Revise Cardio

Today we had some exposure of working with a post op cardiac patient. This was our first opportunity to utilise some of our (limited) cardio skills learnt in first semester. Practising on ourselves in labs is good, but getting in and doing the same on an elderly patient with actual presentations was very interesting. I think I could have done a better job of my auscultation skills. While the supervisor checked the same lung points as I did, and found what I did, I didn't feel overly confident about positioning the stethoscope. I believe I need to review my lung anatomy and lung sounds to complete the same task, but with a little more confidence. This should put me in a better position come our cardio placement in coming pracs.

Pain then, pain now

Wow, what a contrast some (limited) experience makes. We saw a patient today who presents very similar to our very first patient we saw on the ward. The patient has a fractured NOF, just as our first patient. The contrast is understanding the process of healing in a clinical setting (on an individual basis) and just how much pain might be expected and for how long. Treating our first patient with the fractured NOF (who had severe dementia) was initially a little bewildering. Our lady was a tiny little thing, in a beautiful dress and so pleasantly spoken. When we began our therapy, we literally put her through substantial pain, it was in fact worrying and a little daunting, pressing her to do her exercises and continue. A discussion was had with our supervisor regarding our concerns as to how much pain is appropriate, and are we in fact "damaging" her. Today was a different story. We were able to gauge expected pain levels given the time post fracture, educate the patient about appropriate loading and the importance of mobilising appropriately. We can now do this with more confidence and progress our patient as required. We will still monitor her pain and watch for possible increased requirements of pain relief, but it will be done so with a little more experience and direction.

What did I do with my memory dear?

Today we had a patient who has a list of complications, such as unmanaged diabetes, CHF and plenty of social issues (to name a few). This patient has a large problem list and a subsequent treatment plan to match, impairments we have been slowly working at over the last week. Over the sessions, regardless of patient education we would give, the same repetitive questions were arising, to us, and other staff on the ward. These questions and a couple of other verbal "idiosyncrasies" were a little tiresome, as it felt we weren't making head-way regarding education with the patient. After discussing this with our supervisor, it was concluded that the patient may in fact be displaying early signs of vascular dementia. She has subsequently been booked in for a full, comprehensive psychiatric assessment at the hospital to get a better and more accurate guide as to how she is doing cognitively. It will be interesting to find the result as she manages to hid her mental limitation quite well. In future sessions, I think we could break down her tasks (has struggled with tasks), repeat the exercises or activity, and not give her too much information. I hope these modifications are successful for the coming sessions. 

Guts and Gore!

Kristy and I were able to sit in on theatre today to watch some surgeries take place. This was such a great experience and one I hope to have again. While they weren't relevant specifically to our placement, it still gave us great exposure to what exactly happens in theatre, and justifies why at times the patients feel so poorly post op - and are not keen for physio! 

A particular patient today had her physio session for the second time. The management of her presentation has probably been the most complicated to date. With comorbidities, an endless list of medications and the psychosocial influence on her recovery, this all came to the fore today in my mind. I found myself treating this patient a little differently to others. She presents as being grossly overweight, de-conditioned, with poor personal hygiene and a character that (with respect) is not that likeable. Half way through the session I realised that while still treating the patient appropriately physically and verbally - in my mind I had judged her. I could not get out of my head how bad this woman had become in terms of her health. I found it extremely challenging to treat her with (to put it politely) her body odour, matted and greased up hair, conjunctivits eyes, and a general disregard for basic personal hygiene. On a couple of occassions I was overwhelmed by her smell and had to physically stand back a moment. This sounds terrible and  disrespetful, and I know that, though this is how she presented. What I did manage to do mid treatment was put back the perhaps indifferent thoughts of how this lady became to be in such a state, and aimed to have a successful treatment with her. She returned to her room in an improved state physically and mentally. Prior to her session she reported of not wanting to do rehab and felt tired. Post treatment she felt less stiff for having had her treatment and legs massaged and I believe felt better emotionally also as she actually said thanks! My take home message is of course (and one I'm sure we'd like to think we dont do) dont judge someone on how they are at this point in time (or at all), and always treat a patient to the best of your ability. Even if it does take latex gloves, a gas mask and aquigel!!!

Family Factors

Ahhh, family!!!

