The 5 weeks I spent in Kalgoorlie proved to be easily the most challenging clinical placement thus far. I was aware that it wasn’t going to be an easy placement but being put into the environment of a private practice opened my eyes to the difficulty involved with not only being a good clinician but also aware of physiotherapy from a business point of view. I found that being able to put all the musculoskeletal learning and knowledge into practice very rewarding since for years we have been assessing and treating each other which 99% of the time means not finding any issues. So to actually assess someone, find an issue, treat the issue and improve their movement or reduce their pain was very rewarding and made it a lot easier to understand the nature of conditions and how they can be improved.
As I mentioned prior to commencing this placement one of the main difficulties I thought I would face would be diagnosis and not having access to a clear and thorough medical history as is provided at hospitals. Initially I found this particularly overwhelming with not only having to diagnose the problem but make it quick and then figure out a treatment and plan all while questioning the patient and thinking about the situation on the go. As I saw more patients this process became more effcicient and I was able to quickly diagnose but I understand that there is still a lot of work to do and this process will be refined more and more after finishing study.
I could not have anticipated the intensity of the placement and the amount of information being thrown at me. As mentioned there is always more to learn both for the rest of the year but also beyond graduation but I believe that I made some very strong and solid in roads into developing my skills and also made me aware of just how much there is to know. I also refined the process of knowledge acquisition to make learning much more efficient and enable me to accurately learn of the many different clinical conditions and how they may present to the physiotherapist.
As I gathered I began the placement from more of an observer point of view but was regularly quizzed on what was happening in the room to ensure I was clear on the session’s situation. As time went on and I began developing my skills I was able to treat patients with more and more independence. By the end I was confident with conducting an efficient and effective treatment session.
Kalgoorlie really did open my eyes as to how far physiotherapy students really have to go before they become completely proficient. The learning never stops and we need to be open to continuing this development and also strive to add more skills every time we are exposed to the clinical environment.
Sunday, April 25, 2010
Sunday, April 18, 2010
Week 5 STARES - Kalgoorlie MSk
Situation
On the 16th of April a 25 yr old man presented with LBP and hamstring tightness following a soccer game 3 days earlier. The hamstring tightness occurred immediately following the game and the LBP presented the next morning. Since this time the pain/tightness has gotten gradually worse and he presented looking very stiff with slow movements. He felt that his left hamstring was tighter but overall the pain in his lower back, gluteals and hamstring is bilateral. This same situation has occurred on 3 other occasions but none as bad as this and all had resolved with no intervention. His pain was aggravated by activity especially with twisting and when standing or sitting for an extended period of time. The pain would ease off with rest and lying down. The patient had not had any time off work but had ceased playing sport since the incident. Prior to visiting the physiotherapist he had consulted a chiropractor who had manipulated the patient with only moderate immediate pain relief but the pain had returned worse the next day. No official diagnosis had been reported to the patient during these visits.
Task
To determine the nature of the patient’s injury by performing the required musculoskeletal examination and generate a working diagnosis to then treat the patient and reduce his symptoms to allow him operate with less pain.
Action
Initially I had the patient perform Active ROM movements to determine into what directions he is mainly deficient. He was restricted into all directions with flexion being the asterisk direction. His pain was increased when returning from any given direction to neutral position. His straight leg raise was 40° on left and 50° on the right, both very low for someone so young and active. Due to the bilateral nature of his symptoms it was necessary to perform some neural integrity testing to ascertain what neural involvement might be present. His patella tendon reflex on the right was noticeably reduced relative to the left, but all myotomes and sensation testing was negative. A slump test was then performed which produced a positive result, especially on the right where knee extension was stopped as a result of pain 5° short of full extension with the neck extended and 20° short with passive neck flexion added. After this neural testing the patient reported slight tingling in his right foot.
Result
The most important diagnosis to be made was that there were some definite neural issues which with the bilateral nature of the symptoms suggest a discal pathology impacting upon the spinal nerves, mainly on the right. As a result there is also some facet and muscle restrictions possibly as a reaction to the dysfunction being caused by the problem disc. The exact level was not clear but it is likely to be at either the L3/4 or L4/5 level.
Evaluation
Since I had never come across a patient who had diminished reflexes this was something new for me and hence had to think differently to what I had previously. I was fairly comfortable with the diagnosis but in terms of a treatment for the disc dysfunction I was not clear on which direction things had to head. Techniques to reduce the load on the disc such as traction were an option but after discussions with my supervisor we did not know the exact nature of the disc so improving the patient’s movement was the primary goal for this first session by using mobilizations techniques.
