel under affected side. This decision was made as the patient had good sitting balance, activation of trunk muscles. The patient could realign himself although does fatigue.
To explain this as a decision that would help the patient if left for about 30mins was very difficult!!!! Instead of thinking in terms of getting the pt to active muscles they could control she wanted the support there for constant good alignment.
She was... well angry really... as the patient did sit with the head more to the affected side, therefore she confirmed as not ready for the progression due to poor BALANCE and alignment...
Any pointers of how to speak to other members of the health care team in such situations? I did ask my supervisor and she was happy about our decision to remove the extra support...
Thanks :-)

Stress cycle

Hey guys,

This is probably something we have all had to face on prac...getting the right balance with your supervisor. I often don't feel like prac is about physio skills as much as it is about knowing how to relate with your supervisor and understanding expectations. Don't get me wrong my supervisor is lovely, but here is my dilemma, I want to look good in front of my supervisor so I don't like to ask for help, however because of this she assumes I know exactly what I am doing...then when she watches me I tend to freak out and 'fumble' my way through it and then we are both left feeling a little unsatisfied with my performance! Does anyone know what I mean? It's so annoying because it feels like the more I try, the more stressed I get and then the more likely I'll do something to stuff up.

Does anyone have any helpful ideas on how to manage stress when they are in this kind of situation? One thing I am learning is to put less pressure on myself...we can't expect to be perfect when this is the first time we are treating for example a child who has just had a stroke, and I'm learning that it's OK to ask questions!

PPIVMs & PAIVMs

Currently on my musculoskeletal prac, I'm having a lot of trouble assessing joint mobility/stiffness. During PPIVMs and PAIVMs along the spine, changes are very subtle, especially when the entire spine is equally stiff. I don't have a wealth of experience with these assessments so I have no idea of "normal" segmental moblity. I try to form an opinion on what I've felt, then my supervisor comes along and has a feel for herself, and usually has totally different opinions from me.

I've come to a conclusion that accurate PPIVM and PAIVM assessment not only takes time and experience to develop, you also require an accurate and consistent teacher to teach and check every finding you have made. The 4 weeks I have in this prac seem very insufficient. I just wonder how possible it is to have this sort of guidance if we are new grads working in a private clinic. Did you guys find that you had a grasp of it by the end of your placements?

wasting time

Hey guys, Im still on my musculo prac at the moment and like most musculo pracs I am required to come out in between my assessment and treatment to speak to my supervisor about what I have found and what I am planning to do. Whilst I think this is very important as clearly after only two weeks of musculo I definatley dont know everything (or very much at all!) it is becoming increasingly frustrating. I find that it just breaks up the session too much and many times I end up leaving my pt alone in the cubicle while I am desperatley trying to find my supervisor. Quite often my supervispor is either busy with his own pts or one of the other students is speaking with him about their pts. It is a tricky situation because whilst I think it is crucial in developing our clinical reasoning and making sure we are giving the pt the best treatment it also cuts into their appointment time quite a bit and therefore they dont get as much from the session as they possibly could! Just wondering if anyone has any thoughts on this issue?

Helping Family

Hi all,
I admit it is often the case that after prac the last thing I want to do is give my aching mum a massage, trigger point my dads spasming piriformis or assess my crazy brothers sore ankle who doesnt train then runs a half marathon in 5 min kms.
Ha, ha. But I am wanting to help my granddad who infact does not seem to eager to receive my help. He had a L CVA 5 yrs ago and is still has a drop foot-like gait (uses a stick), poor dynamic balance, poor STS, doesnt really use his R hand, cant really write etc......
So any how, Im on Neuro prac and thinking of more and more things I could help him with.
However, he does not like to show me how weak/ limited in his ADL's he is as I am his grand daughter. He stopped physio after ~12/12 Rx as he gets too tired from it and says he is coping but is always exhausted when I see him from things like dressing, showering etc. and appears quite depressed.
So the question I pose to you all is what approach would you take to get your granddad to allow you to help without making him feel more depressed or uncomfortable.
Note, he lost his partner so cant get her to help with the challenge.
Thanks

Home Exercise Programs...

I'm currently on my musculoskeletal prac. Just last week alone, I encountered 2 patients who were very reluctant to do any home exercises. As the home exercises (strengthening and stretching) are important to maintain any progress achieved during treatment (soft tissue massage and mobs), the patients turn up at every session no better than the previous one. It is very frustrating to see the hard work put into improving the patients' conditions go down the drain every week. As a physio, it seems to me that all I can do is educate and negotiate with the patient (which the previous students have all tried to no avail with these 2 patients). I still gave it a go with education this week but have the impression that both patients are going turn up this week without having done their HEP.

