Communication
Situation
A 23yr old female patient presented to the facility who, with a ten year history of Fibromyalgia, had a neuro-toxic reaction to a drug to address the said condition. She had a relatively sudden reaction to the drug, and had a sequence of events that lead her to being hospitalised and confined to a wheelchair due to the drugs physical affects on her nervous system. Her recovery had been slow, going from a highly active and functional university student, to being unable to walk, with debilitating choreiform movements associated with the nervous system’s interruption. She was admitted to a city hospital at the time of her fall (as a result of the medication effects), and saw numerous medical staff and specialists, all of whom were unable to diagnose her current physical state. According to her, she was often used as an “interesting case”, and saw numerous professionals, throughout which she felt she was a learning tool for others, rather than being treated with respect and discretion. She was considered to have conversion syndrome at one stage, and had psychiatric assessments and judgements made, based on her unusual mental state (grossly confused as a result of the drug), and anorexia was also assumed because she was of a small physical frame. She had expressed frustration at the treatment to date by the relevant hospital and its staff, and was cautious of again being shunted around with incorrect information and diagnoses.
Task
I was to prescribe a strengthening program for the patient, as it is known that for patients such as this, a resistance exercise program is highly beneficial. I was also to help write correspondence to the relevant parties at the city hospital and other allied health staff she was involved with, updating them on her current status, and clarify the various streams of information (that lacked a common understanding of the problem).
Action
Research was done on the (uncommonly known, but widely documented) adverse drug reaction, and an objective measure of her chorieform movements was given to the patient to complete, rating the severity of the affects and her eventual progress. After contact with the Fibromyalgia physio at the relevant hospital she was first treated at, it was determined that this objective measure had not been used before for this particular patient or others. Much discussion was had with the patient, and plenty of support given, ensuring the patient knew that everything would be done to fine tune the paper and information trail, making it very clear that what she had was in fact legitimate, and that all relevant parties were aware of this (and it wasn’t in fact Conversion Syndrome, as was randomly written with query in her files and correspondence).
Result
Letters were written to staff, education to local allied health staff stating she was not in fact “that freak”, and a common understanding and agreement between professionals and specialists of her condition was achieved. A validated objective measure was brought to the attention of the Fibromyalgia physio, and was now used to measure the patients physical affects as she progresses. Some education was needed for those the patient came into contact with, and strategies given for times when she has occurances such as freezing. For her return to the city, and subsequently being under the city hospital’s care again, we faxed all possible relevant parties of her status and progression, making sure to exclude the “conversion syndrome” (CS) term. This questionable diagnosis (CS) was completely discredited after speaking with one of her specialists in the city, who failed to remove it from her correspondence (though without question stated she did not have the disorder).
Evaluation
From the outset it was clear this patient had been through an anxious, frustrating and scary period in her life, which was made worse by the lack of understanding and particular treatment given to her by many medical staff. She had to take time off her studies because of the drug reaction, and postpone exams, all while her long term partner was overseas. She had stayed south with family for a length of time to focus on her recovery, which is why we saw her in the private facility. She expressed to us that for the first time she actually felt listened to, and that she finally felt she was working with professionals to get her back on track. It was clear that much distrust and frustration occurred previously. Because we were students looking after her down south, I was initially wary that perhaps she’d had enough of sharing with others (she certainly was not obliged to us as students), but she was happy to have a real connection with us, given we had clearly researched the drug reaction, and validated everything she had been going through. She had responded well to the strengthening program, and had returned to us for a progression of those activities. She vocalised her relief and appreciation for our attention to her situation.
Strategies
I think the best strategy used in this situation was listening, and follow-up action. The patient stated she did not have CS, yet her correspondence was not clear on that. We followed up on this, and proceeded to “set the record straight” once it was absolute. Building a trusting rapport was also vital in this situation, particularly since she had been treated as a condition first, person second. Genuine attention to her concerns also went a long way, we weren’t just filling time with her until she returned to the city, leaving others to continue along the miscommunication highway. My own discretion was also vital as it was in fact the same university we attend, and she specifically asked that any correspondence I did, did not include any personal details, given the sheer size of the university and likelihood of cross-communication. So in writing this, I have endeavoured to express what I myself have learnt from this situation, while respecting her requested anonymity and confidentiality.