Probably the main difficulty I had with this patient was explaining to him the nature of the issue but also making him understand that having a disc problem is very common and not as debilitating as most people believe. His anxiety increased after receiving this news so limiting this became a very important factor. My supervisor was able to assist me with explaining to the patient in the best possible way the situation and that referral to a specialist could be an option.
Strategies
The most important thing I should take away from this scenario is that I need to keep the patient’s needs and limitations in mind and not hope to cure them in one session, especially with a more complex case as presented here. But in saying that some progress should be achieved to improve the patient’s function and maintain as normal as possible their ADLs. Explaining the situation to the patient and what the possible progression will be is something I need to work on and this involves me learning a lot more about the condition and what the options are for treatment.
On the 16th of April a 25 yr old man presented with LBP and hamstring tightness following a soccer game 3 days earlier. The hamstring tightness occurred immediately following the game and the LBP presented the next morning. Since this time the pain/tightness has gotten gradually worse and he presented looking very stiff with slow movements. He felt that his left hamstring was tighter but overall the pain in his lower back, gluteals and hamstring is bilateral. This same situation has occurred on 3 other occasions but none as bad as this and all had resolved with no intervention. His pain was aggravated by activity especially with twisting and when standing or sitting for an extended period of time. The pain would ease off with rest and lying down. The patient had not had any time off work but had ceased playing sport since the incident. Prior to visiting the physiotherapist he had consulted a chiropractor who had manipulated the patient with only moderate immediate pain relief but the pain had returned worse the next day. No official diagnosis had been reported to the patient during these visits.
Task
To determine the nature of the patient’s injury by performing the required musculoskeletal examination and generate a working diagnosis to then treat the patient and reduce his symptoms to allow him operate with less pain.
Action
Initially I had the patient perform Active ROM movements to determine into what directions he is mainly deficient. He was restricted into all directions with flexion being the asterisk direction. His pain was increased when returning from any given direction to neutral position. His straight leg raise was 40° on left and 50° on the right, both very low for someone so young and active. Due to the bilateral nature of his symptoms it was necessary to perform some neural integrity testing to ascertain what neural involvement might be present. His patella tendon reflex on the right was noticeably reduced relative to the left, but all myotomes and sensation testing was negative. A slump test was then performed which produced a positive result, especially on the right where knee extension was stopped as a result of pain 5° short of full extension with the neck extended and 20° short with passive neck flexion added. After this neural testing the patient reported slight tingling in his right foot.
Result
The most important diagnosis to be made was that there were some definite neural issues which with the bilateral nature of the symptoms suggest a discal pathology impacting upon the spinal nerves, mainly on the right. As a result there is also some facet and muscle restrictions possibly as a reaction to the dysfunction being caused by the problem disc. The exact level was not clear but it is likely to be at either the L3/4 or L4/5 level.
Evaluation
Since I had never come across a patient who had diminished reflexes this was something new for me and hence had to think differently to what I had previously. I was fairly comfortable with the diagnosis but in terms of a treatment for the disc dysfunction I was not clear on which direction things had to head. Techniques to reduce the load on the disc such as traction were an option but after discussions with my supervisor we did not know the exact nature of the disc so improving the patient’s movement was the primary goal for this first session by using mobilizations techniques.
Probably the main difficulty I had with this patient was explaining to him the nature of the issue but also making him understand that having a disc problem is very common and not as debilitating as most people believe. His anxiety increased after receiving this news so limiting this became a very important factor. My supervisor was able to assist me with explaining to the patient in the best possible way the situation and that referral to a specialist could be an option.
Strategies
The most important thing I should take away from this scenario is that I need to keep the patient’s needs and limitations in mind and not hope to cure them in one session, especially with a more complex case as presented here. But in saying that some progress should be achieved to improve the patient’s function and maintain as normal as possible their ADLs. Explaining the situation to the patient and what the possible progression will be is something I need to work on and this involves me learning a lot more about the condition and what the options are for treatment.
Saturday, April 10, 2010
Week 3 STARES - Kalgoorlie MSk
Situation
On the 6th of April a 45yo lady presented to me with right calf pain following a traumatic incident at a netball game 2 days prior. She had been running when she suddenly felt pain in her calf and was unable to continue playing. There was no previous history of calf injury or issues and up till consulting a physio she had been icing 2x/day and only walking on crutches due to significant pain when walking especially just prior to push off and with push of itself. From the history of incident the most likely diagnosis was likely to be a strained or torn calf muscle.