Since this is only the beginning of my second week in this prac, I would really like to get some compliance and improvement while I'm here. Would really appreciate any advice from anyone who's had similar experience and success with improving compliance in the outpatient setting!

Notes over-rated??

Hey guys,

WOW I feel like a stranger to blogging after having P1 off! Hope everyone's pracs are really satisfying so far :)

I'm on my paeds prac at the moment, and I'm doing neuro inpt's. I am really loving it, but there are a few challenges to encounter (as always!) I haven't done my neuro prac yet and so I am finding it a little challenging to approach neuro in general, and on top of that working with kids and their families. My supervisor will often give me a verbal handover and then we will just go straight in to see the kid, without me having a read of the notes. So i'm feeling like I'm walking in a little blind. Also, sometimes my supervisor will involve me in the Rx and explain as we go along. This is fine except I feel like I'm missing out on the Ax stage and jumping straight into Rx. I guess I feel like I'm doing things a bit backward, as I'm so used to the uni 'formula'. Doing things this way is quite helpful in developing flexibility, as there may not always be time for a thorough look at the notes, but at the same time, having not been exposed to many neuro pt's I would feel safer going through the full procedure, and once I'm comfortable with that, then start cutting it down a little.

I have been able to explain my situation to my supervisor and I am now getting the chance to read the notes and give my supervisor a verbal handover and plan my Ax and Rx. Although I feel like I've given myself more work, I think this is really helpful in developing the skills required to be a good clinician!

Multi Tasking!

Hi all,
I have just started my community physio prac which is great, taking lots of different exercise classes in neuro, cardio, resp, osteo, etc. My dilemma concerns the fact that I have 8 different supervisors (all from different ex classes) whom are all wonderful...however have all given me little extra tasks to do in addition to the classes such as critiques, home exercise programs, filing work at the CPS office, etc. I must say that this is keeping me a busy little bee (as well as trying to write my honours!). There are only about 20 hours per week of classes/travel time, so it sounds like a cruisy placement, however I spent 12 hours over the weekend doing the class critiques and plans and am feeling a tad overwhelmed still!
Hope everyone is settling in nicely to their new pracs (or time off!)
Cheers, Amanda

Follow up pts

Hey guys, Im on my musculo prac at the moment at Bentley outpts department. It has been a scary and very full on week but I am enjoying it! Being our first week the majority of my pts have been follow ups from the students who just finished the placement. In a way this has been good as it has sort of eased me into the placement as generally you just continue with what the previous treatment has focused on. Our supervisor and CCT have told us that they would prefer it if we assessed and treat the pt in the same way that the last student did for at least the first session so that a)the pt isnt overloaded with infotmation and confused by new treatment techniques and b) so that the pt dosn't think that we think that what the last student was doing was incorrect or not effective. I can completley understand the logic behind this however I am finding it hard to get a good understanding of the pt's whoke presentation and deciding where I actually want to go with this pt in terms of treatment goals as the examination/treatment that I am performing (at least on the first appointment) is so limited. I just find it quite fustrating that because the prac is so short you may only see the pt twice over the whole four weeks and just when your starting to get to know them/their Mx plan you have to pass them on to a new student! Must also be quite fustrating for the pt too swapping physios so often! Anyways I guess this cant be helped..just wanted to see what everyone else thought!

who to blame?

hi guys,
Just wondering if anyone has had similar experience as this. During my last placement (cardio), I got one of my patient up who was a day 4 post whipples up and walking. I checked everything I had to and constantly monitored her SpO2 during the walk and she was doing fine and not having any complain. However, 2 days later she had a second episode of partial resection of stomach and pancreas and came back to the ward few days after her stay in ICU. Her condition obviously declined significantly after 2 major operations and as I went to see her again to get her up as her chests were sounding very quiet bibasally and ambulation would definitely be the best treatment option for the lady for the day, her husband started to imply that Physio wasn't necessary and would prefer his wife to RIB. As I explained to him why PT is important for her right now, husband started to blame PT for the incident and implied that if the pt didn't go for the first walk, the 2nd episode of surgery wouldn't have been necessary. For a second the whole atmosphere became quiet awkward for me and other fellow student for we did not know how to convince the husband that PT would not cause complications like that and so we explained & said that complications do occur with surgeries and told him that no one really knows the cause of the incident (of course he became grumpy thoughtout Rx). And knowing that we can't really blame the surgeons neither as complications do occur with surgeries. Does everyone know any other more convincing way of convincing families in a situation like that?

