The patient we saw today was progressing very well since we had seen 2/52 ago. She had had a TKR and we were dealing with her return to normal function and reporting back to her surgeon when the time came. She did not believe that she was moving along well at all but we reassured her that she is going very well and on track to having a great recovery from such an invasive operation. In the first week we may not have been able to make this call but with treating 6 patients and dealing with another 10 people in a class designed for those people who have undergone TKRs we felt we were in a good position to offer our opinion on how she was progressing. The patient had also been ill the last few weeks and showed some concern for possible complications such as infection. Our supervisor was able to offer his thoughts on the situation and suggested that the patient mention this to her doctor when she visited him in the next couple of days.
This made me think about all the questions we ask that are designed to clear the possibility of more severe conditions such as infection, cauda equina issues and vertebral artery insufficiencies. At what point does an answer warrant more investigation. For instance we have had many patients who have mentioned losing 5kgs in 2 weeks, dizziness with certain movements or increased frequency of urination. Ultimately most people will lose some weight following surgery thru decreased exercise and food intake, many people get small dizzy spells when moving suddenly etc. Since most of the time the question can appear odd in the context of a musculoskeletal examination, (as we discovered when we asked a 16yo girl about her bowel/bladder function) a patient may begin to worry that there may be something more severe wrong with them. Therefore having a thorough knowledge of the specifics of the question is vital so the patient can be assured that it is simply a routine question. The prevalence of such circumstances may be very low but I’m guessing that at some point in all of our careers we will be faced with dealing with such a situation and it is not something we should disregard at this stage.
At this point in the placement I am feeling very comfortable and confident with treating patients, more so the communication side of things and just making the patient feel comfortable to discuss and trust the treatments which we are applying. I have found that I have developed my ability to explain to patients clearly what is occurring and make them understand what my intention is and how they will progress with time. Also I see that it is very important to build a complete and smooth assessment and treatment process so that the patient can have total confidence in the physiotherapist, as I increase my knowledge base about all the different conditions I imagine this will become second nature to me.
If possible the best option is to plan the process ahead of time and anticipate numerous different scenarios and then deal with the situation as it presents itself. We have learnt this many times with expecting simple situations but been suprised when a patient has many more complicating factors than we could have imagined.
Tuesday, November 11, 2008
Friday, November 7, 2008
Week 4.3 Entry
Today we saw the disappointment that can occur when a patient’s return is not as quick as they would have hoped or that they were promised.
I have spoken about the patient with bilateral calcaneal fractures after falling from a height several weeks ago. His progress has been steady but as expected slow which he understands to a certain extent but is very keen to get back to work since he is not receiving any workers compensation and is self employed. His work involves him working at height and at some points he needs to jump down from scaffolding that is up to 1m off the ground. He thought that this may be possible sooner rather than later but with an injury such as a fracture and particularly on a constantly weight bearing structure as the calcaneus this is not going to be happening in a hurry. As well the soft tissue damage may not be sufficiently strong and stable enough to allow him to land from such a height. He controls his emotions very well and but it was obvious that he was annoyed that his return would be delayed. To make the matter even worse we made a comment that he should stop drinking everyday….well before midday anyway. This seemed ridiculous to him but when we told him that alcohol is not helpful for improving his injury he seemed to realize that he may need to make the change.
Another patient of ours was recovering from a TKR approximately 8/52 ago and was doing really well when we first saw him and had only improved from there. He could walk well and was affected more by pain in his other knee. Last week we had progressed him to low grade WB ex’s which he was managing very well and was expecting to move him onto some higher grade ex’s and include some more functional ex’s. This session was to be after his visit to the surgeon to see how his knee was going and also decide if he was able to return to work (just gardening and maintenance at a primary school). All 3 of us had expected for him to be able to return to work and were anticipating this by organizing a more extensive exercise list for him to leave us with. Unfortunately the surgeon rejected his request to return to work! This was after the surgeon said originally that he should be able to return to work. His reasoning was….wait for it….the prothesis he had put in was not designed for work such as his!! Bec and I were as amazed as the patient (our supervisor couldn’t believe it as well) and decided that we would keep seeing him but 2/52 apart from now on. The patient is needing to get the other knee done in the near future so was not as forceful with getting an explanation out of him but we expect him to get pretty fired up after the second operation. It was important that we assured him that he was doing really well and to look on the brightside that he gets a permanent holiday on retirement but he really wanted to keep busy.
I realized that it is important to not promise too much to patients and give them false hope on where they will end up by the end of their rehabilitation. Giving a conservative opinion is the best option and possibly avoiding giving a stead fast answer is even better. Everything health professionals say is often taken as gospel by patients and people will base their life around the predictions we have made.
I have spoken about the patient with bilateral calcaneal fractures after falling from a height several weeks ago. His progress has been steady but as expected slow which he understands to a certain extent but is very keen to get back to work since he is not receiving any workers compensation and is self employed. His work involves him working at height and at some points he needs to jump down from scaffolding that is up to 1m off the ground. He thought that this may be possible sooner rather than later but with an injury such as a fracture and particularly on a constantly weight bearing structure as the calcaneus this is not going to be happening in a hurry. As well the soft tissue damage may not be sufficiently strong and stable enough to allow him to land from such a height. He controls his emotions very well and but it was obvious that he was annoyed that his return would be delayed. To make the matter even worse we made a comment that he should stop drinking everyday….well before midday anyway. This seemed ridiculous to him but when we told him that alcohol is not helpful for improving his injury he seemed to realize that he may need to make the change.