Task
To confirm the nature of the injury and rule out other possible issues by completing a thorough objective assessment. Then I was to conduct a treatment and advise the patient on home maintenance and exercises to manage & treat the injury.
Action
The examination initially involved seeing what active movements the patient could achieve. She could only dorsiflex to ~2° before pain was produced during a bilateral squat and couldn’t perform a heel raise on her right leg due to pain. Her single leg balance on her right was less than the left but she could still maintain her balance with more postural sway for 30 seconds. Passively her dorsiflexion with her leg straight was far more painful than with the knee bent. There was some bruising in the medial head of her right gastroc and her achilles tendon was slightly decreased in width relative to the left. She was very tender on palpation in her medial gastroc and a noticeable depression was felt within the medial gastroc head. She was also very tender around the medial border of the right Achilles close to the musculo-tendon junction.
From this assessment and the patient’s history it was determined that the patient had suffered a Grade 2 right medial head gastroc strain and also a strain on the structures at the musculo-tendon junction on the medial side of her achilles tendon.
The treatment in this early stage was very conservative with only ultrasound and some gentle soft tissue massage used. The main emphasis at this early stage was patient education and home exercises. She was encouraged to use her crutches when having the walk long distances, avoid use around the home and wear shoes to limit dysfunction due to an aberrant gait pattern. Some very low grade stretching using a towel and the use of hot/cold therapy to decrease swelling and pain was also prescribed.
Result
The patient seemed aware of the situation and was happy to take heed of my instructions and not cause herself anymore damage. The treatment in the practice was not designed to improve her status there and then but simply but her tissue into a better position to begin the healing process.
Evaluation
The patient was eager to follow the instructions given to her but when she returned two days later I found that she had not followed them as I had desired. Her pain had increased and she was limping noticeably. I had given her simple instructions to follow but I believe that the way I explained it to her was what caused the misunderstanding. The only exercises I gave her had been conducted correctly but she had been experiencing pain after each session but this did not deter her from repeating when the next set was required. Once again I should have explained to her to use pain as her guide and only continue if there is not pain or it is at a manageable level.
Strategies
I need to ensure that I explain clearly to the patient that pain should be used as a guide to limit her with the exercises and with ambulation. Because everyone’s ideas of pain differ I need to use more a measureable guide to limit her activity levels. In these early stages a hard and fast rule of use crutches every time you go outside would have been better than letting the patient decide when and where to use them. Using partial weight bearing and trying to imitate the movement the foot should be doing would have also been useful otherwise the patient would probably think they could walk on it normally with just some balance support from the crutches. Essentially clear and concise explanation of what the patient should be doing and exactly how much of it throughout the course of the day is required to maintain improvements in tissue structure and also limit dysfunction.
On the 6th of April a 45yo lady presented to me with right calf pain following a traumatic incident at a netball game 2 days prior. She had been running when she suddenly felt pain in her calf and was unable to continue playing. There was no previous history of calf injury or issues and up till consulting a physio she had been icing 2x/day and only walking on crutches due to significant pain when walking especially just prior to push off and with push of itself. From the history of incident the most likely diagnosis was likely to be a strained or torn calf muscle.
Task
To confirm the nature of the injury and rule out other possible issues by completing a thorough objective assessment. Then I was to conduct a treatment and advise the patient on home maintenance and exercises to manage & treat the injury.
Action
The examination initially involved seeing what active movements the patient could achieve. She could only dorsiflex to ~2° before pain was produced during a bilateral squat and couldn’t perform a heel raise on her right leg due to pain. Her single leg balance on her right was less than the left but she could still maintain her balance with more postural sway for 30 seconds. Passively her dorsiflexion with her leg straight was far more painful than with the knee bent. There was some bruising in the medial head of her right gastroc and her achilles tendon was slightly decreased in width relative to the left. She was very tender on palpation in her medial gastroc and a noticeable depression was felt within the medial gastroc head. She was also very tender around the medial border of the right Achilles close to the musculo-tendon junction.
From this assessment and the patient’s history it was determined that the patient had suffered a Grade 2 right medial head gastroc strain and also a strain on the structures at the musculo-tendon junction on the medial side of her achilles tendon.
The treatment in this early stage was very conservative with only ultrasound and some gentle soft tissue massage used. The main emphasis at this early stage was patient education and home exercises. She was encouraged to use her crutches when having the walk long distances, avoid use around the home and wear shoes to limit dysfunction due to an aberrant gait pattern. Some very low grade stretching using a towel and the use of hot/cold therapy to decrease swelling and pain was also prescribed.