Robin

Freak OUT!

Hey guys, Wishing you well on your new pracs. This will be my last blog as I only have my rural prac remaining and have expressed myself for the past three pracs but I promise to continue to read and comment, if thats allowed!

During my last day on friday on the cardiotx ward I encountered a scary moment. The other student and myself were "running" the ward and had taken on the majority of the workload so things were a bit hectic (and there was me thinking the last day would be crusie!). Anyway, being a friday there was a huge push to d/c pt's, so it was made pretty clear in what order you were to see patients. There was one inparticular who was waiting the physio tick of approval before he could go so I was under the pump. Patient had recently had surgery on his lung, hx of COPD but quite active. During our treatment the previous day the pt desated to 80% RA. He stated that he usually sated around 91%RA during rest and 85%RA after exertion. I stated on the ward round the numbers and asked what saturation they were happy with after exertion and the doctors stated 88%RA. I questioned this as he was unable to achieve this before surgery so how likely was it for him to achieve it afterwards. Doctor's didn't listen and it wasn't until my supervisor spoke up that they changed their minds to 85%RA!

So later (well actually straight after the ward round) I went in to treat/ax pt for d/c. Patient was SOOB and eagar to mobilise. Placed the oximeter on and the readings stated Spo2 94%RA and pulse 145. I freaked. I'd never seen a reading that high. I questioned the patient about his heart etc. but he stated he didn't feel any different from normal. I took a manual pulse and sat there for about 2mins b/c I couldn't believe what I was feeling. Very hard to explain in words but basically something that was very irregular! I tried at a different site but no different, still very irregular. I tried my hardest not to let the patient see my concern but I'm pretty sure he knew something wasn't quite right b/c we weren't going for a walk as I had explained was the plan for the rx!! Went out and told supervisor and nurse co-ordinator. To cut this short - patient was in AF and therefore would not be going anywhere. I later went back in to explain this to the patient so he didn't feel like he was in the dark and to make sure he understood what the situation was. So basically im just wondering if anyone else has experienced something like this where you felt a little out of your depth and are not too good at not freaking out. Lucky for me (and the patient) I recognised that something wasn't right and told someone so wasn't completely useless, but definately still had a freak out!!!!

Best of Luck Guys! Suanne xoxox

The Dreaded Blue Forms!

Hi guys this is not supposed to be a whinge but more of an observation about my blue form from my CCT from my last prac :) I got some great verbal feedback about my treatment with teenagers in my second last week, and so my CCT decided to 'challenge' me and help me learn more by deciding to give me an 8month old kid for my final assessment. I agree that it was a great learning experience (as i had only seen about 3hours worth of kids under the age of 2 during my prac) as my handling skills need a lot of practice. My final blue form reflected this with lots of comments about handling needing more experience, etc, which was fine. However, I felt that this didn't accurately show the fact that I was good with older kids and that I had been thrown out of my depth with a bub. I tried to explain this to my CCt but didnt want to make a fuss as she was a fantastic tutor and I learned heaps from her. Just wondering if anyone else has had similar experience cheers! Good luck with the beginning of new pracs!

Hi guys, cant believe we just finished another prac..those four weeks just flew by! I blogged a few weeks ago about one of my pts, an elderly lady with spastic paraperisis who was very depressed and quite difficult to motivate. My blogg today is concerning this same pt. Over the past few weeks she hasn’t necessarily been declining in function but she hasn’t exactly made any improvements. Recently she reported that she doesn’t really do any walking at home (she uses a 4 wheeled walker) as she is afraid that she will fall. This pt lives at home with her husband, however it seems as though he is also quite weak and unable to care for her. My concern is that if this pt stays in the situation she is in now (ie. at home) she will just continue to do as little as possible and her strength and hence her functional abilities will deteriorate quite quickly. I asked the pt if she has any help at home and she said that she has a cleaner who comes once a fortnight and her daughter comes to cook for her every now and then. In my opinion this really isn’t enough, this pt and her husband need more frequent services or perhaps they need to move to a nursing home where they are guaranteed more care. However as I am working in the neuro out-pt department we do not have much contact with the rest of the health care team and therefore communication with social services etc is difficult. Therefore I decided the best way to handle the situation was just to document this in the notes and told my supervisor of my concerns. Would anyone have handled the situation any differently? I felt as though I should have done more however wasn’t really sure in this particular clinical setting how to go about it.