Rapport, seeking out further information when needed, and following through with the patient were imperative in this situation. An already horrific and stressful time in her life was made worse by a medical model of treatment. I’ll remember this story and try to avoid repeating that same poor treatment.
Monday, June 28, 2010
Saturday, June 19, 2010
Last Placement Initial Entry
Last one!!! Can’t believe it!!!
I’m off to do another rural placement, but this time it’s my musculoskeletal prac. I’m a little anxious of this placement as none of my previous placements over the last 2-3 years has been musculo oriented (specifically). Most placements obviously involve your general anatomy and physiology knowledge, but it’s been a while since doing the specific assessments etc. To add to my apprehension, I’ll be seeing my own patients from day 1. This is to be expected I guess, given we are so close to becoming qualified practitioners. I hope it’s not expected though to be as fluid as a graduate, as only experience will allow that, none of which I have in this particular field.
I’m guessing I’ll see a variety of presentations on this placement, and given it’s pruning season down here (on the vineyards), there might be some tendonopathies and over use injuries of the upper limbs? As my study over the clinical prep week as indicated, there may also be a high prevalence of low back pain in the patient mix, given there is a high percentage of the population that has it at any one time.
I’ve heard positive things about the supervisor at this placement. He apparently has students year-round, and I believe has recently won an award for his contributions for doing so. I hope to make the most of such a mentor, as I’m basically a clean slate with no experience and I can only learn from such an experienced practitioner.
It will be a relief not to have to drive so far for this placement. It’s relatively close, with trips to Augusta weekly. I believe Augusta is more of a retirement location than being an industry driven locale, so again there may be an older demographic representation of Augusta patients? This might bring in a broader range of presentations related to that age group.
While I am certainly intimidated by the coming placement, I really hope to absorb as much of the experience as possible, and get comfortable with the muscluoskeletal process. I hope to work in the region eventually, and these are obviously skills I’ll need and be proficient at whichever field I work in. In comparison to my last placement, this time I’ll get to be hands on in a traditional physio way, making diagnostic calls and treatments accordingly.
I also hope to make the most of the networking opportunities during this prac. Physio is a relatively small industry as it is, and to have access to contacts and potential collegues/employers is an invaluable aspect of this final rural placement. I look forward (maybe?) to binge thrown in the deep end, and seeing how I respond to that, lets hope I come out the other end knowing more about the musculoskeletal process (and myself).
I’m off to do another rural placement, but this time it’s my musculoskeletal prac. I’m a little anxious of this placement as none of my previous placements over the last 2-3 years has been musculo oriented (specifically). Most placements obviously involve your general anatomy and physiology knowledge, but it’s been a while since doing the specific assessments etc. To add to my apprehension, I’ll be seeing my own patients from day 1. This is to be expected I guess, given we are so close to becoming qualified practitioners. I hope it’s not expected though to be as fluid as a graduate, as only experience will allow that, none of which I have in this particular field.
I’m guessing I’ll see a variety of presentations on this placement, and given it’s pruning season down here (on the vineyards), there might be some tendonopathies and over use injuries of the upper limbs? As my study over the clinical prep week as indicated, there may also be a high prevalence of low back pain in the patient mix, given there is a high percentage of the population that has it at any one time.
I’ve heard positive things about the supervisor at this placement. He apparently has students year-round, and I believe has recently won an award for his contributions for doing so. I hope to make the most of such a mentor, as I’m basically a clean slate with no experience and I can only learn from such an experienced practitioner.
It will be a relief not to have to drive so far for this placement. It’s relatively close, with trips to Augusta weekly. I believe Augusta is more of a retirement location than being an industry driven locale, so again there may be an older demographic representation of Augusta patients? This might bring in a broader range of presentations related to that age group.
While I am certainly intimidated by the coming placement, I really hope to absorb as much of the experience as possible, and get comfortable with the muscluoskeletal process. I hope to work in the region eventually, and these are obviously skills I’ll need and be proficient at whichever field I work in. In comparison to my last placement, this time I’ll get to be hands on in a traditional physio way, making diagnostic calls and treatments accordingly.