Result
The patient seemed aware of the situation and was happy to take heed of my instructions and not cause herself anymore damage. The treatment in the practice was not designed to improve her status there and then but simply but her tissue into a better position to begin the healing process.
Evaluation
The patient was eager to follow the instructions given to her but when she returned two days later I found that she had not followed them as I had desired. Her pain had increased and she was limping noticeably. I had given her simple instructions to follow but I believe that the way I explained it to her was what caused the misunderstanding. The only exercises I gave her had been conducted correctly but she had been experiencing pain after each session but this did not deter her from repeating when the next set was required. Once again I should have explained to her to use pain as her guide and only continue if there is not pain or it is at a manageable level.
Strategies
I need to ensure that I explain clearly to the patient that pain should be used as a guide to limit her with the exercises and with ambulation. Because everyone’s ideas of pain differ I need to use more a measureable guide to limit her activity levels. In these early stages a hard and fast rule of use crutches every time you go outside would have been better than letting the patient decide when and where to use them. Using partial weight bearing and trying to imitate the movement the foot should be doing would have also been useful otherwise the patient would probably think they could walk on it normally with just some balance support from the crutches. Essentially clear and concise explanation of what the patient should be doing and exactly how much of it throughout the course of the day is required to maintain improvements in tissue structure and also limit dysfunction.
Friday, March 26, 2010
Week 1 STARES - Kalgoorlie MSk
Situation
40 yr old male presented to the physiotherapy clinic with insidious onset of LBP that started 2/52 ago and has remained consistent throughout that period of time. The pain is localized to his left lower back and was described as an aching pain that becomes tight with certain movements and positions. The pain is worst when waking in the morning when it feels stiff and loosens up as the day progresses. The pain is aggravated by sustained standing and with walking for long distances (~20mins). It is eased with sitting or lying down. All special questions were negative and no other issues were present.
The patient has a history of LBP. 6/12 earlier he presented with LBP under the same conditions and was forced to take 3/52 off his work as a fitter working at a minesite (no time has been taken off work on this occasion). He received physiotherapy on this occasion which treated him for decreased mobility within the lumbar spine and prescription of exercises to improve lumbar muscle control.
Task
I was to conduct a thorough objective assessment to explore if this occasion was similar to previous and then treat as required to decrease his impairment and prescribe exercises to minimise the chance of this problem occurring again.
Action
The examination was begun by explaining to the patient how the session would be progressing and that with information we gained from the examination a treatment would be determined & delivered to solve his problem.
I began by assessing all active movements of the lumber spine; flexion, extension, left & right side flexion. From this it was found that flexion and RSF were restricted and thus were the asterisk movements. SLR was then tested in supine which found that L was less than R, with pain at the end of range for left SLR. This could be used as a baseline measure to be re-tested at the end of the treatment. PAIVMs were then applied to the lumber spine with the patient in prone to determine an asterisk level. It was found that L4-5 on the R, L4 central & L3-4 on the L were all stiff with L4-5 painful on the R.
Treatment was then decided to be PPIVMs to promote RSF by treating in R rotation & slight flexion of the lumbar spine. Also unilateral PAs on L3-5 on the L in lumbar spine flexion & central PAs on the same levels in the same position. Soft tissue massage was performed on the quadratus lumborum on the L to loosen the muscle that may be restricting RSF.
Result
The patient responded well to the PPIVMS and PAVIMs with increases in flexion & RSF with the patient also commenting that it felt less restricted. At the end of treatment the massage was used and this actually worked against us and returned the patient to his previous level of restriction. The previous mobilizations were repeated which gave the patient back the freedom he initially had.
Evaluation
The initial mobilizations were very effective and noticeable changes occurred in the patient’s ROM. When treating on a couple of occasions I neglected to re-measure the patients ROM after each set as I assumed they would still be having the same effect. I also didn’t re-assess the patient’s SLR which although not crucial could have been a good way of assessing the success of the treatment. I didn’t perform any clearing tests to assess the involvement of the hip or thoracic spine. It turned out that there was no involvement but I was too focused on the lumbar spine as the source of pain which it was but deficiencies in the other areas could be contributing to this issue.