Professionalism

hi guys,
Sorry i am not sure if this post is appropriate for this blog but its just a thought that i have had for a long time. The question being 'where should the fine line be drawn across to determine the acceptable level of outlook/appearance professionalism in health care service providers'. As in what kind of hair style/colour, ear rings, nose rings, eye brow rings and so on.... I have seen doctors and nurses with crazy colour/style as well as other 'accessories/piercings' (however have not come across any Physio like that yet). Just wondering what everybody's thought about that is and if the above is acceptable for a clinician during work and during interactions with patients as well as other professionals?and us being students representing curtin, i also understand that the school policy has a dresscode set up for us during clinic but nothing else is restricted and... what are the limitations for us to stay professional in a sense of appearance during clinics??

NO Cover!

Hey guys, another post from me!!
I just wanted to know if the present situation regarding the lack of cover for physio's who take leave is widespread or just at the current hospital im at. During my placment both the senior and the rotating jnr aswell as the other senior on the rotating jnr's other ward have been sick and to my absolute shock they aren't covered by anyone i.e. no one comes in to replace them. This then increases the work load for everyone else and ultimately it is the patients who then suffer. It appears that without students, this situation would be a whole lot worse and probably unachieveable. I don't even want to think what would happen if the senior and the junior were away......could the ward run with just students and is that even allowed? What I don't undersatnd is why there is not an on-call physio or even an agency for example. Im pretty sure that if a nurse/doctor is sick they get someone to cover for them. It kind of puts out the impression that we and what we do is expendable, as its not necessary to cover those who are sick. Just something that has got under my skin, so just wondering what ye all thought! Suanne xo

Cardiothoracic surgery

Hey guys, Hope you are all enjoying your placements. Im on Cardiotx surg. atm and i thought id share some facts with you 'cos i know all of you wont get to see this particular area. In particular I wanted to comment on how quickly these patients who have had open heart surgery recover and are discharged from hospital. It is not uncommon at all, for patients to be d/c'd on the fifth day following their surgery....amazing!! (Well I think so anyway, after having seen the surgery that they go through.) They are ambulating the day after they come out of ICU and are usually encouraged to ambulate independently by day 3-4. (All cardio surg. pt's go to ICU after their surgery.) It is amazing (I've said that alot, I know!) how fast the turn over is on this ward. There are so so many people having open heart surgery, its kind of scary. I never imagined that a) the patients would recover so quickly and b) the number of patients who actually under go cardiotx surgery. Just wondering if anyone else could shed some light on something interesting they have experienced on a placement that the rest of us might not get to see. Enjoy your week. Suanne xo

Managing a minor panic attack!

Just wondering if anyone goes through those 5-second 'forget to breathe' moments when they find out they have a new patient with a random condition/forget to do their stats/are about to get feedback from a supervisor/etc :) On Friday I didn't get to see my supervisor all day as I was with my own patients, so i got back to my desk at 4.45pm and it had a note on it 'Amanda make sure you see me before you go home today' from my supervisor. Uh-Oh! I feared the worst...had I done something unsafe with a patient, treated the wrong condition?! I had a minor freak-out! However i just wanted to share with you guys how I learned to not always fear the worst when your supervisor wants to have a chat. Rather than having a minor panic attack, I should have thought logically about my treatments for the day and realised that I had not done anything that drastically disastrous! It turned out that my supervisor needed me to pose as an incontinent CF teenage girl for a PhD study poster (the things we have to do as a student!). So the moral of the story is that we shouldn't always fear the worst as a student... although there is a very very fine line between being over-confident and being comfortably confident, I think sometimes I stress out a little more than I should! Have a great last week of prac - Amanda the incontinent CF gal xx

seminar frustration

Hi everyone, Im writing this blogg to express my frustration over the seminars that we are having to present. My seminar presentation is this Monday and I have been stressing about it all week due to the fact that we were only able to secure a guest speaker on Friday! My group members and I have had regular meetings and the content of our presentation was coming along well however we have had huge dramas getting a guest speaker. This is due to the fact that almost every person we had in mind for the job work on Monday mornings and therefore couldn’t attend due to their professional commitments. When we finally organized for someone to do it, they pulled out on us at the last minute leaving us all very stressed out! We have now got someone to speak for us which is fantastic..we are all very relieved. I just wanted to know if anyone else has found it as difficult as us to get a guest speaker and if anyone else thinks that the seminars would be a lot easier to organize if we were able to choose our own groups rather than randomly being put in groups. I personally think it would have been a lot easier that way simply because we don’t all have the same afternoon off prac, everyone has different working commitments on the weekends and everyone lives in different areas which combined make it very hard to organize group meetings! Whereas if we could choose our groups we would be able to control for some of these factors..any thoughts?

