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?
Monday, 19 November 2007
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?
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?
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....
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?
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!
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.
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.
Saturday, 17 November 2007
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
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??
Friday, 16 November 2007
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!
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
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
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
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
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
Thursday, 15 November 2007
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?
Tuesday, 13 November 2007
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!
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!
Monday, 5 November 2007
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?
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?
Thursday, 1 November 2007
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!
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!
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