Strategies
Next I will behave more systematically and work through the process in stages. Re-assessment after every single treatment is critical as may mean the treatment isn’t right or that the treatment wasn’t applied correctly. LBP is a very common occurrence (approximately 40% of cases I’ve seen are LBP related) so I need to be clear on the progression of assessment and treatment for the sake of efficiency of the session.
40 yr old male presented to the physiotherapy clinic with insidious onset of LBP that started 2/52 ago and has remained consistent throughout that period of time. The pain is localized to his left lower back and was described as an aching pain that becomes tight with certain movements and positions. The pain is worst when waking in the morning when it feels stiff and loosens up as the day progresses. The pain is aggravated by sustained standing and with walking for long distances (~20mins). It is eased with sitting or lying down. All special questions were negative and no other issues were present.
The patient has a history of LBP. 6/12 earlier he presented with LBP under the same conditions and was forced to take 3/52 off his work as a fitter working at a minesite (no time has been taken off work on this occasion). He received physiotherapy on this occasion which treated him for decreased mobility within the lumbar spine and prescription of exercises to improve lumbar muscle control.
Task
I was to conduct a thorough objective assessment to explore if this occasion was similar to previous and then treat as required to decrease his impairment and prescribe exercises to minimise the chance of this problem occurring again.
Action
The examination was begun by explaining to the patient how the session would be progressing and that with information we gained from the examination a treatment would be determined & delivered to solve his problem.
I began by assessing all active movements of the lumber spine; flexion, extension, left & right side flexion. From this it was found that flexion and RSF were restricted and thus were the asterisk movements. SLR was then tested in supine which found that L was less than R, with pain at the end of range for left SLR. This could be used as a baseline measure to be re-tested at the end of the treatment. PAIVMs were then applied to the lumber spine with the patient in prone to determine an asterisk level. It was found that L4-5 on the R, L4 central & L3-4 on the L were all stiff with L4-5 painful on the R.
Treatment was then decided to be PPIVMs to promote RSF by treating in R rotation & slight flexion of the lumbar spine. Also unilateral PAs on L3-5 on the L in lumbar spine flexion & central PAs on the same levels in the same position. Soft tissue massage was performed on the quadratus lumborum on the L to loosen the muscle that may be restricting RSF.
Result
The patient responded well to the PPIVMS and PAVIMs with increases in flexion & RSF with the patient also commenting that it felt less restricted. At the end of treatment the massage was used and this actually worked against us and returned the patient to his previous level of restriction. The previous mobilizations were repeated which gave the patient back the freedom he initially had.
Evaluation
The initial mobilizations were very effective and noticeable changes occurred in the patient’s ROM. When treating on a couple of occasions I neglected to re-measure the patients ROM after each set as I assumed they would still be having the same effect. I also didn’t re-assess the patient’s SLR which although not crucial could have been a good way of assessing the success of the treatment. I didn’t perform any clearing tests to assess the involvement of the hip or thoracic spine. It turned out that there was no involvement but I was too focused on the lumbar spine as the source of pain which it was but deficiencies in the other areas could be contributing to this issue.
Strategies
Next I will behave more systematically and work through the process in stages. Re-assessment after every single treatment is critical as may mean the treatment isn’t right or that the treatment wasn’t applied correctly. LBP is a very common occurrence (approximately 40% of cases I’ve seen are LBP related) so I need to be clear on the progression of assessment and treatment for the sake of efficiency of the session.
Saturday, March 20, 2010
Initial Entry - Rotation 2: Kalgoorlie
For a while I have been looking forward to completing a rural placement and being in Kalgoorlie where I have lived before makes the transition all the more easier. I’ve always enjoyed getting away from Perth and getting a chance to take a break and in this case more time to spend studying & revising (since there isn’t a whole lot else to do in this town). From a clinical point of view I am excited about the chance to experience a musculoskeletal private practice setting and utilise the knowledge I have been accumulating since first year. For many years I have been treated in private practice settings so on this occasion I think I’ll find it interesting & rewarding to experience the profession from the other side of the plinth.
The catch is that from the other side of the plinth you are running the show. For all the other placements I’ve been on there has been patient notes, some more detailed than others, that essentially provided me with a picture of each patient before setting eyes on them. In private practice this luxury is not always available and this does provide a bit of uncertainty about what to expect with each patient. Even though I am still a student I would like to be at a level where I can efficiently & effectively diagnose patients by the end of the 5 week period which at the moment seems slightly daunting.