pt with bipolar disorder

Hey guys,
I am still doing cardio prac at the moment and as you all know, Physio input daily can be very vital for these patients to prevent any post op complications and nasty infections which greatly affects the prognosis. Provided that there are so many patients to be seen, its always important to have a good planning for each treatment session to make sure the patient gets the most out of the session (i.e. trying to get as much secretions out and expand lungs as much as possible). However, it can be very frustrating if you have a patient who is 100% compliant and suddenly becoming 100% antisocial in following visit which spoils all your plannings and your hardwork you have developed in them in the past and then having to start again right from the beginning when they are compliant again. I am seeing a patient like that at the moment who has developed pneumonia and producing large amount of secretions but who also has a reduced lung volume due to immobility. I started mobilizing this pt last week and his cough was becoming more and more effective and was able to independently clear secretions and agreed to continue mobilizing on his own during the weekend and hence I put him down as W/E PT not indicated. However, from the notes from doctors this morning, I found out that there are alot of crackles developed in the chests and through subjective assessment, he told me that he has not been ambulating at all through the weekend as promised and not feeling up to it today. After attempted to edu. + encourage pt, he became impulsive and told me to leave him alone and saying that its his option to want to get better or not and so I left him as it was. Just wondering if anyone has come across similar pt like that and can lend me a hand here? thanks

Playing the big bad physio in the cancer ward...

Hi guys hope all is well! I have a quickie about my current prac at PMH. In oncology, we see some of the patients who are undergoing chemo treatment to do exercises with them as tolerated. I have a patient who is 15yo ,with testicular and abdominal cancer, currently undergoing his second chemo maintenance. The consultant has specially requested we see him daily for 'mobilisation' as she is worried about his rapid deconditioning (including muscle weakness from particular drugs, etc). However, on thurs and fri last week both the patient and his dad were reluctant for him to GOOB as he was feeling very tired because 1) thurs he had had to stand for a chest xray 2) Friday he was nauseated from the chemo. I felt I did not want to be pushy to a kid dying of cancer but at the same time know how important it is for him to get up. So we did some SLRs,resisted ankle pumps, UL and DBXs instead of ambulating...just wondering if anyone had any comments on how much we should push patients like this who are clearly having such a rough time already? Thanks xx

sore back!

Hi guys, I am still on my neuro prac at the moment and whilst I am really enjoying it I am finding it to be very exhausting! I am working in the neuro out-pt department and a lot of my pts require quite a bit of assistance in terms of transfers etc. I have a few pts in particular who are suffering from MS and have little to know active mvt of their legs. They also have increased tone and decreased muscle length particularly in their lower limbs. As you can imagine these impairments contribute to the fact that they have quite extensive functional limitations. Two of the pts that I see twice a week are males and are both quite heavy and I find it very difficult to transfer them. I know that by using the correct technique and good body mechanics etc that it shouldn’t be that hard to move them, however I am finding that I am not being very successful in doing so. I have found it very difficult to move them even on the bed without using a lot of lifting and manual force. As you can imagine after using techniques that are not the most effective to move these pts over the last 2 weeks I have developed a very sore lower back. I usually suffer from a sore back anyway but this is making it ten times worse L. I have been to see a physio for treatment and I know that I should make sure that I brace with my TA’s and pelvic floor etc but its just really hard to actually put all these things into practice at the time as generally I am more concerned for the pts safety and getting and achieving what I want to with the pt and therefore end up using bad techniques. The other problem is that there are only two hi-low plinths in the gym and thus a lot of the time I end up with a non-adjustable plinth that is way too low for me, causing me to bend over my pts…not good for my back! Just wondering if anyone has any suggestions to help me out, because my worst fear is that I am going to develop a serious injury which really wouldn’t be fun! Thanks guys

Psychophysiotherapy

I have a patient who has what is likely to be a conversion/somatic disorder (where she believes she has an encephalopathy but presents with clear CT head, MRI, etx). She has been unable to walk and relies on her mother to help transfer her. On Friday we took her to the parallel bars and without much input she walked about a dozen laps on her own! So yesterday I started working on some bridging, etc. with her and she walked 20 laps. Although slightly medico, my question is this….what are the overriding factors here, mind or body?

Frustration!