I also hope to make the most of the networking opportunities during this prac. Physio is a relatively small industry as it is, and to have access to contacts and potential collegues/employers is an invaluable aspect of this final rural placement. I look forward (maybe?) to binge thrown in the deep end, and seeing how I respond to that, lets hope I come out the other end knowing more about the musculoskeletal process (and myself).
Thursday, June 17, 2010
Placement 3 Final Entry
This rural paediatric placement concerned me a little before I started. It was the first time the facility had had a student, and I had no clinical mixes or previous experiences to go off.
I had presumed the nature of the placement would encompass the biopsychosocial model, and it certainly did like no other placement I’ve had. The whole thread of what the therapist does is woven into and dictated by the familys circumstances in every regard. The school visits were an eye opener, as there are so many factors to consider for a child with severe and complex disabilities. The home visits were the same again, but there was a real respect needed for the family, in allowing a stranger to enter their home and sanctuary, with the hope of improving its function and quality somehow. I did my best at being appreciative, understanding and respectful when interacting with the families, and found the majority of families were happy to have a student in their home/working with their child (they certainly didn’t have to be).
The gravity of what these families have gone through had an interesting affect on me. I didn’t pity them, I just an astounding respect for what they go through, albeit having only seen a pinch of their lifetime and its struggles. I think they would have found it offensive to elicit pity or sympathy. Empathy instead I think came naturally to me. Given my current physical condition (birth of own child impending), the realisation that things don’t always go as we’d hope, and that it can in fact happen to any one of us was a stark reminder. They too had the same hopes and ambitions for their children as I do, disability doesn’t pick selectively.
Prior to starting, I had predicted the travel to be a little demanding. That was probably an understatement. While I knew I’d be travelling a lot, the nature of the placement is one of a dynamic and changing nature, therefore I found myself doing a lot of km’s on the road. This was somewhat compensated for with start times, but as mentioned to my supervisor when asked, I think it might be best if the next student is based a little closer to the facility most visited. That in mind, I got so much from the placement that I would do the same again.
The conditions I experienced on the placement were a little different from what I expected. There were random chromosomal disorders, plenty of CP clients, and autism children also. I saw a wide variety of conditions, and even ones that differed within the same diagnosis. Each child was different, and had a different set of requirements. I have a great appreciation for the struggles that rural children and their families have to deal with, purely by living in the country. This was one of the things I was looking forward to on this placement, that satisfaction of helping those clients that really do survive on the help of rural allied health members. One mother travelled 2 hours each way to get her son to the hydrotherapy classes that he loves. That’s the closest facility that offers the specialised service allowing his condition, and that weekly activity is a vital part of his and his families quality of life. Allied health really does have an impact on these families lives.
Not sweating the small stuff and having a respect for the families that struggle every day to do the smallest and seemingly insignificant tasks, is what I got out of this placement. It was a very rewarding placement and an area that I could see myself working in in the future. Having the ability to get along with differing characters and personalities is vital in such a role, one that I think perhaps I might have. We’ll see how the next (oh so contrasting) placement goes – private practice musculoskeletal, oh you have a sore knee!!!! Bless, we each have our roles, all of which are just as important. I’ll always have a respect for those doing it tougher than the rest of us, for that I’m thankful.
This rural paediatric placement concerned me a little before I started. It was the first time the facility had had a student, and I had no clinical mixes or previous experiences to go off.
I had presumed the nature of the placement would encompass the biopsychosocial model, and it certainly did like no other placement I’ve had. The whole thread of what the therapist does is woven into and dictated by the familys circumstances in every regard. The school visits were an eye opener, as there are so many factors to consider for a child with severe and complex disabilities. The home visits were the same again, but there was a real respect needed for the family, in allowing a stranger to enter their home and sanctuary, with the hope of improving its function and quality somehow. I did my best at being appreciative, understanding and respectful when interacting with the families, and found the majority of families were happy to have a student in their home/working with their child (they certainly didn’t have to be).