Another reason why I selected Kalgoorlie private practice as a placement is that I had heard good reports from other physiotherapy students that it was a great learning experience. This has been combined with reports of my supervisor being a hard task master & very challenging. Since I am very interested in private practice physiotherapy I hope that I am able to benefit as well as other people have in the past and learn a lot about physiotherapy in this environment.
Information I have gathered concerning my role has me observing for a couple of days then gradually increasing my involvement in the process to the point of treating the patients independently with consultation from the head physiotherapist. I believe this would involve me carrying out a subjective assessment, objective assessment and then treatment with input from my supervisor after each part. At this stage having my supervisor oversea all my actions would be beneficial but I hope to be able to accurately run a session with minimal supervisor input and importantly gain the trust of the patients since I see this as a potential major hurdle to furthering my involvement with patients. I hope to be able to develop a strong rapport with the patients that then transfers to them having confidence in my ability to treat them effectively.
There will also be a component of offsite work with visiting minesites to assess and treat people in their work environment. I am not sure what to expect from this at this stage but it will be an interesting experience to assess people at work and analyse first hand if factors at their workplace are impacting upon their health status as opposed to relying on second hand information.
Although daunting at this stage I am looking forward to experiencing a private practice environment and the broad range of conditions that should present themselves with being a first contact health practice. I hope to develop my professional and clinical skills to graduate levels and also enjoy the experience of potentially being the only health profession to treat and help individuals.
The catch is that from the other side of the plinth you are running the show. For all the other placements I’ve been on there has been patient notes, some more detailed than others, that essentially provided me with a picture of each patient before setting eyes on them. In private practice this luxury is not always available and this does provide a bit of uncertainty about what to expect with each patient. Even though I am still a student I would like to be at a level where I can efficiently & effectively diagnose patients by the end of the 5 week period which at the moment seems slightly daunting.
Another reason why I selected Kalgoorlie private practice as a placement is that I had heard good reports from other physiotherapy students that it was a great learning experience. This has been combined with reports of my supervisor being a hard task master & very challenging. Since I am very interested in private practice physiotherapy I hope that I am able to benefit as well as other people have in the past and learn a lot about physiotherapy in this environment.
Information I have gathered concerning my role has me observing for a couple of days then gradually increasing my involvement in the process to the point of treating the patients independently with consultation from the head physiotherapist. I believe this would involve me carrying out a subjective assessment, objective assessment and then treatment with input from my supervisor after each part. At this stage having my supervisor oversea all my actions would be beneficial but I hope to be able to accurately run a session with minimal supervisor input and importantly gain the trust of the patients since I see this as a potential major hurdle to furthering my involvement with patients. I hope to be able to develop a strong rapport with the patients that then transfers to them having confidence in my ability to treat them effectively.
There will also be a component of offsite work with visiting minesites to assess and treat people in their work environment. I am not sure what to expect from this at this stage but it will be an interesting experience to assess people at work and analyse first hand if factors at their workplace are impacting upon their health status as opposed to relying on second hand information.
Although daunting at this stage I am looking forward to experiencing a private practice environment and the broad range of conditions that should present themselves with being a first contact health practice. I hope to develop my professional and clinical skills to graduate levels and also enjoy the experience of potentially being the only health profession to treat and help individuals.
Friday, March 12, 2010
Final Entry - Rotation 1
Now that I have completed the first of my placements for the year I am much more prepared for the year ahead. On the first day I was thrown in the deep end to assess and treat a patient, which although being tough/daunting at the time put me in good stead for the remainder of the placement. This was shown by all 3 of my supervisors (everyone was taking holidays) feeling comfortable to leave me to my own devices & operate independently on a daily basis, with regular catch-ups through out the day. As I mentioned in my Initial Entry having just completed the cardio unit last semester I didn’t have to delve to far in the memory bank to find out what I needed to know. This made reading up on assessments and treatments far easier and consequently more effective in the hospital setting.
Before starting my placement I was anxious about getting treatments right given a patient may have multiple co-morbidities that complicate their cardiorespiratory problem. As I found almost all patients had a co-morbidity of some description but it was simply a matter of just scaling back the treat intensity and progressing as the patient improved. Surgical patient’s for example are regularly treated for respiratory complications following surgery under GA but their may concern obviously is their wound & main medical problem. I encountered this many times but it’s just a matter of working out what the patient can managed within pain limits without adversely impacting on the wound or the goal of the surgery itself. Thorough reading of the notes and effective communication with the patient are crucial to deciding what direction the intervention needs to head in.