Hey guys, I trust everyone is enjoying their time back on pracs and I know ill be glad not to be blogging to myself!!

Im currently on a cardiotx surgery ward at charlies and I have been allocated a pt who had a stroke post-op, mainly because I just came of neuro. Anyway, because the pt originally came in for heart surgery and is on a cardio ward, his chest/lungs are the doctors/physio's/nurses main concern, but this does not in anyway help on his road to recovery from the stroke. If he was on a neuro ward he would be being seen twice daily for up to an hour each but on this ward, because he is for "rehab" and is no longer an acute chest, I can only offer him 30mins max. of my time. My supervisor stated b/c he was rehab, only 3 times a week. I feel so sorry for this pt, as it seems that he is just being sweeped under the rug. I understand that hospitals are at capacity and so so understaffed but it appears this is to the detrement of everyone. Unfortunately, rehab will not accept him until he is medically stable, meanwhile he deteriorates every day. It is just so sad to know how much I could do for the recovery of this pt yet due to time contraints and what appears the finer points of hospital legistics, my treatments are very incidental. Just wondering if anyone else has experienced the frustration of this situation, and whether us as a new generation of physio's are concerned about our hospital system and what we are going to do about it!!
Thanks for reading. Suanne

depressed pt

Hi everyone, hope you enjoyed your break!
I am currently on my neurology prac at the Shenton park neuro out-pt department and have come across a difficult pt, Mrs W. This pt is a 71 year old woman who was diagnosed with spastic paraparisis in 1991.As a result of this disease the pt has experienced a progressive loss of strength in both LL (most muscles 2/5) and also suffers an increase in tone and decrease in length of bilateral h/strings, hip adductors and plantar-flexors. Consequently the pt requires mod/max assistance for all transfers and bed mobility. The pt mobilizes using a WC and will ambulate very short distances (from bedroom to bathroom) using a four-wheeled walker. Mrs W attends physiotherapy two times a week for 1.5hrs each session.
The problem I am having with this pt is that she is suffering from depression and has a very disheartened attitude towards her physiotherapy treatment. Mrs W believes that there is no point in performing strengthening exercises as she just continues to get weaker. I have tried to convince Mrs W that the exercises are of benefit and that she shouldn’t give up however I do not want to come across as being patronizing. I acknowledge the fact that this pt has been living with this progressively debilitating disease for a long time and can understand that after many attempts at improving her function (she has been attending physio at the NOPD for over a yr) she has not seen much in the way of benefits. Mrs W does appreciate the LL stretches provided during the physio treatment sessions however I get the impression that she doesn’t see the point of many of the other exercises due to her lack of motivation. After speaking to my supervisor I have learnt that Mrs W has just commenced psychological treatment, which I think will be beneficial and will hopefully help with her depression. I think that it is important to base the treatment session around the goals of the pt however I also understand that I do have to push Mrs W to increase her level of independence. Does anyone have any suggestions/techniques to achieve this? Would love to hear your thoughts!

OUT OF the LOOP

Hey guys, Hope you are all doing well. I survived neuro...woo hoo! It was an amazing four weeks which i thoroughly enjoyed. My blog is about feeling "out of the loop", which i think we often feel as a student. Where do you stand, talk, does your opinion matter etc.? While on this prac. you receive your own patients, however you are not involved in any discussion about them for example in attending the team meetings. I found this very hard as it felt like you were "out of the loop." It was difficult to determine what the plan was for each of your patients and often information was not passed on to you as a student. To add to this the supervisor discussed with me that i needed to be more aware of the d/c plan and liasing with the allied health team. But how am I meant to know this when i am totally unaware of what is happening. It made for much more extra work and was very frustrating. On a previous prac. I attended the team meetings with my physio and therefore was well aware of the plan for each and could therefore treat accordingly. Just wondereing if anyone else out there is feeling a little bit "out of the loop" and any suggestions as to how to overcome this or is it just something to put up with as a student.

cardio

Currently in my cardio prac at the moment.... as you all know there are thousands and thousands of facts in cardio such as the 10 cardio problems, 10 systematic ways to look at an xray without missing anything, whipples and all other surgical approaches and what they are, the drugs and their side effects... etcetc to memorize and supervisors often expect you to dig out all these facts somewhere in our brains accumulated with info. of cardio as well as neuro and musculo.....
Does anyone have any good strategy to organize them in our heads so they are readily accesible when tested? I tried using acronyms but in the end I ended up remembering the acronyms but not what the letters stand for.....