Have to love them, but at the moment, a family member of a patient on my placement is making our sessions with her elderly mother somewhat trying. I noted this week that at times it can be helpful to have a motivating factor like a family member pop into the exercise sessions. On the other hand, this particular daughter, watching in on her elderly mother seriously crowded the patient and us, confused the patient, and simply made the session more difficult. With the two of us physio students trying to direct the patient (who has severe dementia), and the daughter constantly "contributing", it made for a frustrating couple of sessions. We've now considered timing our sessions with her mother when she is on her her own - hard to manage as family drop in anytime. Anyhow, the biggest thing I noted from these sessions was having three people talking to the patient was overwhelming and confusing her. I adapted my treatment by toning my voice down drastically and really honing in on her directly. The noise level rose (other sessions being conducted in the same small physio area), so I tried to cut through the noise - and ilicit a direct response from the patient. This change, along with clear, simple and precise directions helped with this patient - not having her daughter there will also seriously benefit the patient. See how we go next week.

The Power of Coercion

It does not surprise me really, but this placement has reiterated the importance of communication, motivation skills, and particularly the appropriate and select use of words.

On a couple of occasions now, I have had a particular patient who is very pessimistic, negative and low in confidence regarding her ability to participate in the exercises for our soon-to-start session. Dare I ask "how are you today?", I am bombarded with all that is wrong with this patient. To the patients credit, we are not seeing her at her best, she is away from her home/family/comfortable environment, and desperately wants to get home again, of course she is not going to be herself. GIven that, I have quickly learnt to adjust my use of words, and time them appropriately. Its important obviously to ask the patient if they have any pain, but not focus or pander to the pain overtly. I have also found that education regarding the patients presentations can play a large role in physio Rx. If the patient has some misunderstandings regarding their pain etc (as happens often in our gero ward with plenty of dementia) this can cause unnecessary grief and anxiety about physical activity and moving. I have found that my patient at the start of the sessions was extremely concerned about moving because of her pain in the lower back region and hip. With a little dementia, she often forgets that this pain is a normal response of her OA, which has flared up because of her recent fall. By educating her and ensuring she has adequate pain relief, I have found that our sessions still have a little hesitation to begin with, but are conducted relatively smoothly with the patient understanding that if she was to do nothing at all 1)she would physically decline with immobility, and 2) she would be stuck in the gero rehab for longer. Motivation, education and a hint of empathy and humour, has allowed our sessions to become something that i think the patient now enjoys and understands the benefit of.

Pain

My new patient today on our first treatment had not taken her pain relief medication prior to our session. This proved to be a considerable setback to our session as the patient was clearly unable to partake in the exercises. We had the pain relief administered, and the session was conducted later in the morning.

  The point to note was, had I taken a harder approach with this patient on that first visit (without pain relief), I'm sure the session would not have been overly successful and the patient would certainly not appreciate any of our further sessions together due to our bad start. It is expected that some patients will have pain, though if they are not pushed to this pain, then they are less likely to progress and recover as successfully (pain will be present during healing, but should not limit their compliance). It also helps to determine if their pain relief is an adequate dose. Pain is not always an indicator of "something wrong", it can be a great indicator of the healing process. With my new patient, it was trying to determine if her earlier pain level (preventing the Rx session) was substantial enough to reschedule for later that morning. We did reschedule. My patient went from being very low in mood, and pessimistic about our session together, due to the pain, to a patient that was thrilled and surprised as to how much she could do post the pain relief having been taken.

The important thing I noted from this was to ensure that pain relief is administered or taken prior to sessions for those that require it. As she was a new patient of mine, I was unable to do this initially, but certainly for further sessions, it will be emphasised.

Great day 1

This is written post my first day. 

My first day today was great. Bentley hospital was everything I was hoping for. It was full of paperwork, orientation and talking, but it was good to visually take in the surrounds, and then get our heads around what we'll be dealing with. We weren't thrown in the deep end, unlike our outpatient counterparts (Arnika and Mons), and our supervisor was very supportive and understanding of our current knowledge level. Our supervisors goal is to facilitate our learning in a way that allows quality of the learning experience, rather than rushing through a great deal, and only absorbing a little. There are, and certainly will be expectations of us over the placement but I am eternally grateful for such a friendly and accommodating first day experience. 

The range of clients we'll be seeing is also exciting. It is such a varied placement as we have mornings in Ward 4 - Gero Rehab, and afternoons in a post surgical ward - a diverse range of patients and presentations to be seen on a daily basis. We did get hands-on during our first day, which was  good to break the nerves. We have a little to plan for tonight as "homework", as we'll be doing our first full assessment tomorrow - will include COVS, FR, 6mwt etc - we have the whole morning to complete the test - make as many mistakes (hopefully not too many) and be corrected on the spot with constructive feedback. Am looking forward to putting this semesters Gero lectures and labs to good use - clinically using what we've learnt and making sense of it all. No doubt the experience will shift as we gain more confidence and experience - just glad we didnt have to assess and treat on our own for our first day of prac, as Arnika and Mons did in outpatients - without a supervisor! Deep end suits some, good work girls!