My supervisor/s and I developed a great rapport over the period of the placement which translated into effective learning and confidence in me to conduct sessions independently. This meant that I spent the majority of the time working alone and running sessions and my case load to my own time schedule. This enabled me maximum time to develop the skills needed to treat patients in the hospital environment. Parts of those skills are liaising with other health professionals which was necessary on a daily basis. I developed a good relationship with the OTs and nursing staff and consulted with the medical team when necessary. This enabled more effective development of treatment options for each patient since it used the skills and knowledge of many instead of operating in my own little physio bubble. It also allowed effective planning of patient goals and ultimately discharge into the appropriate living environment
In my Initial Entry I mentioned that wanted to develop my communication and documentation skills. I believe that I improved markedly in both areas through developing strong rapports with patients and constantly working on time management and being concise with documentation. Both made it easier to decide on the treatment required and progression as well as patient compliance with ongoing exercise programs prescribed.
Before starting my placement I was anxious about getting treatments right given a patient may have multiple co-morbidities that complicate their cardiorespiratory problem. As I found almost all patients had a co-morbidity of some description but it was simply a matter of just scaling back the treat intensity and progressing as the patient improved. Surgical patient’s for example are regularly treated for respiratory complications following surgery under GA but their may concern obviously is their wound & main medical problem. I encountered this many times but it’s just a matter of working out what the patient can managed within pain limits without adversely impacting on the wound or the goal of the surgery itself. Thorough reading of the notes and effective communication with the patient are crucial to deciding what direction the intervention needs to head in.
My supervisor/s and I developed a great rapport over the period of the placement which translated into effective learning and confidence in me to conduct sessions independently. This meant that I spent the majority of the time working alone and running sessions and my case load to my own time schedule. This enabled me maximum time to develop the skills needed to treat patients in the hospital environment. Parts of those skills are liaising with other health professionals which was necessary on a daily basis. I developed a good relationship with the OTs and nursing staff and consulted with the medical team when necessary. This enabled more effective development of treatment options for each patient since it used the skills and knowledge of many instead of operating in my own little physio bubble. It also allowed effective planning of patient goals and ultimately discharge into the appropriate living environment
In my Initial Entry I mentioned that wanted to develop my communication and documentation skills. I believe that I improved markedly in both areas through developing strong rapports with patients and constantly working on time management and being concise with documentation. Both made it easier to decide on the treatment required and progression as well as patient compliance with ongoing exercise programs prescribed.
Week 5 STARES - Joondalup Cardio
Situation
I had been treating a 58 yr old man who had been admitted for acute exacerbation of COPD with ↑SOB occurring of the previous 1/7. He had a history of bronchiectatsis & had been admitted 4 times previously in the last year for the same condition (“frequent flyer”). The patient appeared very fatigued & anxious and was regularly productive of thick grey sputum which was evident due to widespread crackles & wheezes on auscultation as well as audible moisture when breathing & coughing. He was normally on home O2 @ 4L but was gradually put on increasing amounts as the days passed & eventually steadied at 35L O2 via high flow nasal prongs with humidification. In the time while I had been treating him he had had 2 MET calls (Medical Emergency Team) for increasing SOB at rest.
Task
From a physio point of view the main goals of treatment were to assist the patient with expectorating secretions, improve his SOB and improve his exercise tolerance. To assess the success of treatments I had to use auscultation and measures of exercise tolerance before & after treatment. Analysis of the patient’s sputum was also necessary.
Action
Subjective questioning was very difficult since the patients SpO2 regularly dropped from 97% to 90% just with talking, so clear concise questioning was a must. I asked questions about his previous levels of activity, what assistance he receives at home & who from, how his condition has progressed over time and what he has done at home in the past in terms of exercise & maintaining his health. Essentially to determine what his goals might be and if he is doing anything at home to prevent having more exacerbations.
Objectively I ausculatated and found that all areas of his lungs contained infiltrates (which was confirmed by CXR). Prior to the auscultation I asked the patient to cough which was strong, moist & productive of thick brown sputum (~1tspn). I then got the patient to walk which he could only manage for ~5m before his SpO2 dropped significantly and he became v. SOB+++. After the patient was allowed to recover for ~10mins I began to educate him on UL & LL ex’s which he responded to well and agreed to carry out when I wasn’t there seeing him. On the next occasion I carried out some percussions & vibrations after nebulisers had been administered but as time went by his tolerance for ambulation and percussion & vibes diminished as he was very anxious at how SOB he became with these interventions
Result
The percussion & vibes enabled the patient to expectorate some more sputum but since his lungs were very consolidated this did not show up in changes during auscultation. The patient reported that he had been completing the UL & LL ex’s in my absence but had suspicions about this fact since he could never accurately reproduce the exercises given to him.