The gravity of what these families have gone through had an interesting affect on me. I didn’t pity them, I just an astounding respect for what they go through, albeit having only seen a pinch of their lifetime and its struggles. I think they would have found it offensive to elicit pity or sympathy. Empathy instead I think came naturally to me. Given my current physical condition (birth of own child impending), the realisation that things don’t always go as we’d hope, and that it can in fact happen to any one of us was a stark reminder. They too had the same hopes and ambitions for their children as I do, disability doesn’t pick selectively.
Prior to starting, I had predicted the travel to be a little demanding. That was probably an understatement. While I knew I’d be travelling a lot, the nature of the placement is one of a dynamic and changing nature, therefore I found myself doing a lot of km’s on the road. This was somewhat compensated for with start times, but as mentioned to my supervisor when asked, I think it might be best if the next student is based a little closer to the facility most visited. That in mind, I got so much from the placement that I would do the same again.
The conditions I experienced on the placement were a little different from what I expected. There were random chromosomal disorders, plenty of CP clients, and autism children also. I saw a wide variety of conditions, and even ones that differed within the same diagnosis. Each child was different, and had a different set of requirements. I have a great appreciation for the struggles that rural children and their families have to deal with, purely by living in the country. This was one of the things I was looking forward to on this placement, that satisfaction of helping those clients that really do survive on the help of rural allied health members. One mother travelled 2 hours each way to get her son to the hydrotherapy classes that he loves. That’s the closest facility that offers the specialised service allowing his condition, and that weekly activity is a vital part of his and his families quality of life. Allied health really does have an impact on these families lives.
Not sweating the small stuff and having a respect for the families that struggle every day to do the smallest and seemingly insignificant tasks, is what I got out of this placement. It was a very rewarding placement and an area that I could see myself working in in the future. Having the ability to get along with differing characters and personalities is vital in such a role, one that I think perhaps I might have. We’ll see how the next (oh so contrasting) placement goes – private practice musculoskeletal, oh you have a sore knee!!!! Bless, we each have our roles, all of which are just as important. I’ll always have a respect for those doing it tougher than the rest of us, for that I’m thankful.
Week 5 Blog Entry
Communication
Situation
My supervisor and I were to do a home visit to a 3 yo girl who has cerebral palsy. She has spastic hemiplegia, currently pushes herself backwards along the floor to get around, and also uses a Mulholland walker at home. She currently uses no sleep systems for her night-time posture, and displays a gross lack of trunk extension and stability, limiting her ability to be upright. She is non communicable, but is able to express her distress with high-pitched noises. Her father is the sole carer for her and her 2 yo brother. The exact details are unclear, but the mother is no longer present in the home, and as indicated by the child’s father, is abusive towards him and the children and has issues with drugs and alcohol. Before each home visit, there is a risk assessment form that is filled out, alerting any allied health member to be aware of any risks that may be incurred whilst at the family home. This clients risk assessment did not have anything notable, but my supervisor expressed her concerns regarding the fathers own mental health, and his unusual behaviour and tendencies to confabulate during conversations. He has not been coping as sole carer at home, and his daughter’s health is a concern to the allied health team, as she is not getting the early intervention strategies required for such a condition. The fathers stories change each time my supervisor visits, and it is apparently clear the daughter’s condition is deteriorating because of the lack of intervention.
Task
I was to conduct an informal gross motor assessment of the child in the home (mainly for practice and to allow my supervisor to chat with the father), while my supervisor discussed current issues and concerns with her father. As this organisation is greatly based on family partnerships and the essential rapport between the therapist and client, my supervisor wished to delicately nut out some concerning issues she’s come across, regarding the status of his child’s health and her management. My supervisor also wanted to broach the subject of perhaps involving social work during this visit, due to his inability to cope with the current family demands, as indicated by phone calls and previous assessments.