Another patient of ours was recovering from a TKR approximately 8/52 ago and was doing really well when we first saw him and had only improved from there. He could walk well and was affected more by pain in his other knee. Last week we had progressed him to low grade WB ex’s which he was managing very well and was expecting to move him onto some higher grade ex’s and include some more functional ex’s. This session was to be after his visit to the surgeon to see how his knee was going and also decide if he was able to return to work (just gardening and maintenance at a primary school). All 3 of us had expected for him to be able to return to work and were anticipating this by organizing a more extensive exercise list for him to leave us with. Unfortunately the surgeon rejected his request to return to work! This was after the surgeon said originally that he should be able to return to work. His reasoning was….wait for it….the prothesis he had put in was not designed for work such as his!! Bec and I were as amazed as the patient (our supervisor couldn’t believe it as well) and decided that we would keep seeing him but 2/52 apart from now on. The patient is needing to get the other knee done in the near future so was not as forceful with getting an explanation out of him but we expect him to get pretty fired up after the second operation. It was important that we assured him that he was doing really well and to look on the brightside that he gets a permanent holiday on retirement but he really wanted to keep busy.
I realized that it is important to not promise too much to patients and give them false hope on where they will end up by the end of their rehabilitation. Giving a conservative opinion is the best option and possibly avoiding giving a stead fast answer is even better. Everything health professionals say is often taken as gospel by patients and people will base their life around the predictions we have made.
Monday, November 3, 2008
Week 4.1 Entry
At this stage of our placement we are predominantly seeing patients who we have seen before and their treatment revolves mainly around applying similar treatment techniques as previously or modifying them if the desired results aren’t being achieved. Assessing the benefits of the exercises prescribed and progressing these is also important since we will hopefully be discharging a lot of our patients and we need them to be able to continue improving/maintaining their situation.
All of our patients today were making headway with their recovery and the decision had to be made whether we were to progress with treatment/exercises dependent on our latest assessment. With some of them it had gotten to a point where they were coming along great but they simply had to increase their strength and the only way to do this was to keep the same exercise but increase the resistance. Not very exciting for the patient but therabands can only take you so far. This is problem for those that find trouble weight bearing for example but need a high resistance for their HEP. Very few patients will have any kind of exercise equipment at home. We have needed to become a bit inventive on occasion to keep the patient interested and also progress the exercise.
One of our patients is working through a VMO/ leg strengthening exercise program and is almost pain free and able to walk up stairs which he had trouble with before. We moved his exercises to weight bearing and far more functional than the previously used theraband. He enquired about possibly being given the all clear and sent on his way. Since this was the first week which we had seen a significant improvement in his condition and we were only getting onto some tougher exercises today we decided that we needed to see the results from this latest exercise prescription and then reassess. Of course we want to see him head off in a better state but not too soon since we think that it is vital he is aware that his situation needs to be maintained and exercises need to continue well after we have stopped seeing him. Otherwise he will simply be back in a few months complaining of the same problem.
This made me aware of how important it is to have a discharge plan even in an outpatients setting. The proposal at the start of our placement was to formulate a plan to discharge the majority of our patients by the end of our 5 week stint. Some of them will be fine to discharge with exercises to continue their improvements whilst others will need to be handed over to the other physiotherapists which will require detailed handover notes and short & long term goals. This will be an important part of life in the physio world so the sooner I get the hang of it the easier it will be when the real world is reached in 2yrs.
All of our patients today were making headway with their recovery and the decision had to be made whether we were to progress with treatment/exercises dependent on our latest assessment. With some of them it had gotten to a point where they were coming along great but they simply had to increase their strength and the only way to do this was to keep the same exercise but increase the resistance. Not very exciting for the patient but therabands can only take you so far. This is problem for those that find trouble weight bearing for example but need a high resistance for their HEP. Very few patients will have any kind of exercise equipment at home. We have needed to become a bit inventive on occasion to keep the patient interested and also progress the exercise.
One of our patients is working through a VMO/ leg strengthening exercise program and is almost pain free and able to walk up stairs which he had trouble with before. We moved his exercises to weight bearing and far more functional than the previously used theraband. He enquired about possibly being given the all clear and sent on his way. Since this was the first week which we had seen a significant improvement in his condition and we were only getting onto some tougher exercises today we decided that we needed to see the results from this latest exercise prescription and then reassess. Of course we want to see him head off in a better state but not too soon since we think that it is vital he is aware that his situation needs to be maintained and exercises need to continue well after we have stopped seeing him. Otherwise he will simply be back in a few months complaining of the same problem.
This made me aware of how important it is to have a discharge plan even in an outpatients setting. The proposal at the start of our placement was to formulate a plan to discharge the majority of our patients by the end of our 5 week stint. Some of them will be fine to discharge with exercises to continue their improvements whilst others will need to be handed over to the other physiotherapists which will require detailed handover notes and short & long term goals. This will be an important part of life in the physio world so the sooner I get the hang of it the easier it will be when the real world is reached in 2yrs.
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