The patient’s level of SOB and SpO2 were severely affected by my intervention which as mentioned made him very anxious and in numerous sessions refused to take part due to not feeling well or not being prepared to be involved. This was despite being explained what the benefits of physio treatment were.
Evaluation
The patient’s response to the treatments was very hard to tell as he was so negatively affected after each session yet expectorated large quantities of sputum. His anxiety contributed to me not being able to reassess what improvements had been made in this regard but I strongly suspected that no improvements had been made.
On one occasion a MET call was initiated which resulted in the Dr requesting more regular physio. It was explained to the patient by the Dr that he had to have physio. On reflection I should have been a bit more of a bully and pushed him in the earlier stages since a small bit of discomfort during physio could lead to big improvements later on.
Strategies
I think closer liaison with the medical team to explain the patient’s constant refusal for treatment may have alerted them to the fact that he was receiving little physio and action being taken sooner. As mentioned explaining even clearer & honestly to the patient the benefits of regular physio and that his state will deteriorate with constant refusal.
I had been treating a 58 yr old man who had been admitted for acute exacerbation of COPD with ↑SOB occurring of the previous 1/7. He had a history of bronchiectatsis & had been admitted 4 times previously in the last year for the same condition (“frequent flyer”). The patient appeared very fatigued & anxious and was regularly productive of thick grey sputum which was evident due to widespread crackles & wheezes on auscultation as well as audible moisture when breathing & coughing. He was normally on home O2 @ 4L but was gradually put on increasing amounts as the days passed & eventually steadied at 35L O2 via high flow nasal prongs with humidification. In the time while I had been treating him he had had 2 MET calls (Medical Emergency Team) for increasing SOB at rest.
Task
From a physio point of view the main goals of treatment were to assist the patient with expectorating secretions, improve his SOB and improve his exercise tolerance. To assess the success of treatments I had to use auscultation and measures of exercise tolerance before & after treatment. Analysis of the patient’s sputum was also necessary.
Action
Subjective questioning was very difficult since the patients SpO2 regularly dropped from 97% to 90% just with talking, so clear concise questioning was a must. I asked questions about his previous levels of activity, what assistance he receives at home & who from, how his condition has progressed over time and what he has done at home in the past in terms of exercise & maintaining his health. Essentially to determine what his goals might be and if he is doing anything at home to prevent having more exacerbations.
Objectively I ausculatated and found that all areas of his lungs contained infiltrates (which was confirmed by CXR). Prior to the auscultation I asked the patient to cough which was strong, moist & productive of thick brown sputum (~1tspn). I then got the patient to walk which he could only manage for ~5m before his SpO2 dropped significantly and he became v. SOB+++. After the patient was allowed to recover for ~10mins I began to educate him on UL & LL ex’s which he responded to well and agreed to carry out when I wasn’t there seeing him. On the next occasion I carried out some percussions & vibrations after nebulisers had been administered but as time went by his tolerance for ambulation and percussion & vibes diminished as he was very anxious at how SOB he became with these interventions
Result
The percussion & vibes enabled the patient to expectorate some more sputum but since his lungs were very consolidated this did not show up in changes during auscultation. The patient reported that he had been completing the UL & LL ex’s in my absence but had suspicions about this fact since he could never accurately reproduce the exercises given to him.
The patient’s level of SOB and SpO2 were severely affected by my intervention which as mentioned made him very anxious and in numerous sessions refused to take part due to not feeling well or not being prepared to be involved. This was despite being explained what the benefits of physio treatment were.
Evaluation
The patient’s response to the treatments was very hard to tell as he was so negatively affected after each session yet expectorated large quantities of sputum. His anxiety contributed to me not being able to reassess what improvements had been made in this regard but I strongly suspected that no improvements had been made.
On one occasion a MET call was initiated which resulted in the Dr requesting more regular physio. It was explained to the patient by the Dr that he had to have physio. On reflection I should have been a bit more of a bully and pushed him in the earlier stages since a small bit of discomfort during physio could lead to big improvements later on.
Strategies
I think closer liaison with the medical team to explain the patient’s constant refusal for treatment may have alerted them to the fact that he was receiving little physio and action being taken sooner. As mentioned explaining even clearer & honestly to the patient the benefits of regular physio and that his state will deteriorate with constant refusal.
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