Action
We entered the home and after greeting the father and thanking him for letting me visit his home, I proceeded to the floor to interact with the young girl with the CP. My supervisor took a seat at the couch, along with the father and 2 yo and began chatting. While I was doing my motor assessment with the child, the father expressed his ongoing concerns regarding the inappropriateness of the behaviour of the children’s mother. He stated Homeswest would have a modified home ready soon in Perth to suit his child’s needs, but says he’s” not racist, but doesn’t like all those muslims in the city”, so probably won’t move (even for the obvious benefit of his child). When questioned as to how his daughter was doing of late, he said she was fine, and that she had a whole T bone steak after her own dinner just recently. The father spoke constantly throughout the visit, and indicated that all was well with his daughter and the family at the moment, except the issue of their mother. He spoke enthusiastically and appeared quite wound up, using overt hand gestures, and only managed to stay seated for short periods. When he was seated he rapidly tapped his foot.
Result
When the issue of possible social work involvement (to help address any social issues) was raised, the fathers’ mood immediately became defensive and he quickly shut down the conversation with my supervisor. He declined any social work involvement and again indicated everything was fine at the moment. Repeated visits have resulted in conflicting information from the father, and this visit was no different. On leaving the house, my supervisor stated she was not keen to push the issue of social work further during this visit, as she felt the fathers tension had risen to un inappropriate level. The visit had obviously been cut short by this topic being raised.
Evaluation
My supervisor expressed her frustration about this case. The child is clearly not doing as well as she could be, regardless of the fact she’s made every attempt to help manage her condition as her therapist. Grants are applied for mobility equipment for the child to improve their quality of life and function. On looking at the walking frame retrieved from the back room of the house, it was obvious she was not spending the recommended amount of time in the frame, and missing out on the physical and emotional benefits of doing so. My supervisor stated the child was obviously not able to eat a steak, along with her own dinner, and said this was an example of the unusual information the father would pass on. My supervisor questions the possibility of the father having a mental illness himself, though this is obviously not something she herself can raise, as she is the. The most notable issue for the therapist in this case is the importance of communication. It is clearly frustrating to have a case such as this, where they are on the organisations files, but they decline any involvement or intervention. An agreement to something/course of action one day, does not always translate into reality. I actually think the visit went as best as it probably could of. It would be wrong not to offer the family some social help (particularly for helping organise specialist appts, housing issues etc). Because of the fathers dynamic personality/mental health, it’s a tough case to manage. Overall the child health is suffering, but I don’t think its a result of therapist issues, more likely intrinsic family issues.
Strategies
I’d be unqualified to assume knowledge on this subject, but from what I gather in a case such as this, the trust and rapport you build with the family is vital. You may not agree with everything they are doing, but having some common ground or connection may end up making a huge difference on the quality of the child’s life. Being flexible to the familys needs is also important, as being rigid with visit times or compliance of therapy (for example), may only ostracise the family. For the child’s sake, subtle persistence will be required. A window of opportunity where the father agrees to a therapy may not be present now, but it may open up in the future at some time. I believe being understanding of each individuals case is important. The father clearly feels he’s doing as best he can for his child, we are just there to help facilitate that if possible. In the end, if a family refuses treatment then that’s their choice (we can’t force them), but it should an informed choice, regardless of how much they may not want the help. As long as we (as therapists) have exhausted every avenue and remained diplomatic and open on all fronts, only then should we concede their position. It’s such a complex and dynamic process, one I’ve learnt from certainly.
Communication
Situation
My supervisor and I were to do a home visit to a 3 yo girl who has cerebral palsy. She has spastic hemiplegia, currently pushes herself backwards along the floor to get around, and also uses a Mulholland walker at home. She currently uses no sleep systems for her night-time posture, and displays a gross lack of trunk extension and stability, limiting her ability to be upright. She is non communicable, but is able to express her distress with high-pitched noises. Her father is the sole carer for her and her 2 yo brother. The exact details are unclear, but the mother is no longer present in the home, and as indicated by the child’s father, is abusive towards him and the children and has issues with drugs and alcohol. Before each home visit, there is a risk assessment form that is filled out, alerting any allied health member to be aware of any risks that may be incurred whilst at the family home. This clients risk assessment did not have anything notable, but my supervisor expressed her concerns regarding the fathers own mental health, and his unusual behaviour and tendencies to confabulate during conversations. He has not been coping as sole carer at home, and his daughter’s health is a concern to the allied health team, as she is not getting the early intervention strategies required for such a condition. The fathers stories change each time my supervisor visits, and it is apparently clear the daughter’s condition is deteriorating because of the lack of intervention.