Helping fellow students

One afternoon in the clinic, I was told by my supervisor to help a fellow student with putting one of his patients on a tilt-table. As I had more experience than the other student with tilt-tables, I did my best to help organise things and avoid any potential problems. When the student was out of the room getting a wedge, the supervisor told me to just be a passive assistant and let the other student take charge. This put me in an awkward situation when the student returned, as it seemed natural to me help someone in an area where I had more experience. Also, the other student was not aware of my role change but I was worried about offending the supervisor if I had informed the student about the conversation. In the end, the student got drilled by the supervisor for his performance, which made me feel a bit guilty and sorry for him.

Has anyone been in a similar situation, or would have handled the situation otherwise?

Thinking outside the BOX!

hey guys. Hope you are all well. I have been on neuro prac for the past four weeks and i wanted to share one particular experience with you. A patient that I was treating who had recently suffered a stroke also presented with marked kyphoscoliosis. She described that it was an effort to breath but that she had be accustomed to it has it was a long term issue. Initially, we were a bit skeptical about how much we could "touch" her spine but after we discussed it with our supervisor she gave us the all clear. We performed some central key point tx extension techniques over the next few days and remarkably the patient said that her breathing had become less effortful. The best part of it was however, that objectively we had made a difference too! Sats rose from 84-88% RA to 94-96% RA. WOW!!!!! It was so rewarding to see your treatment make a difference. It was also very rewarding knowing that we had thought outside the "stroke" box and were able to make a difference to the patients QOL! Just wondering if anyone else has had this experience and been able to use our knowledge to treat outside the area your currently treating in!

Time management for writing SOAPIER

During my outpatient neuro prac, patient appointments were booked back-to-back and patients were expected to be treated for the full 90 minutes. This left no time for me to write up a SOAPIER at the end of each treatment session. After the last patient had finished, there were 30 minutes left for cleaning up the treatment area and writing notes. Given that I saw 4 patients a day, it was really insufficient! The clinic had a rule that notes were to be written within the same week, and I found myself staying back on Friday afternoons (we had half day off on Friday) to catch up with my notes.

Writing notes at the end of the day and week affected the accuracy of my notes. I would get muddled up about the reps/sets or evaluation of each patient’s treatment and sometimes memory lapses were filled with guesswork. To cope with this, I tried carrying a notebook around with me so that I could jot down the treatment details. As I was bringing the notebook home, I had to be careful not to breach any confidentiality issues by using patient initials.

I wonder if I have a short-term memory problem, or if anyone else has had difficulty in this aspect. Any tips to improve the system or the way I could work would be much appreciated too!

Acute vs Rehab

HI guys, Im currently on an acute stroke ward and just thought Id raise the question of the different settings we can work in. Im loving the acute ward for the majority of reasons but there is one thing in particular which is getting to me. Its so great to see the progress your patient's make from one day to the next. Its really rewarding and well at least some part of it could be becasue of your treatment. Its amazing but then they get d/c somewhere else to rehab and thats the end of them. You never get to see what thier final outocme is, whether they got to walk again or eat using a regular knife and fork. I find this really hard to move from one patient to the next and just forget about them. As a learning expierence I feel we need to see both ends of the spectrum, i.e. what the presentation of the pt is actuely and various rx techniques but then what the pt can achieve for themselves before being d/c'd home and the rx techinicques you used to get them there. Does anyone else feel the same on their ward? Maybe I just become too attached. Or could someone shed some light on the rehab side of stroke? Thanks Suanne

Treating progressive neurological disorders

One of my patients on my previous placement was an elderly lady with progressive spastic paraparesis of unknown cause. She was at the stage where she could only walk 20m with a 4WW and she had difficulty performing transfers. Treatment was based around maintenance of current function for as long as possible. The patient was extremely unmotivated as physiotherapy could not cure her and instead caused pain. She gave up easily during exercises, complaining that she “could not do any more” and that they were “difficult for her”. She had low exercise tolerance and complained that she was tired after treatment.

We were taught in uni that we are, on top of being clinicians, largely motivators for our patients. For this patient, however, I did not want to cause more pain and grief during treatment, so I dropped the role as a motivator and just let her do only as much exercise as she wished. The aim of physio from my point of view was just to keep her moving as much as she could to condition her muscles and maximise function.

It was just disappointing for me to know that there was very little I could do for the patient, given her condition. It is easy and rewarding to encourage patients during treatment, telling them that the exercises they were doing were good for them and would help them get better. In this instance, whether exercise was beneficial or detrimental was debatable.

I wonder if anyone else would have approached the situation differently or have had experience with similar situations?