Task
I was to conduct an informal gross motor assessment of the child in the home (mainly for practice and to allow my supervisor to chat with the father), while my supervisor discussed current issues and concerns with her father. As this organisation is greatly based on family partnerships and the essential rapport between the therapist and client, my supervisor wished to delicately nut out some concerning issues she’s come across, regarding the status of his child’s health and her management. My supervisor also wanted to broach the subject of perhaps involving social work during this visit, due to his inability to cope with the current family demands, as indicated by phone calls and previous assessments.
Action
We entered the home and after greeting the father and thanking him for letting me visit his home, I proceeded to the floor to interact with the young girl with the CP. My supervisor took a seat at the couch, along with the father and 2 yo and began chatting. While I was doing my motor assessment with the child, the father expressed his ongoing concerns regarding the inappropriateness of the behaviour of the children’s mother. He stated Homeswest would have a modified home ready soon in Perth to suit his child’s needs, but says he’s” not racist, but doesn’t like all those muslims in the city”, so probably won’t move (even for the obvious benefit of his child). When questioned as to how his daughter was doing of late, he said she was fine, and that she had a whole T bone steak after her own dinner just recently. The father spoke constantly throughout the visit, and indicated that all was well with his daughter and the family at the moment, except the issue of their mother. He spoke enthusiastically and appeared quite wound up, using overt hand gestures, and only managed to stay seated for short periods. When he was seated he rapidly tapped his foot.
Result
When the issue of possible social work involvement (to help address any social issues) was raised, the fathers’ mood immediately became defensive and he quickly shut down the conversation with my supervisor. He declined any social work involvement and again indicated everything was fine at the moment. Repeated visits have resulted in conflicting information from the father, and this visit was no different. On leaving the house, my supervisor stated she was not keen to push the issue of social work further during this visit, as she felt the fathers tension had risen to un inappropriate level. The visit had obviously been cut short by this topic being raised.
Evaluation
My supervisor expressed her frustration about this case. The child is clearly not doing as well as she could be, regardless of the fact she’s made every attempt to help manage her condition as her therapist. Grants are applied for mobility equipment for the child to improve their quality of life and function. On looking at the walking frame retrieved from the back room of the house, it was obvious she was not spending the recommended amount of time in the frame, and missing out on the physical and emotional benefits of doing so. My supervisor stated the child was obviously not able to eat a steak, along with her own dinner, and said this was an example of the unusual information the father would pass on. My supervisor questions the possibility of the father having a mental illness himself, though this is obviously not something she herself can raise, as she is the. The most notable issue for the therapist in this case is the importance of communication. It is clearly frustrating to have a case such as this, where they are on the organisations files, but they decline any involvement or intervention. An agreement to something/course of action one day, does not always translate into reality. I actually think the visit went as best as it probably could of. It would be wrong not to offer the family some social help (particularly for helping organise specialist appts, housing issues etc). Because of the fathers dynamic personality/mental health, it’s a tough case to manage. Overall the child health is suffering, but I don’t think its a result of therapist issues, more likely intrinsic family issues.
Strategies
I’d be unqualified to assume knowledge on this subject, but from what I gather in a case such as this, the trust and rapport you build with the family is vital. You may not agree with everything they are doing, but having some common ground or connection may end up making a huge difference on the quality of the child’s life. Being flexible to the familys needs is also important, as being rigid with visit times or compliance of therapy (for example), may only ostracise the family. For the child’s sake, subtle persistence will be required. A window of opportunity where the father agrees to a therapy may not be present now, but it may open up in the future at some time. I believe being understanding of each individuals case is important. The father clearly feels he’s doing as best he can for his child, we are just there to help facilitate that if possible. In the end, if a family refuses treatment then that’s their choice (we can’t force them), but it should an informed choice, regardless of how much they may not want the help. As long as we (as therapists) have exhausted every avenue and remained diplomatic and open on all fronts, only then should we concede their position. It’s such a complex and dynamic process, one I’ve learnt from certainly.
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