NEURO

Hey guys, I think this might be a blog to myself but ill give it ago anyway!

Im currently doing my neuro prac at SCGH and wow is it nothing like I expected. NO matter how much you study don't expect to be prepared. Im on the acute stroke ward and astounded at the wide range of ages that are currently on the ward. Aswell as the wide variety of presentations a stroke may have. I don't think when learning about stroke I truely understood the true meaning or many meanings of the word. For example there are pts two days post "stroke" who are able to balance SLS on affected side for 15sec and then at the other end of the scale there are pts three weels post "stroke" who are fully dependant with very little active movement present. It also has become apparent that changes/ recovery can happen overnight, something I never really thought happened. My reflection therefore is how could I have been better prepared for this placement. I studied and read over my notes but nothing I did really helped me. Does the information we aquire at uni become obsolete until we are able to see for ourselves a "real" example of a stroke patient. Has anyone else found this one their placements that no matter how much "written" study and preparation they have done, it all appears different when out in the "real" world of physiotherapy.

Not sure if anyone else is on a placement atm, so hope you are enjoying your holidays!
Suanne xo

ICU as a cardiopulmonary area of physiotherapy?

Looking back on the almost finished 5 weeks in ICU I have thought about the skills we have learnt and have pondered how this relates to the whole wide world of physiotherapy! ICU physio's definitely have a huge role to play which is pretty cool. Luckily the four of us have been able to practice oodles of manual hyperinflation, suctioning and the occasional thoracic expansion exercise with our patients. Moreso we have learnt heaps about other systems - renal, cardiovasc, neuro, musculo,gut, etc. It's funny to think that there are some people who dont get to suction at all during their pracs, or never see an ICP monitor, coz we are pretty used to these kind of things now... but on the other hand there is a lot we haven't been able to practise cardiopulmonry-wise eg. the pulmonary rehab side of things. Being a bit of a hot topic me thinks that the pulmonary rehab side of things will be examined at the end of the year, and will also be extremely relevant in the hospital sector if we choose to work in it....and so it's kind of scary thinking that ICU prac students could potentially graduate without ever conducting a 6MWT! We have done a few more 'rehabby' case studies to make up for this, but is this sufficient for the big wide cardiopulmonary rehab world?! Have a good break ya'll!xoxo

Clingy patients

I am currently at Curtin Clinic and I have found a somewhat common theme with patients referred from Bentley Hospital. They come in with a referral for one condition then once this has been treated for some time would like a new problem to be treated. In such a case it is required that they go back to their doctor and receive a new referral or they must pay the full fee. This is not too hard to explain to the patient if they are complaining of pain in an opposing peripheral joint with an unrelated cause. However, if it is a series of related problems to the initial presentation it begins to get tricky. It also gets silly in Rx sessions... so what pain is worst today? What do you feel needs Rx today...etc. ha ha
For example, a patient I have been treating referred for L epicondylagia. Who then developed it in the R F/A also... fair enough. Who then released both shoulders were getting painful (over used UT's, deltoid, pecs) fair enough, related to elbow dysfunction. Who then was getting neck pain... yeah ok relationship here also...
However, this is a patient who does not do her HEP and does not allow herself to rest as she is a single parent with two jobs that require her to repetitively use her UL's and lazy kids who refuse to help her with domestic chores that agg her pain (cleaning, washing, vacuuming, mopping, wiping surfaces... the list cont.s) She is also stubborn in the sense that she does not do anything suggested to ease her pain besides applying heat at night and continues to over do it with, ADL's and gym exs (only focus on her biceps/ triceps/ lats/ PECS) which merely increase the tightness of her tight muscles and do not focus on control/ endurance and the weak mms (LT's, SA). This is despite educating her of what physiotherapy deems best for her condition. Also talked about how it is her responsibility to complete an effective HEP to reduce her pain. The patients response is not enough time, need money, not enough help so pushes through the pain.
Her aim with physio when asked is to get some relief so she can cont to function in the way that she always does. She does not wish to D/C soon as her pain is still high when exacerbated and she needs a Rx...
So my point is, it just does not seem fair. I feel that it is an abuse of the system on her part as she does not pay for the Rx and expects to be continually treated without actively participating in her Rx. Do I write a letter to her Dr explaining her plateauing progress. Do I persist to tell her she must D/C soon as she is "wasting my time" if she doesn't try to Mx gaining with a HEP (for lack of figuring a nicer way to say it at this moment in time). I dunno suggestions, what you think? Thanks